The single bootstrap is implemented by using a saddlepoint approximation to determine estimates for the survival and hazard functions of ®rst-passage times in complicated semi-Markov processes. The double bootstrap is also implemented by resampling saddlepoint inversions and provides BC a con®dence bands for these functions. Con®dence intervals for the mean and variance of ®rst-passage times are easily computed. A new characterization of the asymptotic hazard rate for survival times is presented and leads to an indirect method for constructing its bootstrap con®dence interval.
Background and objectivesMany kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown.Design, setting, participants, & measurementsWe conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation.ResultsAmong 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non–Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1).ConclusionsMost dually enrolled veterans underwent transplantation at a non–Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration–only post-transplant care had the lowest 5-year mortality.
Purpose: The Department of Veterans Affairs (VA) provides surgical care and services through a network of Veterans Health Administration (VHA) Surgical Programs. This study examined the impact of benchmarking on improvements in VHA surgery program operating room efficiency.Methods: The VA National Surgery Office (NSO) developed the operating room (OR) Efficiency Matrix with four common metrics that characterize OR processes. The OR Efficiency Matrix assigned a performance level to each VHA Surgery Program identified in the NSO Quarterly Report. The NSO Quarterly Report provided ongoing and regular feedback allowing VHA Surgery Programs to develop action plans and improve performance.Results: Beginning with the Fiscal Year (FY) 2013 Quarter (Q) 2 NSO Quarterly Report, the NSO has been reporting to VHA Surgery Programs on the OR Efficiency Matrix through several tables and figures in the NSO Quarterly Report. Overall, raw metric rates have improved nationally, with most improvements coming in the metrics of OR first time starts and surgical case cancellation.Conclusions: The NSO developed and implemented the OR Efficiency Matrix, representing four well recognized metrics, to assess, track, and report OR efficiency at 137 VHA Surgery Programs. This internal benchmarking process and data reporting was associated with sustainable improvements in OR efficiency over time.
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