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

Prediction of 30-day morbidity after primary cytoreductive surgery for advanced stage ovarian cancer

OBJECTIVE

Treatment in advanced stage epithelial ovarian cancer (EOC) is based on primary cytoreductive surgery followed by platinum-based chemotherapy. Successful cytoreduction to minimal residual tumour burden is the most important determinant of prognosis. However, extensive surgical procedures to achieve maximal debulking are inevitably associated with postoperative morbidity and mortality. The objective of this study is to determine predictors of 30-day morbidity after primary cytoreductive surgery for advanced stage EOC.

METHODS

All patients in the South Western part of the Netherlands who underwent primary cytoreductive surgery for advanced stage EOC between January 2004 and December 2007 were identified from the Rotterdam Cancer Registry database. All peri- and postoperative complications within 30 days after surgery were registered and classified according to the definitions of the National Surgical Quality Improvement Programme (NSQIP). To investigate independent predictors of 30-day morbidity, a Cox proportional hazards model with backward stepwise elimination was utilised. The identified predictors were entered into a nomogram.

RESULTS

Two hundred and ninety-three patients entered the study protocol. Optimal cytoreduction was achieved in 136 (46%) patients. 30-day morbidity was seen in 99 (34%) patients. Postoperative morbidity could be predicted by age (P=0.007; odds ratio [OR] 1.034), WHO performance status (P=0.046; OR 1.757), extent of surgery (P=0.1308; OR=2.101), and operative time (P=0.017; OR 1.007) with an optimism corrected c-statistic of 0.68.

CONCLUSION

30-day morbidity could be predicted by age, WHO performance status, operative time and extent of surgery. The generated nomogram could be valuable for predicting operative risk in the individual patient.

Body mass index and major cancer surgery outcomes: lack of association or need for alternative measurements of obesity?

BACKGROUND

Although surgical studies have reported inconsistent associations between increased body mass index (BMI) and operative outcomes, the accuracy of BMI for measuring obesity has been questioned in previous epidemiologic studies. Simultaneously, BMI has known comorbidities, which may mediate the effect of BMI if included in multivariable models. We sought to examine the effect of BMI on operative outcomes after adjusting for preoperative factors.

METHODS

We identified 8858 patients who underwent major thoracic, abdominal, and pelvic surgery for solid organ tumors in American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) centers from 2005 to 2007. We used multivariable analyses to assess the effect of BMI on short-term operative outcomes after controlling for covariates.

RESULTS

Increased BMI was not associated with worse short-term operative outcomes in our bivariable analyses. However, patients with BMI > or = 35 had higher American Society of Anesthesiologists scores, longer operative times, and an increased number of postoperative complications (P < 0.0001). After adjusting for pre- and intraoperative factors, BMI did not predict any short-term operative outcome except for an increased total number of complications in BMI > or = 35. These results persisted after removing potential mediators from the multivariable analysis.

CONCLUSIONS

In ACS NSQIP, BMI has minimal association with short-term operative outcomes after major cancer surgery. Although these findings may suggest a lack of association between obesity and cancer surgery outcomes, it confirms the previously examined limitations of BMI. Because of the rising incidence of obesity in the United States and its challenging effect on surgeon's practice, ACS NSQIP should consider exploring alternative measures of general and abdominal obesity.

Shoulder arthroplasties have fewer complications than hip or knee arthroplasties in US veterans

Total shoulder arthroplasties (TSA) are being performed more commonly for treatment of arthritis, although fewer than either hip (THA) or knee (TKA) arthroplasties. Total shoulder arthroplasty also provides general health improvements that are comparable to THA. One study suggests TSAs are associated with lower morbidity and mortality than THAs and TKAs. To confirm and extend that study, we therefore examined the association of patient characteristics (sociodemographics, comorbid illness, and other risk factors) with 30-day complications for patients undergoing TSAs, THAs, or TKAs. We used data from the Veterans Administration (VA) National Surgical Quality Improvement Program (NSQIP) for fiscal years 1999 to 2006. Sociodemographics, comorbidities, health behaviors, operative factors, and complications (mortality, return to the operating room, readmission within 14 days, cardiovascular events, and infections) were available for 10,407 THAs, 23,042 TKAs, and 793 TSAs. Sociodemographic features were comparable among groups. The mean operative time was greater for TSAs (3.0 hours) than for TKAs (2.2 hours) and THAs (2.4 hours). The 30-day mortality rates were 1.2%, 1.1%, and 0.4% for THAs, TKAs, and TSAs, respectively. The corresponding postoperative complication rates were 7.6%, 6.8%, and 2.8%. Adjusting for multiple risk factors, complications, readmissions, and postoperative stays were less for TSAs versus THAs and TKAs. In a VA population, TSAs required more operative time but resulted in shorter stays, fewer complications, and fewer readmissions than THAs and TKAs.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Resection for esophageal cancer in the elderly

Although studies differ in their definition of the older patient, increasing age, when considered as a continuum, is associated with greater operative mortality. Complication rates also seem to be significantly higher with advancing age, possibly because of limited physiologic reserve. As the understanding of risk factors for perioperative morbidity and mortality following esophagectomy has improved, investigators have sought to develop models for risk stratification in which patient age is a significant but not the sole determinant of prospective assessment of risk for complication or mortality. Such prognostic indicators, if validated among independent patient cohorts, can serve as useful adjuncts in decision making with appropriate clinical judgment. In addition, reported patient survival differs dramatically between rates reported by single centers and rates observed in population-based studies, with operative mortality rates typically lower in single-center reports. Although such reports usually are issued from groups with higher operative volume that might be a surrogate for surgical experience, it also is possible that the association between operation volume and improved outcomes reflects optimization of institution-specific infrastructure and/or clinical care pathways. As these processes of care evolve, they should be tailored with attention to differences in the care of older patients who have esophageal cancer. Whether widespread application of such processes of care then can lead to less perioperative mortality and fewer complications and to improved long-term survival remains untested.

Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization

BACKGROUND

Little is known about the significance of blood transfusion in patients with peripheral arterial disease. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to examine the effect of intraoperative blood transfusion on the morbidity and mortality in patients who underwent lower extremity revascularization.

METHODS

We analyzed data from the participant use data file containing vascular surgical cases submitted to the ACS NSQIP in 2005, 2006, and 2007 by 173 hospitals. Current procedural terminology codes were used to select lower extremity procedures that were grouped into venous graft, prosthetic graft, or thromboendarterectomy. Thirty-day outcomes analyzed were (1) mortality, (2) composite morbidity, (3) graft/prosthesis failure, (4) return to the operating room within 30 days, (5) wound occurrences, (6) sepsis or septic shock, (7) pulmonary occurrences, and (8) renal insufficiency or failure. Intraoperative transfusion of packed red blood cells was categorized as none, 1 to 2 units, and 3 or more units. Outcome rates were compared between the transfused and nontransfused groups using the chi(2) test and multivariable regression adjusting for transfusion propensity, comorbid and procedural risk.

RESULTS

A total of 8799 patients underwent lower extremity revascularization between 2005 and 2007. Mean age was 66.8 +/- 12.0 years and 5569 (63.3%) were male. Transfusion rates ranged from 14.5% in thromboendarterectomy patients to 27.1% in prosthetic bypass patients (P < .05). After adjustment for transfusion propensity and patient and procedural risks, transfusion of 1 or 2 units remained significantly predictive of mortality, composite morbidity, sepsis/shock, pulmonary occurrences, and return to the operating room. The adjusted odds ratios for 30-day mortality ranged from 1.92 (95% confidence interval [CI] 1.36-2.70) for 1 to 2 units to 2.48 (95% CI 1.55-3.98) for 3 or more units.

CONCLUSION

In a large number of patients undergoing lower extremity revascularization, we have found that there is a higher risk of postoperative mortality, pulmonary, and infectious complications after receiving intraoperative blood transfusion. Additional studies are necessary to better define transfusion triggers that balance the risk/benefit ratio for blood transfusion.

Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach

The history and development of the NSQIP, from its inception in the Veterans Administration Health System to its implementation within the private sector sponsored by the ACS, documents the growth of a program that has substantially improved the quality of surgical care and has had a considerable influence on the culture of quality improvement in the profession. The success of the ACS NSQIP is the result of providing hospitals with rigorous, clinical data, networking opportunities, and resources to improve their risk-adjusted outcomes. In this manner, the ACS NSQIP challenges its hospitals and health care providers to continually improve the care they provide. In addition to reducing the complications and mortality experienced by patients after surgical procedures, hospitals that participate in the ACS NSQIP have seen the financial rewards of their quality improvement efforts. Continued growth of the ACS NSQIP will facilitate achievement of the primary goal surrounding the current health care reform debate: efficient, high-quality care.

Impact of obesity on outcomes after open surgical and endovascular abdominal aortic aneurysm repair

BACKGROUND

This study examined impact of obesity on outcomes after abdominal aortic aneurysm repair.

STUDY DESIGN

Data were obtained from the Veterans Affairs National Surgical Quality Improvement Program. Body mass index (BMI) was categorized according to National Institutes of Health guidelines. Multivariate regression adjusted for 40 other risk factors to analyze trends in complications and death within 30 days.

RESULTS

We identified 2,201 patients undergoing 1,185 open and 1,016 endovascular aneurysm repairs (EVAR) for abdominal aortic aneurysms from January 2004 through December 2005. BMI distribution was identical in both groups and reflected national population statistics: approximately 30% were normal (BMI 18.5 to 24.9), 40% were overweight (25.0 to 29.9), and 30% were obese class I (30.0 to 34.9), II (35.0 to 39.9), or III (>/=40.0). After open repair, obesity of any class was independently predictive of wound complications (adjusted odds ratio = 2.4; 95% CI, 1.5 to 5.3; p = 0.002). Class III obesity was also an independent predictor or renal complications (adjusted odds rato = 6.3; 95% CI, 2.2 to 18.0; p < 0.0001) and cardiac complications (adjusted odds ratio = 4.5; 95% CI, 1.1 to 22.9; p = 0.045. After EVAR, obesity (any class) was predictive of wound complications (adjusted odds ratio = 3.1; 95% CI, 1.1 to 8.1; p = 0.026), but not predictive of other complications or death. Between the two types of operation, there were fewer complications and deaths after EVAR compared with open repair across all BMI categories, but outcomes were most disparate among the obese.

CONCLUSIONS

Obesity is an independent risk factor that surgeons should consider during patient selection and operative planning for abdominal aortic aneurysm repair. Obese patients appear to particularly benefit from successful EVAR over open repair, but if open repair is required, special attention should be paid to cardiac risk, perioperative renal protection, and aggresive wound infection prevention measures.

Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis

OBJECTIVES

Hyperglycemia during critical illness is common and is associated with increased mortality. Intensive insulin therapy has improved outcomes in some, but not all, intervention trials. It is unclear whether the benefits of treatment differ among specific patient populations. The purpose of the study was to determine the association between hyperglycemia and risk- adjusted mortality in critically ill patients and in separate groups stratified by admission diagnosis. A secondary purpose was to determine whether mortality risk from hyperglycemia varies with intensive care unit type, length of stay, or diagnosed diabetes.

DESIGN

Retrospective cohort study.

SETTING

One hundred seventy-three U.S. medical, surgical, and cardiac intensive care units.

PATIENTS

Two hundred fifty-nine thousand and forty admissions from October 2002 to September 2005; unadjusted mortality rate, 11.2%.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A two-level logistic regression model determined the relationship between glycemia and mortality. Age, diagnosis, comorbidities, and laboratory variables were used to calculate a predicted mortality rate, which was then analyzed with mean glucose to determine the association of hyperglycemia with hospital mortality. Hyperglycemia was associated with increased mortality independent of illness severity. Compared with normoglycemic individuals (70-110 mg/dL), adjusted odds of mortality (odds ratio, [95% confidence interval]) for mean glucose 111-145, 146-199, 200-300, and >300 mg/dL was 1.31 (1.26-1.36), 1.82 (1.74-1.90), 2.13 (2.03-2.25), and 2.85 (2.58-3.14), respectively. Furthermore, the adjusted odds of mortality related to hyperglycemia varied with admission diagnosis, demonstrating a clear association in some patients (acute myocardial infarction, arrhythmia, unstable angina, pulmonary embolism) and little or no association in others. Hyperglycemia was associated with increased mortality independent of intensive care unit type, length of stay, and diabetes.

CONCLUSIONS

The association between hyperglycemia and mortality implicates hyperglycemia as a potentially harmful and correctable abnormality in critically ill patients. The finding that hyperglycemia-related risk varied with admission diagnosis suggests differences in the interaction between specific medical conditions and injury from hyperglycemia. The design and interpretation of future trials should consider the primary disease states of patients and the balance of medical conditions in the intensive care unit studied.

Chemotherapy within 30 days prior to liver resection does not increase postoperative morbidity or mortality

BACKGROUND

Liver resections (LRs) are performed with increasing frequency for metastatic disease. To minimize the risk of postoperative complications, a period of 6 weeks between the last dose of chemotherapy and LR is typically recommended. The current study examines postoperative morbidity and mortality following LR in patients who received chemotherapy within 30 days prior to LR.

METHODS

The merged 2005-2007 National Surgical Quality Improvement Program (NSQIP) Participant Use File was queried for perioperative risk factors, laboratory values and postoperative occurrences or complications in patients who underwent LR. Patients were grouped according to their receipt or non-receipt of chemotherapy within 30 days prior to LR and major postoperative complications.

RESULTS

A total of 2331 patients underwent LR; 2147 did not receive chemotherapy within 30 days of resection (No Chemo group) and 184 received chemotherapy within 30 days prior to resection (Chemo group). The groups were similar with regard to preoperative co-morbidities and operative factors. The median NSQIP statistically computed morbidity probability was similar between the groups (No Chemo 0.32, Chemo 0.34; P= 0.07), whereas the median mortality probability was higher in the Chemo group (0.02) than the No Chemo group (0.014; P= 0.001). Thirty-day survival was similar between the two groups (No Chemo 97%, Chemo 98%; P= 0.44). Major complication rates did not differ between the groups (No Chemo 20%, Chemo 18%; P= 0.51). Factors associated with major complications in the Chemo group included: extent of resection; intraoperative transfusion; preoperative ascites, and preoperative haematocrit.

DISCUSSION

Major morbidity was not increased in Chemo patients. The strongest predictors of major postoperative complications in the Chemo group were extent of resection and intraoperative red cell transfusion. Although the NSQIP dataset does not include data about tumour type or chemotherapy regimen, these data suggest that LR may be safely performed within 30 days of chemotherapy, thereby minimizing the length of time during which patients do not receive systemic treatment.

Importance of nutritional management in diseases with exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) resulting from conditions such as chronic pancreatitis (CP), acute pancreatitis (AP) and upper gastrointestinal (GI) surgery increases risk for malnutrition and metabolic problems. Poor nutrition is associated with more complications and higher mortality. Therefore, effective nutritional management should be a high priority in these patients. In CP, poor nutrition has been shown to significantly affect quality of life and functional status. Clinical study data show that dietary counselling combined with pancreatic enzyme replacement therapy is effective in improving nutritional status and is therefore recommended in these patients. In AP, early enteral nutrition reduces complications and mortality. However, EPI persists in many cases after the resolution of AP; these patients remain at increased risk for malnutrition and require further nutritional support. In patients undergoing surgery, preoperative weight loss is a risk factor for postoperative morbidity and mortality; outcomes can be improved considerably by preoperative screening to identify high-risk patients and by providing appropriate perioperative nutritional support. Pre- and perioperative enteral nutrition are cost-effective interventions that can improve outcomes in patients undergoing GI surgery. In all of these patient populations, nutritional management, including risk assessment and individualized nutritional support, is a key component of an effective multimodal therapeutic approach.

Rates of surgical site infection as a performance measure: Are we ready?

With the introduction of quality assurance in health care delivery, there has been a proliferation of research studies that compare patient outcomes for similar conditions among many health care delivery facilities. Since the 1990s, increasing interest has been placed in the incorporation of clinical adverse events as quality indicators in hospital quality assurance programs. Adverse post-operative events, and very especially surgical site infection (SSI) rates after specific procedures, gained popularity as hospital quality indicators in the 1980s. For a SSI rate to be considered a valid indicator of the quality of care, it is essential that a proper adjustment for patient case mix be performed, so that meaningful comparisons of SSI rates can be made among surgeons, institutions, or over time. So far, a significant impediment to developing meaningful hospital-acquired infection rates that can be used for intra- and inter-hospital comparisons has been the lack of an adequate means of adjusting for case mix. This paper discusses what we have learned in the last years regarding risk adjustment of SSI rates for provider performance assessment, and identifies areas in which significant improvement is still needed.

Detecting adverse events in dermatologic surgery

BACKGROUND

Despite increasing awareness of and public attention to patient safety, little is documented about how adverse events (AEs) can or should be monitored in dermatologic surgery. Data to address this shortcoming are needed, although well-defined methodologies have yet to be implemented. OBJECTIVE To summarize current strategies in detecting adverse outcomes of dermatologic surgical procedures.

MATERIALS AND METHODS

A Medline literature search was conducted using the terms "adverse event,""detection,""reporting,""monitoring," and "surgery." Articles selected addressed the efficacy of one or more AE reporting techniques in surgical patients.

RESULTS

Prospective and retrospective reporting methods were identified, with morbidity and mortality conference being the most commonly used method of AE reporting. Retrospective medical record review, the retrospective trigger tool approach, and an anonymous electronic reporting system were more sensitive approaches. The Surgical Quality Improvement Program, a program that has successfully translated AE data into lower postoperative morbidity and mortality, was analyzed.

CONCLUSIONS

Although generally considered safe, dermatologic surgery has no current standard for AE reporting. Standard definitions and high-quality data regarding AEs" currently limit this analysis. Pilot studies are needed to develop feasible measures, with the goal of increasing the sensitivity of AE detection and ultimately improving patient outcomes.

Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Data used for evaluating quality of medical care need to be of high reliability to ensure valid quality assessment and benchmarking. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) has continually emphasized the collection of highly reliable clinical data through its program infrastructure.

STUDY DESIGN

We provide a detailed description of the various mechanisms used in ACS NSQIP to assure collection of high quality data, including training of data collectors (surgical clinical reviewers) and ongoing audits of data reliability. For the 2005 through 2008 calendar years, inter-rater reliability was calculated overall and for individual variables using percentages of agreement between the data collector and the auditor. Variables with > 5% disagreement are flagged for educational efforts to improve accurate collection. Cohen's kappa was estimated for selected variables from the 2007 audit year.

RESULTS

Inter-rater reliability audits show that overall disagreement rates on variables have fallen from 3.15% in 2005 (the first year of public enrollment in ACS NSQIP) to 1.56% in 2008. In addition, disagreement levels for individual variables have continually improved, with 26 individual variables demonstrating > 5% disagreement in 2005, to only 2 such variables in 2008. Estimated kappa values suggest substantial or almost perfect agreement for most variables.

CONCLUSIONS

The ACS NSQIP has implemented training and audit procedures for its hospital participants that are highly effective in collecting robust data. Audit results show that data have been reliable since the program's inception and that reliability has improved every year.

Pancreatic necrosectomy: North American mortality is much lower than expected

BACKGROUND

The aim of this analysis was to explore the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine outcomes of patients undergoing debridement for pancreatic and peripancreatic necrosis. Single-institution series suggest that the mortality of patients undergoing pancreatic necrosectomy has improved but remains at 15% to 20%. But no national data have been available for patients with necrotizing pancreatitis. In 2007, a CPT code specific for debridement of pancreatic necrosis became available.

STUDY DESIGN

The ACS-NSQIP Participant Use File was queried for all patients who had debridement of pancreatic and peripancreatic necrosis (CPT code 48105) from January 1, 2007, through December 31, 2007. Patient demographics, observed (O) and expected (E) morbidity and mortality, and indices (O/E) were evaluated. A multivariate stepwise logistic regression was performed to determine predictors of mortality.

RESULTS

During this 12-month period, data were accumulated on 161 patients. The mean age was 54 years; 71% were male; and 75% were Caucasian. The mean body mass index was 30.3 kg/m(2); 29% had diabetes; and 11% abused alcohol. Forty-two percent were transferred to NSQIP hospitals from other facilities. Overall morbidity was 62%, and 30-day mortality was 6.8%, but morbidity and mortality indices were 0.86 and 0.33, respectively. Increased age and blood urea nitrogen were independent predictors of mortality.

CONCLUSIONS

These data suggest that patients undergoing debridement for pancreatic and peripancreatic necrosis at ACS-NSQIP hospitals provide a new North American sample and have better than predicted outcomes. We concluded that ACS-NSQIP is a powerful tool to assess contemporary outcomes of uncommon, high-risk procedures.

National assessment of melanoma care using formally developed quality indicators

PURPOSE

There is considerable variation in the quality of cancer care delivered in the United States. Assessing care by using quality indicators could help decrease this variability. The objectives of this study were to formally develop valid quality indicators for melanoma and to assess hospital-level adherence with these measures in the United States.

METHODS

Quality indicators were identified from available literature, consensus guidelines, and melanoma experts. Thirteen experts ranked potential measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. Adherence with individual valid indicators and a composite measure of all indicators were assessed at 1,249 Commission on Cancer hospitals by using the National Cancer Data Base (NCDB; 2004 through 2005).

RESULTS

Of 55 proposed quality indicators, 26 measures (47%) were rated as valid. These indicators assessed structure (n = 1), process (n = 24), and outcome (n = 1). Of the 26 measures, 10 are readily assessable by using cancer registry data. Adherence with valid indicators ranged from 11.8% to 96.5% at the patient level and 3.7% to 83.0% at the hospital level. (Adherence required that >OR= 90% of patients at a hospital receive concordant care.) Most hospitals were adherent with 50% or fewer of the individual indicators (median composite score, five; interquartile range, four to seven). Adherence was higher for diagnosis and staging measures and was lower for treatment indicators.

CONCLUSION

There is considerable variation in the quality of melanoma care in the United States. By using these formally developed quality indicators, hospitals can assess their adherence with current melanoma care guidelines through feedback mechanisms from the NCDB and can better direct quality improvement efforts.

Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals

BACKGROUND/OBJECTIVE

The National Surgical Quality Improvement Program (NSQIP) has demonstrated quality improvement in the VA and pilot study of 14 academic institutions. The objective was to show that American College of Surgeons (ACS)-NSQIP helps all enrolled hospitals.

METHODS

ACS-NSQIP data was used to evaluate improvement in hospitals longitudinally over 3 years (2005-2007). Improvement was defined as reduction in risk-adjusted "Observed/Expected" (O/E) ratios between periods with risk adjustment held constant. Multivariable logistic regression-based adjustment was performed and included indicators for procedure groups. Additionally, morbidity counts were modeled using a negative binomial model, to estimate the number of avoided complications.

RESULTS

Multiple perspectives reflected improvement over time. In the analysis of 118 hospitals (2006-2007), 66% of hospitals improved risk-adjusted mortality (mean O/E improvement: 0.174; P < 0.05) and 82% improved risk adjusted complication rates (mean improvement: 0.114; P < 0.05). Correlations between starting O/E and improvement (0.834 for mortality, 0.652 for morbidity), as well as relative risk, revealed that initially worse-performing hospitals had more likelihood of improvement. Nonetheless, well-performing hospitals also improved. Modeling morbidity counts, 183 hospitals (2007), avoided ~9598 potential complications: ~52/hospital. Due to sampling this may represent only 1 of 5 to 1of 10 of the true total. Improvement reflected aggregate performance across all types of hospitals (academic/community, urban/rural). Changes in patient risk over time had important contributions to the effect.

CONCLUSIONS

ACS-NSQIP indicates that surgical outcomes improve across all participating hospitals in the private sector. Improvement is reflected for both poor- and well-performing facilities. NSQIP hospitals appear to be avoiding substantial numbers of complications- improving care, and reducing costs. Changes in risk over time merit further study.

Variation in hospital mortality associated with inpatient surgery

BACKGROUND

Hospital mortality that is associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality. However, effective management of complications once they have occurred may be equally important.

METHODS

We studied 84,730 patients who had undergone inpatient general and vascular surgery from 2005 through 2007, using data from the American College of Surgeons National Surgical Quality Improvement Program. We first ranked hospitals according to their risk-adjusted overall rate of death and divided them into five groups. For hospitals in each overall mortality quintile, we then assessed the incidence of overall and major complications and the rate of death among patients with major complications.

RESULTS

Rates of death varied widely across hospital quintiles, from 3.5% in very-low-mortality hospitals to 6.9% in very-high-mortality hospitals. Hospitals with either very high mortality or very low mortality had similar rates of overall complications (24.6% and 26.9%, respectively) and of major complications (18.2% and 16.2%, respectively). Rates of individual complications did not vary significantly across hospital mortality quintiles. In contrast, mortality in patients with major complications was almost twice as high in hospitals with very high overall mortality as in those with very low overall mortality (21.4% vs. 12.5%, P<0.001). Differences in rates of death among patients with major complications were also the primary determinant of variation in overall mortality with individual operations.

CONCLUSIONS

In addition to efforts aimed at avoiding complications in the first place, reducing mortality associated with inpatient surgery will require greater attention to the timely recognition and management of complications once they occur.

Defining high quality health care

Most health care quality improvement efforts target measures of health care structures, processes, and/or outcomes. Structural measures examine relatively fixed aspects of health care delivery such as physical plant and human resources. Process measures, the focus of the largest proportion of quality improvement efforts, assess specific transactions in clinical-patient encounters, such as use of appropriate surgical antibiotic prophylaxis, which are expected to improve outcomes. Outcome measures, which comprise quality of life endpoints as well as morbidity and mortality, are of greatest interest to clinicians and patients, but entail the greatest complexity, as the majority of variance in outcomes is attributable to patient and environmental factors that may not be readily modifiable. Selecting among structure, process, and outcome measures for quality improvement efforts generally will be dictated by the specific clinical situation for which improvement is desired. One aspect of health care quality that has received a great deal of attention in recent years is the relationship between surgical volume and health outcomes. Volume, an inherent characteristic of a health care facility or provider, is generally considered a structural measure of quality. Many studies have demonstrated a positive association between volume and outcomes, and policymakers in the private and public sectors have begun to consider volume in certification and reimbursement decisions. The volume-outcome association is not without controversy, however. Most studies in the field are limited by the nature of the administrative data on which they are based, and some studies have found that variation in quality within volume quantiles exceeds differences between quantiles. Moreover, regionalization driven by a focus on volume may exert adverse effects on access to care. The movement for health care quality improvement faces substantial methodological, clinical, financial, and political challenges. Despite these challenges, it is a movement that is gaining momentum, and the emphasis on quality in health care delivery is likely only to increase in the future. It is crucial, therefore, that physicians assume increasing leadership roles in efforts to define, measure, report, and improve quality of care.

Extreme makeover: Transformation of the veterans health care system

The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.

Revisiting the validity of APACHE II in the trauma ICU: improved risk stratification in critically injured adults

BACKGROUND

Quality and benchmarking initiatives highlight the need for accurate stratified risk adjustment. The stratification of trauma patients has relied on scores specific to trauma populations. While the Acute Physiologic and Chronic Health Evaluation (APACHE) II score has been considered "invalid" in the trauma population, we hypothesized that APAHCE II would more accurately predict outcomes in critically injured patients in whom commonly used trauma scores have inherent limitations.

METHODS

A prospective cohort of critically injured patients was enrolled. Severity scores and their sub-components were collected, and in-hospital mortality was assessed. The area under the receiver operating characteristic (AUROC) curve was used to determine the predictive value of each score. Logistic regression estimated the odds of death associated with incremental changes in severity scores and their subcomponents.

RESULTS

1019 patients were available for analysis. APACHE II was the best predictor of mortality (AUROC 0.77 versus AUROC 0.54 for ISS and 0.64 for TRISS). A unit increase in APACHE II was associated with an OR of death of 1.18 (95% CI 1.14-1.22). The components of APACHE II that contributed the most to its accuracy included temperature, serum creatinine and the Glasgow Coma Scale (GCS).

CONCLUSION

Critically injured patients have physiologic derangements not accurately accounted for by commonly used trauma scores. In this subset a more general ICU scoring system is useful for risk adjustment for research, administrative and quality improvement purposes.

Quality of health care in the United States: implications for pediatric inflammatory bowel disease

The Institute of Medicine's publications To Error is Human and Crossing the Quality Chasm publicized the widespread deficits in US health care quality. Emerging studies continue to reveal deficits in the quality of adult and pediatric care, including subspecialty care. In recent years, key stakeholders in the health care system including providers, purchasers, and the public have been applying various quality improvement methods to address these concerns. Lessons learned from these efforts in other pediatric conditions, including asthma, cystic fibrosis, neonatal intensive care, and liver transplantation may be applicable to the care of children with inflammatory bowel disease (IBD).This review is intended to be a primer on the quality of care movement in the United States, with a focus on pediatric IBD. In this article, we review the history, rationale, and methods of quality measurement and improvement, and we discuss the unique challenges in adapting these general strategies to pediatric IBD care.

The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery

OBJECTIVE

We sought to examine the effect of body mass index (BMI) on 30-day morbidity and mortality in a large cohort of patients undergoing nonbariatric general surgery.

SUMMARY BACKGROUND DATA

Obesity has long been considered a risk factor for poor outcomes from a variety of surgical procedures, yet recent studies of critically and chronically ill patients suggest that overweight and obese patients may paradoxically have better outcomes than "normal" weight patients.

METHODS

A prospective, multi-institutional, risk-adjusted cohort study of 118,707 patients undergoing nonbariatric general surgery who were included in the National Surgical Quality Improvement Program Participant Use database in 2005 and 2006 was performed. Outcomes and risk variables were compared across NIH-defined BMI class using analysis of variance, Bonferroni multiple comparisons of means tests, and multivariable logistic regression.

RESULTS

After adjusting for all significant perioperative risk factors, the risk of death according to BMI exhibited a reverse J-shaped relationship, with the highest rates in the underweight and morbidly obese extremes and the lowest rates in the overweight and moderately obese. Overweight (odds ratio, 0.85; 95% CI, 0.75-0.99) and moderately obese (odds ratio, 0.73; 95% CI, 0.57-0.94) patients had a significantly lower risk of death than normal weight patients. There was a progressive increase in the likelihood of a complication with increasing BMI class, almost entirely due to increasing rates of wound infection.

CONCLUSIONS

Overweight and moderately obese patients undergoing nonbariatric general surgery have paradoxically "lower" crude and adjusted risks of mortality compared with patients at a "normal" weight. This finding is in contrast to observations from the general population, confirming the existence of an "obesity paradox" in this patient population.

ACS-NSQIP has the potential to create an HPB-NSQIP option

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was started in 2004. Presently, 58% of the 198 hospitals participating in ACS-NSQIP are academic or teaching hospitals. In 2008, ACS-NSQIP initiated a number of changes and made risk-adjusted data available for use by participating hospitals. This analysis explores the ACS-NSQIP database for utility in developing hepato-pancreato-biliary (HPB) surgery-specific outcomes (HPB-NSQIP).

METHODS

The ACS-NSQIP Participant Use File was queried for patient demographics and outcomes for 49 HPB operations from 1 January 2005 through 31 December 2007. The procedures included six hepatic, 16 pancreatic and 23 complex biliary operations. Four laparoscopic or open cholecystectomy operations were also studied. Risk-adjusted probabilities for morbidity and mortality were compared with observed rates for each operation.

RESULTS

During this 36-month period, data were accumulated on 9723 patients who underwent major HPB surgery, as well as on 44,189 who received cholecystectomies. The major HPB operations included 2847 hepatic (29%), 5074 pancreatic (52%) and 1802 complex biliary (19%) procedures. Patients undergoing hepatic resections were more likely to have metastatic disease (42%) and recent chemotherapy (7%), whereas those undergoing complex biliary procedures were more likely to have significant weight loss (20%), diabetes (13%) and ascites (5%). Morbidity was high for hepatic, pancreatic and complex biliary operations (20.1%, 32.4% and 21.2%, respectively), whereas mortality was low (2.3%, 2.7% and 2.7%, respectively). Compared with laparoscopic cholecystectomy, the open operation was associated with higher rates of morbidity (19.2% vs. 6.0%) and mortality (2.5% vs. 0.3%). The ratios between observed and expected morbidity and mortality rates were <1.0 for hepatic, pancreatic and biliary operations.

CONCLUSIONS

These data suggest that HPB operations performed at ACS-NSQIP hospitals have acceptable outcomes. However, the creation of an HPB-NSQIP has the potential to improve quality, provide risk-adjusted registries with HPB-specific data and facilitate multi-institutional clinical trials.

Causes of postoperative mortality after surgery for ovarian cancer

Residual disease after cytoreductive surgery is an important prognostic factor in patients with advanced stage epithelial ovarian cancer (EOC). Aggressive surgical procedures necessary to achieve maximal cytoreduction are inevitably associated with postoperative morbidity and mortality. To determine causes of postoperative mortality (POM) after surgery for EOC all postoperative deaths in the southwestern part of the Netherlands over a 17-year period were identified and analysed by reviewing medical notes. Between 1989 and 2005, 2434 patients underwent cytoreductive surgery for EOC. Sixty-seven patients (3.1%) died within 30 days after surgery. Postoperative mortality increased with age from 1.5% (26/1765) for the age group 20-69 to 6.6% (32/486) for the age group 70-79 and 9.8% (18/183) for patients aged 80 years or older. Pulmonary failure (18%) and surgical site infection (15%) were the most common causes of death. Only a quarter of deaths resulted from surgical site complications. Our results suggest that causes of postoperative mortality after surgery for EOC are very heterogeneous. Given the impact of general complications, progress in preoperative risk assessment, preoperative preparation and postoperative care seem essential to reduce the occurrence of fatal complications.

Preoperative risk stratification for mortality and major morbidity in major colorectal surgery

INTRODUCTION

Risk stratification in major colorectal surgery, in general, has used preoperative, intraoperative, and postoperative variables, and has been used for purposes of comparative audit. To enable preoperative clinical use, this study aimed to stratify risk by use of preoperative risk factors only.

METHODS

This is a single-institutional prospective observational study.

RESULTS

There were 887 major colorectal procedures assessed. Independent risk factors for mortality were American Society of Anesthesiologists' physical status Grades III to V, age, high comorbidity count, and low surgeon case volume. For major morbidity, risk factors were American Society of Anesthesiologists' Grades III to V, urgent operation, and operation to excise the rectum. Overall, mortality was 4.51%, and major morbidity was 19.6%. The estimated risk of mortality was stratified by risk factor profile from 0.12% (95% CI, 0.02-0.93) to 42.4% (95% CI, 23.5-63.9). The risk of major morbidity was stratified from 7.22% (95% CI, 4.82-10.7) to 49.2% (95% CI, 34.2-64.4). Model discrimination was favorable to the existing risk adjustment models applied to our cohort. The Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (including Portsmouth and ColoRectal modifications), and Association of ColoProctology of Great Britain and Ireland Colorectal Cancer models (mortality: area under receiver operating characteristic (AU ROC) curves 0.87 compare 0.70-0.81, major morbidity: 0.69 compare 0.66)).

CONCLUSIONS

Simple and readily available preoperative risk factors can achieve risk stratification. Risk stratification based on preoperative risk factors only possibly has comparable efficacy with those models that use preoperative, intraoperative, and postoperative risk factors.

Assessment of pancreatic cancer care in the United States based on formally developed quality indicators

BACKGROUND

Pancreatic cancer outcomes vary considerably among hospitals. Assessing pancreatic cancer care by using quality indicators could help reduce this variability. However, valid quality indicators are not currently available for pancreatic cancer management, and a composite assessment of the quality of pancreatic cancer care in the United States has not been done.

METHODS

Potential quality indicators were identified from the literature, consensus guidelines, and interviews with experts. A panel of 20 pancreatic cancer experts ranked potential quality indicators for validity based on the RAND/UCLA Appropriateness Methodology. The rankings were rated as valid (high or moderate validity) or not valid. Adherence with valid indicators at both the patient and the hospital levels and a composite measure of adherence at the hospital level were assessed using data from the National Cancer Data Base (2004-2005) for 49 065 patients treated at 1134 hospitals. Summary statistics were calculated for each individual candidate quality indicator to assess the median ranking and distribution.

RESULTS

Of the 50 potential quality indicators identified, 43 were rated as valid (29 as high and 14 as moderate validity). Of the 43 valid indicators, 11 (25.6%) assessed structural factors, 19 (44.2%) assessed clinical processes of care, four (9.3%) assessed treatment appropriateness, four (9.3%) assessed efficiency, and five (11.6%) assessed outcomes. Patient-level adherence with individual indicators ranged from 49.6% to 97.2%, whereas hospital-level adherence with individual indicators ranged from 6.8% to 99.9%. Of the 10 component indicators (contributing 1 point each) that were used to develop the composite score, most hospitals were adherent with fewer than half of the indicators (median score = 4; interquartile range = 3-5).

CONCLUSIONS

Based on the quality indicators developed in this study, there is considerable variability in the quality of pancreatic cancer care in the United States. Hospitals can use these indicators to evaluate the pancreatic cancer care they provide and to identify potential quality improvement opportunities.

Surgical outcomes in American Indian veterans: a closer look

BACKGROUND

American Indian/Alaska Native (AI/ANs) male veterans have considerably higher postoperative mortality rates than their Caucasian counterparts, but similar postoperative morbidity rates even after adjusting for major preoperative risk factors. This study seeks to explain the discrepancy in morbidity and mortality.

STUDY DESIGN

We obtained data from the Veterans Affairs National Surgical Quality Improvement Program on major, noncardiac, surgical procedures performed from 1991 to 2002 for all AI/AN men (n = 2,155), and a random sample of Caucasian men (n = 2,264), matched by site. We compared the number and types of postoperative complications and mortality rates for those patients in whom complications developed. We also examined complication and mortality rates by whether they occurred after hospital discharge, or by specific type of surgical procedure. Preoperative risk factors were assessed in patients who died. Chi-square or Fisher's exact tests were used for all comparisons.

RESULTS

AI/ANs and Caucasians did not differ by number of complications but Caucasian patients had considerably higher rates for three specific complications. There was no difference in deaths after discharge or in mortality rates after specific surgical procedures. The groups differed considerably in the types of procedures performed. Among patients who died, three preoperative risk factors, ie, hemiplegia, diabetes, and wound infection, occurred more frequently among AI/AN than Caucasian veterans.

CONCLUSIONS

We cannot fully explain higher postoperative mortality rates experienced by AI/AN relative to Caucasian veterans after examining complications, types of procedures, and other relevant factors. AI/ANs with certain preoperative risk factors can be vulnerable to 30-day postoperative mortality and benefit from closer postoperative surveillance.

Modifiable surgical and anesthesiologic risk factors for the development of cardiac and pulmonary complications after laparoscopic colorectal surgery

BACKGROUND

In contrast to patient-related risk factors, which are difficult to influence, factors relating to surgery and anesthesia that can be influenced have hardly been investigated. This study aimed to identify such risk factors.

METHODS

Pre- and intraoperative surgical and anesthesiologic factors of 388 colonic and 112 rectal procedures performed by a single surgeon within 50 months were recorded and analyzed for correlations with postoperative complications requiring treatment.

RESULTS

Higher American Society of Anesthesiology (ASA) emergency interventions and intraoperative factors (bleeding, long operating time) had an elevated risk for general complications. Furthermore, patients benefited from the clinical experience of the anesthesiologist, especially in terms of emergency procedures, hemorrhagic complications, and a longer operating time.

CONCLUSIONS

Standardization of the surgical technique, "bloodless" surgery, standardization of intraoperative monitoring, and the use of board-certified anesthesiologists for high-risk cases, emergency procedures, and patients with high ASA stages are able to reduce postoperative morbidity.

Laparoscopy decreases postoperative complication rates after abdominal colectomy: results from the national surgical quality improvement program

OBJECTIVE

Compare outcomes of non-emergent laparoscopic to open colon surgery.

BACKGROUND

Laparoscopy has revolutionized much of gastrointestinal surgery. Colon and rectal surgery has seen drastic changes with many of the abdominal operations being performed laparoscopically. However, data comparing recovery and complications in patients undergoing laparoscopic and open colon surgery has shown only slight benefits for laparoscopy. Given the large benefits of laparoscopy in most gastrointestinal surgical procedures, this outcome is surprising. We, therefore, have set out to test the hypothesis that laparoscopic approaches decreases postoperative complications.

METHODS

We have undertaken a review of the database maintained by the American College of Surgeon's National Surgical Quality Improvement Program. We have identified 8660 patients who met inclusion criteria for this study. Postoperative complication data were collected for patients undergoing laparoscopic or open colon surgery. Using a combination of univariate and multivariate analyses we evaluated for statistical significance.

RESULTS

We found that laparoscopy decreased overall complications as well as individual complications. We found a decreased length of stay as well as a decreased risk for postoperative complications in the elderly. We found that laparoscopy decreased complication rate independent of the probability of morbidity statistic.

CONCLUSIONS

When controlled for probability of morbidity, laparoscopy decreases the rate of postoperative complications. Given the equivalent outcomes of laparoscopic approaches, we conclude that laparoscopy should be offered to all patients who lack an absolute contraindication for laparoscopic surgery.

Ethical issues in using data from quality management programs

Since the advent of formal, data-driven quality improvement programs in health care in the late 1980s and early 1990s, there are have been questions raised about requirements for ethical committee review of quality improvement activities. A form of consensus emerged through a series of articles published between 1996 and 2007, but there is still significant variation among ethics review committees and individual project leaders in applying broad policies on requirements for committee review and/or written informed consent by participants. Recent developments in quality management, particularly the creation and use of multi-site disease registries, have raised new questions about requirements for review and consent, since the activities often have simultaneous research and quality improvement goals. This article discusses ways in which policies designed for local quality improvement projects and data bases may be adapted to apply to multi-site registries and research projects related to them.

Obesity, diabetes, and smoking are important determinants of resource utilization in liver resection: a multicenter analysis of 1029 patients

OBJECTIVE

To investigate independent contributions of obesity, diabetes, and smoking to resource utilization in patients following liver resection.

SUMMARY BACKGROUND DATA

Despite being highly resource-intensive, liver resections are performed with increasing frequency. This study evaluates how potentially modifiable factors affect measures of resource utilization after hepatectomy.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) public-use database was queried for patients undergoing liver resection. Resource variables were operative time (OT), intraoperative transfusion, length of stay (LOS), ventilator support at 48 hours, and reoperation. Bivariable and multivariable linear and logistic regressions were performed.

RESULTS

There were 1029 patients identified. Most resections involved less than a hemiliver (599 patients, 58.2%). Mean BMI was 28.0 +/- 6.0. Mean OT was 253 +/- 122 minutes (range, 27 to 794) but varied by procedure (P < 0.001). Mean LOS was 8.7 +/- 10.7 days (range, 0 to 202). Morbid obesity added 48 minutes to OT (P = 0.018), 1.1 units to transfusions (P = 0.049), 2.2 days to LOS (P < 0.001), and accounted for delayed ventilator weaning (odds ratio, 4.5; P = 0.022). Underweight patients had shorter OT, but stayed 3.3 days longer than normal weight patients (P < 0.001). Insulin-treated patients with diabetes had longer OT (P < 0.001), increased transfusions (P < 0.001), and delayed ventilator weaning (odds ratio, 6.7; P < 0.001), while orally-treated patients with diabetes showed opposite trends. Smokers stayed 1.9 days longer (P < 0.001), with increased risk of prolonged ventilation (odds ratio, 3.3; P = 0.002) and reoperation (odds ratio, 2.3; P = 0.015).

CONCLUSION

Obesity, diabetes, and smoking are each associated with important components of healthcare expenditure. Education and prevention programs are needed to limit their impact on overall resource utilization.

Postoperative mortality after primary cytoreductive surgery for advanced stage epithelial ovarian cancer: a systematic review

OBJECTIVE

Accurate estimation of the risk of postoperative mortality (POM) is essential for the decision whether or not to perform cytoreductive surgery in a patient with advanced stage ovarian cancer. To ascertain modern reference figures, a systematic review of studies reporting POM after primary cytoreductive surgery for advanced stage epithelial ovarian cancer (EOC) was performed.

MATERIALS AND METHODS

A Medline search was performed to retrieve papers on primary cytoreductive surgery for advanced stage EOC. Twenty-three papers met the inclusion criteria and were reviewed.

RESULTS

According to population-based studies, POM after primary cytoreductive surgery for EOC is 3.7% on average. Single centre studies report an average rate of 2.5%. The overall mean POM is 2.8%. POM is more frequent for elderly women and after extensive procedures. Accurate information on age-specific and procedure-specific rates could not be obtained.

CONCLUSION

POM rates after surgery for EOC are satisfactorily low. There is a clear need for reliable reference figures for mortality after debulking surgery in the elderly.