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

Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program

OBJECTIVE

Readmission is associated with high mortality, morbidity, and cost. We used the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) to determine risk factors for readmission after lower extremity bypass (LEB).

METHODS

We identified all patients who received LEB in the 2011 ACS-NSQIP database. Multivariable logistic regression was used to assess independent predictors of 30-day readmission. We also identified our institutional contribution of LEB patients to the ACS-NSQIP from 2005 to 2011 to determine our institution's rate of readmission and readmission indications.

RESULTS

Among 5018 patients undergoing LEB, ACS-NSQIP readmission analysis was performed on 4512, excluding those whose readmission data were unavailable, who suffered a death on index admission, or who remained in the hospital at 30 days. Overall readmission rate was 18%, and readmission rate of those with NSQIP-captured complications was 8%. Multivariable predictors of readmission were dependent functional status (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.08-1.79), dyspnea (OR, 1.28; 95% CI, 1.02-1.60), cardiac comorbidity (OR, 1.46; 95% CI, 1.16-1.84), dialysis dependence (OR, 1.44; 95% CI, 1.05-1.97), obesity (OR, 1.28; 95% CI, 1.07-1.53), malnutrition (OR, 1.42; 95% CI, 1.12-1.79), critical limb ischemia operative indication (OR, 1.40; 95% CI, 1.10-1.79), and return to the operating room on index admission (OR, 8.0; 95% CI, 6.68-9.60). The most common postdischarge complications occurring in readmitted patients included wound complications (55%), multiple complications (22%), and graft failure (5%). Our institutional data contributed 465 LEB patients to the ACS-NSQIP from 2005 to 2012, with an overall readmission rate of 14%. Unplanned readmissions related to the original LEB (related unplanned) made up 75% of cases. The remainder 25% included readmissions that were planned staged procedures related to the original LEB (related planned, 11%) and admissions for a completely unrelated reason (unrelated unplanned, 14%). The most common readmission indications included wound infection (37%) and graft failure (10%). Readmissions were attributable to NSQIP-captured postdischarge complications in 44% of cases, an additional 44% had a non-NSQIP-defined reason for readmission, and the remainder (12%) included patients admitted for complications described in NSQIP but not meeting strict NSQIP criteria.

CONCLUSIONS

Readmissions are common after LEB. Optimization of select chronic conditions, closer follow-up of patients in poor health and those who required return to the operating room, and early detection of surgical site infections may improve readmission rates. Our finding that 25% of readmissions after LEB are not procedure related informs the broader discussion of how a readmission penalty affects vascular surgery in particular.

Reliability of evaluating hospital quality by colorectal surgical site infection type

OBJECTIVE

To determine whether risk-adjusted colorectal SSI rates are statistically reliable as hospital quality measures.

BACKGROUND

Policymakers use surgical site infections (SSI) for public reporting of hospital quality and pay-for-performance because they are a relatively common and costly cause of patient morbidity.

METHODS

Patients who underwent a colorectal procedure in 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program. We developed hierarchical multivariate logistic models for (1) superficial SSI, (2) deep/organ-space SSI, and (3) "any SSI" and compared how each model ranked hospital-level risk-adjusted performance. Statistical reliability of hospital quality measurements was estimated on a scale from 0 to 1; with 0 indicating that apparent variation between a hospital's quality measurement and the average hospital is statistically unreliable, and 1 indicating that any observed variation is due to a real difference in performance.

RESULTS

Mean reliability of hospital-level quality measurements was 0.650 for superficial, 0.404 for deep/organ-space, and 0.586 for "any SSI." Lower reliability was accounted for by relatively little variation in risk-adjusted SSI rates between hospitals and insufficient numbers of colorectal cases submitted by individual hospitals. In 2009, we estimate that 22.1% of all US hospitals performed a sufficient number of colorectal cases to report superficial SSI rates at a high standard of statistical reliability and 1.0% did for deep/organ-space SSI.

CONCLUSIONS

As currently constructed, colorectal SSI quality measures might not meet a high standard of statistical reliability for most hospitals, limiting their ability to confidently differentiate high and low performance. Despite an expectation of improving statistical power, combining superficial and deep/organ-space SSI into an "any SSI" measure worsens reliability.

The concept of a composite perioperative quality index in kidney transplantation

BACKGROUND

Public reporting of patient and graft outcomes in a national registry and close Centers for Medicare and Medicaid Services oversight has resulted in transplantation being a highly regulated surgical discipline. Despite this, transplantation surgery lacks comprehensive tracking and reporting of perioperative quality measures. Therefore, the aim of this study was to determine the association between a kidney transplantation centers' perioperative quality benchmarking and graft and patient outcomes.

STUDY DESIGN

This was an analysis of 2011 aggregate data compiled from 2 national datasets that track outcomes from member hospitals and transplantation centers. The transplantation centers included in this study were composed of accredited US kidney transplantation centers that report data through the national registry and are associate members of the University HealthSystem Consortium.

RESULTS

A total of 16,811 kidney transplantations were performed at 236 centers in the United States in 2011, of which 10,241 (61%) from 93 centers were included in the analysis. Of the 6 perioperative quality indicators, 3 benchmarked metrics were significantly associated with a kidney transplantation center's underperformance: mean ICU length of stay (C-statistic 0.731; p = 0.002), 30-day readmissions (C-statistic 0.697; p = 0.012) and in-hospital complications (C-statistic 0.785; p = 0.001). The composite quality index strongly correlated with inadequate center performance (C-statistic 0.854; p < 0.001, R(2) = 0.349). The centers in the lowest quartile of the quality index performed 2,400 kidney transplantations in 2011, which led to 2,640 more hospital days, 4,560 more ICU days, 120 more postoperative complications, and 144 more patients with 30-day readmissions, when compared with centers in the 3 higher-quality quartiles.

CONCLUSIONS

An objective index of a transplantation center's quality of perioperative care is significantly associated with patient and graft survival.

Identification of modifiable factors for reducing readmission after colectomy: a national analysis

BACKGROUND

Rates of hospital readmission are currently used for public reporting and pay for performance. Colectomy procedures account for a large number of readmissions among operative procedures. Our objective was to compare the importance of 3 groups of clinical variables (demographics, preoperative risk factors, and postoperative complications) in predicting readmission after colectomy procedures.

METHODS

Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Patient demographics (n = 2), preoperative risk factors (n = 23), and 30-day postoperative complications (n = 17) were identified from ACS-NSQIP, whereas 30-day postoperative readmissions and costs were determined from Medicare. Multivariable logistic regression models were used to examine risk-adjusted predictors of colectomy readmission.

RESULTS

Among 12,981 colectomy patients, the 30-day postoperative readmission rate was 13.5%. Readmitted patients had slightly greater rates of comorbidities and indicators of clinical severity and substantially greater rates of complications than non-readmitted patients. After risk adjustment, patients with a complication were 3.3 times as likely to be readmitted as patients without a complication. Among individual complications, progressive renal failure and organ-space surgical site infection had the highest risk-adjusted relative risks of readmission (4.6 and 4.0, respectively). Demographic, preoperative risk factor, and postoperative complication variables increased the ability to discriminate readmissions (reflected by the c-statistic) by 5.3%, 23.3%, and 35.4%, respectively.

CONCLUSION

Postoperative complications after colectomy are more predictive of readmission than traditional risk factors. Focusing quality improvement efforts on preventing and managing postoperative complications may be the most important step toward reducing readmission rates.

Quality improvement in gastrointestinal surgical oncology with American College of Surgeons National Surgical Quality Improvement Program

OBJECTIVE

To assess the impact of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participation on outcomes in gastrointestinal surgical oncology.

STUDY DESIGN

A total of 6,076 resections for esophageal, gastric, pancreatic, hepatobiliary, and colorectal cancers at 316 hospitals from the 2006 to 2011 ACS NSQIP were examined. Thirty-day complication rates were analyzed longitudinally over time with the use of multiple regression; we adjusted for operation type and preoperative risk factors.

RESULTS

The procedure mix was 3% esophagectomy, 5% gastrectomy, 16% pancreatectomy, 4% hepatectomy, 63% colectomy, and 9% proctectomy. Median age was 66 years, and 52% were male, 41% were American Society of Anesthesiologists class 2, and 52% were American Society of Anesthesiologists 3. Depending on anatomic surgical site, 21-45% of patients experienced a postoperative complication and 1.1-4.4% died. The incidence of patients with any complication decreased from 28 to 24% over the period (risk-adjusted odds ratio 0.95 per year, 95% confidence interval 0.94-0.96). In contrast, there was no substantial change in risk-adjusted mortality over the period (odds ratio 1.03, 95% confidence interval 0.99-1.07).

CONCLUSION

There was a decrease in complications over time for ACS NSQIP participants in gastrointestinal surgical oncology, but mortality did not decrease.

Frequency and predictors of complications in neurological surgery: national trends from 2006 to 2011

OBJECT

Surgical complications increase the cost of health care worldwide and directly contribute to patient morbidity and mortality. In an effort to mitigate morbidity and incentivize best practices, stakeholders such as health insurers and the US government are linking reimbursement to patient outcomes. In this study the authors analyzed a national database to determine basic metrics of how comorbidities specifically affect the subspecialty of neurosurgery.

METHODS

Data on 1,777,035 patients for the years 2006-2011 were acquired from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (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, and 95% confidence intervals were determined for the resultant risk ratios. A multivariate model was constructed using significant variables from the univariate analysis (p < 0.05) with binary logistic regression.

RESULTS

Over 38,000 neurosurgical cases were analyzed, with complications occurring in 14.3%. Cranial cases were 2.6 times more likely to have complications than spine cases, and African Americans and Asians/Pacific Islanders were also at higher risk. The most frequent complications were bleeding requiring transfusion (4.5% of patients) and reoperation within 30 days of the initial operation (4.3% of patients), followed by failure to wean from mechanical ventilation postoperatively (2.5%). Significant predictors of complications included preoperative stroke, sepsis, blood transfusion, and chronic steroid use.

CONCLUSIONS

Understanding the landscape of neurosurgical complications will allow better targeting of the most costly and harmful complications of preventive measures. Data from the ACS NSQIP database provide a starting point for developing paradigms of improved care of neurosurgical patients.

Failure to rescue after major gynecologic surgery

OBJECTIVE

There is growing recognition that, in addition to occurrence of perioperative complications, the treatment of patients with complications influences outcome. We examined complications, failure to rescue (death in patients with a complication), and mortality rates for women who underwent abdominal hysterectomy.

STUDY DESIGN

Women who underwent abdominal hysterectomy from 1998-2010 and whose data were recorded in the Nationwide Inpatient Sample were identified. Hospitals were stratified based on risk-adjusted mortality rates into 5 quintiles, and rates of complications and failure to rescue were examined.

RESULTS

A total of 664,229 women who had been treated at 741 hospitals were identified. The overall mortality rate for the cohort was 0.17%. The risk-adjusted, hospital-level mortality rate ranged from 0-1.12%. The complication rate was 6.5% at the hospitals with the lowest mortality rates, 9.9% at the second quintile hospitals, 9.5% at both the third and fourth quintile hospitals, and 7.9% at the hospitals with the highest mortality rates. In contrast to complications, the failure-to-rescue rate increased with each successive risk-adjusted mortality quintile. The failure-to-rescue rate was 0% at the hospitals with the lowest mortality rates and increased with each successive quintile to 1.1%, 2.1%, 2.7%, and 4.4% in the hospitals with the highest mortality rates (P < .0001).

CONCLUSION

For women who underwent abdominal hysterectomy, hospital complication rates correlated poorly with mortality rates; failure-to-rescue is strongly associated with in-hospital mortality rates. The treatment of complications, not the actual development of a complication, is the most important factor to use to predict death after major gynecologic surgery.

Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP

Recently, the government has moved towards public reporting of 30-day readmission rates after elective primary total knee (TKA) and total hip arthroplasty (THA). We identified 11,814 and 8105 patients who underwent primary TKA and THA from the 2011 ACS NSQIP. Overall readmission rates within 30-days of surgery were 4.6% for TKA and 4.2% for THA. Complications associated with readmission were predominantly wound infections, sepsis, thromboembolic, cardiac, and respiratory related. In TKA, multivariate analysis identified age (P=0.002), male gender (P=0.03), cancer history (P=0.008), elevated BUN (P=0.002), a bleeding disorder (P<0.001) and high ASA class (P<0.001) as predictors of readmission. In THA, obesity (P=0.008), steroid use (P=0.037), a bleeding disorder (P=0.002), dependent functional status (P=0.022), and high ASA class (P<0.001) predicted readmission. Understanding characteristics associated with readmission will be essential for equitable patient risk stratification.

Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons

BACKGROUND

Accurately estimating surgical risks is critical for shared decision making and informed consent. The Centers for Medicare and Medicaid Services may soon put forth a measure requiring surgeons to provide patients with patient-specific, empirically derived estimates of postoperative complications. Our objectives were to develop a universal surgical risk estimation tool, to compare performance of the universal vs previous procedure-specific surgical risk calculators, and to allow surgeons to empirically adjust the estimates of risk.

STUDY DESIGN

Using standardized clinical data from 393 ACS NSQIP hospitals, a web-based tool was developed to allow surgeons to easily enter 21 preoperative factors (demographics, comorbidities, procedure). Regression models were developed to predict 8 outcomes based on the preoperative risk factors. The universal model was compared with procedure-specific models. To incorporate surgeon input, a subjective surgeon adjustment score, allowing risk estimates to vary within the estimate's confidence interval, was introduced and tested with 80 surgeons using 10 case scenarios.

RESULTS

Based on 1,414,006 patients encompassing 1,557 unique CPT codes, a universal surgical risk calculator model was developed that had excellent performance for mortality (c-statistic = 0.944; Brier score = 0.011 [where scores approaching 0 are better]), morbidity (c-statistic = 0.816, Brier score = 0.069), and 6 additional complications (c-statistics > 0.8). Predictions were similarly robust for the universal calculator vs procedure-specific calculators (eg, colorectal). Surgeons demonstrated considerable agreement on the case scenario scoring (80% to 100% agreement), suggesting reliable score assignment between surgeons.

CONCLUSIONS

The ACS NSQIP surgical risk calculator is a decision-support tool based on reliable multi-institutional clinical data, which can be used to estimate the risks of most operations. The ACS NSQIP surgical risk calculator will allow clinicians and patients to make decisions using empirically derived, patient-specific postoperative risks.

Determining the elements of procedural quality

Object

The definition and determination of quality health care is an important topic. The purpose of this study was to develop a longitudinal method to define a quality procedure by creating a formal approach to pre- and postoperative outcomes documentation. The authors worked to define quality outcomes by first documenting the patient's condition. Goals were determined together by the surgeon and the patient and then were evaluated to see if those goals were met.

Methods

The population consisted of cancer patients with newly diagnosed metastatic brain disease who were scheduled to undergo stereotactic radiosurgery. Surgeons recorded perioperatively objective information related to preoperative goals, clinical findings, surgical performance and/or error, and whether goals were met. In addition, patients completed pre- and postprocedure questionnaires (Rand 36-Item Short-Form Health Survey 1.0 [SF-36]).

Results

Procedural goals, defined as completing radiosurgery without error or complication and same-day discharge, were met in all patients. The clinically predetermined goal of tumor palliation was met in all but 1 patient at follow-up. The SF-36 scores remained stable except for the general health domain, which was lower (p = 0.006).

Conclusions

Procedural goals can be defined and objectively measured serially. The authors think that quality care can be defined as a process that achieves predefined goals without significant error and maintains or improves health.

Exploring the frontier of electronic health record surveillance: the case of postoperative complications

BACKGROUND

The aim of this study was to build electronic algorithms using a combination of structured data and natural language processing (NLP) of text notes for potential safety surveillance of 9 postoperative complications.

METHODS

Postoperative complications from 6 medical centers in the Southeastern United States were obtained from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) registry. Development and test datasets were constructed using stratification by facility and date of procedure for patients with and without complications. Algorithms were developed from VASQIP outcome definitions using NLP-coded concepts, regular expressions, and structured data. The VASQIP nurse reviewer served as the reference standard for evaluating sensitivity and specificity. The algorithms were designed in the development and evaluated in the test dataset.

RESULTS

Sensitivity and specificity in the test set were 85% and 92% for acute renal failure, 80% and 93% for sepsis, 56% and 94% for deep vein thrombosis, 80% and 97% for pulmonary embolism, 88% and 89% for acute myocardial infarction, 88% and 92% for cardiac arrest, 80% and 90% for pneumonia, 95% and 80% for urinary tract infection, and 77% and 63% for wound infection, respectively. A third of the complications occurred outside of the hospital setting.

CONCLUSIONS

Computer algorithms on data extracted from the electronic health record produced respectable sensitivity and specificity across a large sample of patients seen in 6 different medical centers. This study demonstrates the utility of combining NLP with structured data for mining the information contained within the electronic health record.

Older age increases short-term surgical complications after primary knee arthroplasty

BACKGROUND

Age is a known risk factor for complications after knee arthroplasty; however, age-related risks for a variety of complications of total and partial knee arthroplasties have not been well quantified.

QUESTIONS/PURPOSES

Our study addressed three questions to better understand age-related risk of complications: (1) At what age do different types of complications increase? (2) Is the increase in complications with age resulting from age-related patient comorbidities, sociodemographic characteristics, and surgical conditions? (3) What is the probability of complications at different ages for an average patient?

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2009 was used to analyze complications for 8950 patients. Complications included NSQIP events, and complications described by the 2003 National Institutes of Health (NIH) consensus statement on total knee arthroplasty as well as 30-day mortality, deep vein thrombosis, return to the operating room, extended length of stay, and technical aspects of the surgery itself. Logistic regression analysis was performed.

RESULTS

Mortality was higher for those aged 85 and older. NSQIP complications increased starting at age 70 years and NIH complications at 85 years. Age remained an independent risk factor for multiple complications with controls. The predicted risk for an average patient ranged from 4% (40-64 years old) to 17% (90 years or older) for NSQIP complications and 2.8% to 8.8% for NIH complications.

CONCLUSIONS

Age is an important independent predictor of surgical complications after knee arthroplasties. Surgeons can share these quantified age-specific risks with patients to guide management decisions.

Quality of life, risk assessment, and safety research in liver transplantation: new frontiers in health services and outcomes research

PURPOSE OF REVIEW

In this review, we briefly summarize three fruitful, emerging areas in liver transplantation research, quality of life; risk assessment; and patient safety. Our goal is to highlight recent findings in these areas, with a call for increased integration of social scientists and transplant clinicians to address how best to shape policy and improve outcomes.

RECENT FINDINGS

After liver transplantation, recipients generally experience clinically significant, sustained improvement in their physical, social and emotional well being. However, a sizeable minority of patients do experience excess morbidity that may benefit from ongoing surveillance and/or intervention. There is growing body of research that describes risks associated with liver transplantation, which can be useful aids to better inform decision making by patients, clinicians, payers, and policy makers. In contrast, there has been a relative lack of empirical data on transplant patient safety vulnerabilities, placing the field of surgery in stark contrast to other high-risk industries, wherein such assessments inform continuous process improvement.

SUMMARY

Health services and outcomes research has grown in importance in the liver transplantation literature, but several important questions remain unanswered that merit programmatic, interdisciplinary research.

The cost-effectiveness of neoadjuvant chemoradiation is superior to a surgery-first approach in the treatment of pancreatic head adenocarcinoma

BACKGROUND

In treating pancreatic cancer, there is no clearly defined optimal sequence of chemotherapy, radiation therapy and surgery. Therefore, cost-effectiveness should be considered. The objective of this study was to compare cost and outcomes between a surgery-first approach versus neoadjuvant chemoradiation followed by surgery for resectable pancreatic head cancer.

METHODS

A decision analytic model was constructed to compare the 2 approaches. Data from the National Cancer Database, National Surgical Quality Improvement Program, and literature populated the surgery-first arm. Data from our prospectively maintained institutional pancreatic cancer database populated the neoadjuvant arm. Costs were estimated by Medicare payment (2011 U.S. dollars). Survival was reported in quality-adjusted life-months (QALMs).

RESULTS

The neoadjuvant chemoradiation arm consisted of 164 patients who completed preoperative therapy. Of these, 36 (22 %) did not proceed to surgery; 12 (7 %) underwent laparotomy but had unresectable disease; and 116 (71 %) underwent definitive resection. The surgery-first approach cost $46,830 and yielded survival of 8.7 QALMs; the neoadjuvant chemoradiation approach cost $36,583 and yielded survival of 18.8 QALMs. In the neoadjuvant arm, costs and survival times for patients not undergoing surgery, those with unresectable disease at laparotomy, and those completing surgery were $12,401 and 7.7 QALMs, $20,380 and 7.1 QALMs, and $45,673 and 23.4 QALMs, respectively.

CONCLUSIONS

Neoadjuvant chemoradiation for pancreatic cancer identifies patients with early metastases or poor performance status, who can be spared an ineffective or prohibitively morbid operation, and is associated with improved survival at significantly lower cost than a surgery-first approach. Neoadjuvant chemoradiation followed by surgery is a strategy that provides more cost-effective care than a surgery-first approach.

Key factors associated with postoperative complications in patients undergoing colorectal surgery

BACKGROUND

Surgical outcomes are determined by complex interactions among a variety of factors including patient characteristics, diagnosis, and type of procedure.

OBJECTIVE

The aim of this study was to prioritize the effect and relative importance of the surgeon (in terms of identity of a surgeon and surgeon volume), patient characteristics, and the intraoperative details on complications of colorectal surgery including readmission, reoperation, sepsis, anastomotic leak, small-bowel obstruction, surgical site infection, abscess, need for transfusion, and portal and deep vein thrombosis.

DESIGN

This study uses a novel classification methodology to measure the influence of various risk factors on postoperative complications in a large outcomes database.

METHODS

Using prospectively collected information from the departmental outcomes database from 2010 to 2011, we examined the records of 3552 patients who underwent colorectal surgery. Instead of traditional statistical methods, we used a family of 7000 bootstrap classification models to examine and quantify the impact of various factors on the most common serious surgical complications. For each complication, an ensemble of multivariate classification models was designed to determine the relative importance of potential factors that may influence outcomes of surgery. This is a new technique for analyzing outcomes data that produces more accurate results and a more reliable ranking of study variables in order of their importance in producing complications.

PATIENTS

Patients who underwent colorectal surgery in 2010 and 2011 were included.

SETTINGS

This study was conducted at a tertiary referral department at a major medical center.

MAIN OUTCOME

Postoperative complications were the primary outcomes measured.

RESULTS

Factors sorted themselves into 2 groups: a highly important group (operative time, BMI, age, identity of the surgeon, type of surgery) and a group of low importance (sex, comorbidity, laparoscopy, and emergency). ASA score and diagnosis were of intermediate importance. The outcomes most influenced by variations in the highly important factors included readmission, transfusion, surgical site infection, and abscesses.

LIMITATIONS

This study was limited by the use of data from a single tertiary referral department at a major medical center.

CONCLUSIONS

Body mass index, operative time, and the surgeon who performed the operation are the 3 most important factors influencing readmission rates, rates of transfusions, and surgical site infection. Identification of these contributing factors can help minimize complications.

The effect of do-not-resuscitate status on postoperative mortality in the elderly following emergency surgery

Elderly patients who have preexisting DNR orders experience a high incidence of mortality and major morbidity within 30 days after emergency general surgery. Although not a risk factor for major morbidity, preoperative DNR status does represent an independent risk factor for mortality after emergency general surgery. The most plausible reason for the excess mortality in DNR patients is their decreased willingness to undergo aggressive treatment of major postoperative complications. Whether patient-driven failure-to-pursue-rescue also explains to some extent the high mortality of non-DNR elderly emergency general surgery patients deserves further investigation.

Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program--driven multidisciplinary single-institution experience

BACKGROUND

Surgical site infections (SSI) are a major cause of morbidity in surgical patients and they increase health care costs considerably. Colorectal surgery is consistently associated with high SSI rates. No single intervention has demonstrated efficacy in reducing colorectal SSIs. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a nationally validated system that uses clinically abstracted data on surgical patients and their outcomes to assist participating institutions drive quality improvement.

STUDY DESIGN

A multidisciplinary team was assembled to develop a colorectal SSI-reduction bundle at an academic tertiary care medical center. The ACS NSQIP data were used to identify patterns of SSIs during a 2-year period. Multiple interventions across the entire surgical episode of care were developed and implemented in January 2011. Monthly ACS NSQIP data were used to track progress.

RESULTS

Our ACS NSQIP overall colorectal SSI rate for 2009 and 2010 was 9.8%. One year after implementation of the SSI reduction bundle, we demonstrated a significant decline (p < 0.05) in both overall and superficial SSIs, to 4.0% and 1.5%, respectively. Organ space infections declined to 2.6%, which was not a significant change (p = 0.10). During the entire analysis period (2009 to 2011), there was no change in our colorectal-specific Surgical Care Improvement Program performance.

CONCLUSIONS

Using our ACS NSQIP colorectal SSI outcomes, a multidisciplinary team designed a colorectal SSI reduction bundle that resulted in a substantial and sustained reduction in SSIs. Our study is not able to identify which specific elements contributed to the reduction.

Effect of immediate reconstruction on postmastectomy surgical site infection

INTRODUCTION

Surgical site infections (SSI) are a source of significant postoperative morbidity and cost. Although immediate breast reconstruction after mastectomy has become routine, the data regarding the incidence of SSI in immediate breast reconstruction is highly variable and series dependent.

METHODS

Using the National Surgical Quality Improvement Program database, all female patients undergoing mastectomy, with or without immediate reconstruction, from 2005 to 2009 were identified. Only "clean" procedures were included. The primary outcome was incidence of SSI within 30 days of operation. Stepwise logistic regression analysis was used to identify risk factors associated with SSI.

RESULTS

A total of 48,393 mastectomies were performed during the study period, of which 9315 (19.2%) had immediate breast reconstruction. The incidence of SSI was 3.5% (330/9315) (95% CI [confidence interval]: 3.2%-4%) in patients undergoing mastectomy with reconstruction and 2.5% (966/39,078) (95% CI: 2.3%-2.6%) in patients undergoing mastectomy without reconstruction (P < 0.001). Independent risk factors for SSI include increased preoperative body mass index (BMI), heavy alcohol use, ASA (American Society of Anesthesiologists) score greater than 2, flap failure, and operative time of 6 hours or longer.

CONCLUSIONS

Immediate breast reconstruction is associated with a statistically significant increase in risk of SSI in patients undergoing mastectomy (3.5% vs 2.5%). However, this difference was not considered to be clinically significant. In this large series, increased BMI, alcohol use, ASA class greater than 2, flap failure, and prolonged operative time were associated with increased risk of SSI.

The power of the National Surgical Quality Improvement Program--achieving a zero pneumonia rate in general surgery patients

The National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons provides risk-adjusted surgical outcome measures for participating hospitals that can be used for performance improvement of surgical mortality and morbidity. A surgical clinical nurse reviewer collects 135 clinical variables including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures. A report on mortality and complications is prepared twice a year. This article summarizes briefly the history of NSQIP and how its report on surgical outcomes can be used for performance improvement within a hospital system. In particular, it describes how to drive performance improvement with NSQIP data using the example of postoperative respiratory complications--a major factor of postoperative mortality. In addition, this article explains the benefit of a collaborative of several participating NSQIP hospitals and describes how to develop a "playbook" on the basis of an outcome improvement project.

Preventable errors in organ transplantation: an emerging patient safety issue?

Several widely publicized errors in transplantation including a death due to ABO incompatibility, two HIV transmissions and two hepatitis C virus (HCV) transmissions have raised concerns about medical errors in organ transplantation. The root cause analysis of each of these events revealed preventable failures in the systems and processes of care as the underlying causes. In each event, no standardized system or redundant process was in place to mitigate the failures that led to the error. Additional system and process vulnerabilities such as poor clinician communication, erroneous data transcription and transmission were also identified. Organ transplantation, because it is highly complex, often stresses the systems and processes of care and, therefore, offers a unique opportunity to proactively identify vulnerabilities and potential failures. Initial steps have been taken to understand such issues through the OPTN/UNOS Operations and Safety Committee, the OPTN/UNOS Disease Transmission Advisory Committee (DTAC) and the current A2ALL ancillary Safety Study. However, to effectively improve patient safety in organ transplantation, the development of a process for reporting of preventable errors that affords protection and the support of empiric research is critical. Further, the transplant community needs to embrace the implementation of evidence-based system and process improvements that will mitigate existing safety vulnerabilities.

Laparoscopic lavage for perforated diverticulitis: a population analysis

BACKGROUND

Laparoscopic lavage has shown promising results in nonfeculent perforated diverticulitis. It is an appealing strategy; it avoids the complications associated with resection. However, there has been some reluctance to widespread uptake because of the scarcity of large-scale studies.

OBJECTIVE

This study investigated national trends in management of perforated diverticulitis.

DESIGN

This retrospective population study used an Irish national database to identify patients acutely admitted with diverticulitis, as defined by the International Classification of Diseases. Demographics, procedures, comorbidities, and outcomes were obtained for the years 1995 to 2008.

SETTINGS

The study was conducted in Ireland.

PATIENTS

Patients with International Classification of Diseases codes corresponding to diverticulitis who underwent operative intervention were included.

MAIN OUTCOME MEASURES

The primary outcome was mortality, and secondary outcomes were length of stay and postoperative complications.

RESULTS

Two thousand four hundred fifty-five patients underwent surgery for diverticulitis, of whom 427 underwent laparoscopic lavage. Patients selected for laparoscopic lavage had lower mortality (4.0% vs 10.4%, p < 0.001), complications (14.1% vs 25.0%, p < 0.001), and length of stay (10 days vs 20 days, p < 0.001) than those requiring laparotomy/resection. Patients older than 65 years were more likely to die (OR 4.1, p < 0.001), as were those with connective tissue disease (OR 7.3, p < 0.05) or chronic kidney disease (OR 8.0, p < 0.001).

LIMITATIONS

This retrospective study is limited by the quality of data obtained and is subject to selection bias. Furthermore, the lack of disease stratification means it is not possible to identify the extent of peritonitis; feculent peritonitis has worse outcomes and is not likely to be included in the lavage group.

CONCLUSIONS

The number of patients selected for laparoscopic lavage in perforated diverticulitis is increasing, and the outcomes in this study are comparable to other reports. Those patients in whom laparoscopic lavage alone was suitable had lower mortality and morbidity than those in whom resection was considered necessary.

Identifying risk factors for surgical site infections in mastectomy patients using the National Surgical Quality Improvement Program database

BACKGROUND

The Centers for Disease Control and Prevention reported that surgical site infections (SSIs) create a significant hospital burden. To date, few multi-institutional studies have been performed to evaluate the risk factors for SSIs in mastectomy patients.

METHODS

By using the American College of Surgeons' National Surgical Quality Improvement Program database, all patients undergoing mastectomy from 2005 to 2009 were identified. The outcome was to determine the incidence rate and identify significant independent risk factors of SSIs.

RESULTS

The incidence of SSI was 2.3% (891 of 38,739; 95% confidence interval, 2.2%-2.5%) in patients undergoing mastectomy without reconstruction. Significant (P < .05) risk factors for SSI included a body mass index greater than 25, American Society of Anesthesiology classification of 3 or higher, diabetes mellitus, surgical time of 2 hours or longer (75th percentile), and current smoking status.

CONCLUSIONS

Before this study, there was wide variation in the incidence rate of surgical site infections in this patient population. This was a large-scale study to address these inconsistencies.

The effect and durability of a pregraduation boot cAMP on the confidence of senior medical student entering surgical residencies

OBJECTIVE

Medical school does not specifically prepare students for surgical internship. Preinternship courses are known to increase confidence in multiple key areas. We examined the immediate effect and durability of effect of a surgical pregraduation preparatory course or "boot camp" on provider confidence in technical and medical management skills.

DESIGN

A 5-day boot camp was offered to senior medical students (SMS) entering surgical programs. SMS were anonymously surveyed before, after, and 6 months following the course. The same survey was given 6 months into internship to a control group of surgical interns who graduated from the same medical school but did not participate in boot camp before graduation. Data were compared between the time intervals and across cases and controls using the Wilcoxon rank-sum and signed-rank tests and the Student t test.

SETTING

A joint effort between the University of Pennsylvania School of Medicine, the Department of Surgery at the Hospital of the University of Pennsylvania, and the Penn Medicine Simulation Center in Philadelphia, PA.

PARTICIPANTS

All senior medical students set to graduate from a single institution entering general surgery or surgery subspecialties were offered the course. Twenty-nine students participated in the course.

RESULTS

Post-boot camp confidence scores of SMS were significantly greater in all areas except placement of a peripheral intravenous catheter compared with pre-boot camp scores. Six months into internship, the SMS boot camp group felt more confident than controls in their ability to perform a cricothyroidotomy (median 2.5 vs 1.0, p = 0.04) and to insert a chest tube (median 3.3 vs 1.0, p = 0.05). Otherwise, there was no residual difference in confidence levels between the boot camp group and the controls.

CONCLUSIONS

Boot camps can improve self-confidence in young doctors in many areas of perioperative care before enrolling in surgical residency. The effect is most durable in high risk, infrequently performed technical tasks. Future studies are under design to examine the impact of boot camps on the "July Effect."

Identifying worsening surgical site infection performance: control charts versus risk-adjusted rate outlier status

Control charts are used in industry to monitor performance and are being used increasingly in hospitals as a quality improvement tool. The authors' objective was to determine if control charts using surgical site infection (SSI) rates predict changes in outlier status for risk-adjusted SSI rates using data from a surgical registry, the American College of Surgeons National Surgical Quality Improvement Program. Control charts of monthly SSI rates for 100 hospitals were analyzed for indicators of a performance change in 2009 (vs 2008) using standard rules. Hospitals also were classified as having better, worse, or no change in outlier status for risk-adjusted SSI rates in 2009 (vs 2008). There was moderate agreement between these methods (weighted κ = 0.401). Control charts predicted nonworsening performance well (specificity = 92.9%) and identified changes in SSI performance sooner; however, they failed to identify 31.2% of hospitals with worsened outlier status. This study demonstrates that these quality measurement tools have unique strengths and weaknesses and are complementary uses of the same clinical data source.

Diagnoses influence surgical site infections (SSI) in colorectal surgery: a must consideration for SSI reporting programs?

BACKGROUND

Colorectal surgery is associated with high rates of surgical site infection (SSI). The National Surgery Quality Improvement Program is a validated, risk-adjusted quality-improvement program for surgical patients. Patient stratification and risk adjustment are associated with Current Procedural Terminology codes and primary disease diagnosis is not considered. Our aim was to determine the association between disease diagnosis and SSI rates.

METHODS

Data from all 2009 National Surgery Quality Improvement Program institutions were analyzed. ICD-9 codes were used to differentiate patients into cancer (colon or rectal), ulcerative colitis, regional enteritis, diverticular disease, and others. Diagnosis-specific SSI rates were compared with benign neoplasm, which had the lowest rate (8.9%). Logistic regression was performed adjusting for age, body mass index, American Society of Anesthesiologists classification, wound type, and relative value unit.

RESULTS

There were 24,673 colorectal procedures, with 1,956 superficial incisional (SSSI), 398 deep incisional (DSSI), and 1,096 organ/space (O/SSSI) infections. Odds ratio (OR) and 95% confidence intervals compared with benign neoplasm diagnosis were computed after adjustment for each diagnosis category. In rectal cancer patients, significantly more SSSI (OR = 1.6; 95% CI, 1.3-2.1; p < 0.0001), DSSI (OR = 2.1; 95% CI, 1.3-3.7; p = 0.006), and O/SSSI (OR = 2.2; 95% CI, 1.6-3.0; p < 0.0001) developed. In diverticular patients, more SSSI (OR = 1.6; 95% CI, 1.3-2.0; p < 0.0001), but not DSSI or O/SSSI, developed. In ulcerative colitis patients, more DSSI (OR = 2.4; 95% CI, 1.2-4.9; p = 0.01), O/SSSI (OR = 2.1; 95% CI, 1.4-3.1; p = 0.0004), but fewer SSSIs, developed.

CONCLUSIONS

We found that SSI type is associated with the underlying disease diagnosis. To facilitate colorectal SSI-reduction efforts, the disease process must be considered to design appropriate interventions. In addition, institutional comparisons based on aggregate or stratified SSI rates can be misleading if the colorectal disease mix is not considered.

The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients

OBJECTIVE

To assess the impact of postoperative complications on full in-hospital costs per case.

BACKGROUND

Rising expenses for complex medical procedures combined with constrained resources represent a major challenge. The severity of postoperative complications reflects surgical outcomes. The magnitude of the cost created by negative outcomes is unclear.

PATIENTS AND METHODS

Morbidity of 1200 consecutive patients undergoing major surgery from 2005 to 2008 in a tertiary, high-volume center was assessed by a validated, complication score system. Full in-hospital costs were collected for each patient. Statistical analysis was performed using a multivariate linear regression model adjusted for potential confounders.

RESULTS

This study population included 393 complex liver/bile duct surgeries, 110 major pancreas operations, 389 colon resections, and 308 Roux-en-Y gastric bypasses. The overall 30-day mortality rate was 1.8%, whereas morbidity was 53.8%. Patients with an uneventful course had mean costs per case of US$ 27,946 (SD US$ 15,106). Costs increased dramatically with the severity of postoperative complications and reached the mean costs of US$ 159,345 (SD US$ 151,191) for grade IV complications. This increase in costs, up to 5 times the cost of a similar operation without complications, was observed for all types of investigated procedures, although the magnitude of the increase varied, with the highest costs in patients undergoing pancreas surgery.

CONCLUSION

This study demonstrates the dramatic impact of postoperative complications on full in-hospital costs per case and that complications are the strongest indicator of costs. Furthermore, the study highlights a relevant savings capacity for major surgical procedures, and supports all efforts to lower negative events in the postoperative course.

Quality of care in humanitarian surgery

Humanitarian surgical programs are set up de novo, within days or hours in emergency or disaster settings. In such circumstances, insuring quality of care is extremely challenging. Basic structural inputs such as a safe structure, electricity, clean water, a blood bank, sterilization equipment, a post-anesthesia recovery unit, appropriate medications should be established. Currently, no specific credentials are needed for surgeons to operate in a humanitarian setting; the training of more humanitarian surgeons is desperately needed. Standard perioperative protocols for the humanitarian setting after common procedures such as Cesarean section, burn care, open fractures, and amputations and antibiotic prophylaxis, and post-operative pain management must be developed. Outcome data, especially long-term outcomes, are difficult to collect as patients often do not return for follow-up and may be difficult to trace; standard databases for post-operative infections and mortality rates should be established. Checklists have recently received significant attention as an instrument to support the improvement of surgical quality; knowing which items are most applicable to humanitarian settings remains unknown. In conclusion, the quality of surgical services in humanitarian settings must be regulated. Many other core medical activities of humanitarian organizations such as therapeutic feeding, mass vaccination, and the treatment of infectious diseases, such as tuberculosis and human immunodeficiency virus, are subject to rigorous reporting of quality indicators. There is no reason why surgery should be exempted from quality oversight. The surgical humanitarian community should pull together before the next disaster strikes.

Morbidity and mortality after colorectal procedures: comparison of data from the American College of Surgeons case log system and the ACS NSQIP

BACKGROUND

Improving the quality of surgical care depends upon collection of robust data. The American College of Surgeons Case Log System enables surgeons to self-report patient risk factors and outcomes. In contrast, the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) uses trained data abstractors to record similar data and uses a strict data collection methodology. The objective of this study was to assess bias in data entry for colorectal cases by comparing data in these 2 registries.

STUDY DESIGN

One year of NSQIP (July 1, 2008 to June 30, 2009) and 7 years of Case Log (2003 to 2010) data were examined. Colorectal cases were identified by current procedural terminology code. The frequencies of comparably defined variables were compared, and mortality models were developed using logistic regression. Observed and expected mortality rates were compared.

RESULTS

Rates of most risk factor and outcome variables were significantly higher in NSQIP than those in Case Log. NSQIP had a higher unadjusted mortality rate (4.46% versus 3.69%, p < 0.001); however, the adjusted odds of mortality was significantly higher in Case Log (odds ratio 1.32, p < 0.05). The Case Log model overpredicted mortality in NSQIP by 22%, whereas the NSQIP model underpredicted mortality in Case Log by 12%.

CONCLUSIONS

Significant differences exist between risk factor and outcome data in NSQIP and Case Log for colorectal procedures. These differences demonstrate the need for standardized data collection methods, as is required by NSQIP, including use of standard definitions, adherence to a follow-up period for outcomes, and use of audits. These measures would improve the validity of using a self-reported database to evaluate and benchmark performance.

Bring Out Your Data

Recent healthcare legislation, financial pressures, and regulatory oversight have increased the need to create improved mechanisms for performance measurement, quality management tracking, and outcomes-based research. The Anesthesia Quality Institute (AQI) has established the National Anesthesia Clinical Outcomes Registry (NACOR) to support these requirements for a wide-range of customers including individual anesthesiologists, anesthesia practices, hospitals, and credentialing agencies. Concurrently, the availability of increased digital sources of healthcare data make it possible to capture massive quantities of data in a more efficient and cost-effective manner than ever before. With NACOR, AQI has established a user-friendly, automated process to effectively and efficiently collect a wide-range of anesthesia-related data directly from anesthesia practices. This review will examine the issues guiding the evolution of NACOR as well as some potential pitfalls in its growth and usage.