The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program

Functional status as a predictor of outcomes in open and endovascular abdominal aortic aneurysm repair

BACKGROUND

Functional status is a simple and rapidly assessable metric that may be used as a predictor for surgical outcomes. This study examined the association of functional status with short-term mortality after abdominal aortic aneurysm (AAA) repair in octogenarians to characterize the utility of functional status as a means of preoperative risk assessment.

METHODS

All patients who underwent endovascular and open AAA repair from 2002 to 2010 within the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database were identified. Functional status, defined as an ordinal scale from 1 to 3 (1, independent; 2, partially dependent; 3, totally dependent), was examined using multivariate regression models with 30-day mortality as the primary outcome. For the purpose of analysis, this 3-point scale was converted into a binomial scale of function, with "normal" including 1 (completely independent) and "abnormal" including 2 or 3 (partially to totally dependent).

RESULTS

We identified 9030 patients who underwent AAA repair (46.6% open and 53.4% endovascular). Mortality at 30 days was 2.8% for the entire cohort (4.2% open, 1.7% endovascular; P < .001). There were 1340 patients aged ≥80 years, of which 67.3% underwent endovascular AAA repair. Among all age groups, functional status was a significant predictor of 30-day mortality (<80 years, P < .001; ≥80 years, P < .001). The ≥80 cohort with abnormal function status also demonstrated increased operative mortality (P = .002), length of stay (P = .001), and incidence of pulmonary complications (P = .025) compared with the cohort with normal functional status. Multivariate logistic regression demonstrated that within the ≥80-year-old cohort, only functional status remained a significant predictor of mortality (P < .001). In addition, the strength of the association between functional status and mortality was greater in the older cohort than in the younger one (Cox regression hazard ratio: 3.13 vs 2.18).

CONCLUSIONS

Functional status is a simple and rapidly applicable predictor of mortality within AAA patients and may be a useful tool to help preoperatively risk-stratify elderly patients presenting with AAA in need of repair. Further studies are needed to understand how best to apply these data to the clinical setting to guide preoperative decision making.

30-day mortality after elective colorectal surgery can reasonably be predicted

BACKGROUND

The aim of the present study was to develop a clinically relevant, accurate and usable risk assessment scoring system solely for colorectal cancer patients undergoing elective resection.

METHODS

All colorectal resections for colorectal cancer 2006-2012 were identified from the American College of Surgeons Quality Improvement Program. Independent risk factors for 30-day mortality after elective surgery were identified using univariable and multivariable logistic regression. A points-calculator based on factors most strongly associated with mortality and accurately predicting risk of mortality was developed.

RESULTS

Fifty-nine thousand nine hundred eighty-six patients underwent elective colorectal cancer surgery, and 1096 (1.8 %) died within 30 days. On multivariable analysis, the strongest risk factors for mortality were age ≥65 years [odds ratio (OR) 2.17, 95 % confidence interval (CI) 1.61-2.92], American Society of Anesthesiologists score ≥3 (OR 1.77, 95 % CI 1.29-2.42), renal failure (OR 3.15, 95 % CI 1.01-9.77), disseminated cancer (OR 2.56, 95 % CI 1.96-3.35), hypoalbuminemia (OR 2.84, 95 % CI 2.21-3.65), preoperative ascites (OR 3.17, 95 % CI 2.07-4.87), heart failure (OR 2.08, 95 % CI 1.35-3.20) and functional status (OR 2.05, 95 % CI 1.56-2.70). A model that accurately predicted risk of mortality was created using forward stepwise logistic regression and externally validated (area under the curve 0.826). This allowed for development of an eight-factor predictive score; maximum points conferred mortality of 96.1 % (p < 0.0001).

CONCLUSIONS

A simple preoperative scoring system predicting 30-day mortality with good capability may allow better preoperative risk assessment, optimization and decision-making.

Fault Tree Analysis

The purpose of this study was to use fault tree analysis to evaluate the adequacy of quality reporting programs in identifying root causes of postoperative bloodstream infection (BSI). A systematic review of the literature was used to construct a fault tree to evaluate 3 postoperative BSI reporting programs: National Surgical Quality Improvement Program (NSQIP), Centers for Medicare and Medicaid Services (CMS), and The Joint Commission (JC). The literature review revealed 699 eligible publications, 90 of which were used to create the fault tree containing 105 faults. A total of 14 identified faults are currently mandated for reporting to NSQIP, 5 to CMS, and 3 to JC; 2 or more programs require 4 identified faults. The fault tree identifies numerous contributing faults to postoperative BSI and reveals substantial variation in the requirements and ability of national quality data reporting programs to capture these potential faults. Efforts to prevent postoperative BSI require more comprehensive data collection to identify the root causes and develop high-reliability improvement strategies.

Right Versus Left-Sided Colectomies: A Comparison of Outcomes

Surgeons often consider that a right colectomy (RC) carries less risk than a left or sigmoid colectomy (L/SC). Our aim was to compare outcomes between RC and L/SC. Review of the Carolinas Medical Center National Surgical Quality Improvement Program data from 2013 to February 2015 was performed. Procedures were categorized as RC versus L/SC based on current procedural terminology codes for both open and laparoscopic colectomies. Demographics and minor and major complications were evaluated using standard statistical methods. A total of 164 RC and 211 L/SC were studied. RC patients were older (63.9 ± 14.2 vs 59.4 ± 13.0, P < 0.001). Patients undergoing RC had more comorbidities, and 64.6 per cent had an American Society of Anesthesiologist (ASA) Class III or above versus 51.7 per cent of those undergoing L/SC ( P = 0.02). RC had significantly higher rates of postop urinary tract infection (7.3% vs 2.8%, P = 0.04) and postop transfusions ( P = 0.01). Average length of stay was longer for RC (10.1 ± 8.6 days vs 8.3 ± 7.0 days, P < 0.01). After controlling for ASA class, preoperative hematocrit and surgical technique (lap versus open), multivariate analysis indicated that there were no longer any significant differences in outcomes between RC and L/SC. There were no differences between the group complications including superficial or deep surgical site infections, anastomotic leak, myocardial infarction (MI), pneumonia, or 30-day mortality. RC patients tended to be sicker and had more medical complications postop with initial evaluation of the data. However, when controlling for ASA, hematocrit, and techniques, there were no differences in complications when RC was compared to L/SC. The belief that L/SC has a higher rate of complications compared to RC is not supported.

Colorectal Surgery Outcomes in Chronic Dialysis Patients: An American College of Surgeons National Surgical Quality Improvement Program Study

BACKGROUND

More than 450,000 US patients with end-stage renal disease currently dialyze. The risk of morbidity and mortality for these patients after colorectal surgery has been incompletely described.

OBJECTIVE

We analyzed the 30-day morbidity and mortality rates of chronic dialysis patients who underwent colorectal surgery.

DESIGN

This was a retrospective analysis.

SETTINGS

Hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program were included.

PATIENTS

The study included adult patients who underwent emergency or elective colon or rectal resection between 2009 and 2014.

MAIN OUTCOME MEASURES

Baseline characteristics were compared by dialysis status. The impact of chronic dialysis on 30-day mortality and serious postoperative morbidity was examined using multivariate logistic regression.

RESULTS

We identified 128,757 patients who underwent colorectal surgery in the American College of Surgeons National Surgical Quality Improvement Program database. Chronic dialysis patients accounted for 1% (n = 1285) and were more likely to be older (65.4 vs 63.2 years; p < 0.0001), black (27.2% vs 8.7%; p < 0.0001), preoperatively septic (22.1% vs 7.1%; p < 0.0001), require emergency surgery (52.0% vs 14.7%; p < 0.0001), have ischemic bowel (15.7% vs 1.6%; p < 0.0001), or have perforation/peritonitis (15.5% vs 4.2%; p < 0.0001). Chronic dialysis patients were also less likely to have a laparoscopic procedure (17.3% vs 45.0%; p < 0.0001). Chronic dialysis patients had higher unadjusted mortality (22.4% vs 3.3%; p < 0.0001), serious postoperative morbidity (47.9% vs 18.8%; p < 0.0001), and median length of stay (9 vs 6 days; p < 0.0001). In emergent cases (n = 19,375), multivariate logistic regression models demonstrated a higher risk of mortality for dialysis patients (OR = 1.73 (95% CI, 1.38-2.16)) but not for serious morbidity. Models for elective surgery demonstrated a similar effect on mortality (OR = 2.47 (95% CI, 1.75-3.50)) but also demonstrated a higher risk of serious morbidity (OR = 1.28 (95% CI, 1.04-1.56)).

LIMITATIONS

The postoperative 30-day window may underestimate the true incidence of serious morbidity and mortality.

CONCLUSIONS

Chronic dialysis patients undergoing elective or emergent colorectal procedures have a higher risk-adjusted mortality.

Classifying Cause of Death After Cancer Surgery

A retrospective, single-center study was conducted to understand variation in mortality after elective cancer surgery. Fifty-two patients who died perioperatively after elective cancer resections (colon, esophageal, pancreatic, lung, gastric and liver) were identified. A methodology was developed and used during medical record review to capture the occurrence and chronology of 21 postoperative complications. Data were reviewed by 3 attending surgeons who assigned cause of death based on information from the entire clinical record. This methodology demonstrated good construct validity, with 81% agreement between cause of death assigned by expert review of data from the instrument and that assigned by expert review of the clinical records (κ = 0.75, P < .005). Cause-specific mortality can be reliably and systematically measured after cancer surgery. Understanding variation in cause-specific mortality can inform future quality improvement efforts.

Disparities in Treatment of Patients With High-risk Prostate Cancer: Results From a Population-based Cohort

OBJECTIVE

To assess the variation in primary treatment of high-risk prostate cancer (PCa) by different hospital characteristics in the United States.

MATERIALS AND METHODS

We used the National Cancer Data Base to identify patients diagnosed with pretreatment high-risk PCa from 2004 to 2011. The primary outcomes were different forms of primary therapy or watchful waiting (WW) across different types of hospitals (community, comprehensive cancer community, and academic hospitals). Multivariable logistic regression analyses were used to test for differences in treatment by hospital type.

RESULTS

During the study period, we identified 102,701 men diagnosed with high-risk PCa. Overall, the most common treatment was radical prostatectomy (37.0%) followed by radiation therapy (33.2%) and WW (8.5%). Compared with white men with high-risk PCa, black men had lower adjusted odds ratios (OR) for surgery at comprehensive community (OR: 0.64; P <.001) and academic (OR: 0.62; P <.001) hospitals. Similarly, black men were also more likely to be managed with WW at community (OR: 1.49; P <.001), comprehensive cancer community (OR: 1.24; P <.001), and academic (OR: 1.55; P <.001) hospitals, as well as with radiation therapy at comprehensive cancer community (OR: 1.27; P <.001) and academic hospitals (OR: 1.23; P <.001).

CONCLUSION

Disparities in the use of WW and different primary treatments among patients with high-risk PCa persisted across different types of hospitals and over time. Our findings highlight a significant racial disparity in the use of curative therapy for high-risk PCa that should be urgently addressed to ensure that all men with PCa receive appropriate care across all racial groups and cancer care facilities.

Defining the timing and causes of death amongst patients undergoing colorectal resection in England

AIM

Historically, postoperative deaths have been reported up to 30 days following surgery. There is, however, emerging evidence that deaths attributable to surgery continue to occur much later than this time frame. This aim of this study was to analyse the timing and causes of mortality following colorectal resection.

METHOD

Data were obtained from the Hospital Episode Statistics database with linkage to mortality data from the Office for National Statistics. Patients who underwent colorectal resection between April 2001 and February 2007 were included. Causes of death were classified into colorectal cancer (CRC), other malignancy, cardiac, respiratory, gastrointestinal, neurological and other.

RESULTS

During the study period 171 791 patients underwent a colorectal resection. Thirty-day mortality rates for elective procedures were 1.3, 3.5, 7.0 and 12.1% for the ≤ 65, 66-75, 76-85 and > 85 year age groups, respectively, compared with 2.2, 5.4, 9.8 and 16.7% at 90 days. For elective operations, at 30 days, 38.6% of patients who died had CRC recorded as the primary cause of death, whilst 25.4% died of cardiac causes. In the younger population undergoing a resection, deaths due to cardiac causes were significantly higher than the national average for the same age group even beyond 30 days (13.5% at 30 days, 11.1% at 90 days and 5.7% at 1 year).

CONCLUSION

This study shows that deaths attributable to colorectal surgery occur beyond the conventionally utilized 30-day period. Information presented to patients on the basis of 30-day mortality estimates is likely to underestimate the true risk of surgical intervention.

Risk of Surgical Site Infection Varies Based on Location of Disease and Segment of Colorectal Resection for Cancer

BACKGROUND

Current quality-monitoring initiatives do not accurately evaluate surgical site infections based on type of surgical procedure.

OBJECTIVE

This study aimed to characterize the effect of the anatomical site resected (right, left, rectal) on wound complications, including superficial, deep, and organ space surgical site infections, in patients who have cancer.

SETTINGS

Data were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database.

DESIGN

This study was designed to determine the independent risk associated with the anatomical location of cancer resection for all subtypes of surgical site infection. Statistical methods included the Fisher exact test, the χ test, and univariable and multivariable analyses for each outcome of interest.

PATIENTS

All colon and rectal resections for colorectal cancer between 2006 and 2012 were selected. Included were 45,956 patients: 17,993 (39.2%) underwent right colectomy, 11,538 (25.1%) underwent left colectomy, and 16,425 (35.7%) underwent rectal resections.

RESULTS

The overall surgical site infection rate was 12.3%: 3.7% organ space, 1.4% deep, and 7.2% superficial. On multivariable analysis, rectal resection was associated with the greatest odds of overall surgical site infections in comparison with left- or right-sided resections (rectal OR, 1.51; 95% CI, 1.35-1.69 vs left OR, 1.09; 95% CI, 0.97-1.23 vs right OR, 1). Rectal resections were also associated with greater odds of developing a deep surgical site infection than either right (rectal OR, 1.45; 95% CI, 1.06-1.99) or left (OR, 0.89; 95% CI, 0.62-1.27). The likelihood of organ space surgical site infection followed a similar pattern (rectal OR, 1.83; 95% CI 1.49-2.25; left colon, OR, 0.95; 95% CI, 0.75-1.19). Rectal and left resections had increased odds of superficial surgical site infections compared with right resections (rectal OR, 1.31; 95% CI, 1.14-1.51; left OR, 1.19; 95% CI, 1.03-1.37).

LIMITATIONS

This is a retrospective observational study.

CONCLUSIONS

Rectal resections for cancer are independently associated with an increased likelihood of superficial, deep, and organ space infections. The policy on surgical site infections as a quality measure currently in place requires modification to adjust for the location of pathology and, hence, the anatomical segment resected when assessing the risk for type of surgical site infection.

Predictors of wound complications after laryngectomy: A study of over 2000 patients

OBJECTIVES: To identify risk factors for and the rate of wound complications after laryngectomy in a large, prospectively collected national dataset, and to generate a predictive model.

STUDY DESIGN: We used the National Surgical Quality Improvement Program (NSQIP) registry created by the Department of Veterans Affairs (VA) to identify patients undergoing total laryngectomy from 1989 to 1999 (n = 2063). We linked these data to inpatient and outpatient VA administrative records to capture data for prior radiation. Over 20 preoperative and intraoperative risk factors were analyzed using bivariate techniques. Those significant at the P < 0.01 level were analyzed with logistic regression and conjunctive consolidation to identify independent predictors of wound complications.

RESULTS: The overall wound complication rate was 10.0%. In adjusted analyses, prolonged operative time (> 10 hours, odds ratio = 2.10, 95% confidence interval: 1.32-3.36), exposure to prior radiation therapy (OR =1.63, 1.07-2.46), presence of diabetes (OR = 1.78, 1.04-3.04), preoperative hypoalbumine-mia (OR =1.90, 1.32-2.74), anemia (OR =1.59, 1.07-2.36), and thrombocytosis (OR =1.48, 1.04-2.10) were independently associated with postoperative wound complications. A prognostic model using three variables—prior radiation therapy, diabetes, and hypoalbuminemia—provided excellent risk stratification into three tiers (6.3%, 13.7%, 21.7%).

CONCLUSIONS: Preoperative radiation, prolonged operative time, low albumin, and diabetes were independently associated with postoperative wound infections. These results will help to identify patients at risk for wound complications, thus allowing for heightened surveillance and preventive measures where possible.

Comparison of observed to predicted outcomes using the ACS NSQIP risk calculator in patients undergoing pancreaticoduodenectomy

BACKGROUND

Postoperative outcomes predicted by the ACS NSQIP universal risk calculator have not been validated for specific procedures like pancreaticoduodenectomy (PD).

METHODS

A random sample of 400 PD patients from the NSQIP database was analyzed. Patients were categorized into four groups of 100 each based on ICD-9 diagnosis (211.6, 157.0, 156.2, and 577.1). Estimated risks of postoperative outcomes recorded by the calculator were compared to observed outcomes using the Brier Score (BS). The calculated BS was compared to a null model BS. A BS of zero indicated perfect prediction, while a BS of one indicated the poorest prediction.

RESULTS

BS for all groupings was generally low, reflecting good prediction. BS for any and major complications was higher (0.23 and 0.22, respectively). This was also seen within ICD-9 subgroups. For patients with ampullary cancer, BS for these outcomes was higher (0.27 and 0.26, respectively). Comparison to the null model BS (0.24 and 0.24, respectively) correlated lesser predictive accuracy of the calculator for this subgroup.

CONCLUSIONS

The ACS NSQIP risk calculator, although accurate in predicting outcomes in patients undergoing PD, shows variation when accounting for specific ICD-9 diagnoses. Incorporating the diagnosis may better guide surgeons and patients preoperatively in making informed decisions. J. Surg. Oncol. 2016;114:157-162. © 2016 Wiley Periodicals, Inc.

Risk Assessment of Pancreatic Surgery by Surgical Apgar Score and Body Mass Index

Postoperative morbidity is high after pancreatic surgery. Recently, a simple and easy-to-use surgical complication prediction system, the surgical Apgar score (SAS), calculated using 3 intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate) has been proposed for general surgery. In this study, we evaluated the predictability of the SAS for severe complications after pancreatic surgery for pancreatic cancer. We investigated 189 patients who underwent pancreatic surgery at Kanagawa Cancer Center between 2005 and 2014. Clinicopathologic data, including the intraoperative parameters, were collected retrospectively. In this study, the patients with postoperative morbidities classified as Clavien-Dindo grade 2 or higher were classified as having severe complications. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for morbidity. Postoperative complications were identified in 73 patients, and the overall morbidity rate was 38.6%. The results of both univariate and multivariate analyses of various factors for overall operative morbidity showed that an SAS of 0 to 4 points and a body mass index ≥25 kg/m2 were significant independent risk factors for overall morbidity (P = 0.046 and P = 0.013). The SAS and body mass index were significant risk factors for surgical complications after pancreatic surgery for pancreatic cancer.

The First 100 Years of American College of Surgeons Presidential Addresses

INTRODUCTION

We reviewed the first 100 years of presidential addresses delivered at the fall congress of the American College of Surgeons (ACS). Our hypothesis was that these addresses would be an excellent indicator of the College's position on surgical policy, ethics, methods, and education.

METHODS

All ACS presidential addresses from 1913 to 2013 were identified through the ACS archives website. This included the presenter, title, year, and citation if published in a peer reviewed journal. The text of each address was obtained from the ACS archives, or from the listed citations. Addresses were then classified into 1 of 6 subgroups based on content-surgical credo, medical innovation, medical education, surgical history, business and legal, and personal tribute. The 100-year period was divided into 5 interval each of 20-year and the frequency of each category was graphed over time.

RESULTS

There were 111 ACS presidential addresses delivered in the study period. Distribution by category was surgical credo (57%), surgical history (14%), medical innovation (10%), medical education (8%), business and legal (6%), and personal tributes (5%). The frequency of surgical credo has remained stable over time. Business and legal emerged as a new category in 1975. The other topics had low, but stable frequency.

CONCLUSION

ACS presidential addresses do reflect the College's position on surgical policy and practice. The college has remained consistent in serving its members, maintaining, and defining the role of its organization, the qualifications for membership, and the expectations for the professional conduct of its members.

Obesity Is an Independent Risk Factor of Early Complications After Revision Spine Surgery

STUDY DESIGN

Retrospective cohort analysis of risk factors in revision spine surgery using a prospectively collected database.

OBJECTIVE

To examine the risk of developing early (30-day) complications across obesity level after adjusting for comorbidities in patients undergoing revision spine surgery.

SUMMARY OF BACKGROUND DATA

Prior studies suggest obesity influences early complications after primary surgery. The association between obesity and early complications after revision surgery remains to be characterized.

METHODS

Data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012. Adult Caucasian patients undergoing removal/revision of instrumentation or exploration of fusion were included. Patients were categorized by WHO body mass index (BMI, kg/m): Non-Obese (18.5-29.9), Obese Class I (30-34.9), and Obese Class II/III (≥35). Univariate regression was performed to assess the predictive value of obesity level and baseline risk factors in the presence of at least one early complication, and significant predictors were entered into the multivariable model.

RESULTS

Of 2538 patients, 57.6% were nonobese, 23% Obese Class I, and 19.4% Obese Class II/III. Obesity was associated with diabetes, hypertension, respiratory disease, and American Society of Anesthesiologists (ASA) score of 3-4 (all P < 0.001). BMI group (P = 0.01), older age (P = 0.008), functional dependence (P < 0.001), ASA 3-4 (P = 0.008), bleeding disorder (P = 0.04), and diabetes (P = 0.016) were identified as univariate predictors for early complications. In the multivariable model, higher BMI (P = 0.04), older age (P = 0.014), and functional dependence (P < 0.001) remained significant predictors for early complications. Notably, patients who were Obese Class II/III (OR 1.66, 95% CI [1.12-2.45]), age ≥75 (OR 1.83, [1.20-2.81]), and functionally dependent (OR 3.02 [1.85-4.94]) had significantly higher risk compared with their reference groups.

CONCLUSION

Obesity is an independent risk factor for early complications after revision spine surgery. Although obesity may not contraindicate revision surgery, its status as a modifiable risk factor warrants disclosure and preoperative counseling to optimize outcomes.

LEVEL OF EVIDENCE

3.

An Objective Assessment of the Surgical Trainee in an Urban Trauma Unit in South Africa: A Pilot Study

BACKGROUND

Surgical outcomes are provider specific. This prospective audit describes the surgical activity of five general surgery residents on their trauma surgery rotation. It was hypothesized that the operating surgical trainee is an independent risk factor for adverse outcomes following major trauma.

MATERIALS AND METHODS

This is a prospective cohort study. All patients admitted, over a 6-month period (August 2014-January 2015), following trauma requiring a major operation performed by a surgical trainee at Groote Schuur Hospital's trauma unit in South Africa were included. Multiple logistic regression models were built to compare risk-adjusted surgical outcomes between trainees. The primary outcome measure was major in-hospital complications.

RESULTS

A total of 320 major operations involving 341 procedures were included. The mean age was 28.49 years (range 13-64), 97.2 % were male with a median ISS of 9 (IQR 1-41). Mechanism of injury was penetrating in 93.42 % of cases of which 51.86 % were gunshot injuries. Surgeon A consistently had the lowest risk-adjusted outcomes and was used as the reference for all outcomes in the regression models. Surgeon B, D, and E had statistically significant higher rates of major in-hospital complications than Surgeon A and C, after adjusting for multiple confounders. The final model used to calculate the risk estimates for the primary outcome had a ROC of 0.8649.

CONCLUSION

Risk-adjusted surgical outcomes vary by operating surgical trainee. The analysis thereof can add value to the objective assessment of a surgical trainee.

The role of Model for End-Stage Liver Disease (MELD) score in predicting outcomes for lower extremity bypass

OBJECTIVE

The Model for End-Stage Liver Disease (MELD) score has traditionally been used to prioritize liver transplantation. However, its use has been extended to predict overall and postoperative outcomes in patients with hepatic and renal dysfunction. Our objective was to use the MELD score to predict outcomes in patients undergoing lower extremity bypass.

METHODS

Patients undergoing infrainguinal bypass were identified in the American College of Surgeons National Surgical Quality Improvement Program data sets from 2005 to 2012. The MELD score was calculated using serum bilirubin and creatinine values and the international normalized ratio. Patients were grouped into low (<9), moderate (9-14), and high (15+) MELD classifications. The associations of the MELD score on postoperative morbidity and mortality were assessed by multivariable logistic and gamma regressions and by propensity matching.

RESULTS

There were 5967 patients who underwent infrainguinal bypass with the following MELD score distribution: <9, 3795 (64%); 9 to 14, 1819 (30%); and 15+, 353 (6%). Matched analysis in comparing low, moderate, and high MELD scores showed a higher risk for cardiac complications (2.8% vs 3.2% vs 5.4%; P < .001), bleeding complications (9.3% vs 11.1% vs 13.9%; P = .048), and increased postoperative length of stay (median [range], 5 [0-93] vs 6 [0-73] vs 6 [0-86]; P < .001). The MELD score had no association with early bypass failure, wound complications, or operative time. Moderate and high MELD scores were independent predictors of postoperative myocardial infarction/cardiac arrest (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001; and OR, 4.1; 95% CI, 2.3-7.3; P < .01), bleeding complications (OR, 1.3; 95% CI, 1.1-1.6; P < .01; and OR, 1.8; 95% CI, 1.3-2.5; P < .01), return to the operating room (OR, 1.3; 95% CI, 1.1-1.5; P < .01; and OR, 1.4; 95% CI, 1.03-1.8; P = .03), extended postoperative length of stay (means ratio, 1.2; 95% CI, 1.1-1.2; P < .01; and means ratio, 1.2; 95% CI, 1.2-1.3; P < .01), and perioperative mortality (OR, 1.6; 95% CI, 1.02-2.5; P = .04; and OR, 2.9; 95% CI, 1.6-5.4; P = .01), respectively. Propensity matching between low, moderate, and high MELD score groups confirmed an increased risk of postoperative myocardial infarction/cardiac arrest (P < .01), bleeding complications (P = .05), and extended postoperative length of stay (P < .01) with a trend toward increased mortality and return to operating room.

CONCLUSIONS

An elevated MELD score places patients undergoing infrainguinal bypass at higher risk of perioperative morbidity and mortality. This provides an evidence base for risk stratification and informed consent for these patients. Alternative treatment may be considered in these patients; however, the overall morbidity and mortality rates may still be acceptable, even in high-risk patients.

Rescue management of early complications after liver transplantation-key for the long-term success

PURPOSE

Postoperative complications may have not only immediate but also long-term effects on the outcomes. Here, we analyzed the effect of postoperative complications requiring a reoperation (grade 3b) within the first 30 days on patients' and graft survival following liver transplantation.

METHODS

Graft and patient survival in relation to donor and recipient variables and the need of reoperation for complications of 277 consecutive liver transplants performed from January 2007 to December 2012 were analyzed.

RESULTS

Two hundred seventy-seven liver transplants were performed in 252 patients. Overall patient and graft survival at 1, 2, and 3 years were significantly reduced in patients requiring a reoperation. The labMELD score was significantly elevated (p = 0.04) and cold ischemia time was prolonged (p = 0.03) in recipients undergoing reoperations. Kaplan-Meier curves indicate that complications impact the outcome primarily within the first 3 months after transplantation. In multivariate analyses, the actual need of reoperation (p < 0.001), the labMELD score (p = 0.05), cold ischemia time (p = 0.02), and the need for hemodialysis pre-transplant (p = 0.05) were the only variables which correlated with the overall survival.

CONCLUSION

Postoperative complications resulting in reoperations have a significant impact on the outcome primarily in the early phase after liver transplantation. Successful management of postoperative complications is key to every successful liver transplant program.

Same-Day Major Breast Cancer Surgery is Safe: An Analysis of Short-Term Outcomes Using NSQIP Data

INTRODUCTION

Most patients undergoing significant breast cancer surgery stay in hospital postoperatively. We sought to determine whether there was a difference in complication rates among patients undergoing same-day surgery (SDS) versus overnight or inpatient stay.

METHODS

Analysis of the American College of Surgeons, National Surgical Quality Improvement Program participant user files was performed. Patients with breast cancer undergoing mastectomy and/or axillary lymph node dissection between 2005 and 2012 were examined (high-risk comorbidities and concurrent surgery were excluded). Thirty-day postoperative morbidity was analyzed. Multivariable regression was performed identifying independent predictors of complications.

RESULTS

The final population consisted of 40,575 patients; 8365 had SDS, 23,252 stayed overnight, and 8958 stayed in hospital longer postoperatively. Those admitted to hospital were older, more obese, had higher American Society of Anesthesiology (ASA) class, medical comorbidities, or had bilateral surgery. The overall 30-day morbidity was 4.7 %. On univariate analysis, patients undergoing SDS had significantly lower 30-day morbidity (2.4 %) compared with overnight (3.9 %) or inpatient stay (8.8 %) (p < 0.0001). After controlling for the above differences between groups, patients staying overnight had a higher odds of postoperative complications [1.37, 95 % confidence interval (CI) 1.16-1.63, p = 0.004] and inpatients had over twice the odds of postoperative complications (2.65, 95 % CI 2.21-3.18, p < 0.0001) compared with SDS patients.

CONCLUSION

This is the largest study examining the safety of SDS for breast cancer. Complication rates were significantly higher for patients admitted to hospital postoperatively, even after controlling for baseline differences. These data suggest that, with appropriate selection, it is safe to perform major breast cancer surgery on a same-day basis.

Increased Operative Time for Benign Cranial Nerve Tumor Resection Correlates with Increased Morbidity Postoperatively

OBJECTIVES

Operative time, previously identified as a risk factor for postoperative morbidity, is examined in patients undergoing benign cranial nerve tumor resection.

DESIGN/SETTING/PARTICIPANTS

This retrospective cohort analysis included patients enrolled in the ACS-NSQIP registry from 2007 through 2013 with a diagnosis of a benign cranial nerve neoplasm.

MAIN OUTCOME MEASURES

Primary outcomes included postoperative morbidity and mortality. Readmission and reoperation served as secondary outcomes.

RESULTS

A total of 565 patients were identified. Mean (median) operative time was 398 (370) minutes. The 30-day complication, readmission, and return to the operating room rates were 9.9%, 9.9%, and 7.3%, respectively, on unadjusted analyses. CSF leak requiring reoperation or readmission occurred at a rate of 3.1%. On multivariable regression analysis, operations greater than 413 minutes were associated with an increased odds of overall complication (OR 4.26, 95% CI 2.08-8.72), return to the operating room (OR 2.65, 95% CI 1.23-5.67), and increased length of stay(1.6 days, 95% CI 0.94-2.23 days). Each additional minute of operative time was associated with an increased odds of overall complication (OR 1.004, 95% CI 1.002-1.006) and increased length of stay (0.006 days, 95% CI 0.004-0.008).

CONCLUSION

Increased operative time in patients undergoing surgical resection of a benign cranial nerve neoplasm was associated with an increased rate of complications.

Relationship Between Comorbid Conditions and Utilization Patterns of Immediate Breast Reconstruction Subtypes Post-mastectomy

There is limited information on the influence of a patient's comorbid status on the type of immediate breast reconstruction (IBR) selected. Our aim was to provide a population-based review of the relationship between baseline comorbid conditions and IBR subtype selected. This is a retrospective cohort study using the National Surgical Quality Improvement Program database to identify IBR recipients. Multivariable regression analyses was performed to identify the association between comorbidity and IBR subtype selection (prosthetic, pedicled, and free autologous). A total of 48,096 mastectomy patients were identified, of which 17,404 patients received IBR. IBR patients were younger (51 ± 10.4 versus 61.5 ± 13.6 years) and had a lower body mass index (27.1 ± 6.4 versus 28.9 ± 7.3) relative to patients who did not pursue IBR (p < 0.001 for all). Overall, IBR patients had a significantly lower incidence of comorbid conditions. In adjusted models, patients aged 45-64 years were more likely to pursue pedicled-autologous reconstruction (OR: 1.43, p < 0.001) and those older than 65 years were less likely to undergo free-autologous reconstruction (OR: 0.64, p = 0.02). Class I and II obesity was associated with pedicled (class I OR: 1.57, class II OR: 1.41) and free transfer (class I OR: 1.81, class II OR: 1.66) autologous IBR utilization (all p < 0.001). Also, smoking was related to increased chance of prosthetic reconstruction while preoperative radiotherapy was linked to free-autologous IBR. IBR patients were noted to be healthier than their non-IBR counterparts, and each IBR subtype was associated with a particular comorbidity profile. This has significant implications with regard to creation of an IBR-predictive model. Such a tool will improve preoperative counseling and decision making.

Shorter Hospital Stay and Lower 30-Day Readmission After Unicondylar Knee Arthroplasty Compared to Total Knee Arthroplasty

BACKGROUND

Reducing hospital stay and unplanned hospital readmission of arthroplasty patients has been a topic of recent interest. The aim of the present study was to query the National Surgical Quality Improvement Program database to compare the length of hospital stay (LOS) and the subsequent 30-day hospital readmission rates in patients undergoing primary unicondylar knee arthroplasty (UKA) and total knee arthroplasty (TKA).

METHODS

We identified 1340 UKAs and 36,274 TKAs over a 2-year period (2011-2012). Patient demographics, comorbidities, LOS, 30-day postoperative complications, and readmission rates were compared between the groups. Multivariate regression analysis was used to determine the effect of procedure type on LOS and readmission rates.

RESULTS

Unicondylar knee arthroplasty patients had a median LOS of 2 days compared to 3 days for TKAs (P < .001). The readmission rate in the TKA group was nearly double that of the UKA group (4.1% vs 2.2%) (P < .0001). Multivariate regression analysis identified that undergoing a UKA was predictive for a shorter LOS (coefficient -1 day) and was protective for 30-day readmission (odds ratio, 0.60; 95% confidence interval, 0.41-0.88).

CONCLUSION

Patients undergoing UKA had a shorter LOS and a lower 30-day readmission rate compared to TKA patients. After adjusting for selected cofounders, we demonstrated that undergoing a UKA is a protective factor for 30-day readmission.

Variation in Clinical Practice: A Priority Setting Approach to the Staged Funding of Quality Improvement

Variation in adherence to clinical guidelines, and in the organisation and delivery of health care significantly impact patient outcomes and health service costs. Despite mounting evidence of variation in clinical practice, the funds allocated to improve the quality of existing services remain small, relative to the resources allocated to new technologies. Quality improvement is a complex intervention, with a lack of focus on outcomes, and greater uncertainty around its effects. These factors have contributed to a relatively narrow, mainstream view of quality improvement as focussing on safety, with efforts to improve adherence to best practice limited to high profile clinical areas. This paper presents an analysis of linked, routinely collected data to identify variation in patient outcomes and processes of care across hospitals for patients presenting with low-risk chest pain. Such analyses provide a low cost, broadly applicable approach to identifying potentially important areas of variation in clinical practice, to inform the prioritisation of more detailed analyses to validate, and further investigate the causes of variation.

Attitudes of Pulmonary and Critical Care Training Program Directors toward Quality Improvement Education

RATIONALE

Quality improvement (QI) is a required component of fellowship training in pulmonary, critical care, and sleep medicine. However, little is known about how training programs approach QI education.

OBJECTIVES

We sought to understand the perceptions of pulmonary, critical care, and sleep medicine training program directors toward QI education.

METHODS

We developed and fielded an internet survey of pulmonary, critical care, and sleep medicine training program directors during 2013. Survey domains included program characteristics, the extent of trainee and faculty involvement in QI, attitudes toward QI education, and barriers to successful QI education in their programs.

MEASUREMENTS AND MAIN RESULTS

A total of 75 program directors completed the survey (response rate = 45.2%). Respondents represented both adult (n = 43, 57.3%) and pediatric (n = 32, 42.7%) programs. Although the majority of directors (n = 60, 80.0%) reported substantial fellow involvement in QI, only 19 (26.0%) reported having a formal QI education curriculum. QI education was primarily based around faculty mentoring (n = 46, 61.3%) and lectures (n = 38, 50.7%). Most directors agreed it is an important part of fellowship training (n = 63, 84.0%). However, fewer reported fellows were well integrated into ongoing QI activities (n = 45, 60.0%) or graduating fellows were capable of carrying out independent QI (n = 28, 50.7%). Key barriers to effective QI education included lack of qualified faculty, lack of interest among fellows, and lack of time.

CONCLUSIONS

Training program directors in pulmonary, critical care, and sleep medicine value QI education but face substantial challenges to integrating it into fellowship training.

Reducing healthcare costs facilitated by surgical auditing: a systematic review

BACKGROUND

Surgical auditing has been developed in order to benchmark and to facilitate quality improvement. The aim of this review is to determine if auditing combined with systematic feedback of information on process and outcomes of care results in lower costs of surgical care.

METHOD

A systematic search of published literature before 21-08-2013 was conducted in Pubmed, Embase, Web of Science, and Cochrane Library. Articles were selected if they met the inclusion criteria of describing a surgical audit with cost-evaluation.

RESULTS

The systematic search resulted in 3608 papers. Six studies were identified as relevant, all showing a positive effect of surgical auditing on quality of healthcare and therefore cost savings was reported. Cost reductions ranging from $16 to $356 per patient were seen in audits evaluating general or vascular procedures. The highest potential cost reduction was described in a colorectal surgical audit (up to $1,986 per patient).

CONCLUSIONS

All six identified articles in this review describe a reduction in complications and thereby a reduction in costs due to surgical auditing. Surgical auditing may be of greater value when high-risk procedures are evaluated, since prevention of adverse events in these procedures might be of greater clinical and therefore of greater financial impact.

IMPLICATION OF KEY FINDINGS

This systematic review shows that surgical auditing can function as a quality instrument and therefore as a tool to reduce costs. Since evidence is scarce so far, further studies should be performed to investigate if surgical auditing has positive effects to turn the rising healthcare costs around. In the future, incorporating (actual) cost analyses and patient-related outcome measures would increase the audits' value and provide a complete overview of the value of healthcare.

An artificial system for selecting the optimal surgical team

We introduce an intelligent system to optimize a team composition based on the team's historical outcomes and apply this system to compose a surgical team. The system relies on a record of the procedures performed in the past. The optimal team composition is the one with the lowest probability of unfavorable outcome. We use the theory of probability and the inclusion exclusion principle to model the probability of team outcome for a given composition. A probability value is assigned to each person of database and the probability of a team composition is calculated from them. The model allows to determine the probability of all possible team compositions even if there is no recoded procedure for some team compositions. From an analytical perspective, assembling an optimal team is equivalent to minimizing the overlap of team members who have a recurring tendency to be involved with procedures of unfavorable results. A conceptual example shows the accuracy of the proposed system on obtaining the optimal team.

The Use of Surgical Care Improvement Projects in Prevention of Venous Thromboembolism

Venous thromboembolism (VTE) is a potentially mortal complication in patients undergoing surgery. Deep venous thrombosis and pulmonary embolism can be seen up to 40 % of patients who have no or inappropriate VTE prophylaxis during perioperative period.In addition to the preoperative and intraoperative preventive measures, the standardization of postoperative care and follow-up are essential to reduce VTE risk. Modern healthcare prioritizes patient's safety and aims to reduce postoperative morbidity by using standardized protocols. Use of quality improvement projects with well-organized surgical care has an important role to prevent VTE during hospital stay. Present surgical care improvement projects have provided us the opportunity to identify patients who are vulnerable to VTE. Description and introduction of the quality standards for VTE prevention in the educational materials, meetings and at the medical schools will increase the VTE awareness among the health care providers. You are going to find the characteristics of the major surgical quality improvement projects and their relations with VTE in the chapter.

National Clinical Database feedback implementation for quality improvement of cancer treatment in Japan: from good to great through transparency

The National Clinical Database (NCD) of Japan was established in April, 2010 with ten surgical subspecialty societies on the platform of the Japan Surgical Society. Registrations began in 2011 and over 4,000,000 cases from more than 4100 facilities were registered over a 3-year period. The gastroenterological section of the NCD collaborates with the American College of Surgeons' National Surgical Quality Improvement Program, which shares a similar goal of developing a standardized surgical database for surgical quality improvement, with similar variables for risk adjustment. Risk models of mortality for eight procedures; namely, esophagectomy, partial/total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, pancreaticoduodenectomy, and surgery for acute diffuse peritonitis, have been established, and feedback reports to participants will be implemented. The outcome measures of this study were 30-day mortality and operative mortality. In this review, we examine the eight risk models, compare the procedural outcomes, outline the feedback reporting, and discuss the future evolution of the NCD.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for ovarian cancer

OBJECTIVE

To develop an observed-to-expected ratio (O/E) for adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines as a risk-adjusted hospital measure of quality care correlated with disease-specific survival.

METHODS

Consecutive patients with stages I-IV epithelial ovarian cancer were identified from the California Cancer Registry (1/1/96-12/31/06). Using a fit logistic regression model, O/E for guideline adherence was calculated for each hospital and distributed into quartiles stratified by hospital annual case volume: lowest O/E quartile or annual hospital case volume <5, middle two O/E quartiles and volume ≥5, and highest O/E quartile and volume ≥5. A multivariable logistic regression model was used to characterize the independent effect of hospital O/E on ovarian cancer-specific survival.

RESULTS

Overall, 18,491 patients were treated at 405 hospitals; 37.3% received guideline adherent care. Lowest O/E hospitals (n=285) treated 4661 patients (25.2%), mean O/E=0.77±0.55 and median survival 38.9months (95%CI=36.2-42.0months). Intermediate O/E hospitals (n=85) treated 8715 patients (47.1%), mean O/E=0.87±0.17 and median survival of 50.5months (95% CI=48.4-52.8months). Highest O/E hospitals (n=35) treated 5115 patients (27.7%), mean O/E=1.34±0.14 and median survival of 53.8months (95% CI=50.2-58.2months). After controlling for other variables, treatment at highest O/E hospitals was associated with independent and statistically significant improvement in ovarian cancer-specific survival compared to intermediate O/E (HR=1.06, 95% CI=1.01-1.11) and lowest O/E (1.16, 95% CI=1.10-1.23) hospitals.

CONCLUSIONS

Calculation of hospital-specific O/E for NCCN treatment guideline adherence, combined with minimum case volume criterion, as a measure of ovarian cancer quality of care is feasible and is an independent predictor of survival.

Ninety-day Postoperative Mortality Is a Legitimate Measure of Hepatopancreatobiliary Surgical Quality

OBJECTIVE

To investigate the legitimacy of 90-day mortality as a measure of hepatopancreatobiliary quality.

BACKGROUND

The 90-day mortality rate has been increasingly but not universally reported after hepatopancreatobiliary surgery. The legitimacy of this definition as a measure of surgical quality has not been evaluated.

METHODS

We retrospectively reviewed the causes of all deaths that occurred within 365 postoperative days in patients undergoing hepatectomy (n = 2811) and/or pancreatectomy (n = 1092) from January 1997 to December 2012. The rates of surgery-related, disease-related, and overall mortality within 30 days, within 30 days or during the index hospitalization, within 90 days, and within 180 days after surgery were calculated.

RESULTS

Seventy-nine (3%) surgery-related deaths and 92 (3%) disease-related deaths occurred within 365 days after hepatectomy. Twenty (2%) surgery-related deaths and 112 (10%) disease-related deaths occurred within 365 days after pancreatectomy. The overall mortality rates at 99 and 118 days optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. The 90-day overall mortality rate was a less sensitive but equivalently specific measure of surgery-related death.

CONCLUSIONS AND RELEVANCE

The 99- and 118-day definitions of postoperative mortality optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. However, among commonly reported metrics, the 90-day overall mortality rate represents a legitimate measure of surgical quality.

Improving quality on the pediatric surgery service: Missed opportunities and making it happen

In surgery, quality improvement efforts have evolved from the traditional case-by-case review typical for morbidity and mortality conferences to more accurate and comprehensive data collection accomplished through participation in national registries such as the National Surgical Quality Improvement Program. Gaining administrative support to participate in these kinds of initiatives and commitment of the faculty and staff to make change in a data-driven manner rather than as a reaction to individual events can be a challenge. This article guides the reader through the process of interacting with administrative leadership to gain support for evidence-based quality improvement endeavors. General principles that are discussed include stakeholder engagement, taking advantage of preexisting resources, and the sharing of data in order to shape QI efforts and demonstrate their effectiveness.

Improving surgical care for children through multicenter registries and QI collaboratives

The role of the healthcare organization is shifting and must overcome the challenges of fragmented, costly care, and lack of evidence in practice, to reduce cost, ensure quality, and deliver high-value care. Notable gaps exist within the expected quality and delivery of pediatric healthcare, necessitating a change in the role of the healthcare organization. To realize these goals, the use of collaborative networks that leverage massive datasets to provide information for the development of learning healthcare systems will become increasingly necessary as efforts are made to narrow the gap in healthcare quality for children. By building upon the lessons learned from early collaborative efforts and other industries, operationalizing new technologies, encouraging clinical-community partnerships, and improving performance through transparent pursuit of meaningful goals, pediatric surgery can increase the adoption of best practices by developing collaborative networks that provide evidence-based clinical decision support and accelerate progress toward a new culture of delivering high-quality, high-value, and evidenced-based pediatric surgical care.

Costs Associated With Surgical Site Infections in Veterans Affairs Hospitals

IMPORTANCE

Surgical site infections (SSIs) are potentially preventable complications that are associated with excess morbidity and mortality.

OBJECTIVE

To determine the excess costs associated with total, deep, and superficial SSIs among all operations and for high-volume surgical specialties.

DESIGN, SETTING, AND PARTICIPANTS

Surgical patients from 129 Veterans Affairs (VA) hospitals were included. The Veterans Health Administration Decision Support System and VA Surgical Quality Improvement Program databases were used to assess costs associated with SSIs among VA patients who underwent surgery in fiscal year 2010.

MAIN OUTCOMES AND MEASURES

Linear mixed-effects models were used to evaluate incremental costs associated with SSIs, controlling for patient risk factors, surgical risk factors, and hospital-level variation in costs. Costs of the index hospitalization and subsequent 30-day readmissions were included. Additional analysis determined potential cost savings of quality improvement programs to reduce SSI rates at hospitals with the highest risk-adjusted SSI rates.

RESULTS

Among 54,233 VA patients who underwent surgery, 1756 (3.2%) experienced an SSI. Overall, 0.8% of the cohort had a deep SSI, and 2.4% had a superficial SSI. The mean unadjusted costs were $31,580 and $52,620 for patients without and with an SSI, respectively. In the risk-adjusted analyses, the relative costs were 1.43 times greater for patients with an SSI than for patients without an SSI (95% CI, 1.34-1.52; difference, $11,876). Deep SSIs were associated with 1.93 times greater costs (95% CI, 1.71-2.18; difference, $25,721), and superficial SSIs were associated with 1.25 times greater costs (95% CI, 1.17-1.35; difference, $7003). Among the highest-volume specialties, the greatest mean cost attributable to SSIs was $23,755 among patients undergoing neurosurgery, followed by patients undergoing orthopedic surgery, general surgery, peripheral vascular surgery, and urologic surgery. If hospitals in the highest 10th percentile (ie, the worst hospitals) reduced their SSI rates to the rates of the hospitals in the 50th percentile, the Veterans Health Administration would save approximately $6.7 million per year.

CONCLUSIONS AND RELEVANCE

Surgical site infections are associated with significant excess costs. Among analyzed surgery types, deep SSIs and SSIs among neurosurgery patients are associated with the highest risk-adjusted costs. Large potential savings per year may be achieved by decreasing SSI rates.

Ninety-day readmission after colorectal cancer surgery in a Veterans Affairs cohort

BACKGROUND

Readmissions following colorectal surgery are common. However, there are limited data examining unplanned readmissions (URs) after colorectal cancer (CRC) surgery. The goal of this study was to identify reasons and predictors of UR, and to examine their clinical impact on CRC patients.

METHODS

A retrospective cohort study using a prospective CRC surgery database of patients treated at a VA tertiary referral center was performed (2005-2011). Ninety-day URs were recorded and classified based on reason for readmission. Clinical impact of UR was measured using a validated classification for postoperative complications. Multivariate logistic regression analyses were performed to identify predictors of UR.

RESULTS

487 patients were included; 104 (21%) required UR. Although the majority of UR were due to surgical reasons (n = 72, 69%), medical complications contributed to 25% of all readmission events. Nearly half of UR (n = 44, 40%) had significant clinical implications requiring invasive interventions, intensive care unit stays, or led to death. After multivariate logistic regression, the following independent predictors of UR were identified: African-American race (odds ratio [OR] 0.47 [0.27-0.88]), ostomy creation (OR 2.50 [1.33-4.70]), and any postoperative complication (OR 4.36 [2.48-7.68]).

CONCLUSIONS

Ninety-day URs following colorectal cancer surgery are common, and represent serious events associated with worse outcomes. In addition to postoperative complications, surgical details that can be anticipated (i.e., ileostomy creation) and medical events unrelated to surgery, both contribute as important and potentially preventable reasons for UR. Future studies should focus on developing and examining interventions focused at improving the process of perioperative care for this high-risk population.