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

Individual- versus neighborhood-level social determinants of health-related factors and their associations with postoperative morbidity

BACKGROUND

Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are neighborhood-level measures of social determinants of health. This study compares individual-level Z codes with these neighborhood-level measures through spatial analysis and their associations with postoperative morbidity.

METHODS

This retrospective cohort study included patients at an urban hospital between 2015 and 2021. Spatial autocorrelation was assessed using Global Moran's I. A multivariable logistic regression model assessed their association with 30-day postoperative morbidity.

RESULTS

There was no spatial autocorrelation for Z codes (Moran's I: 0.001, p ​= ​.96), but there was for ADI (Moran's I:0.013, p ​< ​.001) and SVI (Moran's I:0.007, p ​< ​.001). Z codes were associated with 90 ​% increased odds of morbidity [CI:1.39-2.58]. For every one-point increase in ADI, odds of morbidity increased by 7 ​% [CI:1.04-1.11], but SVI was not associated.

CONCLUSIONS

Both individual- and neighborhood-level factors were associated with increased postoperative morbidity. However, Z codes demonstrate greater predictive value than neighborhood-level measures.

Is There a Diminishing Benefit With Increasing Operative Time of Minimally Invasive Sacrocolpopexy? A Retrospective Analysis

OBJECTIVE

To determine whether there is an operative time threshold beyond which minimally invasive sacrocolpopexy (MI-SCP) is less beneficial than abdominal sacrocolpopexy (ASCP).

DESIGN

Retrospective analysis.

SETTING

The National Surgical Quality Improvement Program (NSQIP) database.

POPULATION

Patients undergoing MI-SCP or ASCP from 2011 to 2018.

METHODS

Preoperative characteristics, operative variables and 30-day postoperative data were collected for each case. Groups were compared using the chi-squared or Kruskal-Wallis tests. Multivariable regression to identify risks of complications and prolonged hospital stay was performed using logistic and negative binomial models. Generalised additive models were applied to account for non-linear relationships between dependent and independent variables.

MAIN OUTCOME MEASURES

Occurrence of any major surgical complications and the length of stay.

RESULTS

13 678 sacrocolpopexies were performed, with the majority (78.6%) being MI-SCP. Although the groups were similar in age and BMI, those undergoing ASCP were more likely to have medical comorbidities. After adjusting for confounders, ASCP was not significantly associated with an increase in the probability of major complications compared to MI-SCP (aOR = 1.59, 95% CI: 0.99-2.54) and there was no significant interaction between procedure and operative time (aOR = 1.06, 95% CI: 0.94-1.20). ASCP was still associated with a prolonged LOS (aIRR = 2.19, 95% CI: 2.00-2.38). The interaction between procedure and operative time was significant (aIRR = 0.958, 95% CI: 0.93-0.98), but the LOS for MI-SCP never exceeded that of ASCP for operative times less than 6 h.

CONCLUSIONS

For surgeries lasting less than 6 h, MI-SCP is associated with similar morbidity and a shorter LOS when compared with ASCP.

Peri- and Postoperative Complications in Abdominal, Vaginal Extraperitoneal, and Vaginal Intraperitoneal Colpopexy

Introduction Pelvic organ prolapse (POP) is a very common concern for women that can often necessitate surgical intervention, including sacral colpopexy. There are multiple surgical approaches, including vaginal, extraperitoneal, and intraperitoneal. This study aims to identify predictors of the outcomes with the different surgical approaches. Methods This retrospective study utilized data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) gynecologic-specific database for those who underwent sacral colpopexy for POP. The group was subdivided into surgical approaches that included abdominal, vaginal extraperitoneal, and vaginal intraperitoneal. ANOVA analysis was performed between the three groups, and a multivariate logistic regression was performed to determine the 30-day complication rate. Results Among the 1,275 cases analyzed, 326 (25.6%) utilized an abdominal approach, 425 (33.3%) utilized a vaginal approach, and 524 (41.1%) utilized an extraperitoneal approach. The mean age was significantly higher for patients undergoing a vaginal extraperitoneal (64.5 years) compared to abdominal (62.1 years) and vaginal intraperitoneal (61.6 years). There was no difference in the 30-day complication rate between the surgical approaches on adjusted analysis; however, the vaginal extraperitoneal approach had the longest hospital stay, days from operation to discharge, and total operation time. Conclusion A variety of surgical approaches for sacral colpopexy can be employed. In our study, we show that the 30-day complication rate was similar between the three approaches; however, the complications were only significant with the abdominal approach showing an increased occurrence of bleeding transfusions when compared to the extraperitoneal approach.

Automating excellence: A breakthrough in emergency general surgery quality benchmarking

BACKGROUND

Given the high mortality and morbidity of emergency general surgery (EGS), designing and implementing effective quality assessment tools is imperative. Currently accepted EGS risk scores are limited by the need for manual extraction, which is time-intensive and costly. We developed an automated institutional electronic health record (EHR)-linked EGS registry that calculates a modified Emergency Surgery Score (mESS) and a modified Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) score and demonstrated their use in benchmarking outcomes.

METHODS

The EHR-linked EGS registry was queried for patients undergoing emergent laparotomies from 2018 to 2023. Data captured included demographics, admission and discharge data, diagnoses, procedures, vitals, and laboratories. The mESS and modified POTTER (mPOTTER) were calculated based off previously defined variables, with estimation of subjective variables using diagnosis codes and other abstracted treatment variables. This was validated against ESS and the POTTER risk calculators by chart review. Observed versus expected (O:E) 30-day mortality and complication ratios were generated.

RESULTS

The EGS registry captured 177 emergent laparotomies. There were 32 deaths (18%) and 79 complications (45%) within 30 days of surgery. For mortality, the mean difference between the mESS and ESS risk predictions for mortality was 3% (SD, 10%) with 86% of mESS predictions within 10% of ESS. The mean difference between the mPOTTER and POTTER was -2% (SD, 11%) with 76% of mPOTTER predictions within 10% of POTTER. Observed versus expected ratios by mESS and ESS were 1.45 and 1.86, respectively, and for mPOTTER and POTTER, they were 1.45 and 1.30, respectively. There was similarly good agreement between automated and manual risk scores in predicting complications.

CONCLUSION

Our study highlights the effective implementation of an institutional EHR-linked EGS registry equipped to generate automated quality metrics. This demonstrates potential in enhancing the standardization and assessment of EGS care while mitigating the need for extensive human resources investment.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic Study; Level IV.

Validation and Recalibration of a Model for Predicting Surgical-Site Infection After Pelvic Organ Prolapse Surgery

INTRODUCTION AND HYPOTHESIS

The objective was to externally validate and recalibrate a previously developed model for predicting postoperative surgical-site infection (SSI) after pelvic organ prolapse (POP) surgery.

METHODS

This study utilized a previously validated model for predicting post-POP surgery SSI within 90 days of surgery using a Medicare population. For this study, the model was externally validated and recalibrated using the Premier Healthcare Database (PHD) and the National Surgical Quality Improvement Project (NSQIP) database. Discriminatory performance was assessed via the c-statistic and calibration was assessed using calibration curves. Methods of recalibration in the large and logistic recalibration were used to update the models.

RESULTS

The PHD contained 420,277 POP procedures meeting the inclusion criteria and 1.6% resulted in SSI. The NSQIP dataset contained 62,553 POP surgeries and 1.4% resulted in SSI. Discrimination of the original model was comparable with that seen in the initial validation (c-statistic = 0.57 in PHD, 0.59 in NSQIP vs 0.60 in the original Medicare data). Recalibration greatly improved model calibration when evaluated in NSQIP data.

CONCLUSION

A previously developed model for predicting SSI after POP surgery demonstrated stable discriminatory ability when externally validated on the PHD and NSQIP databases. Model recalibration was necessary to improve prediction. Prospective studies are needed to validate the clinical utility of such a model.

Obesity is an independent risk factor for postoperative pulmonary embolism after anterior cervical discectomy and fusion

BACKGROUND

Over the past decade, the prevalence of obesity has risen in the United States, in parallel with the demand for anterior cervical discectomy with fusion (ACDF). Prior studies have evaluated the role of obesity classes in cervical spine surgery in smaller patient populations. We aimed to evaluate any potential correlation to a national population sample by utilizing a large multicenter database.

PURPOSE

The purpose of this study was to analyze obesity level's influence on perioperative complication rates in patients undergoing ACDF.

STUDY DESIGN/SETTING

A retrospective cohort, large multicenter database study.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify patients who had undergone an elective ACDF procedure between 2011 and 2020 using Current Procedural Terminology (CPT) code 22551.

OUTCOME MEASURES

Medical and surgical complications within thirty days of operation.

METHODS

Patients were categorized into four BMI groups: nonobese (BMI 18.5-29.9 kg/m2), obese class I (BMI 30-34.9 kg/m2), obese class II (BMI 35-39.9 kg/m2), and obese class III (BMI ≥40 kg/m2). A univariate analysis conducted for demographic variables and preoperative comorbidities identified age, sex, race, smoking status, hypertension requiring medication, diabetes, history of congestive heart failure, history of bleeding disorder, and chronic obstructive pulmonary disease as risk factors. Chi-square test was used to compare incidence of complications among groups. A multivariable logistic regression analysis was subsequently performed to adjust for these preoperative risk factors and compare obesity classes I-III to nonobese patients.

RESULTS

About 64,718 patients were identified of whom 33,365 were nonobese, 17,190 were obese class I, 8,608 were obese class II, and 5,555 were obese class III. Obese classes I-III patients had a higher incidence of surgical site infections (0. 33%, 0.36%, 0.41%, vs 0.24%, p=.039) and pulmonary embolism (PE) (0.25%, 0.31, 0.29 vs 0.15%, p=.003). Obese classes I-III had a lower incidence of blood transfusion (0.23%, 0.17%, 0.27% vs 0.4%, p<.001) obese class I, obese class II, and obese class III independently increased the risk for PE (OR: 1.716, 95% CI (1.129-2.599); OR: 2.213, 95% CI (1.349-3.559); OR: 2.207, 95% CI (1.190--3.892), respectively).

CONCLUSIONS

Risk for postoperative PEs after an ACDF was significantly higher for obese classes I-III compared to nonobese patients. These findings may further support the use of additional prophylaxis measures and precaution in the perioperative setting.

Smoking's Impact on 30-Day Complications in Mesh and Nonmesh Prolapse Surgery

IMPORTANCE

Tobacco smoking is linked to poor surgical outcomes, leading many physicians to avoid synthetic implants like mesh in smokers due to concerns about impaired healing. While long-term outcomes for smokers have been studied, the effect of smoking on 30-day postoperative complications, especially related to surgical mesh, is less understood.

OBJECTIVES

This study aimed to quantify the association between tobacco smoking and risk of postoperative infection, readmission, and reoperation within 30 days of minimally invasive apical prolapse repair. We also examined whether these associations differed based on whether mesh was used.

STUDY DESIGN

We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database for patients who underwent minimally invasive apical pelvic organ prolapse repair from 2012 to 2022. Smoking in the last year was the exposure. Outcomes included postoperative infection, unplanned readmission, and reoperation within 30 days. We calculated adjusted risk ratios for complications and stratified results based on mesh use.

RESULTS

Of 67,235 cases, 5,518 (8.2%) patients smoked in the past year. Smokers had a significantly higher likelihood of infection and unplanned readmission. Smoking did not increase the risk of unplanned reoperation. The association between smoking and 30-day complications did not differ based on mesh use (all P for interaction ≥0.24).

CONCLUSIONS

Tobacco use was associated with an increase in postoperative complications within 30 days, though the absolute risk was low. There was no evidence of effect modification by mesh use; suggesting that mesh-augmented repairs could be considered in smokers who receive appropriate counseling.

An algorithm for identifying causes of reoperations after orthopedic fracture surgery in health administrative data: a diagnostic accuracy study using the Danish National Patient Register

BACKGROUND AND PURPOSE

 Disease- or procedure-specific registers offer valuable information but are costly and often inaccurate regarding outcome measures. Alternatively, automatically collected data from administrative systems could be a solution, given their high completeness. Our primary aim was to validate a method for identifying secondary surgical procedures (reoperations) in the Danish National Patient Register (DNPR) within the first year following primary fracture surgery. The secondary aim was to evaluate the accuracy of the diagnosis and procedure codes used to determine the causes of these reoperations. Finally, we developed algorithms to enhance precision in identifying the reasons for reoperations.

METHODS

 In a national cohort of 11,551 patients with primary fracture surgery, reoperations were identified through subsequent surgical procedure codes in the DNPR. Each patient record was reviewed to confirm the reoperations and causes. To improve accuracy, a stepwise algorithm was developed for each cause.

RESULTS

 We identified 2,347 possible reoperations; 2,212 were validated as true reoperations by review of patient record, i.e., a 94% positive predictive value (PPV). However, the coding for the causes of these reoperations was inaccurate. Our algorithm identified major reoperations with a sensitivity/PPV of 89/77%, minor reoperations 99%/89%, infections 77/85%, nonunion 82/56%, early re-osteosynthesis 90/75%, and secondary arthroplasties 95/87%.

CONCLUSION

 While the overall reported reoperations in the DNPR had a high PPV, the predefined diagnosis and procedure codes alone were not sufficient to accurately determine the causes of these reoperations. An algorithm was developed for this purpose, yielding acceptable results for all causes except nonunion.

Assessment of intermediate-term mortality following pancreatectomy for cancer

BACKGROUND

Pancreatic cancer remains highly lethal, and resection represents the only chance for cure. Although patients are counseled regarding short-term (0-3 months) mortality, little is known about mortality 3-6 months (intermediate-term) following surgery. We assessed predictors of intermediate-term mortality, evaluated hospital-level variation, and developed a nomogram to predict intermediate-term mortality risk.

METHODS

Patients undergoing pancreatic cancer resection were identified from the National Cancer Database (2010-2020). Multivariable logistic regression identified predictors of intermediate-term mortality and assessed differences between short-term and intermediate-term mortality. Multinomial regression grouped by intermediate-term mortality quartiles evaluated hospital-level variation. A neural network model was constructed to predict intermediate-term mortality risk. All statistical tests were 2-sided.

RESULTS

Of 45 297 patients, 3974 (8.9%) died within 6 months of surgery of which 2216 (5.1%) were intermediate-term. Intermediate-term mortality was associated with increasing T category, positive nodes, lack of systemic therapy, and positive margins (all P < .05) compared with survival beyond 6 months. Compared with short-term mortality, intermediate-term mortality was associated with treatment at high-volume hospitals, positive nodes, neoadjuvant systemic therapy, adjuvant radiotherapy, and positive margins (all P < .05). Median intermediate-term mortality rate per hospital was 4.5% (interquartile range [IQR] = 2.6-6.5). Highest quartile hospitals had decreased odds of treatment with neoadjuvant systemic therapy, neoadjuvant radiotherapy, and adjuvant radiotherapy (all P < .05). The neural network nomogram was highly accurate (accuracy = 0.9499; area under the receiver operating characteristics curve = 0.7531) in predicting individualized intermediate-term mortality risk.

CONCLUSION

Nearly 10% of patients undergoing pancreatectomy for cancer died within 6 months, of which one-half occurred in the intermediate term. These data have real-world implications to improve shared decision making when discussing curative-intent pancreatectomy.

Utility of Frailty Index in Predicting Adverse Outcomes in Patients With the Same American Society of Anesthesiologists Class in Video-assisted Thoracoscopic Surgery

OBJECTIVES

To investigate the utility of the five-item Modified Frailty Index (MFI-5) as a preoperative risk-stratification tool in video-assisted thoracoscopic surgery (VATS) for patients with the same American Society of Anesthesiologists (ASA) class.

DESIGN

This was a retrospective cohort study utilizing data from The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database from 2008 to 2021.

SETTING

The NSQIP includes 685 participating hospitals in all 50 states, the majority being large, academic medical centers.

PARTICIPANTS

All patients undergoing VATS were identified via CPT codes in the deidentified NSQIP dataset. Patients with invalid values for any variables of interest or significant covariates were excluded.

INTERVENTIONS

No interventions were applied to any patients in this retrospective cohort study.

MEASUREMENTS AND MAIN RESULTS

69,145 patients undergoing VATS were included, with the largest number having single lobectomy (32%) or unilateral wedge resection (26%). A total of 1,277 (1.8%) had unplanned reintubation, and 1,155 (1.7%) had ventilator dependence (VentDep) >48 hours after surgery. Of these patients, 66% were ASA class 3. Overall, ASA classification had a stronger correlation with both VentDep rates (adjusted R2 difference: +6.1%) and reintubation rates (adjusted R2 difference: +1.5%) than the MFI-5 score. However, combining ASA class with MFI-5 score was a stronger predictor for both primary outcomes than the ASA class alone (adjusted R2 difference: +1.5%, p < 0.001). The MFI-5 had the strongest correlation with both outcomes among ASA class 3 patients, demonstrating exponentially increasing odds of VentDep and reintubation (MFI 3 v MFI 0: odds ratio = 5.1 [3.7, 7], p = 0.002). MFI-5 also helped classify risk within ASA class 2 patients but not as reliably as for ASA class 3 (ASA class 2 reintubation: increased probability from MFI 0-1 and 1-2; VentDep: increased probability from MFI 0-1 only, p = 0.005).

CONCLUSIONS

The MFI-5 is a comorbidity-based scale that can be calculated preoperatively and considers distinct, but complementary information to the ASA class. Among VATS patients with identical ASA classes 2 and 3, the MFI-5 further stratified risk for reintubation and ventilator dependence >48 hours postsurgery.

Effect of Chronic Steroid Use on Postoperative Wound Complications in Patients Undergoing Arterial Bypass Surgery for Lower Extremity Peripheral Arterial Disease

BACKGROUND

While existing literature reports adverse effects of chronic steroid use on surgical wound outcomes, there remains lack of data exploring the effect of steroids on postoperative outcomes following lower extremity arterial bypass surgery. This study aims to explore the effect of chronic steroid use on surgical outcomes in patients undergoing open revascularization for lower extremity arterial occlusive disease.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2020, all patients receiving aortoiliac or infrainguinal arterial bypass for peripheral arterial disease (PAD) were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and 30-day outcomes were compared using χ2 test and independent t-test, and the association of chronic steroid use with wound complications was studied using multivariable logistic regression analysis.

RESULTS

A total of 44,675 patients undergoing open lower extremity revascularization (LER) were identified, of which 1,807 patients were on chronic steroids, and 42,868 patients were not on chronic steroids. On multivariable logistic regression analysis, being on chronic steroids was associated with higher rates of deep surgical site infections (SSIs) (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.03-1.83), any SSI (OR 1.22, 95% CI 1.04-1.43), and wound dehiscence (OR 1.42, 95% CI 1.03-1.96). Chronic steroid users also had significantly increased odds of developing sepsis (OR 1.56, 95% CI 1.19-2.04), pneumonia (OR 1.44, 95% CI 1.08-1.91), urinary tract infection (UTI) (OR 1.54, 95% CI 11.13-2.09), deep vein thrombosis (DVT) (OR 1.60, 95% CI 1.01-2.53), 30-day readmission (OR 1.30, 95% CI 1.12-1.50), reoperation (OR 1.17, 95% CI 1.01-1.37), and mortality (OR 1.33, 95% CI 1.01-1.76) compared with nonchronic steroid users.

CONCLUSIONS

This study confirms that chronic corticosteroid use is associated with higher risk of SSIs in patients undergoing lower extremity arterial bypass surgery. These patients typically have various underlying health issues, emphasizing the need for personalized treatment and management to reduce steroid-related postoperative complications and improve survival.

Surgical Management of Fibroids: A Changing Landscape

Background: Uterine fibroids affect patients' quality of life and contribute significantly to health care costs. Studies from 2009 to 2011 demonstrated that fibroids disproportionately affect Black women, with lower odds of uterine preservation and minimally invasive approaches. Objective: This is a retrospective cohort study of data abstracted from the National Surgical Quality Improvement Program database from 2015 to 2019 examining trends in surgical management of uterine fibroids and exploring disparities in surgical approach in a modern cohort. Results: In total, 52,909 women underwent hysterectomy and 15,485 women underwent myomectomy between 2015 and 2019. Over the study period, the overall number of surgeries for fibroids increased by 44.2% with minimally invasive hysterectomy responsible for the majority of this increase. The proportion of patients who underwent myomectomy significantly increased (20.85% to 24.62%, p value <0.0001), whereas hysterectomy significantly decreased (79.15% to 75.38%, p value <0.0001). Bivariate analysis identified younger age, non-White race, and body mass index (BMI) <25 as significantly associated with performance of myomectomy. Non-Hispanic Black (adjusted odds ratio [aOR]: 3.55, 95% confidence interval [CI]: 3.23-3.89), Asian (aOR: 3.26, 95% CI: 2.80-3.80), and Hispanic Black (aOR: 5.50, 95% CI: 3.29-9.25) women were more likely to undergo myomectomy than non-Hispanic White women. Conclusion: Surgical treatment for fibroids increased over time, shifting toward uterine preservation. Myomectomy performance is associated with lower age and BMI and identifying as a racial and/or ethnic minority. These trends may represent improved access to surgical treatment of fibroids, resulting from the growth of minimally invasive gynecological surgery as a specialty and advocacy for equitable health care for all patients.

Insulin dependence negatively impacts outcomes in anterior cervical discectomy with fusions: a 10-year retrospective analysis

BACKGROUND CONTEXT

Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing diabetic patient population, there is a paucity of literature focusing on insulin-dependence as a risk-factor for postoperative ACDF complications.

PURPOSE

To evaluate the differential impact of insulin dependence on perioperative outcomes including total length of stay, surgical, and medical complications within thirty days following ACDF.

STUDY DESIGN/SETTING

A retrospective cohort, large multicenter database study.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551.

OUTCOME MEASURES

Perioperative surgical and medical complications.

METHODS

The study population was divided into 3 groups 1) insulin-dependent diabetes mellitus (IDDM), 2) noninsulin-dependent diabetes mellitus (NIDDM), and 3) no diabetes mellitus (non-DM). One-way analysis of variance for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the 3 groups. Multivariable logistic regression analysis assessed the effect of diabetes mellitus status on postoperative medical and surgical outcomes.

RESULTS

A total of 85,758 ACDF procedures were identified between 2011 and 2021, of which 5,178 were IDDM, 9,652 were NIDDM, and 70,982 were non-DM. The rates of surgical and medical complication varied between the 3 groups. IDDM patients had the highest rates of at least one medical complication (6.1%). Only IDDM increased the risk for medical complications (OR: 1.320, 95% CI [1.144-1.518]) and extended hospital length of stay (LOS) (OR: 1.244, 95% CI [1.071-1.441]) following a multivariate logistic regression analysis.

CONCLUSION

Patients with IDDM were at an increased risk for postoperative medical complications and extended hospital LOS. Personalized postoperative management, guided by risk assessment is indicated for this population. These findings can be used to improve risk stratification and informed consent for DM patients who are insulin dependent.

Integrating equity frameworks into surgical quality improvement and health administrative databases: A narrative review

Ensuring safe, timely, and effective surgery is critical for high-quality healthcare and is the goal of surgical quality monitoring systems. At the heart of these systems are health administrative databases which house patient clinico-demographic information, healthcare processes and outcomes. Through analysis of monitoring systems outputs, we can identify gaps within healthcare delivery, patient experience, and surgical outcomes. However, gaps in our healthcare can only be measured by the variables we collect. Equity stratifiers are sociodemographic descriptors that can identify patient populations who experience differences in health and healthcare that may be considered unjust or unfair. They include age, education, gender, geographic location, income, Indigenous identity, racialized group, and sex at birth. These equity stratifiers represent measurable components of the social determinants of health housed within health administrative databases and allow for standardized analysis and reporting of health inequity. However, not all databases collect these stratifiers - making granular analysis of patient subgroups who may experience health inequity impossible to measure. Moreover, in databases that do collect this information, a wide range in the classification systems used makes for comparisons across jurisdictions challenging. The focus of this narrative review will be to apply the principles of the equity stratifier framework to examine what measures are collected in surgical quality improvement databases, cancer monitoring systems and provincial/state health administrative databases in the United States of America and Canada. The goal of this narrative review is to 1) inform researchers, surgeons, and policymakers of the current landscape of social variables collected within common health administrative databases. 2) Outline the pros and cons of the current collection system. 3) Issue a call to action for policymakers to incorporate health equity frameworks into the collection and reporting of data.

Earned outcomes correlate with reliability-adjusted surgical mortality after abdominal aortic aneurysm repair and predict future performance

OBJECTIVE

Cumulative, probability-based metrics are regularly used to measure quality in professional sports, but these methods have not been applied to health care delivery. These techniques have the potential to be particularly useful in describing surgical quality, where case volume is variable and outcomes tend to be dominated by statistical "noise." The established statistical technique used to adjust for differences in case volume is reliability-adjustment, which emphasizes statistical "signal" but has several limitations. We sought to validate a novel measure of surgical quality based on earned outcomes methods (deaths above average [DAA]) against reliability-adjusted mortality rates, using abdominal aortic aneurysm (AAA) repair outcomes to illustrate the measure's performance.

METHODS

Earned outcomes methods were used to calculate the outcome of interest for each patient: DAA. Hospital-level DAA was calculated for non-ruptured open AAA repair and endovascular aortic repair (EVAR) in the Vascular Quality Initiative database from 2016 to 2019. DAA for each center is the sum of observed - predicted risk of death for each patient; predicted risk of death was calculated using established multivariable logistic regression modeling. Correlations of DAA with reliability-adjusted mortality rates and procedure volume were determined. Because an accurate quality metric should correlate with future results, outcomes from 2016 to 2017 were used to categorize hospital quality based on: (1) risk-adjusted mortality; (2) risk- and reliability-adjusted mortality; and (3) DAA. The best performing quality metric was determined by comparing the ability of these categories to predict 2018 to 2019 risk-adjusted outcomes.

RESULTS

During the study period, 3734 patients underwent open repair (106 hospitals), and 20,680 patients underwent EVAR (183 hospitals). DAA was closely correlated with reliability-adjusted mortality rates for open repair (r = 0.94; P < .001) and EVAR (r = 0.99; P < .001). DAA also correlated with hospital case volume for open repair (r = -.54; P < .001), but not EVAR (r = 0.07; P = .3). In 2016 to 2017, most hospitals had 0% mortality (55% open repair, 57% EVAR), making it impossible to evaluate these hospitals using traditional risk-adjusted mortality rates alone. Further, zero mortality hospitals in 2016 to 2017 did not demonstrate improved outcomes in 2018 to 2019 for open repair (3.8% vs 4.6%; P = .5) or EVAR (0.8% vs 1.0%; P = .2) compared with all other hospitals. In contrast to traditional risk-adjustment, 2016 to 2017 DAA evenly divided centers into quality quartiles that predicted 2018 to 2019 performance with increased mortality rate associated with each decrement in quality quartile (Q1, 3.2%; Q2, 4.0%; Q3, 5.1%; Q4, 6.0%). There was a significantly higher risk of mortality at worst quartile open repair hospitals compared with best quartile hospitals (odds ratio, 2.01; 95% confidence interval, 1.07-3.76; P = .03). Using 2016 to 2019 DAA to define quality, highest quality quartile open repair hospitals had lower median DAA compared with lowest quality quartile hospitals (-1.18 DAA vs +1.32 DAA; P < .001), correlating with lower median reliability-adjusted mortality rates (3.6% vs 5.1%; P < .001).

CONCLUSIONS

Adjustment for differences in hospital volume is essential when measuring hospital-level outcomes. Earned outcomes accurately categorize hospital quality and correlate with reliability-adjustment but are easier to calculate and interpret. From 2016 to 2019, highest quality open AAA repair hospitals prevented >40 perioperative deaths compared with the average hospital, and >80 perioperative deaths compared with lowest quality hospitals.

Peri-operative outcomes following radical prostatectomy in the setting of advanced prostate cancer

OBJECTIVE

To compare the peri-operative outcomes of radical prostatectomy (RP) for locally advanced, node-positive, and metastatic prostate cancer (PCa), as determined through pathological staging, using the American College of Surgeons National Surgical Quality Improvement Project.

METHODS

We identified RP procedures performed between 2019 and 2021. Patients were stratified by pathological staging to compare the effect of locally advanced disease (T3-4), node positivity (N+) and metastasis (M+) vs localised PCa (T1-2 N0 M0). Baseline demographics and 30-day outcomes, including operating time, length of hospital stay (LOS), 30-day mortality, readmissions, reoperations, major complications, minor complications and surgery-specific complications, were compared between groups.

RESULTS

Pathological staging data were available for 9276 RPs. Baseline demographics were comparable. There was a slightly higher rate of minor complications in the locally advanced cohort, but no significant difference in major complications, 30-day mortality, readmissions, or rectal injuries. Node positivity was associated with longer operating time, LOS, and some slightly increased rates of 30-day complications. RP in patients with metastatic disease appeared to be similarly safe to RP in patients with M0 disease, although it was associated with a longer LOS and slightly increased rates of certain complications.

CONCLUSIONS

For patients with pathologically determined locally advanced, node-positive, and metastatic PCa, RP appears to be safe, and is not associated with significantly higher rates of 30-day mortality or major complications compared to RP for localised PCa. This study adds to the growing body of literature investigating the role of RP for advanced PCa; further studies are needed to better characterise the risks and benefits of surgery in such patients.

A Systematic Review on the Impact of Quality Assurance Programs on Outcomes after Radical Prostatectomy

BACKGROUND AND OBJECTIVE

The implementation of quality assurance programs (QAPs) within urological practice has gained prominence; yet, their impact on outcomes after radical prostatectomy (RP) remains uncertain. This paper aims to systematically review the current literature regarding the implementation of QAPs and their impact on outcomes after robot-assisted RP, laparoscopic RP, and open prostatectomy, collectively referred to as RP.

METHODS

A systematic Embase, Medline (OvidSP), and Scopus search was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) process, on January 12, 2024. Studies were identified and included if these covered implementation of QAPs and their impact on outcomes after RP. QAPs were defined as any intervention seeking quality improvement through critically reviewing, analyzing, and discussing outcomes. Included studies were assessed critically using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool, with results summarized narratively.

KEY FINDINGS AND LIMITATIONS

Ten included studies revealed two methodological strategies: periodic performance feedback and surgical video assessments. Despite conceptual variability, QAPs improved outcomes consistently (ie, surgical margins, urine continence, erectile function, and hospital readmissions). Of the two strategies, video assessments better identified suboptimal surgical practice and technical errors. Although the extent of quality improvements did not appear to correlate with the frequency of QAPs, there was an apparent correlation with whether or not outcomes were evaluated collectively.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Current findings suggest that QAPs have a positive impact on outcomes after RP. Caution in interpretation due to limited data is advised. More extensive research is required to explore how conceptual differences impact the extent of quality improvements.

PATIENT SUMMARY

In this paper, we review the available scientific literature regarding the implementation of quality assurance programs and their impact on outcomes after radical prostatectomy. The included studies offered substantial support for the implementation of quality assurance programs as an incentive to improve the quality of care continuously.

Impact of postoperative pancreatic fistula on outcomes in pancreatoduodenectomy: a comprehensive analysis of American College of Surgeons National Surgical Quality Improvement Program data

BACKGROUND

Pancreatoduodenectomy (PD) is a major surgical procedure associated with significant risks, particularly postoperative pancreatic fistula (POPF). Studies have highlighted the importance of certain risk factors for POPF, which are crucial for surgical decision-making and the management of high-risk patients undergoing PD. This study aimed to assess the surgical outcomes of patients undergoing PD who met the International Study Group of Pancreatic Surgery - Class D (ISGPS-D) criteria.

METHODS

This study analyzed American College of Surgeons National Surgical Quality Improvement Program data (2014-2021) for patients undergoing ISGPS-D PD, classified as having a soft pancreatic texture and a pancreatic duct of ≤3 mm. This study focused on mortality rates and the correlation between several factors and POPF (ISGPS grade B/C).

RESULTS

From 5964 patients who underwent PD and met the ISGPS-D criteria, the 30-day mortality rate was 1.98%. Males had a higher incidence of POPF than females (57.42% vs 47.35%, respectively; P < .001). Patients with POPF experienced significantly higher rates of major postoperative complications (Clavien-Dindo grade ≥ IIIa), including thrombosis, pneumonia, sepsis, delayed gastric emptying, wound disruption, infections, and acute renal failure. There was a marked increase in the 30-day readmission and mortality rates in patients with POPF (30.0% vs 17.6% and 3.2% vs 1.4%, respectively; all P < .001). Multivariate analysis highlighted female sex as a protective factor against mortality (odds ratio [OR], 0.47; P < .001) and extended hospital stay (>10 days) as a predictor of increased mortality risk (OR, 2.37; P < .001).

CONCLUSION

This study underscored the significant association between POPF and increased postoperative morbidity and mortality rates. Future efforts should concentrate on refining surgical techniques and improving preoperative assessments to mitigate the risks associated with POPF in patients undergoing PD.

Outcomes of minimally invasive vs. open pancreatoduodenectomies in pancreatic adenocarcinoma: analysis of ACS-NSQIP data

INTRODUCTION

Pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) presents a significant challenge owing to its aggressive nature. Traditionally performed as open surgery, the advent of minimally invasive surgery (MIS) including laparoscopic and robotic techniques, offers a potential alternative. This study assessed the use and outcomes of MIS and open PD for PDAC treatment.

METHODS

We analyzed ACS-NSQIP data (2015-2021) using regression models to compare patient outcomes across open PD, MIS PD, and conversions from MIS to open (MIS-O).

RESULTS

Of 19,812 PDAC patients, 1,293 (6.53%) underwent MIS, 18,116 (91.44%) underwent open PD, and 403 (2.03%) underwent MIS converted to open PD (MIS-O). The MIS rate increased from 6.1% to 9.2%. Black patients had a higher MIS-O rate (RR, 1.55; p = 0.025). Open PD was associated with more severe conditions (ASA ≥ III, malnutrition) and prior radiation therapy. MIS patients more often had neoadjuvant chemotherapy. Complex procedures, such as vein resection, favored open PD. Need for arterial resection was associated with MIS-O (RR, 2.11; p = 0.012), and operative time was significantly associated with MIS (OR: 4.32, 95% CI: 3.43-5.43, p-value: < 0.001) No differences in the overall morbidity or 30-day mortality were observed. MIS led to shorter stays but higher risks of reoperation and pulmonary embolism. MIS-O increased the delayed gastric emptying rate (RR, 1.79; p < 0.001).

CONCLUSION

During 2015-2021, an increasing number of patients with PDAC are undergoing MIS PD. Morbidity and mortality did not differ between open and MIS PD. MIS was performed more frequently in patients with better nutritional status and lower ASA, or when vascular resection was not anticipated. In well selected patients, short-term outcomes of MIS and open PD seem similar.

Low serum creatinine levels are associated with major post-operative complications in patients undergoing surgery with gynecologic oncologists

OBJECTIVE

Serum creatinine is a byproduct of muscle metabolism, and low creatinine is postulated to be associated with diminished muscle mass. This study examined the association between low pre-operative serum creatinine and post-operative outcomes.

METHODS

This retrospective cohort study utilized the 2014-2021 National Surgical Quality Improvement Program to identify patients undergoing surgery with gynecologic oncologists. Patients with missing pre-operative creatinine, end-stage renal disease, sepsis, septic shock, dialysis, or pregnancy were excluded. Pre-operative creatinine was categorized into markedly low (≤0.44 mg/dL), mildly low (0.45-0.64 mg/dL), normal (0.65-0.84 mg/dL), and four categories of elevated levels (0.85-1.04, 1.05-1.24, 1.25-1.44, and ≥1.45 mg/dL). Outcomes included major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, and thromboembolic complications. Also examined were 30-day readmissions, reoperations, and mortality. Logistic regressions assessed the association between creatinine and complications, with stratification by albumin and sensitivity analysis with propensity score matching.

RESULTS

Among 84 786 patients, 0.8% had markedly low, 19.6% mildly low, and 50.2% normal creatinine; the remainder had elevated creatinine. As creatinine decreased, the risks of major complications increased in a dose-dependent manner on univariable and multivariable analyses. A total of 9.6% (n=63) markedly low patients experienced major complications, second to creatinine ≥1.45 mg/dL (9.9%, n=141). On multivariable models, both markedly and mildly low creatinine were associated with higher odds of major complications (OR 1.715, 95% CI 1.299 to 2.264 and OR 1.093, 95% CI 1.001 to 1.193) and infections (OR 1.575, 95% CI 1.118 to 2.218 and OR 1.165, 95% CI 1.048 to 1.296) versus normal. Markedly low creatinine had similar ORs to creatinine ≥1.45 mg/dL and was further associated with higher odds of cardiovascular and pulmonary complications (OR 2.301, 95% CI 1.300 to 4.071), readmissions (OR 1.403, 95% CI 1.045 to 1.884), and mortality (OR 2.718, 95% CI 1.050 to 7.031). After albumin stratification, associations persisted for markedly low creatinine. Propensity-weighted analyses demonstrated congruent findings.

CONCLUSIONS

Low creatinine levels are associated with major post-operative complications in gynecologic oncology in a dose-dependent manner. Low creatinine can offer useful information for pre-operative risk stratification, surgical counseling, and peri-operative management.

Thrombotic and Hemorrhagic Outcomes After Elective Surgery in Preoperatively Anticoagulated Patients

OBJECTIVE

To better understand the incidence and timing of thrombotic and hemorrhagic complications in anticoagulated patients undergoing elective surgery.

METHODS

Using institutional American College of Surgeons National Surgical Quality Improvement Program data, we identified patients receiving preoperative anticoagulation undergoing elective surgery between 2011 and 2021. Medical records review supplemented National Surgical Quality Improvement Program data to detail complication and anticoagulation type and timing. Outcomes for postoperative hemorrhage, acute venous thromboembolism (VTE), and cerebrovascular accident (CVA) were collected.

RESULTS

A total of 1442 patients met inclusion criteria, and 84 patients (5.8%) experienced 1 or more complications. There were 4 CVA (0.3%), 16 VTE (1.1%), and 68 bleeding (4.7%) events postoperatively. Three patients (75%) with CVA, 10 patients (62.5%) with VTE, and 18 patients (26.5%) with postoperative bleeding had resumed therapeutic anticoagulation before the complication. In terms of long-term sequelae in the CVA cohort, there was 1 mortality (25%), and an additional patient (25%) continues to experience long-term physical and mild cognitive impairments. Patients who experienced postoperative VTE required only anticoagulation adjustments. In patients who experienced bleeding complications, 6 (8.8%) required intensive care unit admissions, and there was 1 mortality (1.5%).

CONCLUSION

Despite the increased use of anticoagulation over time, balancing postoperative bleeding and thrombotic risks remains challenging. Bleeding complications were most common in preoperatively anticoagulated patients undergoing elective surgery. Earlier postoperative resumption of anticoagulation is unlikely to prevent thrombotic events as 65% of patients had already resumed therapeutic anticoagulation.

Association of pathologic factors with postoperative venous thromboembolism after gastrointestinal cancer surgery

BACKGROUND

Venous thromboembolism (VTE) chemoprophylaxis is the standard of care after gastrointestinal (GI) cancer surgery; however, variation in risk based on pathologic factors (eg, stage and histology) is unclear. This study aimed to evaluate the association of pathologic factors with VTE after GI cancer surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program procedure targeted datasets were queried for patients who underwent colorectal, pancreatic, primary hepatic, and esophageal cancer surgery between 2017 and 2020. Disease-specific and pathologic factors associated with postoperative VTE were evaluated using multivariable logistic regression.

RESULTS

Among 70,934 patients who underwent GI cancer surgery, the incidence rates of 30-day postoperative VTE were 3.3% for pancreatic cancer, 3.2% for esophageal cancer, 2.7% for primary hepatic, and 1.3% for colorectal cancer. T stage was associated with VTE for colorectal cancer (T4 vs T1; odds ratio [OR], 1.79; 95% CI, 1.24-2.60), pancreatic cancer (all T stages vs T1; P < .05), and primary hepatic cancer (T4 vs T1; OR, 2.80; 95% CI, 1.55-5.08). N stage was associated with VTE for colorectal cancer (N2 vs N0; OR, 1.33; 95% CI, 1.04-1.68) and pancreatic cancer (N2 vs N0; OR, 1.36; 95% CI, 1.03-1.81). M stage was associated with VTE for colorectal cancer (OR, 1.47; 95% CI, 1.17-1.85) and esophageal cancer (OR, 2.54; 95% CI, 1.24-5.19). Histologic subtype was not associated with VTE, except for pancreatic neuroendocrine tumors vs adenocarcinoma (OR, 1.34; 95% CI, 1.03-1.74).

CONCLUSION

Pathologic factors were associated with higher 30-day VTE risk after GI cancer surgery. Acknowledging the association of pathologic factors on VTE is an important first step to considering a more tailored approach to chemoprophylaxis.

Structured feedback and operative video debriefing with critical view of safety annotation in training of laparoscopic cholecystectomy: a randomized controlled study

BACKGROUND

The learning curve in minimally invasive surgery (MIS) is lengthened compared to open surgery. It has been reported that structured feedback and training in teams of two trainees improves MIS training and MIS performance. Annotation of surgical images and videos may prove beneficial for surgical training. This study investigated whether structured feedback and video debriefing, including annotation of critical view of safety (CVS), have beneficial learning effects in a predefined, multi-modal MIS training curriculum in teams of two trainees.

METHODS

This randomized-controlled single-center study included medical students without MIS experience (n = 80). The participants first completed a standardized and structured multi-modal MIS training curriculum. They were then randomly divided into two groups (n = 40 each), and four laparoscopic cholecystectomies (LCs) were performed on ex-vivo porcine livers each. Students in the intervention group received structured feedback after each LC, consisting of LC performance evaluations through tutor-trainee joint video debriefing and CVS video annotation. Performance was evaluated using global and LC-specific Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores.

RESULTS

The participants in the intervention group had higher global and LC-specific OSATS as well as global and LC-specific GOALS scores than the participants in the control group (25.5 ± 7.3 vs. 23.4 ± 5.1, p = 0.003; 47.6 ± 12.9 vs. 36 ± 12.8, p < 0.001; 17.5 ± 4.4 vs. 16 ± 3.8, p < 0.001; 6.6 ± 2.3 vs. 5.9 ± 2.1, p = 0.005). The intervention group achieved CVS more often than the control group (1. LC: 20 vs. 10 participants, p = 0.037, 2. LC: 24 vs. 8, p = 0.001, 3. LC: 31 vs. 8, p < 0.001, 4. LC: 31 vs. 10, p < 0.001).

CONCLUSIONS

Structured feedback and video debriefing with CVS annotation improves CVS achievement and ex-vivo porcine LC training performance based on OSATS and GOALS scores.

Shifting trends and sicker patients: Reassessing hysterectomy performed for benign indications by gynecologic oncologists

OBJECTIVE

To assess trends and differences in patient characteristics, complications, and distributions of hysterectomy for benign indications by benign gynecologists (BG) and gynecologic oncologists (GO).

METHODS

This retrospective cohort study identified patients undergoing hysterectomy for benign indications using the National Surgical Quality Improvement Program data from 2014 to 2021. Exclusions were made for gynecologic or disseminated cancers, ascites, non-gynecologic surgeons, and cesarean hysterectomies. Primary outcome was major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, andthromboembolic complications. Thirty-day readmissions, reoperations, and mortality were also analyzed. Propensity score matching was performed in a 1:1 match of GO to BG patients and was compared. Linear regressions assessed trends.

RESULTS

Among 198,767 patients, 18% (n = 37,707) underwent hysterectomy for benign indications with GO. GO patients exhibited more risk factors for complications and differed significantly from BG patients in comorbidities and perioperative characteristics. Overall, GO patients had higher major complication rates (3.1% vs 2.2%, p < 0.001) and for several other composite complications. After matching, compared to BG, GO-performed hysterectomies had similar rates of major complications (3.0% vs 3.0%, p = 0.55) and no differences in other composite complications, except fewer reoperations (1.2 % vs 1.5%, p < 0.01) and wound complications (0.4% vs 0.5%, p = 0.02) in GO patients. Over the eight years, the percentage of GO-performed hysterectomy (β = 0.41, R2 = 0.71,p < 0.01) increased significantly whereas BG-performed surgeries decreased by the same magnitude. BG had a significant decrease in frail patients (β = -0.47, R2 = 0.90, p < 0.01), but GO did not (β = -0.36, R2 = 0.38, p = 0.10).

CONCLUSIONS

GO are performing more hysterectomies for benign indications on higher-risk patients. However, on a matched cohort, risks of major complications were similar between GO and BG.

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.

Assessing the utility of natural language processing for detecting postoperative complications from free medical text

BACKGROUND

Postoperative complication rates are often assessed through administrative data, although this method has proven to be imprecise. Recently, new developments in natural language processing have shown promise in detecting specific phenotypes from free medical text. Using the clinical challenge of extracting four specific and frequently undercoded postoperative complications (pneumonia, urinary tract infection, sepsis, and septic shock), it was hypothesized that natural language processing would capture postoperative complications on a par with human-level curation from electronic health record free medical text.

METHODS

Electronic health record data were extracted for surgical cases (across 11 surgical sub-specialties) from 18 hospitals in the Capital and Zealand regions of Denmark that were performed between May 2016 and November 2021. The data set was split into training/validation/test sets (30.0%/48.0%/22.0%). Model performance was compared with administrative data and manual extraction of the test data set.

RESULTS

Data were obtained for 17 486 surgical cases. Natural language processing achieved a receiver operating characteristic area under the curve of 0.989 for urinary tract infection, 0.993 for pneumonia, 0.992 for sepsis, and 0.998 for septic shock, whereas administrative data achieved a receiver operating characteristic area under the curve of 0.595 for urinary tract infection, 0.624 for pneumonia, 0.571 for sepsis, and 0.625 for septic shock.

CONCLUSION

The natural language processing approach was able to capture complications with acceptable performance, which was superior to administrative data. In addition, the model performance approached that of manual curation and thereby offers a potential pathway for complete real-time coverage of postoperative complications across surgical procedures based on natural language processing assessment of electronic health record free medical text.

Quality Improvement and Patient Safety Rounds-A New Paradigm in Cardiothoracic Surgery

Background

The delivery of cardiothoracic health care is complex, and despite best efforts, adverse patient outcomes do occur. There is significant heterogeneity in morbidity and mortality rounds within and between institutions as well as undertones of a "blame and shame" culture prohibitive to meaningful quality assessment and improvement of patient care. The Quality Improvement and Patient Safety (QIPS) program was designed to address these issues.

Methods

QIPS is built on the Donabedian model of quality and established phase-of-care adverse event analysis. It focuses on cultivating a culture of transparency. Every case review yields important demographic data, event factors, and the case inflection point, creating an institution-specific QIPS database. The QIPS format was presented by The Society of Thoracic Surgeons Workforce on Patient Safety at 2 Society of Thoracic Surgeons webinar series in December 2021 and August 2022. Descriptive data on both presentations were collected.

Results

The December 2021 webinar had 75 unique viewers from 13 countries, and there were 343 asynchronous playbacks. The August 2022 webinar had 38 unique viewers from 9 countries and 310 asynchronous playbacks.

Conclusions

The standardized QIPS methods allow consistent recording of event factors and the inflection point, which are root causes of case morbidity or mortality. Dedication to the program will build a granular databank and identify recurring individual or system issues to launch quality improvement initiatives that address institution-specific needs. QIPS is simple, effective, and reproducible and seeks to create a culture of patient-centered quality and excellence in cardiothoracic surgery programs.

Role of pre-operative counseling with NSQIP surgical risk calculator in the surgical patients

Introduction

Patient satisfaction is important tool to monitor health care performance and quality of health plans, emphasizing effective counseling and consent processes. The objective of the study is to assess patient satisfaction and anxiety with the use of NSQIP surgical risk calculator in comparison to standardized questionnaires.

Methodology

This is an interventional prospective randomized study. Difference in patient satisfaction is assessed by a 7-point Likert scale and anxiety assessment by 5-point Likert scale of Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire written in Nepalese. Satisfaction scores were compared using analysis of variance (ANOVA), or the Kruskal-Wallis test. P- value <0.05 was considered statistically significant.

Results

Satisfaction score regarding comfort during counseling and consent process was similar with and without use of NSQIP surgical risk calculator (83.3 % and 76.9 %, respectively). Satisfaction score regarding plan of anesthesia was 63.33 % with the use of NSQIP and 53.8 % without NSQIP tool. 30.76 % of patients with high school education developed negative feelings following counseling when NSQIP tool was not used (p value 0.002). NSQIP usage increased anxiety about anesthesia and surgery and led to higher continual thinking about the procedure.Duration of counseling was 12 min with NSQIP tool use in comparison to 9.67 min following conventional counseling (p value 0.047).

Conclusion

NSQIP surgical risk calculator is a reliable tool that can be used alongside conventional methods during preoperative period for decision-making and counseling with similar satisfaction scores but a higher incidence of anxiety and continual thinking about procedures.

Effect of conditions being present at time of surgery (PATOS) on outcomes in liver surgery

INTRODUCTION

Information about condition(s) being present at time of surgery (PATOS) in the American College of Surgeons (ASC) National Surgical Quality Improvement Program (NSQIP) database can influence the postoperative complication rates after liver surgeries. Here, we compare the postoperative complication rates with and without taking condition(s) being PATOS into account.

METHODS

We retrospectively reviewed the ACS NSQIP Participant User Files (PUFs) from 2015 through 2019. We analyzed rates of eight different postoperative complications: superficial surgical site infection (SSI), deep SSI, organ space SSI, pneumonia, urinary tract infection, ventilator, sepsis, and septic shock. In addition, we calculated the percent change in event rates after taking into account whether a condition is PATOS.

RESULTS

Of the 22,463 patients in the ACS NSQIP PUFs for liver surgery, 334 (1.49%) had one or more conditions PATOS. The percentages of patients with PATOS events ranged from 2.03% for superficial SSI to 14.74% for sepsis. For all complications, event rates declined when taking condition(s) PATOS into account. From 2015 through 2019, the observed-to-expected ratios for most complications remained unchanged.

CONCLUSION

Whether a condition is PATOS is important in reporting postoperative complication rates for patients undergoing liver surgery. When taking whether a condition is PATOS into account, we demonstrated an overall decrease in event rates across all eight postoperative complications.

Appraising the Quality of Reporting of Vascular Surgery Studies That Use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database

OBJECTIVE

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is an important data source for observational studies. While there are guides to ensure appropriate study reporting, there has been no evaluation of NSQIP studies in vascular surgery. We sought to evaluate the adherence of vascular-surgery related NSQIP studies to best reporting practices.

METHODS

In January 2022, we queried PubMed for all vascular surgery NSQIP studies. We used the REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) statement and the JAMA Surgery (JAMA-Surgery) checklist to assess reporting methodology. We also extracted the Journal Impact Factor (IF) of each article.

RESULTS

One hundred and fifty-nine studies published between 2002 and 2022 were identified and analyzed. The median score on the RECORD statement was 6 out of 8. The most commonly missed RECORD statement items were describing any validation of codes and providing data cleaning information. The median score on the JAMA-Surgery checklist was 2 out of 7. The most commonly missed JAMA-Surgery checklist items were identifying competing risks, using flow charts to help visualize study populations, having a solid research question and hypothesis, identifying confounders, and discussing the implications of missing data. We found no difference in the reporting methodology of studies published in high vs low IF journals.

CONCLUSION

Vascular surgery studies using NSQIP data demonstrate poor adherence to research reporting standards. Critical areas for improvement include identifying competing risks, including a solid research question and hypothesis, and describing any validation of codes. Journals should consider requiring authors use reporting guides to ensure their articles have stringent reporting methodology.

A reduction in hospital length of stay reduces costs for colorectal surgery: an economic evaluation of the National Surgical Quality Improvement Program in Singapore

PURPOSE

In 2017, the National Surgical Quality Improvement Program (NSQIP) was introduced in the Department of Colorectal Surgery at Singapore General Hospital as a pilot quality improvement initiative. This study aimed to examine the cost-effectiveness of NSQIP by evaluating its effects on surgical outcomes, length of stay (LOS), and costs.

METHODS

We retrospectively reviewed patients undergoing colorectal surgery (2017-2020). Patients were divided into two cohorts: pre-NSQIP (2017-2018) and post-NSQIP (2019-2020). Outcomes evaluated were 30-day postoperative complications, LOS, and costs. Total cost-savings from NSQIP intervention's impact on LOS were estimated using a decision model with a one-way sensitivity analysis. Multivariate logistic regression was performed to identify factors for prolonged LOS.

RESULTS

1905 patients underwent colorectal surgery, with 996 in the pre-NSQIP cohort and 909 in the post-NSQIP cohort. A significant reduction in overall postoperative complications of 4.7% was observed in the post-NSQIP cohort (36.5% vs. 31.8%, p = 0.029). Patients in the post-NSQIP cohort had a shorter median LOS (8.0 vs. 6.0 days, p < 0.001). The implementation of NSQIP resulted in an 8.5% decrease in prolonged LOS > 6 days (p < 0.001), saving S$0.31 million on LOS. Total costs per case were reduced by 20.8% following NSQIP (S$39,539.05 vs. S$31,311.93, p < 0.001).

CONCLUSION

Implementing NSQIP has significantly reduced overall postoperative complications, LOS, and costs and achieved cost savings following colorectal surgery.

Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review

Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.

Effect of Present at Time of Surgery (PATOS) on Outcomes in Pancreatic Surgery

INTRODUCTION

While there is some data available on the importance of accounting for the effect of present at time of surgery (PATOS) when estimating unadjusted postoperative complication rates, little is known about the impact of PATOS on outcomes in patients undergoing pancreatic surgery specifically. By taking PATOS into account, we hypothesized that unadjusted, observed postoperative complication rates might be reduced, with these reductions being different across outcomes; however, we expected fewer differences in risk-adjusted results, i.e., observed to expected ratios (O/E ratios).

METHODS

We retrospectively analyzed the ACS NSQIP Participant Use Files (PUFs) from 2015 to 2019. PATOS data were analyzed for the 8 postoperative complications of superficial, deep, and organ space surgical site infection; pneumonia; urinary tract infection; ventilator dependence; sepsis; and septic shock. Postoperative complication rates were compared by ignoring PATOS vs. taking PATOS into account.

RESULTS

Of the 31,919 patients in the ACS NSQIP PUFs who underwent pancreatic surgery, 1120 (3.51%) patients had one or more PATOS conditions. The event rates after taking PATOS into account declined for all outcomes-superficial surgical site infection (SSI) rates reduced by 2.56%, deep SSI rates reduced by 4.28%, organ space SSI rates reduced by 9.31%, pneumonia rates reduced by 2.91%, urinary tract infection rates declined by 4.69%, and septic shock rates declined by 9.27%.

CONCLUSION

Our paper highlights that accounting for PATOS is important for estimating unadjusted postoperative complication rates in patients undergoing pancreatic surgery. Risk adjustment is essential to any attempt at quality assessment and benchmarking. Failure to account for PATOS may penalize surgeons who care for the sickest and most complicated patients and subsequently encourage cherry-picking of less risky patients and procedures.

Outcomes After Supratentorial Craniotomy for Primary Malignant Brain Tumor Resection in Adult Patients: A National Surgical Quality Improvement Program Analysis

BACKGROUND

The rate of complications remains significant after craniotomy for supratentorial primary malignant brain tumors despite recent advances.

OBJECTIVE

The goal of this study is to characterize factors associated with these complications.

METHODS

Data were extracted from the National Surgical Quality Improvement Program database from 2016 to 2019. Patients who underwent a craniotomy for resection of supratentorial primary malignant brain tumors were included. Covariates included demographics/comorbidities, preoperative laboratory values, American Society of Anesthesiologists (ASA) classification, operative time, and postoperative complications. Multivariable logistic regression with backward and forward selection was used to evaluate independent predictors of death, prolonged hospitalization, postoperative stroke with neurologic deficit (CVA), and unplanned readmission. Predictive fit of the model was evaluated using the area under the receiver operating curve (AUC).

RESULTS

Of 8965 included cases, the 30-day postoperative risks were 1.9% for CVA, 10.1% for unplanned readmission, 1.2% for prolonged hospitalization, and 2.4% for death. Age, ASA category, disseminated cancer, preoperative functional dependence, and postoperative respiratory complications were predictors of 30-day mortality (AUC, 0.83; P < 0.001). CVA was best predicted by increased operation time (P < 0.001), age, ASA category, and recent weight loss (AUC, 0.63; P = 0.009). Prolonged hospitalization was predicted by nonelective surgery status, time from admission to surgery, reintubation, and postoperative sepsis (AUC, 0.78; P < 0.001). Unplanned readmission was predicted by chronic steroid use, postoperative thrombotic complications after surgery, organ/space surgical site infection, deep vein thrombosis, postoperative systemic sepsis, and septic shock (AUC, 0.68; P < 0.001).

CONCLUSIONS

Our study identifies predictors of major 30-day complications after craniotomy for this subset of patients with brain tumor.

Changes in Surgical Outcomes in a Statewide Quality Improvement Collaborative with Introduction of Simultaneous, Comprehensive Interventions

BACKGROUND

Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes.

STUDY DESIGN

Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control.

RESULTS

There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance.

CONCLUSIONS

Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes.

Postoperative rehospitalization in older surgical patients: an age-stratified analysis

BACKGROUND

Older adults comprise 40% of surgical inpatients and are at increased risk of postoperative rehospitalization. A decade ago, 30-day rehospitalizations for Medicare patients were reported as 15%, and more than 70% was attributed to medical causes. In the interim, there have been several large-scale efforts to establish best practice for older patients through surgical quality programs and national initiatives by Medicare and the National Health Service. To understand the current state of rehospitalization in the USA, we sought to report the incidence and cause of 30-day rehospitalization across surgical types by age.

STUDY DESIGN

We performed a retrospective study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset from 2015 to 2019. Our primary exposure of interest was age. Patients were categorized into four groups: 18-49, 50-64, 65-74, and 75 + years old. Reasons for rehospitalization were evaluated using NSQIP defined causes and reported International Classification of Disease (ICD)-9 and ICD-10 codes. Our primary outcome was the incidence of unplanned 30-day rehospitalization and secondary outcome the cause for rehospitalization. Variables were summarized by age group through relative (%) and absolute (n) frequencies; chi-square tests were used to compare proportions. Since rehospitalization is a time-to-event outcome in which death is a competing event, the cumulative incidence of rehospitalization at 30 days was estimated using the procedure proposed by Gray. The same strategy was used for estimating the cumulative incidence for unplanned rehospitalizations.

RESULTS

A total of 2,798,486 patients met inclusion criteria; 198,542 had unplanned rehospitalization (overall 7.09%). Rehospitalization by age category was 6.12, 6.99, 7.50, and 9.50% for ages 18-49, 50-64, 65-74, and 75 + , respectively. Complications related to the digestive system were the single most common cause of rehospitalization across age groups. Surgical site infection was the second most common cause, with the relative frequency decreasing with age as follows: 21.74%, 19.08%, 15.09%, and 9.44% (p < .0001). Medical causes such as circulatory or respiratory complications were more common with increasing age (2.10%, 4.43%, 6.27%, 8.86% and 3.27, 4.51, 6.07, 8.11%, respectively).

CONCLUSION

We observed a decrease in overall rehospitalization for older surgical patients compared to studies a decade ago. The oldest (≥ 75) surgical patients had the highest 30-day rehospitalization rates (9.50%). The single most common reason for rehospitalization was the same across age groups and likely attributed to surgery (ileus). However, the aggregate of medical causes of rehospitalization was more common in older patients; surgical and respiratory reasons were twice as common in this group. Rehospitalization increased by age for some surgery types, e.g., lower extremity bypass, more than others, e.g., ventral hernia repair. Future investigations should focus on interventions to reduce medical complications and further decrease postoperative rehospitalization for older surgical patients undergoing high-risk procedures.

The BETTY Score to Predict Perioperative Outcomes in Surgical Patients

The aim of this study is to evaluate a new user-friendly scoring system, namely the BETTY score, that aims to predict 30-day patient outcomes after surgery. In this first description, we rely on a population of prostate cancer patients undergoing robot-assisted radical prostatectomy. The BETTY score includes the patient's American Society of Anesthesiologists score, the body mass index, and intraoperative data, including operative time, estimated blood loss, any major intraoperative complications, hemodynamic, and/or respiratory instability. There is an inverse relationship between the score and severity. Three clusters assessing the risk of postoperative events were defined: low, intermediate, and high risk of postoperative events. A total of 297 patients was included. The median length of hospital stay was 1 day (IQR1-2). Unplanned visits, readmissions, any complications, and serious complications occurred in 17.2%, 11.8%, 28.3%, and 5% of cases, respectively. We found a statistically significant correlation between the BETTY score and all endpoints analyzed (all p ≤ 0.01). A total of 275, 20, and 2 patients were classified as low-, intermediate-, and high-risk according to the BETTY scoring system, respectively. Compared with low-risk patients, patients at intermediate-risk were associated with worse outcomes for all endpoints analyzed (all p ≤ 0.04). Future studies, in various surgical subspecialties, are ongoing to confirm the usefulness of this easy-to-use score in routine.

Association of Viral Hepatitis Status and Post-hepatectomy Outcomes in the Era of Direct-Acting Antivirals

BACKGROUND

The role of viral hepatitis status in post-hepatectomy outcomes has yet to be delineated. This large, multicentred contemporary study aimed to evaluate the effect of viral hepatitis status on 30-day post-hepatectomy complications in patients treated for hepatocellular carcinoma (HCC).

METHODS

Patients from the National Surgical Quality Improvement Program (NSQIP) database with known viral hepatitis status, who underwent hepatectomy for HCC between 2014 and 2018, were included. Patients were classified as HBV-only, HCV-only, HBV and HCV co-infection (HBV/HCV), or no viral hepatitis (NV). Multivariable models were used to assess outcomes of interest. The primary outcome was any 30-day post-hepatectomy complication. The secondary outcomes were major complications and post-hepatectomy liver failure (PHLF). Subgroup analyses were performed for cirrhotic and noncirrhotic patients.

RESULTS

A total of 3234 patients were included. The 30-day complication rate was 207/663 (31.2%) HBV, 356/1077 (33.1%) HCV, 29/81 (35.8%) HBV/HCV, and 534/1413 (37.8%) NV (p = 0.01). On adjusted analysis, viral hepatitis status was not associated with occurrence of any 30-day post-hepatectomy complications (ref: NV, HBV odds ratio (OR) 0.89 [95% confidence interval (CI): 0.71-1.12]; HCV OR 0.91 [95% CI: 0.75-1.10]; HBV/HCV OR 1.17 [95% CI: 0.71-1.93]). Similar results were found in cirrhotic and noncirrhotic subgroups, and for secondary outcomes: occurrence of any major complications and PHLF.

CONCLUSIONS

In patients with HCC managed with resection, viral hepatitis status is not associated with 30-day post-hepatectomy complications, major complications, or PHLF compared with NV. This suggests that clinical decisions and prognostication of 30-day outcomes in this population likely should not be made based on viral hepatitis status.

Preoperative Prediction of Unplanned Reoperation in a Broad Surgical Population

INTRODUCTION

Unplanned reoperation is an undesirable outcome with considerable risks and an increasingly assessed quality of care metric. There are no preoperative prediction models for reoperation after an index surgery in a broad surgical population in the literature. The Surgical Risk Preoperative Assessment System (SURPAS) preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict unplanned reoperation has not been assessed. This study's objective was to determine whether the SURPAS model could accurately predict unplanned reoperation.

METHODS

This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database, 2012-2018. An unplanned reoperation was defined as any unintended operation within 30 d of an initial scheduled operation. The 8-variable SURPAS model and a 29-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program nonlaboratory preoperative variables, were developed using multiple logistic regression and compared using discrimination and calibration metrics: C-indices (C), Hosmer-Lemeshow observed-to-expected plots, and Brier scores (BSs). The internal chronological validation of the SURPAS model was conducted using "training" (2012-2017) and "test" (2018) datasets.

RESULTS

Of 5,777,108 patients, 162,387 (2.81%) underwent an unplanned reoperation. The SURPAS model's C-index of 0.748 was 99.20% of that for the full model (C = 0.754). Hosmer-Lemeshow plots showed good calibration for both models and BSs were similar (BS = 0.0264, full; BS = 0.0265, SURPAS). Internal chronological validation results were similar for the training (C = 0.749, BS = 0.0268) and test (C = 0.748, BS = 0.0250) datasets.

CONCLUSIONS

The SURPAS model accurately predicted unplanned reoperation and was internally validated. Unplanned reoperation can be integrated into the SURPAS tool to provide preoperative risk assessment of this outcome, which could aid patient risk education.

A machine learning approach to predicting early and late postoperative reintubation

Accurate estimation of surgical risks is important for informing the process of shared decision making and informed consent. Postoperative reintubation (POR) is a severe complication that is associated with postoperative morbidity. Previous studies have divided POR into early POR (within 72 h of surgery) and late POR (within 30 days of surgery). Using data provided by American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), machine learning classification models (logistic regression, random forest classification, and gradient boosting classification) were utilized to develop scoring systems for the prediction of combined, early, and late POR. The risk factors included in each scoring system were narrowed down from a set of 37 pre and perioperative factors. The scoring systems developed from the logistic regression models demonstrated strong performance in terms of both accuracy and discrimination across the different POR outcomes (Average Brier score, 0.172; Average c-statistic, 0.852). These results were only marginally worse than prediction using the full set of risk variables (Average Brier score, 0.145; Average c-statistic, 0.870). While more work needs to be done to identify clinically relevant differences between the early and late POR outcomes, the scoring systems provided here can be used by surgeons and patients to improve the quality of care overall.

Trends and Variations in Drain Use Following Pancreatoduodenectomy: Is Early Drain Removal Becoming More Common?

BACKGROUND

Although previous studies have noted the potential benefit of early drain removal (EDR) after pancreatoduodenectomy (PD), there is a paucity of data on the timing of drain removal utilizing a national database that reflect the "real world" setting. Given the ongoing controversy related to PD drain use and management, we sought to define trends in drain use among a large national cohort, as well as identify factors associated with EDR following PD.

METHODS

The ACS NSQIP targeted pancreatectomy database was used to identify patients who underwent PD between 2014 and 2020. The trend in proportion of patients with EDR (removal ≤ POD3) as well as predictors of EDR were assessed. Risk-adjusted postoperative outcomes were evaluated by multivariable regression analysis.

RESULTS

Among 14,356 patients, 16.2% of patients (N = 2324) experienced EDR, and the proportion of patients with EDR increased by 68% over the study period (2014: 10.9% vs. 2020: 18.3%, p < 0.001). Higher drain fluid amylase on POD1-3 [LogWorth (LW) = 44.3], operative time (LW = 33.2), and use of minimally invasive surgery (LW = 14.0) were associated with EDR. Additionally, EDR was associated with decreased risk of overall and serious morbidity, PD-related morbidity (e.g., pancreatic fistula), reoperation, prolonged length of stay and readmission (all p < 0.05).

CONCLUSIONS

Routine drain placement remains a common practice among most surgeons. EDR following PD increased over time was associated with lower post-operative complications and shorter LOS. Despite evidence that EDR was safe and may even be associated with lower complications, only 1 in 6 patients were managed with EDR.

The implications of fragmented practice in hepatopancreatic surgery

BACKGROUND

Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an "optimal" postoperative course.

METHODS

Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon's volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression.

RESULTS

A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84-0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54-0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52-0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52-0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54-0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12-1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28-1.46]).

CONCLUSION

Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.

Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy?

BACKGROUND

It is well known that, in general, total laparoscopic hysterectomy is associated with less perioperative morbidity compared with total abdominal hysterectomy. However, total laparoscopic hysterectomy is also associated with longer operating times, which itself is an independent predictor of morbidity. Currently, it is unknown whether there is an operative time threshold beyond which total laparoscopic hysterectomy provides a diminishing return and higher risk of morbidity than a shorter abdominal hysterectomy.

OBJECTIVE

This study aimed to determine whether there is an operative time limit beyond which the benefits of total laparoscopic hysterectomy diminished compared with shorter total abdominal hysterectomy.

STUDY DESIGN

Targeted hysterectomy-specific data from the National Surgical Quality Improvement Project was used to identify patients undergoing total laparoscopic hysterectomy and total abdominal hysterectomy for benign indications between the years 2014 and 2018. The primary outcomes of interest were any major morbidity, and the length of stay after surgery was analyzed using generalized linear models. The models controlled for demographic data, comorbidities, and hysterectomy-specific information, such as uterine weight, presence of endometriosis, and pelvic inflammatory disease at the time of surgery. Missing data were addressed using multiple imputation analysis. Sensitivity analyses using propensity score matching and generalized additive models were performed to assess the effect of selection bias and nonlinear interactions between covariates and the outcomes, respectively. Common Procedural Terminology codes were used to identify women who underwent total abdominal hysterectomy (n=58,152) or total laparoscopic hysterectomy (n=58,570-58,573). Conventional laparoscopy could not be differentiated from robotic surgery as there is no mechanism for doing so within the National Surgical Quality Improvement Project. Therefore, total laparoscopic hysterectomy also includes robotic-assisted surgery. Additional exclusion criteria included any surgery lasting >360 minutes, as these represent significant outliers in the data and clinical practice; pelvic reconstructive procedure; anti-incontinence surgery; lymphadenectomy; radical hysterectomy; cytoreductive surgery; a pre- or postoperative diagnostic code for gynecologic malignancy; preoperative sepsis or renal failure; emergency surgery; or any concurrent nongynecologic surgery. Patients who underwent ureteral stenting during the procedure with no additional urologic procedures were included, as this may be performed at the time of hysterectomy or to address ureteral injury.

RESULTS

The mean operating time was similar for both routes, 129±60 minutes for total laparoscopic hysterectomy and 129±64 minutes for total abdominal hysterectomy (P=.45). The complication rate was higher for total abdominal hysterectomy than total laparoscopic hysterectomy (16.6% vs 7.7%; P<.001); and the median length of stay was longer for total abdominal hysterectomy (2 [interquartile range, 2-3] days vs 1 [interquartile range, 0-1] days; P<.001). After adjusting for confounders, an increase of 1 hour in operative time for hysterectomy was associated with a 45% (95% confidence interval, 41%-49%) increase in the risk of major morbidity; furthermore, total abdominal hysterectomy was associated with an additional time detriment, such that there was an additional 61% (95% confidence interval, 53%-68%) increase in the risk of a major morbidity for each additional hour of a total abdominal hysterectomy. There was no time point at which total abdominal hysterectomy was associated with less morbidity or a shorter length of stay than total laparoscopic hysterectomy, even if total laparoscopic hysterectomy was significantly longer than total abdominal hysterectomy. The same conclusions remained true with the propensity-matched analysis and generalized additive model analyses.

CONCLUSION

Our findings showed that there is no reasonable operative time at which total laparoscopic hysterectomy is associated with a higher rate of complications or longer length of stay than total abdominal hysterectomy.

A Machine Learning-Based Online Prediction Tool for Predicting Short-Term Postoperative Outcomes Following Spinal Tumor Resections

Background: Preoperative prediction of short-term postoperative outcomes in spinal tumor patients can lead to more precise patient care plans that reduce the likelihood of negative outcomes. With this study, we aimed to develop machine learning algorithms for predicting short-term postoperative outcomes and implement these models in an open-source web application. Methods: Patients who underwent surgical resection of spinal tumors were identified using the American College of Surgeons, National Surgical Quality Improvement Program. Three outcomes were predicted: prolonged length of stay (LOS), nonhome discharges, and major complications. Four machine learning algorithms were developed and integrated into an open access web application to predict these outcomes. Results: A total of 3073 patients that underwent spinal tumor resection were included in the analysis. The most accurately predicted outcomes in terms of the area under the receiver operating characteristic curve (AUROC) was the prolonged LOS with a mean AUROC of 0.745 The most accurately predicting algorithm in terms of AUROC was random forest, with a mean AUROC of 0.743. An open access web application was developed for getting predictions for individual patients based on their characteristics and this web application can be accessed here: huggingface.co/spaces/MSHS-Neurosurgery-Research/NSQIP-ST. Conclusion: Machine learning approaches carry significant potential for the purpose of predicting postoperative outcomes following spinal tumor resections. Development of predictive models as clinically useful decision-making tools may considerably enhance risk assessment and prognosis as the amount of data in spinal tumor surgery continues to rise.

Impact of Prolonged Operative Duration on Postoperative Symptomatic Venous Thromboembolic Events After Thoracolumbar Spine Surgery

OBJECTIVE

To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion.

METHODS

We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE.

RESULTS

We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event.

CONCLUSIONS

Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.

A comparison of NSQIP and CESQIP in data quality and ability to predict thyroidectomy outcomes

BACKGROUND

The Collaborative Endocrine Surgery Quality Improvement Program tracks thyroidectomy outcomes with self-reported data, whereas the National Surgical Quality Improvement Program uses professional abstractors. We compare completeness and predictive ability of these databases at a single-center and national level.

METHOD

Data consistency in the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program at a single institution (2013-2020) was evaluated using McNemar's test. At the national level, data from the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program (2016-2019) were used to compare predictive capability for 4 outcomes within each data source: thyroidectomy-specific complication, systemic complication, readmission, and reoperation, as measured by area under curve.

RESULTS

In the single-center analysis, 66 cases were recorded in both the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program. The reoperation variable had the most discrepancies (2 vs 0 in the National Surgical Quality Improvement Program versus the Collaborative Endocrine Surgery Quality Improvement Program, respectively; χ² = 2.00, P = .16). At the national level, there were 24,942 cases in the National Surgical Quality Improvement Program and 17,666 cases in the Collaborative Endocrine Surgery Quality Improvement Program. In the National Surgical Quality Improvement Program, 30-day thyroidectomy-specific complication, systemic complication, readmission, and reoperation were 13.25%, 2.13%, 1.74%, and 1.39%, respectively, and in the Collaborative Endocrine Surgery Quality Improvement Program 7.27%, 1.95%, 1.64%, and 0.81%. The area under curve of the National Surgical Quality Improvement Program was higher for predicting readmission (0.721 [95% confidence interval 0.703-0.737] vs 0.613 [0.581-0.649]); the area under curve of the Collaborative Endocrine Surgery Quality Improvement Program was higher for thyroidectomy-specific complication (0.724 [0.708-0.737] vs 0.677 [0.667-0.687]) and reoperation (0.735 [0.692-0.775] vs 0.643 [0.611-0.673]). Overall, 3.44% vs 27.22% of values were missing for the National Surgical Quality Improvement Program and the Collaborative Endocrine Surgery Quality Improvement Program, respectively.

CONCLUSION

The Collaborative Endocrine Surgery Quality Improvement Program was more accurate in predicting thyroidectomy-specific complication and reoperation, underscoring its role in collecting granular, disease-specific variables. However, a higher proportion of data are missing. The National Surgical Quality Improvement Program infrastructure leads to more rigorous data capture, but the Collaborative Endocrine Surgery Quality Improvement Program is better at predicting thyroid-specific outcomes.

Effect of Present at Time of Surgery on Unadjusted and Risk-Adjusted Postoperative Complication Rate

BACKGROUND

Present at the time of surgery (PATOS) is an important measure to collect in postoperative complication surveillance systems because it may affect a patient's risk of a subsequent complication and the estimation of postoperative complication rates attributed to the healthcare system. The American College of Surgeons (ACS) NSQIP started collecting PATOS data for 8 postoperative complications in 2011, but no one has used these data to quantify how this may affect unadjusted and risk-adjusted postoperative complication rates.

STUDY DESIGN

This study was a retrospective observational study of the ACS NSQIP database from 2012 to 2018. PATOS data were analyzed for the 8 postoperative complications of superficial, deep, and organ space surgical site infection; pneumonia; urinary tract infection; ventilator dependence; sepsis; and septic shock. Unadjusted postoperative complication rates were compared ignoring PATOS vs taking PATOS into account. Observed to expected ratios over time were also compared by calculating expected values using multiple logistic regression analyses with complication as the dependent variable and the 28 nonlaboratory preoperative variables in the ACS NSQIP database as the independent variables.

RESULTS

In 5,777,108 patients, observed event rates for each outcome were reduced by between 6.1% (superficial surgical site infection) and 52.5% (sepsis) when PATOS was taken into account. The observed to expected ratios were similar each year for all outcomes, except for sepsis and septic shock in the early years.

CONCLUSIONS

Taking PATOS into account is important for reporting unadjusted event rates. The effect varied by type of complication-lowest for superficial surgical site infection and highest for sepsis and septic shock. Taking PATOS into account was less important for risk-adjusted outcomes (observed to expected ratios), except for sepsis and septic shock.

Complications and postoperative non-steroidal anti-inflammatory use of three extracapsular cruciate ligament repair techniques performed in a general practice clinic environment

OBJECTIVE

To report complications and postoperative non-steroidal anti-inflammatory use associated with fabellotibial suture, Tightrope and Ligafiba Isotoggle procedures performed on dogs of varying weights within a general practice setting.

MATERIALS AND METHODS

Clinical records of eligible patients from 2009 to 2018 were retrospectively extracted from five general practice clinics. Data for signalment, patient weight, surgery performed, complications, postoperative use of non-steroidal anti-inflammatory drugs, and timing thereof were extracted and analysed using multinomial logistic regression. Predicted probability tables were generated for complications and non-steroidal anti-inflammatory drug use.

RESULTS

The study included 370 surgeries, with 97 fabellotibial suture, 158 Tightrope and 42 Ligafiba Isotoggle procedures in patients less than 15 kg, and 43 fabellotibial suture, 16 Tightrope and 30 Ligafiba Isotoggle procedures in patients at least 15 kg. The proportion of patients that can be expected to have no complications was greatest for older dogs (9 years) weighing less than 15 kg (fabellotibial suture, 91%; Tightrope/Ligafiba Isotoggle, 88%), and the highest major medical and surgical complication risks were expected in young dogs (1 year) weighing over 15 kg (fabellotibial suture, 28%; Tightrope/Ligafiba Isotoggle, 59%). The predicted risk of requiring repeated non-steroidal anti-inflammatory drug prescriptions in the 18-month postoperative period for an 15 kg patient was 37% to 39%.

CONCLUSION

Weight and age were significant factors influencing complications and postoperative non-steroidal anti-inflammatory drug use in fabellotibial suture, Tightrope and Ligafiba Isotoggle surgical patients in a general practice setting.

CLINICAL SIGNIFICANCE

Clinicians should consider the possibility of complications and requirement for ongoing non-steroidal anti-inflammatory drug use before performing extracapsular procedures in patients weighing more than 15 kg.

Preparing for participation in the centers for Medicare and Medicaid Services' bundle care payment initiative-advanced for major bowel surgery

BACKGROUND

As healthcare costs rise, there is an increasing emphasis on alternative payment models to improve care efficiency. The bundled payment represents an alternative reimbursement model gaining popularity within the surgical sphere. We aimed to assess where the largest opportunities for care improvement lay and how best to identify patients at high risk of suffering costly complications.

METHODS

We utilized itemized CMS claims data for a retrospective cohort of patients between 2014 and 2016 who met inclusion criteria for the Major Bowel Bundled Payment Program and performed a cost analysis to identify opportunities for improved care efficiency. Based on the results of this cost analysis, we identified readmissions as a target for improvement. We then assessed whether the American College of Surgeons' National Surgical Quality Improvement Program surgical risk calculator (ACS NSQIP SRC) could accurately identify patients within our bundled payment population who were at high risk of readmission using a logistic regression model.

RESULTS

Our study cohort included 252 patients. Readmissions accounted for 12.8% of the average total care episode cost with a coefficient of variation of 2.72, thereby representing the most substantial, non-fixed cost for our bundled payment patients. Patients readmitted within their 90-day care episode were 2.53 times more likely to be high-cost (>$60,000) than patients not readmitted. However, the ACS NSQIP SRC did not accurately predict patients at high risk of readmission within the first 30 days with an AUROC of 0.58.

CONCLUSIONS

Our study highlights the importance of reducing readmissions as a central component of improving care for bowel surgery bundled payment patients. Preventing such readmissions requires accurate identification of patients at high risk of readmission; however, current risk prediction models lack the adaptability necessary for this task.

Respiratory Compromise After Anterior Cervical Spine Surgery: Incidence, Subsequent Complications, and Independent Predictors

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Respiratory compromise (RC) is a rare but catastrophic complication of anterior cervical spine surgery (ACSS) commonly due to compressive fluid collections or generalized soft tissue swelling in the cervical spine. Established risk factors include operative duration, size of surgical exposure, myelopathy, among others. The purpose of this current study is to identify the incidence and clinical course of patients who develop RC, and identify independent predictors of RC in patients undergoing ACSS for cervical spondylosis.

METHODS

A large, prospectively-collected registry was used to identify patients undergoing ACSS for spondylosis. Patients with posterior cervical procedures were excluded. Baseline patient characteristics were compared using bivariate analysis, and multivariate analysis was employed to compare postoperative complications and identify independent predictors of RC.

RESULTS

298 of 52,270 patients developed RC (incidence 0.57%). Patients who developed RC had high rates of 30-day mortality (11.7%) and morbidity (75.8%), with unplanned reoperation and pneumonia the most common. The most common reason for reoperations were hematoma evacuation and tracheostomy. Independent patient-specific factors predictive of RC included increasing patient age, male gender, comorbidities such as chronic cardiac and respiratory disease, preoperative myelopathy, prolonged operative duration, and 2-level ACCFs.

CONCLUSION

This is among the largest cohorts of patients to develop RC after ACSS identified to-date and validates a range of independent predictors, many previously only described in case reports. These results are useful for taking preventive measures, identifying high risk patients for preoperative risk stratification, and for surgical co-management discussions with the anesthesiology team.