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

Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery

OBJECT

As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.

METHODS

The authors performed a PubMed search using search terms "cerebral aneurysm", "cerebral arteriovenous malformation", "intracerebral hemorrhage", "intracranial hemorrhage", "subarachnoid hemorrhage", and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events.

RESULTS

The review revealed hemorrhage-related hyperglycemia (incidence rates ranging from 27% to 71%) and cerebral salt-wasting syndromes (34%-57%) to be the most common perioperative adverse events related to subarachnoid hemorrhage (SAH). Next in terms of frequency was new cerebral infarction associated with SAH, with a rate estimated at 40%. Many techniques are advocated for use during surgery to minimize risk of this development, including intraoperative neurophysiological monitoring, but are not universally used due to surgeon preference and variable availability of appropriate staffing and equipment. The comparative effectiveness of using or omitting monitoring technologies has not been evaluated. The incidence of perioperative seizure related to vascular neurosurgery is unknown, but reported seizure rates from observational studies range from 4% to 42%. There are no standard guidelines for the use of seizure prophylaxis in these patients, and there remains a need for prospective studies to support such guidelines. Intraoperative rupture occurs at a rate of 7% to 35% and depends on aneurysm location and morphology, history of rupture, surgical technique, and surgeon experience. Preventive strategies include temporary vascular clipping. Technical adverse events directly involving application of the aneurysm clip include incomplete aneurysm obliteration and parent vessel occlusion. The rates of these events range from 5% to 18% for incomplete obliteration and 3% to 12% for major vessel occlusion. Intraoperative angiography is widely used to confirm clip placement; adjuncts include indocyanine green video angiography and microvascular Doppler ultrasonography. Use of these technologies varies by institution.

DISCUSSION

A significant proportion of these complications may be avoidable through development and testing of standardized protocols to incorporate monitoring technologies and specific technical practices, teamwork and communication, and concentrated volume and specialization. Collaborative monitoring and evaluation of such protocols are likely necessary for the advancement of open cerebrovascular neurosurgical quality.

Postoperative complications in the oldest old gastric cancer patients

BACKGROUND

With the aging of the population, the number of elderly patients with gastric cancer is anticipated to increase. This study evaluated the feasibility of gastrectomy for patients over 85 years old.

METHODS

A total of 176 patients who underwent gastrectomy for gastric cancer were assigned into two groups: 75-84 years group (n = 152); and ≥85 years group (n = 24). Preoperative comorbidities, operative results, and postoperative outcomes were retrospectively analyzed.

RESULTS

In terms of concurrent illness, no significant differences were observed between groups. Preoperative lymphocyte (Lym) count, hemoglobin (Hb) level and serum albumin (Alb) levels were significantly lower in the ≥85 years group than in the 75-84 years group (Lym: 11.0 ± 2.2 × 10²/mm³ vs. 14.9 ± 3.2 × 10²/mm³, P = 0.0009; Hb: 11.2 ± 2.3 mg/dl vs. 12.4 ± 1.5 mg/dl, P = 0.038; Alb: 3.5 ± 0.5 mg/dl vs. 4.1 ± 0.3 mg/dl, P = 0.0006, respectively). Percent vital capacity was likewise lower in the ≥85 years group than in the 75-84 years group (86.2 ± 11.4% vs. 96.1 ± 12.2%, P = 0.04). Percentage forced expiratory volume in 1 s showed no significant difference. Incidence of postoperative pneumonia was higher in the ≥85 years group than in the 75-84 years group (P = 0.006). Time to first flatus and postoperative hospital stay were similar in both groups.

CONCLUSION

Patients over 85 years old are more likely to suffer postoperative pneumonia after gastrectomy than younger old patients. Preoperative risk assessment is essential for the oldest old patients.

Distance bias and surgical outcomes

BACKGROUND

A body of research has found that patients who travel a significant distance to obtain medical treatment experience better outcomes, a phenomenon termed "distance bias." This study uses risk-adjusted surgical outcomes data to analyze distance bias in a population of patients treated surgically at a tertiary care institution.

METHODS

We used risk-adjusted surgical outcomes data from the National Surgical Quality Improvement Project at the Mayo Clinic to calculate observed and expected risk of a severe complication. Operations were stratified into quintiles based on the distance traveled by the patient.

RESULTS

The average age of patients in our cohort was 56.7 years, and 59.2% were female; patients traveled an average of 226 miles for treatment. Patients living closest to the Mayo Clinic (quintile 1) had lower observed and expected risks of a severe complication relative to patients in quintiles 2-5. Patients from quintile 1 had outcomes which were better than predicted [observed:expected risk ratio of 0.82 (range, 0.63-0.99)]. Patients traveling intermediate distances (quintile 2) had outcomes which were worse than predicted [observed:expected risk ratio of 1.18 (range, 1.00-1.42)]. Operations performed on patients from greater distances (quintiles 3-5) had an observed risk of severe complications which was similar to expected.

DISCUSSION

The phenomenon of distance bias which has previously been documented in medical and oncologic treatment is not demonstrated in this study. An opposite phenomenon may be more pertinent, where patients who are treated locally are less likely to have a severe complication and have outcomes which are better than predicted.

Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: a multivariate analysis of 13,082 patients?

BACKGROUND

There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes.

METHODS

Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL).

RESULTS

A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes.

CONCLUSIONS

Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.

Predictors and costs of surgical site infections in patients with endometrial cancer

OBJECTIVE

Technological advances in surgical management of endometrial cancer (EC) may allow for novel risk modification in surgical site infection (SSI).

METHODS

Perioperative variables were abstracted from EC cases surgically staged between January 1, 1999, and December 31, 2008. Primary outcome was SSI, as defined by American College of Surgeons National Surgical Quality Improvement Program. Counseling and global models were built to assess perioperative predictors of superficial incisional SSI and organ/space SSI. Thirty-day cost of SSI was calculated.

RESULTS

Among 1369 EC patients, 136 (9.9%) had SSI. In the counseling model, significant predictors of superficial incisional SSI were obesity, American Society of Anesthesiologists (ASA) score >2, preoperative anemia (hematocrit <36%), and laparotomy. In the global model, significant predictors of superficial incisional SSI were obesity, ASA score >2, smoking, laparotomy, and intraoperative transfusion. Counseling model predictors of organ/space SSI were older age, smoking, preoperative glucose >110 mg/dL, and prior methicillin-resistant Staphylococcus aureus (MRSA) infection. Global predictors of organ/space SSI were older age, smoking, vascular disease, prior MRSA infection, greater estimated blood loss, and lymphadenectomy or bowel resection. SSI resulted in a $5447 median increase in 30-day cost.

CONCLUSIONS

Our findings are useful to individualize preoperative risk counseling. Hyperglycemia and smoking are modifiable, and minimally invasive surgical approaches should be the preferred surgical route because they decrease SSI events. Judicious use of lymphadenectomy may decrease SSI. Thirty-day postoperative costs are considerably increased when SSI occurs.

How to Link outcomes data to quality initiatives in plastic surgery?

In recent decades, the expansion of health services research has created an opportunity to crate salient, evidence-based guidelines for diagnosis, treatment, and prognosis. However, for many aspects of care, incorporation of new scientific knowledge into clinical practice often lags, particularly among the surgical subspecialties. This article highlights the development of evidence-based medicine, the principles of innovation diffusion, and successes and challenges in developing plastic surgery quality initiatives.

A multi-institutional perspective of complication rates for elective nonreconstructive breast surgery: an analysis of NSQIP data from 2006 to 2010

BACKGROUND

As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications.

OBJECTIVE

The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery.

METHODS

Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications.

RESULTS

Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%).

CONCLUSIONS

Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

The Differential Effects of Intermediate Complications with Postoperative Mortality

Most attempts at understanding perioperative mortality have been based on assessing individual patient risk factors, types of operations, and hospital characteristics. The hypothesis of this study is that there is a relationship between postoperative mortality and postoperative complications; therefore, understanding this relationship may provide a basis for prevention and rescue. Using the 2007 SemiAnnual National Surgical Quality Improvement Program Report, we obtained data for each reporting hospital's rates of observed mortality, overall observed morbidity, observed cardiac, respiratory, renal complications, venothromboemoblic events (VTEs), surgical site infections (SSIs), and urinary tract infections (UTIs). Simple and multiple linear regression analyses were done comparing absolute rate of observed mortality with absolute rate of observed morbidity and each morbidity group. One hundred ninety-seven hospitals were included in the study. There were statistically significant associations between observed mortality rates and observed morbidity rates, cardiac complications, respiratory complications, and VTE rates. Renal complications, SSIs, and UTIs showed no statistically significant association with observed morbidity. This study demonstrates that rates of observed morbidity, especially cardiac, respiratory, and VTE complications, are associated with observed mortality. These findings suggest that care providers should focus efforts at prevention and rescue of cardiac, respiratory, and VTE complications.

An Overview of Administrative and National Survey Databases for Use in Otolaryngology Research

An emerging focus on measurement and reporting of health care quality indicators calls for a sound evidence base that otolaryngologists can use to support clinical care decisions. In addition to traditional clinical trials, practitioners are heeding results of high-quality comparative-effectiveness and health services research analyses to better understand the complexity of disease epidemiology, care variation, health care costs, and surgical utilization for common conditions. Many national publicly available data sources exist for use in clinical research that may be of benefit for the academic and clinical otolaryngologist. The strength and value of these sources vary depending on the intended use or research question. The purpose of this commentary is to introduce and provide an overview of some major national and administrative databases, highlight potential strengths and limitations of these data, and suggest applications for use in advancing the care of our patients in otolaryngology.

Postoperative surgical site infections after ventral/incisional hernia repair: a comparison of open and laparoscopic outcomes

BACKGROUND

The purpose of this study was to compare the incidence of postoperative surgical site infections (SSIs), operative times (OTs), and length of hospital stay (LOS) after open and laparoscopic ventral/incisional hernia repair (VIHR) using multicenter, prospectively collected data.

METHODS

The incidence of postoperative SSIs, OTs, and LOS was determined for cases of VIHR in the American College of Surgeons' National Surgical Quality Improvement Program database in 2009 and 2010. Open and laparoscopic techniques were compared using a propensity score model to adjust for differences in patient demographics, characteristics, comorbidities, and laboratory values.

RESULTS

A total of 26,766 cases met the inclusion criteria; 21,463 cases were open procedures (reducible, n = 15,520 [72 %]; incarcerated/strangulated, n = 5,943 [28 %]), and 5,303 cases were laparoscopic procedures (reducible, n = 3,883 [73 %]; incarcerated/strangulated, n = 1,420 [27 %]). Propensity score adjusted odds ratios (ORs) were significantly different between open and laparoscopic VIHR for reducible and incarcerated/strangulated hernias with regard to superficial SSI (OR 5.5, p < 0.01 and OR 3.1, p < 0.01, respectively), deep SSI (OR 6.9, p < 0.01, and OR 8.0, p < 0.01, respectively) and wound disruption (OR 4.6, p < 0.01 and OR 9.3, p = 0.03, respectively). The risk for organ/space SSI was significantly greater for open operations among reducible hernias (OR 1.9, p = 0.02), but there was no significant difference between the open and laparoscopic repair groups for incarcerated/strangulated hernias (OR 0.8, p = 0.41). The OT was significantly longer for laparoscopic procedures, both for reducible (98.5 vs. 84.9 min, p < 0.01) and incarcerated/strangulated hernias (96.4 vs. 81.2 min, p < 0.01). LOS (mean, 95 % confidence interval) was significantly longer for open repairs for both reducible (open = 2.79, 2.59-3.00; laparoscopic = 2.39, 2.20-2.60; p < 0.01) and incarcerated/strangulated (open = 2.64, 2.55-2.73; laparoscopic = 2.17, 2.02-2.33; p < 0.01) hernias.

CONCLUSIONS

Laparoscopic VIHR for reducible and incarcerated/strangulated hernias is associated with shorter LOS and decreased risk for superficial SSI, deep SSI, and wound disruption, but longer OTs when compared to open repair.

Classic Whipple versus pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP

BACKGROUND

The classic Whipple operation carries substantial risk of complications. A pylorus-preserving pancreaticoduodenectomy might confer the benefit of decreased perioperative morbidity, but existing data comparing both techniques are inconclusive.

METHODS

Using a propensity score model to adjust for potentially confounding differences in patient characteristics, 30-d mortality, operative time, red blood cell transfusion requirements, major complications, and length of hospital stay were compared between both techniques in the American College of Surgeons' National Surgical Quality Improvement Program database. Separate analyses were carried out for underlying malignancy or benign disease, as defined by International Classification of Diseases, Ninth Revision codes.

RESULTS

A total of 6988 pancreaticoduodenectomies from 2005 through 2010 were included. In 5424 patients (77.6%) with underlying malignancy, there were no significant differences for 30-d mortality (2.4% versus 2.8%, P = 0.33) and major organ system complications (all P > 0.10). Patients undergoing the classic Whipple operation had a significantly longer operative time (389 versus 366 min, P < 0.01), longer length of hospital stay (13.1 versus 12.0 days, P < 0.01), and higher red blood cell transfusion requirements (1.0 versus 0.8 units, P < 0.01). Results were similar for 1564 patients (22.4%) with underlying benign disease, except for a higher occurrence of postoperative pulmonary (P = 0.02) and renal (P = 0.05) complications in patients undergoing the classic Whipple operation.

CONCLUSIONS

Short-term outcomes after classic and pylorus-preserving pancreaticoduodenectomy in this large, multicenter database are excellent, without significant differences in postoperative mortality and most major organ system complications. However, small advantages in resource and blood utilization may be accomplished with the pylorus-preserving technique.

Race as a predictor of morbidity, mortality, and neurologic events after carotid endarterectomy

OBJECTIVE

Racial disparities in the outcomes of patients undergoing carotid endarterectomy (CEA) have been reported. We sought to examine the contemporary relationship between race and outcomes and to report postdischarge events after CEA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were reviewed to identify all CEAs performed from 2005 to 2010 by vascular surgeons. The influence of race on outcomes was examined. Multivariate analysis was performed using variables found to be significant on bivariate analysis. The primary outcomes were stroke and mortality. Secondary outcomes were other 30-day complications, including postdischarge events.

RESULTS

CEA was performed on 29,114 white patients (95.7%) and on 1316 black patients (4.3%); the overall stroke and mortality rates were 1.65% and 0.7%, respectively. The stroke rate was 1.6% for whites and 2.5% blacks (P = .009). The 30-day mortality rate was 0.7% for whites and 1.4% for blacks (P = .002). There was a longer operating time (P < .001) and total length of stay (P < .001), more postoperative pneumonias (P = .049), unplanned intubations (P < .001), ventilator dependence (P < .001), cardiac arrests (P < .001), bleeding requiring transfusions (P = .024), and reoperations within 30 days (P = .021) among black patients. Multivariate logistic regression modeling identified black race as an independent risk factor for 30-day mortality (odds ratio, 1.9; P = .007). Black patients also had a greater proportion of in-hospital deaths than white patients (73.7% vs 43.1%; P = .01). There was no between-group difference in the rate of postdischarge strokes. Thirty-six percent of all strokes occurred after discharge at a mean of 8.3 days, and 54.3% of deaths occurred after discharge at a mean of 11 days.

CONCLUSIONS

Black race is an independent risk factor for 30-day mortality after CEA. A significant proportion of strokes and deaths occur after discharge in both racial groups evaluated.

Validation of new readmission data in the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Hospital readmissions are gathering increasing attention as a measure of health care quality and as a cost-saving target. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) recently began collecting data related to 30-day postoperative readmissions. Our objectives were to assess the accuracy of the ACS NSQIP readmission variable by comparison with the medical record, and to evaluate the readmission variable against administrative data.

STUDY DESIGN

Readmission data captured in ACS NSQIP at a single academic institution between January and December 2011 were compared with data abstracted from the medical record and administrative data.

RESULTS

Of 1,748 cases captured in ACS NSQIP, 119 (6.8%) had an all-cause readmission event identified, and ACS NSQIP had very high agreement with chart review for identifying all-cause readmission events (κ = 0.98). For 1,110 inpatient cases successfully matched with administrative data, agreement with chart review for identifying all-cause readmissions was also very high (κ = 0.97). For identifying unplanned readmission events, ACS NSQIP had good agreement with chart review (κ = 0.67). Overall, agreement with chart review on cause of readmission was higher for ACS NSQIP (κ = 0.75) than for administrative data (κ = 0.46).

CONCLUSIONS

The ACS NSQIP accurately captured all-cause and unplanned readmission events and had good agreement with the medical record with respect to cause of readmission. Administrative data accurately captured all-cause readmissions, but could not identify unplanned readmissions and less consistently agreed with chart review on cause. The granularity of clinically collected data offers tremendous advantages for directing future quality efforts targeting surgical readmission.

Human Acellular Dermis versus Submuscular Tissue Expander Breast Reconstruction: A Multivariate Analysis of Short-Term Complications

Background

Acellular dermal matrix (ADM) allografts and their putative benefits have been increasingly described in prosthesis based breast reconstruction. There have been a myriad of analyses outlining ADM complication profiles, but few large-scale, multi-institutional studies exploring these outcomes. In this study, complication rates of acellular dermis-assisted tissue expander breast reconstruction were compared with traditional submuscular methods by evaluation of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) registry.

Methods

Patients who underwent immediate tissue expander breast reconstruction from 2006-2010 were identified using surgical procedure codes. Two hundred forty tracked variables from over 250 participating sites were extracted for patients undergoing acellular dermis-assisted versus submuscular tissue expander reconstruction. Thirty-day postoperative outcomes and captured risk factors for complications were compared between the two groups.

Results

A total of 9,159 patients underwent tissue expander breast reconstruction; 1,717 using acellular dermis and 7,442 with submuscular expander placement. Total complications and reconstruction related complications were similar in both cohorts (5.5% vs. 5.3%, P=0.68 and 4.7% vs. 4.3%, P=0.39, respectively). Multivariate logistic regression revealed body mass index and smoking as independent risk factors for reconstructive complications in both cohorts (P<0.01).

Conclusions

The NSQIP database provides large-scale, multi-institutional, independent outcomes for acellular dermis and submuscular breast reconstruction. Both thirty-day complication profiles and risk factors for post operative morbidity are similar between these two reconstructive approaches.

Quality assessment in pancreatic surgery: what might tomorrow require?

INTRODUCTION

The Institute of Medicine (IOM) defines healthcare quality across six domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability. We asked experts in pancreatic surgery (PS) whether improved quality metrics are needed, and how they could align to contemporary IOM healthcare quality domains.

METHODS

We created and distributed a web-based survey to pancreatic surgeons. Respondents ranked 62 proposed PS quality metrics on level of importance (LoI) and aligned each metric to one or more IOM quality domains (multi-domain alignment (MDA)). LoI and MDA scores for a given quality metric were averaged together to render a total quality score (TQS) normalized to a 100-point scale.

RESULTS

One hundred six surgeons (21 %) completed the survey. Ninety percent of respondents indicated a definite or probable need for improved quality metrics in PS. Metrics related to mortality, to rates and severity of complications, and to access to multidisciplinary services had the highest TQS. Metrics related to patient satisfaction, costs, and patient demographics had the lowest TQS. The least represented IOM domains were equitability, efficiency, and patient-centeredness.

CONCLUSIONS

Experts in pancreatic surgery have significant consensus on 12 proposed metrics of quality that they view as both highly important and aligned with more than one IOM healthcare quality domain.

American College of Surgeons National Surgical Quality Improvement Program Pediatric: a beta phase report

PURPOSE

The American College of Surgeons (ACS) National Surgical Quality Improvement Program Pediatric (NSQIP-P) expanded to beta phase testing with the enrollment of 29 institutions. Data collection and analysis were aimed at program refinement and development of risk-adjusted models for inter-institutional comparisons.

METHODS

Data from the first full year of beta-phase NSQIP-P were analyzed. Patient accrual used ACS-NSQIP methodology tailored to pediatric specialties. Preliminary risk adjusted modeling for all pediatric and neonatal operations and pediatric (excluding neonatal) abdominal operations was performed for all cause morbidity (other than death) and surgical site infections (SSI) using hierarchical logistic regression methodology and eight predictor variables. Results were expressed as odds ratios with 95% confidence intervals.

RESULTS

During calendar year 2010, 29 institutions enrolled 37,141 patients. 1644 total CPT codes were entered, of which 456 accounted for 90% of the cases. 450 codes were entered only once (1.2% of cases). For all cases, overall mortality was 0.25%, overall morbidity 7.9%, and the SSI rate 1.8%. For neonatal cases, mortality was 2.39%, morbidity 18.7%, and the SSI rate 3%. For the all operations model, risk-adjusted morbidity institutional odds ratios ranged 0.48-2.63, with 9/29 hospitals categorized as low outliers and 9/29 high outliers, while risk-adjusted SSI institutional odds ratios ranged 0.36-2.04, with 2/29 hospitals low outliers and 7/29 high outliers.

CONCLUSION

This report represents the first risk-adjusted hospital-level comparison of surgical outcomes in infants and children using NSQIP-P data. Programmatic and analytic modifications will improve the impact of this program as it moves into full implementation. These results indicate that NSQIP-P has the potential to serve as a model for determining risk-adjusted outcomes in the neonatal and pediatric population with the goal of developing quality improvement initiatives for the surgical care of children.

Rheumatoid arthritis patients are not at increased risk for 30-day cardiovascular events, infections, or mortality after total joint arthroplasty

INTRODUCTION

Serious infection, cardiovascular disease, and mortality are increased in rheumatoid arthritis (RA). Whether RA affects the risk for these complications after total joint arthroplasty (TJA) is unknown, we hypothesize that it does. We compared the occurrence of 30-day postoperative complications and mortality in a large cohort of RA and osteoarthritis (OA) patients undergoing hip or knee TJA.

METHODS

Analyses included 7-year data from the Veterans Affairs Surgical Quality Improvement Program. The 30-day complications were compared by diagnosis by using logistic regression, and long-term mortality was examined by using Cox proportional hazards regression. All analyses were adjusted for age, sex, and clustering by surgical site. Additional covariates included sociodemographics, comorbidities, health behaviors, and operative risk factors.

RESULTS

The 34,524 patients (839 RA, 33,685 OA) underwent knee (65.9%) or hip TJA. Patients were 95.7% men with a mean (SD) age of 64.4 (10.7) years and had 3,764 deaths over a mean follow-up of 3.7 (2.3) years. Compared with OA patients, those with RA were significantly more likely to require a return to the operating room (odds ratio (OR), 1.45 (95% CI, 1.08 to 1.94), but had similar rates of 30-day postoperative infection, OR 1.02 (0.72 to 1.47), cardiovascular events, OR 0.69 (0.37 to 1.28), and mortality, OR 0.94 (0.38 to 2.33). RA was associated with a significantly higher long-term mortality; hazard ratio (HR), 1.22 (1.00 to 1.49).

CONCLUSION

In this study of US veterans, RA patients were not at an increased risk for short-term mortality or other major complications after TJA, although they returned to the operating room more often and had increased long-term mortality.

Safety of surgical resident training

The current structure of residency training allows for safe participation of residents in the care of surgical patients. In part, this is likely due to the ability of attending-level surgeons and educators to adequately select and provide the supervision needed for different levels of residents. Nonetheless, efforts have to be made to ensure the optimal safety of patients in several settings of modern health care. For laparoscopic surgery, training and simulation are highly advisable in preparing residents to perform well in the early stage of their learning curves. Attention has to be given to safe and complete hand-offs, especially with the increased focus on restricting work hours and the increased number of changing shifts. Measures to ensure optimal preparation of surgical residents to perform well in stressful situations should also be taken, because such situations are an intrinsic part of this specialty. It is only by focusing on all these aspects that we can ensure the safety for our patients and provide the best possible training for the next generation of surgeons.

Variability in spinal surgery outcomes among children's hospitals in the United States

BACKGROUND

We performed a retrospective cohort study of 7637 spinal fusion surgical cases from 2004 to 2006 at 38 children's hospitals participating in the Pediatric Health Information System database to evaluate the variability of in-hospital outcomes by patient factors and between facilities in children who underwent spinal surgery.

METHODS

Outcomes were stratified by whether children did or did not have neurological impairment. Multilevel multivariate logistic regression models were used to determine patient and hospital factors associated with in-hospital infections, surgical complications, and length of stay (LOS)≥10 days.

RESULTS

Neurologically impaired (NI) children (N=2117 out of 7637) represented 28% of the cases. The interhospital interquartile range of LOS for NI children was 6 to 8 days (median 7 d) and for non-neurologically impaired (NNI) children was 5 to 6 days (median 5 d). Children with NI had roughly 6 times higher rates of in-hospital infection and 3 times higher complication rates: major interhospital variation was seen for both of these outcomes. Hospital rates of infection ranged from 0% to 27% (median 10%) for NI and from 0% to 14% (median 2%) for NNI children. Complication rates ranged from 0% to 89% (median 33%) for NI and from 3% to 68% (median 9%) for NNI children. The following factors were associated with a LOS≥10 days: in-hospital infection (P<0.0001), surgical complication (P<0.0001), and anterior/posterior versus posterior-only surgery (P<0.0001). Hospital case volume was not associated with infection, surgical complication, or LOS≥10 days.

CONCLUSIONS

Substantial variation exists in reported outcomes for children undergoing spinal surgery in children's hospitals within the United States. Further study is needed to characterize hospital-level factors related to surgical outcome to direct future quality improvement.

The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source.

METHODS

A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities.

RESULTS

3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22-3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05-1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team.

CONCLUSIONS

Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

Brief history of quality movement in US healthcare

The current healthcare quality improvement infrastructure is a product of a century long experience of cumulative efforts. It began with an acknowledgement of the role of quality in healthcare, and gradually evolved to encompass the prioritization of quality improvement and the development of systems to monitor, quantify, and incentivize quality improvement in healthcare. We review the origins and the evolution of the US healthcare quality movement, identify existing initiatives specific to musculoskeletal care, outline significant challenges and opportunities, and propose recommendations for the future. Elements noted to be associated with successful healthcare quality improvement efforts include the presence of physician leadership, infrastructural support, and prioritization of healthcare quality within the culture of the organization. Issues that will require continued work include the development of a valid and reliable evidence base, accurate and replicable performance measurement and data collection methods, and development of a standard set of specialty specific performance metrics, with accurate provider attribution, risk adjustment and reporting mechanisms.

Blood transfusion and cancer surgery outcomes: a continued reason for concern

BACKGROUND

The adverse effects of blood transfusion after cancer surgery have been recently challenged in older anemic persons or those with substantial intraoperative blood loss. We hypothesized that intraoperative blood transfusions continue to adversely impact short-term cancer surgery outcomes regardless of age or preoperative hematocrit levels.

METHODS

Using the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program, we identified 38,926 patients who underwent cancer surgery. Pre-, intra-, and postoperative factors were compared by units of blood transfusion a patient received. Stratified multivariable analyses, by age and hematocrit level, were performed to assess the impact of blood transfusion on operative outcomes, adjusting for covariates.

RESULTS

Fourteen percent of patients received an intraoperative blood transfusion. Of those, >60% received only 1 to 2 units of blood. Receipt of intraoperative blood transfusion was associated with higher rates of 30-day operative mortality, major complications, total number of complications, and prolonged length of stay across age groups and in persons with low to normal hematocrit levels.

CONCLUSION

The present study shows that intraoperative blood transfusion adversely impacts short-term operative cancer surgery outcomes across all age groups and in those with low to normal hematocrit levels. These findings provide insightful implications on the patterns of blood transfusion during cancer surgery that deserve further investigation.

Patient-specific surgical outcomes assessment using population-based data analysis for risk model development

Optimal surgical planning and decision making surrounding surgical interventions requires patient-specific risk assessment which incorporates patient pre-operative clinical assessment and clinical literature. In this paper, we utilized population-based data analysis to construct surgical outcome predictive models for spinal fusion surgery using hospital, patient and admission characteristics. We analyzed population data from the Nationwide Inpatient Sample (NIS) -a nationally representative database- to identify data elements affecting inpatient mortality, length of stay, and disposition status for patients receiving spinal fusion surgery in the years 2004-2008. In addition to outcomes assessment, we want to make the analytic model results available to clinicians and researchers for pre-operative surgical risk assessment, hospital resource allocation, and hypothesis generation for future research without an individual patient data management burden. Spinal fusion was the selected prototype procedure due to it being a high volume and typically inpatient procedure where patient risk factors will likely affect clinical outcomes.

Quantifying surgical complexity through textual descriptions of current procedural terminology codes

Models for surgical complications are a requirement for evaluating patients by the bedside or for risk-adjusted quality and outcomes assessment of healthcare providers. Developing such models requires quantifying the complexities of surgical procedures. Existing approaches to quantify procedural complexity rely on coding system generalities or factors designed for reimbursement. These approaches measure complexity of surgical procedures through the time taken for the procedures or their correspondence to rough anatomical ranges. We address this limitation through a novel approach that provides a fine-grained estimate of individual procedural complexity by studying textual descriptions of current procedure terminology (CPT) codes associated with these procedures. We show that such an approach can provide superior assessment of procedural complexity when compared to currently used estimates. This text-based score can improve surgical risk adjustment even after accounting for a large array of patient factors, indicating the potential to improve quality assessment of surgical care providers.

Defining, measuring, and improving surgical quality: beyond teamwork and checklists to systems redesign and transformation

BACKGROUND

Surgical complications are multifactorial but often are attributable to deficiencies in the quality of care. This review examines how quality is defined in surgery, the modalities employed to measure quality, and the approaches to improving the quality of surgical care. Beyond developing a hospital environment supportive of organizational learning, the next generation of surgical performance improvement will include broader, more innovative approaches. These ideas will create partnerships among patients, clinicians, industry, the arts, hospital leaders, and other sectors to look for ways to reinvent the system rather than simply to make a better hospital.

METHODS

Review of pertinent English-language literature on surgical quality, definitions of quality, quality measures, performance improvement, and organizational learning in health care.

RESULTS

Medical care should be safe, effective, patient-centered, timely, efficient, and equitable, as defined by the Institute of Medicine core values for health care quality. There is substantive lack of agreement as to how to measure the quality of care. Although the goal of each measurement system is to give patients the ability to compare hospitals nationally, most of the methodologies measure widely different aspects of hospital care, resulting in conflicting illustrations of institutional performance and confounded decision making for patients and for purchasers of healthcare services and insurance.

CONCLUSIONS

The best pathway for surgical quality and performance improvement includes the application of systems engineering and innovation to determine ways to do better what we do currently, and to improve the present system while developing ideas for better delivery of high-quality care in the future.

Patterns in neurosurgical adverse events: intracranial neoplasm surgery

Object

Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to measuring and improving outcomes. As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in cranial tumor resection concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.

Methods

The authors performed a PubMed search using search terms “intracranial neoplasm,” “cerebral tumor,” “cerebral meningioma,” “glioma,” and “complications” or “adverse events.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to maximize the range of rates of occurrence for the reported adverse events.

Results

Review of the tumor neurosurgery literature showed that documented overall complication rates ranged from 9% to 40%, with overall mortality rates of 1.5%–16%. There was a wide range of types of adverse events overall. Deep venous thromboembolism (DVT) was the most common adverse event, with a reported incidence of 3%–26%. The presence of new or worsened neurological deficit was the second most common adverse event found in this review, with reported rates ranging from 0% for the series of meningioma cases with the lowest reported rate to 20% as the highest reported rate for treatment of eloquent glioma. Benign tumor recurrence was found to be a commonly reported adverse event following surgery for intracranial neoplasms. Rates varied depending on tumor type, tumor location, patient demographics, surgical technique, the surgeon's level of experience, degree of specialization, and changes in technology, but these effects remain unmeasured. The incidence on our review ranged from 2% for convexity meningiomas to 36% for basal meningiomas. Other relatively common complications were dural closure–related complications (1%–24%), postoperative peritumoral edema (2%–10%), early postoperative seizure (1%–12%), medical complications (6%–7%), wound infection (0%–4%), surgery-related hematoma (1%–2%), and wrong-site surgery.

Strategies to minimize risk of these events were evaluated. Prophylactic techniques for DVT have been widely demonstrated and confirmed, but adherence remains unstudied. The use of image guidance, intraoperative functional mapping, and real-time intraoperative MRI guidance can allow surgeons to maximize resection while preserving neurological function. Whether the extent of resection significantly correlates with improved overall outcomes remains controversial.

Discussion

A significant proportion of adverse events in intracranial neoplasm surgery may be avoidable by use of practices to encourage use of standardized protocols for DVT, seizure, and infection prophylaxis; intraoperative navigation among other steps; improved teamwork and communication; and concentrated volume and specialization. Systematic efforts to bundle such strategies may significantly improve patient outcomes.

Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery

Object

As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality.

Methods

The authors performed a PubMed search using search terms “cerebral shunt,” “cerebrospinal fluid shunt,” “CSF shunt,” “ventriculoperitoneal shunt,” “cerebral shunt AND complications,” “cerebrospinal fluid shunt AND complications,” “CSF shunt AND complications,” and “ventriculoperitoneal shunt AND complications.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported.

Results

In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36–0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half.

Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation.

Conclusions

Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.

Patterns in neurosurgical adverse events and proposed strategies for reduction

Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery.

They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems.

On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementation of a national registry for outcome data and monitoring; 2) full integration of the WHO Surgical Safety Checklist into the operating room workflow, which improves fundamental aspects of surgical care such as adherence to antibiotic protocols and communication within surgical teams; and 3–5) activity by neurosurgical societies to drive increased standardization for the safety of specialized equipment used by neurosurgeons (3), more widespread regionalization and/or subspecialization (4), and establishment of data-driven guidelines and protocols (5). The fraction of adverse events that might be avoided if proposed strategies to improve practice and decrease variability are fully adopted remains to be determined. The authors hope that this consolidation of what is currently known and practiced in neurosurgery, the application of relevant advances in other fields, and attention to proposed strategies will serve as a basis for informed and concerted efforts to improve outcomes and patient safety in neurosurgery.

Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections

BACKGROUND

Surgical site infection is a major cause of morbidity after colorectal resections. Despite evidence that preoperative oral antibiotics with mechanical bowel preparation reduce surgical site infection rates, the use of oral antibiotics is decreasing. Currently, the administration of oral antibiotics is controversial and considered ineffective without mechanical bowel preparation.

OBJECTIVE

The aim of this study is to examine the use of mechanical bowel preparation and oral antibiotics and their relationship to surgical site infection rates in a colorectal Surgical Care Improvement Project cohort.

DESIGN

This retrospective study used Veterans Affairs Surgical Quality Improvement Program preoperative risk and surgical site infection outcome data linked to Veterans Affairs Surgical Care Improvement Project and Pharmacy Benefits Management data. Univariate and multivariable models were performed to identify factors associated with surgical site infection within 30 days of surgery.

SETTINGS

This study was conducted in 112 Veterans Affairs hospitals.

PATIENTS

Included were 9940 patients who underwent elective colorectal resections from 2005 to 2009.

MAIN OUTCOME MEASURE

The primary outcome measured was the incidence of surgical site infection.

RESULTS

Patients receiving oral antibiotics had significantly lower surgical site infection rates. Those receiving no bowel preparation had similar surgical site infection rates to those who had mechanical bowel preparation only (18.1% vs 20%). Those receiving oral antibiotics alone had an surgical site infection rate of 8.3%, and those receiving oral antibiotics plus mechanical bowel preparation had a rate of 9.2%. In adjusted analysis, the use of oral antibiotics alone was associated with a 67% decrease in surgical site infection occurrence (OR=0.33, 95% CI 0.21-0.50). Oral antibiotics plus mechanical bowel preparation was associated with a 57% decrease in surgical site infection occurrence (OR=0.43, 95% CI 0.34-0.55). Timely administration of parenteral antibiotics (Surgical Care Improvement Project-1) had a modest protective effect, with no effect observed for other Surgical Care Improvement Project measures. Hospitals with higher rates of oral antibiotics use had lower surgical site infection rates (R = 0.274, p < 0.0001).

LIMITATIONS

Determination of the use of oral antibiotics and mechanical bowel preparation is based on retrospective prescription data, and timing of actual administration cannot be determined.

CONCLUSIONS

Use and type of preoperative bowel preparation varied widely. These results strongly suggest that preoperative oral antibiotics should be administered for elective colorectal resections. The role of oral antibiotics independent of mechanical bowel preparation should be examined in a prospective randomized trial.

Patterns in neurosurgical adverse events: endovascular neurosurgery

As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in endovascular neurosurgery concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.

Based on a review of the literature, thromboembolic events appeared to be the most common adverse events in endovascular neurosurgery, with a reported incidence ranging from 2% to 61% depending on aneurysm rupture status and mode of detection of the event. Intraprocedural and periprocedural prevention and rescue regimens are advocated to minimize this risk; however, evidence on the optimal use of anticoagulant and antithrombotic agents is limited. Furthermore, it is unknown what proportion of eligible patients receive any prophylactic treatment.

Groin-site hematoma is the most common access-related complication. Data from the cardiac literature indicate an overall incidence of 9% to 32%, but data specific to neuroendovascular therapy are scant. Manual compression, compression adjuncts, and closure devices are used with varying rates of success, but no standardized protocols have been tested on a broad scale. Contrast-induced nephropathy is one of the more common causes of hospital-acquired renal insufficiency, with an incidence of 30% in high-risk patients after contrast administration. Evidence from medical fields supports the use of various preventive strategies.

Intraprocedural vessel rupture is infrequent, with the reported incidence ranging from 1% to 9%, but it is potentially devastating. Improvements in device technology combined with proper endovascular technique play an important role in reducing this risk.

Occasionally, anatomical or technical difficulties preclude treatment of the lesion of interest. Reports of such occurrences are scant, but existing series suggest an incidence of 4% to 6%. Management strategies for radiation-induced effects are also discussed. The incidence rates are unknown, but protective techniques have been demonstrated.

Many of these complications have strategies that appear effective in reducing their risk of occurrence, but development and evaluation of systematic guidelines and protocols have been widely lacking. Furthermore, there has been little monitoring of levels of adherence to potentially effective practices. Protocols and monitoring programs to support integrated implementation may be broadly effective.

Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down?

OBJECTIVE

The time it takes to complete an operation is important. Operating room (OR) time is costly and directly associated with infectious complications and length of stay. Intuitively, procedures take longer when a surgical resident is operating. How much extra time should we take to train residents? We examined the relationship between laparoscopic inguinal hernia repair (IHR) procedure duration and resident participation and its impact on the development of complications and hospital stay.

METHODS

Data from patients undergoing laparoscopic IHR in participating institutions of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2007 to 2009 were retrospectively reviewed. Patients with current procedural terminology (CPT) codes 49650 and 49651 (laparoscopic initial and recurrent IHR) comprised our patient cohort. Participation of staff surgeon and resident postgraduate year level (PGY) were used as the main predictors for operative outcomes.

RESULTS

A total of 6223 patients underwent laparoscopic IHR as their main procedure with no additional or concurrent procedures; 92% were men, 21% of the repairs were bilateral. In total, there were 98 patients with at least 1 complication (1.6%). Resident involvement was present in 3565 cases (57%) broken down by PGY1: 12%, PGY2: 12%, PGY3: 21%, PGY4: 19%, PGY5 or above: 36%. Median operative time was 45 minutes for staff surgeons alone and 64 minutes when there was a resident present (p < 0.001). PGY level predicted operative duration: higher PGY levels correlated with greater operative times (PGY1 median time 58 min vs PGY ≥ 5 = 67 min, p < 0.001). Resident participation was not a significant predictor for the development of complications (p = 0.30).

CONCLUSIONS

Laparoscopic IHR is performed faster by staff surgeons without residents. There was no difference in the complication rate when residents were involved. Teaching and mentoring residents in the OR for laparoscopic IHR is safe and laudable.

The power of the National Surgical Quality Improvement Program--achieving a zero pneumonia rate in general surgery patients

The National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons provides risk-adjusted surgical outcome measures for participating hospitals that can be used for performance improvement of surgical mortality and morbidity. A surgical clinical nurse reviewer collects 135 clinical variables including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures. A report on mortality and complications is prepared twice a year. This article summarizes briefly the history of NSQIP and how its report on surgical outcomes can be used for performance improvement within a hospital system. In particular, it describes how to drive performance improvement with NSQIP data using the example of postoperative respiratory complications--a major factor of postoperative mortality. In addition, this article explains the benefit of a collaborative of several participating NSQIP hospitals and describes how to develop a "playbook" on the basis of an outcome improvement project.

Risk stratification of serious adverse events after gastric bypass in the Bariatric Outcomes Longitudinal Database

BACKGROUND

There is now sufficient demand for bariatric surgery to compare bariatric surgeons and bariatric centers according to their postsurgical outcomes, but few validated risk stratification measures are available to enable valid comparisons. The purpose of this study was to develop and validate a risk stratification model of composite adverse events related to Roux-en-Y gastric bypass (RYGB) surgery.

METHODS

The study population included 36,254 patients from the Bariatric Outcomes Longitudinal Database (BOLD) registry who were 18-70 years old and had RYGB between June 11, 2007, and December 2, 2009. This population was randomly divided into a 50% testing sample and a 50% validation sample. The testing sample was used to identify significant predictors of 90-day composite adverse events and estimate odds ratios, while the validation sample was used to assess model calibration. After validating the fit of the risk stratification model, the testing and validation samples were combined to estimate the final odds ratios.

RESULTS

The 90-day composite adverse event rate was 1.48%. The risk stratification model of 90-day composite adverse events included age (40-64, ≥ 65), indicators for male gender, body mass index (50-59.9, ≥ 60), obesity hypoventilation syndrome, back pain, diabetes, pulmonary hypertension, ischemic heart disease, functional status, and American Society of Anesthesiology classes 4 or 5. Our final gastric bypass model was predictive (c-statistic = .68) of serious adverse events 90 days after surgery.

CONCLUSIONS

With additional validation, this risk model can inform both the patient and surgeon about the risks of bariatric surgery and its different procedures, as well as enable valid outcomes comparisons between surgeons and surgical programs.

Laparoscopy impacts outcomes favorably following colectomy for ulcerative colitis: a critical analysis of the ACS-NSQIP database

INTRODUCTION

The surgical management of ulcerative colitis (UC) often involves complex operations. We investigated the outcome of patients who underwent surgery for UC by analyzing a nationwide database.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005-2008) for all UC patients who underwent colectomy. To analyze by operation, groupings included: partial colectomy (PC; n = 265), total abdominal colectomy (TAC; n = 232), total proctocolectomy with ileostomy (TPC-I; n = 134), and total proctocolectomy with ileal pouch-anal anastomosis (IPAA; n = 446) to analyze 30-day outcomes.

RESULTS

From 1,077 patients (mean age, 44 years; 45 % female; 7 % emergent), a laparoscopic approach was used in 29.2 %, with rates increasing 8.5 % each year (18.5 % in 2005 to 41.3 % in 2008, P < 0.001). Complications occurred in 29 %, and laparoscopy was associated with a lower complication rate (21 vs. 32 % open, P < 0.001). On multivariate regression, postoperative complications increased when patients were not functionally independent [odds ratio (OR) = 3.2], had preoperative sepsis (OR = 2.0), or prior percutaneous coronary intervention (OR = 2.8). A laparoscopic approach was associated with a lower complication rate (OR = 0.63). When stratified by specific complications, laparoscopy was associated with lower complications, including superficial surgical site infections (11.4 vs. 6.7 %, P = 0.0011), pneumonia (2.9 vs. 0.6 %, P = 0.023), prolonged mechanical ventilation (3.9 vs. 1.3 %, P = 0.023), need for transfusions postoperatively (1.6 vs. 0 %, P = 0.016), and severe sepsis (2.9 vs. 1.0 %, P = 0.039). Laparoscopy was also was associated with a lower complication rate in TACs (41.7 vs. 18.8 %, P < 0.0001) and IPAA (29.9 vs. 18.2 %, P = 0.005) and had an overall lower mortality rate (0.2 vs. 1.7 %, P = 0.046).

CONCLUSIONS

Results from a large nationwide database demonstrate that a laparoscopic approach was utilized in an increasing number of UC patients undergoing colectomy and was associated with lower morbidity and mortality, even in more complex procedures, such as TAC and IPAA.

Poor survival for veterans with pathologic stage I non-small-cell lung cancer

BACKGROUND

Pathologic stage (pStage) IA and IB non-small-cell lung cancer (NSCLC) has a median survival time of 119 and 81 months, respectively. We describe the outcomes of veterans with pStage I NSCLC.

METHODS

A retrospective review of 78 patients with pStage I NSCLC who underwent cancer resection was performed at the Tennessee Valley Veterans Affairs Hospital between 2005 and 2010. All-cause 30-day, 90-day, and overall mortality were determined. Survival was assessed with the Kaplan-Meier and Cox proportional hazards methods.

RESULTS

There were 55 (71%) pStage IA and 23 (29%) IB patients. Thirty- and 90-day mortality was 3.8% (3 of 78) and 6.4% (5 of 78), respectively. Median survival was 59 and 28 months for pStage 1A and 1B, respectively. Postoperative events were associated with impaired survival on multivariable analysis (hazard ratio, 1.26, P = .03).

CONCLUSIONS

Veterans with pStage I NSCLC at our institution have poorer survival than the general population. More research is needed to determine the etiology of this disparity.

Do ophthalmology training programs affect corrective procedure rates after cataract surgery?

The Veterans Health Administration (VHA) plays a major role in training surgeons in the United States. This study examined the rates of corrective procedures after routine cataract surgery stratified for VHA institutions according to the presence or absence of ophthalmology training programs. There was a wide range of rates of corrective surgeries in the 111 centers that performed cataract surgery. VHA medical centers affiliated with training programs had nearly twice the rates of corrective surgery after cataract extraction than those institutions without such programs. Variation in secondary procedure rates has implications for the development of quality improvement in ophthalmology.

Racial differences and disparities in cancer care and outcomes: where's the rub?

Despite a profusion of studies over the past several years documenting racial differences in cancer outcomes, there is a paucity of data as to the root causes underlying these observations. This article reviews work to date focusing on black-white differences in cancer outcomes, explores potential mechanisms underlying these differences, and identifies patient, physician, and health care system factors that may account for persistent racial disparities in cancer care. Research strategies to elucidate the relative influence of these various factors and policy recommendations to reduce persistent disparities are also discussed.