Association of postoperative complications with hospital costs and length of stay in a tertiary care center

Cost-effectiveness of a quality improvement bundle for emergency laparotomy

BACKGROUND

The recent Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) study showed that the use of a specific care bundle reduced mortality in patients undergoing emergency laparotomy. However, the costs of implementation of the ELPQuiC bundle remain unknown. The aim of this study was to assess the in-hospital and societal costs of implementing the ELPQuiC bundle.

METHODS

The ELPQuiC study employed a before-after approach using quality improvement methodology. To assess the costs and cost-effectiveness of the bundle, two models were constructed: a short-term model to assess in-hospital costs and a long-term model (societal decision tree) to evaluate the patient's lifetime costs (in euros).

RESULTS

Using health economic modelling and data collected from the ELPQuiC study, estimated costs for initial implementation of the ELPQuiC bundle were €30 026·11 (range 1794·64-40 784·06) per hospital. In-hospital costs per patient were estimated at €14 817·24 for standard (non-care bundle) treatment versus €15 971·24 for the ELPQuiC bundle treatment. Taking a societal perspective, lifetime costs of the patient in the standard group were €23 058·87, compared with €19 102·37 for patients receiving the ELPQuiC bundle. The increased life expectancy of 4 months for patients treated with the ELPQuiC bundle was associated with cost savings of €11 410·38 per quality-adjusted life-year saved.

CONCLUSION

Implementation of the ELPQuiC bundle is associated with lower mortality and higher in-hospital costs but reduced societal costs.

Application of a simple, affordable quality metric tool to colorectal, upper gastrointestinal, hernia, and hepatobiliary surgery patients: the HARM score

BACKGROUND

Quality is the major driver for both clinical and financial assessment. There remains a need for simple, affordable, quality metric tools to evaluate patient outcomes, which led us to develop the HospitAl length of stay, Readmission and Mortality (HARM) score. We hypothesized that the HARM score would be a reliable tool to assess patient outcomes across various surgical specialties.

METHODS

From 2011 to 2015, we identified colorectal, hepatobiliary, upper gastrointestinal, and hernia surgery admissions using the Vizient Clinical Database. Individual and hospital HARM scores were calculated from length of stay, 30-day readmission, and mortality rates. We evaluated the correlation of HARM scores with complication rates using the Clavien-Dindo classification.

RESULTS

We identified 525,083 surgical patients: 206,981 colorectal, 164,691 hepatobiliary, 97,157 hernia, and 56,254 upper gastrointestinal. Overall, 53.8% of patients were admitted electively with a mean HARM score of 2.24; 46.2% were admitted emergently with a mean HARM score of 1.45 (p < 0.0001). All HARM components correlated with patient complications on logistic regression (p < 0.0001). The mean length of stay increased from 3.2 ± 1.8 days for a HARM score < 2 to 15.1 ± 12.2 days for a HARM score > 4 (p < 0.001). In elective admissions, for HARM categories of < 2, 2-< 3, 3-4, and > 4, complication rates were 9.3, 23.2, 38.8, and 71.6%, respectively. There was a similar trend for increasing HARM score in emergent admissions as well. For all surgical procedure categories, increasing HARM score, with and without risk adjustment, correlated with increasing severity of complications by Clavien-Dindo classification.

CONCLUSIONS

The HARM score is an easy-to-use quality metric that correlates with increasing complication rates and complication severity across multiple surgical disciplines when evaluated on a large administrative database. This inexpensive tool could be adopted across multiple institutions to compare the quality of surgical care.

Effect of a newly designed observation, response and discharge chart in the Post Anaesthesia Care Unit on patient outcomes: a quasi-expermental study in Australia

OBJECTIVES

This study aimed to evaluate whether use of a discharge criteria tool for nursing assessment of patients in Post Anaesthesia Care Unit (PACU) would enhance nurses' recognition and response to patients at-risk of deterioration and improve patient outcomes.

METHODS

A prospective non-randomised pre-post intervention study was conducted in three hospitals in Australia. Participants were adults undergoing elective surgery before (n=723) and after (n=694) implementation of the Post-Anaesthetic Care Tool (PACT).

RESULTS

Nursing response to patients at-risk of deterioration was higher using PACT, with more medical consultations initiated by PACU nurses (19% vs 30%, P<0.001) and more patients with Medical Emergency Team activation criteria modified by an anaesthetist while in PACU (6.5% vs 13.8%, P<0.001). There were higher rates of analgesia administration (37.3% vs 54.2%, P=0.001), nursing assessment of pain and documentation of ongoing analgesia prior to discharge (55% vs 85%, P<0.001). More adverse events were recorded in PACU after introduction of the PACT (8.3% vs 16.7%, P<0.001). The rate of adverse events after discharge from PACU remained constant (16.5%), but the rate of cardiac events (5.1% vs 2.6%, P=0.021) and clinical deterioration (8.7% vs 4.3%, P=0.001) following PACU discharge significantly decreased, using the PACT. Despite the increased number of patients with adverse events in phase 2, healthcare costs did not increase significantly. Length of stay in PACU and length of hospital admission for those patients who had an adverse event in PACU were significantly reduced after implementation of the PACT.

CONCLUSION

This study found that using a structured discharge criteria tool, the PACT, enhanced nurses' recognition and response to patients who experienced clinical deterioration, reduced length of stay for patients who experienced an adverse event in PACU and was cost-effective.

Association of Hospital Costs With Complications Following Total Gastrectomy for Gastric Adenocarcinoma

Importance

Postoperative complications are associated with increased hospital costs following major surgery, but the mechanism by which they increase cost and the categories of care that drive this increase are poorly described.

Objective

To describe the association of postoperative complications with hospital costs following total gastrectomy for gastric adenocarcinoma.

Design, Setting, and Participants

This retrospective analysis of a prospectively collected gastric cancer surgery database at a single National Cancer Institute-designated comprehensive cancer center included all patients undergoing curative-intent total gastrectomy for gastric adenocarcinoma between January 2009 and December 2012 and was conducted in 2015 and 2016.

Main Outcomes and Measures

Ninety-day normalized postoperative costs. Hospital accounting system costs were normalized to reflect Medicare reimbursement levels using the ratio of hospital costs to Medicare reimbursement and categorized into major cost categories. Differences between costs in Medicare proportional dollars (MP $) can be interpreted as the amount that would be reimbursed to an average hospital by Medicare if it paid differentially based on types and extent of postoperative complications.

Results

In total, 120 patients underwent curative-intent total gastrectomy for stage I through III gastric adenocarcinoma between 2009 and 2012. Of these, 79 patients (65.8%) were men, and the median (interquartile range) age was 64 (52-70) years. The 51 patients (42.5%) who underwent an uncomplicated total gastrectomy had a mean (SD) normalized cost of MP $12 330 (MP $2500), predominantly owing to the cost of surgical care (mean [SD] cost, MP $6830 [MP $1600]). The 34 patients (28.3%) who had a major complication had a mean (SD) normalized cost of MP $37 700 (MP $28 090). Surgical care was more expensive in these patients (mean [SD] cost, MP $8970 [MP $2750]) but was a smaller contributor to total cost (24%) owing to increased costs from room and board (mean [SD] cost, MP $11 940 [MP $8820]), consultations (mean [SD] cost, MP $3530 [MP $2410]), and intensive care unit care (mean [SD] cost, MP $7770 [MP $14 310]).

Conclusions and Relevance

Major complications were associated with tripled normalized costs following curative-intent total gastrectomy. Most of the excess costs were related to the treatment of complications. Interventions that decrease the number or severity of postoperative complications could result in substantial cost savings.

Postoperative Adverse Events Inconsistently Improved by the World Health Organization Surgical Safety Checklist: A Systematic Literature Review of 25 Studies

BACKGROUND

The World Health Organization Surgical Safety Checklist (SSC) has been widely implemented in an effort to decrease surgical adverse events.

METHOD

This systematic literature review examined the effects of the SSC on postoperative outcomes. The review included 25 studies: two randomised controlled trials, 13 prospective and ten retrospective cohort trials. A meta-analysis was not conducted as combining observational studies of heterogeneous quality may be highly biased.

RESULTS

The quality of the studies was largely suboptimal; only four studies had a concurrent control group, many studies were underpowered to examine specific postoperative outcomes and teamwork-training initiatives were often combined with the implementation of the checklist, confounding the results. The effects of the checklist were largely inconsistent. Postoperative complications were examined in 20 studies; complication rates significantly decreased in ten and increased in one. Eighteen studies examined postoperative mortality. Rates significantly decreased in four and increased in one. Postoperative mortality rates were not significantly decreased in any studies in developed nations, whereas they were significantly decreased in 75 % of studies conducted in developing nations.

CONCLUSIONS

The checklist may be associated with a decrease in surgical adverse events and this effect seems to be greater in developing nations. With the observed incongruence between specific postoperative outcomes and the overall poor study designs, it is possible that many of the positive changes associated with the use of the checklist were due to temporal changes, confounding factors and publication bias.

Pulmonary Complications after Surgery for Rectal Cancer in Elderly Patients: Evaluation of Laparoscopic versus Open Approach from a Multicenter Study on 477 Consecutive Cases

AIM

To evaluate the impact of open or laparoscopic rectal surgery on pulmonary complications in elderly (>75 years old) patients.

METHODS

Data from consecutive patients who underwent elective laparoscopic or open rectal surgery for cancer were collected prospectively from 3 institutions. Pulmonary complications were defined according to the ACS/NSQUIP definition.

RESULTS

A total of 477 patients (laparoscopic group: 242, open group: 235) were included in the analysis. Postoperative pulmonary complications were significantly more common after open surgery (8 out of 242 patients (3.3%) versus 23 out of 235 patients (9.8%); p = 0.005). In addition, PPC occurrence was associated with the increasing of postoperative pain (5.04 ± 1.62 versus 5.03 ± 1.58; p = 0.001) and the increasing of operative time (270.06 ± 51.49 versus 237.37 ± 65.97; p = 0.001).

CONCLUSION

Our results are encouraging to consider laparoscopic surgery a safety and effective way to treat rectal cancer in elderly patients, highlighting that laparoscopic surgery reduces the occurrence of postoperative pulmonary complications.

Effect of individual patient risk, centre, surgeon and anaesthetist on length of stay in hospital after cardiac surgery: Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) consecutive cases series study of 10 UK specialist centres

OBJECTIVES

To determine the relative contributions of patient risk profile, local and individual clinical practice on length of hospital stay after cardiac surgery.

DESIGN

Ten-year audit of prospectively collected consecutive cardiac surgical cases. Case-mix adjusted outcomes were analysed in models that included random effects for centre, surgeon and anaesthetist.

SETTING

UK centres providing adult cardiac surgery.

PARTICIPANTS

10 of 36 UK specialist centres agreed to provide outcomes for all major cardiac operations over 10 years. After exclusions (duplicates, cases operated by more than one consultant, deaths and procedures for which the EuroSCORE risk score for cardiac surgery is not appropriate), there were 107 038 cardiac surgical procedures between April 2002 and March 2012, conducted by 127 consultant surgeons and 190 consultant anaesthetists.

MAIN OUTCOME MEASURE

Length of stay (LOS) up to 3 months postoperatively.

RESULTS

The principal component of variation in outcomes was patient risk (represented by the EuroSCORE and remaining patient heterogeneity), accounting for 95.43% of the variation for postoperative LOS. The impact of the surgeon and centre was moderate (intra-class correlation coefficients ICC=2.79% and 1.59%, respectively), whereas the impact of the anaesthetist was negligible (ICC=0.19%). Similarly, 96.05% of the variation for prolonged LOS (>11 days) was attributable to the patient, with surgeon and centre less but still influential components (ICC=2.12% and 1.66%, respectively, 0.17% only for anaesthetists). Adjustment for year of operation resulted in minor reductions in variation attributable to surgeons (ICC=2.52% for LOS and 2.23% for prolonged LOS).

CONCLUSIONS

Patient risk profile is the primary determinant of variation in LOS, and as a result, current initiatives to reduce hospital stay by modifying consultant performance are unlikely to have a substantial impact. Therefore, substantially reducing hospital stay requires shifting away from a one-size-fits-all approach to cardiac surgery, and seeking alternative treatment options personalised to high-risk patients.

Totally laparoscopic aortobifemoral bypass surgery in the treatment of aortoiliac occlusive disease or abdominal aortic aneurysms - a systematic review and critical appraisal of literature

PURPOSE

This systematic review aims to evaluate the published literature regarding totally laparoscopic aortobifemoral bypass (LABF) surgery in the treatment of aortoiliac occlusive disease (AIOD) or abdominal aortic aneurysms (AAA), compared with open aortobifemoral bypass surgery.

MATERIALS AND METHODS

A systematic review of the medical literature between 1990 and 2016 was performed, searching the medical databases Cochrane Library, OVID Medline, Embase and PubMed. Studies concerning totally LABF with or without control group and containing more than 10 patients were included in the analysis. Operative and aortic cross-clamping times, blood loss, rate of conversion to open surgery, mortality and morbidity within the first 30 postoperative days, hospital stay and primary and secondary patency of the graft were extracted and compared with open surgery when possible.

RESULTS

Sixty-six studies were deemed eligible for inclusion in this review, 16 of them matched the inclusion criteria for quantitative synthesis. The patient material consisted of 588 patients undergoing totally LABF, 22 due to AAA, and the remaining 566 for AIOD. Five comparative studies regarding AIOD compared 211 totally LABF procedures with 246 open procedures. Only one study concerning AAA was eligible for inclusion, and this study did not provide a comparison against an open group. The operating and aortic cross-clamping times were shorter in the open group. Conversion rates ranged from 0% to 27%. There was no statistically significant difference in mortality between the two groups (p=0.64). Hospital stays ranged from 4.0 to 12.1 and 5.0 to 12.8 days in the laparoscopic group and open group, respectively. Most of the studies provided low levels of evidence, mainly due to lack of blinding, randomization and correction of bias.

CONCLUSION

Totally laparoscopic aortoiliac surgery seems to be a feasible technique with unaffected mortality and trend toward benefits in hospital stay and possibly also in complication rates. The literature published this far is sparse and with inconsistent results. More randomized controlled trials are required before this method can be widely implemented.

Adverse Outcomes Associated with Preventable Complications in Hospitalized Patients with CKD

BACKGROUND

and objectives Patients with CKD are at risk of hospital-acquired complications (HACs). We sought to determine the association of preventable HACs with mortality, length of stay (LOS), and readmission.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

All adults hospitalized from April of 2003 to March of 2008 in Alberta were characterized by kidney function and occurrence of preventable HACs. CKD was defined by eGFR<60 ml/min per 1.73 m2 and/or albumin-to-creatinine ratio >3-30 mg/mmol for >3 months in the time frame from 365 to 90 days before admission. Regression models examined the association of HACs with outcomes.

RESULTS

Of 536,549 hospitalizations, 8.5% (n=45,733) had CKD and 9.8% of patients with CKD had one or more potentially preventable HAC. In patients with potentially preventable HACs, proportions of death within index hospitalization and from discharge to 90 days were 17.7% and 6.8%, respectively. In patients with CKD, comparing with those hospitalizations without potentially preventable HACs, the adjusted odds ratio (OR) of mortality during index hospitalization and from hospital discharge to 90 days in patients with one or more preventable HAC was 4.67 (95% confidence interval [95% CI], 4.17 to 5.22) and 1.08 (95% CI, 0.94 to 1.25), respectively. Median incremental LOS in patients with one or more preventable HAC was 9.86 days (95% CI, 9.25 to 10.48). The OR for readmission with preventable HAC was 1.24 (95% CI, 1.15 to 1.34). In a cohort with and without CKD, the adjusted ORs of mortality during index hospitalization in patients with CKD and no preventable HACs, patients without CKD and with preventable HACs, and patients with CKD and preventable HACs were 2.22 (95% CI, 1.69 to 2.94), 5.26 (95% CI, 4.98 to 5.55), and 9.56 (95% CI, 7.23 to 12.56), respectively (referenced to patients without CKD or preventable HACs).

CONCLUSIONS

Preventable HACs are associated with higher mortality, incremental LOS, and greater risk of readmission, especially in people with CKD. Targeted strategies to reduce complications should be a high priority.

Accelerating Chart Review Using Automated Methods on Electronic Health Record Data for Postoperative Complications

Manual Chart Review (MCR) is an important but labor-intensive task for clinical research and quality improvement. In this study, aiming to accelerate the process of extracting postoperative outcomes from medical charts, we developed an automated postoperative complications detection application by using structured electronic health record (EHR) data. We applied several machine learning methods to the detection of commonly occurring complications, including three subtypes of surgical site infection, pneumonia, urinary tract infection, sepsis, and septic shock. Particularly, we applied one single-task and five multi-task learning methods and compared their detection performance. The models demonstrated high detection performance, which ensures the feasibility of accelerating MCR. Specifically, one of the multi-task learning methods, propensity weighted observations (PWO) demonstrated the highest detection performance, with single-task learning being a close second.

Risk of Hospital-Acquired Complications in Patients with Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

Unintended injuries or complications in hospitalized patients are common, potentially preventable, and associated with adverse consequences, including greater mortality and health care costs. Patients with CKD may be at higher risk of hospital-acquired complications (HACs).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Adults from a population-based cohort (Alberta Kidney Disease Network) who were hospitalized from April 1, 2003, to March 31, 2008, made up the study cohort. Kidney function was defined using outpatient eGFR and proteinuria (protein-to-creatinine ratio or dipstick) in the year before index hospitalization. Comorbid conditions were identified using validated algorithms applied to administrative data. A specific diagnostic indicator was used to identify HACs. Complications were classified into clinically homogeneous groups and subclassified as potentially preventable (p-HACs) or always preventable (a-HACs). Multivariable logistic regressions models were used to examine the association of CKD with HACs, accounting for confounders.

RESULTS

Of 536,549 patients, 8.5% had CKD; those with CKD were older and more likely to be admitted for circulatory system diseases than those without CKD. In fully adjusted models, the odds ratio (OR) of any hospital complication in patients with CKD (reference: no CKD) was 1.19 (95% confidence interval [95% CI], 1.18 to 1.26); there was a graded relation between the risk of HACs and CKD severity, with an OR of 1.81 (95% CI, 1.51 to 2.17) in those with the most severe CKD (eGFR, 15-29 ml/min per 1.73 m(2) and proteinuria, >30 mg/mmol). Findings were similar for p-HACs (OR, 1.20 [95% CI, 1.16 to 1.24] and 1.78 [95% CI, 1.43 to 2.11], respectively). The a-HACs had similar point estimates.

CONCLUSIONS

The presence of CKD and its severity are associated with a higher risk of HACs, including those considered preventable. Targeted strategies to reduce complications in patients with CKD admitted to the hospital should be considered.

Application of Machine Learning Techniques to High-Dimensional Clinical Data to Forecast Postoperative Complications

Objective

To compare performance of risk prediction models for forecasting postoperative sepsis and acute kidney injury.

Design

Retrospective single center cohort study of adult surgical patients admitted between 2000 and 2010.

Patients

50,318 adult patients undergoing major surgery.

Measurements

We evaluated the performance of logistic regression, generalized additive models, naïve Bayes and support vector machines for forecasting postoperative sepsis and acute kidney injury. We assessed the impact of feature reduction techniques on predictive performance. Model performance was determined using the area under the receiver operating characteristic curve, accuracy, and positive predicted value. The results were reported based on a 70/30 cross validation procedure where the data were randomly split into 70% used for training the model and the 30% for validation.

Main Results

The areas under the receiver operating characteristic curve for different models ranged between 0.797 and 0.858 for acute kidney injury and between 0.757 and 0.909 for severe sepsis. Logistic regression, generalized additive model, and support vector machines had better performance compared to Naïve Bayes model. Generalized additive models additionally accounted for non-linearity of continuous clinical variables as depicted in their risk patterns plots. Reducing the input feature space with LASSO had minimal effect on prediction performance, while feature extraction using principal component analysis improved performance of the models.

Conclusions

Generalized additive models and support vector machines had good performance as risk prediction model for postoperative sepsis and AKI. Feature extraction using principal component analysis improved the predictive performance of all models.

Sustained-release synthetic biomarkers for monitoring thrombosis and inflammation using point-of-care compatible readouts

Postoperative infection and thromboembolism represent significant sources of morbidity and mortality but cannot be easily tracked after hospital discharge. Therefore, a molecular test that could be performed at home would significantly impact disease management. Our lab has previously developed intravenously delivered 'synthetic biomarkers' that respond to dysregulated proteases to produce a urinary signal. These assays, however, have been limited to chronic diseases or acute diseases initiated at the time of diagnostic administration. Here, we formulate a subcutaneously administered sustained release system by using small PEG scaffolds (<10 nm) to promote diffusion into the bloodstream over a day. We demonstrate the utility of a thrombin sensor to identify thrombosis and an MMP sensor to measure inflammation. Finally, we developed a companion paper ELISA using printed wax barriers with nanomolar sensitivity for urinary reporters for point-of-care detection. Our approach for subcutaneous delivery of nanosensors combined with urinary paper analysis may enable facile monitoring of at-risk patients.

Ulcerative Colitis Patients With Clostridium difficile are at Increased Risk of Death, Colectomy, and Postoperative Complications: A Population-Based Inception Cohort Study

OBJECTIVES

Clostridium difficile (C. difficile) may worsen the prognosis of ulcerative colitis (UC). The objectives of this study were to: (i) validate the International Classification of Diseases-10 (ICD-10) code for C. difficile; (ii) determine the risk of C. difficile infection after diagnosis of UC; (iii) evaluate the effect of C. difficile infection on the risk of colectomy; and (iv) assess the association between C. difficile and postoperative complications.

METHODS

The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated by comparing ICD-10 codes for C. difficile with stool toxin tests. A population-based surveillance cohort of newly diagnosed UC patients living in Alberta, Canada were identified from 2003 to 2009 (n=1,754). The effect of a C. difficile infection on colectomy was modeled using competing risk survival regression after adjusting for covariates. The effect of a C. difficile infection on postoperative complications was assessed using a mixed effects logistic regression model.

RESULTS

The sensitivity, specificity, PPV, and NPV of the ICD-10 code for C. difficile were 82.1%, 99.4%, 88.4%, and 99.1%, respectively. The risk of C. difficile infection within 5 years of diagnosis with UC was 3.4% (95% confidence interval (CI): 2.5-4.6%). The risk of colectomy was higher among UC patients diagnosed with C. difficile (sub-hazard ratio (sHR)=2.36; 95% CI: 1.47-3.80). C. difficile increased the risk of postoperative complications (odds ratio=4.84; 95% CI: 1.28-18.35). C. difficile was associated with mortality (sHR=2.56 times; 95% CI: 1.28-5.10).

CONCLUSIONS

C. difficile diagnosis worsens the prognosis of newly diagnosed patients with UC by increasing the risk of colectomy, postoperative complications, and death.

Hospital costs of complications after a pancreatoduodenectomy

BACKGROUND

A pancreatoduodenectomy (PD) is a highly advanced procedure associated with considerable post-operative complications and substantial costs. In this study the hospital costs associated with complications after PD were assessed.

METHODS

A retrospective cohort study was conducted on 100 consecutive patients who underwent a pylorus-preserving (PP)PD between January 2012 and July 2013. Per patient, all complications occurring during admission or in the 30-day period after discharge were documented. All hospital costs related to the (PP)PD were defined as the costs of all medical interventions and resources during the hospitalisation period as recorded by the electronic supply tracking system.

RESULTS

The median hospital costs ranged from €17 482 for a patient without complications to €55 623 for a patient with a post-operative haemorrhage. A post-operative haemorrhage was associated with a 39.6% increase in total hospital costs after adjusting for patient characteristics. Other factors significantly associated with an increase in total hospital costs were: the presence of a malignancy other than a pancreatic adenocarcinoma (29.4% cost increase), the severity grade of a complication (34.3-70.6% increase) and the presence of a post-operative infection (32.4% increase).

CONCLUSIONS

This study provides an in-depth analysis of hospital costs and identifies factors that are associated with substantial cost consequences of specific complications occurring after a PD.

Minimising post-operative risk using a Post-Anaesthetic Care Tool (PACT): protocol for a prospective observational study and cost-effectiveness analysis

INTRODUCTION

While the risk of adverse events following surgery has been identified, the impact of nursing care on early detection of these events is not well established. A systematic review of the evidence and an expert consensus study in post-anaesthetic care identified essential criteria for nursing assessment of patient readiness for discharge from the post-anaesthetic care unit (PACU). These criteria were included in a new nursing assessment tool, the Post-Anaesthetic Care Tool (PACT), and incorporated into the post-anaesthetic documentation at a large health service. The aim of this study is to test the clinical reliability of the PACT and evaluate whether the use of PACT will (1) enhance the recognition and response to patients at risk of deterioration in PACU; (2) improve documentation for handover from PACU nurse to ward nurse; (3) result in improved patient outcomes and (4) reduce healthcare costs.

METHODS AND ANALYSIS

A prospective, non-randomised, pre-implementation and post-implementation design comparing: (1) patients (n=750) who have surgery prior to the implementation of the PACT and (2) patients (n=750) who have surgery after PACT. The study will examine the use of the tool through the observation of patient care and nursing handover. Patient outcomes and cost-effectiveness will be determined from health service data and medical record audit. Descriptive statistics will be used to describe the sample and compare the two patient groups (pre-intervention and post-intervention). Differences in patient outcomes between the two groups will be compared using the Cochran-Mantel-Haenszel test and regression analyses and reported as ORs with the corresponding 95% CIs.

CONCLUSIONS

This study will test the clinical reliability and cost-effectiveness of the PACT. It is hypothesised that the PACT will enable nurses to recognise and respond to patients at risk of deterioration, improve handover to ward nurses, improve patient outcomes, and reduce healthcare costs.

Quantifying the Economic Impact of Provider Volume Through Adverse Events: The Case of Sports Medicine

BACKGROUND

Procedures performed by surgeons with higher provider volumes offer advantages both to the individual patient and the health system, with studies documenting fewer adverse events, shorter surgical times, and decreased reoperation rates. With workforce requirements for surgeons growing, it is increasingly necessary to establish the most efficient structure of this workforce.

HYPOTHESIS

Substantial economic savings are realized when procedures are performed by high-volume providers as compared with low-volume providers in the areas of readmission, prolonged admission, and subsequent surgery.

STUDY DESIGN

Economic and decision analysis; Level of evidence, 2.

METHODS

This study utilized decision modeling to estimate the cost savings to high-volume providers in sports medicine. Simple decision models were constructed for 3 common procedures: anterior cruciate ligament (ACL) reconstruction, rotator cuff repair, and total shoulder arthroplasty. Outcome probabilities for adverse events (readmission, prolonged admission, and subsequent surgery) and costs were taken from the literature. A Monte Carlo simulation reflecting the incidence of these procedures in the United States was performed to estimate the total nationwide cost of these procedures, and the impact of both negative and positive policies on this cost were examined using sensitivity analysis.

RESULTS

The costs per case attributable to adverse outcomes for ACL reconstruction (in 2010 US$) were $496, $781, and $868 for high-, medium-, and low-volume providers, respectively. For rotator cuff repair, these numbers were $523, $640, and $872, and for total shoulder arthroplasty, $1692, $1876, and $2021, respectively. Sensitivity analysis revealed that a 50% increase in the number of these 3 procedures performed by high-volume surgeons could save the health system $23.1 million. If all procedures were performed by high-volume surgeons, the health system could save $72 million.

CONCLUSION

The hypothesis was accepted; higher provider volumes for surgeons do convey substantial societal economic benefits. Policies to incentivize and facilitate a greater portion of procedures being performed by high-volume surgeons may increase the efficiency of resource utilization in health care delivery.

Incidence and risk factors of postoperative pulmonary complications in noncardiac Chinese patients: a multicenter observational study in university hospitals

Purpose. To assess the incidence of postoperative pulmonary complications (PPCs) in Chinese inpatients, and to develop a brief predictive risk index. Methods. Between August 6, 2012, and August 12, 2012, patients undergoing noncardiac operations in four university hospitals were enrolled. The cohort was divided into two subsamples, cohort 1 to develop a predictive risk index of PPCs and cohort 2 to validate it. Results. 1673 patients were enrolled. PPCs were recorded for 163 patients (9.7%), of whom the hospital length of stay (LOS) was longer (P < 0.001). The mortality was 1.84% in patients with PPCs and 0.07% in those without. Logistic Regression modeling in cohort 1 identified nine independent risk factors, including smoking, respiratory infection in the last month, preoperative antibiotic use, preoperative saturation of peripheral oxygen, surgery site, blood lost, postoperative blood glucose, albumin, and ventilation. The model was validated within cohort 2 with an area under the receiver operating characteristic curve of 0.90 (95% CI 0.86 to 0.94). Conclusions. PPCs are common in noncardiac surgical patients and are associated with prolonged LOS in China. The current study developed a risk index, which can be used to assess individual risk of PPCs and guide individualized perioperative respiratory care.

Incidence, outcome, and attributable resource use associated with pulmonary and cardiac complications after major small and large bowel procedures

Background

Complications increase the costs of care of surgical patients. We studied the Premier database to determine the incidence and direct medical costs related to pulmonary complications and compared it to cardiac complications in the same cohort.

Methods

We identified 45,969 discharges in patients undergoing major bowel procedures. Postoperative pulmonary and cardiac complications were identified through the use of International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes and through the use of daily resource use data. Pulmonary complications included pneumonia, tracheobronchitis, pleural effusion, pulmonary failure, and mechanical ventilation more than 48 h after surgery. Cardiac complications included ventricular fibrillation, acute myocardial infarction, cardiogenic shock, cardiopulmonary arrest, transient ischemia, premature ventricular contraction, and acute congestive heart failure.

Results

Postoperative pulmonary complications (PPC) or postoperative cardiac complications (PCC) were present in 22% of cases; PPC alone was most common (19.0%), followed by PPC and PCC (1.8%) and PCC alone (1.2%). The incremental cost of PPC is large ($25,498). In comparison, PCC alone only added $7,307 to the total cost.

Conclusions

The current study demonstrates that postoperative pulmonary complications represent a significant source of morbidity and incremental cost after major small intestinal and colon surgery and have greater incidence and costs than cardiac complications alone. Therefore, strategies to reduce the incidence of these complications should be targeted as means of improving health and bending the cost curve in health care.

Severe postoperative complications adversely affect long-term survival after R1 resection for pancreatic head adenocarcinoma

BACKGROUND

Survival after pancreatic head adenocarcinoma surgery is determined by tumor characteristics, resection margins, and adjuvant chemotherapy. Few studies have analyzed the long-term impact of postoperative morbidity. The aim of the present study was to assess the impact of postoperative complications on long-term survival after pancreaticoduodenectomy for cancer.

METHODS

Of 294 consecutive pancreatectomies performed between January 2000 and July 2011, a total of 101 pancreatic head resections for pancreatic ductal adenocarcinoma were retrospectively analyzed. Postoperative complications were classified on a five-grade validated scale and were correlated with long-term survival. Grade IIIb to IVb complications were defined as severe.

RESULTS

Postoperative mortality and morbidity were 5 and 57 %, respectively. Severe postoperative complications occurred in 16 patients (16 %). Median overall survival was 1.4 years. Significant prognostic factors of survival were the N-stage of the tumor (median survival 3.4 years for N0 vs. 1.3 years for N1, p = 0.018) and R status of the resection (median survival 1.6 years for R0 vs. 1.2 years for R1, p = 0.038). Median survival after severe postoperative complications was decreased from 1.9 to 1.2 years (p = 0.06). Median survival for N0 or N1 tumor or after R0 resection was not influenced by the occurrence and severity of complications, but patients with a R1 resection and severe complications showed a worsened median survival of 0.6 vs. 2.0 years without severe complications (p = 0.0005).

CONCLUSIONS

Postoperative severe morbidity per se had no impact on long-term survival except in patients with R1 tumor resection. These results suggest that severe complications after R1 resection predict poor outcome.

Hospital costs associated with surgical morbidity after elective colorectal procedures: a retrospective observational cohort study in 530 patients

BACKGROUND

Postoperative complications contribute to morbidity and mortality. This study assessed the impact of surgical complications on healthcare resource utilization for patients undergoing elective colorectal procedures.

METHOD

Data were obtained on 530 consecutive colorectal operations performed from January 2010 to January 2011. Patient demographics, type of procedure, surgical complications classified as Clavien 1-5, length of stay, 60-day readmission rate, and hospital costs were recorded.

RESULTS

Seventy-five percent of the operations were associated with malignancy, and 26% were pelvic procedures. Thirty-five percent of the patients developed at least one complication, 21% of the complications did not require intervention. The readmission rate was 7.4%. Nine patients died during 60-day post discharge follow up.Median length of stay was 9 (3-34) days in uncomplicated and 16 (4-205) days in complicated cases. Occurrence of any complication at index admission increased total hospital costs 2.1-fold (EUR 25,680 vs. EUR 12,405), with the largest cost differential attributed to wound dehiscence and/or suture line failure requiring reoperation. These increases were primarily due to prolonged hospitalization and ICU expenditures. Readmission resulted in a further increase to an average cost of EUR 12,585 per re-admitted patient.Multivariate analysis showed that BMI > 25, obesity, operation complexity and surgeon significantly affected the risk for complication. Also, hospital costs were significantly increased by any postoperative complications, reoperations, high complexity of surgical procedures and high comorbidity index.

CONCLUSIONS

Reducing morbidity after colorectal procedures improves quality of care and patient safety, and may also substantially reduce hospital costs and increase the efficiency of resource utilization.

Tracking the aesthetic outcomes of prosthetic breast reconstructions that have complications

BACKGROUND

Aesthetic results following breast reconstruction have been shown to be a major contributor to patient satisfaction. While many presume that complications after reconstruction impact final aesthetic results, little data exist to substantiate this putative relationship.

OBJECTIVE

To track and evaluate aesthetic outcomes following implant reconstructions with complications.

METHODS

A chart review was conducted on a series of consecutive expander-implant breast reconstructions performed by the senior author between 2004 and 2012. Included patients completed their prosthetic reconstruction or converted to autologous methods and had a minimum follow-up period of 130 days. Four blinded members of the division of plastic surgery independently rated postoperative anterior photographs of patients' breasts using a validated scoring scale with respect to five distinct aesthetic domains: breast mound volume, contour, placement, scarring and inframammary fold.

RESULTS

Of the 172 patients who met the inclusion criteria, 36 experienced a complication. The tissue expander in one-half of these patients was salvaged and the remaining patients converted to autologous reconstruction. The average aesthetic scores for each domain did not differ significantly between patients who experienced a complication and retained their expander and those who did not experience a complication. Patients who converted to autologous tissue reconstruction after experiencing a complication had the highest aesthetic scores.

DISCUSSION

The ability to obtain aesthetic results following a complication that were not statistically different from results in those without complications may reflect the surgeon's refined attempt to salvage the initial implant reconstruction; in other circumstances, the improved cosmesis was achieved through conversion to an autologous tissue-based method.

CONCLUSION

The present study quantitatively assessed the impact of complications on aesthetic outcomes following implant breast reconstruction. Continuance of prosthetic reconstruction and conversion to autologous reconstruction serve as viable options to obtain adequate aesthetic scores following a complication. Information gained from the present analysis will help manage patient expectations.

Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy

BACKGROUND

Prolonged operative duration is associated with increased postoperative morbidity and mortality. Although laparoscopic colectomy (LC) is associated with longer operative duration compared with open colectomy (OC), research shows paradoxically decreased morbidity following LC versus OC. The direct impact of operative duration on postoperative pulmonary complications (PPC) following LC versus OC has not been analyzed.

METHODS

We queried the ACS/NSQIP 2009-2010 Public Use File for patients who underwent elective LC and OC. The associations between operative duration and a PPC (pneumonia, intubation >48 h, and unplanned intubation) were evaluated. Multivariable regression models were created to determine the independent effect of operative time on the development of PPC controlling for LC versus OC.

RESULTS

A total of 25,419 colectomies (13,741 laparoscopic and 11,678 open) were reviewed; 765 (3 %) patients experienced at least one PPC. Regression modeling demonstrated that for both LC and OC each 60-min increase in operative time up to 480 min was associated with 13 % increased odds of PPC [odds ratio (OR) 1.13; 95 % confidence interval (CI) 1.07-1.19]. Beyond 480 min, each additional 60-min interval was associated with 33 % increased risk of PPC (OR 1.33; 95 % CI 1.12-1.58). Overall, PPCs occurred half as often following LC [270 (2 %) laparoscopic vs. 497 (4.3 %) open; OR 0.45; 95 % CI 0.39-0.53].

CONCLUSIONS

Operative duration is independently associated with increased risk of PPC in patients undergoing LC and OC. However, a laparoscopic approach carries half the absolute risk of PPC and, when safe, should be preferentially utilized despite a potential for prolonged operative duration.

Exploring predictors of complication in older surgical patients: a deficit accumulation index and the Braden Scale

OBJECTIVES

To determine whether readily collected perioperative information might identify older surgical patients at higher risk of complications.

DESIGN

Retrospective cohort study.

SETTING

Medical chart review at a single academic institution.

PARTICIPANTS

One hundred two individuals aged 65 and older who underwent abdominal surgery between January 2007 and December 2009.

MEASUREMENTS

Primary predictor variables were first postoperative Braden Scale score (within 24 hours of surgery) and a Deficit Accumulation Index (DAI) constructed based on 39 available preoperative variables. The primary outcome was presence or absence of complication within 30 days of surgery.

RESULTS

Of 102 patients, 64 experienced at least one complication, with wound infection being the most common. In models adjusted for age, race, sex, and open versus laparoscopic surgery, lower Braden Scale scores were predictive of 30-day postoperative complication (odds ratio (OR) = 1.30, 95% confidence interval (CI) = 1.06-1.60), longer length of stay (β = 1.44 (0.25) days; P ≤ .001), and discharge to an institution rather than home (OR = 1.23, 95% CI = 1.02-1.48). The cut-off value for the Braden score with the highest predictive value for complication was ≤ 18 (OR = 3.63, 95% CI = 1.43-9.19; c statistic 0.744). The DAI and several traditional surgical risk factors were not significantly associated with 30-day postoperative complications.

CONCLUSION

This is the first study to identify the perioperative Braden Scale score, a widely used risk-stratifier for pressure ulcers, as an independent predictor of other adverse outcomes in geriatric surgical patients. Further studies are needed to confirm this finding and to investigate other uses for this tool, which correlates well to phenotypic models of frailty.

Economics of less invasive spinal surgery: an analysis of hospital cost differences between open and minimally invasive instrumented spinal fusion procedures during the perioperative period

BACKGROUND

There is great debate about the costs and benefits of technology-driven medical interventions such as instrumented lumbar fusion. With most analyses using charge data, the actual costs incurred by medical institutions performing these procedures are not well understood. The object of the current study was to examine the differences in hospital operating costs between open and minimally invasive spine surgery (MIS) during the perioperative period.

METHODS

Data were collected in the form of a prospective registry from a community hospital after specific Institutional Review Board approval was obtained. The analysis included consecutive adult patients being surgically treated for degenerative conditions of the lumbar spine, with either an MIS or open approach for two-level instrumented lumbar fusion. Patient outcomes and costs were collected for the perioperative period. Hospital operating costs were grouped by hospitalization/operative procedure, transfusions, reoperations, and residual events (health care interactions).

RESULTS

One hundred and one open posterior lumbar interbody fusion (Open group) and 109 MIS patients were treated primarily for stenosis coupled with instability (39.6% and 59.6%, respectively). Mean total hospital costs were $27,055.53 for the Open group and $24,320.16 for the MIS group. This represents a statistically significant cost savings of $2,825.37 (10.4% [95% confidence interval: $522.51-$5,128.23]) when utilizing MIS over traditional Open techniques. Additionally, residual events, complications, and blood transfusions were significantly more frequent in the Open group, compared to the MIS group.

CONCLUSIONS/LEVEL OF EVIDENCE

Utilizing minimally invasive techniques for instrumented spinal fusion results in decreased hospital operating costs compared to similar open procedures in the early perioperative period. Additionally, patient benefits of minimally invasive techniques include significantly less blood loss, shorter hospital stays, lower complication rate, and a lower number of residual events. Long-term outcome comparisons are needed to evaluate the efficacy of the two treatments.

LEVEL OF EVIDENCE

III CLINICAL RELEVANCE: This work represents a true cost-of-operating comparison between open and MIS approaches for lumbar spine fusion, which has relevance to surgeons, hospitals and payers in medical decision-making.

Perception of surgical complications among patients, nurses and physicians: a prospective cross-sectional survey

Background

Several scores grade the severity of post-operative complications but it is unclear whether such scores truly reflect the perception of patients and practicing nurses and physicians.

Study Design

227 patients, 143 nurses and 245 physicians independently rated the severity of 30 common post-operative complications on a numerical analogue scale from 0 (not severe at all) to 100 (extremely severe) while being blinded towards the Clavien-Dindo classification. We considered a difference in ratings of >10 to be clinically important in distinguishing between grades of severity and groups. We evaluated the level of reproducibility of responses by calculating intraclass correlation coefficients (ICC) and compared scores across severity grades and between groups using the generalized estimating equations.

Results

Reproducibility of the ratings was good for all three groups (ICCpatients 0.71 (95%-CI 0.64-0.76), ICCnurses 0.83 (0.78-0.87) and ICCphysicians 0.87 (0.83-0.90)). The participants' perceptions of the severity of complications reflected the Clavien-Dindo classification (median of grade I: 20 (IQR 10-30), grade II: 40 (31.3-52.5), grade IIIa: 50 (40-60), grade IIIb: 70 (60-75), grade IVa: 85 (80-90) and grade IVB: 95 (90-100)). Although patients' perception differed significantly from those of physicians (average difference -8.7 (95%-CI -10.4 to -6.9, p < 0.001) and nurses (difference -2.8 (-4.8 to -0.8, p = 0.007) they did not reach our thresholds for clinical importance.

Conclusions

The severity of post-operative complications is perceived similarly by patients, nurses and physicians and reflects the Clavien-Dindo classification well. Our results support the use of Clavien-Dindo classification system as part of the shared or informed decision making process.

Non-cardiac surgery in developing countries: epidemiological aspects and economical opportunities--the case of Brazil

Background

Worldwide distribution of surgical interventions is unequal. Developed countries account for the majority of surgeries and information about non-cardiac operations in developing countries is scarce. The purpose of our study was to describe the epidemiological data of non-cardiac surgeries performed in Brazil in the last years.

Methods and Findings

This is a retrospective cohort study that investigated the time window from 1995 to 2007. We collected information from DATASUS, a national public health system database. The following variables were studied: number of surgeries, in-hospital expenses, blood transfusion related costs, length of stay and case fatality rates. The results were presented as sum, average and percentage. The trend analysis was performed by linear regression model. There were 32,659,513 non-cardiac surgeries performed in Brazil in thirteen years. An increment of 20.42% was observed in the number of surgeries in this period and nowadays nearly 3 million operations are performed annually. The cost of these procedures has increased tremendously in the last years. The increment of surgical cost was almost 200%. The total expenses related to surgical hospitalizations were more than $10 billion in all these years. The yearly cost of surgical procedures to public health system was more than $1.27 billion for all surgical hospitalizations, and in average, U$445.24 per surgical procedure. The total cost of blood transfusion was near $98 million in all years and annually approximately $10 million were spent in perioperative transfusion. The surgical mortality had an increment of 31.11% in the period. Actually, in 2007, the surgical mortality in Brazil was 1.77%. All the variables had a significant increment along the studied period: r square (r²) = 0.447 for the number of surgeries (P = 0.012), r² = 0.439 for in-hospital expenses (P = 0.014) and r² = 0.907 for surgical mortality (P = 0.0055).

Conclusion

The volume of surgical procedures has increased substantially in Brazil through the past years. The expenditure related to these procedures and its mortality has also increased as the number of operations. Better planning of public health resource and strategies of investment are needed to supply the crescent demand of surgery in Brazil.

Validation of coding algorithms for the identification of patients with primary biliary cirrhosis using administrative data

BACKGROUND

Large-scale epidemiological studies of primary biliary cirrhosis (PBC) have been hindered by difficulties in case ascertainment.

OBJECTIVE

To develop coding algorithms for identifying PBC patients using administrative data--a widely available data source.

METHODS

Population-based administrative databases were used to identify patients with a diagnosis code for PBC from 1994 to 2002. Coding algorithms for confirmed PBC (two or more of antimitochondrial antibody positivity, cholestatic liver biochemistry and/or compatible liver histology) were derived using chart abstraction data as the reference. Patients with a recorded PBC diagnosis but insufficient confirmatory data were classified as 'suspected PBC'.

RESULTS

Of 189 potential PBC cases, 119 (60%) had confirmed PBC and 28 (14%) had suspected PBC. The optimal algorithm including two or more uses of a PBC code had a sensitivity of 94% (95% CI 71% to 100%) and positive predictive values of 73% (95% CI 61% to 75%) for confirmed PBC, and 89% (95% CI 82% to 94%) for confirmed or suspected PBC. Sensitivity analyses revealed greater accuracy among women, and with the use of multiple data sources and one or more years of data. Inclusion of diagnosis codes for conditions frequently misclassified as PBC did not improve algorithm performance.

CONCLUSIONS

Administrative databases can reliably identify patients with PBC and may facilitate epidemiological investigations of this condition.

Antimicrobial prophylaxis in colorectal surgery: focus on ertapenem

Despite improvement in infection control measures and surgical practice, surgical site infections (SSIs) remain a major cause of morbidity and mortality. In colorectal surgery, perioperative administration of a suitable antimicrobial regimen that covers both anaerobic and aerobic bacteria is universally accepted. In a prospective, double-blind, randomized study ertapenem was recently found to be more effective than cefotetan, a parenteral cephalosporin so broadly used as to be considered as gold standard in the prevention of SSIs following colorectal surgery. In this adequate and well controlled study, the superiority of ertapenem over cefotetan was clearly demonstrated from the clinical and bacteriological points of view. However, data that directly compares ertapenem with other antimicrobial regimen effective in preventing SSIs following colorectal surgery are lacking; furthermore, the possible risk of promotion of carbapenem resistance associated with widespread use of ertapenem prophylaxis as well as the ertapenem effects on the intestinal gut flora are of concern. Further comparative studies of ertapenem versus other widely used prophylactic regimens for colorectal surgery in patients submitted to mechanical bowel preparation versus no preparation as well as further research on adverse events of antibiotic prophylaxis, including emergence of resistance and Clostridium difficile infection, seem warranted.

Point prevalence of wounds in a sample of acute hospitals in Canada

To provide new information on wound prevalence and the potential resource impact of non healing wounds in the acute sector by summarising results from wound audits carried out at 13 acute hospitals in Canada in 2006 and 2007. Audits were carried out in each hospital by the same independent team of advanced practice nurses using standard data-collection forms. The results reported here were derived from the summary reports for each hospital. A total of 3099 patients were surveyed (median 259 patients per hospital). In the sample hospitals, the mean prevalence of patients with wounds was 41.2%. Most wounds were pressure ulcers (56.2%) or surgical wounds (31.1%). The mean prevalence of pressure ulcers was 22.9%. A majority of pressure ulcers (79.3%) were hospital-acquired, and 26.5% were severe (Stage III or IV). The rate of surgical wound infection was 6.3%. Forty-five percent of patients had dressings changed at least daily and the mean dressing time was 10.5 minutes. Wounds are a common and potentially expensive occurrence in acute hospitals. Any wound has the potential to develop complications which compromise patient safety and increase hospital costs. Ensuring consistent, best-practice wound management programmes should be a key priority for hospital managers.

Patient personality predicts postoperative stay after colorectal cancer resection

OBJECTIVE

Postoperative length of stay (LOS) is an important outcome after colorectal cancer surgery. The aim of this study was to evaluate the putative effects of personality, mood, coping and quality of life on LOS.

METHOD

A consecutive series of 110 eligible patients undergoing elective resection for colorectal cancer were invited to participate in the study. A battery of psychometric questionnaires including the Hospital Anxiety and Depression Scale, the Functional Assessment of Cancer Therapy (colorectal), the Courtauld Emotional Control Scale, the Positive and Negative Affectivity Scale and the Eysenck Personality Questionnaire (EPQ) were administered 5-12 days before surgery. Nonparametric correlations were computed for psychometric scores, demographic variables and the LOS. Factors found to be significantly correlated on this analysis were entered into a multiple regression model to determine the independent predictors of LOS.

RESULTS

One hundred and four patients with colorectal cancer participated. Seventy were male (67%) and the mean age was 68 years (range 39-86). The median LOS was 10 days (range 4-108). LOS was negatively correlated with pre- and postoperative albumin levels, PANAS +ve affect, Functional Assessment of Cancer Therapy questionnaire with the colorectal module functional well-being score and EPQ extroversion score. LOS was strongly positively correlated with postoperative morbidity. LOS was positively correlated with CECS anger score, age and being male. Postoperative morbidity (beta = 0.379, P = 0.007) and extroversion (beta = -0.318, P = 0.05) were independent predictors of LOS.

CONCLUSION

Personality as measured by EPQ predicts postoperative LOS in patients with colorectal cancer. Extroverts have a higher pain threshold and this may be part of the explanation.

Validation of ICD-9-CM/ICD-10 coding algorithms for the identification of patients with acetaminophen overdose and hepatotoxicity using administrative data

Background

Acetaminophen overdose is the most common cause of acute liver failure (ALF). Our objective was to develop coding algorithms using administrative data for identifying patients with acetaminophen overdose and hepatic complications.

Methods

Patients hospitalized for acetaminophen overdose were identified using population-based administrative data (1995–2004). Coding algorithms for acetaminophen overdose, hepatotoxicity (alanine aminotransferase >1,000 U/L) and ALF (encephalopathy and international normalized ratio >1.5) were derived using chart abstraction data as the reference and logistic regression analyses.

Results

Of 1,776 potential acetaminophen overdose cases, the charts of 181 patients were reviewed; 139 (77%) had confirmed acetaminophen overdose. An algorithm including codes 965.4 (ICD-9-CM) and T39.1 (ICD-10) was highly accurate (sensitivity 90% [95% confidence interval 84–94%], specificity 83% [69–93%], positive predictive value 95% [89–98%], negative predictive value 71% [57–83%], c-statistic 0.87 [0.80–0.93]). Algorithms for hepatotoxicity (including codes for hepatic necrosis, toxic hepatitis and encephalopathy) and ALF (hepatic necrosis and encephalopathy) were also highly predictive (c-statistics = 0.88). The accuracy of the algorithms was not affected by age, gender, or ICD coding system, but the acetaminophen overdose algorithm varied between hospitals (c-statistics 0.84–0.98; P = 0.003).

Conclusion

Administrative databases can be used to identify patients with acetaminophen overdose and hepatic complications. If externally validated, these algorithms will facilitate investigations of the epidemiology and outcomes of acetaminophen overdose.

The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery

Among the most common complications that occur after surgery are surgical site infections and postoperative sepsis, cardiovascular complications, respiratory complications (including postoperative pneumonia), and thromboembolic complications. Patients who experience postoperative complications have dramatically increased hospital length of stay, hospital costs, and mortality rates. The Centers for Medicare & Medicaid Services, in collaboration with the Centers for Disease Control and Prevention, has implemented the Surgical Infection Prevention Project to decrease the morbidity and mortality associated with postoperative surgical site infections. More recently, the Surgical Care Improvement Project, a national quality partnership of organizations committed to improving the safety of surgical care, has been announced. This review will provide an update from the Surgical Infection Prevention Project and provide an introduction to the Surgical Care Improvement Project.