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

Using local rather than general anesthesia for inguinal hernia repair is associated with shorter operative time and enhanced postoperative recovery

BACKGROUND

Inguinal hernia repair is the most common general surgery procedure and can be performed under local or general anesthesia. We hypothesized that using local rather than general anesthesia would improve outcomes, especially for older adults.

METHODS

This is a retrospective review of 97,437 patients in the Veterans Affairs Surgical Quality Improvement Program who had open inguinal hernia surgery under local or general anesthesia. Outcomes included 30-day postoperative complications, operative time, and recovery time.

RESULTS

Our cohort included 22,333 (23%) Veterans who received local and 75,104 (77%) who received general anesthesia. Mean age was 62 years. Local anesthesia was associated with a 37% decrease in the odds of postoperative complications (95% CI 0.54-0.73), a 13% decrease in operative time (95% CI 17.5-7.5), and a 27% shorter recovery room stay (95% CI 27.5-25.5), regardless of age.

CONCLUSIONS

Using local rather than general anesthesia is associated with a profound decrease in complications (equivalent to "de-aging" patients by 30 years) and could significantly reduce costs for this common procedure.

The past, present, and future of urological quality improvement collaboratives

Surgical quality improvement collaboratives (QIC) have been established across the nation in numerous specialties. These QICs have shown efficacy in improving the quality, safety and value of care delivered to patients with a wide range of medical conditions. In recent years, urological QICs have emerged, including regional collaboratives such as the Michigan Urological Surgical Improvement Collaborative (MUSIC) and Pennsylvania Urologic Regional Collaborative (PURC), as well as the national American Urological Association Quality Registry Program (AQUA). These urological collaboratives, developed with an initial focus on prostate cancer, have demonstrated an ability to accurately measure prostate cancer outcomes, compare these outcomes among providers and institutions, and enact change among both patients and providers to optimize outcomes for men with prostate cancer. Physician-led regional collaboratives may be uniquely positioned to respond quickly to the rapidly-evolving healthcare landscape and enact practice and provider-level changes when appropriate. This review describes the historical background, current structure and function, and potential future directions of these urologic QICs.

Prolonged surgical time increases the odds of complications following total knee arthroplasty

Background:

The aim of this study was to evaluate the influence of operating time on complications and readmission within 30 days of total knee arthroplasty (TKA) and to determine if there were specific time intervals associated with worse outcomes.

Methods:

The American College of Surgeons’ National Surgical Quality Improvement Program database was used to identify patients 18 years of age and older who underwent TKA between 2006 and 2017, using procedural codes. Patient demographic characteristics, operation length and 30-day major and minor complication and readmission rates were captured. We used multivariable regression to determine if the rates of complications and readmission differed depending on the length of the operation, while adjusting for relevant covariables.

Results:

A total of 263 174 patients who underwent TKA were identified from the database. Their mean age was 66.8 (standard deviation 9.7) years. Within 30 days of the index procedure, 5700 patients (2.2%) experienced a major complication, 5185 (2.0%) experienced a minor complication and 7730 (3.1% of 249 746 patients from 2011 to 2017) were readmitted. Mean operation length was 91.7 minutes (range 30–240 min). After adjustment for relevant covariables, an operating time of 90 minutes or more was a significant predictor of major and minor complications as well as readmission. There was no difference in the odds of complications or readmission for operations lasting 30–49, 50–69 or 70–89 minutes (p > 0.05).

Conclusion:

Our data suggest that operating times of 90 minutes or more may be associated with an increase in the 30-day odds of complications and readmission following TKA. Further studies are needed to confirm our findings and determine the influence of surgical time on outcomes when there is increased case complexity.

A NSQIP-based randomized clinical trial evaluating choice of prophylactic antibiotics for pancreaticoduodenectomy

Surgical site infection after pancreaticoduodenectomy is often caused by pathogens resistant to standard prophylactic antibiotics, suggesting that broad-spectrum antibiotics may be more effective prophylactic agents. This article describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first US randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials.

Preliminary data demonstrate the Geriatric Surgery Verification program reduces postoperative length of stay

OBJECTIVES/BACKGROUND

The Geriatric Surgery Verification (GSV) Program promotes clinical standards aimed to optimize the quality of surgical care delivered to older adults. The purpose of this study was to determine if preliminary implementation of the GSV Program standards improves surgical outcomes.

DESIGN

Prospective study with cohort matching.

SETTING

Data from a single institution compared with a national data set cohort.

PARTICIPANTS

All patients aged ≥75 years undergoing inpatient operations between January 2018 and December 2019 were included. Cohort matching by age and procedure code was performed using a national data set.

MEASUREMENTS

Baseline pre- and intraoperative characteristics prospectively recorded using Veterans Affairs Surgical Quality Improvement Program (VASQIP) variable definitions. Postoperative outcomes were recorded including complications as defined by VASQIP, 30-day mortality, and length of stay.

RESULTS

A total of 162 patients participated in the GSV program, and 308 patients comprised the matched comparison group. There was no difference in postoperative occurrence of one or more complications (p = 0.81) or 30-day mortality (p = 0.61). Patients cared for by the GSV Program had a reduced postoperative length of stay (median 4 days [range 1,31] vs. 5 days [range 1,86]; p < 0.01; and mean 5.4 ± 4.8 vs. 8.8 ± 11.8 days; p < 0.01) compared with the matched cohort. In a multivariable regression model, the GSV Program's reduced length of stay was independent of other associated covariates including age, operative time, and comorbidities (p < 0.01).

CONCLUSION

Preliminary implementation of the GSV Program standards reduces length of stay in older adults undergoing inpatient operations. This finding demonstrates both the clinical and financial value of the GSV Program.

How does the multidimensional frailty score compare with grip strength for predicting outcomes after hip fracture surgery in older patients? A retrospective cohort study

Background

Frailty and low handgrip strength (HGS) are associated with adverse outcomes after hip fracture (HF) surgery. We aimed to compare the predictive role of frailty and HGS for adverse outcome in HF patients.

Methods

We included older patients (age ≥ 65 years) who underwent HF surgery to compare the predictive role of HGS and hip-multidimensional frailty score (Hip-MFS) for postoperative complications and mortality. The Hip-MFS was calculated based on comprehensive geriatric assessment (CGA), and HGS was measured with a hand dynamometer. The primary outcome was a composite of postoperative complications (e.g., pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). The secondary outcomes were 6-month mortality and mortality at the end of follow-up.

Results

The median observation time was 620.5 days (interquartile range: 367.0–784.8 days). Among the 242 patients (mean age: 81.5 ± 6.7 years, 73.1% women), 106 (43.8%) experienced postoperative complications. The 6-month mortality and mortality at the end of follow-up were 7.4% (n = 18) and 20.7% (n = 50), respectively. The Hip-MFS (odds ratio [OR], 1.250; 95% confidence interval [CI], 1.092–1.432) and HGS (OR, 1.147; 95% CI, 1.082–1.215) could predict postoperative complications. The Hip-MFS could predict both 6-month mortality (hazard ratio [HR], 1.403; 95% CI, 1.027–1.917) and mortality at the end of follow-up (HR, 1.493; 95% CI, 1.249–1.769) after adjustment, while HGS was only associated with mortality at the end of follow-up (HR, 1.080; 95% CI, 1.024–1.139). For mortality at the end of follow-up, predictive models with the Hip-MFS were superior to those with HGS in the time-dependent receiver-operating curve analysis after adjustment (p = 0.017). Furthermore, the addition of Hip-MFS or HGS to the American Society of Anesthesiologists (ASA) classification improved its prognostic ability.

Conclusions

Both the Hip-MFS and HGS could predict postoperative complications and improve prognostic utility when combined with the ASA classification. The Hip-MFS was a stronger predictor of mortality than HGS after HF surgery. HGS could be a useful pre-screening tool to identify patients at a high risk of postoperative complications and those who may benefit from further CGA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02150-9.

Sentinel Contributions of US Department of Veterans Affairs Surgeons in Shaping the Face of Health Care

The vast accomplishments of the US Department of Veterans Affairs (VA) during the past century have contributed to the advancement of medicine and benefited patients worldwide. This article highlights some of those accomplishments and the advantages in the VA system that promulgated those successes. Through its affiliation with medical schools, its formation of a structured research and development program, its Cooperative Studies Program, and its National Surgical Quality Improvement Program, the VA has led the world in the progress of health care. The exigencies of war led not only to the organization of VA health care but also to groundbreaking, landmark developments in colon surgery; surgical treatments for vascular disease, including vascular grafts, carotid surgery, and arteriovenous dialysis fistulas; cardiac surgery, including implantable cardiac pacemaker and coronary artery bypass surgery; and the surgical management of many conditions, such as hernias. The birth of successful liver transplantation was also seen within the VA, and countless other achievements have benefited patients around the globe. These successes have created an environment where residents and medical students are able to obtain superb education and postgraduate training and where faculty are able to develop their clinical and academic careers.

Impact of Psychiatric Diagnoses and Treatment on Postoperative Outcomes Among Patients Undergoing Surgery for Colorectal Cancer

OBJECTIVE

Psychiatric diagnoses may be a risk factor for poor colorectal cancer (CRC) surgery outcomes. The authors investigated the risk of psychiatric diagnoses and benefit of mental health treatment for surgery outcomes among CRC patients.

METHODS

This retrospective cohort study of patients undergoing CRC surgery in the 2000-2014 period identified documentation of psychiatric diagnosis and mental health treatment (no treatment, medication only, psychotherapy only, or both medication and psychotherapy) 30 days before surgery. Associations between psychiatric diagnoses, mental health treatment, and postoperative outcomes (postoperative complications, length of stay [LOS], and 90-day readmission rate) were evaluated with multivariable generalized estimating equations.

RESULTS

Among 58,961 patients undergoing CRC surgery, 9,029 (15.3%) had psychiatric diagnoses, 4,601 (51.0%) of whom received preoperative mental health treatment (90.0% psychiatric medication, 6.7% psychotherapy, and 3.0% medication and psychotherapy). Patients with psychiatric diagnoses had an increased risk for postoperative complications (odds ratio [OR]=1.09, 95% confidence interval [CI]=1.03-1.15) and 90-day readmission (OR=1.11, 95% CI=1.06-1.17) compared with patients without psychiatric diagnoses. Patients with psychiatric diagnoses who received no mental health treatment or only medication had a 7%-17% increased risk for postoperative complications and 90-day readmission compared with patients without psychiatric diagnoses. Patients who received medication only also had a 4% increase in LOS relative to patients without psychiatric diagnoses. Patients with psychiatric diagnoses receiving only psychotherapy and patients without psychiatric diagnoses had similar postoperative outcomes.

CONCLUSIONS

Preoperative psychiatric diagnoses were associated with worse postoperative outcomes. Surgical quality-improvement efforts should focus on identifying patients with preoperative psychiatric diagnoses and addressing these conditions presurgery.

Effect of length of surgery on the incidence of venous thromboembolism after benign hysterectomy

BACKGROUND

Venous thromboembolism is a leading cause of morbidity and mortality postoperatively. The current venous thromboembolism risk assessment tools have not been validated in gynecologic patients. Most patients undergoing hysterectomy for benign indications will receive mechanical or pharmacologic prophylaxis based on preoperative risk assessment. However, current guidelines do not incorporate newer data that indicate additional risk of venous thromboembolism with prolonged surgery times or mode of hysterectomy.

OBJECTIVE

This study aimed to determine the effect of length of surgery, or operative time, on the risk of venous thromboembolism within 30 days after hysterectomy and determine whether differences in the effect of operative time exist across age, body mass index, and surgical approach.

STUDY DESIGN

We performed a secondary analysis of prospectively collected surgical quality improvement data using the American College of Surgeons National Surgical Quality Improvement Program database, which contains demographic and perioperative information and 30-day postoperative outcomes from >500 hospitals, and targeted data files including procedure-specific risk factors and outcomes for a subset of hospitals. We analyzed patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign conditions from 2014 to 2017, identified by the Current Procedural Terminology codes. We excluded patients with cancer, patients whose surgery was not performed by a gynecologist, patients who were not in the targeted files, and patients with missing operative time or with an operative time of <30 minutes. Patients were compared with respect to the incidence of venous thromboembolism and operative time, stratified by age, body mass index, and surgical approach. Multivariable logistic regression was performed; operative time was treated as a continuous, linear variable.

RESULTS

A total of 70,606 patients were included. The 30-day venous thromboembolism incidence was 0.4% (n=259). Patients with venous thromboembolism were more likely to be obese, have inpatient procedures, and had, on average, greater uterine weight. Hysterectomy approach was vaginal in 11,641 patients, laparoscopic in 41,557 patients, and abdominal in 17,408 patients. After adjustment, for each 60-minute increase in operative time, there was a 35% increase in the odds of venous thromboembolism (adjusted odds ratio, 1.35; 95% confidence interval, 1.25-1.45). Stratified by surgical approach, the odds of venous thromboembolism per 60-minute increase in operative time was greatest among abdominal hysterectomy (adjusted odds ratio, 1.49; 95% confidence interval, 1.35-1.65) compared with laparoscopic hysterectomy (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.38) and vaginal hysterectomy (adjusted odds ratio, 1.27; 95% confidence interval, 0.97-1.66) (P=.01). Increasing body mass index and increasing age did not modify the impact of operative time on venous thromboembolism incidence (P=.66 and P=.58, respectively).

CONCLUSION

Every 60-minute increase in operative time was independently associated with a 35% increased odds of venous thromboembolism within 30 days of hysterectomy, and this risk was cumulative. Minimally invasive hysterectomy had lower odds of venous thromboembolism than abdominal hysterectomy across all time points.

Postoperative infectious complications in elderly patients after elective surgery in China: results of a 7-day cohort study from the International Surgical Outcomes Study

AIM

Despite initiatives to increase elderly patients' access to surgical treatments, the prevalence and impact of postoperative infectious complications (PICs) in elderly patients in China are poorly described. The aim of our study was to describe PICs and associated mortality in elderly patients undertaking elective surgery in China.

METHODS

We analyzed data about elderly patients from China during the International Surgical Outcomes Study (ISOS), a 7-day prospective cohort study of outcomes after elective surgery in in-patient adults. All elderly patients (age ≥60 years) from 28 hospitals in China included in the ISOS study were included in this study as well. A review of 2014 elderly patients who underwent elective surgery in April 2014 was conducted.

RESULTS

Of 2014 elderly patients, 209 (10.4%) developed at least one postoperative complication. Infectious complications were most frequent, affecting 154 patients (7.6%); there was one death, or 0.6% 30-day mortality, which was a significantly higher rate than among patients without PICs (0%). The most frequent infectious complication was superficial surgical-site infection (3.3%). The length of hospital stay was longer in elderly patients with PICs than in those without PICs. Moreover, a total of 142 elderly patients (7.1%) were routinely sent to critical care after surgery, of whom 97 (68.3%) developed PICs. Compared to elderly patients admitted to a standard ward, those admitted to critical care immediately after surgery had a higher postoperative complication rate and critical care admission rate to treat complications.

CONCLUSIONS

The present prospective, multicentre study found that 7.6% of elderly patients in China had PICs after elective surgery that could prolong hospital stay and increase 30-day mortality. The clinical effectiveness of admission to critical care after surgery on elderly patients is not identified. Initiatives to increase elderly patients' access to surgical interventions should also enhance safe perioperative care to reduce PICs in China.

Preoperative coronary artery calcifications in veterans predict higher all-cause mortality in early-stage lung cancer: a cohort study

Background

Lung cancer patients often have comorbidities that may impact survival. This observational cohort study examines whether coronary artery calcifications (CAC) impact all-cause mortality in patients with resected stage I non-small cell lung cancer (NSCLC).

Methods

Veterans with stage I NSCLC who underwent resection at a single institution between 2005 and 2018 were selected from a prospectively collected database. Radiologists blinded to patient outcomes graded CAC severity (mild, moderate, or severe) in preoperative CT scans using a visual estimation scoring system. Inter-rater reliability was calculated using the kappa statistic. All-cause mortality was the primary outcome. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to compare time-to-death by varying CAC.

Results

The Veteran patients (n=195) were predominantly older (median age of 67) male (98%) smokers (96%). The majority (68%) were pathologic stage IA. Overall, 12% of patients had no CAC, 27% mild, 26% moderate, and 36% severe CAC. Median unadjusted survival was 8.8 years for patients with absent or mild CAC versus 6.3 years for moderate and 5.9 years for severe CAC (P=0.01). The adjusted hazard ratio for moderate CAC was 1.44 (95% CI, 0.85–2.46) and for severe CAC was 1.73 (95% CI, 1.03–2.88; P for trend <0.05).

Conclusions

The presence of severe CAC on preoperative imaging significantly impacted the all-cause survival of patients undergoing resection for stage I NSCLC. This impact on mortality should be taken into consideration by multidisciplinary teams when making treatment plans for patients with early-stage disease.

Safety of Same-day Discharge in High-risk Patients Undergoing Ambulatory General Surgery

BACKGROUND

Same-day surgery is an increasingly utilized and cost-effective strategy to manage common surgical conditions. However, many institutions limit ambulatory surgical services to only healthy individuals. There is also a paucity of data on the safety of same-day discharge among high-risk patients. This study aims to determine whether same-day discharge is associated with higher major morbidity and readmission rates compared with overnight stay in high-risk general surgery patients.

METHODS

This is a retrospective cohort using the data from the National Surgical Quality Improvement Program from 2005 to 2017. Patients with an American Society of Anesthesiologists class ≥3 undergoing general surgical procedures amenable to same-day discharge were identified. Primary and secondary outcomes were major morbidity and readmission at 30 d. A multivariable logistic regression model using mixed effects was used to adjust for the effect of same-day discharge.

RESULTS

Of 191,050 cases, 137,175 patients (72%) were discharged on the same day. At 30 d, major morbidity was 1.0%, readmission 2.2%, and mortality <0.1%. Adjusted odds ratio of same-day discharge was 0.59 (95% confidence interval 0.54-0.64; P < 0.001) for major morbidity and 0.75 (95% confidence interval 0.71-0.80; P < 0.001) for readmission. Significant risk factors for morbidity and readmission included nonindependent functional status, ascites, renal failure, and disseminated cancer.

CONCLUSIONS

Major morbidity and readmission rates are low among this large sample of high-risk general surgery patients undergoing common ambulatory procedures. Same-day discharge was not associated with increased adverse events and could be considered in most high-risk patients after uncomplicated surgery.

Evaluation of Postoperative Functional Health Status Decline Among Older Adults

Importance

Functional outcomes have value for older adults who undergo surgical procedures. Preventing postoperative functional decline in this patient population necessitates the identification of the factors associated with this outcome and minimizing their implications.

Objectives

To assess the prevalence of functional decline 30 days after a surgical procedure among older adults 80 years or older, examine the risk factors of this decline, and identify ways to minimize this decline by addressing its mutable factors.

Design, Setting, and Participants

This retrospective cohort study used patient data from the Geriatric Surgery Pilot Project, a multi-institutional data registry of the American College of Surgeons National Surgical Quality Improvement Program. Inclusion criteria were patients 80 years or older who underwent a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the Geriatric Surgery Pilot Project from January 1, 2015, to December 31, 2018, and had preoperative and postoperative functional health status data. Data analysis was performed from January 7, 2019, to December 2, 2019.

Exposures

Adults 80 years or older who underwent an inpatient surgical procedure.

Main Outcomes and Measures

The primary outcome was 30-day postoperative functional decline defined by a change in functional health status from admission or before the surgical procedure (ie, from independent to partially or totally dependent, or from partially dependent to totally dependent). Functional health status was measured by a patient's ability to perform activities of daily living. Secondary outcomes were hospital readmission and 30-day postoperative living location.

Results

Of the 2013 patients analyzed in this study, 1128 were women (56.0%) and the mean (SD) age was 84.9 (3.9) years. Functional decline at 30 days after the surgical procedure was present in 406 patients (20.2%). Prevalence of this outcome increased with age, with 337 of 1751 patients aged 80 to 89 years (19.2%) experiencing decline compared with 69 of 262 patients 90 years or older (26.3%). In a risk-adjusted model, the geriatric-specific risk factors statistically significantly associated with this outcome included preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22; P < .001) and malnutrition (OR, 1.88; 95% CI, 1.04-3.43; P = .04) as well as postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02; P < .001), pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30; P = .04), and mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59; P < .001). Among patients with a 30-day functional decline, 106 (26.1%) required hospital readmission and only 219 (53.9%) were living at home compared with 388 patients (95.6%) living at home before the procedure.

Conclusions and Relevance

In this study, 1 in 5 older adults experienced a functional decline that persisted 30 days after a surgical procedure, an outcome that appeared to be associated with several geriatric-specific risk factors. Future trials are needed to evaluate whether the prevention or mitigation of these factors can decrease the rates of postoperative functional decline in this patient population.

Using a Data-Driven Improvement Methodology to Decrease Surgical Site Infections in a Community Neurosurgery Practice: Optimizing Preoperative Screening and Perioperative Antibiotics

OBJECTIVE

We used a data-driven methodology to decrease the departmental surgical site infection rate to a goal of 1%.

METHODS

A prospective interventional study with historical controls comparing preimplementation/intervention (unknown methicillin-sensitive Staphylococcus aureus [MSSA]/methicillin-resistant Staphylococcus aureus [MRSA] status and standard weight and drug allergy-based preoperative antibiotics) with postimplementation/intervention (optimized preoperative chlorhexidine showers, MSSA/MRSA screening, MSSA/MRSA decolonization, and optimized preoperative antibiotic order set implementation). The American College of Surgeons National Surgical Quality Improvement Program was used for case surveillance. The primary outcome was the presence of a surgical site infection with a secondary outcome of cost(s) of implementation.

RESULTS

A total of 317 National Surgical Quality Improvement Program abstracted neurosurgical cases were analyzed, 163 cases before implementation and 154 cases after implementation. There were no significant differences between the preimplementation and postimplementation cohorts regarding patient demographics and baseline comorbidities, with the exceptions of inpatient and functional status (P < 0.001). The most common procedures were lumbar decompression (31%), lumbar discectomy (27%), and anterior cervical discectomy and fusion (10.4%). After implementation, 30 patients were MSSA positive (20%) and 4 MRSA positive (2.6%). Thirty patients received preoperative intranasal mupirocin decolonization (88%), and 4 patients received adjusted preoperative antibiotics (12%). After protocol implementation, the surgical site infection rate decreased from 6.7% (odds ratio, 2.82) to 0.96% (odds ratio, 0.91). The cost of implementation was $27,179, or $58 per patient.

CONCLUSIONS

The findings highlight the importance of systematically investigating areas of gap in existing clinical practice and quality improvement projects to increase patient safety and enhance the value of care delivered to neurosurgical patients.

The American College of Surgeons Surgical Risk Calculator performs well for pulmonary resection: A validation study

OBJECTIVE

The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP SRC) was developed to estimate the risk of postoperative morbidity and mortality within 30 days of an operation. We sought to externally evaluate the performance of the NSQIP SRC for patients undergoing pulmonary resection.

METHODS

Patients undergoing pulmonary resection at our center between January 2016 and December 2018 were included. Using data from our institution's prospectively maintained Society of Thoracic Surgeons General Thoracic Database, we identified 2514 patients. We entered requisite patient demographic information, preoperative risk factors, and procedural details into the online calculator. Predicted performance of the calculator versus observed outcomes was assessed by discrimination (concordance index [C-index]) and calibration.

RESULTS

The observed and predicted probabilities of any complication were 8.3% and 9.9%, respectively, and of serious complications were 7.4% and 9.2%, respectively. Observed and predicted 30-day mortality were 0.5% and 0.9%, respectively. The C-index for readmission was 0.644; the C-indices corresponding to all other outcomes in the NSQIP SRC ranged from 0.703 to 0.821. Calibration curves indicated excellent calibration for all binary end points, with the exception of renal failure (predicted underestimated observed probabilities), discharge to a nursing or rehabilitation facility (overestimated), and sepsis (overestimated). Correlation between predicted and observed length of stay was moderate (Spearman coefficient, 0.562), and calibration was good.

CONCLUSIONS

Except for readmission, renal failure, discharge to a location other than home, and sepsis, the NSQIP SRC can be used to reasonably predict postoperative complications in patients undergoing pulmonary resection.

Ascertaining service quality and medical practitioners' sensitivity towards surgical instruments using SERVQUAL

Purpose

Service quality (SQ) has become an essential and indispensable component in healthcare and many other industries. SQ can deliver guaranteed stakeholder value and consequent consumer delight in the healthcare sector. The purpose of this study is to identify the relationships of various SERVQUAL elements with respect to the SQ of surgical instrument suppliers among surgeons.

Design/methodology/approach

Data were collected from a sample of 112 surgeons working in the USA using the “snowball sampling” technique. A few standardised questionnaires, including SERQUAL, were used to collect the data. R-programming was used to perform structural equation modelling (SEM) analysis on the collected data.

Findings

The research study identified that service delivery factors and the SQ of surgical instruments contribute significantly towards medical practitioner sensitivity in the US healthcare industry. Word of mouth (WOM) did not have any significant impact on the medical practitioners' sensitivity.

Originality/value

A review of related literature revealed that studies that examine the surgeon's perspectives of SQ are scarce. Thus, the present study is directed towards this gap in literature. The findings of the study are significant in nature and have made a substantial contribution to management literature.

Impact of Trainee Involvement on Video-Assisted Thoracoscopic Lobectomy for Cancer

BACKGROUND

Previous literature in other surgical disciplines regarding the impact of resident and fellow involvement on operative time and outcomes has yielded mixed results. The impact of trainee involvement on minimally invasive thoracic surgery is unknown. This study compared risk-adjusted differences in operative time and outcomes of video-assisted thoracoscopic lobectomy for cancer between cases performed with and without residents and fellows involved.

METHODS

All patients undergoing elective video-assisted thoracoscopic lobectomy for cancer between 2008 and 2018 were identified in the Veterans Affairs Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: cases with residents and fellows involved, and cases performed only by attending surgeons. Primary outcomes included operative time, postoperative hospital length of stay, and composite 30-day morbidity and mortality. Secondary outcomes included factors associated with high and low trainee operative autonomy.

RESULTS

A total of 3678 patients met study inclusion criteria. In all, 1780 cases were performed with residents and fellows involved (median postgraduate year, 5; interquartile range, 4-7). Multivariate analysis showed that operative time was significantly shorter in resident- and fellow-involved cases compared with attending-only cases (mean [SD], 3.6 [1.4] versus 3.8 [1.6] hours; P < .001). There were no significant differences in composite 30-day morbidity and mortality (16.0% versus 17.1%; adjusted odds ratio = 0.93; 95% confidence interval, 0.77-1.11; P = .40) or length of stay. Substratification of trainees by postgraduate year resulted in similar findings. Cases performed in July through October and those in the Northeastern United States were associated with low autonomy.

CONCLUSIONS

Current training paradigms in thoracic surgery are safe, and the involvement of motivated and skilled trainees with appropriate supervision may benefit operative duration.

Development of a nomogram for predicting the operative mortality of patients who underwent pneumonectomy for lung cancer: a population-based analysis

Background

Although many studies have reported that patients have undergone entire lung removal for lung cancer along with high operative mortality, the trends in the incidence and associated risk factors for operative death have not been explored in a national population-based study. In addition, a clinical decision-making nomogram for predicting postpneumonectomy mortality remains lacking.

Methods

A total of 10,337 patients diagnosed with lung cancer who underwent pneumonectomy between 1998 and 2016 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) cancer registry. Multivariate logistic regression analysis was used to identify risk factors for predicting operative mortality. Thereafter, these independent predictors were integrated into a nomogram, and bootstrap validation was applied to assess the discrimination and calibration. Additionally, decision curve analysis (DCA) was used to calculate the net benefit of this forecast model.

Results

The overall postpneumonectomy mortality between 1998 and 2016 was 10.3%, including a 30-day mortality of 4.2%; however, there were statistically significant decreases in the operative death rates from 8.8% in 1998 to 6.7% in 2016 (P=0.009). Higher operative mortality was associated with advanced patients (P<0.001), male sex (P<0.001), right-sided pneumonectomy (P<0.001), squamous cell carcinoma (SCC) (P=0.008), number of positive lymph nodes (npLNs) 5 or greater (P=0.010), and distant metastasis (P<0.001). However, induction radiotherapy (RT) was a protective factor (P<0.001). The nomogram integrating all of the above independent predictors was well calibrated and had a relatively good discriminative ability, with a C-statistic of 0.687 and an area under the receiver operating characteristic (ROC) curve (AUC) of 0.682; moreover, DCA demonstrated that our model was clinically useful.

Conclusions

If pneumonectomy was considered inevitable, clinical decision-making based on this simple but efficient predictive nomogram could help minimize the risk of operative death and maximize the survival benefit.

Validation of an Electronic Surveillance Algorithm to Identify Patients With Post-Operative Surgical Site Infections Using National Surgical Quality Improvement Program Pediatric Data

BACKGROUND

Surgical site infections (SSIs) are common, but data related to these infections maybe difficult to capture. We developed an electronic surveillance algorithm to identify patients with SSIs. Our objective was to validate our algorithm by comparing it with our institutional National Surgical Quality Improvement Program Pediatric (NSQIP Peds) data.

METHODS

We applied our algorithm to our institutional NSQIP Peds 2015-2017 cohort. The algorithm consisted of the presence of a diagnosis code for post-operative infection or the presence of 4 criteria: diagnosis code for infection, antibiotic administration, positive culture, and readmission/surgery related to infection. We compared the algorithm's SSI rate to the NSQIP Peds identified SSI. Algorithm performance was assessed using sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and Cohen's kappa. The charts of discordant patients were reviewed to understand limitations of the algorithm.

RESULTS

Of 3879 patients included, 2.5% had SSIs by NSQIP Peds definition and 1.9% had SSIs by our algorithm. Our algorithm achieved a sensitivity of 44%, specificity of 99%, NPV of 99%, PPV of 59%, and Cohen's kappa of 0.5. Of the 54 false negatives, 37% were diagnosed/treated as outpatients, 31% had tracheitis, and 17% developed SSIs during their post-operative admission. Of the 30 false positives, 33% had an infection at index surgery and 33% had SSIs related to other surgeries/procedures.

CONCLUSIONS

Our algorithm achieved high specificity and NPV compared with NSQIP Peds reported SSIs and may be useful when identifying SSIs in patient populations that are not actively monitored for SSIs.

Optimizing Peripandemic Care for Veteran Major Non-Traumatic Lower Extremity Amputees: A Proposal Informed by a National Retrospective Descriptive Analysis of COVID-19 Risk Factor Prevalence

INTRODUCTION

In response to the Coronavirus 2019 (COVID-19) pandemic, vascular surgeons in the Veteran Affairs Health Care System have been undertaking only essential cases, such as advanced critical limb ischemia. Surgical risk assessment in these patients is often complex, considers all factors known to impact short- and long-term outcomes, and the additional risk that COVID-19 infection could convey in this patient population is unknown. The European Centre for Disease Prevention and Control (ECDC) published risk factors (ECDC-RF) implicated in increased COVID-19 hospitalization and case-fatality which have been further evidenced by initial reports from the United States Centers for Disease Control and Prevention. CDC reports additionally indicate that African American (AA) patients have incurred disparate infection outcomes in the United States. We set forth to survey the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database over a nearly 20 year span to inform ongoing risk assessment with an estimation of the prevalence of ECDC-RF in our veteran critical limb ischemia population and investigate whether an increased COVID-19 comorbidity burden exists for AA veterans presenting for major non-traumatic amputation.

MATERIALS AND METHODS

The VASQIP database was queried for all above knee amputation (AKA) and below knee amputation (BKA) completed 1999-2018 after IRB approval (MIRB:#02507). Patient race and ECDC-RF including male gender, age > 60 years, smoking status, hypertension, diabetes, chronic obstructive pulmonary disease, cancer, and cardiovascular disease were recorded from preoperative patient history. AKA and BKA cohorts were compared via χ2-test with Yates correction or unpaired t-test and a subgroup analysis was conducted between AA and all other race patients for COVID-19 comorbidities in each cohort.

RESULTS

VASQIP query returned 50,083 total entries. Average age was 65.1 ± 10.4 years and 68.2 ± 10.5 years for BKA and AKA cohorts, respectively, (P < .0001) and nearly all patients were male (99%). At least one ECDC-RF comorbidity was present in 25,526 (88.7%) of BKA and 17,558 (82.4%) of AKA patients (P < .0001). AA BKA patients were significantly more likely than non-AA BKA patients to present with at least one ECDC-RF comorbidity (P = .01).

CONCLUSIONS

According to a large national Veterans Affairs database, there are high rates of ECDC-RF in veteran amputees. During the present crisis, management of these patients should incorporate telehealth, expedient discharge, and ongoing COVID-19 transmission precautions.

Facilitated Regional Collaboration and In-Hospital Surgical Complication

BACKGROUND

Surgical quality improvement efforts are challenging due to the multidisciplinary nature of care, difficulties obtaining reliable data, and variability in quality metrics. The objective of this analysis was to assess whether participation in a regional collaborative quality initiative was associated with decreased in-hospital surgical complication in South Carolina.

STUDY DESIGN

In-hospital surgical complication rates were determined using a statewide all-payer claims data set. Retrospective, univariate, and longitudinal multivariable analyses were performed and adjustments were made to account for aggregated hospital-level patient characteristics.

RESULTS

The analysis included 275,387 general surgery cases performed in South Carolina hospitals between January 2016 and December 2018. Eight hospitals involved in the South Carolina Surgical Quality Collaborative (SCSQC) performed 56,179 cases and 51 non-SCSQC hospitals performed 219,208 cases. Univariate analysis revealed SCSQC hospitals performed operations in older patients (p < 0.0001) and patients with higher mean Charlson Comorbidity Index scores (p < 0.0001). SCSQC hospitals had higher mean in-hospital surgical complication rates at the surgery level compared with non-SCSQC hospitals (8.3% vs 7.0%; p < 0.0001). However, in multivariable analyses, the rate ratio for in-hospital surgical complication in SCSQC hospitals was 0.994 (95% CI, 0.989 to 0.998; p = 0.008) per month compared with non-SCSQC hospitals. This suggests a 21.6% (95% CI, 7.2% to 39.6%) proportional decrease in the rate of in-hospital surgical complication during 3 years associated with participation in the regional collaborative quality initiative.

CONCLUSIONS

Structured collaboration between facilities, reliable data abstraction support, timely data review, and active member participation resulted in outcomes improvements for participating hospitals compared with hospitals that did not participate in a regional collaborative quality initiative.

Outcomes of cholecystectomy in US veterans with cirrhosis: Predicting outcomes using nomogram

BACKGROUND

This study examines the outcomes of open and laparoscopic cholecystectomy (OC/LC) in veterans with cirrhosis and develops a nomogram to predict outcomes.

METHODS

We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent cholecystectomy from 2008 to 2015. Univariate and multivariate regression were used to identify predictors of morbidity and mortality. A predictive nomogram was constructed and internally validated.

RESULTS

A total of 349 patients were identified. Overall, complications occurred in 18.7% of patients, and mortality was 3.8%. LC was performed in 58.9%, and 19.2% were preformed emergently. Overall, Model for End-Stage Liver Disease score was an independent factor of morbidity and mortality, while laparoscopic approach had a protective effect on morbidity.

CONCLUSIONS

Although cholecystectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing cholecystectomy is proposed.

Advanced ovarian cancer and cytoreductive surgery: Independent validation of a risk-calculator for perioperative adverse events

OBJECTIVE

To independently validate a published risk-calculator for adverse perioperative outcomes in patients with epithelial ovarian cancer undergoing debulking surgery at a high-volume surgical center.

METHODS

Using our institution's curated prospective ovarian cancer database, we identified patients with epithelial ovarian cancer who underwent a debulking procedure from 7/2015 to 5/2019, to be used as the validation cohort. Variables used in the published nomogram were collected. These included American Society of Anesthesiology classification, preoperative albumin, history of bleeding disorder, presence of ascites on preoperative imaging, designation of elective or emergent surgery, age of the patient, and a procedure score. Patients were included if they had information available for all the variables used in the nomogram, and 30-day follow-up within our institution. The primary outcome was Clavien-Dindo Class IV with specific conditions (postoperative sepsis, septic shock, cardiac arrest, myocardial infarction, pulmonary embolism, ventilation >48 h, or unplanned intubation) and 30-day mortality. The combination of these endpoints is called the combined complication rate.

RESULTS

A total of 700 patients who underwent debulking surgery for epithelial ovarian cancer during the timeframe met inclusion criteria. The combined complication rate was 11.7%; 9.9% of patients were readmitted; 2.7% required reoperation. Sepsis was the most common primary endpoint complication (4.4%), followed by septic shock (1.4%). There was no 30-day mortality in our cohort. The nomogram performed well, with a c index of 0.715 (95% CI 0.66-0.768), which was comparable to the published nomogram.

CONCLUSIONS

We independently validated a complication nomogram at a high-volume surgical center. This nomogram performs well at predicting a lower likelihood of serious postoperative complications. An enhanced nomogram would help identify patients at higher risk for serious complications.

Ensemble machine learning for the prediction of patient-level outcomes following thyroidectomy

BACKGROUND

Accurate prediction of thyroidectomy complications is necessary to inform treatment decisions. Ensemble machine learning provides one approach to improve prediction.

METHODS

We applied the Super Learner (SL) algorithm to the 2016-2018 thyroidectomy-specific NSQIP database to predict complications following thyroidectomy. Cross-validation was used to assess model discrimination and precision.

RESULTS

For the 17,987 patients undergoing thyroidectomy, rates of recurrent laryngeal nerve injury, post-operative hypocalcemia prior to discharge or within 30 days, and neck hematoma were 6.1%, 6.4%, 9.0%, and 1.8%, respectively. SL improved prediction of thyroidectomy-specific outcomes when compared with benchmark logistic regression approaches. For postoperative hypocalcemia prior to discharge, SL improved the cross-validated AUROC to 0.72 (95%CI 0.70-0.74) compared to 0.70 (95%CI 0.68-0.72; p < 0.001) when using a manually curated logistic regression algorithm.

CONCLUSION

Ensemble machine learning modestly improves prediction for thyroidectomy-specific outcomes. SL holds promise to provide more accurate patient-level risk prediction to inform treatment decisions.

Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition

BACKGROUND

There has been a dramatic increase in worldwide health care spending over the last several decades. Operative procedures and perioperative care in the USA represent some of the most expensive episodes per patient. In view of both the rising cost of health care in general and the rising cost of surgical care specifically, policymakers and stakeholders have sought to identify ways to increase the value-improving quality of care while controlling (or diminishing) costs. In this context, we reviewed data relative to achieving the "value proposition" in the delivery of gastrointestinal surgical care.

METHODS

The National Library of Medicine online repository (PubMed) was text searched for human studies including "cost," "quality," "outcomes," "health care," "surgery," and "value." Results from this literature framed by the Donabedian conceptual model (identifying structures, processes, and outcomes), and the resulting impact of efforts to improve quality on costs.

RESULTS

The relationship between quality and costs was nuanced. Better quality care, though associated with better outcomes, was not always reported as concomitant with low costs. Moreover, some centers reported higher costs of surgical care commensurate with higher quality. Conversely, higher costs in health care delivery were not always linked to improved outcomes. While higher quality surgical care can lead to lower costs, higher costs of care were not necessarily associated with better outcomes. Strategies to improve quality, reduce cost, or achieve both simultaneously included regionalization of complex operations to high-volume centers of excellence, overall reduction in complications, introducing evidence-based improvements in perioperative care pathways including as enhanced recovery after surgery (ERAS), and elimination of inefficient or low-value care.

CONCLUSIONS

The relationship between quality and cost following gastrointestinal surgical procedure is complex. Data from the current study should serve to highlight the various means available to improve the value proposition related to surgery, as well as encourage surgeons to become more engaged in the national conversation around the Triple Aim of better health care quality, lower costs, and improved health care outcomes.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs.

RESULTS

Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9 years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA (81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups.

CONCLUSION

In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Preexisting Dementia Is Associated with Increased Risks of Mortality and Morbidity Following Major Surgery: A Nationwide Propensity Score Matching Study

Patients with dementia are predisposed to multiple physiological abnormalities. It is uncertain if dementia associates with higher rates of perioperative mortality and morbidity. We used reimbursement claims data of Taiwan’s National Health Insurance and conducted propensity score matching analyses to evaluate the risk of mortality and major complications in patients with or without dementia undergoing major surgery between 2004 and 2013. We applied multivariable logistic regressions to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for the outcome of interest. After matching to demographic and clinical covariates, 7863 matched pairs were selected for analysis. Dementia was significantly associated with greater risks of 30-day in-hospital mortality (aOR: 1.71, 95% CI: 1.09–2.70), pneumonia (aOR: 1.48, 95% CI: 1.16–1.88), urinary tract infection (aOR: 1.59, 95% CI: 1.30–1.96), and sepsis (OR: 1.77, 95% CI: 1.34–2.34) compared to non-dementia controls. The mortality risk in dementia patients was attenuated but persisted over time, 180 days (aOR: 1.49, 95% CI: 1.23–1.81) and 365 days (aOR: 1.52, 95% CI: 1.30–1.78) after surgery. Additionally, patients with dementia were more likely to receive blood transfusion (aOR: 1.32, 95% CI: 1.11–1.58) and to need intensive care (aOR: 1.40, 95% CI: 1.12–1.76) compared to non-dementia controls. Senile dementia and Alzheimer’s disease were independently associated with higher rates of perioperative mortality and complications, but vascular dementia was not affected. We found that preexisting dementia was associated with mortality and morbidity after major surgery.

Frailty and outcomes after craniotomy for brain tumor

Frailty has been associated with increased morbidity and mortality in a variety of surgical disciplines. Few data exist regarding the relationship of frailty with adverse outcomes in craniotomy for brain tumor resection. We assessed the relationship between frailty and the incidence of major post-operative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after elective craniotomy for brain tumor resection. A retrospective cohort study was conducted on 20,333 adult patients undergoing elective craniotomy for tumor resection in the 2012-2018 ACS-NSQIP Participant Use File. Multivariate logistic regression was performed using all covariates deemed eligible through clinical and statistical significance. 6,249 patients (30.7%) were low-frailty and 2,148 patients (10.6%) were medium-to-high frailty. In multivariate logistic regression adjusting for age, gender, BMI, ASA classification, smoking status, dyspnea, significant pre-operative weight loss, chronic steroid use, bleeding disorder, tumor type, and operative time, low frailty was associated with increased adjusted odds ratio of major complication (1.41, 95% CI: 1.23-1.60, p < 0.001), discharge destination other than home (1.32, 95% CI: 1.20-1.46, p < 0.001), 30-day readmission (1.29, 95% CI: 1.15-1.44, p < 0.001), and 30-day mortality (1.87, 95% CI: 1.41-2.47, p < 0.001). Moderate-to-high frailty was also associated with increased adjusted odds of major complication (1.61, 95% CI: 1.35-1.92, p < 0.001), discharge destination other than home (1.80, 95% CI: 1.58-2.05), 30-day readmission (1.39, 95% CI: 1.19-1.62, p < 0.001), and 30-day mortality (2.42, 95% CI: 1.74-3.38, p < 0.001). CONCLUSIONS: Frailty is associated with increased odds of major post-operative complication, discharge to destination other than home, 30-day readmission, and 30-day mortality.

Mortality calculator as a possible prognostic predictor of overall survival after gastrectomy in elderly patients with gastric cancer

Background

The number of elderly patients with gastric cancer has been increasing. Most elderly patients have associated reduced physiologic functions that can sometimes become an obstacle to safe surgical treatment. The National Clinical Database Risk Calculator, which based on a large Japanese surgical database, provides predicted mortality and morbidity in each case as the surgical-related risks. The purpose of this study was to investigate the clinical significance of the risk for operative mortality (NRC-mortality), as calculated by the National Clinical Database Risk Calculator, during long-term follow-up after gastrectomy for elderly patients with gastric cancer.

Methods

We enrolled 73 patients aged ≥ 80 years and underwent gastrectomy at our institution. Their surgical risk was evaluated based on the NRC-mortality. Several clinicopathologic factors, including NRC-mortality, were selected and analyzed as the possible prognostic factors for elderly patients who have undergone gastrectomy for gastric cancer. Statistical analysis was performed using the log-rank test and Cox proportional hazard model.

Results

NRC-mortality ranged from 0.5 to 10.6%, and the median value was 1.7%. Dividing the patients according to mortality, the overall survival was significantly worse in the high mortality group (≥ 1.7%, n = 38) than in the low mortality group (< 1.7%, n = 35), whereas disease-specific survival was not different between the two groups. In the Cox proportional hazard model, multivariate analysis revealed NRC-mortality, performance status, and surgical procedure as the independent prognostic factors for overall survival. For disease-specific survival, the independent prognostic factors were performance status and pathological stage but not NRC-mortality.

Conclusion

The NRC-mortality might be clinically useful for predicting both surgical mortality and overall survival after gastrectomy in elderly patients with gastric cancer.

External Validation of Surgical Risk Preoperative Assessment System in Pulmonary Resection

BACKGROUND

Accurate preoperative risk assessment is necessary for informed decision making for patients and surgeons. Several preoperative risk calculators are available but few have been examined in the general thoracic surgical patient population. The Surgical Risk Preoperative Assessment System (SURPAS), a risk-assessment tool applicable to a wide spectrum of surgical procedures, was developed to predict the risks of common adverse postoperative outcomes using a parsimonious set of preoperative input variables. We sought to externally validate the performance of SURPAS for postoperative complications in patients undergoing pulmonary resection.

METHODS

Between January 2016 and December 2018, 2514 patients underwent pulmonary resection at our center. Using data from our institution's prospectively maintained database, we calculated the predicted risks of 12 categories of postoperative outcomes using the latest version of SURPAS. Performance of SURPAS against observed patient outcomes was assessed by discrimination (concordance index) and calibration (calibration curves).

RESULTS

The discrimination ability of SURPAS was moderate across all outcomes (concordance indices, 0.640 to 0.788). Calibration curves indicated good calibration for all outcomes except infectious and cardiac complications, discharge to a location other than home, and mortality (all overestimated by SURPAS).

CONCLUSIONS

SURPAS demonstrates outcomes for pulmonary resections with reasonable predictive ability. Discretion should be applied when assessing risk for postoperative infectious and cardiac complications, discharge to a location other than home, and mortality. Although the parsimonious nature of SURPAS is one of its strengths, its performance might be improved by including additional factors known to influence outcomes after pulmonary resection, such as sex and pulmonary function.

Performance Comparison Between SURPAS and ACS NSQIP Surgical Risk Calculator in Pulmonary Resection

BACKGROUND

Accurate preoperative risk assessment is critical for informed decision making. The Surgical Risk Preoperative Assessment System (SURPAS) and the National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator (SRC) predict risks of common postoperative complications. This study compares observed and predicted outcomes after pulmonary resection between SURPAS and NSQIP SRC.

METHODS

Between January 2016 and December 2018, 2514 patients underwent pulmonary resection and were included. We entered the requisite patient demographics, preoperative risk factors, and procedural details into the online NSQIP SRC and SURPAS formulas. Performance of the prediction models was assessed by discrimination and calibration.

RESULTS

No statistically significant differences were found between the 2 models in discrimination performance for 30-day mortality, urinary tract infection, readmission, and discharge to a nursing or rehabilitation facility. The ability to discriminate between a patient who will develop a complication and a patient who will not was statistically indistinguishable between NSQIP and SURPAS, except for renal failure. With a C index closer to 1.0, the NSQIP performed significantly better than the SURPAS SRC in discriminating risk of renal failure (C index, 0.798 vs 0.694; P = .003). The calibration curves of predicted and observed risk for each model demonstrate similar performance with a tendency toward overestimation of risk, apart from renal failure.

CONCLUSIONS

Overall, SURPAS and NSQIP SRC performed similarly in predicting outcomes for pulmonary resections in this large, single-center validation study with moderate to good discrimination of outcomes. Notably, SURPAS uses a smaller set of input variables to generate the preoperative risk assessment. The addition of thoracic-specific input variables may improve performance.

Frailty and Outcomes after Craniotomy or Craniectomy for Atraumatic Chronic Subdural Hematoma

OBJECTIVE

Frailty is a measure of decreased physiologic reserve and has been associated with increased morbidity and mortality in a variety of surgical disciplines. No data exist regarding the relationship of frailty with adverse outcomes in craniotomy for chronic subdural evacuation. We assessed the relationship between frailty and the incidence of major postoperative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after craniotomy for atraumatic subdural evacuation.

METHODS

A retrospective cohort study was conducted on a population of 1647 adult patients undergoing craniotomy for evacuation of atraumatic subdural hematoma in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index (mFI-5). Multivariable logistic regression was performed using all covariates deemed eligible through clinical relevance and statistical significance.

RESULTS

The overall rates of major complication (25.4%), discharge to destination other than home (49.8%), 30-day readmission (11.7%), and 30-day mortality (12.8%) in this analysis were high and rose with increasing frailty. In multivariable regression analyses, medium frailty (mFI-5 = 2) was associated with increased odds of major complication (adjusted odds ratio [aOR] 1.64, 95% confidence interval [CI] 1.03-2.63), discharge to destination other than home (aOR 2.04, 95% CI 1.38-3.02), and 30-day mortality (aOR 2.27, 95% CI 1.08-4.78). High frailty (mFI-5 >2) was associated with increased odds of 30-day mortality (aOR 2.85, 95% CI 1.13-7.14).

CONCLUSIONS

Preoperative frailty, as determined by mFI-5, is associated with increased odds of major postoperative complication, discharge to destination other than home, and 30-day mortality after craniotomy for chronic subdural hematoma.

Open innovation facilitates department-wide engagement in quality improvement: experience from the Massachusetts General Hospital

BACKGROUND

Quality improvement (QI) initiatives commonly originate 'top-down' from senior leadership, as staff engagement is often sporadic. We describe our experience with a technology-enabled open innovation contest to encourage participation from multiple stakeholders in a Department of Surgery (DoS) to solicit ideas for QI. We aimed to stimulate engagement and to assist DoS leadership in prioritizing QI initiatives.

METHODS

Observational study of a process improvement. The process had five phases: anonymous online submission of ideas by frontline staff; anonymous online crowd-voting to rank ideas on a scale whether the DoS should implement each idea (1 = No, 3 = Maybe, 5 = Yes); ideas with scores ≥ 95th percentile were invited to submit implementation plans; plans were reviewed by a multi-disciplinary panel to select a winning idea; an award ceremony celebrated the completion of the contest.

RESULTS

152 ideas were submitted from 95 staff (n = 850, 11.2%). All Divisions (n = 12) and all staff roles (n = 12) submitted ideas. The greatest number of ideas were submitted by faculty (27.6%), patient service coordinators (18.4%), and residents (17.8%). The most common QI category was access to care (20%). 195 staff (22.9%) cast 3559 votes. The mean score was 3.5 ± 0.5. 10 Ideas were objectively invited to submit implementation plans. One idea was awarded a grand prize of funding, project management, and leadership buy-in.

CONCLUSION

A web-enabled open innovation contest was successful in engaging faculty, residents, and other critical role groups in QI. It also enabled the leadership to re-affirm a positive culture of inclusivity, maintain an open-door policy, and also democratically vet and prioritize solutions for quality improvement.

The Impact of Malnutrition on 30-Day Postoperative Complications following Surgical Fixation of Distal Radius Fractures

Introduction  Distal radius fractures (DRFs) are increasingly managed surgically among fragility fractures due to prolonged life expectancy and surgical advancements. Yet, malnutrition can impact postoperative outcomes and complications. We sought to determine the impact of malnutrition on open reduction and internal fixation (ORIF) of DRFs during the perioperative and 30-day postoperative periods. Materials and Methods  Using the National Surgical Quality Improvement Program database, all patients who underwent ORIF of a DRF between January 1, 2008, and December 31, 2016, were identified and stratified by preoperative serum albumin levels: normal (≥3.5 g/dL; n = 2,546) or hypoalbuminemia (<3.5 g/dL; n = 439). Demographical and perioperative data were compared. Operative complications were stratified into major and minor complications, and data were analyzed using descriptive statistics and multivariate regression models. Results  Compared with patients with normal levels, a higher proportion of hypoalbuminemia patients had ASA scores > 3 (9.1 vs. 2%) and a longer mean length of stay (3.16 vs. 0.83 days). Hypoalbuminemia patients also had 625% greater odds for developing major complications during the 30-day postoperative period (odds ratio = 7.25; 95% confidence interval: 1.91-27.49). Conclusion  Malnutrition significantly affected outcomes and complications of distal radius ORIF. This study highlights the importance of prevention and treatment of malnutrition in the setting of fragility fractures.

Am I out of control? The application of statistical process control charts to children's surgery

AIMS

To illustrate the construction of statistical control charts and show their potential application to analysis of outcomes in children's surgery.

PATIENTS AND METHODS

Two datasets recording outcomes following esophageal atresia repair and intestinal resection for Crohn's disease maintained by the author were used to construct four types of charts. The effects of altering the target signal, the alarm signal and the limits are illustrated. The dilemmas in choice of target rate are described. Simulated data illustrate the advantages over hypothesis testing.

RESULTS

The charts show the author's institutional leak rate for esophageal atresia repair may be within acceptable limits, but that this is dependent on the target set. The desirable target is contentious. The leak rate for anastomoses following intestinal resection for Crohn's disease leak is also within acceptable limits when compared to published experience, but may be deteriorating. The charts are able to detect deteriorating levels of performance well before hypothesis testing would suggest a systematic problem with outcomes.

CONCLUSIONS

Statistical process control charts can provide surgeons with early warning of systematic poor performance. They are robust to volume-outcome influences, since the outcome is tested sequentially after each procedure or patient. They have application in a specialty with low frequencies of operations such as children's surgery.

TYPE OF STUDY

Diagnostic test.

LEVEL OF EVIDENCE

Level II.

The Obesity Paradox: Body Mass Index Complication Rates Vary by Gender and Age Among Primary Total Hip Arthroplasty Patients

BACKGROUND

High body mass index (BMI) has long been recognized as a risk factor for postoperative complication among total hip arthroplasty (THA) patients. However, recent studies showed mixed results in the effect of high BMI on surgical outcomes. Our study is to examine the association of preoperative BMI with complication incidence, stratified by age and gender.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Project database to identify patients who underwent elective primary THA between 2012 and 2016. We examined the associations between BMI as a continuous and a categorical variable and risk of 30-day postoperative complication, using 2 multiple polynomial logistic regression models. We also created predictive plots to graphically assess the relationship between BMI and complication by gender and age.

RESULTS

In total, 117,567 eligible patients were included in the analyses. The predictive probability of all-type postoperative complications showed a U-shaped relationship with continuous BMI values (range 10-65 kg/m²). The lowest complication risks occurred in patients with BMI between 35 and 40. Females had higher complication rate than males across all BMI values. This U-shaped relationship was only observed among patients younger than 60 years old, while the associations appear to be inversely linear among patients aged greater than 60 years.

CONCLUSION

Our results suggest that the current theory of a linear association between BMI and complication risk may not apply to elective primary THA. Strict BMI cutoffs may not minimize risk, especially among patients over 60 years old. Orthopedic surgeons should factor in patient-specific variables of age and gender when determining acceptable surgical risk given a particular BMI value.

Malnutrition increases the 30-day complication and re-operation rates in hip fracture patients treated with total hip arthroplasty

INTRODUCTION

This study sought to determine the effect that malnutrition, defined as hypoalbuminemia, has on hip fracture patients treated with total hip arthroplasty (THA). Specifically, we evaluated: (1) demographics and perioperative data; (2) postoperative complications; and (3) re-operation rates.

METHODS

The National Surgical Quality Improvement Program database was utilised to identify hip fracture patients who underwent THA from 2008 to 2015. Propensity scores were calculated for the likelihood of having a preoperative albumin measurement. Hip fracture patients who underwent THA and had preoperative hypoalbuminemia (<3.5 g/dL) (n = 569) were compared to those who had normal albumin levels (⩾3.5 g/dL) (n = 1098) in terms of demographics and perioperative data. Regression models were adjusted for age, sex, modified Charlson/Deyo scores, and propensity scores to evaluate complication and re-operation rates.

RESULTS

Compared to controls, hypoalbuminemia patients were older (p = 0.006), more likely male (p = 0.024), had higher Charlson/Deyo scores (p = 0.0001), more likely smokers (p < 0.0001), more likely functionally dependent (p < 0.0001), had ASA scores ⩾3 (p < 0.0001) and had longer LOS (p < 0.0001). Compared to controls, hypoalbuminemia patients had 80% higher risk for any complication (OR = 1.80; 95% CI, 1.43-2.26), 113% higher risk for major complications (OR = 2.13; 95% CI, 1.31-3.48), and 79% higher risk for minor complications (OR = 1.79; 95% CI, 1.42-2.26), and 97% increased risk for re-operation (OR = 1.97; 95% CI, 1.20-3.23).

CONCLUSIONS

The findings in the present study indicate the need to develop better pre- and postoperative medical and nutritional care for malnourished hip fracture patients who undergo THA in order to potentially mitigate their increased risk.

Postoperative delirium is associated with decreased recovery of ambulation one-month after surgery

BACKGROUND

We hypothesized that postoperative delirium is associated with diminished recovery toward baseline preoperative ambulation levels one-month postoperatively.

METHODS

Patients included were ≥60 years old undergoing inpatient operations. Ambulation was measured as steps/day using an accelerometer worn for ≥3-days preoperatively and ≥28-days postoperatively. Primary outcome was the percent recovery of preoperative steps.

RESULTS

109 patients were included; 17 (16%) developed postoperative delirium. Recovery of ambulation toward preoperative baseline at postoperative day-28 was decreased in delirium group (34% vs. 69%; p < 0.01). Immediate postoperative ambulation was similar in the delirium vs. no-delirium groups (p = 0.79). Delirium occurred on average on postoperative 3 ± 4 days. Subsequently, ambulation was decreased in the delirium group compared to non-delirium group at postoperative week-1 (p = 0.01), week-2 (p = 0.02), week-3 (p < 0.01) and week-4 (p < 0.01).

CONCLUSION

Patients undergoing inpatient operations who develop delirium recover only one-third of their baseline steps one-month postoperatively. Postoperative delirium results in a decreased recovery towards baseline ambulation for at least 4-weeks following major operations in comparison to non-delirious patients. The decrease in ambulation in the delirium versus no-delirium groups occurred after the occurrence of postoperative delirium.

Preliminary Results of the Outpatient Endovascular and Interventional Society National Registry

Purpose

To present a new outcomes-based registry to collect data on outpatient endovascular interventions, a relatively new site of service without adequate historical data to assess best clinical practices. Quality data collection with subsequent outcomes analysis, benchmarking, and direct feedback is necessary to achieve optimal care.

Materials and Methods

The Outpatient Endovascular and Interventional Society (OEIS) established the OEIS National Registry in 2017 to collect data on safety, efficacy, and quality of care for outpatient endovascular interventions. Since then, it has grown to include a peripheral artery disease (PAD) module with plans to expand to include cardiac, venous, dialysis access, and other procedures in future modules. As a Qualified Clinical Data Registry approved by the Centers for Medicare and Medicaid Services, this application also supports new quality measure development under the Quality Payment Program. All physicians operating in an office-based laboratory or ambulatory surgery center can use the Registry to analyze de-identified data and benchmark performance against national averages. Major adverse events were defined as death, stroke, myocardial infarction, acute onset of limb ischemia, index bypass graft or treated segment thrombosis, and/or need for urgent/emergent vascular surgery.

Results

Since Registry inception in 2017, 251 participating physicians from 64 centers located in 18 states have participated. The current database includes 18,134 peripheral endovascular interventions performed in 12,403 PAD patients (mean age 72.3±10.2 years; 60.1% men) between January 2017 and January 2020. Cases were performed primarily in an office-based laboratory (85.1%) or ambulatory surgery center setting (10.4%). Most frequently observed procedure indications from 16,086 preprocedure form submissions included claudication (59%), minor tissue loss (16%), rest pain (9%), acute limb ischemia (5%), and maintenance of patency (3%). Planned diagnostic procedures made up 12.2% of cases entered, with the remainder indicated as interventional procedures (87.6%). The hospital transfer rate was 0.62%, with 88 urgent/emergent transfers and 24 elective transfers. The overall complication rate for the Registry was 1.87% (n=338), and the rate of major adverse events was 0.51% (n=92). Thirty-day mortality was 0.03% (n=6).

Conclusion

This report describes the current structure, methodology, and preliminary results of OEIS National Registry, an outcomes-based registry designed to collect quality performance data with subsequent outcome analysis, benchmarking, and direct feedback to aid clinicians in providing optimal care.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis(UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs.

RESULTS

Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9 years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA(81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups.

CONCLUSIONS

In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Protocol for the development of a core outcome set for reporting outcomes of management of velopharyngeal dysfunction

INTRODUCTION

Velopharyngeal dysfunction (VPD) is present in up to 40% of patients following cleft palate repair. Children with VPD display hypernasal speech, nasal air emission and are at a high risk for developing articulation disorders. The overall result is decreased intelligibility and acceptability of speech, as well as significant functional and social impairments. Although there are several surgical approaches for the management of children with VPD, standard treatment protocols have not been well defined. There is a need for a core outcome set (COS) to reduce outcome reporting bias and heterogeneity across studies of VPD. The COS-VPD Initiative is an international effort to establish a COS for the reporting of studies of the management of VPD.

METHODS AND ANALYSIS

The study has been developed according to the Core Outcome Set-STAandards for Development standards for the design of a COS study and will be carried out according to the guidance of the Core Outcome Measures in Effectiveness Trials (COMET) initiative. A long list of clinical and patient-reported outcomes will be identified from a systematic review of the literature. A two-stage Delphi consensus process will be used to refine this list into a COS. An international panel of key stakeholders including patients, parents and multidisciplinary clinical and academic experts will be invited to participate in this process. Consensus criteria will be specified a priori and the steering group will ratify the final COS.

ETHICS AND DISSEMINATION

The study has ethical approval through Children's Health Ireland at Crumlin Research and Ethics Committee, Ref: GEN/683/18. The study is registered with the COMET Initiative (http://www.cometinitiative.org/studies/details/1146?result=true). The COS will be disseminated by publication in the peer-reviewed literature, presentation at international research meetings and distribution to patient-representative organisations. This will facilitate the application of the COS in future studies of the management of VPD.

Association between interhospital transfer and morbid obesity in emergency general surgery procedures

BACKGROUND

Obese patients may have unique surgical needs. The goal of this study is to determine if there is an association between obesity and transfer in patients undergoing EGS.

METHODS

EGS patients were identified in the NSQIP 2011-2016 database. Outcome variables included interhospital transfer, days to surgery, SSI, postoperative LOS, discharge destination, and 30-day readmission. Descriptive statistics and multivariable regression were utilized.

RESULTS

419,373 EGS patients were identified, and transfer status varied by obesity class. After controlling for other factors, obese patients had increased odds of interhospital transfer (OR = 1.07-1.53), SSI (OR = 1.22-1.69), and decreased odds of discharge to home (OR = 0.42-0.71, all p < 0.01) but not of 30-day readmission or delay from admission to surgical intervention.

CONCLUSIONS

Obese patients undergoing EGS procedures have an increased likelihood of transfer from an acute care hospital. As obese EGS patients are increasingly prevalent, determining best triage practices for this unique patient population warrants additional investigation.

Short-Term Risk of Performing Concurrent Procedures with Hepatic Artery Infusion Pump Placement

BACKGROUND

Hepatic artery infusion pump (HAIP) chemotherapy is an advanced cancer therapy for primary and secondary hepatic malignancies. The risk of concurrent hepatic and/or colorectal operations with HAIP placement is unknown. Our objective was to characterize the short-term outcomes of concurrent surgery with HAIP placement.

METHODS

The 2005-2017 ACS NSQIP dataset was queried for patients undergoing hepatic and colorectal operations with or without HAIP placement. Outcomes were compared for HAIP placement with different combined procedures. Patients who underwent procedures without HAIP placement were propensity score matched with those with HAIP placement. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included infectious complications, wound complications, length of stay (LOS), and operative time.

RESULTS

Of 467 patients who underwent HAIP placement, 83.9% had concurrent surgery. The rate of DSM was 10.7% for HAIP placement alone, 19.2% with concurrent minor hepatic procedures, 22.1% with concurrent colorectal resection, 23.2% with concurrent minor hepatic plus colorectal procedures, 28.4% with concurrent major hepatic resection, and 41.7% with concurrent major hepatic plus colorectal resection. On matched analyses, there was no difference in DSM, infectious, or wound complications for procedures with HAIP placement compared with the additional procedure alone, but operative time (294.7 vs 239.8 min, difference 54.9, 95% CI 42.8-67.0) and LOS (6 vs 5, IRR 1.20, 95% CI 1.08-1.33) were increased.

CONCLUSIONS

HAIP placement is not associated with additional morbidity when performed with hepatic and/or colorectal surgery. Decisions regarding HAIP placement should consider the risks of concurrent operations, and patient- and disease-specific factors.

Operative Incision and Drainage for Perirectal Abscesses: What Are Risk Factors for Prolonged Length of Stay, Reoperation, and Readmission?

BACKGROUND

Perirectal abscess is a common problem. Despite a seemingly simple disease to manage, clinical outcomes of perirectal abscesses can vary significantly given the wide array of patients who are susceptible to this disease.

OBJECTIVE

Our aims were to evaluate the outcomes after operative incision and drainage for perirectal abscess and to examine factors associated with length of stay, reoperations, and readmissions.

DESIGN

This was a retrospective analysis of the National Surgical Quality Improvement Program database.

SETTINGS

The study was conducted with hospitals participating in the surgical database.

PATIENTS

Adult patients undergoing outpatient perirectal abscess procedures from 2011 through 2016 were included.

MAIN OUTCOME MEASURES

Study outcomes were length of stay, reoperation, and readmission.

RESULTS

We identified 2358 patients undergoing incision and drainage for perirectal abscesses. Approximately 35% of patients required hospital stay. Reoperations occurred in 3.4%, with median time to reoperation of 15.5 days. The majority of reoperations (79.7%) were performed for additional incision and drainage. Readmissions rate was 3.0%, with median time to readmission of 10.5 days. Common indications for readmissions included recurrent/persistent abscess (41.4%) and fever/sepsis (8.6%). Risk factors for hospitalization in multivariable analysis were preoperative sepsis, bleeding disorder, and non-Hispanic black and Hispanic races. For reoperations, risk factors included morbid obesity, preoperative sepsis, and dependent functional status. Lastly, for readmissions, female sex, steroid/immunosuppression, and dependent functional status were significant risk factors.

LIMITATIONS

The study was limited by its retrospective analysis and potential selection bias in decisions on hospital stay, reoperation, and readmission.

CONCLUSIONS

Suboptimal outcomes after outpatient operative incision and drainage for perirectal abscesses are not uncommon in the United States. In the era of value-based care, additional work is needed to optimize use outcomes for high-risk patients undergoing perirectal incision and drainage. Strategies to prevent inadequate drainage at the time of the initial operative incision and drainage (ie, use of imaging modalities and thorough examination under anesthesia) are warranted to improve patient outcomes. See Video Abstract at http://links.lww.com/DCR/B229. INCISIÓN Y DRENAJE QUIRÚRGICOS DE ABSCESOS PERIRRECTALES: CUALES SON LOS FACTORES DE RIESGO PARA UNA ESTADÍA PROLONGADA, REINTERVENCIÓN Y READMISION?: Los abscesos perirrectales son un problema frecuente. A pesar que parecen ser una afección aparentemente simple de manejar, los resultados clínicos de la incisión y drenaje quirúrgicos pueden variar significativamente dada la amplia variedad de pacientes susceptibles de sufrir esta afección.Evaluar los resultados después de la incisión y el drenaje quirúrgicos de un absceso perirrectal y analizar los factores asociados con la duración de la hospitalización, la reoperación y la readmisión.Análisis retrospectivo de la base de datos del Programa Americano de Mejora de la Calidad Quirúrgica.Hospitales que participan en la base de datos quirúrgica.Pacientes adultos sometidos a incisión y drenaje quirúrgico ambulatorio de un absceso perirrectal desde 2011 hasta 2016.Los resultados del estudio fueron la duración de la hospitalización, la reoperación y el reingreso.Fueron estudiados 2,358 pacientes sometidos a incisión y drenaje por abscesos perirrectales. Aproximadamente el 35% de los pacientes requirieron hospitalización. Las reoperaciones ocurrieron en 3.4% con una mediana de tiempo de reoperación de 15.5 días. La mayoría de las reoperaciones (79.7%) se realizaron para una incisión y drenaje adicionales. La tasa de reingreso fue del 3.0% con una mediana de tiempo de reingreso de 10.5 días. Las indicaciones comunes para los reingresos incluyeron abscesos recurrentes / persistentes (41.4%) y fiebre / sepsis (8.6%). Los factores de riesgo para la hospitalización en el análisis multivariable fueron sepsis preoperatoria, trastorno hemorrágico, raza negra no hispánica y raza hispana. Para las reoperaciones, los factores de riesgo incluyeron obesidad mórbida, sepsis preoperatoria y estado funcional dependiente. Por último, para los reingresos, el sexo femenino, uso de corticoides / inmunosupresores y un estadío funcional dependiente fueron factores de riesgo significativos.Análisis retrospectivo y posible sesgo de selección en las decisiones sobre hospitalización, reoperación y reingreso.Un resultado poco satisfactorio después de la incisión quirúrgica el drenaje de abscesos perirrectales ambulatoriamente no son infrecuentes en los Estados Unidos. En la era de la atención basada en los resultados, se necesita mucho más trabajo para optimizar los mismos en pacientes de alto riesgo sometidos a incisión y drenaje perirrectales. Las estrategias para prevenir el drenaje inadecuado en el momento de la incisión quirúrgica inicial y el drenaje (es decir, el uso de modalidades de imágenes, un examen completo bajo anestesia) son una garantía para mejorar los resultados en estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B229.

Use of Machine Learning for Prediction of Patient Risk of Postoperative Complications After Liver, Pancreatic, and Colorectal Surgery

BACKGROUND

Surgical resection is the only potentially curative treatment for patients with colorectal, liver, and pancreatic cancers. Although these procedures are performed with low mortality, rates of complications remain relatively high following hepatopancreatic and colorectal surgery.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program was utilized to identify patients undergoing liver, pancreatic and colorectal surgery from 2014 to 2016. Decision tree models were utilized to predict the occurrence of any complication, as well as specific complications. To assess the variability of the performance of the classification trees, bootstrapping was performed on 50% of the sample.

RESULTS

Algorithms were derived from a total of 15,657 patients who met inclusion criteria. The algorithm had a good predictive ability for the occurrence of any complication, with a C-statistic of 0.74, outperforming the ASA (C-statistic 0.58) and ACS-Surgical Risk Calculator (C-statistic 0.71). The algorithm was able to predict with high accuracy thirteen out of the seventeen complications analyzed. The best performance was in the prediction of stroke (C-statistic 0.98), followed by wound dehiscence, cardiac arrest, and progressive renal failure (all C-statistic 0.96). The algorithm had a good predictive ability for superficial SSI (C-statistic 0.76), organ space SSI (C-statistic 0.76), sepsis (C-statistic 0.79), and bleeding requiring transfusion (C-statistic 0.79).

CONCLUSION

Machine learning was used to develop an algorithm that accurately predicted patient risk of developing complications following liver, pancreatic, or colorectal surgery. The algorithm had very good predictive ability to predict specific complications and demonstrated superiority over other established methods.

Venous thromboembolism prevention compliance: A multidisciplinary educational approach utilizing NSQIP best practice guidelines

BACKGROUND

Review of our institutional National Surgical Quality Improvement Project (NSQIP) data found higher rate of Venous Thromboembolic Events (VTE) (2.5% vs. 1.1%). Compared to the national benchmark. Our goal was to identify opportunities for quality improvement.

METHODS

We compared NSQIP general surgery data from January 2015-December 2016 (period 1) to January 2017-December 2018 (period 2). A multidisciplinary committee was developed and patient centered education implemented to enhance VTE compliance.

RESULTS

Over 50% of all the patients who developed VTE were non-compliant with chemical prophylaxis. The majority of non-compliance was due to pain. During period 1 there were 12 VTEs in 482 cases, while in period two, 18 VTEs in 2347 cases (2.5% vs. 0.8%; RR 2.3, 95% CI 1.5-3.7, p < 0.001). Missed chemical prophylaxis decreased from 50 to 17 per week after the intervention.

CONCLUSION

A multidisciplinary, patient centered approach to increase VTE prevention decreases VTE rates to below a comparable benchmark.