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

Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs

BACKGROUND

The purpose of this study was to examine the impact of the sequential implementation of the enhanced recovery program (ERP) and surgical site infection bundle (SSIB) on short-term outcomes in colorectal surgery (CRS) to determine if the presence of multiple standardized care programs provides additive benefit.

STUDY DESIGN

Institutional ACS-NSQIP data were used to identify patients who underwent elective CRS from September 2006 to March 2013. The cohort was stratified into 3 groups relative to implementation of the ERP (February 1, 2010) and SSIB (July 1, 2011). Unadjusted characteristics and 30-day outcomes were assessed, and inverse proportional weighting was then used to determine the adjusted effect of these programs.

RESULTS

There were 787 patients included: 337, 165, and 285 in the pre-ERP/SSIB, post-ERP/pre-SSIB, and post-ERP/SSIB periods, respectively. After inverse probability weighting (IPW) adjustment, groups were balanced with respect to patient and procedural characteristics considered. Compared with the pre-ERP/SSIB group, the post-ERP/pre-SSIB group had significantly reduced length of hospitalization (8.3 vs 6.6 days, p = 0.01) but did not differ with respect to postoperative wound complications and sepsis. Subsequent introduction of the SSIB then resulted in a significant decrease in superficial SSI (16.1% vs 6.3%, p < 0.01) and postoperative sepsis (11.2% vs 1.8%, p < 0.01). Finally, inflation-adjusted mean hospital cost for a CRS admission fell from $31,926 in 2008 to $22,044 in 2013 (p < 0.01).

CONCLUSIONS

Sequential implementation of the ERP and SSIB provided incremental improvements in CRS outcomes while controlling hospital costs, supporting their combined use as an effective strategy toward improving the quality of patient care.

National estimates of predictors of outcomes for emergency general surgery

BACKGROUND

Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the predictors of in-hospital complications and mortality among EGS patients.

METHODS

The Nationwide Inpatient Sample (2003-2011) was queried for patients with conditions encompassing EGS as determined by the American Association for Surgery of Trauma, categorizing them into predefined EGS groups using DRG International Classification of Diseases-9th Rev.-Clinical Modification codes. Primary outcomes considered included incidence of a major complication (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital mortality. Separate multivariate logistic regression analyses for complications and mortality were performed to identify risk factors of either outcome from the following domains: patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics (location, teaching status, and bed size).

RESULTS

This study included 6,712,151 discharge records, weighted to represent 32,910,446 visits for EGS conditions. Mean age was 58.50 (19.74) years; slightly more than half (54.66%) were female. Uninsured patients were more likely to die (odds ratio,1.25; 95% confidence interval, 1.20-1.30), whereas patients in the highest income quartile had the least likelihood of mortality (odds ratio, 0.86; 95% confidence interval, 0.84-0.87). Old age was an independent predictor of mortality for all EGS subdiagnoses. The overall mortality rate was 1.76%; the overall complication rate was 10.03%. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease.

CONCLUSION

Death patterns of EGS patients were discerned using an administrative data set. Understanding patterns of mortality and complications derived from studies such as this could improve hospital benchmarking for EGS, akin to trauma surgery's previous success.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy

OBJECT

Patients undergoing craniotomy are at risk for developing venous thromboembolism (VTE). The safety of anticoagulation in these patients is not clear. The authors sought to identify risk factors predictive of VTE in patients undergoing craniotomy.

METHODS

The authors reviewed a national surgical quality database, the American College of Surgeons National Surgical Quality Improvement Program. Craniotomy patients were identified by current procedural terminology code. Clinical factors were analyzed to identify associations with VTE.

RESULTS

Four thousand eight hundred forty-four adult patients who underwent craniotomy were identified. The rate of VTE in the cohort was 3.5%, including pulmonary embolism in 1.4% and deep venous thrombosis in 2.6%. A number of factors were found to be statistically significant in multivariate binary logistic regression analysis, including craniotomy for tumor, transfer from acute care hospital, age ≥ 60 years, dependent functional status, tumor involving the CNS, sepsis, emergency surgery, surgery time ≥ 4 hours, postoperative urinary tract infection, postoperative pneumonia, on ventilator ≥ 48 hours postoperatively, and return to the operating room. Patients were assigned a score based on how many of these factors they had (minimum score 0, maximum score 12). Increasing score was predictive of increased VTE incidence, as well as risk of mortality, and time from surgery to discharge.

CONCLUSIONS

Patients undergoing craniotomy are at low risk of developing VTE, but this risk is increased by preoperative medical comorbidities and postoperative complications. The presence of more of these clinical factors is associated with progressively increased VTE risk; patients possessing a VTE Risk Score of ≥ 5 had a greater than 20-fold increased risk of VTE compared with patients with a VTE score of 0.

Evaluation of the National Surgical Quality Improvement Program Universal Surgical Risk Calculator for a gynecologic oncology service

OBJECTIVES

The National Surgical Quality Improvement Program is aimed at preventing perioperative complications. An online calculator was recently published, but the primary studies used limited gynecologic surgery data. The purpose of this study was to evaluate the performance of the National Surgical Quality Improvement Program Universal Surgical Risk Calculator (URC) on the patients of a gynecologic oncology service.

STUDY DESIGN

We reviewed 628 consecutive surgeries performed by our gynecologic oncology service between July 2012 and June 2013. Demographic data including diagnosis and cancer stage, if applicable, were collected. Charts were reviewed to determine complication rates. Specific complications were as follows: death, pneumonia, cardiac complications, surgical site infection (SSI) or urinary tract infection, renal failure, or venous thromboembolic event. Data were compared with modeled outcomes using Brier scores and receiver operating characteristic curves. Significance was declared based on P < 0.05.

RESULTS

The model accurately predicated death and venous thromboembolic event, with Brier scores of 0.004 and 0.003, respectively. Predicted risk was 50% greater than experienced for urinary tract infection; the experienced SSI and pneumonia rates were 43% and 36% greater than predicted. For any complication, the Brier score 0.023 indicates poor performance of the model.

CONCLUSIONS

In this study of gynecologic surgeries, we could not verify the predictive value of the URC for cardiac complications, SSI, and pneumonia. One disadvantage of applying a URC to multiple subspecialties is that with some categories, complications are not accurately estimated. Our data demonstrate that some predicted risks reported by the calculator need to be interpreted with reservation.

Article Commentary: Rural Pediatric Surgery

Published outcome studies support regionalization of pediatric surgery, in which all children suspected of having surgical disease are transferred to a specialty center. Transfer to specialty centers, however, is an expensive approach to quality, both in direct costs of hospitalization and the expense incurred by families. A related question is the role of well-trained rural surgeons in an adequately resourced facility in the surgical care of infants and children. Local community facilities provide measurably equivalent results for straightforward emergencies in older children such as appendicitis. With education, training, and support such as telemedicine consultation, rural surgeons and hospitals may be able to care for many more children such as single-system trauma and other cases for which they have training such as pyloric stenosis. They can recognize surgical disease at earlier stages and initiate appropriate treatment before transfer so that patients are in better shape for surgery when they arrive for definitive care. Rural and community facilities would be linked in a pediatric surgery system that covers the spectrum of pediatric surgical conditions for a geographical region.

Incidence and risk factors for 30-day readmission in patients undergoing nephrectomy procedures: a contemporary analysis of 5276 cases from the National Surgical Quality Improvement Program database

OBJECTIVE

To explore factors associated with readmission after nephrectomy procedures using a large national database.

MATERIALS AND METHODS

A national surgical outcomes database, the American College of Surgeon-National Surgical Quality Improvement Program registry, was queried for data on all patients undergoing open partial nephrectomy (OPN), minimally invasive (laparoscopic + robotic) partial nephrectomy (MIPN), and minimally invasive radical nephrectomy (MIRN) in 2011 and 2012. Patients undergoing these procedures were identified using the Current Procedural Terminology codes. The primary outcome was unplanned 30-day hospital readmission. A multivariate logistic regression model was constructed to assess for factors independently associated with the primary outcome.

RESULTS

Overall, 5276 cases were identified and included in the analysis: 1411 OPN (26.7%), 2210 MIPN (41.8%), and 1655 MIRN (31.3%). Overall, the 30-day readmission rate was 5.9% (7.8% for OPN, 4.5% for MIPN, and 6.1% for MIRN). On multivariate analysis, the odds for 30-day readmission for MIPN was approximately 70% that of OPN (P = .012). The odds for 30-day readmission for 2012 was about 80% of that of 2011 (P <.001). History of steroid use and of bleeding disorder and occurrence of postoperative transfusion increase the odds of readmission by approximately 2 (P = .005, P = .038, and P <.001, respectively). A postoperative urinary infection increased the odds of readmission by 5.5 (P <.001).

CONCLUSION

Contemporary 30-day readmission rates after nephrectomy procedures are influenced by specific patients' characteristics as well as postoperative adverse events. Moreover, contemporary MIPN seems to carry lower odds of readmission than OPN. It remains to be determined to what extent these findings are influenced by the expanding role of robotic technology.

Hospital volume and operative mortality in the modern era

OBJECTIVE

To determine whether the relationship between hospital volume and mortality has changed over time.

BACKGROUND

It is generally accepted that hospital volume is associated with mortality in high-risk procedures. However, as surgical safety has improved over the last decade, recent evidence has suggested that the inverse relationship has diminished or been eliminated.

METHODS

Using national Medicare claims data from 2000 through 2009, we examined mortality among 3,282,127 patients who underwent 1 of 8 gastrointestinal, cardiac, or vascular procedures. Hospitals were stratified into quintiles of operative volume. Using multivariable logistic regression models to adjust for patient characteristics, we examined the relationship between hospital volume and mortality, and assessed for changes over time. We performed sensitivity analyses using hierarchical logistic regression modeling with hospital-level random effects to confirm our results.

RESULTS

Throughout the 10-year period, a significant inverse relationship was observed in all procedures. In 5 of the 8 procedures studied, the strength of the volume-outcome relationship increased over time. In esophagectomy, for example, the adjusted odds ratio of mortality in very low volume hospitals compared to very high volume hospitals increased from 2.25 [95% confidence interval (CI): 1.57-3.23] in 2000-2001 to 3.68 (95% CI: 2.66-5.11) in 2008-2009. Only pancreatectomy showed a notable decrease in strength of the relationship over time, from 5.83 (95% CI: 3.64-9.36) in 2000-2001, to 3.08 (95% CI: 2.07-4.57) in 2008-2009.

CONCLUSIONS

For all procedures examined, higher volume hospitals had significantly lower mortality rates than lower volume hospitals. Despite recent improvements in surgical safety, the strong inverse relationship between hospital volume and mortality persists in the modern era.

Assessing Outcomes and Safety of Inpatient Versus Outpatient Tissue Expander Immediate Breast Reconstruction

BACKGROUND

With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database.

METHODS

NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications.

RESULTS

Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16).

CONCLUSIONS

Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.

Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries

IMPORTANCE

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides feedback to hospitals on risk-adjusted outcomes. It is not known if participation in the program improves outcomes and reduces costs relative to nonparticipating hospitals.

OBJECTIVE

To evaluate the association of enrollment and participation in the ACS NSQIP with outcomes and Medicare payments compared with control hospitals that did not participate in the program.

DESIGN, SETTING, AND PARTICIPANTS

Quasi-experimental study using national Medicare data (2003-2012) for a total of 1,226,479 patients undergoing general and vascular surgery at 263 hospitals participating in ACS NSQIP and 526 nonparticipating hospitals. A difference-in-differences analytic approach was used to evaluate whether participation in ACS NSQIP was associated with improved outcomes and reduced Medicare payments compared with nonparticipating hospitals that were otherwise similar. Control hospitals were selected using propensity score matching (2 control hospitals for each ACS NSQIP hospital).

MAIN OUTCOMES AND MEASURES

Thirty-day mortality, serious complications (eg, pneumonia, myocardial infarction, or acute renal failure and a length of stay >75th percentile), reoperation, and readmission within 30 days. Hospital costs were assessed using price-standardized Medicare payments during hospitalization and 30 days after discharge.

RESULTS

After accounting for patient factors and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes at 1, 2, or 3 years after (vs before) enrollment in ACS NSQIP. For example, in analyses comparing outcomes at 3 years after (vs before) enrollment, there were no statistically significant differences in risk-adjusted 30-day mortality (4.3% after enrollment vs 4.5% before enrollment; relative risk [RR], 0.96 [95% CI, 0.89 to 1.03]), serious complications (11.1% after enrollment vs 11.0% before enrollment; RR, 0.96 [95% CI, 0.91 to 1.00]), reoperations (0.49% after enrollment vs 0.45% before enrollment; RR, 0.97 [95% CI, 0.77 to 1.16]), or readmissions (13.3% after enrollment vs 12.8% before enrollment; RR, 0.99 [95% CI, 0.96 to 1.03]). There were also no differences at 3 years after (vs before) enrollment in mean total Medicare payments ($40 [95% CI, -$268 to $348]), or payments for the index admission (-$11 [95% CI, -$278 to $257]), hospital readmission ($245 [95% CI, -$231 to $721]), or outliers (-$86 [95% CI, -$1666 to $1495]).

CONCLUSIONS AND RELEVANCE

With time, hospitals had progressively better surgical outcomes but enrollment in a national quality reporting program was not associated with the improved outcomes or lower Medicare payments among surgical patients. Feedback on outcomes alone may not be sufficient to improve surgical outcomes.

Limitations of ACS-NSQIP in reporting complications for patients undergoing pancreatectomy: underscoring the need for a pancreas-specific module

BACKGROUND

Large centralized databases are used with increasing frequency for reporting hospital-specific and nationwide trends and outcomes after various surgical procedures in order to improve quality of surgical care. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) is a risk-adjusted, case-weighted complication tracking initiative that reports 30-day outcomes from more than 400 academic and community institutions in the US. However, the accuracy of event reporting specific to pancreatic surgery has never been examined in depth.

METHODS

We retrospectively reviewed medical records of patients, the information on whose postoperative course was originally reported through ACS-NSQIP between 2006 and 2010. Preoperative characteristics, operative data, and postoperative events were recorded after review of electronic medical records including physician and nursing notes, operative room records and anesthesiologist reports. Fidelity of reported clinical events was assessed. Accuracy, sensitivity, and specificity were calculated for each variable of interest.

RESULTS

Two hundred and forty-nine pancreatectomies were reviewed, including 145 (58.2 %) Whipple procedures, 19 (7.6 %) total pancreatectomies, 65 (26.1 %) distal pancreatectomies, and 15 (6.0 %) central or partial resections. Median age was 65.7, males comprised 41.5 % of the group, and 74.3 % of patients were Caucasian. The overall rate of complications reported by NSQIP was 44.0 %, compared with 45.0 % in our review, however discordance was observed in 27.3 % of the time, including 34 cases of reporting a complication where there was not one, and 34 cases of missed complication. The most frequently reported event was postoperative bleeding requiring transfusion, however this was also the event most commonly misclassified. Additionally, three procedures unrelated to the index operation were recorded as reoperation events. While a pancreas-specific module does not yet exist, ACS-NSQIP reports a 7.6 % rate of organ-space surgical site infections; when compared with our institutional rate of Grades B and C postoperative fistula (10.4 %), we observed discordance 4.4 % of the time. Delayed gastric emptying, a common post-pancreatectomy morbidity, was not captured at all. Additionally, there were significant inaccuracies in reporting urinary tract infections, postoperative pneumonia, wound complications, and postoperative sepsis, with discordance rates of 4.4, 3.2, 3.6, and 6.8 %, respectively.

CONCLUSIONS

ACS-NSQIP data are an important and valuable tool for evaluating quality of surgical care, however pancreatectomy-specific postoperative events are often misclassified, underscoring the need for a hepatopancreatobiliary-specific module to better capture key outcomes in this complex and unique patient population.

Implementation of a hospital-based quality assessment program for rectal cancer

PURPOSE

Quality improvement programs in Europe have had a markedly beneficial effect on the processes and outcomes of rectal cancer care. The quality of rectal cancer care in the United States is not as well understood, and scalable quality improvement programs have not been developed. The purpose of this article is to describe the implementation of a hospital-based quality assessment program for rectal cancer, targeting both community and academic hospitals.

METHODS

We recruited 10 hospitals from a surgical quality improvement organization. Nurse reviewers were trained to abstract rectal cancer data from hospital medical records, and abstracts were assessed for accuracy. We conducted two surveys to assess the training program and limitations of the data abstraction. We validated data completeness and accuracy by comparing hospital medical record and tumor registry data.

RESULTS

Nine of 10 hospitals successfully performed abstractions with ≥ 90% accuracy. Experienced nurse reviewers were challenged by the technical details in operative and pathology reports. Although most variables had less than 10% missing data, outpatient testing information was lacking from some hospitals' inpatient records. This implementation project yielded a final quality assessment program consisting of 20 medical records variables and 11 tumor registry variables.

CONCLUSION

An innovative program linking tumor registry data to quality-improvement data for rectal cancer quality assessment was successfully implemented in 10 hospitals. This data platform and training program can serve as a template for other organizations that are interested in assessing and improving the quality of rectal cancer care.

Redundancy and variability in quality and outcome reporting for cardiac and thoracic surgery

Health care is evolving into a value-based reimbursement system focused on quality and outcomes. Reported outcomes from national databases are used for quality improvement projects and public reporting. This study compared reported outcomes in cardiac and thoracic surgery from two validated reporting databases-the Society of Thoracic Surgeons (STS) database and the National Surgical Quality Improvement Program (NSQIP)-from January 2011 to June 2012. Quality metrics and outcomes included mortality, wound infection, prolonged ventilation, pneumonia, renal failure, stroke, and cardiac arrest. Comparison was made by chi-square analysis. A total of 737 and 177 cardiac surgery cases and 451 and 105 thoracic surgery cases were captured by the STS database and NSQIP, respectively. Within cardiac surgery, there was a statistically significant difference in the reported rates of prolonged ventilation, renal failure, and mortality. No significant differences were found for the thoracic surgery data. In conclusion, our data indicated a significant discordance in quality reporting for cardiac surgery between the NSQIP and the STS databases. The disparity between databases and duplicate participation strongly indicates that a unified national quality reporting program is required. Consolidation of reporting databases and standardization of morbidity definitions across all databases may improve participation and reduce hospital cost.

Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence

BACKGROUND

Cardiac complications are a major cause of postoperative morbidity. The purpose of this study was to determine the rates, risk factors, and time of occurrence for cardiac complications within thirty days after primary unilateral total knee arthroplasty and total hip arthroplasty.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program data set from 2006 to 2011 was used to identify all total knee arthroplasties and total hip arthroplasties. Cardiac complications occurring within thirty days after surgery were the primary outcome measure. Patients were designated as having a history of cardiac disease if they had a new diagnosis or exacerbation of chronic congestive heart failure or a history of angina within thirty days before surgery, a history of myocardial infarction within six months, and/or any percutaneous cardiac intervention or other major cardiac surgery at any time. An analysis of the occurrence of all major cardiac complications and deaths within the thirty-day postoperative time frame was performed.

RESULTS

For the 46,322 patients managed with total knee arthroplasty or total hip arthroplasty, the cardiac complication rate was 0.33% (n = 153) at thirty days postoperatively. In both the total knee arthroplasty and total hip arthroplasty groups, an age of eighty years or more (odds ratios [ORs] = 27.95 and 3.72), hypertension requiring medication (ORs = 4.74 and 2.59), and a history of cardiac disease (ORs = 4.46 and 2.80) were the three most significant predictors for the development of postoperative cardiac complications. Of the patients with a cardiac complication, the time of occurrence was within seven days after surgery for 79% (129 of the 164 patients for whom the time of occurrence could be determined).

CONCLUSIONS

An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty. Consideration should be given to a preoperative cardiology evaluation and co-management in the perioperative period for individuals with these risk factors.

Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates

BACKGROUND

The aim of this study was to analyze NSQIP (National Surgical Quality Improvement Program) data to better understand the incidence, risk factors, and thirty-day complication rates associated with transfusions in primary total hip and knee arthroplasty.

METHODS

We identified 9362 total hip and 13,662 total knee arthroplasty procedures from the database and separated those in which any red blood-cell transfusion was performed within seventy-two hours after surgery from those with no transfusion. Patient demographics, comorbidities, preoperative laboratory values, intraoperative variables, and postoperative complications were compared between patients who received a transfusion and those who did not. Multivariate logistic regression was used to identify independent risk factors for receiving a transfusion as well as for associated postoperative complications (thirty-day incidences of infection, venous thromboembolism, and mortality).

RESULTS

The transfusion rate after total hip arthroplasty was 22.2%. Significant risk factors for receiving a transfusion were age (OR [odds ratio] per ten years = 10.1), preoperative anemia (OR = 3.6), female sex (OR = 2.0), BMI (body mass index) of <30 kg/m(2) (OR = 1.4), and ASA (American Society of Anesthesiologists) class of >2 (OR = 1.3). Multivariate logistic regression analysis indicated that adjusted odds of infection, venous thromboembolism, and mortality did not differ significantly between patients who received a transfusion and those who did not. The transfusion rate after total knee arthroplasty was 18.3%. Risk factors for receiving a transfusion were age (OR per ten years = 10.2), preoperative anemia (OR = 3.8), BMI of <30 kg/m(2) (OR = 1.4), female sex (OR = 1.3), and ASA class of >2 (OR = 1.3). Multivariate logistic regression indicated that a transfusion was significantly associated with mortality (OR = 2.7) but not with infection or venous thromboembolism.

CONCLUSIONS

We did not find a strong association between perioperative red blood-cell transfusion and thirty-day incidences of infection, venous thromboembolism, or mortality; however, the odds of mortality were higher in patients who received a transfusion during total knee arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acceptability of the decision support for safer surgery tool

BACKGROUND

We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events.

METHODS

The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests.

RESULTS

During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably.

CONCLUSION

The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.

Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database

BACKGROUND

For more than thirty-five years, the sliding hip screw, an extramedullary implant, has been the standard treatment for the stabilization of intertrochanteric fractures. Over the last decade, intramedullary implants have replaced extramedullary implants as the most commonly used type of implant in the United States for the treatment of this condition, without strong evidence of superior outcomes.

METHODS

We conducted a retrospective cohort study with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients seventy years of age or older who had sustained an intertrochanteric fracture treated with extramedullary or intramedullary implant during 2009 to 2012 were identified. General surgical outcomes were compared between implant types, with adjustment for demographic data and comorbidities.

RESULTS

A total of 4432 patients were identified; 1612 (36.4%) were treated with an extramedullary implant, and 2820 (63.6%) with an intramedullary implant. The rates of the composite outcomes "serious adverse events" and "any adverse events" did not differ by implant type. The mean postoperative length of stay was shorter for patients treated with an intramedullary implant compared with those treated with an extramedullary implant (5.4 compared with 6.5 days; p < 0.001). Operation time, operating room time, and the rate of hospital readmission did not differ by implant type.

CONCLUSIONS

These results reinforce the results of previous randomized trials, demonstrating little difference in rates of general surgical adverse events between implant types. The present study presents an important departure from previous trials in its finding that patients treated with intramedullary implants have, on average, a shorter postoperative length of stay (by 1.1 days). The finding may negate the perceived excess cost associated with intramedullary treatment. Limitations regarding the ACS NSQIP database include a lack of detail regarding fracture subtype, outcomes beyond thirty days, and orthopaedic-specific outcomes.

Morbidity and mortality in the thirty-day period following total hip arthroplasty: risk factors and incidence

The study sought to ascertain the incidence rates and risk factors for 30-day post-operative complications after primary total hip arthroplasty (THA). Complications were categorized as systemic or local and subcategorized as major or minor. There were 17,640 individuals who received primary THA identified from the 2006-2011 ACS NSQIP. The mortality rate was 0.35% and complications occurred in 4.9%. Age groups ≥ 80 years (P <0.001) and 70-79 years old (P = 0.003), and renal insufficiency (P = 0.02) best predicted mortality. Age ≥80 years (P <0.001) and cardiac disease (P = 0.01) were the strongest predictors of developing any postoperative complication. Morbid obesity (P <0.001) and operative time > 141 minutes (P <0.001) were strongly associated with the development of major local complications.

What clinical factors predict the incidence of deep venous thrombosis and pulmonary embolism in neurosurgical patients?

Object

Venous thromboembolisms (VTEs) occur frequently in surgical patients and can manifest as pulmonary emboli (PEs) or deep venous thromboses (DVTs). While many medical therapies have been shown to prevent VTEs, neurosurgeons are concerned about the use of anticoagulants in the postoperative setting. To better understand the prevalence of and the patient-level risk factors for VTE, the authors analyzed data from the National Surgical Quality Improvement Program (NSQIP).

Methods

Retrospective data on 1,777,035 patients for the years from 2006 to 2011 were acquired from the American College of Surgeons NSQIP database. Neurosurgical cases were extracted by querying the data for which the surgical specialty was listed as “neurological surgery.” Univariate statistics were calculated using the chi-square test, with 95% confidence intervals used for the resultant risk ratios. Multivariate models were constructed using binary logistic regression with a maximum number of 20 iterations.

Results

Venous thromboembolisms were found in 1.7% of neurosurgical patients, with DVTs roughly twice as common as PEs (1.3% vs 0.6%, respectively). Significant independent predictors included ventilator dependence, immobility (that is, quadriparesis, hemiparesis, or paraparesis), chronic steroid use, and sepsis. The risk of VTE was significantly higher in patients who had undergone cranial procedures (3.4%) than in those who had undergone spinal procedures (1.1%).

Conclusions

Venous thromboembolism is a common complication in neurosurgical patients, and the frequency has not changed appreciably over the past several years. Many factors were identified as independently predictive of VTEs in this population: ventilator dependence, immobility, and malignancy. Less anticipated predictors included chronic steroid use and sepsis. Venous thromboembolisms appear significantly more likely to occur in patients undergoing cranial procedures than in those undergoing spinal procedures. A better appreciation of the prevalence of and the risk factors for VTEs in neurosurgical patients will allow targeting of interventions and a better understanding of which patients are most at risk.

Nutritional predictors of complications following radical cystectomy

PURPOSE

To determine the impact of preoperative nutritional status on the development of surgical complications following cystectomy using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

We performed a retrospective review of the NSQIP 2005-2012 Participant Use Data Files. ACS-NSQIP collects data on 135 variables, including pre- and intraoperative data and 30-day postoperative complications and mortality on all major surgical procedures at participating institutions. Preoperative albumin (<3.5 or >3.5 g/dl), weight loss 6 months before surgery (>10 %), and body mass index (BMI) were identified as nutritional variables within the database. The overall complication rate was calculated, and predictors of complications were identified using multivariable logistic regression models.

RESULTS

A total of 1,213 patients underwent cystectomy for bladder cancer between 2005 and 2012. The overall 30-day complication rate was 55.1 % (n = 668). While 14.7 % (n = 102) had a preoperative albumin <3.5 g/dL, 3.4 % had >10 % weight loss in the 6 months prior to surgery and the mean BMI was 28 kg/m(2). After controlling for age, sex, medical comorbidities, medical resident involvement, operation year, operative time, and prior operation, only albumin <3.5 g/dl was a significant predictor of experiencing a postoperative complication (p = 0.03). This remained significant when albumin was evaluated as a continuous variable (p = 0.02).

CONCLUSIONS

Poor nutritional status measured by serum albumin is predictive of an increased rate of surgical complications following radical cystectomy. This finding supports the importance of preoperative nutritional status in this population and highlights the need for the development of effective nutritional interventions in the preoperative setting.

Is American College of Surgeons NSQIP organ space infection a surrogate for pancreatic fistula?

BACKGROUND

In the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), pancreatic fistula has not been monitored, although organ space infection (OSI) data are collected. Therefore, the purpose of this analysis was to determine the relationship between ACS NSQIP organ space infection and pancreatic fistulas.

STUDY DESIGN

From 2007 to 2011, 976 pancreatic resection patients were monitored via ACS NSQIP at our institution. From this database, 250 patients were randomly chosen for further analysis. Four patients were excluded because they underwent total pancreatectomy. Data on OSI were gathered prospectively. Data on pancreatic fistulas and other intra-abdominal complications were determined retrospectively.

RESULTS

Organ space infections (OSIs) were documented in 22 patients (8.9%). Grades B (n = 26) and C (n = 5) pancreatic fistulas occurred in 31 patients (12.4%); grade A fistulas were observed in 38 patients (15.2%). Bile leaks and gastrointestinal (GI) anastomotic leaks each developed in 5 (2.0%) patients. Only 17 of 31 grade B and C pancreatic fistulas (55%), and none of 38 grade A fistulas were classified as OSIs in ACS NSQIP. In addition, only 2 of 5 bile leaks (40%) and 2 of 5 GI anastomotic leaks (40%) were OSIs. Moreover, 3 OSIs were due to bacterial peritonitis, a chyle leak, and an ischemic bowel.

CONCLUSIONS

This analysis suggests that the sensitivity (55%) and specificity (45%) of organ space infection (OSI) in ACS NSQIP are too low for OSI to be a surrogate for grade B and C pancreatic fistulas. We concluded that procedure-specific variables will be required for ACS NSQIP to improve outcomes after pancreatectomy.

Higher rate of breast surgery complications in patients with metastatic breast cancer: an analysis of the NSQIP database

BACKGROUND

Four percent of breast cancer patients present with metastatic disease. To date, no one has examined whether these patients are at higher risk of postoperative complications. The objective of this study was to determine morbidity and mortality associated with breast surgery in the metastatic setting.

METHODS

We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including breast cancer patients undergoing primary breast surgery from 2005 to 2012. Patients with bilateral surgery or severe comorbidities were excluded. Multivariable logistic regression was performed to determine the independent effect of metastatic breast cancer on postoperative morbidity and mortality.

RESULTS

We identified 68,316 patients who underwent breast surgery for invasive breast cancer; 1,031 (1.5 %) had metastatic disease. The 30-day unadjusted morbidity was significantly higher in the metastatic cohort (7.5 vs. 3.7 %; p < 0.001), as was the all-cause 30-day mortality (1.8 vs. 0.06 %; p < 0.001). The metastatic cohort was more likely to experience an: infectious, respiratory, thromboembolic, cardiac, or bleeding complication than non-metastatic patients. However, preoperative chemo- and radiation therapy did not contribute to an overall increased complication rate. The adjusted odds ratio for postoperative complications in the setting of metastatic disease was 1.6 (95 % confidence limit 1.2-2.1).

CONCLUSIONS

This is the first study documenting the morbidity and mortality associated with breast surgery in metastatic breast cancer. The 30-day morbidity and mortality in this population is higher than in patients with stage I-III disease. Although the complication rate is increased, operating on the primary in metastatic breast cancer is relatively safe.

Racial/Ethnic Disparities in Revascularization for Limb Salvage

Introduction:

Previous reports have suggested that black patients have a higher rate of major lower extremity amputation and a lower rate of revascularization for limb salvage when compared to white patients.

Objective:

We undertook this study to determine the extent of this ethnic disparity in recent years and to evaluate whether the widespread adoption of endovascular techniques has had an impact on this disparity.

Methods:

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who had undergone an above- or below-knee amputation as well as all patients who had undergone an open or endovascular revascularization procedure for critical limb ischemia for the years 2005 to 2006. Patient demographics and 30-day outcomes were recorded, and comparisons were made among the different ethnic groups.

Results:

There were 1568 patients identified in the NSQIP database as having undergone a major lower extremity amputation in 2005 and 2006. Of these patients, 54% were white, 29% black, 8% Hispanic, and 0.7% Asian. Eight percent of patients did not have identifying ethnic data. The group undergoing amputation was primarily male (61%) with a mean age of 65. Median length of stay was 11 days, and 30-day mortality was 9% following amputation. During this same time period, 4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes of limb salvage. Of those patients undergoing an open procedure, 74% were white, 12% black, 4% Hispanic, 0.4% Asian, and 10% did not have identifying ethnic data. Open surgical patients were primarily male (63%) with a mean age of 66. Median length of stay was 6 days, and 30-day mortality was 3.3%. Of those patients undergoing an endovascular procedure, 79% were white, 10% black, 2% Hispanic, 1% Asian, and 8% did not have identifying ethnic data. The endovascular group was also primarily male (61%) with a mean age of 68. Median length of stay was 5 days, and 30-day mortality was 4%.

Conclusion:

There remains a significant ethnic disparity in limb-salvage revascularization. Blacks comprise 29% of patients undergoing a major lower extremity amputation, but only 12% of those undergoing an open surgical procedure and 10% of those undergoing an endovascular procedure for limb salvage. The widespread adoption of endovascular revascularization techniques appears not to have had much impact on this disparity.

Centralization of esophagectomy: how far should we go?

BACKGROUND

This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy.

METHODS

Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment.

RESULTS

Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65-0.83) and 0.67 (0.58-0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79-0.93).

CONCLUSIONS

Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40-60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.

Performance measurement in surgery through the National Quality Forum

BACKGROUND

Performance measurement has become central to surgical practice. We systematically reviewed all endorsed performance measures from the National Quality Forum, the national clearing house for performance measures in health care, to identify measures relevant to surgical practice and describe measure stewardship, measure types, and identify gaps in measurement.

STUDY DESIGN

Performance measures current to June 2014 were categorized by denominator statement as either assessing surgical practice in specific or as part of a mixed medical and surgical population. Measures were further classified by surgical specialty, Donabedian measure type, patients, disease and events targeted, reporting eligibility, and measure stewards.

RESULTS

Of 637 measures, 123 measures assessed surgical performance in specific and 123 assessed surgical performance in aggregate. Physician societies (51 of 123, 41.5%) were more common than government agencies (32 of 123, 26.0%) among measure stewards for surgical measures, in particular, the Society for Thoracic Surgery (n = 32). Outcomes measures rather than process measures were common among surgical measures (62 of 123, 50.4%) compared with aggregate medical/surgical measures (46 of 123, 37.4%). Among outcomes measures, death alone was the most commonly specified outcome (24 of 62, 38.7%). Only 1 surgical measure addressed patient-centered care and only 1 measure addressed hospital readmission. We found 7 current surgical measures eligible for value-based purchasing.

CONCLUSIONS

Surgical society stewards and outcomes measure types, particularly for cardiac surgery, were well represented in the National Quality Forum. Measures addressing patient-centered outcomes and the value of surgical decision-making were not well represented and may be suitable targets for measure innovation.

The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program

Postoperative adverse events occur all too commonly and contribute greatly to our large and increasing healthcare costs. Surgeons, as well as hospitals, need to know their own outcomes in order to recognise areas that need improvement before they can work towards reducing complications. In the USA, the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) collects clinical data that provide benchmarks for providers and hospitals. This review summarises the history of ACS NSQIP and its components, and describes the evidence that feeding outcomes back to providers, along with real-time comparisons with other hospital rates, leads to quality improvement, better patient outcomes, cost savings and overall improved patient safety. The potential harms and limitations of the program are discussed.

The incidence and risk factors for short-term morbidity and mortality in pediatric deformity spinal surgery: an analysis of the NSQIP pediatric database

STUDY DESIGN

Retrospective review of a prospective cohort.

OBJECTIVE

To determine the incidence and risk factors for 30-day morbidity and mortality after pediatric deformity spinal surgery.

SUMMARY OF BACKGROUND DATA

Pediatric deformity spinal surgery is generally considered a safe and effective treatment option. The rising costs associated with spinal surgery and related perioperative complications have received national attention. Few studies with standardized definitions and data collection methods exist.

METHODS

A large, multicenter clinical registry specifically designed to collect pediatric surgical outcomes was queried for all patients undergoing spinal deformity surgery in 2012. Current Procedural Terminology codes were used to select patients undergoing anterior, posterior, and combined fusions. Detailed patient and case characteristics were analyzed. Thirty-day morbidity and mortality rates were calculated. Univariate and multivariate logistic regression analyses were used to identify patient characteristics, comorbidities, and operative variables predictive of complication.

RESULTS

In total, 2005 pediatric patients undergoing deformity spinal fusion were included. The rate of 30-day complications was 10.0%; with a mortality rate of 0.15% (3 patients), a morbidity rate of 8.4%, reoperation rate of 3.74%, and readmission rate of 3.94%. The morbidity rate was highest in the neuromuscular group (13.09%) and lowest in the idiopathic cohort (5.69%), P < 0.01). Compared with posterior fusions, anterior fusions and those extending to the pelvis were associated with higher complication rates (P < 0.01). Risk factors for complication included hepatobiliary disease (P = 0.03), cognitive impairment (P = 0.02), elevated American Society of Anesthesiologists class (P < 0.01), and prolonged operative time (P < 0.01).

CONCLUSION

The overall rate of 30-day morbidity after pediatric spinal deformity surgery was 10%. Multiple patient comorbidities and surgical duration and invasiveness were associated with an increased complication risk. These data may aid in the informed consent process, facilitate patient risk assessment, and allow quality comparisons between surgeons and institutions.

LEVEL OF EVIDENCE

2.

The effect of resident participation on short-term outcomes after orthopaedic surgery

BACKGROUND

The influence of resident involvement on short-term outcomes after orthopaedic surgery is mostly unknown.

QUESTIONS/PURPOSES

The purposes of our study were to examine the effects of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay, and reoperation rate and to analyze these parameters by level of training.

METHODS

The 2005–2011 American College of Surgeons National Surgical Quality Improvement Program data set was queried using Current Procedural Terminology codes for 66,817 cases across six orthopaedic procedural domains: 28,686 primary total joint arthroplasties (TJAs), 2412 revision TJAs, 16,832 basic and 5916 advanced arthroscopies, 8221 lower extremity traumas, and 4750 spine arthrodeses (fusions). Bivariate and multivariate logistic regression and propensity scores were used to build models of risk adjustment. We compared the morbidity and mortality rates, length of operating time, hospital length of stay, and reoperation rate for cases with or without resident involvement. For cases with resident participation, we analyzed the same parameters by training level.

RESULTS

Resident participation was associated with higher morbidity in TJAs (odds ratio [OR], 1.6; range, 1.4–1.9), lower extremity trauma (OR, 1.3; range, 1.2–1.5), and fusion (OR, 1.4; range, 1.2–1.7) after adjustment. However, resident involvement was not associated with increased mortality. Operative time was greater (all p < 0.001) with resident involvement in all procedural domains. Longer hospital length of stay was associated with resident participation in lower extremity trauma (p < 0.001) and fusion cases (p = 0.003), but resident participation did not affect length of stay in other domains. Resident involvement was associated with greater 30-day reoperation rates for cases of lower extremity trauma (p = 0.041) and fusion (p < 0.001). Level of resident training did not consistently influence surgical outcomes.

CONCLUSIONS

Results of our study suggest resident involvement in surgical procedures is not associated with increased short-term major morbidity and mortality after select cases in orthopaedic surgery. Findings of longer operating times and differences in minor morbidity should lead to future initiatives to provide resident surgical skills training and improve perioperative efficiency in the academic setting.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

The future of quality measurement in the United States

The need to practice cost efficient medicine and provide it in the safest way possible is paving the way for quality improvement (QI) programs to take off. American College of Surgeons National Surgical QI Project and Surgical Care and Outcomes Assessment Program are some of the leading examples and have provided useful data to evaluate our systems and decrease morbidity and mortality. With proven outcomes driving morbidity and mortality rates down, we have to wonder how to refine these measures to make them more relevant to specialty surgeries such as colorectal. On the contrary, participation in programs like these has placed extended requirements on hospitals and physicians. In addition, some of the quality measures may be inaccurately identifying low and high performing hospitals and individuals because of inherent flaws in the database. This could potentially be in conflict with the mission of these programs. What will be presented are some alternatives and different directions QI is moving toward.

Validity of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) screening for sepsis in surgical mortalities

BACKGROUND

Sepsis is among the leading causes of death in the United States. The Agency for Healthcare Research and Quality uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) billing code screening for the identification of sepsis. We investigated the incidence of sepsis in mortality at our academic medical center through ICD-9-CM screening of billing codes corresponding to sepsis and compared this approach for accuracy using physician chart review as the gold-standard.

METHODS

Two hundred forty-three surgical mortalities between January 2012 and January 2013 were reviewed by a Performance Improvement team. All mortalities were screened and evaluated for sepsis using physician chart review and ICD-9-CM codes for sepsis (995.91), severe sepsis (995.92), and septic shock (785.52).

RESULTS

Unexpected mortalities were associated with higher rates of sepsis and expected mortalities than anticipated (p<0.0001). A total of 40.6% of patients with sepsis suffered from more than one infection; the most common infectious sources were intra-abdominal (43.5%), blood stream (40.3%), and pulmonary (38.7%) infections. Screening by ICD-9-CM identified sepsis in 23.0% of mortalities, and physician review identified sepsis in 25.5% of mortalities. The sensitivity and specificity of ICD-9-CM screening were 82.3% and 78.3%, respectively. The positive and negative predictive values were 91.1% and 62.1%, respectively.

CONCLUSION

Sepsis is a common concurrent condition in surgical patients who die unexpectedly. Screening by ICD-9-CM for sepsis is accurate in identifying patients with sepsis but misses the identification of all patients with sepsis. The diagnostic accuracy of ICD-9-CM screening for sepsis is currently not adequate for public reporting or benchmarking, and is useful only as a guide for institutional quality improvement.

Infrastructure and resources for an aging population: embracing complexity in translational research

The population of the United States and most industrialized nations is undergoing rapid expansion of persons aged 65 years and older. This group experiences more illness, disability, and dependency than young adults and consumes the majority of heath care resources. This demographic change presents a number of challenges to current research infrastructure aimed at translating discoveries to improved human health. Key issues include the need to expand the workforce trained in aging research, development of specific resources and harmonization of measures and outcomes, and a culture change within the scientific community. In particular, complexity must be represented within research design and embraced as an important aspect of review panel critiques.

Morbidity and mortality associated with gastrectomy for gastric cancer

BACKGROUND

Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complications is needed for multidisciplinary planning.

MATERIAL AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) from 2005 to 2010. Thirty-day mortality and morbidity were evaluated.

RESULTS

Overall, 2,580 patients underwent gastrectomy for malignancy, divided as total gastrectomy 999 (38.7 %) and partial gastrectomy 1,581 (61.3 %). Overall, serious morbidity occurred in 23.6 %, and the 30-day mortality was 4.1 %. Patients receiving a total gastrectomy were younger and healthier than those receiving a partial gastrectomy for the following measured criteria: age, diabetes, chronic obstructive pulmonary disease and hypertension. Serious morbidity and mortality were significantly higher in the total gastrectomy group than the partial gastrectomy group (29.3 vs. 19.9 %, p < 0.001; and 5.4 vs. 3.4 %, p < 0.015, respectively). The inclusion of additional procedures increased the risk of mortality for the following: splenectomy (odds ratio [OR] 2.8; p < 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p < 0.001), enterectomy (OR 2.7; p = 0.030), esophagectomy (OR 3.5; p = 0.035). Abdominal lymphadenectomy was not associated with increased morbidity (OR 1.1; p = 0.41); rather, it was associated with decreased mortality (OR 0.468; p = 0.028).

CONCLUSIONS

Gastrectomy for cancer as currently practiced carries significant morbidity and mortality. Inclusion of additional major procedures increases these risks. The addition of lymphadenectomy was not associated with increased morbidity or mortality. Strategies are needed to optimize surgical outcomes to ensure delivery of multimodality therapy for advanced-stage disease.

Neoadjuvant chemotherapy for bladder cancer does not increase risk of perioperative morbidity

OBJECTIVE

To determine whether neoadjuvant chemotherapy (NAC) is a predictor of postoperative complications, length of stay (LOS), or operating time after radical cystectomy (RC) for bladder cancer.

PATIENTS AND METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed to identify patients receiving NAC before RC from 2005 to 2011. Bivariable and multivariable analyses were used to determine whether NAC was associated with 30-day perioperative outcomes, e.g. complications, LOS, and operating time.

RESULTS

Of the 878 patients who underwent RC for bladder cancer in our study, 78 (8.9%) received NAC. Excluding those patients who were ineligible for NAC due to renal insufficiency, 78/642 (12.1%) received NAC. In all, 457 of the 878 patients (52.1%) undergoing RC had at least one complication ≤30 days of RC, including 43 of 78 patients (55.1%) who received NAC and 414 of 800 patients (51.8%) who did not (P = 0.58). On multivariable logistic regression, NAC was not a predictor of complications (P = 0.87), re-operation (P = 0.16), wound infection (P = 0.32), or wound dehiscence (P = 0.32). Using multiple linear regression, NAC was not a predictor of increased operating time (P = 0.24), and patients undergoing NAC had a decreased LOS (P = 0.02).

CONCLUSIONS

Our study is the first large multi-institutional analysis specifically comparing complications after RC with and without NAC. Using a nationally validated, prospectively maintained database specifically designed to measure perioperative outcomes, we found no increase in perioperative complications or surgical morbidity with NAC. Considering these findings and the well-established overall survival benefit over surgery alone, efforts are needed to improve the uptake of NAC.

The impact of complications following open colectomy on hospital finances: a retrospective cohort study

Background

When hospitals suffer financial losses when postoperative complications occur, they may have a direct financial incentive to initiate quality improvement programs. The purpose of this research was to determine the relationship between complications following open colectomy and hospital finances.

Methods

After obtaining Institutional Review Board approval, we conducted a retrospective chart review of 276 open colectomies performed at the Hospital of the University of Pennsylvania. The medical records were manually reviewed for complications that occurred within 30 days after surgery. Financial information, including total, fixed and variable costs, was obtained from the hospital’s cost accounting database. Reimbursement assuming payment by Medicare was calculated. Differences in costs, reimbursements and total margins were analyzed.

Results

Of 276 patient records reviewed, 61 (22%) of the patients experienced postoperative complications. When complications occurred, mean total costs increased from $23,101 to $48,180, fixed costs increased from $14,516 to $30,339 and variable costs increased from $8,535 to $17,848 (P < 0.001 for each comparison); the mean reimbursement increased from $23,231 to $35,651 (P < 0.001); and the total margin decreased from $131 to - $12,528 (P < 0.001). Complications were associated with a more than twofold increase in length of stay in the hospital. Multiple regression modeling indicated similar increases in each of the financial variables and length of stay as a result of postoperative complications. The impact of these complications on each outcome measure was similar in effect for patients in the matched subset of 100 patients.

Conclusion

Our results demonstrate a financial incentive for hospitals to investigate quality improvement measures to prevent postoperative complications and avoid the associated financial losses.

Delivering High-Quality Cancer Care: The Critical Role of Quality Measurement

In 1999, the Institute of Medicine (IOM) published Ensuring Quality Cancer Care, an influential report that described an ideal cancer care system and issued ten recommendations to address pervasive gaps in the understanding and delivery of quality cancer care. Despite generating much fervor, the report's recommendations-including two recommendations related to quality measurement-remain largely unfulfilled. Amidst continuing concerns regarding increasing costs and questionable quality of care, the IOM charged a new committee with revisiting the 1999 report and with reassessing national cancer care, with a focus on the aging US population. The committee identified high-quality patient-clinician relationships and interactions as central drivers of quality and attributed existing quality gaps, in part, to the nation's inability to measure and improve cancer care delivery in a systematic way. In 2013, the committee published its findings in Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, which included two recommendations that emphasize coordinated, patient-centered quality measurement and information technology enhancements: Develop a national quality reporting program for cancer care as part of a learning health care system; and,Develop an ethically sound learning health care information technology system for cancer that enables real-time analysis of data from cancer patients in a variety of care settings. These recommendations underscore the need for independent national oversight, public-private collaboration, and substantial funding to create robust, patient-centered quality measurement and learning enterprises to improve the quality, accessibility, and affordability of cancer care in America.

A risk calculator for short-term morbidity and mortality after hip fracture surgery

OBJECTIVE

Hip fractures are a common source of morbidity and mortality among the elderly. Although multiple prior studies have identified risk factors for poor outcomes, few studies have presented a validated risk stratification calculator.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 4331 patients undergoing surgery for hip fracture between 2005 and 2010. Patient demographics, comorbidities, laboratory values, and operative characteristics were compared in a univariate analysis, and a multivariate logistic regression analysis was then used to identify independent predictors of 30-day morbidity and mortality. Weighted values were assigned to each independent risk factor and used to create predictive models of 30-day morbidity, minor complication risk, major complication risk, and total complication risk. The models were internally validated with randomly partitioned 80%/20% cohort groups.

RESULTS

Thirty-day mortality was 5.9% and morbidity was 30.0%. Patient age, especially age greater than 80 years [mortality: odds ratio (OR): 2.41, 95% confidence interval (CI): 1.17-4.99); morbidity: OR: 1.43, 95% CI: 1.05-1.94], and male gender (mortality: OR: 2.28, 95% CI: 1.61-3.22; morbidity: OR: 1.26, 95% CI: 1.03-1.54) were associated with both increased mortality and morbidity. An increased American Society of Anesthesia class had the highest negative impact on total complication incidence in the scoring models. Additionally, complete functional dependence, active malignancy, patient race, cardiopulmonary disease, laboratory derangements, prolonged operating time, and open versus percutaneous surgery independently influenced outcomes. Risk scores, based on weighted models, which included the aforementioned variables, predicted mortality (P < 0.001, C index: 0.702) and morbidity (P < 0.001, C index: 0.670) after hip fracture surgery.

CONCLUSIONS

In this study, we have developed an internally validated method for risk stratifying patients undergoing hip fracture surgery, and this model is predictive of both 30-day morbidity and mortality. Our model could be useful for identifying high-risk individuals, for obtaining informed consent, and for risk-adjusted comparisons of outcomes between institutions.

LEVEL OF EVIDENCE

Prognostic level II. See instructions for authors for a complete description of levels of evidence.

Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway

BACKGROUND

After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use.

OBJECTIVE

The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes.

DESIGN

This was a case-matched study.

METHODS

After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex.

SETTINGS

This study was performed at a tertiary referral center.

PATIENTS

Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included.

MAIN OUTCOME MEASURES

The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway.

RESULTS

Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen.

LIMITATIONS

The single-surgeon, single-institution design was a limitation of this study.

CONCLUSIONS

The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.