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Dhimal T, Loria A, Juviler P, Hilty BK, Levatino E, Schiralli MP, Fleming FJ. Quality improvement in surgical collaboratives: Characterizing resources and care variation to facilitate implementation and dissemination. Surgery 2024; 176:214-216. [PMID: 38729886 DOI: 10.1016/j.surg.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/04/2024] [Accepted: 03/21/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Totadri Dhimal
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Peter Juviler
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Bailey K Hilty
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth Levatino
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Silver CM, Yang AD, Shan Y, Love R, Prachand VN, Cradock KA, Johnson J, Halverson AL, Merkow RP, McGee MF, Bilimoria KY. Changes in Surgical Outcomes in a Statewide Quality Improvement Collaborative with Introduction of Simultaneous, Comprehensive Interventions. J Am Coll Surg 2023; 237:128-138. [PMID: 36919951 DOI: 10.1097/xcs.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
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.
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Affiliation(s)
- Casey M Silver
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
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Hospital-level variation in mesh use for ventral and incisional hernia repair. Surg Endosc 2023; 37:1501-1507. [PMID: 35851814 DOI: 10.1007/s00464-022-09357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/16/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Placement of prosthetic mesh during ventral and incisional hernia repair has been shown to reduce the incidence of postoperative hernia recurrence. Consequently, multiple consensus guidelines recommend the use of mesh for ventral hernias of any size. However, the extent to which real-world practice patterns reflect these recommendations is unclear. METHODS We performed a retrospective review of the Michigan Surgical Quality Collaborative Hernia Registry (MSQC-HR) to identify patients undergoing clean ventral or incisional hernia repair between January 1, 2020 and December 31, 2021. The primary outcome was mesh use. We used two-step hierarchical logistic regression modeling with empirical Bayes estimates to evaluate the association of hospital-level mesh use with patient, operative, and hernia characteristics. RESULTS A total of 5262 patients underwent ventral and incisional hernia repair at 65 hospitals with a mean age of 53.8 (14.5) years, 2292 (43.6%) females, and a mean hernia width of 3.2 (3.4) cm. Mean hospital volume was 81 (49) cases. Mesh was used in 4098 (77.9%) patients. At the patient level, hernia width and surgical approach were significantly associated with mesh use. Specifically, mesh use was 6.2% (95% CI 4.8-7.5%) more likely with each additional centimeter of hernia width and 28.0% (95% CI 26.1-29.8%) more likely for minimally invasive repair compared to open repair. At the hospital level, there was wide variation in mesh use, ranging from 38.0% (95% CI 31.5-44.9%) to 96.4% (95% CI 95.3-97.2%). Hospital-level mesh use was not associated with differences in hernia size (β = - 0.003, P = 0.978), surgical approach (β = - 1.109, P = 0.414), or any other patient factors. CONCLUSIONS Despite strong evidence supporting the use of mesh in ventral and incisional hernia repair, there is substantial variation in mesh use between hospitals that is not explained by differences in patient characteristics or operative approach. This suggests that opportunities exist to standardize surgical practice to better align with evidence supporting the use of mesh in the management of these hernias.
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Howard R, Hendren S, Duby AA, Wezner M, Englesbe M, Dimick JB, Byrn JC, Byrnes ME. "Learn from each other": A qualitative exploration of collaborative quality improvement. Surgery 2022; 172:1415-1421. [PMID: 36088171 DOI: 10.1016/j.surg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/01/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Collaborative quality improvement is an established method to conduct quality improvement in surgical care. Despite the success of this method, little is known about the experiences, perceptions, and attitudes of those who participate in collaborative quality improvement. The following study elicited common themes associated with the experiences and perceptions of surgeons participating in collaborative quality improvement. METHODS We conducted an interpretive description qualitative study of surgeons participating in the Michigan Surgical Quality Collaborative, which is a statewide collaborative quality improvement consortium in Michigan. Semi-structured interviews were conducted using an interview guide. RESULTS A sample of 24 participants completed interviews with a mean (SD) age of 48.7 (11.5) years and 16 (80%) male participants. Two major themes were identified. First, the contextualization of individual performance was seen as key to identifying opportunities for improvement and creating motivation to improve. Contextualization of individual performance relative to peer performance was collaborative rather than punitive. Second, peer learning emerged as the primary way to inform practice change and overcome hesitancy to change. Rather than draw upon external evidence, practice change within the collaborative was informed by the practices of peer institutions. Both themes were strongly exemplified in one of the Michigan Surgical Quality Collaborative's largest initiatives-reducing excessive postoperative opioid prescribing. CONCLUSION In this qualitative study of surgeons participating in statewide collaborative quality improvement, contextualization of individual outcomes and peer learning were the most salient themes. Collaborative quality improvement relied upon comparing one's own performance to peer performance, motivating improvement using this comparison, deriving evidence from peers to inform improvement initiatives, and overcoming hesitancy to change by highlighting peer success.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, Ann Arbor, MI. http://www.twitter.com/rhowmd
| | - Samantha Hendren
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Ashley A Duby
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Matthew Wezner
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI. http://www.twitter.com/MichaelEnglesbe
| | - Justin B Dimick
- Department of Surgery, Michigan Medicine, Ann Arbor, MI. http://www.twitter.com/jdimick1
| | - John C Byrn
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Mary E Byrnes
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, Ann Arbor, MI.
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Howard R, Ehlers A, Delaney L, Solano Q, Fry B, Englesbe M, Dimick J, Telem D. Incidence and trends of decision regret following elective hernia repair. Surg Endosc 2022; 36:6609-6616. [PMID: 35879569 DOI: 10.1007/s00464-021-08766-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND One approach to evaluate decision-making is using the concept of decision regret, which measures patient remorse after a healthcare decision. This is particularly important for elective, preference-sensitive conditions with multiple treatment options, such as ventral and inguinal hernia repair. In this study, we assessed decision regret among patients who pursued surgical management of ventral and inguinal hernias. METHODS We retrospectively reviewed a statewide registry of adult patients who underwent elective ventral and inguinal hernia repair between January 2017 and March 2020 and completed a validated survey measuring decision regret. 30-day outcomes included complications, emergency department (ED) utilization, readmission, and reoperation. Multivariable logistic regression examined the association of regret with age, sex, race, insurance status, ASA, tobacco use, diabetes, admission status, surgical approach (open vs. laparoscopic vs. robotic), year, and outcomes. RESULTS 8315 patients underwent surgery during the study period with a mean age of 60.5 (14.7) years and 1812 (22%) female patients. Among 2159 patients who underwent ventral hernia repair, 248 (11%) reported regret to undergo surgery, 64 (3%) experienced a complication, 160 (7%) visited an ED, 86 (4%) were readmitted, and 29 (1%) underwent reoperation. Outcomes associated with regret after ventral hernia repair included complications (OR 2.33, 95% CI 1.26-4.29) and readmission (OR 2.67, 95% CI 1.51-4.71). Among 6,156 patients who underwent inguinal hernia repair, 533 (9%) reported regret to undergo surgery, 41 (1%) experienced a complication, 304 (5%) visited an ED, 72 (1%) were readmitted, and 63 (1%) underwent reoperation. Outcomes associated with regret after inguinal hernia repair included ED visits (OR 2.03, 95% CI 1.44-2.87) and readmission (OR 4.23, 95% CI 2.35-7.61). CONCLUSION Roughly 1 in 10 patients undergoing hernia repair report regret with their decision to undergo surgery. Developing a better understanding of the factors associated with decision regret after hernia repair may better inform both patients and surgeon decision-making.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Anne Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Lia Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Quintin Solano
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian Fry
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA
| | - Dana Telem
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA.
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