Value in acute care surgery, part 2: Defining and measuring quality outcomes

Value in acute care surgery, part 4: The economic value of an acute care surgery service to a hospital system

ABSTRACT

The Healthcare Economics Committee of the American Association for the Surgery of Trauma has published a series of three articles on the topic of value in acute care surgery (ACS). In this series, the key elements of value, cost and outcomes, and the impact of stakeholder perspective on what constitutes high-value care are discussed. The fourth article in this series continues the discussion by focusing on the unique economic value that an ACS service brings to a hospital system and its patients. Characterized by the immediate 24-hour availability of surgeons trained in trauma management, emergency general surgery, and surgical critical care, acute care surgeons extend the benefits of surgical rescue and critical care to all hospitalized patients. As such, an ACS service acts as a vital part of a hospital's infrastructure to successfully care for complex and seriously ill patients, in addition to enabling the establishment of other, high revenue-generating services such as vascular, transplant, and complex oncologic surgery programs. The trauma service acts as intake for patients that lead to downstream revenue creation by other disciplines such as orthopedic and neurological surgery, while trauma center designation itself results in dedicated state funding to ensure trauma readiness in many states in the United States. The traditional "value equation" in health care of outcomes achieved per dollar spent is ill-suited to capture many of these unique aspects and benefits of ACS. This article provides the background to understand the economic value of an ACS service and future directions toward improving overall value of care.

Days at home after surgery as a perioperative outcome: scoping review and recommendations for use in health services research

BACKGROUND

Days at home after surgery is a promising new patient-centred outcome metric that measures time spent outside of healthcare institutions and mortality. The aim of this scoping review was to synthesize the use of days at home in perioperative research and evaluate how it has been termed, defined, and validated, with a view to inform future use.

METHODS

The search was run on MEDLINE, Embase, and Scopus on 30 March 2023 to capture all perioperative research where days at home or equivalent was measured. Days at home was defined as any outcome where time spent outside of hospitals and/or healthcare institutions was calculated.

RESULTS

A total of 78 articles were included. Days at home has been increasingly used, with most studies published in 2022 (35, 45%). Days at home has been applied in multiple study design types, with varying terminology applied. There is variability in how days at home has been defined, with variation in measures of healthcare utilization incorporated across studies. Poor reporting was noted, with 14 studies (18%) not defining how days at home was operationalized and 18 studies (23%) not reporting how death was handled. Construct and criterion validity were demonstrated across seven validation studies in different surgical populations.

CONCLUSION

Days at home after surgery is a robust, flexible, and validated outcome measure that is being increasingly used as a patient-centred metric after surgery. With growing use, there is also growing variability in terms used, definitions applied, and reporting standards. This review summarizes these findings to work towards coordinating and standardizing the use of days at home after surgery as a patient-centred policy and research tool.

Complication reporting in trauma: An environmental scan and comparison of nationwide trauma registry data

BACKGROUND

To explore variability in quality measurement, this study aimed to compare abstraction and definitions of complications reported across trauma registries in Canada.

METHODS

A literature search was performed to identify active trauma registries used in Canadian hospitals. Registry characteristics, data abstraction, and reported complications and definitions based on registry data dictionaries were compared.

RESULTS

Nine registries were included, most of which were provincial-level registries (67 ​%). A total of 53 individual complications were identified. Twenty-one (40 ​%) were recorded by only one registry each whereas 5 (9 ​%) were collected by all. Of the 32 complications collected by ​> ​1 registry, 18 (56 ​%) had different definitions. Of the 18 with different definitions, 12 (67 ​%), 5 (28 ​%), and 1 (6 ​%) had 2, 3, and 4 different definitions across registries, respectively.

CONCLUSIONS

Complications reported by trauma registries are variable. Reliable benchmarking is likely challenging, and efforts to standardize complication reporting may be a valuable undertaking.

Methods and evaluation metrics for reducing material waste in the operating room: a scoping review

BACKGROUND

Operating rooms contribute up to 70% of total hospital waste. Although multiple studies have demonstrated reduced waste through targeted interventions, few examine processes. This scoping review highlights methods of study design, outcome assessment, and sustainability practices of operating room waste reduction strategies employed by surgeons.

METHODS

Embase, PubMed, and Web of Science were screened for operating room-specific waste-reduction interventions. Waste was defined as hazardous and non-hazardous disposable material and energy consumption. Study-specific elements were tabulated by study design, evaluation metrics, strengths, limitations, and barriers to implementation in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

A total of 38 articles were analyzed. Among them, 74% of studies had pre- versus postintervention designs, and 21% used quality improvement instruments. No studies used an implementation framework. The vast majority (92%) of studies measured cost as an outcome, whereas others included disposable waste by weight, hospital energy consumption, and stakeholder perspectives. The most common intervention was instrument tray optimization. Common barriers to implementation included lack of stakeholder buy-in, knowledge gaps, data capture, additional staff time, need for hospital or federal policies, and funding. Intervention sustainability was discussed in few studies (23%) and included regular waste audits, hospital policy change, and educational initiatives. Common methodologic limitations included limited outcome evaluation, narrow scope of intervention, and inability to capture indirect costs.

CONCLUSION

Appraisal of quality improvement and implementation methods are critical for developing sustainable interventions for reducing operating room waste. Universal evaluation metrics and methodologies may aid in both quantifying the impact of waste reduction initiatives and understanding their implementation in clinical practice.

Retrospective value assessment of a dedicated, trauma hybrid operating room

BACKGROUND

In traumatic hemorrhage, hybrid operating rooms offer near simultaneous performance of endovascular and open techniques, with correlations to earlier hemorrhage control, fewer transfusions, and possible decreased mortality. However, hybrid operating rooms are resource intensive. This study quantifies and describes a single-center experience with the complications, cost-utility, and value of a dedicated trauma hybrid operating room.

METHODS

This retrospective cohort study evaluated 292 consecutive adult trauma patients who underwent immediate (<4 hours) operative intervention at a Level I trauma center. A total of 106 patients treated before the construction of a hybrid operating room served as historical controls to the 186 patients treated thereafter. Demographics, hemorrhage-control procedures, and financial data as well as postoperative complications and outcomes were collected via electronic medical records. Value and incremental cost-utility ratio were calculated.

RESULTS

Demographics and severity of illness were similar between cohorts. Resuscitative endovascular occlusion of the aorta was more frequently used in the hybrid operating room. Hemorrhage control occurred faster (60 vs. 49 minutes, p = 0.005) and, in the 4- to 24-hour postadmission period, required less red blood cell (mean, 1.0 vs. 0 U, p = 0.001) and plasma (mean, 1.0 vs. 0 U, p < 0.001) transfusions. Complications were similar except for a significant decrease in pneumonia (7% vs. 4%, p = 0.008). Severe complications (Clavien-Dindo classification, ≥3) were similar. Across the patient admission, costs were not significantly different ($50,023 vs. $54,740, p = 0.637). There was no change in overall value (1.00 vs. 1.07, p = 0.778).

CONCLUSION

The conversion of our standard trauma operating room to an endovascular hybrid operating room provided measurable improvements in hemorrhage control, red blood cell and plasma transfusions, and postoperative pneumonia without significant increase in cost. Value was unchanged.

LEVEL OF EVIDENCE

Economic/Value-Based Evaluations; Level III.