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

Faculty Clinical Quality Goals Drive Improvement in University HealthSystem Consortium Outcome Measures

Mortality, length of stay (LOS), patient safety indicators (PSIs), and hospital-acquired conditions (HACs) are routinely reported by the University HealthSystem Consortium (UHC) to measure quality at academic health centers. We hypothesized that a clinical quality measurable goal assigned to individual faculty members would decrease UHC measures of mortality, LOS, PSIs, and HACs. For academic year (AY) 2010–2011, faculty members received a clinical quality goal related to mortality, LOS, PSIs, and HACs. The quality metric constituted 25 per cent of each faculty member's annual evaluation clinical score, which is tied to compensation. The outcomes were compared before and after goal assignment. Outcome data on 6212 patients from AY 2009–2010 were compared with 6094 patients from AY 2010–2011. The mortality index (0.89 vs 0.93; P = 0.73) was not markedly different. However, the LOS index decreased from 1.01 to 0.97 ( P = 0.011), and department-wide PSIs decreased significantly from 285 to 162 ( P = 0.011). Likewise, HACs decreased from 54 to 18 ( P = 0.0013). Seven (17.9%) of 39 faculty had quality grades that were average or below. Quality goals assigned to individual faculty members are associated with decreased average LOS index, PSIs, and HACs. Focused, relevant quality assignments that are tied to compensation improve patient safety and outcomes.

Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data

BACKGROUND

The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma. Our study compared the surgical outcomes of patients with perforated diverticulitis who underwent a HP to primary anastomosis with proximal diversion (PAPD).

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2009 to identify all cases of perforated diverticulitis classified as contaminated or dirty/infected. Patients were stratified into HP or PAPD, and logistic regression models were created to control for patient demographics, comorbidities, perioperative risk, and illness severity to determine the impact of surgical procedure on outcome.

RESULTS

There were 2,018 patients meeting the inclusion criteria of which 340 (17%) underwent PAPD and the remainder underwent HP. Significant independent predictors of infectious outcomes were alcohol use, preoperative sepsis, and operative time. There was no significant difference in risk of infectious complications, return to the operating room, prolonged ventilator use, death, or hospital length of stay between the two procedures. When considering only dirty/infected cases, the mortality risk was twofold greater when PAPD was performed.

CONCLUSION

The treatment of acute diverticulitis in the setting of contamination can be safely treated with resection, primary anastomosis, and proximal diversion as opposed to a HP in certain circumstances. Given the decreased morbidity of subsequent loop ileostomy takedown compared with a Hartmann's reversal, this procedure should be given consideration in the management of acute, perforated diverticulitis but may not be warranted in cases of feculent peritonitis.

Should Compliance with the Surgical Care Improvement Project (SCIP) Process Measures Determine Medicare and Medicaid Reimbursement Rates?

The Surgical Care Improvement Project (SCIP) is aproject that focuses on improving surgical care by reducing surgical morbidity and mortality by 25 per cent by 2010. Starting in 2011, SCIP compliance affects Medicare and Medicaid reimbursement rates. Although SCIP reinforces better practices in surgical care, does compliance with SCIP measures actually result in a decrease in surgical morbidity and mortality? This study examined compliance with the SCIP surgical site infection (SSI) module (prophylactic antibiotic received within 1 hour before surgical incision) during 2009 to 2010 (n = 703) to determine whether patients compliant with SCIP data had a correlation with SSI rates as reported by National Surgery Quality Improvement Program (NSQIP) data for the same time period. We found no statistically significant association in patients that have failed SCIP INF1 in the years 2009 to 2010 (n = 43) and the rates of SSI (n = 0) for the same time period. These data suggest that SCIP compliance should not be used to determine Medicare and Medicaid reimbursement rates because there is no correlation between failure of SCIP INF1 and SSI. Instead, further effort should be placed on developing tools designed to acknowledge outcome measures that result in decreased morbidity/mortality and change practices accordingly such as NSQIP.

Little evidence of correlation between growth in health care spending and reduced mortality

As rapid U.S. health care spending growth continues, the question of whether additional dollars purchase better health or unnecessary care remains in sharp focus for policy makers, large employers, and other stakeholders. To investigate this question, we measured changes in mortality and cost for seven common diagnoses at 122 U.S. hospitals from 2000 to 2004. After adjusting for inflation, we found little correlation between reduced mortality for certain conditions and increased spending on patients with those conditions. The message to be underscored once again for policy makers is that health care dollars provide inconsistent value, and future spending increases should be targeted to care that improves outcomes.

Laparoscopic vs open appendectomy in obese patients: outcomes using the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Although open and laparoscopic appendectomies are comparable operations in terms of outcomes, it is unknown whether this is true in the obese patient. Our objective was to compare short-term outcomes in obese patients after laparoscopic vs open appendectomy.

STUDY DESIGN

Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2009), 13,330 obese patients (body mass index ≥ 30) who underwent an appendectomy were identified (78% laparoscopic, 22% open). The association between surgical approach (laparoscopic vs open) and outcomes was first evaluated using multivariable logistic regression. Next, to minimize the influence of treatment selection bias, we created a 1:1 matched cohort using all 41 of the preoperative covariates in the National Surgical Quality Improvement Program database. Reanalysis was then performed with the unmatched patients excluded. Main outcomes measures included patient morbidity and mortality, operating room return, operative times, and hospital length of stay.

RESULTS

Laparoscopic appendectomy was associated with a 57% reduction in overall morbidity in all the obese patients after the multivariable risk-adjusted analysis (odds ratio = 0.43; 95% CI, 0.36-0.52; p < 0.0001), and a 53% reduction in risk in the matched cohort analysis (odds ratio = 0.47; 95% CI, 0.32-0.65; p < 0.0001). Mortality rates were the same. In the matched cohort, length of stay was 1.2 days shorter for obese patients undergoing laparoscopic appendectomy compared with open appendectomy (mean difference 1.2 days; 95% CI, 0.98-1.42).

CONCLUSIONS

In obese patients, laparoscopic appendectomy had superior clinical outcomes compared with open appendectomy after accounting for preoperative risk factors.

Surgical therapy for epidermoid carcinoma of the anal canal: an NSQIP assessment of short-term outcomes

BACKGROUND

Although modern therapy for anal canal cancer typically consists of combined chemoradiation therapy (CRT), surgery remains an option for patients with small lesions, for palliative purposes, and for failure of nonoperative management. This study assesses the short-term outcomes of surgical management for epidermoid carcinoma of the anal canal using a large nationwide database.

METHODS

We performed a retrospective review of 30-d outcomes using American College of Surgeons National Surgical Quality Improvement Program database (2005-2009) for all patients with the primary diagnosis of anal canal cancer undergoing oncologic or palliative surgery. We defined preoperative CRT using standard National Surgical Quality Improvement Program time frames of 30 and 90 d, respectively, before surgery.

RESULTS

We identified 295 patients (mean age, 58.6 y; 54% female; 77% white). A total of 34 patients received prior CRT and had age, body mass index, American Society of Anesthesiologists class, and preoperative laboratory values similar to those without CRT; the only significant differences was a lower hematocrit and platelet count in the CRT group. For the entire cohort, 30% (N = 89) underwent local excision (LE), 24% (N = 71) diversion, and 46% (N = 135) abdominoperineal resection (APR). Complications occurred in 23.7% of the entire cohort, and overall complication rates significantly differed based on the type of procedure [3.4% for LE and 18.3% for diversion, versus 40% for APR (P < 0.001)]. Only operative approach significantly affected morbidity, as patients receiving APR had a 1.67-fold (range, 1.14-2.45; P = 0.008) increased risk of complications. The 30-d mortality for the entire cohort was 2.7%, and was highest in the diversion group (7%) compared with the APR (1.5%) and local excision groups (1.1%; P = 0.036). However, by multivariate analysis, the only factors associated with death were preoperative sepsis (hazard ratio [HR] = 27.5; P = 0.005), lack of functional independence (HR = 26.3; P = 0.001), hypertension (HR = 14.4; P = 0.028), and prior alcohol use (HR = 21.4; P = 0.026). Chemoradiation therapy use did not have a significant effect on complication (36.0% versus 40.9%; P = 0.651) or mortality rates (0% versus 1.8%; P = 0.497).

CONCLUSIONS

Surgical intervention for anal canal cancer remains a necessary option for select patients. Morbidity rates vary significantly based on the type of treatment; operative approach is the primary factor associated with postoperative short-term complications. When surgery is required, recent CRT is not associated with a higher complication rate. With proper perioperative care and surgical technique, mortality rates remain low, and the increased death rate with diversion, even in the short term, likely represents advanced disease.

Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly

BACKGROUND

Preoperative risk stratification is commonly performed by assessing end-organ function (such as cardiac and pulmonary) to define postoperative risk. Little is known about impaired preoperative cognition and outcomes. The purpose of this study was to evaluate the impact of baseline impaired cognition on postoperative outcomes in geriatric surgery patients.

STUDY DESIGN

Subjects 65 years and older undergoing a planned elective operation requiring postoperative ICU admission were recruited prospectively. Preoperative baseline cognition was assessed using the validated Mini-Cog test. Impaired cognition was defined as a Mini-Cog score of ≤ 3. Delirium was assessed using the Confusion Assessment Method-ICU by a trained research team. Adverse outcomes were defined using the Veterans Affairs Surgical Quality Improvement Program definitions.

RESULTS

One hundred and eighty-six subjects were included, with a mean age of 73 ± 6 years. Eighty-two subjects (44%) had baseline impaired cognition. The impaired cognition group had the following unadjusted outcomes: increased incidence of 1 or more postoperative complications (41% vs 24%; p = 0.011), higher incidence of delirium (78% vs 37%; p < 0.001), longer hospital stays (15 ± 14 vs 9 ± 9 days; p = 0.001), higher rate of discharge institutionalization (42% vs 18%; p = 0.001), and higher 6-month mortality (13% vs 5%; p = 0.040). Adjusting for potential confounders determined by univariate analysis, logistic regression found impaired cognition was still associated with the occurrence of 1 or more postoperative complications (odds ratio = 2.401; 95% CI, 1.185-4.865; p = 0.015). Kaplan-Meier survival analysis revealed higher mortality in the impaired cognition group (log-rank p = 0.008).

CONCLUSIONS

Baseline cognitive impairment in older adults undergoing major elective operations is related to adverse postoperative outcomes including increased complications, length of stay, and long-term mortality. Improved understanding of baseline cognition and surgical outcomes can aid surgical decision making in older adults.

Influence of obesity on complications and costs after intestinal surgery

BACKGROUND

Obesity is a risk factor for many comorbid conditions that increase the cost of health care. We sought to examine the effect of obesity on surgical complications and cost in a group of patients undergoing intestinal surgery.

METHODS

Using the Veterans Affairs Surgical Quality Improvement Program (VASQIP), which includes clinical data abstracted from medical records for Veterans Affairs (VA) surgical patients, and the VA Decision Support System, which provides the costs of individual patient encounters on the basis of relative values assigned to intermediate products, we examined surgical complications and costs of care in 4,881 patients undergoing intestinal surgery in 2006. Patients were classified into 4 groups based on body mass index (BMI): malnourished (<18), normal weight (18-30), obesity class I to II (30-40), and obesity class III (>40). Patient endpoints included the occurrence of any complication and surgical costs incurred within 30 days of surgery. Endpoints were compared across the 4 BMI categories in unadjusted analyses and risk-adjusted analyses and hospital-level variation using multivariable models.

RESULTS

After controlling for patient risk factors and hospital-level variation, patients in obesity class I to II were 1.21 times more likely to have any complication and patients in obesity class III were 1.41 times more likely to have any complication when compared with normal-weight patients. Similarly, patients in obesity class I to II were 1.44 times more likely to develop a wound complication compared with normal-weight patients, and patients in class III were 1.84 times more likely to develop a wound complication and 1.55 times more likely to develop a respiratory complication compared with normal-weight patients. In contrast, costs were greatest for malnourished patients at $45,000 compared with normal-weight patients at $37,000. However, after controlling for patient risk factors and variation in costs attributable to the admitting hospital, there were no significant cost differences between the 4 BMI categories.

CONCLUSIONS

Obesity leads to increased wound and respiratory complications in intestinal surgery. Nevertheless, obesity alone is not an independent risk factor for increased costs in intestinal surgery.

Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study

BACKGROUND

Intramedullary nails for stabilizing intertrochanteric proximal femoral fractures have been available since the early 1990s. The nails are inserted percutaneously and have theoretical mechanical advantages over plates and screws, but they have not been demonstrated to improve patient outcomes. Still, use of intramedullary nails is becoming more common. The goal of this study was to examine trends in the use and associated outcomes of intramedullary nailing compared with sliding hip screws in Veterans Affairs (VA) hospitals.

METHODS

Review of the VA Surgical Quality Improvement Program (VASQIP) data identified 5244 male patients in whom an intertrochanteric proximal femoral fracture had been treated in a VA hospital between 1998 and 2005. The overall sample was used to assess trends in device use, thirty-day mortality, thirty-day surgical complications, and one-year mortality. Next, propensity score matching methods were used to compare 1013 patients identified as having been treated with an intramedullary nail with 1013 patients who had a sliding-screw procedure. Multiple logistic regression models for the matched sample were used to calculate odds ratios for mortality and complications according to the choice of internal fracture fixation.

RESULTS

Use of intramedullary nails in VA facilities increased from 1998 through 2005 and varied by geographic region. Unadjusted mortality and complication percentages were similar for the two procedures, with approximately 8% of patients dying within thirty days after surgery, 28% dying within one year, and 19% having at least one perioperative complication. While the choice of an intramedullary nail or sliding-screw procedure was related to the geographic region, year of surgery, surgeon characteristics, and several patient characteristics, it was not associated with thirty-day outcomes in either the descriptive or the multiple regression analysis.

CONCLUSIONS

Intramedullary nail use increased from 1998 through 2005 but did not decrease perioperative mortality or comorbidity compared with standard plate-and-screw devices for patients treated for intertrochanteric proximal femoral fractures in VA facilities.

Burn-Center Quality Improvement: Are Burn Outcomes Dependent on Admitting Facilities and is There a Volume-Outcome “Sweet-Spot”?

Risk factors of mortality in burn patients such as inhalation injury, patient age, and percent of total body surface area (%TBSA) burned have been identified in previous publications. However, little is known about the variability of mortality outcomes between burn centers and whether the admitting facilities or facility volumes can be recognized as predictors of mortality. De-identified data from 87,665 acute burn observations obtained from the National Burn Repository between 2003 and 2007 were used to estimate a multivariable logistic regression model that could predict patient mortality with reference to the admitting burn facility/facility volume, adjusted for differences in age, inhalation injury, %TBSA burned, and an additional factor, percent full thickness burn (%FTB). As previously reported, all three covariates (%TBSA burned, inhalation injury, and age) were found to be highly statistically significant risk factors of mortality in burn patients (P value < 0.0001). The additional variable, %FTB, was also found to be a statistically significant determinant, although it did not greatly improve the multivariable model. The treatment/admitting facility was found to be an independent mortality predictor, with certain hospitals having increased odds of death and others showing a protective effect (decreased odds ratio). Hospitals with high burn volumes had the highest risk of mortality. Mortality outcomes of patients with similar risk factors (%TBSA burned, inhalation injury, age, and %FTB) are significantly affected by the treating facility and their admission volumes.

Burn-center quality improvement: are burn outcomes dependent on admitting facilities and is there a volume-outcome "sweet-spot"?

Risk factors of mortality in burn patients such as inhalation injury, patient age, and percent of total body surface area (%TBSA) burned have been identified in previous publications. However, little is known about the variability of mortality outcomes between burn centers and whether the admitting facilities or facility volumes can be recognized as predictors of mortality. De-identified data from 87,665 acute burn observations obtained from the National Burn Repository between 2003 and 2007 were used to estimate a multivariable logistic regression model that could predict patient mortality with reference to the admitting burn facility/facility volume, adjusted for differences in age, inhalation injury, %TBSA burned, and an additional factor, percent full thickness burn (%FTB). As previously reported, all three covariates (%TBSA burned, inhalation injury, and age) were found to be highly statistically significant risk factors of mortality in burn patients (P value < 0.0001). The additional variable, %FTB, was also found to be a statistically significant determinant, although it did not greatly improve the multivariable model. The treatment/admitting facility was found to be an independent mortality predictor, with certain hospitals having increased odds of death and others showing a protective effect (decreased odds ratio). Hospitals with high burn volumes had the highest risk of mortality. Mortality outcomes of patients with similar risk factors (%TBSA burned, inhalation injury, age, and %FTB) are significantly affected by the treating facility and their admission volumes.

Risk factors for anastomotic leakage after colectomy

BACKGROUND

Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of pre- and intraoperative risk factors may identify patients requiring increased postoperative surveillance for this major complication.

OBJECTIVE

The purpose of this study was to identify risk factors associated with anastomotic leakage after colectomy with primary intra-abdominal anastomosis.

DESIGN

The prospective, statewide multicenter Michigan Surgical Quality Collaborative database was analyzed.

SETTING

This study was performed at academic and community medical centers in the state of Michigan.

PATIENTS

Included were all cases of open and laparoscopic colectomy with primary intra-abdominal anastomosis from 2007 through 2010.

MAIN OUTCOME MEASURES

Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events with respect to the incidence of postoperative anastomotic leakage.

RESULTS

Inclusion criteria were met by 4340 cases. Anastomotic leakage occurred in 85 (3.2%) of the 2626 (60.5%) open colectomies, and in 51 (3.0%) of the 1714 (39.5%) laparoscopic procedures, which was not significantly different (p = 0.63). Significant risk factors associated with anastomotic leakage based on the multivariate logistic regression model were fecal contamination with OR 2.51, 95% CI, 1.16 to 5.45, p = 0.02; and intraoperative blood loss of more than 100 mL and 300 mL, with OR 1.62, 95% CI, 1.10 to 2.40, p = 0.02; and OR 2.22, 95% CI, 1.32 to 3.76, p = 0.003.

LIMITATIONS

The Michigan Surgical Quality Collaborative colectomy project excluded high-risk rectal resections and low pelvic anastomoses. Information about operative technique and intraoperative events is limited, and anastomotic leakage was determined through chart review.

CONCLUSION

Fecal contamination and increased blood loss during colectomy should raise suspicion for potential postoperative anastomotic leakage.

Comparison of the acute physiology and chronic health evaluation score (APACHE) II with GCS in predicting hospital mortality of neurosurgical intensive care unit patients

Background:

The Glasgow Coma Scale (GCS) is popular, simple, and reliable, and provides information about the level of consciousness in trauma patients. However, a systemic evaluation scale especially in patients with multiple traumas is so important. The revised Acute Physiology and Chronic Health Evaluation system type 2 (APACHE II) is a physiologically based system including physiological variables. This study compares the efficacy of the predicting power for mortality and functional outcome of GCS and APACHEII in patients with multiple traumas in intensive care unit.

Methods:

This study included the patients with head injury associated with systemic trauma admitted in the ICU of Shahid Rajaee Hospital in 2007 and 2008. Sensitivity, specificity and correct prediction of outcome by GCS and APACHE II were assessed and compared.

Results:

This study included 93 patients (79 males, 14 females; mean age 60.5; range 14 to 87 years) with head injury associated with systemic trauma in 2007 and 2008. Mortality increased in the elderly group. The mean survival score using APACHE II was 36.5 and death score was 67.4. These values using GCS were 10.3 and 6.8, respectively.

Conclusion:

For the assessment of mortality, the GCS score still provides simple, rapid and effective assessment in head injury patients, however, for the prediction of mortality in patients with multiple trauma APACHE II is superior to GCS since it includes multiple systemic parameters in these patients.

Hospital costs associated with smoking in veterans undergoing general surgery

BACKGROUND

Approximately 30% of patients undergoing elective general surgery smoke cigarettes. The association between smoking status and hospital costs in general surgery patients is unknown. The objectives of this study were to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in Veterans Affairs (VA) hospitals; and to determine whether the relationship between smoking and cost is mediated by postoperative complications.

STUDY DESIGN

Patients undergoing general surgery during the period of October 1, 2005 to September 30, 2006 were identified in the VA Surgical Quality Improvement Program (VASQIP) data set. Inpatient costs were extracted from the VA Decision Support System (DSS). Relative surgical costs (incurred during index hospitalization and within 30 days of operation) for current and former smokers relative to never smokers, and possible mediators of the association between smoking status and cost were estimated using generalized linear regression models. Models were adjusted for preoperative and operative variables, accounting for clustering of costs at the hospital level.

RESULTS

Of the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. After controlling for patient covariates, current smokers had significantly higher costs compared with never smokers: relative cost was 1.04 (95% Cl 1.00 to 1.07; p = 0.04); relative costs for former smokers did not differ significantly from those of never smokers: 1.02 (95% Cl 0.99 to 1.06; p = 0.14). The relationship between smoking and hospital costs for current smokers was partially mediated by postoperative respiratory complications.

CONCLUSIONS

These findings complement emerging evidence recommending effective smoking cessation programs in general surgical patients and provide an estimate of the potential savings that could be accrued during the preoperative period.

Outcomes of carotid endarterectomy under general and regional anesthesia from the American College of Surgeons' National Surgical Quality Improvement Program

OBJECTIVE

Despite multiple studies over more than 3 decades, there still is no consensus about the influence of anesthesia type on postoperative outcomes following carotid endarterectomy (CEA). The objective of this study was to investigate whether anesthesia type, either general anesthesia (GA) or regional anesthesia (RA), independently contributes to the risk of postoperative cardiovascular complications or death using the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database.

METHODS

Retrospective analysis of elective cases of CEA from 2005 through 2009 was performed. A propensity score model using 45 covariates, including demographic factors, comorbidities, stroke history, measures of general health, and laboratory values, was used to adjust for bias and to determine the independent influence of anesthesia type on postoperative stroke, myocardial infarction (MI), and death.

RESULTS

Of 26,070 cases listed in the ACS NSQIP database, GA and RA were used in 22,054 (84.6%) and 4016 (15.4%) cases, respectively. Postoperative stroke, MI, and death occurred in 360 (1.63%), 133 (0.6%), and 154 (0.70%) patients of the GA group, respectively, and in 58 (1.44%), 11 (0.27%), and 27 (0.67%) patients of the RA group, respectively. Stratification by propensity score quintile and adjustment for covariates demonstrated GA to be a significant risk factor for postoperative MI with an adjusted odds ratio (OR) and confidence interval (CI) of 2.18 (95% CI, 1.17-4.04), P = .01 in the entire study population. The OR for MI was 5.41 (95% CI, 1.32-22.16; P = .019) in the subgroup of patients with preoperative neurologic symptoms, and 1.44 (95% CI, 0.71-2.90; P = .31) in the subgroup of patients without preoperative neurologic symptoms.

CONCLUSIONS

This analysis of a large, prospectively collected and validated multicenter database indicates that GA for CEA is an independent risk factor for postoperative MI, particularly in patients with preoperative neurologic symptoms.

Complications after rectal prolapse surgery: does approach matter?

BACKGROUND

Data comparing surgical outcomes following abdominal and transperineal approaches for rectal prolapse are limited.

OBJECTIVE

We sought to identify differences in postoperative complications following abdominal vs transperineal approaches to rectal prolapse.

DESIGN

We studied a retrospective cohort in the American College of Surgeon's National Surgical Quality Improvement Program from January 2005 through December 2008.

PATIENTS

We identified all patients who underwent surgical treatment for rectal prolapse.

INTERVENTION

We compared surgical outcomes of standard abdominal approaches compared with standard transperineal approaches to rectal prolapse.

MAIN OUTCOME MEASURES

The primary outcomes measured were the validated morbidity outcomes and 30-day mortality.

RESULTS

During the study period, 1485 patients underwent rectal prolapse surgery (706 abdominal and 779 transperineal). Patients treated with abdominal approaches had significantly higher rates of infectious (9.8% vs 3.7%) and overall (12.9% vs 7.6%) complications in comparison with those treated with transperineal approaches. On multivariate analysis, risk factors for overall complications were ASA class 4 (OR 6.4) and abdominal surgery (OR 2.3), whereas an albumin level of ≥ 2.5 was protective (OR 0.05). Significant predictors of infectious complications were ASA class 4 (OR 7.5), BMI >25 (OR 1.8), and rectal prolapse surgery performed with an abdominal approach (OR 2.8).

LIMITATIONS

The retrospective design introduces potential selection bias.

CONCLUSIONS

Abdominal surgery for rectal prolapse is a predictor of both infectious and overall complications. Patients with significant comorbidities or a high BMI are at particularly high risk for complications and may be better suited for a transperineal rather than abdominal approach for the treatment of rectal prolapse.

How often do patients return to the operating room after colorectal resections?

AIM

We sought to identify the rate of re-operation after an index colorectal surgical procedure and potential contributing risk factors.

METHOD

This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned or did not return to the operating room after any colorectal resection from January 2005 to December 2008.

RESULTS

From a total cohort of 635, 265 patients included in the National Surgical Quality Improvement Program over the 4-year study period, we identified 54, 237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4 ± 0.1% of non colorectal resection patients and 7.6 ± 0.2% of colorectal resection patients (P < 0.001). The multivariate model identified patients with postoperative diagnostic codes for abdominal cavity hernia or colostomy complication as having the highest odds of return to the operating room within 30 days. Patients returning to the operating room had longer length of stay and higher overall mortality compared with those patients who did not return to the operating room.

CONCLUSION

Return to the operating room is a relatively common occurrence after colorectal resections, with an associated high rate of mortality. Given the association between return to the operating room and adverse patient outcomes, emphasis should be placed on determining strategies to reduce the need for return to the operating room.

Investigating the safety of medication administration in adult critical care settings

BACKGROUND

Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high-risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings.

PURPOSE

This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. SEARCH STRATEGIES (INCLUSION AND EXCLUSION CRITERIA): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer-reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant.

CONCLUSION

The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.

More black box to explore: how quality improvement collaboratives shape practice change

BACKGROUND

Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to "open up the black box" to better understand how and why such collaboratives work.

METHODS

We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data that included audio recordings and field notes of QICs and practice-based team meetings.

RESULTS

Three themes emerged from our analysis: (1) practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance; (2) a mix of content and media in the QIC program was important for reaching all participants; (3) resources offered at the QIC did little to spur practice change efforts.

CONCLUSION

QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most.

The impact of renal function on outcomes of bariatric surgery

The effect of CKD on the risks of bariatric surgery is not well understood. Using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File, we analyzed 27,736 patients who underwent bariatric surgery from 2006 through 2008. Before surgery, 34 (0.12%) patients were undergoing long-term dialysis. Among those not undergoing dialysis, 20,806 patients (75.0%) had a normal estimated GFR or stage 1 CKD, 5011 (18.07%) had stage 2 CKD, 1734 (6.25%) had stage 3 CKD, 94 (0.34%) had stage 4 CKD, and 91 (0.33%) had stage 5 CKD. In an unadjusted analysis, CKD stage was directly associated with complication rate, ranging from 4.6% for those with stage 1 CKD or normal estimated GFR to 9.9% for those with stage 5 CKD (test for trend, P<0.001). Multivariable logistic regression demonstrated that CKD stage predicts higher complication rates (odds ratio for each higher CKD stage, 1.30) after adjustment for diabetes and hypertension. Although patients with higher CKD stage had higher complication rates, the absolute incidence of complications remained <10%. In conclusion, these data demonstrate higher risks of bariatric surgery among patients with worse renal function, but whether the potential benefits outweigh the risks in this population requires further study.

Electronic measures of surgical site infection: implications for estimating risks and costs

OBJECTIVE

Electronic measures of surgical site infections (SSIs) are being used more frequently in place of labor-intensive measures. This study compares performance characteristics of 2 electronic measures of SSIs with a clinical measure and studies the implications of using electronic measures to estimate risk factors and costs of SSIs among surgery patients.

METHODS

Data included 1,066 general and vascular surgery patients at a single academic center between 2007 and 2008. Clinical data were from the National Surgical Quality Improvement Program (NSQIP) database, which includes a nurse-derived measure of SSI. We compared the NSQIP SSI measure with 2 electronic measures of SSI: MedMined Nosocomial Infection Marker (NIM) and International Classification of Diseases, Ninth Revision (ICD-9) coding for SSIs. We compared infection rates for each measure, estimated sensitivity and specificity of electronic measures, compared effects of SSI measures on risk factors for mortality using logistic regression, and compared estimated costs of SSIs for measures using linear regression.

RESULTS

SSIs were observed in 8.8% of patients according to the NSQIP definition, 2.6% of patients according to the NIM definition, and 5.8% according to the ICD-9 definition. Logistic regression for each SSI measure revealed large differences in estimated risk factors. NIM and ICD-9 measures overestimated the cost of SSIs by 134% and 33%, respectively.

CONCLUSIONS

Caution should be taken when relying on electronic measures for SSI surveillance and when estimating risk and costs attributable to SSIs. Electronic measures are convenient, but in this data set they did not correlate well with a clinical measure of infection.

Quality control in ovarian cancer surgery

This study is a literature review of papers in the English language dealing with quality control for ovarian cancer surgery. Quality control in surgery has long been a neglected area of medicine. Initial attempts were limited to cardiac surgery, but only very recently has there been any attempt to look at quality control in ovarian cancer surgery. Investigators from Hesse, Germany were the first to document the surgical quality of patients with ovarian cancer. Subsequently, investigators in the United States and other European countries have demonstrated that patients treated by gynaecological oncologists in large-volume tertiary institutions had the best outcomes. The Gynaecological Cancer Group of the European Organisation for Research and Treatment of Cancer has developed a series of process quality indicators for ovarian cancer surgery that could be used by surgeons or units to audit and improve their practice. These and or other initiatives are important, because pressure is coming from consumers, government, health care insurers and medical risk insurers for surgeons and hospitals to provide transparent patient outcome data. If the profession does not institute adequate internal regulation of the quality of ovarian cancer surgery, regulation is likely to be imposed by government.

All-cause mortality after tracheostomy at a tertiary care hospital over a 10-month period

OBJECTIVE

To evaluate perioperative mortality after tracheostomy in intensive care unit (ICU) patients undergoing routine tracheostomy over a 10-month period.

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary care hospital.

SUBJECTS

Mechanically ventilated patients.

METHODS

Prospective analysis of ICU patients undergoing tracheostomy placement over 10 months was performed. Variables evaluated were demographics, pretracheostomy length of stay, time on ventilator, time to death, preoperative comorbidities, and cause of death.

RESULTS

There were 129 consultations resulting in 115 tracheostomies, of which 100 were included for study. The overall 30-day postoperative mortality rate was 25%, including palliative care deaths. Cause of death in all cases was due to a preexisting condition and not from tracheostomy. Patients who died within the 30-day postoperative period were found to have significant differences in age, pretracheostomy length of stay, location of tracheostomy, and preoperative comorbidity scores. No significant difference was found in time on ventilator, sex, or race/ethnicity. Mean time from consultation to tracheostomy was 2.5 days (range, 0-12 days).

CONCLUSION

High rates of mortality after tracheostomy can possibly affect hospital quality ratings for surgical services. There were no deaths directly related to surgery. Despite this, the mortality rate in this population was quite high. This illustrates the significant disease burden in these patients and the need to stratify postoperative mortality as well as to consider comorbidity and age when evaluating patients for tracheostomy.

Timing and perioperative risk factors for in-hospital and post-discharge venous thromboembolism after colorectal cancer resection

INTRODUCTION

We postulated that the risk of venous thromboembolic disease (VTE) may persist after discharge and tested this hypothesis in patients undergoing colorectal resection for cancer.

METHODS

The American College of Surgeons National Surgery Quality Improvement Program database was queried for patients undergoing colorectal resections for cancer from 2005 to 2009. The outcome analyzed was a 30-day deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Multivariable forward stepwise regression was used to identify independent predictors of VTE.

RESULTS

The database contained 21 943 colorectal cancer resections. The 30-day DVT rate was 1.4% (306 of 21 943), 29% (89 of 306) were diagnosed post-discharge. The 30-day PE rate was 0.8% (180 of 21 943), 33% (60 of 180) was diagnosed post-discharge, the combined DVT/PE rate was 2.0% (446 of 21 943). The median time to diagnosis of VTE was 9 days (interquartile range 4-16) after surgery. Post-discharge VTE rates in patients with length of stay (LOS) less than 1 week (0.6%) were similar to patients with LOS greater than 1 week (0.7%, Fisher exact P not significant). Independent risk factors for post-discharge VTE were preoperative steroid use for chronic condition (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.51-5.57, P = .001) and preoperative systemic inflammatory response syndrome (OR 2.26, 95% CI 1.24-4.10, P = .008).

CONCLUSIONS

Diagnosis of almost one third of postoperative VTE in this patient population occurred after discharge. The duration of the prothrombotic stimulus of surgery is not well defined, and patients with malignancy are at high risk of VTE; thromboprophylaxis after discharge should be considered for these patients.

Synergistic implications of multiple postoperative outcomes

As payment policies for surgical complications evolve, surgeons and hospitals need to understand the financial implications of postoperative events. Using data from the National Surgical Quality Improvement Program (NSQIP), the authors estimated mortality, length of stay (LOS), and total cost attributable to multiple postoperative events in general and vascular surgery patients. Data were collected using standard NSQIP practices at a single academic center between 2007 and 2009. LOS and costs were fit to linear regression models to determine the effect of 19 postoperative events in the setting of 1, 2, or 3+ events. Of 2250 patients sampled, 457 patients developed at least 1 postoperative event. LOS increased by 2.59, 5.18, and 10.99 days (P < .0001) for 1, 2, and 3+ postoperative events; excess costs were $6358, $12 802, and $42 790 (P < .0001), respectively. Multiple postoperative events have a synergistic effect on mortality, LOS, and the financial cost of patient care.

Measuring sustainability within the Veterans Administration Mental Health System Redesign initiative

OBJECTIVE

To examine how attributes affecting sustainability differ across Veterans Health Administration organizational components and by staff characteristics.

SUBJECTS

Surveys of 870 change team members and 50 staff interviews within the Veterans Affairs' Mental Health System Redesign initiative.

METHODS

A 1-way ANOVA with a Tukey post hoc test examined differences in sustainability by Veteran Integrated Service Networks, job classification, and tenure from staff survey data of the Sustainability Index. Qualitative interviews used an iterative process to identify "a priori" and "in vivo" themes. A simple stepwise linear regression explored predictors of sustainability.

RESULTS

Sustainability differed across Veteran Integrated Service Networks and staff tenure. Job classification differences existed for the following: (1) benefits and credibility of the change and (2) staff involvement and attitudes toward change. Sustainability barriers were staff and institutional resistance and nonsupportive leadership. Facilitators were commitment to veterans, strong leadership, and use of quality improvement tools. Sustainability predictors were outcomes tracking, regular reporting, and use of Plan, Do, Study, Adjust cycles.

CONCLUSIONS

Creating homogeneous implementation and sustainability processes across a national health system is difficult. Despite the Veterans Affairs' best evidence-based implementation efforts, there was significant variance. Locally tailored interventions might better support sustainability than "one-size-fits-all" approaches. Further research is needed to understand how participation in a quality improvement collaborative affects sustainability.

Predictors of surgical site infection after liver resection: a multicentre analysis using National Surgical Quality Improvement Program data

BACKGROUND

  Postoperative infections are frequent complications after liver resection and have significant impact on length of stay, morbidity and mortality. Surgical site infection (SSI) is the most common nosocomial infection in surgical patients, accounting for 38% of all such infections.

OBJECTIVES

  This study aimed to identify predictors of SSI and organ space SSI after liver resection.

METHODS

  Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients who underwent liver resection in 2005, 2006 or 2007 in any of 173 hospitals throughout the USA were analysed. All patients who underwent a segmental resection, left hepatectomy, right hepatectomy or trisectionectomy were included.

RESULTS

  The ACS-NSQIP database contained 2332 patients who underwent hepatectomy during 2005-2007. Rates of SSI varied significantly across primary procedures, ranging from 9.7% in segmental resection patients to 18.3% in trisectionectomy patients. A preoperative open wound, hypernatraemia, hypoalbuminaemia, elevated serum bilirubin, dialysis and longer operative time were independent predictors for SSI and for organ space SSI.

CONCLUSIONS

  These findings may contribute towards the identification of patients at risk for SSI and the development of strategies to reduce the incidence of SSI and subsequent costs after liver resection.

Predictors of surgical site infection after liver resection: a multicentre analysis using National Surgical Quality Improvement Program data

BACKGROUND

  Postoperative infections are frequent complications after liver resection and have significant impact on length of stay, morbidity and mortality. Surgical site infection (SSI) is the most common nosocomial infection in surgical patients, accounting for 38% of all such infections.

OBJECTIVES

  This study aimed to identify predictors of SSI and organ space SSI after liver resection.

METHODS

  Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients who underwent liver resection in 2005, 2006 or 2007 in any of 173 hospitals throughout the USA were analysed. All patients who underwent a segmental resection, left hepatectomy, right hepatectomy or trisectionectomy were included.

RESULTS

  The ACS-NSQIP database contained 2332 patients who underwent hepatectomy during 2005-2007. Rates of SSI varied significantly across primary procedures, ranging from 9.7% in segmental resection patients to 18.3% in trisectionectomy patients. A preoperative open wound, hypernatraemia, hypoalbuminaemia, elevated serum bilirubin, dialysis and longer operative time were independent predictors for SSI and for organ space SSI.

CONCLUSIONS

  These findings may contribute towards the identification of patients at risk for SSI and the development of strategies to reduce the incidence of SSI and subsequent costs after liver resection.

Applying trigger tools to detect adverse events associated with outpatient surgery

OBJECTIVE

The objective of this study is to evaluate the performance of 5 triggers to detect adverse events (AEs) associated with outpatient surgery. Triggers use surveillance algorithms derived from clinical logic to flag cases where AEs have most likely occurred. Current efforts to detect AEs have focused primarily on the inpatient setting, despite the increase in outpatient surgery in all health care settings.

METHODS

Using trigger logic, we retrospectively evaluated data from 3 large health care systems' electronic medical records. Patients were eligible for inclusion if they had an outpatient (same-day) surgery in 2007 and at least 1 clinical note in the 6 months after the surgery. Two nurse abstractors reviewed a sample of trigger-flagged cases from each health care system. After reaching interrater reliability targets (κ > 0.60), we calculated the positive predictive value (PPV) of each trigger and the confidence interval of the estimate.

RESULTS

The surgical triggers flagged between 1% and 22% of the outpatient surgery cases, with a wide range in PPVs (6.0%-62.0%). The pulmonary embolism and deep vein thrombosis and emergency department triggers had the lowest proportion of flagged cases along with the highest PPVs, showing the most promise for screening cases with a high probability of AE occurrence.

CONCLUSIONS

Triggers may be useful in identifying a narrow set of surgeries for further review to determine if a surgical AE occurred, complementing existing tools and initiatives used to detect AEs. Improved detection of AEs in outpatient surgery should help target potential areas for quality improvement.

Evaluation of modified Estimation of Physiologic Ability and Surgical Stress in gastric carcinoma surgery

BACKGROUND

We recently modified our prediction scoring system "Estimation of Physiologic Ability and Surgical Stress" and have designated the current version mE-PASS. This scoring system has been designed to obtain predicted postoperative mortality rates before surgery and this study was performed to assess its usefulness in elective surgery for gastric carcinoma.

METHODS

We investigated seven variables for mE-PASS and evaluated the postoperative course in 3,449 patients who underwent elective surgery for gastric carcinoma in Japan between August 20, 1987 and April 9, 2007, in order to quantify the predicted in-hospital mortality rates (R). The calibration and discrimination power of R were assessed using the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (AUC), respectively. The ratios of observed-to-estimated mortality rates (OE ratios) were quantified as a measure of quality.

RESULTS

The overall postoperative morbidity and mortality rates were 19.0 and 2.0%, respectively. R demonstrated good power in calibration (χ(2) value, 12.5; df 8; P = 0.89) as well as discrimination (AUC, 95% confidence intervals: 0.80, 0.75-0.85). The OE ratios between hospitals ranged from 0.44 to 1.8. Overall, the OE ratios seemed to improve with time (OE ratio, 95% confidence intervals: 1.3, 0.73-2.4 for the early period between 1987 and 2000; 1.0, 0.59-1.7 for the middle period between 2001 and 2004; and 0.65, 0.36-1.2 for the late period between 2005 and 2007).

CONCLUSION

Based on these findings, mE-PASS might be useful for medical decision-making and for assessing the quality of care in elective surgery for gastric carcinoma.

Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy

BACKGROUND

The role of obesity as a risk factor after carotid endarterectomy is not well-described. We undertook a study of the association of obesity with 30-day outcomes after carotid endarterectomy.

STUDY DESIGN

After obtaining Institutional Review Board approval, we retrospectively analyzed prospectively collected data from carotid endarterectomies in the 2005-2006 Veterans Affairs Surgical Quality Improvement Program database. The association of body mass index (BMI; calculated as kg/m(2)) on 30-day outcomes was assessed using multivariable logistic regression.

RESULTS

From 3,706 carotid endarterectomies, we excluded 22 for missing BMI and 39 for emergency status; 3,645 carotid endarterectomies were analyzed. BMI was underweight (<18.5) in 1.6%, normal (18.5 to 24.9) in 31.0%, overweight (25.0 to 29.9) in 40.8%, class I obese (30.0 to 34.9) in 19.3%, class II obese (35.0 to 39.9) in 5.8%, and class III obese (≥40) in 1.6%. On multivariable analysis, class II to III (odds ratio = 6.95; 95% CI, 1.89-25.58; p = 0.004) obesity was associated with death, and class II to III obesity was associated with cardiac complications (odds ratio = 3.68; 95% CI, 1.27-10.66; p = 0.02) compared with normal weight.

CONCLUSIONS

Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy. Surgeons should consider this when evaluating the risks and benefits of carotid endarterectomy in obese patients. Carotid artery stenting was not assessed, and future studies are needed to examine its role in management of obese patients.

Development and validation of a model that uses enhanced administrative data to predict mortality in patients with sepsis

OBJECTIVE

We aimed to determine whether a sepsis risk-adjustment model that uses only administrative data could be used when other intensive care unit risk-adjustment methods are unavailable.

DESIGN

Cohort study with development and validation cohorts.

PATIENTS

The development cohort included 166,931 patients at 309 hospitals that cared for at least 100 patients with sepsis between 2004 and 2006. The validation cohort included 357 adult sepsis patients who were enrolled in Project IMPACT, 2002-2009.

MEASUREMENTS AND MAIN RESULTS

We developed a multilevel mixed-effects logistic regression model to predict mortality at the patient level. Predictors included patient demographics (age, sex, race, insurance type), site and source of sepsis, presence of 25 individual comorbidities, treatment (within the first 2 days of hospitalization) with mechanical ventilation and/or vasopressors, and/or admission to the intensive care unit (within 2 days of hospitalization). We validated this model in 357 sepsis patients who were admitted to the intensive care unit at a single academic medical center and who had a valid Acute Physiology and Chronic Health Evaluation II score, a valid Simplified Acute Physiology Score II, and a valid Mortality Probability Model III score. Overall, 33,192 patients (19.9%) died in the hospital. In the development cohort, the predicted mortality ranged from 0.002 to 0.938 with a mean of 0.199. The model's area under the receiver operating characteristic curve was 0.78. In the validation cohort, all models had modest discriminatory ability and the areas under the receiver operating characteristic curves of all models were statistically similar (Acute Physiology and Chronic Health Evaluation II, 0.71; Simplified Acute Physiology Score II, 0.74; Mortality Probability Model III, 0.69; administrative model, 0.69; p value that the areas under the receiver operating characteristic curves are different, .35). The Hosmer-Lemeshow statistic was significant (p < .01) for Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II, and Mortality Probability Model III but was nonsignificant (p = .11) for the administrative model.

CONCLUSIONS

A sepsis mortality model using detailed administrative data has discrimination similar to and calibration superior to those of existing severity scores that require chart review. This model may be a useful alternative method of severity adjustment for benchmarking purposes or for conducting large, retrospective epidemiologic studies of sepsis patients.

Hospital-acquired infections

Health-acquired infection (HAI) is defined as a localized or systemic condition resulting from an adverse reaction to the presence of infectious agents or its toxins. This article focuses on HAIs that are well studied, common, and costly (direct, indirect, and intangible). The HAIs reviewed are catheter-related bloodstream infection, ventilator-associated pneumonia, surgical site infection, and catheter-associated urinary tract infection. This article excludes discussion of Clostridium difficile infections and vancomycin-resistant Enterococcus.

Total Abdominal Colectomy Has a Similar Short-Term Outcome Profile Regardless of Indication: Data from the National Surgical Quality Improvement Program

The purpose of this study was to evaluate the 30-day postoperative complications rate in patients undergoing elective total abdominal colectomy (TAC) for chronic constipation, neoplastic disorders, and inflammatory bowel disease (IBD) using the American College of Surgeons National Quality Improvement Database (ACS-NSQIP). The 2007 ACS-NSQIP sample was used to identify the Current Procedural Terminology codes for TAC and International Classification of Diseases, 9th Revision codes for chronic constipation, neoplasia, and IBD. Preoperative and intraoperative variables and postoperative complications were compared among the three diagnosis groups. Wilcoxon rank sum and Fisher exact tests were used for analysis. P < 0.05 was considered significant. Seven hundred forty-four patients were identified; chronic constipation was found in 107 (14.4%) patients, neoplasia in 312 (42.3%), and IBD in 322 (43.3%). Patients with constipation were predominantly females (85.2%). The neoplastic group was older and had greater body mass index when compared with the other groups. Patients with IBD presented greater use of steroids, lower albumin and hematocrit levels, and higher morbidity probability. Constipated patients had more neurologic and renal complications when compared with the IBD group ( P = 0.01). None of the other categories of complications were statistically different among the diagnosis groups. With the exception of urinary tract infection being higher in the constipation patients compared with IBD (10 vs 4%, P = 0.03), there were no statistically significant differences among the other short-term specific complications. The 30-day complication rate after TAC is similar for chronic constipation, neoplasia, and IBD.

The impact of obesity on outcomes following major surgery for Crohn's disease: an American College of Surgeons National Surgical Quality Improvement Program assessment

BACKGROUND

Whereas Crohn's disease is traditionally thought to represent a wasting disease, little is currently known about the incidence and impact of obesity in this patient cohort.

OBJECTIVE

This study aimed to evaluate the perioperative outcomes in patients with Crohn's disease who were obese vs those who were not obese undergoing major abdominal surgery.

DESIGN

This study is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005-2008). Risk-adjusted 30-day outcomes were assessed by the use of regression modeling accounting for patient characteristics, comorbidities, and surgical procedures.

PATIENTS

Included were all patients with Crohn's disease who were undergoing abdominal operations.

MAIN OUTCOME MEASURE

The primary outcomes measured were short-term perioperative outcomes. Obesity was defined as a BMI of 30 or greater.

RESULTS

We identified 2319 patients (mean age, 41.6 y; 55% female). Of these patients, 379 (16%) met obesity criteria, 2% were morbidly obese, and 0.3% were super obese. Rates of obesity significantly increased each year over the study period. Twenty-five percent of the surgeries were performed laparoscopically (obese 21% vs nonobese 26%). Six percent were emergent, with no difference in patients with obesity. Operative times were significantly longer among patients with obesity (177 min) compared with patients who were not obese (164 min). After adjusting for differences in comorbidities and steroid use, overall perioperative morbidity was significantly higher in the obese cohort (32% vs 22% nonobese; OR 1.9). In addition, the rates of postoperative complications increased directly with rising BMI. Irrespective of procedure type, the patients who were obese were significantly more likely to experience wound infections (OR 1.7), which increased even further in patients who were morbidly obese (BMI >40; OR 7.1). By specific operation, postoperative morbidity was increased in patients with obesity following colectomies with primary anastomosis for both open and laparoscopic approaches (OR 2.9 and OR 3.8). Cardiac, pulmonary, and renal complications as well as overall mortality did not differ significantly based on BMI.

LIMITATIONS

This study was limited by being a retrospective review, and by using data limited to the American College of Surgeons National Surgical Quality Improvement Program database.

CONCLUSION

Increasing BMI adversely affects perioperative morbidity in patients with Crohn's disease.