Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers

Increasing clinical experience and changes in practice protocols improved outcomes of fenestrated branched endovascular repair of complex aortic aneurysms

OBJECTIVE

To evaluate the impact of increased clinical experience and changes in practice protocols on the incidence of early major adverse events (MAEs) during fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

Clinical outcomes of 847 consecutive patients (72% males, median age 74 [69, 79] years) treated by the same operator in two centers were reviewed (2007-2024). Of these, 590 patients were treated under a prospective investigational device exemption study. Changes in practice protocols included routine use of fusion/cone beam computed tomography (F/CBCT, 2012), therapeutic instead of prophylactic cerebrospinal fluid drainage (T-CSFD, 2019, Q3) and preferential use of total transfemoral access (TTFA, 2020, Q4). Primary end-point was 30-day/in-hospital MAE assessment using learning curve cumulative sum (LC-CUSUM) analysis per quartiles of experience. The study period was divided into four quartiles: Q1 (2007-2014), Q2 (2014-2017), Q3 (2017-2020), and Q4 (2020-2024).

RESULTS

There was a significant increase in the proportion of Extent I-III TAAA (16% to 58%, p<.001), chronic post-dissection aneurysms (1.9% to 21%; p<.001), symptomatic aneurysms (5.2% to 10%; p<.001), heritable thoracic aortic diseases (0.5% to 4.2%, p=.011) and prior endovascular aortic repair (8.5% to 51%, <.001) between Q1 and Q4 experience. Despite the increased aneurysm complexity, MAEs significantly decreased over time and across quartiles (p<.01). Use of F/CBCT associated with significant reduction in total operative time and radiation exposure (p<.001). Overall 30-day mortality was 1.7% (14/847). Incidence of MAEs significantly decreased for CAAAs and Extent IV TAAAs (P<.01) and remained stable for Extent I-III TAAAs after institution of T-CSFD and TTFA. LC-CUSUM analysis indicates that 32 consecutive cases were needed to reach a learning curve, 100 cases to reach plateau, with significantly improved outcomes in the 4th quartile of experience.

CONCLUSIONS

FB-EVAR was performed with low mortality (1.7%) in a large cumulative experience. Increased clinical experience and changes in practice protocol associated with significantly improved outcomes of FB-EVAR, despite a significant increase in anatomic and patient complexity. Institution of T-CSFD and TTFA had no deleterious effect on outcomes of Extent I-III TAAAs but improved outcomes in patients with less extensive aneurysms. Among CAAA patients, 21.2% had T-CSFD, and 10.7% had TTFA. For Extent IV aneurysms, 47.3% had T-CSFD, and 22.5% had TTFA.

Tracking Residents' Surgical Outcomes Using Data from the Quality In-Training Initiative

OBJECTIVES

Monitoring resident trainees' patient outcomes is essential to improving surgical performance; however, resident-specific follow-up is rarely provided in the current surgical training environment. Whether there is a correlation between individual resident's surgical performance and patients' clinical outcomes remains undefined. In this study, we aimed to use risk-adjusted patient outcomes as an educational tool to track individual surgical trainee performance.

STUDY DESIGN

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) appendectomy and partial colectomy operations (2013-2021) were examined. Residents performing ≥25 operations were included. The primary outcome was ACS NSQIP-defined morbidity adjusted using estimated probability of morbidity. Observed-to-expected ratios (O/E) of morbidity measured overall performance and risk-adjusted cumulative sum (RA-CUSUM) methodology represented surgical resident's performance over time.

SETTING

Academic quaternary care institution.

PARTICIPANTS

Highest-ranking surgical resident participating in an operation and included in Quality In-Training Initiative.

RESULTS

A total of 449 operations were examined. 12 residents performed 343 appendectomy operations. 7 residents (29.3 ± 5.1 operations each) did not have any postoperative morbidity and demonstrated better-than-expected patient outcomes. Three residents did not have morbidity after their seventh/eleventh/fifteenth appendectomies. Two residents (case volume 29, 33) had an O/E ratio > 3. Partial colectomy (n = 106) performed by 4 residents had 2 residents (case volume 30, 26) with better-than-expected outcomes and 2 with worse-than-expected (case volume 25, 25).

CONCLUSION

Longitudinal monitoring of postoperative patient outcomes provides an opportunity for trainee self-reflection and system examination. RA-CUSUM methodology offers sequential monitoring allowing for early evaluation and intervention when RA-CUSUM results for a trainee demonstrate higher-than-expected morbidity.

Using risk-adjusted cumulative sum to evaluate surgeon, divisional, and institutional outcomes-a feasibility study

BACKGROUND

Few objective, real-time measurements of surgeon performance exist. The risk-adjusted cumulative sum is a novel method that can track surgeon-level outcomes on a continuous basis. The objective of this study was to demonstrate the feasibility of using risk-adjusted cumulative sum to monitor outcomes after colorectal operations and identify clinically relevant performance variations.

METHODS

The National Surgical Quality Improvement Program was queried to obtain patient-level data for 1,603 colorectal operations at a high-volume center from 2011 to 2020. For each case, expected risks of morbidity, mortality, reoperation, readmission, and prolonged length of stay were estimated using the National Surgical Quality Improvement Program risk calculator. Risk-adjusted cumulative sum curves were generated to signal observed-to-expected odds ratios of 1.5 (poor performance) and 0.5 (exceptional performance). Control limits were set based on a false positive rate of 5% (α = 0.05).

RESULTS

The cohort included data on 7 surgeons (those with more than 20 cases in the study period). Institutional observed versus expected outcomes were the following: morbidity 12.5% (vs 15.0%), mortality 2.5% (vs 2.0%), prolonged length of stay 19.7% (vs 19.1%), reoperation 11.1% (vs 11.3%), and 30-day readmission 6.1% (vs 4.8%). Risk-adjusted cumulative sum accurately demonstrated within- and between-surgeon performance variations across these metrics and proved effective when considering division-level data.

CONCLUSION

Risk-adjusted cumulative sum adjusts for patient-level risk factors to provide real-time data on surgeon-specific outcomes. This approach enables prompt identification of performance outliers and can contribute to quality assurance, root-cause analysis, and incentivization not only at the surgeon level but at divisional and institutional levels as well.

Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application

BACKGROUND

The surgical morbidity and mortality (M&M) conference is a vital part of a resident's surgical education, but methods to collect and store M&M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)-compliant, electronic health record (EHR)-connected application and database to report and store complication data.

METHODS

The app is linked to the patient's EHR, and as a result, basic data on each surgical case-including diagnosis, surgery type, and surgeon-are automatically uploaded to the app. In addition, all data are stored in a secure SQL database-with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses.

RESULTS

When implemented, the app improved data collection for the M&M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article.

CONCLUSION

The app developed in this project significantly improves on more common methods for M&M conference complication reporting-transforming M&M data into a valuable resource for resident education and quality improvement.