Preliminary NSQIP results: A tool for quality improvement

Gender Disparities in Aortoiliac Revascularization in Patients with Aortoiliac Occlusive Disease

BACKGROUND

Gender disparities have been previously reported in aortic aneurysm and critical limb ischemia outcomes; however, limited info is known about disparities in aortoiliac occlusive disease. We sought to characterize potential disparities in this specific population.

MATERIAL AND METHODS

Patients who underwent aortobifemoral bypass and aortic thromboendarterectomy (Current Procedural Terminology codes 35646 and 35331) between 2012 and 2019 were identified in the National Surgical Quality Improvement Program database. A binomial regression model was used to estimate gender differences in 30-day morbidity and mortality. Inverse probability weighting was used to standardize demographic and surgical characteristics.

RESULTS

We identified 1,869 patients, of which 39.8% were female and the median age was 61 years. Age, body composition, and other baseline characteristics were overall similar between genders; however, racial data were missing for 26.1% of patients. Females had a higher prevalence of preexisting chronic obstructive pulmonary disease (20.9% vs. 14.7%, prevalence difference 6.1%, P < 0.01), diabetes mellitus (25.4% vs. 19.4%, prevalence difference 6.0%, P < 0.01), and high-risk anatomical features (39.4% vs. 33.7%, prevalence difference 5.8%, P = 0.01). Preprocedural medications included a statin in only 68.2% of patients and antiplatelet agent in 76.7% of patients. Females also had a higher incidence of bleeding events when compared to males (25.2% vs. 17.5%, standardized risk difference 7.2%, P < 0.01), but were less likely to have a prolonged hospitalization greater than 10 days (18.2% vs. 20.9%, standardized risk difference -5.0%, P = 0.01). The 30-day mortality rate was not significantly different between genders (4.7% vs. 3.6%, standardized risk difference 1.2%, P = 0.25).

CONCLUSIONS

Female patients treated with aortobifemoral bypass or aortic thromboendarterectomy are more likely to have preexisting chronic obstructive pulmonary disease, diabetes mellitus, and high-risk anatomical features. Regardless of a patient's gender, there is poor adherence to preoperative medical optimization with both statins and antiplatelet agents. Female patients are more likely to have postoperative bleeding complications while males are more likely to have a prolonged hospital stay greater than 10 days. Future work could attempt to further delineate disparities using databases with longer follow-up data and seek to create protocols for reducing these observed disparities.

Show Me the Money, I'll Show You My Complications: Impacts of Incentivized Incident Self-Reporting Among Surgeons

INTRODUCTION

Trial and error have the propensity to generate knowledge. Near misses and adverse event reporting can improve patient care. Professional ridicule or litigation risks after an incident may lead to decreased reporting by physicians; however, the lack of incident reporting can negatively affect patient safety and halt scientific advancements. This study compares reporting patterns after distribution of financial incentives to surgeons for self-reporting quality incidents.

METHODS

Retrospective review of an internal incident reporting system, RL6, from September 2018 to September 2019 was performed. Incident reporting patterns after incentive distributions across professional classifications and surgical specialties were evaluated. Engagement surveys on incident reporting were completed by physicians. The primary outcomes were changes in reporting patterns and perceptions after distribution of incentives.

RESULTS

Two hundred and eighteen surgical patients were identified in the incidents reported. Financial incentives significantly increased incidents reported (35 to 183) by physicians (37.1% to 67.8%; P < 0.001) and physician assistants (2.9% to 18.6%; P < 0.001). Acute care surgery displayed the largest increase in incidents reported among surgical specialties (5.7% to 20.2%; P = 0.040). Surgeons exhibited an increase in reporting (60.0% to 94.5%; P < 0.001) compared with witnesses after incentivization (2.9% to 1.6%).

CONCLUSIONS

Financial incentives were associated with increased incident reporting. After the establishment of incentives, physicians were more likely to report their incidents, which may dispel professional embarrassment and display incident ownership. Institutions must encourage reporting while supporting providers. Future quality-improvement studies targeting reporting should incorporate incentives aimed to engage and empower health-care providers.

Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era

OBJECTIVE

To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases.

REVIEW METHODS

Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings.

CONCLUSIONS

Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients.

IMPLICATIONS FOR PRACTICE

SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.

National Surgical Quality Improvement Program risk calculator validity in South Australian laryngectomy patients

BACKGROUND

Assessing an individual patient's post-operative risk profile prior to laryngectomy for cancer is difficult. The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator was developed to better inform preoperative decision-making. The calculator uses patient-specific characteristics to estimate the risk of experiencing post-operative complications within 30 days of surgery. We investigated the ACS-NSQIP risk calculator's performance for Australian laryngectomy patients.

METHODS

The ACS-NSQIP risk calculator was used to retrospectively calculate the 30-day post-operative predicted outcomes in patients who underwent laryngectomy for laryngeal, hypopharyngeal and thyroid cancers (with laryngeal involvement) in two institutions in South Australia. These data were compared against the actual mortality, morbidity, complications and length of stay (LOS) collected from a retrospective chart review.

RESULTS

A total of 144 patients underwent surgical intervention for malignancies with laryngeal involvement. The median LOS was 25 days (range 13-197) compared to the predicted LOS of 6.5 days (range 3.5-12.5). Overall mortality was 2.78% with post-operative complications occurring in 63% of patients. The most common complication was wound infection, occurring in 33% of patients. Hosmer-Lemeshow plots demonstrated good agreement between predicted and observed rates for complications.

CONCLUSION

The ACS-NSQIP risk calculator effectively predicted post-operative complication rates in South Australian laryngeal cancer patients undergoing laryngectomy. However, differences in predicted and actual LOS may limit the usefulness of the calculator's LOS predictions for Australian patients.

Predictors of Hospital-Acquired Conditions Are Predominately Similar for Spine Surgery and Other Common Elective Surgical Procedures, With Some Key Exceptions

STUDY DESIGN

Retrospective review of a prospectively collected database.

OBJECTIVE

To predict the occurrence of hospital-acquired conditions (HACs) 30-days postoperatively and to compare predictors of HACs for spine surgery with other common elective surgeries.

METHODS

Patients ≥18 years undergoing elective spine surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Outcome measures included any HACs: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), urinary tract infection (UTI). Spine surgery patients were compared with those undergoing other common procedures. Random forest followed by multivariable regression analysis was used to determine risk factors for the occurrence of HACs.

RESULTS

A total of 90 551 elective spine surgery patients, of whom 3021 (3.3%) developed at least 1 HAC, 1.4% SSI, 1.3% UTI, and 0.8% VTE. The occurrence of HACs for spine patients was predicted with high accuracy (area under the curve [AUC] 77.7%) with the following variables: female sex, baseline functional status, hypertension, history of transient ischemic attack (TIA), quadriplegia, steroid use, preoperative bleeding disorders, American Society of Anesthesiologists (ASA) class, operating room duration, operative time, and level of residency supervision. Functional status and hypertension were HAC predictors for total knee arthroplasty (TKA), bariatric, and cardiothoracic patients. ASA class and operative time were predictors for most surgery cohorts. History of TIA, preoperative bleeding disorders, and steroid use were less predictive for most other common surgical cohorts.

CONCLUSIONS

Occurrence of HACs after spine surgery can be predicted with demographic, clinical, and surgical factors. Predictors for HACs in surgical spine patients, also common across other surgical groups, include functional status, hypertension, and operative time. Understanding the baseline patient risks for HACs will allow surgeons to become more effective in their patient selection for surgery.

Clinical Impact and Economic Burden of Hospital-Acquired Conditions Following Common Surgical Procedures

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common surgical procedures.

SUMMARY OF BACKGROUND DATA

HACs are part of a non-payment policy by the Centers for Medicare and Medicaid Services and thus prompt hospitals to improve patient outcomes and safety.

METHODS

Patients more than 18 years who underwent elective spine surgery were identified in American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Primary outcomes were cost associated with the occurrence of three most common HACs. Cost associated with HAC occurrence derived from the PearlDiver database.

RESULTS

Ninety thousand five hundred fifty one elective spine surgery patients were identified, where 3021 (3.3%) developed at least one HAC. Surgical site infection (SSI) was the most common HAC (1.4%), then urinary tract infection (UTI) (1.3%) and venous thromboembolism (VTE) (0.8%). Length of stay (LOS) was longer for patients who experienced a HAC (5.1 vs. 3.2 d, P < 0.001). When adjusted for age, sex, and Charlson Comorbidity Index, LOS was 1.48 ± 0.04 days longer (P < 0.001) and payments were $8893 ± $148 greater (P < 0.001) for patients with at least one HAC. With the exception of craniotomy, patients undergoing common procedures with HAC had increased LOS and higher payments (P < 0.001). Adjusted additional LOS was 0.44 ± 0.02 and 0.38 ± 0.03 days for total knee arthroplasty and total hip arthroplasty, and payments were $1974 and $1882 greater. HACs following hip fracture repair were associated with 1.30 ± 0.11 days LOS and $4842 in payments (P < 0.001). Compared with elective spine surgery, only bariatric and cardiothoracic surgery demonstrated greater adjusted additional payments for patients with at least one HAC ($9975 and $10,868, respectively).

CONCLUSION

HACs in elective spine surgery are associated with a substantial cost burden to the health care system. When adjusted for demographic factors and comorbidities, average LOS is 1.48 days longer and episode payments are $8893 greater for patients who experience at least one HAC compared with those who do not.

LEVEL OF EVIDENCE

3.

Publicly Available Databases in Otolaryngology Quality Improvement

The historical context for quality improvement is provided. Important differences are described between the two overarching types of databases: clinical registries and administrative databases. The pros and cons of each are provided as are examples of their utilization in otolaryngology-head and neck surgery.

The Impact of Duty-Hour Restrictions on Complication Rates Following Major Head and Neck Procedures

OBJECTIVES/HYPOTHESIS

To assess the impact of resident duty-hour restrictions (DHR) in otolaryngology via comparison of postoperative outcomes between otolaryngology teaching hospitals (Oto-TH) and nonteaching hospitals (NTH) before and after complete implementation.

STUDY DESIGN

Retrospective database review.

METHODS

The Nationwide Inpatient Sample was queried for all major head and neck cases between 2000 and 2002 (n = 34,064) and 2008 and 2010 (n = 33,094). Cases were stratified into Oto-TH (n = 28,771) and NTH (n = 38,387) and assessed for procedure type, patient comorbidities, and complications. A subpopulation matched by procedure type was generated for direct comparison of complication rates using χ² and binary logistic regression analyses.

RESULTS

In the years following DHR, total case volume and average case complexity increased at Oto-TH only. Using a case-matched subpopulation, regression analysis found Oto-TH status to be protective for medical complications both before (odds ratio [OR]: 0.60, P < .001) and after (OR: 0.76, P = .001) DHR. In contrast, Oto-TH cases had lower risk for surgical complications in 2000 to 2002 (OR: 0.77, P < .001) but not 2008 to 2010 (OR: 1.07, P = .275). When comparing time periods, the years following DHR were associated with a significant decrease in medical complications and mortality across hospital cohorts. For surgical complications, rates significantly improved at NTH only (OR: 0.82, P = .002), with no difference at Oto-TH (OR: 0.95, P = .450).

CONCLUSIONS

In the years following DHR, rates of medical complications, surgical complications, and mortality have significantly improved at NTH. At Oto-TH, there has been a lack of similar improvement in surgical complications, even after accounting for increasing case volume and complexity in more recent years. While the cause is likely multifactorial, DHR in otolaryngology residency may play a role.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2804-2810, 2018.

Predictors of adverse discharge disposition in adult spinal deformity and associated costs

BACKGROUND CONTEXT

With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount.

PURPOSE

Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges.

STUDY DESIGN/SETTING

This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database.

PATIENT SAMPLE

Patients undergoing thoracolumbar surgery for correction of ASD were included in the study.

OUTCOME MEASURES

Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups.

METHODS

Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion.

RESULTS

A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22-0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40-0.64), interbody device placement (OR: 0.80, CI: 0.64-0.98), and fixation to the iliac (OR: 0.54, CI: 0.41-0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21-0.57) and blood transfusions (OR: 0.42, CI: 0.34-0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212).

CONCLUSIONS

Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility.

Validity of the American College of Surgeons' National Surgical Quality Improvement Program risk calculator in South Australian glossectomy patients

Background:

Appropriate selection of tongue cancer patients considering surgery is critical in ensuring optimal outcomes. The American College of Surgeons' National Surgical Quality Improvement Program (‘ACS-NSQIP’) risk calculator was developed to assess patients' 30-day post-operative risk, providing surgeons with information to guide decision making.

Method:

A retrospective review of 30-day actual mortality and morbidity of tongue cancer patients was undertaken to investigate the validity of this tool for South Australian patients treated from 2005 to 2015.

Results:

One hundred and twenty patients had undergone glossectomy. Predicted length of stay using the risk calculator was significantly different from actual length of stay. Predicted mortality and other complications were found to be similar to actual outcomes.

Conclusion:

The American College of Surgeons' National Surgical Quality Improvement Program risk calculator was found to be effective in predicting post-operative complication rates in South Australian tongue cancer patients. However, significant discrepancies in predicted and actual length of stay may limit its use in this population.

NSQIP as a Predictor of Length of Stay in Patients Undergoing Free Flap Reconstruction

OBJECTIVE

The National Surgical Quality Improvement Program (NSQIP) calculator was created to improve outcomes and guide cost-effective care in surgery. Patients with head and neck cancer (HNC) undergo ablative and free flap reconstructive surgery with prolonged postoperative courses.

METHODS

A case series with chart review was performed on 50 consecutive patients with HNC undergoing ablative and reconstructive free flap surgery from October 2014 to March 2016 at a tertiary care center. Comorbidities and intraoperative and postoperative variables were collected. Predicted length of stay was tabulated with the NSQIP calculator.

RESULTS

Thirty-five patients (70%) were male. The mean (SD) age was 67.2 (13.4) years. The mean (SD) length of stay (LOS) was 13.5 (10.3) days. The mean (SD) NSQIP-predicted LOS was 10.3 (2.2) days (P = .027).

DISCUSSION

The NSQIP calculator may be an inadequate predictor for LOS in patients with HNC undergoing free flap surgery. Additional study is necessary to determine the accuracy of this tool in this patient population.

IMPLICATIONS FOR PRACTICE

Head and neck surgeons performing free flap reconstructive surgery following tumor ablation may find that the NSQIP risk calculator underestimates the LOS in this population.

Reducing healthcare costs facilitated by surgical auditing: a systematic review

BACKGROUND

Surgical auditing has been developed in order to benchmark and to facilitate quality improvement. The aim of this review is to determine if auditing combined with systematic feedback of information on process and outcomes of care results in lower costs of surgical care.

METHOD

A systematic search of published literature before 21-08-2013 was conducted in Pubmed, Embase, Web of Science, and Cochrane Library. Articles were selected if they met the inclusion criteria of describing a surgical audit with cost-evaluation.

RESULTS

The systematic search resulted in 3608 papers. Six studies were identified as relevant, all showing a positive effect of surgical auditing on quality of healthcare and therefore cost savings was reported. Cost reductions ranging from $16 to $356 per patient were seen in audits evaluating general or vascular procedures. The highest potential cost reduction was described in a colorectal surgical audit (up to $1,986 per patient).

CONCLUSIONS

All six identified articles in this review describe a reduction in complications and thereby a reduction in costs due to surgical auditing. Surgical auditing may be of greater value when high-risk procedures are evaluated, since prevention of adverse events in these procedures might be of greater clinical and therefore of greater financial impact.

IMPLICATION OF KEY FINDINGS

This systematic review shows that surgical auditing can function as a quality instrument and therefore as a tool to reduce costs. Since evidence is scarce so far, further studies should be performed to investigate if surgical auditing has positive effects to turn the rising healthcare costs around. In the future, incorporating (actual) cost analyses and patient-related outcome measures would increase the audits' value and provide a complete overview of the value of healthcare.

Change in Adverse Events After Enrollment in the National Surgical Quality Improvement Program: A Systematic Review and Meta-Analysis

Background

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery.

Study Design

A systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR) and 95% confidence intervals (CI).

Results

Eleven articles reporting on 35 health care institutions were included. Nine (82%) of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72–0.91), deep (pRR 0.82; 95% CI0.64–1.05) and organ space (pRR 1.15; 95% CI 0.96–1.37) infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39–0.77; deep pRR 0.61, 95% CI 0.50–0.75, and organ space pRR 0.60, 95% CI 0.50–0.71). Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program.

Conclusions

These data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.

Developing a Registry for Complications in Otorhinolaryngologic Surgery: Tonsil Surgery as a Pilot Cohort

OBJECTIVE

To find a suitable method to prospectively register all tonsil surgery-related complications.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

From September 2011 to February 2012, patients undergoing tonsillectomy or tonsillotomy were enrolled. A wide range of demographic and clinical data including incidents of postoperative complications was recorded prospectively, and patient records were reviewed 9 months after the end of study period. We evaluated the coverage of prospective data recording, analyzed the complication rates, and assessed the process of registration.

RESULTS

A total of 573 patients were recruited. The study registry including 57 variables required the completion of missing data before analysis. Of all 79 patients with a complication, 69.6% were captured prospectively at the emergency department, and the rest were found when reviewing the patient records. The proportion of prospectively captured complications was highest for the most common complications (eg, 81.1% for secondary hemorrhage). The overall complication rate was 13.8%. Secondary hemorrhage was the most common complication, with the incidence of 9.6%.

CONCLUSION

We have demonstrated the initial feasibility of a prospective complication registry for otorhinolaryngology procedures, and the results can be applied accordingly. We also present 5 practical recommendations when initiating a functional registry. Particular attention should be paid to recognition and registration of both rare and serious events. Regular analysis of the results is required in order to respond to possible changes in the incidence or nature of complications.

Accuracy of administrative and clinical registry data in reporting postoperative complications after surgery for oral cavity squamous cell carcinoma

BACKGROUND

The purpose of this study was to describe and compare how postoperative complications after oral cavity squamous cell carcinoma (SCC) surgery are reported in medical records, institutional billing claims, and national clinical registries.

METHODS

The medical records of 355 previously untreated patients who underwent surgery for oral cavity SCC at our institution were retrospectively reviewed for postoperative complications. Information was compared with claims and National Surgical Quality Improvement Program (NSQIP) data.

RESULTS

We identified 219 patients (62%) experiencing 544 complications (10% major). Billing claims identified 29% of these patients, 36% of overall complications, and 98% of major complications. Of overlapping patients, NSQIP identified 27% of patients, 33% of overall complications, and 100% of major complications noted on chart abstraction.

CONCLUSION

The incidence of minor postoperative complications after oral cavity SCC surgery is relatively high. Both claims data and NSQIP accurately recorded major complications, but were suboptimal compared to chart abstraction in capturing minor complications.

Postdischarge Complications Predict Reoperation and Mortality after Otolaryngologic Surgery

Objectives

(1) Determine procedure-specific rates of postdischarge complications (PDCs) and their risk factors in the first 30 days following inpatient otolaryngologic surgery. (2) Evaluate association between PDCs and risk of reoperation and mortality.

Study Design

Retrospective cohort study.

Setting

American College of Surgeons National Surgical Quality Improvement Program (2005-2011).

Subjects and Methods

We identified 48,028 adult patients who underwent inpatient otolaryngologic surgery. Outcomes of interest included complications, reoperation, and mortality in the first 30 days following surgery. Statistical analysis included chi-square, t tests, and multivariate regression.

Results

Laryngectomy, lip, and tongue/floor of mouth surgery had the highest PDC rates (8.0%, 7.4%, and 4.1%, respectively). Within the first 48 hours, week, and 2 weeks post discharge, 10%, 44%, and 73% of PDCs occurred, respectively. Common PDCs included surgical site infections (53.6%), other infections (37.4%), and venous thromboembolic events (7.4%). Multivariate analysis demonstrated that increasing age (odds ratio [OR] = 1.01; 95% confidence interval [CI], 1.01-1.02), prolonged operative time (OR = 1.68; 95% CI, 1.39-2.03), hospital stay >1 day (OR = 1.49; 95% CI, 1.18-1.86), and American Society of Anesthesiologists (ASA) class ≥3 (OR = 1.45; 95% CI, 1.18-1.78) were independently associated with PDCs. Patients with PDCs were more likely to die (0.9% vs 0.1%, P < .001) or have a reoperation (10.4% vs 1.2%, P < .001).

Conclusion

This is the first study of overall postdischarge events after otolaryngologic surgery. PDC rates in otolaryngology occur soon after discharge, are procedure specific, and are associated with reoperation and mortality. Targeted procedure-specific triage and follow-up plans for high-risk patients may improve outcomes.

Quality of care in head and neck cancer

Improving the quality of health care has become a national priority, as indicated by the establishment of multiple federal initiatives and by the actions of national medical societies and the American Board of Medical Specialties. Health care can be assessed in each of three dimensions: structure, process, and outcomes. Here we review recent efforts to evaluate the quality of care delivered to head and neck cancer patients and to develop methods for improvement and continual assessment, with a particular emphasis on the evaluation of process of care.