Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

Evidence Review for the American College of Surgeons Quality Verification Part III: Standardization, Protocols, and Achieving Better Outcomes for Patient Care

BACKGROUND

After decades of experience supporting surgical quality and safety by the American College of Surgeons (ACS), the ACS Quality Verification Program (ACS QVP) was developed to help hospitals improve surgical quality and safety. This review is the final installment of a 3-part review aimed to synthesize evidence supporting the main principles of the ACS QVP.

STUDY DESIGN

Evidence was systematically reviewed for 3 principles: standardized team-based care across 5 phases of surgical care, disease-based management, and external regulatory review. MEDLINE was searched for articles published from inception to January 2019 and 2 reviewers independently screened studies for inclusion in a hierarchical manner, extracted data, and summarized results in a narrative fashion. A total of 5,237 studies across these 3 topics were identified. Studies were included if they evaluated the relationship between the standard of interest and patient-level or organization measures within the last 20 years.

RESULTS

After applying inclusion criteria, a total of 150 studies in systematic reviews and primary studies were included for assessment. Despite institutional variation in standardized clinical pathways, evidence demonstrated improved outcomes such as reduced length of stay, costs, and complications. Evidence for multidisciplinary disease-based care protocols was mixed, though trended toward improving patient outcomes such as reduced length of stay and readmissions. Similarly, the evidence for accreditation and adherence to external process measures was also mixed, though several studies demonstrated the benefit of accreditation programs on patient outcomes.

CONCLUSIONS

The identified literature supports the importance of standardized multidisciplinary and disease-based processes and external regulatory systems to improve quality of care.

Relationship Between Preoperative Nutritional Status and Predicting Short-Term Complications Following Revision Total Hip Arthroplasty

BACKGROUND

The association between malnutrition and complications following primary total joint arthroplasty is well-delineated, however, nutritional status has yet to be explored specifically in revision total hip arthroplasty (THA). Therefore, our objective was to examine if a patient's nutritional status based on body mass index, diabetic status, and serum albumin predicted complications following a revision THA.

METHODS

A retrospective national database review identified 12,249 patients who underwent revision THA from 2006 to 2019. Patients were stratified based on body mass index (<18.5=underweight, 18.5 to 29.9=healthy/overweight, >30=obese), diagnosis of diabetes (no diabetes, insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM)), and preoperative serum albumin (<3.5=malnourished, >3.5=non-malnourished). Multivariate analyses was performed using Chi-squared tests and multiple logistic regressions.

RESULTS

In all groups including underweight (1.8%), healthy/overweight (53.7%), and obese (44.5%), those without diabetes were less likely to be malnourished (p<0.001), while those with IDDM had a higher rate of malnutrition (p<0.001). Underweight patients were significantly more malnourished compared to healthy/overweight or obese patients (p<0.05). Malnourished patients had an increased risk of wound dehiscence/surgical site infections (p<0.001), urinary tract infection (p<0.001), requiring a blood transfusion (p<0.001), sepsis (p<0.001), and septic shock (p<0.001). Malnourished patients also have worse postoperative pulmonary and renal function.

CONCLUSIONS

Patients who are underweight or have IDDM are more likely to be malnourished. The risk of complications within 30 days of surgery following revision THA significantly increases with malnutrition. This study shows the utility of screening underweight and IDDM patients for malnutrition prior to revision THA to minimize complications.