Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality

The association between participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and postoperative outcomes: A comprehensive analysis of 7,474,298 patients

INTRODUCTION

Prior publications about the association between participation in the American College of Surgeons National Surgical Quality Improvement Program and improved postoperative outcomes have reported mixed results. We aimed to perform a comprehensive analysis of preoperative characteristics and unadjusted and risk-adjusted postoperative complication rates over time in the American College of Surgeons National Surgical Quality Improvement Program dataset.

METHODS

We used the American College of Surgeons National Surgical Quality Improvement Program database, 2005 to 2018, to analyze preoperative patient characteristics and unadjusted and risk-adjusted rates of adverse postoperative outcomes by year. Expected events were calculated using multiple logistic regression, with each complication as the dependent variable and the 28 non-laboratory preoperative American College of Surgeons National Surgical Quality Improvement Program variables as the independent variables. Annual observed-to-expected ratios for each outcome were used to risk-adjust outcomes over time.

RESULTS

The analytic cohort included 7,474,298 operations across 9 surgical specialties. Both the preoperative patient risk and the unadjusted rate of postoperative complications decreased over time. While the observed-to-expected ratio for mortality remained around 1, the observed-to-expected ratios for the other outcomes decreased over time from 2005 to 2018, except for the following cardiac complications: overall morbidity 1.11 (95% confidence interval: 1.10-1.13) to 0.97 (0.96-0.98); pulmonary 1.18 (1.15-1.21) to 0.91 (0.89-0.92); infection 1.19 (1.16-1.21) to 1.01 (1.00-1.01); urinary tract infection 1.29 (1.23-1.34) to 0.87 (0.86-0.89); venous thromboembolism 1.10 (1.03-1.16) to 0.92 (0.90-0.94) ; cardiac 0.76 (0.70-0.81) to 1.04 (1.01-1.07); renal 1.14 (1.08-1.21) to 0.96 (0.93-0.99); stroke 1.12 (1.00-1.25) to 0.98 (0.94-1.03); and bleeding 1.35 (1.33-1.36) to 0.80 (0.79-0.81).

CONCLUSION

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program have experienced a decrease in risk-adjusted postoperative surgical complications over time in all areas except for mortality and cardiac complications.

Continuous monitoring of adverse effects improves surgical outcomes

BACKGROUND

There has been significant debate about the advantages and disadvantages of using administrative databases or clinical registry in healthcare improvement programs. The aim of this study was to review the implementation and outcomes of an accountability policy through a registry maintained by professionals of the surgical department.

MATERIALS AND METHODS

All patients admitted to the department between 2003 and 2022 were prospectively included. All adverse events (AEs) occurring during the admission, convalescent care in facilities, or at home for a minimum period of 30 days after discharge were recorded.

RESULTS

Out of 60,125 records, 24,846 AEs were documented in 16,802 cases (27.9%). There was a progressive increase in the number of AEs recorded per admission (1.17 in 2003 vs. 1.93 in 2022) with a 26% decrease in entries with AEs (from 35.0% in 2003 to 25.8% in 2022), a 57.5% decrease in reoperations (from 8.0% to 3.4%, respectively), and an 80% decrease in mortality (from 1.8% to 1.0%, respectively). It is noteworthy that a significant reduction in severe AEs was observed between 2011 and 2022 (56% vs. 15.6%).

CONCLUSION

A prospective registry of AEs created and maintained by health professionals, along with transparent presentation and discussion of the results, leads to sustained improvement in outcomes in a surgical department of a university hospital.

Lack of associations between hospital rating and outcomes in patients with an acute coronary syndrome

BACKGROUND

Public reporting of performance data has become a common tool in evaluation of healthcare providers. The rating may be misleading if the association between the measured variables and the outcome is weak.

METHODS AND RESULTS

Nationwide, register-based, cohort study. All Swedish patients hospitalised with an acute coronary syndrome during the time periods 2006-2010 and 2015-2017 were included in the study. Possible associations between cardiovascular morbidity and mortality for these patients and ranking scores for each hospital in a Swedish healthcare quality register for acute coronary syndromes were analysed. We found no association between the ranking score and mortality, and no or weak associations between the ranking score and readmissions.

CONCLUSIONS

Lack of associations between quality measurements and patient outcomes warrants improvement in ranking scores. Cautious use of the ranking results is necessary in comparisons between healthcare providers.

Postoperative Complications After Sling Operations for Incontinence: Is Race a Factor?

IMPORTANCE

Racial and ethnic disparities exist in urogynecologic surgery; however, literature identifying specific disparities after sling operations for stress incontinence are limited.

OBJECTIVE

The objective of this study was to evaluate racial and ethnic disparities in surgical complications within 30 days of midurethral sling operations.

STUDY DESIGN

This retrospective cohort study identified women who underwent an isolated midurethral sling operation between 2014 and 2021 using the American College of Surgeons National Surgical Quality Improvement Program database. Women were stratified by racial and ethnic category to assess the primary outcome, 30-day surgical complications, and the secondary outcome, comparison of urinary tract infections (UTIs).

RESULTS

There were 20,066 patients included. Mean age and body mass index were 53.9 years and 30.8, respectively. More Black or African American women had diabetes and hypertension, and more American Indian or Alaska Native women used tobacco. The only difference in 30-day complications was stroke/cerebrovascular accident, which occurred in only 1 Asian, Native Hawaiian or other Pacific Islander patient (0.1%, P < 0.0001). The most frequent complication was UTI (3.3%). Black or African American women were significantly less likely to have a diagnosis of UTI than non-Hispanic White (P = 0.04), Hispanic White (P = 0.03), and American Indian or Alaska Native women (P = 0.04).

CONCLUSIONS

Surgical complications within 30 days of sling operations are rare. No clinically significant racial and ethnic differences in serious complications were observed. Urinary tract infection diagnoses were lower among Black or African American women than in non-Hispanic White, Hispanic White, and American Indian or Alaska Native women despite a greater comorbidity burden. No known biologic reason exists to explain lower UTI rates in this population; therefore, this finding may represent a disparity in diagnosis and treatment.

Case Sampling for Evaluating Hospital Postoperative Morbidity in US Surgical Quality Improvement Programs

Importance

US surgical quality improvement (QI) programs use data from a systematic sample of surgical cases, rather than universal review of all cases, to assess and compare risk-adjusted hospital postoperative complication rates. Given decreasing postoperative complication rates over time and the types of cases eligible for abstraction, it is unclear whether case sampling is robust for identifying hospitals with higher than expected complications.

Objective

To compare the assessment of hospital 30-day complication rates derived from sampling strategy used by some US surgical QI programs relative to universal review of all cases.

Design, Setting, and Participants

This US hospital-level analysis took place from January 1, 2016, through September 30, 2020. Data analysis was performed from July 1, 2022, through December 21, 2022. Quarterly, risk-adjusted, 30-day complication observed to expected (O-E) ratios were calculated for each hospital using the sample (n = 502 730) and universal review (n = 1 725 364). Outlier hospitals (ie, those with higher than expected mortality) were identified using an O-E ratio significantly greater than 1.0. Patients 18 years and older who underwent a noncardiac operation at US Department of Veterans Affairs (VA) hospitals with a record in the VA Surgical Quality Improvement Program (systematic sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases) were included.

Main Outcome Measure

Thirty-day complications.

Results

Most patients in both the representative sample and the universal sample were men (90.2% vs 91.2%) and White (74.7% vs 74.5%). Overall, 30-day complication rates were 7.6% and 5.3% for the sample and universal review cohorts, respectively (P < .001). Over 2145 hospital quarters of data, hospitals were identified as an outlier in 15.0% of quarters using the sample and 18.2% with universal review. Average hospital quarterly complication rates were 4.7%, 7.2%, and 7.4% for outliers identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly complication rates were 7.0% at outliers and 4.4% at nonoutliers. Among outlier hospital quarters in the sample, 54.2% were concurrently identified with universal review. For those identified with universal review, 44.6% were concurrently identified using the sample.

Conclusion

In this observational study, case sampling identified less than half of hospitals with excess risk-adjusted postoperative complication rates. Future work is needed to ascertain how to best use currently collected data and whether alternative data collection strategies may be needed to better inform local QI efforts.

Developing an Automated Registry (Autoregistry) of Spine Surgery Using Natural Language Processing and Health System Scale Databases

BACKGROUND AND OBJECTIVES

Clinical registries are critical for modern surgery and underpin outcomes research, device monitoring, and trial development. However, existing approaches to registry construction are labor-intensive, costly, and prone to manual error. Natural language processing techniques combined with electronic health record (EHR) data sets can theoretically automate the construction and maintenance of registries. Our aim was to automate the generation of a spine surgery registry at an academic medical center using regular expression (regex) classifiers developed by neurosurgeons to combine domain expertise with interpretable algorithms.

METHODS

We used a Hadoop data lake consisting of all the information generated by an academic medical center. Using this database and structured query language queries, we retrieved every operative note written in the department of neurosurgery since our transition to EHR. Notes were parsed using regex classifiers and compared with a random subset of 100 manually reviewed notes.

RESULTS

A total of 31 502 operative cases were downloaded and processed using regex classifiers. The codebase required 5 days of development, 3 weeks of validation, and less than 1 hour for the software to generate the autoregistry. Regex classifiers had an average accuracy of 98.86% at identifying both spinal procedures and the relevant vertebral levels, and it correctly identified the entire list of defined surgical procedures in 89% of patients. We were able to identify patients who required additional operations within 30 days to monitor outcomes and quality metrics.

CONCLUSION

This study demonstrates the feasibility of automatically generating a spine registry using the EHR and an interpretable, customizable natural language processing algorithm which may reduce pitfalls associated with manual registry development and facilitate rapid clinical research.

Case Sampling vs Universal Review for Evaluating Hospital Postoperative Mortality in US Surgical Quality Improvement Programs

Importance

Representative surgical case sampling, rather than universal review, is used by US Department of Veterans Affairs (VA) and private-sector national surgical quality improvement (QI) programs to assess program performance and to inform local QI and performance improvement efforts. However, it is unclear whether case sampling is robust for identifying hospitals with safety or quality concerns.

Objective

To evaluate whether the sampling strategy used by several national surgical QI programs provides hospitals with data that are representative of their overall quality and safety, as measured by 30-day mortality.

Design, Setting, and Participants

This comparative effectiveness study was a national, hospital-level analysis of data from adult patients (aged ≥18 years) who underwent noncardiac surgery at a VA hospital between January 1, 2016, and September 30, 2020. Data were obtained from the VA Surgical Quality Improvement Program (representative sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases). Data analysis was performed from July 1 to December 21, 2022.

Main Outcomes and Measures

The primary outcome was postoperative 30-day mortality. Quarterly, risk-adjusted, 30-day mortality observed-to-expected (O-E) ratios were calculated separately for each hospital using the sample and universal review cohorts. Outlier hospitals (ie, those with higher-than-expected mortality) were identified using an O-E ratio significantly greater than 1.0.

Results

In this study of data from 113 US Department of Veterans Affairs hospitals, the sample cohort comprised 502 953 surgical cases and the universal review cohort comprised 1 703 140. The majority of patients in both the representative sample and the universal sample were men (90.2% vs 91.1%) and were White (74.7% vs 74.5%). Overall, 30-day mortality was 0.8% and 0.6% for the sample and universal review cohorts, respectively (P < .001). Over 2145 quarters of data, hospitals were identified as an outlier in 11.7% of quarters with sampling and in 13.2% with universal review. Average hospital quarterly 30-day mortality rates were 0.4%, 0.8%, and 0.9% for outlier hospitals identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly 30-day mortality rates were 1.0% at outlier hospitals and 0.5% at nonoutliers. Among outlier hospital quarters in the sample, 47.4% were concurrently identified with universal review. For those identified with universal review, 42.1% were concurrently identified using the sample.

Conclusions and Relevance

In this national, hospital-level study, sampling strategies employed by national surgical QI programs identified less than half of hospitals with higher-than-expected perioperative mortality. These findings suggest that sampling may not adequately represent overall surgical program performance or provide stakeholders with the data necessary to inform QI efforts.

Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study

BACKGROUND

The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry.

METHODS

In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods.

RESULTS

We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results.

CONCLUSIONS

Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments.

Risk-Adjusted Cumulative Sum for Early Detection of Hospitals With Excess Perioperative Mortality

Importance

National surgical quality improvement programs lack tools for early detection of quality or safety concerns, which risks patient safety because of delayed recognition of poor performance.

Objective

To compare the risk-adjusted cumulative sum (CUSUM) with episodic evaluation for early detection of hospitals with excess perioperative mortality.

Design, Setting, and Participants

National, observational, hospital-level, comparative effectiveness study of 697 566 patients. Identification of hospitals with excess, risk-adjusted, quarterly 30-day mortality using observed to expected ratios (ie, current criterion standard in the Veterans Affairs Surgical Quality Improvement Program) was compared with the risk-adjusted CUSUM. Patients included in the study underwent a noncardiac operation at a Veterans Affairs hospital, had a record in the Veterans Affairs Surgical Quality Improvement Program (January 1, 2011, through December 31, 2016), and were aged 18 years or older.

Main Outcome and Measure

Number of hospitals identified as having excess risk-adjusted 30-day mortality.

Results

The cohort included 697 566 patients treated at 104 hospitals across 24 quarters. The mean (SD) age was 60.9 (13.2) years, 91.4% were male, and 8.6% were female. For each hospital, the median number of quarters detected with observed to expected ratios, at least 1 CUSUM signal, and more than 1 CUSUM signal was 2 quarters (IQR, 1-4 quarters), 8 quarters (IQR, 4-11 quarters), and 3 quarters (IQR, 1-4 quarters), respectively. During 2496 total quarters of data, outlier hospitals were identified 33.3% of the time (830 quarters) with at least 1 CUSUM signal within a quarter, 12.5% (311 quarters) with more than 1 CUSUM signal, and 11.0% (274 quarters) with observed to expected ratios at the end of the quarter. The CUSUM detection occurred a median of 49 days (IQR, 25-63 days) before observed to expected ratio reporting (1 signal, 35 days [IQR, 17-54 days]; 2 signals, 49 days [IQR, 26-61 days]; 3 signals, 58 days [IQR, 44-69 days]; ≥4 signals, 49 days [IQR, 42-69 days]; trend test, P < .001). Of 274 hospital quarters detected with observed to expected ratios, 72.6% (199) were concurrently detected by at least 1 CUSUM signal vs 42.7% (117) by more than 1 CUSUM signal. There was a dose-response relationship between the number of CUSUM signals in a quarter and the median observed to expected ratio (0 signals, 0.63; 1 signal, 1.28; 2 signals, 1.58; 3 signals, 2.08; ≥4 signals, 2.49; trend test, P < .001).

Conclusions

This study found that with CUSUM, hospitals with excess perioperative mortality can be identified well in advance of standard end-of-quarter reporting, which suggests episodic evaluation strategies fail to detect out-of-control processes and place patients at risk. Continuous performance evaluation tools should be adopted in national quality improvement programs to prevent avoidable patient harm.

Association of body mass index with 30-day outcomes following groin hernia repair

PURPOSE

Although groin hernia repairs are relatively safe, efforts to identify factors associated with greater morbidity and resource utilization following these operations are warranted. An emphasis on obesity has limited studies from a comprehensive evaluation of the association between body mass index (BMI) and outcomes following groin hernia repair. Thus, we aimed to ascertain the association between BMI class with 30-day outcomes following these operations.

METHODS

The 2014-2020 National Surgical Quality Improvement Program database was queried to identify adults undergoing non-recurrent groin hernia repair. Patient BMI was used to stratify patients into six groups: underweight, normal, overweight, and obesity classes I-III. Association of BMI with major adverse events (MAE), wound complication, and prolonged length of stay (pLOS) as well as 30-day readmission and reoperation were evaluated using multivariable regressions.

RESULTS

Of the 163,373 adults who underwent groin hernia repair, the majority of patients were considered overweight (44.4%). Underweight patients more commonly underwent emergent operations and femoral hernia repair compared to others. After adjustment of intergoup differences, obesity class III was associated with greater odds of an MAE (AOR 1.50), wound complication (AOR 4.30), pLOS (AOR 1.40), and 30-day readmission (AOR 1.50) and reoperation (AOR 1.75, all p < 0.05). Underweight BMI portended greater odds of pLOS and unplanned readmission.

CONCLUSION

Consideration of BMI in patients requiring groin hernia repair could help inform perioperative expectations. Preoperative optimization and deployment of a minimally invasive approach when feasible may further reduce morbidity in patients at the extremes of the BMI spectrum.

Formative evaluation of the development and implementation of the automated surveillance of postoperative infections tool

BACKGROUND

The gold standard for detecting postoperative complications uses databases like the American College of Surgeons National Surgical Quality Improvement Program, a multi-centered database based on manual chart review. However, their limitations and costs have led many centers to discontinue participation. Novel techniques to detect postoperative complications must be developed and implemented with surgeon involvement, which is paramount to their adoption. We sought to assess surgeons' opinions of a newly developed postoperative complication detection tool, the Automated Surveillance of Postoperative Infections, within the contextual clinical environment.

METHODS

This was a multi-site qualitative formative evaluation of surgeon perceptions of the Automated Surveillance of Postoperative Infections. We conducted semi-structured interviews and focus groups with surgeons and presented the Automated Surveillance of Postoperative Infections concept. Important domains and constructs, as categorized by Consolidated Framework for Implementation Research, were identified to support the successful adoption and implementation of the Automated Surveillance of Postoperative Infections.

RESULTS

Twenty-four surgeons with 10 surgical subspecialties were interviewed. The following 4 main themes were found: (1) perception of the Automated Surveillance of Postoperative Infections tool-to provide important data that can improve and support clinical outcomes; (2) environment for implementation-description of factors to support or impede implementation; (3) adaptability of the Automated Surveillance of Postoperative Infections-to work with the complexity of surgical cases; and (4) the Automated Surveillance of Postoperative Infections report format and details.

CONCLUSIONS

We successfully captured the perspectives and suggestions of surgeons to improve the Automated Surveillance of Postoperative Infections and potential barriers during the initial development phase. Barriers included fear of punitive action from reports and complex surgical cases. Facilitators identified were the need to improve clinical outcomes and organizational support. The results of this formative evaluation will be used to further develop Automated Surveillance of Postoperative Infections, starting with a prototype, the Automated Surveillance of Postoperative Infections 1.0.

Annual trends of cystectomy complications: A contemporary analysis of the NSQIP database

INTRODUCTION

Despite significant morbidity, radical cystectomy (RC) is standard of care for muscle invasive bladder cancer, certain high-risk nonmuscle invasive tumors and after failure of intravesical or trimodal therapy. Modern efforts have hastened the recovery after this surgery without impact on overall complication rates. Our primary aim was to examine changes in complication rates of RC over time.

METHODS

The National Surgical Quality Improvement Program database included 11,351 RC from 2006 to 2018 for nondisseminated bladder cancer. Baseline characteristics and complication rates were studied across time periods: 2006 to 2011, 2012 to 2014, and 2015 to 2018. Thirty-day complications, readmissions, and mortality were identified.

RESULTS

Overall complication rates decreased over time (56.5%, 57.4%, 50.6%, P < 0.01). Infectious complications were stable, including UTIs (10.1%, 8.8%, 8.3% respectively, P = 0.11) and sepsis (10.4%, 8.8%, 8.7% respectively, P = 0.20). On multivariable analysis, ASA≥3 (OR 1.399, 95% CI 1.279-1.530) was associated with increased complications, while procedures in 2015 to 2018 (OR 0.825, 95% CI 0.722-0.942), laparoscopic/robotic approach (OR 0.555, 95%CI 0.494-0.622), and ileal conduit (OR 0.796, 95% CI 0.719-0.882) were associated with decreased complication rates. Other outcomes of interest included mean length of stay (LOS), which decreased over time (10.5, 9.8, 8.6 days, respectively, P < 0.01) and readmission (20.0%, 21.3%, 21.0%, respectively, P = 0.84) and mortality rates were stable (2.7%, 1.7%, 2.0%, respectively, P = 0.13).

CONCLUSION

Decreased early complications and LOS after RC over time may reflect beneficial effects of recent advances in bladder cancer treatment such as enhanced recovery after surgery protocols and minimally invasive techniques. Further opportunities to improve long term outcomes, readmissions and infection rates are needed.

Building infrastructure to teach quality improvement

With growing emphasis on healthcare quality improvement (QI) at both national and local levels, there has been increased demand for instructional programs to teach quality improvement as a discipline. Design of QI teaching programs must take into account local resources as well as the background and competing commitments of the learner.  In this article, we review elements of successful quality improvement training programs including structure of didactic and experiential curricula. Special considerations for training programs at the undergraduate and graduate medical, hospital, and national/professional society level are presented.

Children's surgery verification and value-based care in pediatric surgery

With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have provided easy correlation to adult disease entities with large populations sharing common pathways and providers in the diagnosis and care of these patients. In pediatric surgery, with smaller populations and larger numbers of rare or unique conditions and anatomic challenges, utilizing the concept of an IPU is more challenging. The literature has generally shown the improvements in quality of care through participation in various programs through the American College of Surgeons (ACS) such as trauma verification, or the National Surgical Quality Improvement Project (NSQIP), but that participation alone does not guarantee better outcomes. Use of these programs in conjunction with participation in quality collaboratives have tended to show favorable returns on investment for these programs. We seek to demonstrate how the Children's Surgery Verification (CSV) program provides pediatric surgeons an effective vehicle with which to engage the value agenda, evaluating and improving care over the care continuum in order to improve the function of children's hospitals as larger integrated units.

A Narrative Review of Multiinstitutional Data Registries of Pediatric Congenital Heart Disease in Pediatric Cardiac Anesthesia and Critical Care Medicine

Congenital heart disease (CHD) is one of the most common birth anomalies. While the care of children with CHD has improved over recent decades, children with CHD who undergo general anesthesia remain at increased risk for morbidity and mortality. Electronic health record systems have enabled institutions to combine data on the management and outcomes of children with CHD in multicenter registries. The application of descriptive analytics methods to these data can improve clinicians' understanding and care of children with CHD. This narrative review covers efforts to leverage multicenter data registries relevant to pediatric cardiac anesthesia and critical care to improve the care of children with CHD.

Development of the Illinois Surgical Quality Improvement Collaborative (ISQIC): Implementing 21 Components to Catalyze Statewide Improvement in Surgical Care

INTRODUCTION

In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research.

METHODS

ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement).

RESULTS

Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois.

DISCUSSION

The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.

Extracorporeal Membrane Oxygenation in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To systematically review and assimilate literature on children receiving extracorporeal membrane oxygenation (ECMO) support in pediatric acute respiratory distress syndrome (PARDS) with the goal of developing an update to the Pediatric Acute Lung Injury Consensus Conference recommendations and statements about clinical practice and research.

DATA SOURCES

Electronic searches of MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

The search used a medical subject heading terms and text words to capture studies of ECMO in PARDS or acute respiratory failure. Studies using animal models and case reports were excluded from our review.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. There were 18 studies identified for full-text extraction. When pediatric data was lacking, adult and neonatal data from randomized clinical trials and observational studies were considered. Six clinical recommendations were generated related to ECMO indications, initiation, and management in PARDS. There were three good practice statements generated related to ECMO indications, initiation, and follow-up in PARDS. Two policy statements were generated involving the impact of ECMO team organization and training in PARDS. Last, there was one research statement.

CONCLUSIONS

Based on a systematic literature review, we propose clinical management, good practice and policy statements within the domains of ECMO indications, initiation, team organization, team training, management, and follow-up as they relate to PARDS.

Development and validation of the modified index of fragility in head and neck cancer surgery

BACKGROUND

This study aims to develop and validate, a clinically useful modified index of fragility (mIFG) to identify patients at risk of fragility and to predict postoperative adverse events.

METHOD

An observational study was performed using the American College of Surgeons National Surgical Quality Improvement Program database, from 2006 to 2018. All patients undergoing nonemergency head and neck cancer surgery were included. A seven-item index (mIFG) was developed using variables associated with frailty, cachexia, and sarcopenia, drawn from the literature (weight loss, low body mass index, dyspnea, diabetes, serum albumin, hematocrit, and creatinine). Multivariable logistic regression was used to model the association between mIFG, postoperative adverse events and death. A validation cohort was then used to ascertain the diagnostic accuracy of the mIFG.

RESULTS

A total of 23,438 cases were included (16,407 in the derivation group and 7031 in the validation group). There was a total of 4273 postoperative major adverse events (AE) and deaths, 1023 postoperative pulmonary complications and 1721 wound complications. Using the derivation cohort, the 7-item mIFG was independently associated with death, major AEs, pulmonary and wound complications, when controlling for significant covariates. The mIFG predicted death and major adverse events using the validation cohort with an accuracy of 0.70 (95% CI: 0.63-0.76) and 0.64 (95% CI: 0.63-0.66), respectively. The mIFG outperformed the modified Frailty index.

CONCLUSION

The modified index of fragility is a reliable and easily accessible tool to predict risk of postoperative adverse events and death in patients undergoing head and neck cancer surgery.

A machine learning approach to high-risk cardiac surgery risk scoring

INTRODUCTION

In patients undergoing high-risk cardiac surgery, the uncertainty of outcome may complicate the decision process to intervene. To augment decision-making, a machine learning approach was used to determine weighted personalized factors contributing to mortality.

METHODS

American College of Surgeons National Surgical Quality Improvement Program was queried for cardiac surgery patients with predicted mortality ≥10% between 2012 and 2019. Multiple machine learning models were investigated, with significant predictors ultimately used in gradient boosting machine (GBM) modeling. GBM-trained data were then used for local interpretable model-agnostic explanations (LIME) modeling to provide individual patient-specific mortality prediction.

RESULTS

A total of 194 patient deaths among 1291 high-risk cardiac surgeries were included. GBM performance was superior to other model approaches. The top five factors contributing to mortality in LIME modeling were preoperative dialysis, emergent cases, Hispanic ethnicity, steroid use, and ventilator dependence. LIME results individualized patient factors with model probability and explanation of fit.

CONCLUSIONS

The application of machine learning techniques provides individualized predicted mortality and identifies contributing factors in high-risk cardiac surgery. Employment of this modeling to the Society of Thoracic Surgeons database may provide individualized risk factors contributing to mortality.

Change in outcomes for trauma patients over time: Two decades of a state trauma system

BACKGROUND

Trauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system.

METHODS

We identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999-2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock.

RESULTS

Of 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29-70), median injury severity score was 16 (IQR 10-24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007-2009 and 2011-2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS < 25, but not for the most severely injured.

CONCLUSIONS

Over 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.

A scoping review of local quality improvement using data from UK perioperative National Clinical Audits

Background

Significant resources are invested in the UK to collect data for National Clinical Audits (NCAs), but it is unclear whether and how they facilitate local quality improvement (QI). The perioperative setting is a unique context for QI due to its multidisciplinary nature and history of measurement. It is unclear which NCAs evaluate perioperative care, to what extent their data have been used for QI, and which factors influence this usage.

Methods

NCAs were identified from the directories held by Healthcare Quality Improvement Partnership (HQIP), Scottish Healthcare Audits and the Welsh National Clinical Audit and Outcome Review Advisory Committee. QI reports were identified by the following: systematically searching MEDLINE, CINAHL Plus, Web of Science, Embase, Google Scholar and HMIC up to December 2019, hand-searching grey literature and consulting relevant stakeholders. We charted features describing both the NCAs and the QI reports and summarised quantitative data using descriptive statistics and qualitative themes using framework analysis.

Results

We identified 36 perioperative NCAs in the UK and 209 reports of local QI which used data from 19 (73%) of these NCAs. Six (17%) NCAs contributed 185 (89%) of these reports. Only one NCA had a registry of local QI projects. The QI reports were mostly brief, unstructured, often published by NCAs themselves and likely subject to significant reporting bias. Factors reported to influence local QI included the following: perceived data validity, measurement of clinical processes as well as outcomes, timely feedback, financial incentives, sharing of best practice, local improvement capabilities and time constraints of clinicians.

Conclusions

There is limited public reporting of UK perioperative NCA data for local QI, despite evidence of improvement of most NCA metrics at the national level. It is therefore unclear how these improvements are being made, and it is likely that opportunities are being missed to share learning between local sites. We make recommendations for how NCAs could better support the conduct, evaluation and reporting of local QI and suggest topics which future research should investigate.

Trial registration

The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018092993).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00273-0.

The Perioperative Quality Improvement Programme (PQIP patient study): protocol for a UK multicentre, prospective cohort study to measure quality of care and outcomes after major surgery

Introduction

Major surgery accounts for a substantial proportion of health service activity, due not only to the primary procedure, but the longer-term health implications of poor short-term outcome. Data from small studies or from outside the UK indicate that rates of complications and failure to rescue vary between hospitals, as does compliance with best practice processes. Within the UK, there is currently no system for monitoring postoperative complications (other than short-term mortality) in major non-cardiac surgery. Further, there is variation between national audit programmes, in the emphasis placed on quality assurance versus quality improvement, and therefore the principles of measurement and reporting which are used to design such programmes.

Methods and analysis

The PQIP patient study is a multi-centre prospective cohort study which recruits patients undergoing major surgery. Patient provide informed consent and contribute baseline and outcome data from their perspective using a suite of patient-reported outcome tools. Research and clinical staff complete data on patient risk factors and outcomes in-hospital, including two measures of complications. Longer-term outcome data are collected through patient feedback and linkage to national administrative datasets (mortality and readmissions). As well as providing a uniquely granular dataset for research, PQIP provides feedback to participating sites on their compliance with evidence-based processes and their patients’ outcomes, with the aim of supporting local quality improvement.

Ethics and dissemination

Ethical approval has been granted by the Health Research Authority in the UK. Dissemination of interim findings (non-inferential) will form a part of the improvement methodology and will be provided to participating centres at regular intervals, including near-real time feedback of key process measures. Inferential analyses will be published in the peer-reviewed literature, supported by a comprehensive multi-modal communications strategy including to patients, policy makers and academic audiences as well as clinicians.

Value in acute care surgery, part 2: Defining and measuring quality outcomes

ABSTRACT

The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.

Machine Learning Refinement of the NSQIP Risk Calculator: Who Survives the "Hail Mary" Case?

BACKGROUND

The American College of Surgeons (ACS) NSQIP risk calculator helps guide operative decision making. In patients with significant surgical risk, it may be unclear whether to proceed with "Hail Mary"-type interventions. To refine predictions, a local interpretable model-agnostic explanations machine (LIME) learning algorithm was explored to determine weighted patient-specific factors' contribution to mortality.

STUDY DESIGN

The ACS-NSQIP database was queried for all surgical patients with mortality probability greater than 50% between 2012 and 2019. Preoperative factors (n = 38) were evaluated using stepwise logistic regression; 26 significant factors were used in gradient boosted machine (GBM) modeling. Data were divided into training and testing sets, and model performance was substantiated with 10-fold cross validation. LIME provided individual subject mortality. The GBM-trained model was interpolated to LIME, and predictions were made using the test dataset.

RESULTS

There were 6,483 deaths (53%) among 12,248 admissions. GBM modeling displayed good performance (area under the curve = 0.65, 95% CI 0.636-0.671). The top 5 factors (% contribution) to mortality included: septic shock (27%), elevated International Normalized Ratio (22%), ventilator-dependence (14%), thrombocytopenia (14%), and elevated serum creatinine (5%). LIME modeling subset personalized patients by factors and weights on survival. In the entire cohort, mortality positive predictive value with 2 factor combinations was 53.5% (specificity 0.713), 3 combinations 64.2% (specificity 0.835), 4 combinations 72.1% (specificity 0.943), and all 5 combinations 77.9% (specificity 0.993). Conversely, mortality positive predictive value fell to 34% in the absence of 4 factors.

CONCLUSIONS

Through the application of machine learning algorithms (GBM and LIME), our model individualized predicted mortality and contributing factors with substantial ACS-NSQIP predicted mortality. USE of machine learning techniques may better inform operative decisions and family conversations in cases of significant surgical risk.

Evaluation of International Contemporary Operative Outcomes and Management Trends Associated With Esophagectomy: A 4-Year Study of >6000 Patients Using ECCG Definitions and the Online Esodata Database

OBJECTIVE

This study aims to verify the utility of international online datasets to benchmark and monitor treatment and outcomes in major oncologic procedures.

BACKGROUND

The Esophageal Complication Consensus Group (ECCG) has standardized the reporting of complications after esophagectomy within the web-based Esodata.org database. This study will utilize the Esodata dataset to update contemporary outcomes and to monitor trends in practice in an era of rapid technical change.

METHODS

This observational study, based on a prospectively developed specific database, updates esophagectomy outcomes collected between 2015 and 2018. Evolution in patient and operative demographics, treatment, complications, and quality outcome measures were compared between patients undergoing surgery in 2015 to 2016 and 2017 to 2018.

RESULTS

Between 2015 and 2018, 6022 esophagectomies from 39 centers were entered into Esodata. Most patients were male (78.3%) with median age 63. Patients having minimally invasive esophagectomy constituted 3177 (52.8%), a chest anastomosis 3838 (63.7%), neoadjuvant chemoradiotherapy 2834 (48.7%), and R0 resections 5441 (93.5%). For quality measures, 30- and 90-day mortality was 2.0% and 4.5%, readmissions 9.7%, transfusions 12%, escalation in care 22.1%, and discharge home 89.4%. Trends in quality measures between 2015 and 2016 (2407 patients) and 2017 and 2018 (3318 patients) demonstrated significant (P < 0.05) improvements in readmissions 11.1% to 8.5%, blood transfusions 14.3% to 10.2%, and escalation in care from 24.5% to 20% A significantly (P < 0.05) reduced incidence in pneumonia (15.3%-12.8%) and renal failure (1.0%-0.4%) was observed. Anastomotic leak rates increased from 11.7% to 13.1%, whereas leaks requiring surgery decreased 3.3% and 3.0%, respectively.

CONCLUSIONS

The Esodata database provides a valuable resource for assessing contemporary international outcomes. This study highlights an increased application of minimally invasive approaches, a high percentage of complications, improvements in pneumonia and key quality metrics, but with anastomotic leak rates still >10%.

Surgical coaching in obstetrics and gynecology: an evidence-based strategy to elevate surgical education and promote lifelong learning

The American Board of Medical Specialties, of which the American Board of Obstetrics and Gynecology is a member, released recommendations in 2019 reimagining specialty certification and highlighting the importance of individualized feedback and data-driven advances in clinical practice throughout the physicians' careers. In this article, we presented surgical coaching as an evidence-based strategy for achieving lifelong learning and practice improvement that can help to fulfill the vision of the American Board of Medical Specialties. Surgical coaching involves the development of a partnership between 2 surgeons in which 1 surgeon (the coach) guides the other (the participant) in identifying goals, providing feedback, and facilitating action planning. Previous literature has demonstrated that surgical coaching is viewed as valuable by both coaches and participants. In particular, video-based coaching involves reviewing recorded surgical cases and can be integrated into the physicians' busy schedules as a means of acquiring and advancing both technical and nontechnical skills. Establishing surgical coaching as an option for continuous learning and improvement in practice has the potential to elevate surgical performance and patient care.

Surgical complications after living and deceased donor liver transplant: The NSQIP transplant experience

This study used the prospective National Surgical Quality Improvement Program (NSQIP) Transplant pilot database to analyze surgical complications after liver transplantation (LT) in LT recipients from 2017-2019. The primary outcome was surgical complication requiring intervention (Clavien-Dindo grade II or greater) within 90 days of transplant. Of the 1684 deceased donor and 109 living donor LT cases included from 29 centers, 38% of deceased donor liver recipients and 47% of living donor liver recipients experienced a complication. The most common complications included biliary complications (19% DDLT; 31% LDLT), hemorrhage requiring reoperation (14% DDLT; 9% LDLT) and vascular complications (6% DDLT; 9% LDLT). Management of biliary leaks (35.3% ERCP, 38.0% percutaneous drainage, 26.3% reoperation) and vascular complications (36.2% angioplasty/stenting, 31.2% medication, 29.8% reoperation) was variable. Biliary (aHR 5.14, 95% CI 2.69-9.8, p<0.001), hemorrhage (aHR 2.54, 95% CI 1.13-5.7, p = 0.024) and vascular (aHR 2.88, 95% CI 0.85-9.7, p = 0.089) complication status at 30-days post-transplant were associated with lower 1-year patient survival. We conclude that biliary, hemorrhagic and vascular complications continue to be significant sources of morbidity and mortality for LT recipients. Understanding the different risk factors for complications between deceased and living donor liver recipients and standardizing complication management represent avenues for continued improvement. This article is protected by copyright. All rights reserved.

A statewide quality improvement collaborative significantly improves quality metric adherence and physician engagement in vascular surgery

BACKGROUND

Quality improvement national registries provide structured, clinically relevant outcome and process-of-care data to practitioners-with regional meetings to disseminate best practices. However, whether a quality improvement collaborative affects processes of care is less clear. We examined the effects of a statewide hospital collaborative on the adherence rates to best practice guidelines in vascular surgery.

METHODS

A large statewide retrospective quality improvement database was reviewed for 2013 to 2019. Hospitals participating in the quality improvement collaborative were required to submit adherence and outcomes data and meet semiannually. They received an incentive through a pay for participation model. The aggregate adherence rates among all hospitals were calculated and compared.

RESULTS

A total of 39 hospitals participated in the collaborative, with attendance of surgeon champions at face-to-face meetings of >85%. Statewide, the hospital systems improved every year of participation in the collaborative across most "best practice" domains, including adherence to preoperative skin preparation recommendations (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.76-1.79; P < .001), intraoperative antibiotic redosing (OR, 1.09; 95% CI, 1.02-1.17; P = .018), statin use at discharge for appropriate patients (OR, 1.18; 95% CI, 1.16-1.2; P < .001), and reducing transfusions for asymptomatic patients with hemoglobin >8 mg/dL (OR, 0.66; 95% CI, 0.66-0.66; P < .001). The use of antiplatelet therapy at discharge remained high and did not change significantly during the study period. Teaching hospital and urban or rural status did not affect adherence. The adherence rates exceeded the professional society mean rates for guideline adherence.

CONCLUSIONS

The use of a statewide hospital collaborative with incentivized semiannual meetings resulted in significant improvements in adherence to "best practice" guidelines across a large, heterogeneous group of hospitals.

Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics

OBJECTIVE

Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics.

METHODS

A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year.

RESULTS

One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period.

CONCLUSIONS

Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.

Does speed matter? A look at NSQIP-P outcomes based on operative time

BACKGROUND

Appendicitis is a common pediatric surgical condition, comprising a large burden of healthcare costs. We aimed to determine if prolonged operative times were associated with increased 30-day complication rates when adjusting for pre-operative risk factors.

METHODS

Patients <18 years old, diagnosed intraoperatively with acute uncomplicated appendicitis and undergoing laparoscopic appendectomy were identified from the NSQIP-P 2012-2018 databases. The primary outcome, "infectious post-operative complications", is a composite of sepsis, deep incisional surgical site infections, wound disruptions, superficial, and organ space infections within 30-days of the operation. Secondary outcomes included return to the operating room and unplanned readmissions within 30 days. Logistic regression models were used to assess associations between operative time and each outcome. A Receiver Operating Characteristic (ROC) curve was generated from the predicted probabilities of the multivariate model for infectious post-operative complications to examine operative times.

RESULTS

Between 2012 and 2018, 27,763 pediatric patients with acute uncomplicated appendicitis underwent a laparoscopic appendectomy. Over half the population was male (61%) with a median operative time of 39 min (IQR 29-52 min). Infectious post-operative complication rate was 2.8% overall and was highest (8%) among patients with operative time ≥ 90 min (Fig. 1). Unplanned readmission occurred in 2.9% of patients, with 0.7% returning to the operating room. Each 30-min increase in operating time was associated with a 24% increase in odds of an infectious post-operative complication (OR=1.24, 95% CI=1.17-1.31) in adjusted models. Operative time thresholds predicted with ROC analysis were most meaningful in younger patients with higher ASA class and pre-operative SIRS/Sepsis/Septic shock. Longer operative times were also associated with higher odds of unplanned readmission (OR=1.11, 95% CI=1.05-1.18) and return to the operating room (OR=1.13, 95% CI=1.02-1.24) in adjusted models.

CONCLUSION

There is a risk-adjusted association between prolonged operative time and the occurrence of infectious post-operative complications. Infectious postoperative complications increase healthcare spending and are currently an area of focus in healthcare value models. Future studies should focus on addressing laparoscopic appendectomy operative times longer than 60 min, with steps such as continuation of antibiotics, shifting roles between attending and resident surgeons, and simulation training.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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

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

Identifying the Optimal case-volume threshold for pancreatectomy in contemporary practice

BACKGROUND

The volume-mortality association led to regionalization recommendations for pancreatic surgery. Mortality following pancreatectomy has declined, but case-volume thresholds remain unchanged.

METHODS

Patients undergoing pancreatectomy from 2004 to 2013 were identified in the National Cancer Database (NCDB). Hospitals were divided into low (LV), medium (MV), and high-volume (HV) strata using 30-day mortality quartiles and logistic regression with cubic splines. Adjusted absolute difference and odds of 30-day mortality between strata were calculated.

RESULTS

Annual volumes for LV, MV, and HV were <4, 4-18 and > 18 cases using quartiles and <6, 6-18 and > 18 using cubic splines. Absolute 30-day mortality trended downwards, with differential improvements for MV and LV. Benchmark 30-day mortality for hospitals with >18 cases was 2.8%. For this benchmark, the case-volume threshold decreased from 31 in 2004 to 6 in 2013.

CONCLUSION

Differential improvement in 30-day mortality at LV and MV hospitals led to similar 30-day mortality odds at MV and HV hospitals by 2013.

Made to Measure: The Ethics of Routine Measurement for Healthcare Improvement

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited-it often produces only modest effects or fails to generate anticipated improvements at all. We seek to show that these concerns do not exhaust the ethics of routine measurement. Even if routine measurement does lead to healthcare improvements, it has associated ethical costs which are not necessarily justified by its benefits. We argue that the practice of routine measurement changes the function of the healthcare system, resulting in an unintended and ethically significant transformation of the sector. It is difficult to determine whether such changes are justified or offset by the benefits of routine measurement because there may be no shared understanding of what is 'good' in healthcare by which to compare the benefits of routine measurement with the goods that are precluded by it. We counsel that the practice of routine measurement should proceed with caution and should be recognised to be an ethically significant choice, rather than an inevitability.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Facilitated Regional Collaboration and In-Hospital Surgical Complication

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Impact of medicaid expansion on disparities in revascularization in patients hospitalized with acute myocardial infarction

INTRODUCTION

Blacks are more likely to live in poverty and be uninsured, and are less likely to undergo revascularization after am acute myocardial infarction compared to whites. The objective of this study was to determine whether Medicaid expansion was associated with a reduction in revascularization disparities in patients admitted with an acute myocardial infarction.

METHODS

Retrospective analysis study using data (2010-2018) from hospitals participating in the University Health Systems Consortium, now renamed the Vizient Clinical Database. Comparative interrupted time series analysis was used to compare changes in the use of revascularization therapies (PCI and CABG) in white versus non-Hispanic black patients hospitalized with either ST-segment elevation (STEMI) or non-ST-segment elevation acute myocardial infarctions (NSTEMI) after Medicaid expansion.

RESULTS

The analytic cohort included 68,610 STEMI and 127,378 NSTEMI patients. The percentage point decrease in the uninsured rate for STEMIs and NSTEMIs was greater for blacks in expansion states compared to whites in expansion states. For patients with STEMIs, differences in black versus white revascularization rates decreased by 2.09 percentage points per year (95% CI, 0.29-3.88, P = 0.023) in expansion versus non-expansion states after adjusting for patient and hospital characteristics. Black patients hospitalized with STEMI in non-expansion states experienced a 7.24 percentage point increase in revascularization rate in 2014 (95% CI, 2.83-11.7, P < 0.001) but did not experience significant annual percentage point increases in the rate of revascularization in subsequent years (1.52; 95% CI, -0.51-3.55, P = 0.14) compared to whites in non-expansion states. Medicaid expansion was not associated with changes in the revascularization rate for either blacks or whites hospitalized with NSTEMIs.

CONCLUSION

Medicaid expansion was associated with greater reductions in the number of uninsured blacks compared to uninsured whites. Medicaid expansion was not associated, however, with a reduction in revascularization disparities between black and white patients admitted with acute myocardial infarctions.

Effect of monitoring surgical outcomes using control charts to reduce major adverse events in patients: cluster randomised trial

OBJECTIVE

To determine the effect of introducing prospective monitoring of outcomes using control charts and regular feedback on indicators to surgical teams on major adverse events in patients.

DESIGN

National, parallel, cluster randomised trial embedding a difference-in-differences analysis.

SETTING

40 surgical departments of hospitals across France.

PARTICIPANTS

155 362 adults who underwent digestive tract surgery. 20 of the surgical departments were randomised to prospective monitoring of outcomes using control charts with regular feedback on indicators (intervention group) and 20 to usual care only (control group).

INTERVENTIONS

Prospective monitoring of outcomes using control charts, provided in sets quarterly, with regular feedback on indicators (intervention hospitals). To facilitate implementation of the programme, study champion partnerships were established at each site, comprising a surgeon and another member of the surgical team (surgeon, anaesthetist, or nurse), and were trained to conduct team meetings, display posters in operating rooms, maintain a logbook, and devise an improvement plan.

MAIN OUTCOME MEASURES

The primary outcome was a composite of major adverse events (inpatient death, intensive care stay, reoperation, and severe complications) within 30 days after surgery. Changes in surgical outcomes were compared before and after implementation of the programme between intervention and control hospitals, with adjustment for patient mix and clustering.

RESULTS

75 047 patients were analysed in the intervention hospitals (37 579 before and 37 468 after programme implementation) versus 80 315 in the control hospitals (41 548 and 38 767). After introduction of the control chart, the absolute risk of a major adverse event was reduced by 0.9% (95% confidence interval 0.4% to 1.4%) in intervention compared with control hospitals, corresponding to 114 patients (70 to 280) who needed to receive the intervention to prevent one major adverse event. A significant decrease in major adverse events (adjusted ratio of odds ratios 0.89, 95% confidence interval 0.83 to 0.96), patient death (0.84, 0.71 to 0.99), and intensive care stay (0.85, 0.76 to 0.94) was found in intervention compared with control hospitals. The same trend was observed for reoperation (0.91, 0.82 to 1.00), whereas severe complications remained unchanged (0.96, 0.87 to 1.07). Among the intervention hospitals, the effect size was proportional to the degree of control chart implementation witnessed. Highly compliant hospitals experienced a more important reduction in major adverse events (0.84, 0.77 to 0.92), patient death (0.78, 0.63 to 0.97), intensive care stay (0.76, 0.67 to 0.87), and reoperation (0.84, 0.74 to 0.96).

CONCLUSIONS

The implementation of control charts with feedback on indicators to surgical teams was associated with concomitant reductions in major adverse events in patients. Understanding variations in surgical outcomes and how to provide safe surgery is imperative for improvements.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02569450.

The Institute for Healthcare Improvement-NeuroPoint Alliance collaboration to decrease length of stay and readmission after lumbar spine fusion: using national registries to design quality improvement protocols

OBJECTIVE

National databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.

METHODS

The NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.

RESULTS

The novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0-10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).

CONCLUSIONS

The NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.

The value of the "Surgical Risk Preoperative Assessment System" (SURPAS) in preoperative consultation for elective surgery: a pilot study

Background

Risk assessment is essential to informed decision making in surgery. Preoperative use of the Surgical Risk Preoperative Assessment System (SURPAS) providing individualized risk assessment, may enhance informed consent. We assessed patient and provider perceptions of SURPAS as a risk assessment tool.

Methods

A convergent mixed-methods study assessed SURPAS’s trial implementation, concurrently collecting quantitative and qualitative data, separately analyzing it, and integrating the results. Patients and providers were surveyed and interviewed on their opinion of how SURPAS impacted the preoperative encounter. Relationships between patient risk and patient and provider assessment of SURPAS were examined.

Results

A total of 197 patients were provided their SURPAS postoperative risk estimates in nine surgeon’s clinics. Of the total patients, 98.8% reported they understood their surgical risks very or quite well after exposure to SURPAS; 92.7% reported SURPAS was very helpful or helpful. Providers shared that 83.4% of the time they reported SURPAS was very or somewhat helpful; 44.7% of the time the providers reported it changed their interaction with the patient and this change was beneficial 94.3% of the time. As patient risk increased, providers reported that SURPAS was increasingly helpful (p < 0.0001).

Conclusions

Patients and providers reported the use of SURPAS helpful and informative during the preoperative risk assessment of patients, thus improving the surgical decision making process. Patients thought that SURPAS was helpful regardless of their risk level, whereas providers thought that SURPAS was more helpful in higher risk patients.

Failure on a Vascular Surgery Board-American Board of Surgery Examination does not predict cardiovascular outcomes in the Society for Vascular Surgery Vascular Quality Initiative

OBJECTIVE

The Vascular Surgery Board of the American Board of Surgery (VSB-ABS) Qualifying and Certifying examinations are meant to assess qualifications to independently practice vascular surgery, but it is unclear whether examination performance correlates with clinical outcomes. We assessed this relationship using clinical outcomes data for VSB-ABS diplomates from the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI).

METHODS

VSB-ABS examination performance for vascular surgeons participating in the SVS-VQI registry was characterized according to pass/fail status. Surgical experience was measured by number of years since completion of training. Examination performance and experience were compared with a composite clinical outcome (in-patient major adverse cardiac events or postoperative death [MACE+POD]) after arterial reconstructions (carotid stenting or endarterectomy, aortic aneurysm repair, open peripheral surgical bypasses) registered in the SVS-VQI. Multivariate mixed effects regression was performed adjusting for sex and surgery type, as well as clustering by surgeon and by hospital.

RESULTS

From 2003 to 2017, complete data were available for 776 vascular surgeons who performed 124,171 arterial reconstructions (carotid n = 56,650; aortic n = 34,764; peripheral n = 32,757) registered in the SVS-VQI. Patient characteristics associated with higher odds of MACE+POD were female sex (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12; P = .006) and advancing age (OR, 1.04; 95% CI, 1.03-1.04; P < .001). Of the 776 surgeons, 149 (17%) had failed at least one VSB-ABS examination (group F). The unadjusted primary composite outcome of MACE+POD was marginally higher after operations performed by surgeons who never failed an examination (group P; 7% vs 6%; P = .03). This difference seems to be driven by higher rates of postoperative congestive heart failure in the aortic and lower extremity bypass cohorts as well as more postoperative myocardial infarctions after lower extremity bypass by group P surgeons. Following multivariable analyses, examination pass status was not associated with MACE+POD (OR, 0.98; 95% CI, 0.89-1.50; P = .517). However, increasing surgical experience correlated with significantly lower odds of MACE+POD (2% lower odds/year of experience since training [OR, 0.98; 95% CI, 0.98-0.99; P < .001]).

CONCLUSIONS

VSB-ABS examination performance by SVS-VQI surgeons does not correlate with registry-reported mortality or cardiovascular complications. Increasing surgical experience is strongly associated with lower odds of cardiovascular morbidity and death.