months he was reduced by pain to cease walking after zoo yards on the flat. Medical treatment gave no results, and surgery was sought in September, 1959. He had worked as a plasterer from 1945 to 1956, and again during the second half of 1958 for six months. In the latter period, almost up to the onset of the pain, he had worked on floors, kneeling on his right knee. The same applied to about 25 per cent of his time in the I r-year period. Since the pain he had driven a small truck around a timber yard.He was a robust man; he had smoked an average of 4 02. of cigarette tobacco per week for the previous eighteen years. There were no cardiac symptoms and the E.C.G. was normal. All pulses were palpable, including right popliteal, posterior and anterior tibials, the latter three being markedly diminished. There were no trophic changes in the toes and feet, but after exercise the right toes and foot would become numb and white.AT OPERATION. -The right femoral arteriogram showed normal vessels with smooth walls, except for the upper popliteal where the lumen was reduced to a thread over I 4 in. by something encroaching from one side. The usual branches of the popliteal were outlined. At exploration a fusiform swelling of the popliteal artery was found bound alongside the artery, compressing it. Dense adhesion to adjacent veins was encountered, particularly at the lower end, but no connexion was made out with the knee-joint. The vessels arising from it were divided in turn until at the lower end a normal vessel was seen disappearing between the gastrocnemius heads. It
Introduction: Within the Military Health System (MHS), facilities have struggled to meet minimum recommended volume thresholds for certain procedures. Understanding variations in complication rates and cost can help policymakers tailor policy to target improvement. Our objective was to quantify the variation in bariatric surgery complication rates and costs across a sample of military hospitals. Materials and Methods: We study a retrospective cohort of 38 military surgeons practicing in 21 military treatment facilities from 2007 to 2014 who performed 1,277 bariatric surgeries. Data from the Centralized Credentials and Quality Assurance System, which provides education and training characteristics of physicians, were linked to patient encounter data from the MHS Data Repository. Physicians were included if they performed at least five bariatric surgeries over the study period. Patients were included if they had a diagnosis of obesity (body mass index > 30) and underwent a bariatric weight loss surgery. We calculated and summarized inpatient costs and complication rates across both surgeons and facilities using multivariable mixed-effects linear or logistic models. We used these models to calculate adjusted complication rates and average costs across both providers and hospitals to characterize variation in bariatric outcomes within the MHS. This study was considered exempt by the Uniformed Services University Institutional Review Board. Results: We find evidence of large variations in both complication rates and costs per admission. Overall, we found a 15.5% complication rate across the sample. When comparing averages across facilities, we find large variation in complications (49.4% coefficient of variation [CV]) and procedure costs (25.9% CV). Controlling for patient comorbidities, BMI, and year attenuates much of the variation (12.6% CV complications, 4.4% CV cost), but cannot completely explain differences across facilities. Our model suggests that complications cost 32% more than complication-free surgeries on average suggesting that quality improvement efforts could potentially yield large savings. Conclusions: We find large variations in complication rates even after controlling for patient health. Furthermore, surgical complications are a significant determinant of cost. Policymakers should target efforts to improve surgical quality across facilities and physicians. Surgical quality improvement initiatives could produce savings to the MHS through reduced complications and improved surgical readiness.
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