title: Restating Surgical Risk: From Patient to Population.
abstract: BACKGROUND
  Recent federal legislation driving transition from fee-for-service to alternative methods of payment makes risk recognition essential for determination of appropriate payment systems. Because negotiations will include bundled population cohorts, we compared risk and results of an urban safety net teaching hospital's surgical population with state and national cohorts.
  
  
  METHODS
  Deidentified summary data for 2013 and 2014 were analyzed to compare the safety net teaching hospital with a statewide collaborative and a national cohort from similar academic centers. Incidence of preoperative risk factors were compared, identifying those that were >50% higher than both state and national experiences. These were compared for change in incidence between years. Outcomes were evaluated by 30-day mortality, readmissions, return to operating room, length of stay, and adverse events incidence.
  
  
  RESULTS
  For both years, incidence of smoking, ventilator dependence, and CHF within 30 days was >50% higher than in the state and national cohorts. In 2014, septic shock was added to this, along with increased diabetes (14.3% to 19.8%), CHF (1.9% to 2.8%), and hypertension (39.9% to 52.5%). Despite these changes, 30-day mortality, return to operating room, length of stay, and readmissions were within ±5% of state and national results. Unplanned intubation, ventilation longer than 48 hours, and acute renal failure were 10th decile outliers. Median and interquartile range for length of stay were similar for all 3 populations across both years.
  
  
  CONCLUSIONS
  The incidence of comorbid conditions defines greater risk in this safety net teaching hospital population. Increased smoking-related pathology reflects local population disease burden, and increased ventilator support defines additional cost for this care. As disease-, procedure-, or population-based payment alternatives evolve, risk recognition, reduction, and resolution will be essential for determination of cost-efficient, optimal, surgical outcomes.
authors.affiliation: Department of Surgery, University of Florida College of Medicine, Jacksonville, FL. Electronic address: jjt@jax.ufl.edu.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Tepas
authors.affiliation: Department of Surgery, University of Florida College of Medicine, Jacksonville, FL.
authors.forename: Andrew James
authors.initials: AJ
authors.lastname: Kerwin
authors.affiliation: Department of Surgery, University of Florida College of Medicine, Jacksonville, FL.
authors.forename: Jhun
authors.initials: J
authors.lastname: de Villa
authors.affiliation: Department of Surgery, University of Florida College of Medicine, Jacksonville, FL.
authors.forename: Jin Hee
authors.initials: JH
authors.lastname: Ra
authors.affiliation: Department of Surgery, University of Florida College of Medicine, Jacksonville, FL.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Nussbaum
mesh_terms: D000368:Aged; D016000:Cluster Analysis; D005260:Female; D006304:Health Status; D006760:Hospitalization; D006786:Hospitals, Urban; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors; D064876:Safety-net Providers; D014481:United States