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

Breast Implant-Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome

BACKGROUND

The most common cause of surgical readmission after breast implant surgery remains infection. Six causative organisms are principally involved: Staphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium. The authors investigated the infection patterns and antibiotic sensitivities to characterize their local microbiome and determine ideal antibiotic selection.

METHODS

A retrospective review of 2285 consecutive implant-based breast procedures was performed. Included surgical procedures were immediate and delayed breast reconstruction, tissue expander exchange, and cosmetic augmentation. Patient demographics, chemotherapy and/or irradiation status, implant characteristics, explantation reason, time to infection, microbiological data, and antibiotic sensitivities were reviewed.

RESULTS

Forty-seven patients (2.1 percent) required inpatient admission for antibiotics, operative explantation, or drainage by interventional radiology. The infection rate varied depending on surgical procedure, with the highest rate seen in mastectomy and immediate tissue expander reconstruction (6.1 percent). The mean time to explantation was 41 days. Only 50 percent of infections occurred within 30 days of the indexed National Surgical Quality Improvement Program operation. The most commonly isolated organisms were coagulase-negative Staphylococcus (27 percent), methicillin-sensitive S. aureus (25 percent), methicillin-resistant S. aureus (7 percent), Pseudomonas (7 percent), and Peptostreptococcus (7 percent). All Gram-positive organisms were sensitive to vancomycin, linezolid, tetracycline, and doxycycline; all Gram-negative organisms were sensitive to gentamicin and cefepime.

CONCLUSIONS

Empiric antibiotics should be vancomycin (with the possible inclusion of gentamicin) based on their broad effectiveness against the authors' unique microbiome. Minor infections should be treated with tetracycline or doxycycline as a second-line agent. National Surgical Quality Improvement Program data are adequate for monitoring and comparing breast infections but certainly not comprehensive.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Safety of Outpatient Thyroid and Parathyroid Surgery

Objective

To test our hypothesis that general and thyroid surgery–specific complications, mortality, and postdischarge utilization for patients undergoing outpatient and inpatient thyroid and parathyroid surgery would not differ when outpatient status was defined as discharge within 8 hours of surgery completion.

Study Design

Retrospective observational cohort, 2008 to 2013.

Setting

Kaiser Permanente Northern California and Kaiser Permanente Southern California.

Subjects and Methods

We used a robust set of variables and propensity score methods to match 2362 patients undergoing hemithyroidectomy, total thyroidectomy, or parathyroidectomy surgery as outpatients to 2362 patients undergoing the same procedures as inpatients. Outcomes assessed were 30-day rates of complications, emergency department visits, all-cause hospital readmissions, and mortality.

Results

After matching, no statistically significant differences between inpatients and outpatients were found for complication rates or postdischarge utilization. After matching, there was no statistically significant difference between inpatients and outpatients in hematoma rates, which were 0.55% in both groups. In the matched-pair groups, 2 deaths occurred among inpatients (0.09%) and none occurred among outpatients (0.00%), a difference that was not statistically significant.

Conclusion

Discharge within 8 hours after completion of thyroid and parathyroid surgery is as safe as inpatient surgery.

Risk factors for infectious readmissions following radical cystectomy: results from a prospective multicenter dataset

INTRODUCTION

Radical cystectomy (RC) is the gold standard treatment for muscle-invasive bladder cancer. This procedure has a high rate of perioperative complications, many of which are infectious in nature. The objective of our study was to evaluate demographic, intrinsic and extrinsic patient variables associated with developing readmission within 30 days due to infectious complications following RC.

METHODS

We acquired data available from the American College of Surgeons National Surgical Quality Improvement Program. We queried this dataset to identify all patients who underwent RC for muscle-invasive malignant disease (CPT 188.x) in 2012 based on CPT coding. Logistic regression analysis was used to investigate the relationship between preoperative variables and readmissions for infectious complications.

RESULTS

Of the 961 patients undergoing cystectomy for malignancy, 159 (17%) required readmission for any indications at a median of 16 days (interquartile range 13-22 days) postoperatively. We identified 71 of a total of 159 (45%) readmissions, which were due to infectious complications. Smoking was more prevalent in the patient population readmitted for an infectious complication compared with the patient population readmitted for a non-infectious complication (37% versus 25%; p = 0.03). Using logistic regression analysis smoking was associated with a significant risk for readmission due to an infectious cause (odds ratio 2.28, 95% confidence interval 1.82-2.97, p = 0.02). Readmission due to an infectious etiology was not associated with other perioperative factors including type of urinary diversion, sex, duration of operation, hypertension, or recent weight loss.

CONCLUSION

Readmission following RC is a common occurrence and infectious complications drive readmission in almost half of the cases. Current smoking was the only independent risk factor for an infectious readmission. Counseling patients in smoking cessation prior to the procedure may provide an avenue for quality improvement to limit readmissions.

Administrative Databases in Orthopaedic Research: Pearls and Pitfalls of Big Data

The drive for evidence-based decision-making has highlighted the shortcomings of traditional orthopaedic literature. Although high-quality, prospective, randomized studies in surgery are the benchmark in orthopaedic literature, they are often limited by size, scope, cost, time, and ethical concerns and may not be generalizable to larger populations. Given these restrictions, there is a growing trend toward the use of large administrative databases to investigate orthopaedic outcomes. These datasets afford the opportunity to identify a large numbers of patients across a broad spectrum of comorbidities, providing information regarding disparities in care and outcomes, preoperative risk stratification parameters for perioperative morbidity and mortality, and national epidemiologic rates and trends. Although there is power in these databases in terms of their impact, potential problems include administrative data that are at risk of clerical inaccuracies, recording bias secondary to financial incentives, temporal changes in billing codes, a lack of numerous clinically relevant variables and orthopaedic-specific outcomes, and the absolute requirement of an experienced epidemiologist and/or statistician when evaluating results and controlling for confounders. Despite these drawbacks, administrative database studies are fundamental and powerful tools in assessing outcomes on a national scale and will likely be of substantial assistance in the future of orthopaedic research.

Advances in Surgical Management of Pancreatic Diseases

The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires an intimate understanding of disease pathobiology, host physiology, technical considerations, and evolving trends. This article highlights key developments in the contemporary surgical management of pancreatic diseases.

How Much Do Adverse Event Rates Differ Between Primary and Revision Total Joint Arthroplasty?

BACKGROUND

It is not known which adverse events occur more commonly following revision than following primary total joint arthroplasty.

METHODS

Patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) during 2011 to 2013 as part of the America College of Surgeons National Surgical Quality Improvement Program were identified. Rates of adverse events were compared between patients undergoing primary and patients undergoing revision procedures with adjustments for demographic and comorbidity characteristics.

RESULTS

In total, 48307 THA patients and 70605 TKA patients met inclusion criteria. Of the THA patients, 43247 (89.5%) underwent primary procedures, while 5060 (10.5%) underwent revision procedures. Of the TKA patients, 65694 (93.0%) underwent primary procedures, while 4911 (7.0%) underwent revision procedures. Patients undergoing revision procedures had higher rates of systemic sepsis (for THA, 0.3% vs 0.1%, adjusted relative risk [RR], 3.5; 95% confidence interval [CI], 1.7-7.0; P < .001; for TKA, 0.3% vs 0.1%, adjusted RR, 3.0; 95% CI, 1.7-5.2, P < .001), deep incisional surgical site infection (for THA, 1.3% vs 0.3%, adjusted RR, 4.3; 95% CI, 3.2-5.8, P < .001; for TKA, 0.7 vs 0.2%, RR, 4.0; 95% CI, 2.7-5.9, P < .001), and organ/space infection (for THA, 1.8% vs 0.2%, RR, 7.4; 95% CI, 5.4-10.0, P < .001; for TKA, 1.1% vs 0.1%, adjusted RR, 7.5; 95% CI, 5.4-10.6, P < .001). Patients undergoing revision procedures did not have higher rates of pulmonary embolism or deep vein thrombosis (P ≥ .05 for each).

CONCLUSIONS

Public reporting of adverse events should be interpreted in the context of the differences between primary and revision procedures, and reimbursement systems should reflect the greater amount of postoperative care that patients undergoing revision procedures require.

Same-Day Major Breast Cancer Surgery is Safe: An Analysis of Short-Term Outcomes Using NSQIP Data

INTRODUCTION

Most patients undergoing significant breast cancer surgery stay in hospital postoperatively. We sought to determine whether there was a difference in complication rates among patients undergoing same-day surgery (SDS) versus overnight or inpatient stay.

METHODS

Analysis of the American College of Surgeons, National Surgical Quality Improvement Program participant user files was performed. Patients with breast cancer undergoing mastectomy and/or axillary lymph node dissection between 2005 and 2012 were examined (high-risk comorbidities and concurrent surgery were excluded). Thirty-day postoperative morbidity was analyzed. Multivariable regression was performed identifying independent predictors of complications.

RESULTS

The final population consisted of 40,575 patients; 8365 had SDS, 23,252 stayed overnight, and 8958 stayed in hospital longer postoperatively. Those admitted to hospital were older, more obese, had higher American Society of Anesthesiology (ASA) class, medical comorbidities, or had bilateral surgery. The overall 30-day morbidity was 4.7 %. On univariate analysis, patients undergoing SDS had significantly lower 30-day morbidity (2.4 %) compared with overnight (3.9 %) or inpatient stay (8.8 %) (p < 0.0001). After controlling for the above differences between groups, patients staying overnight had a higher odds of postoperative complications [1.37, 95 % confidence interval (CI) 1.16-1.63, p = 0.004] and inpatients had over twice the odds of postoperative complications (2.65, 95 % CI 2.21-3.18, p < 0.0001) compared with SDS patients.

CONCLUSION

This is the largest study examining the safety of SDS for breast cancer. Complication rates were significantly higher for patients admitted to hospital postoperatively, even after controlling for baseline differences. These data suggest that, with appropriate selection, it is safe to perform major breast cancer surgery on a same-day basis.

Evaluation of the performance of the ACS NSQIP surgical risk calculator in gynecologic oncology patients undergoing laparotomy

OBJECTIVE

The objective of this study was to evaluate the ability of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) surgical risk calculator to predict complications in gynecologic oncology patients undergoing laparotomy.

METHODS

A chart review of patients who underwent laparotomy on the gynecologic oncology service at a single academic hospital from January 2009 to December 2013 was performed. Preoperative variables were abstracted and NSQIP surgical risk scores were calculated. The risk of any complication, serious complication, death, urinary tract infection, venous thromboembolism, cardiac event, renal complication, pneumonia and surgical site infection were correlated with actual patient outcomes using logistic regression. The c-statistic and Brier score were used to calculate the prediction capability of the risk calculator.

RESULTS

Of the 1094 patients reviewed, the majority were <65years old (70.9%), independent (95.2%), ASA class 1-2 (67.3%), and overweight or obese (76.1%). Higher calculated risk scores were associated with an increased risk of the actual complication occurring for all events (p<0.05). The calculator performed best for predicting death (c-statistic=0.851, Brier=0.008), renal failure (c-statistic=0.752, Brier=0.015) and cardiac complications (c-statistic=0.708, Brier=0.011). The calculator did not accurately predict most complications.

CONCLUSIONS

The NSQIP surgical risk calculator adequately predicts specific serious complications, such as postoperative death and cardiac complications. However, the overall performance of the calculator was worse for gynecologic oncology patients than reported in general surgery patients. A tailored prediction model may be needed for this patient population.

Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity

Age-related cardiovascular disease in older adults is more likely to occur in combination with other age-related diseases, with mounting interactive complexity as multiple morbidities accumulate. Although invasive cardiac procedures are frequently recommended for cardiovascular disease, their value is less certain in the context of age-related intricacies of care. Tools for risk assessment before invasive procedures are insensitive to risks corresponding to the unique challenges of older adults. Recognizing multimorbidity and other age-related risks provides opportunities to intervene and moderate dangers. By refocusing risk assessment in terms of patient-centered goals, the fundamental utility of invasive cardiac procedures may be reconsidered and alternative therapies prioritized.

Major and minor complications in extraoperative electrocorticography: A review of a national database

The risk profile of extraoperative electrocorticography (ECoG) is documented almost exclusively by case series from a limited number of academic medical centers. These studies tend to underreport minor complications, like urinary tract infections (UTIs) and deep venous thromboses (DVTs), that nevertheless affect hospital cost, length of stay, and the patient's quality of life. Herein, we used data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) to estimate the rate of adverse events in extraoperative ECoG surgeries. NSQIP is a validated dataset containing nearly 3 million procedures from over 600 North American hospitals, and uses strict criteria for the documentation of complications. Major complications occurred in 3.4% of 177 extraoperative ECoG cases, while minor complications occurred in 9.6%. The most common minor complication was bleeding requiring a transfusion in 3.4% of cases, followed by sepsis, DVT, and UTI each in 2.3% of cases. No mortality was reported. Overall, in a national database containing a heterogeneous population of hospitals, major complications of extraoperative ECoG were rare (3.4%). Complications such as UTI and DVT tend to be underreported in retrospective case series, yet make up a majority of minor complications for ECoG patients in this dataset.

Postdischarge complications following nonoperative management of blunt splenic injury

BACKGROUND

Nonoperative management (NOM) is the standard of care in majority of blunt splenic injuries. However, little is known about the postdischarge complications.

METHODS

Patients admitted for blunt splenic injury were identified in the California State Inpatient Database (2007 to 2011). We examined patterns and risk factors for postdischarge complications among these patients.

RESULTS

In total, 2,704 (61.45%) patients had NOM without splenic artery embolization (SAE) and 257 (5.84%) had NOM with adjunct SAE. Thirty-day readmission rate was higher in those who had adjunct SAE (12.84% vs 7.36%, P = .002). Subsequent operations during readmission were seen in 18.10% of readmitted patients and 38.10% of all patients were readmitted at nonindex hospitals. Major diagnoses on readmission were spleen injury (36.2%) and respiratory complications (9.05%). Adjunct SAE was an independent risk factor for readmission (adjusted odds ratio 1.82, 95% confidence interval 1.19 to 2.78).

CONCLUSIONS

Nearly one fifth of readmitted patients initially managed nonoperatively required an operative intervention. Improving predischarge assessments and postdischarge follow-up may reduce readmissions among these patients.

Multivariate logistic regression analysis of postoperative complications and risk model establishment of gastrectomy for gastric cancer: A single-center cohort report

BACKGROUND

Reporting of surgical complications is common, but few provide information about the severity and estimate risk factors of complications. If have, but lack of specificity.

METHODS

We retrospectively analyzed data on 2795 gastric cancer patients underwent surgical procedure at the Affiliated Hospital of Qingdao University between June 2007 and June 2012, established multivariate logistic regression model to predictive risk factors related to the postoperative complications according to the Clavien-Dindo classification system.

RESULTS

Twenty-four out of 86 variables were identified statistically significant in univariate logistic regression analysis, 11 significant variables entered multivariate analysis were employed to produce the risk model. Liver cirrhosis, diabetes mellitus, Child classification, invasion of neighboring organs, combined resection, introperative transfusion, Billroth II anastomosis of reconstruction, malnutrition, surgical volume of surgeons, operating time and age were independent risk factors for postoperative complications after gastrectomy. Based on logistic regression equation, p=Exp∑BiXi / (1+Exp∑BiXi), multivariate logistic regression predictive model that calculated the risk of postoperative morbidity was developed, p = 1/(1 + e((4.810-1.287X1-0.504X2-0.500X3-0.474X4-0.405X5-0.318X6-0.316X7-0.305X8-0.278X9-0.255X10-0.138X11))). The accuracy, sensitivity and specificity of the model to predict the postoperative complications were 86.7%, 76.2% and 88.6%, respectively.

CONCLUSIONS

This risk model based on Clavien-Dindo grading severity of complications system and logistic regression analysis can predict severe morbidity specific to an individual patient's risk factors, estimate patients' risks and benefits of gastric surgery as an accurate decision-making tool and may serve as a template for the development of risk models for other surgical groups.

The Use of Surgical Care Improvement Projects in Prevention of Venous Thromboembolism

Venous thromboembolism (VTE) is a potentially mortal complication in patients undergoing surgery. Deep venous thrombosis and pulmonary embolism can be seen up to 40 % of patients who have no or inappropriate VTE prophylaxis during perioperative period.In addition to the preoperative and intraoperative preventive measures, the standardization of postoperative care and follow-up are essential to reduce VTE risk. Modern healthcare prioritizes patient's safety and aims to reduce postoperative morbidity by using standardized protocols. Use of quality improvement projects with well-organized surgical care has an important role to prevent VTE during hospital stay. Present surgical care improvement projects have provided us the opportunity to identify patients who are vulnerable to VTE. Description and introduction of the quality standards for VTE prevention in the educational materials, meetings and at the medical schools will increase the VTE awareness among the health care providers. You are going to find the characteristics of the major surgical quality improvement projects and their relations with VTE in the chapter.

Hypoalbuminemia Independently Predicts Surgical Site Infection, Pneumonia, Length of Stay, and Readmission After Total Joint Arthroplasty

This study investigates the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days after total joint arthroplasty. Patients who underwent elective primary total hip and knee arthroplasty as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration <3.5 g/dL) with adjustment for patient and procedural factors. A total of 49603 patients were included. In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for surgical site infection, pneumonia, extended length of stay, and readmission. Future efforts should investigate methods of correcting nutritional deficiencies prior to total joint arthroplasty. If successful, such efforts could lead to improvements in short-term outcomes for patients.

Improving quality on the pediatric surgery service: Missed opportunities and making it happen

In surgery, quality improvement efforts have evolved from the traditional case-by-case review typical for morbidity and mortality conferences to more accurate and comprehensive data collection accomplished through participation in national registries such as the National Surgical Quality Improvement Program. Gaining administrative support to participate in these kinds of initiatives and commitment of the faculty and staff to make change in a data-driven manner rather than as a reaction to individual events can be a challenge. This article guides the reader through the process of interacting with administrative leadership to gain support for evidence-based quality improvement endeavors. General principles that are discussed include stakeholder engagement, taking advantage of preexisting resources, and the sharing of data in order to shape QI efforts and demonstrate their effectiveness.

Patient-Based and Surgical Risk Factors for 30-Day Postoperative Complications and Mortality After Ankle Fracture Fixation

OBJECTIVE

The purpose was to calculate the incidence rates and determine risk factors for 30-day postoperative mortality and morbidity after ankle fracture open reduction and internal fixation (ORIF).

METHODS

The NSQIP database was queried to identify patients undergoing ankle fracture ORIF from 2006 to 2011, with extraction patient-based or surgical variables and a 30-day clinical course. Multivariable logistic regression analysis identified significant predictors on outcome measures.

RESULTS

Mean age was 50.3 (±18.2) years while diabetes mellitus (12.8%) and body mass index ≥40 kg/m(2) (9.2%) were documented from a total of 3328 patients identified. The 30-day mortality rate was 0.30%, and complications occurred in 5.1%. Chronic obstructive pulmonary disease [odds ratio (OR): 4.23, 95% confidence interval (CI): 1.19-15.06] and a nonindependent functional status before surgery (OR: 2.25, 95% CI: 1.13-4.51) were the sole independent predictors of mortality and major local complications, respectively. Major local complications occurred in 2.2% of patients, and significant predictors were peripheral vascular disease (OR: 6.14; 95% CI: 1.95-19.35), open wound (OR: 5.04; 95% CI: 2.25-11.27), nonclean wound classification (OR: 3.02; 95% CI: 1.31-6.93), and smoking (OR: 2.85; 95% CI: 1.42-5.70). Independent predictors of hospital stay >3 days were cardiac disease, age 70 years or older, open wound, partially/totally dependent functional status, American Society of Anesthesiologists (ASA) classification ≥3, body mass index ≥40 kg/m(2), bimalleolar or trimalleolar ankle fracture pattern, female sex, and diabetes.

CONCLUSIONS

Chronic obstructive pulmonary disease increased the risk of mortality after ankle fracture ORIF. Risk factors for postoperative complications included peripheral vascular disease, open wound, nonclean wound classification, age 70 years or older, and ASA classification ≥3.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk Modeling Predicts Complication Rates for Spinal Surgery

STUDY DESIGN

Retrospective review of clinical data registry.

OBJECTIVE

In the current era of quality reporting and pay for performance, neurosurgeons must develop models to identify patients at high risk of complications. We sought to identify risk factors for complications in spine surgery and to develop a score predictive of complications.

SUMMARY OF BACKGROUND DATA

We examined spinal surgeries from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. 22,430 cases were identified based on common procedural terminology.

METHODS

Univariate analysis followed by multivariate regression was used to identify significant factors.

RESULTS

The overall complication rate for the cohort was 9.9%. The most common complications were postoperative bleeding requiring transfusion (4.1%), nonwound infections (3.1%), and wound-related infections (2.2%). Multivariate regression analysis identified 20 factors associated with complications. Assigning 1 point for the presence of each factor a risk model was developed. The range of scores for the cohort was 0 to 13 with a median score of 4. Complication rates for a risk score of 0 to 4 was 3.7% and for scores 5 to 13 was 18.5%. The risk model robustly predicted complication rates, with complication rate of 1.2% for score of 0 (n = 412, 1.8% of total) and 63.6% and 100% for scores of 12 and 13 (n = 22 patients, 0.1% of total cohort) respectively (P < 0.001). The risk score also correlated strongly with total length of stay, mortality, and total work relative value units for the case.

CONCLUSION

Patient-specific risk factors including comorbidities are strongly associated with surgical complications, length of stay, cost of care, and mortality in spine surgery and can be used to develop risk models that are highly predictive of complications.

LEVEL OF EVIDENCE

3.

Surgeon-Specific Reports in General Surgery: Establishing Benchmarks for Peer Comparison Within a Single Hospital

BACKGROUND

Methods to assess a surgeon's individual performance based on clinically meaningful outcomes have not been fully developed, due to small numbers of adverse outcomes and wide variation in case volumes. The Achievable Benchmark of Care (ABC) method addresses these issues by identifying benchmark-setting surgeons with high levels of performance and greater case volumes. This method was used to help surgeons compare their surgical practice to that of their peers by using merged National Surgical Quality Improvement Program (NSQIP) and Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data to generate surgeon-specific reports.

STUDY DESIGN

A retrospective cohort study at a single institution's department of surgery was conducted involving 107 surgeons (8,660 cases) over 5.5 years. Stratification of more than 32,000 CPT codes into 16 CPT clusters served as the risk adjustment. Thirty-day outcomes of interest included surgical site infection (SSI), acute kidney injury (AKI), and mortality. Performance characteristics of the ABC method were explored by examining how many surgeons were identified as benchmark-setters in view of volume and outcome rates within CPT clusters.

RESULTS

For the data captured, most surgeons performed cases spanning a median of 5 CPT clusters (range 1 to 15 clusters), with a median of 26 cases (range 1 to 776 cases) and a median of 2.8 years (range 0 to 5.5 years). The highest volume surgeon for that CPT cluster set the benchmark for 6 of 16 CPT clusters for SSIs, 8 of 16 CPT clusters for AKIs, and 9 of 16 CPT clusters for mortality.

CONCLUSIONS

The ABC method appears to be a sound and useful approach to identifying benchmark-setting surgeons within a single institution. Such surgeons may be able to help their peers improve their performance.

Preoperative chemotherapy and corticosteroids: independent predictors of cranial surgical-site infections

OBJECT Preoperative corticosteroids and chemotherapy are frequently prescribed for patients undergoing cranial neurosurgery but may pose a risk of postoperative infection. Postoperative surgical-site infections (SSIs) have significant morbidity and mortality, dramatically increase the length and cost of hospitalization, and are a major cause of 30-day readmission. In patients undergoing cranial neurosurgery, there is a lack of data on the role of patient-specific risk factors in the development of SSIs. The authors of this study sought to determine whether chemotherapy and prolonged steroid use before surgery increase the risk of an SSI at postoperative Day 30. METHODS Using the national prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database for 2006-2012, the authors calculated the rates of superficial, deep-incisional, and organ-space SSIs at postoperative Day 30 for neurosurgery patients who had undergone chemotherapy or had significant steroid use within 30 days before undergoing cranial surgery. Trauma patients, patients younger than 18 years, and patients with a preoperative infection were excluded. Univariate analysis was performed for 25 variables considered risk factors for superficial and organ-space SSIs. To identify independent predictors of SSIs, the authors then conducted a multivariate analysis in which they controlled for duration of operation, wound class, white blood cell count, and other potential confounders that were significant on the univariate analysis. RESULTS A total of 8215 patients who had undergone cranial surgery were identified. There were 158 SSIs at 30 days (frequency 1.92%), of which 52 were superficial, 27 were deep-incisional, and 79 were organ-space infections. Preoperative chemotherapy was an independent predictor of organ-space SSIs in the multivariate model (OR 5.20, 95% CI 2.33-11.62, p < 0.0001), as was corticosteroid use (OR 1.86, 95% CI 1.03-3.37, p = 0.04), but neither was a predictor of superficial or deep-incisional SSIs. Other independent predictors of organ-space SSIs were longer duration of operation (OR 1.16), wound class of ≥ 2 (clean-contaminated and further contaminated) (OR 3.17), and morbid obesity (body mass index ≥ 40 kg/m(2)) (OR 3.05). Among superficial SSIs, wound class of 3 (contaminated) (OR 6.89), operative duration (OR 1.13), and infratentorial surgical approach (OR 2.20) were predictors. CONCLUSIONS Preoperative chemotherapy and corticosteroid use are independent predictors of organ-space SSIs, even when data are controlled for leukopenia. This indicates that the disease process in organ-space SSIs may differ from that in superficial SSIs. In effect, this study provides one of the largest analyses of risk factors for SSIs after cranial surgery. The results suggest that, in certain circumstances, modulation of preoperative chemotherapy or steroid regimens may reduce the risk of organ-space SSIs and should be considered in the preoperative care of this population. Future studies are needed to determine optimal timing and dosing of these medications.

Database and Registry Research in Orthopaedic Surgery: Part 2: Clinical Registry Data

The use of large-scale national databases for observational research in orthopaedic surgery has grown substantially in the last decade, and the data sets can be categorized as either administrative claims or clinical registries. Clinical registries contain secondary data on patients with a specific diagnosis or procedure. The data are typically used for patient outcome surveillance to improve patient safety and health-care quality. Registries used in orthopaedic research exist at the regional, national, and international levels, and many were designed to specifically collect outcomes relevant to orthopaedics, such as short-term surgical complications, longer-term outcomes (implant survival or reoperations), and patient-reported outcomes. Although heterogeneous, clinical registries-in contrast to claims data-typically have a more robust list of variables, with relatively precise prospective data input, management infrastructure, and reporting systems. Some weaknesses of clinical registries include a smaller number of patients, inconstant follow-up duration, and use of sampling methods that may limit generalizability. Within the U.S., national joint registry adoption has lagged international joint registries. Given the changing health-care environment, it is likely that clinical registries will provide valuable information that has the potential to influence clinical practice improvement and health-care policy in the future.

Assessing the safety of outpatient ventral hernia repair: a NSQIP analysis of 7666 patients

PURPOSE

Given the paucity of literature on outpatient ventral hernia repair (VHR), and that assessment of the safety of outpatient surgical procedures is becoming an active area of investigation, we have performed a multi-institutional retrospective analysis benchmarking rates of 30-day complications and readmissions and identifying predictive factors for these outcomes.

METHODS

National surgical quality improvement project data files from 2011 to 2012 were reviewed to collect data on all patients undergoing outpatient VHR during that period. The incidence of 30-day peri-operative complication and unplanned readmission was surveyed. We created a multivariate regression model to identify predictive factors for overall, surgical, and medical complications and unplanned readmissions with proper risk adjustment.

RESULTS

30-day complication and readmission rates in outpatient VHR were acceptably low. 3% of the queried outpatients experienced an overall complication, 2.1% a surgical complication, and 1.1% a medical complication. 3.3% of all patients were readmitted within 30 days. Upon multivariate analysis, predictors of overall complications included age, BMI, history of Chronic Obstructive Pulmonary Disease (COPD), and total operation time, predictors of surgical complications included age, BMI, total operation time, predictors of medical complications included total operation time, and predictors of unplanned readmissions included history of COPD, bleeding disorder, American Society of Anesthesiologists Class 3, 4, or 5, total operation time, and use of the laparoscopic technique.

CONCLUSION

We have demonstrated that the risk of peri-operative morbidity in VHR as granularly defined in our study is low in the outpatient setting. Identification of predictive factors will be important to patient risk stratification.

Regional Quality Groups Enhance Effectiveness of Vascular Quality Initiative®

The Vascular Quality Initiative (VQI)® is a national collaborative of regional quality groups that collect and analyze data to improve vascular health care. The Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe) is the regional quality group for southern California. Initial quality initiatives chosen by the So Cal VOICe are preoperative and discharge antiplatelet and statin therapy and vascular access guidance during percutaneous endovascular procedures. The objective of this study is to examine the influence of the regional quality group structure on the effectiveness of the So Cal VOICe. Data are entered by each institution into a cloud-based data collection and reporting system. So Cal VOICe data from January 2011 to July 2014 was analyzed in 6-month intervals. Preoperative statin and antiplatelet use increased from 58.87 to 71.81 per cent ( P = 0.0082) and 60.8 to 78.38 per cent ( P < 0.0001), respectively. Discharge statin and antiplatelet use increased from 69.09 to 80.37 per cent ( P = 0.0037) and 80.47 to 88.11 per cent ( P = 0.0148), respectively. Vascular access guidance improved from 32.89 to 76.23 per cent ( P < 0.0001). Our results demonstrate the unique regional quality group structure of the VQI® improves compliance with selected process measures in the So Cal VOICe. Continued data collection will determine the impact of these process improvements on long-term patient outcomes.

Active Surveillance for Adverse Events Within 90 Days: The Standard for Reporting Surgical Outcomes After Pancreatectomy

BACKGROUND

The rate of adverse events after pancreatectomy is widely reported as a measure of surgical quality. However, morbidity data are routinely acquired retrospectively and often are reported at 30 days. The authors hypothesized that morbidity after pancreatectomy is therefore underreported. They sought to compare rates of adverse events calculated at multiple time points after pancreatectomy.

METHODS

The authors instituted an active surveillance system to detect, categorize, and grade the severity of all adverse events after pancreatectomy, using the modified Accordion system and International Study Group of Pancreatic Surgery definitions. All patients and clinical events were monitored directly for at least 90 days after surgery.

RESULTS

Of 315 consecutively monitored patients, 239 (76 %) experienced 500 unique adverse events. The absolute number of unique adverse events increased by 32 % between index discharge and 90 days and by 10 % between 30 and 90 days. The number of severe adverse events increased by 96 % between discharge and 90 days and by 29 % between 30 and 90 days. In this study, 16 % of the patients experienced at least one severe adverse event within the index hospitalization, 24 % within 30 postoperative days, and 29 % within 90 days. Among the 80 readmissions that occurred within 90 days, 28 (35 %) occurred later than 30 days after pancreatectomy.

CONCLUSIONS

Approximately one-third of severe adverse events and readmissions are reported more than 30 days after surgery. All adverse events that occur within 90 days of surgery must be identified and reported for accurate characterization of the morbidity associated with pancreatectomy.

Timing of Complications After Spinal Fusion Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To characterize the timing of complications after spinal fusion procedures.

SUMMARY OF BACKGROUND DATA

Despite many publications on risk factors for complications after spine surgery, there are few publications on the timing at which such complications occur.

METHODS

Patients undergoing anterior cervical decompression and fusion (ACDF) or posterior lumbar fusion (PLF; with or without interbody) procedures during 2011-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. For each of 8 different complications, the median time from surgery until complication was determined, along with the interquartile range and middle 80%.

RESULTS

A total of 12,067 patients undergoing ACDF and 11,807 patients undergoing PLF were identified. For ACDF, the median day of diagnosis (and interquartile range; middle 80%) for anemia requiring transfusion was 0 (0-1; 0-2), myocardial infarction 2 (1-5; 0-15), pneumonia 4 (2-9; 1-14), pulmonary embolism 5 (2-9; 1-10), deep vein thrombosis 10.5 (7-16.5; 5-21), sepsis 10.5 (4-18; 1-23), surgical site infection 13 (8-19; 5-25), and urinary tract infection 17 (8-22; 4-26). For PLF, the median day of diagnosis (and interquartile range; middle 80%) for anemia requiring transfusion was 0 (0-1; 0-2), myocardial infarction 2 (1-4; 1-8), pneumonia 4 (2-9; 1-17), pulmonary embolism 5 (3-11; 2-17), urinary tract infection 7 (4-14; 2-23), deep vein thrombosis 8 (5-16; 3-20), sepsis 9 (4-16; 2-22), and surgical site infection 17 (13-22; 9-27).

CONCLUSION

These precisely described postoperative time periods enable heightened clinical awareness among spine surgeons. Spine surgeons should have the lowest threshold for testing for each complication during the time period of greatest risk. Authors, reviewers, and surgeons utilizing research on postoperative complications should carefully consider the impact that the duration of follow-up has on study results.

LEVEL OF EVIDENCE

3.

Total Joint Arthroplasty in Patients with Chronic Renal Disease: Is It Worth the Risk?

26-27% of patients with end stage hip and knee arthritis requiring TJR have chronic renal disease. A multi-center, prospective clinical registry was queried for TJA's from 2006 to 2012, and 74,300 cases were analyzed. Renal impairment was quantified using estimated glomerular filtration rate (eGFR) to stratify each patient by stage of CRD (1-5). There was a significantly greater rate of overall complications in patients with moderate to severe CRD (6.1% vs. 7.6%, P<0.001). In those with CRD (Stage 3-5), mortality was twice as high (0.26% vs. 0.48%, P<0.001). Patients with Stage 4 and 5 CRD had a 213% increased risk of any complication (OR 2.13, 95% CI: 1.73-2.62). Surgeons may use these findings to discuss the risk-benefit ratio of elective TJR in patients with CRD.

Readmission destination and risk of mortality after major surgery: an observational cohort study

BACKGROUND

Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations.

METHODS

By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission.

FINDINGS

9,440,503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186,336 (65·8%) of 283,131 patients who were readmitted after coronary artery bypass grafting, to 142,142 (83·2%) of 170,789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189,384 [23%] of 834,070 patients readmitted to index hospital vs 36,792 [13%] of 276,976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio [OR] 0·74, 95% CI 0·66-0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45-0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61-0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91-0·94) than did patients who were less likely to be readmitted to the index hospital.

INTERPRETATION

In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care.

FUNDING

None.

Insulin dependence as an independent predictor of perioperative morbidity after ventral hernia repair: a National Surgical Quality Improvement Program analysis of 45,759 patients

BACKGROUND

Although diabetes mellitus has been identified as a predictor of perioperative morbidity after ventral hernia repair (VHR), it is unclear whether insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) confer the same degree of risk. We examined the variable effect of IDDM and NIDDM on 30-day medical and surgical complications after VHR.

METHODS

We performed a retrospective analysis of patients in the National Surgical Quality Improvement Program database from 2005 to 2012 undergoing VHR. After perioperative variable comparison, regression analysis was performed to determine whether IDDM and/or NIDDM independently predicted increased complications after proper risk adjustment.

RESULTS

A total of 45,759 patients were identified to have undergone VHR. Of these, 38,026 patients (83.1%) were not diabetic, 5,252 (11.5%) were NIDDM patients, and 2,481 (5.4%) were IDDM patients. After controlling for other risk factors, we found that IDDM independently predicted increased rates of overall, surgical, and medical complications (odds ratio, 1.284, 1.251, 1.263, respectively) in open repair. IDDM independently predicted increased overall and medical complications (odds ratio, 1.997, 1.889, respectively) but not surgical complications in laparoscopic repair. NIDDM was not significantly associated with any complication type in either procedure type.

CONCLUSIONS

Our present study suggests that much of the perioperative risk associated with diabetes is attributable to IDDM. The effect of IDDM on laparoscopic and open repair is subtly different. IDDM demonstrates increased overall and medical complications in laparoscopic repair and increased overall, medical, and surgical complications in open repair. Of note, IDDM does not independently predict increased risk for surgical complications in laparoscopic repair.

The Effect of Smoking on Short-Term Complications Following Total Hip and Knee Arthroplasty

BACKGROUND

Total joint arthroplasty is the most frequently performed orthopaedic procedure in the United States. The purpose of the present study was to identify differences in thirty-day morbidity and mortality following primary total hip and total knee arthroplasty according to smoking status and pack-year history of smoking.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who had undergone primary total hip or total knee arthroplasty between 2006 and 2012. Patients were stratified by smoking status and pack-year history of smoking. Thirty-day rates of mortality, wound complications, and total complications were compared with use of univariate and multivariate analyses.

RESULTS

We identified 78,191 patients who had undergone primary total hip or total knee arthroplasty. Of these, 81.8% (63,971) were nonsmokers, 7.9% (6158) were former smokers, and 10.3% (8062) were current smokers. Current smokers had a higher rate of wound complications (1.8%) compared with former smokers and nonsmokers (1.3% and 1.1%, respectively; p < 0.001). Former smokers had a higher rate of total complications (6.9%) compared with current smokers and nonsmokers (5.9% and 5.4%, respectively; p < 0.001). Multivariate analysis identified current smokers as being at increased risk of wound complications (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.21 to 1.78), particularly deep wound infection, while both current smokers (OR, 1.18; 95% CI, 1.06 to 1.31) and former smokers (OR, 1.20; 95% CI, 1.08 to 1.34) were at increased total complication risk. Increasing pack-year history of smoking resulted in increasing total complication risk.

CONCLUSIONS

On the basis of our findings, current smokers have an increased risk of wound complications and both current and former smokers have an increased total complication risk following total hip or total knee arthroplasty.

Association of body mass index and morbidity after abdominal, vaginal, and laparoscopic hysterectomy

OBJECTIVE

To examine the association of body mass index (BMI) and operative time and perioperative morbidity after hysterectomy and determine whether the association varies among abdominal, laparoscopic, and vaginal approaches.

METHODS

Data abstracted from the American College of Surgeons National Safety and Quality Improvement Project registry included 55,409 women who underwent hysterectomy for benign conditions between January 2005 and December 2012. The relationships among BMI, operative time, and morbidity were examined, adjusting for age, race, ethnicity, year of surgery, smoking, diabetes, and American Society for Anesthesiologists physical classification. Adjusted means, incidence rate ratios, or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using linear, Poisson, or logistic regression, respectively.

RESULTS

Body mass index was positively correlated with risk of wound complications and infection in women undergoing abdominal hysterectomy. Compared with those of normal BMI, women with BMIs 40 or higher had five times the odds of wound dehiscence (2.1% compared with 0.3%, crude OR 7.35, CI 3.78-14.30; adjusted OR 5.33, CI 2.63-10.8), five times the odds of wound infection (8.9% compared with 1.4%, crude OR 6.81, CI 5.00-9.27; adjusted OR 5.34, CI 3.85-7.41), and 89% higher odds of sepsis (1.3% compared with 0.6%, crude OR 2.39, CI 1.35-4.24; adjusted OR 1.89, CI 1.01-3.52). The magnitude of the association between wound infection and BMI was smaller after vaginal hysterectomy, and no increased odds of wound complications or sepsis were noted with a laparoscopic approach despite longer operative times. Operative time increased with BMI regardless of surgical approach. No associations were noted between BMI and hospital stay or thromboembolism.

CONCLUSION

Obesity is associated with increased wound complications and infection in women undergoing abdominal hysterectomy and with longer operative times regardless of surgical approach. Vaginal or laparoscopic hysterectomy should be performed whenever feasible.

LEVEL OF EVIDENCE

II.