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Hardman M, Bhandarkar AR, Jarrah RM, Bydon M. Predictors of Airway, Respiratory, and Pulmonary Complications Following Elective Anterior Cervical Discectomy and Fusion. Clin Neurol Neurosurg 2022; 217:107245. [DOI: 10.1016/j.clineuro.2022.107245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/02/2022] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
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Brajcich BC, Yuce TK, Merkow RP, Bilimoria KY, McGee MF, Zhan T, Odell DD. Association of preoperative smoking with complications following major gastrointestinal surgery. Am J Surg 2022; 223:312-317. [PMID: 34119328 PMCID: PMC8648850 DOI: 10.1016/j.amjsurg.2021.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/10/2021] [Accepted: 06/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery. METHODS Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes. RESULTS A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08-1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14-1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70-2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06-1.23]). CONCLUSIONS Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA.
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Tiannan Zhan
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
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Analysis of the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) Database to Identify Factors Associated with Postoperative Mortality After Elective Non-cardiac Surgery. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03249-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Massa I, Ghignone F, Ugolini G, Ercolani G, Montroni I, Capelli P, Garulli G, Catena F, Lucchi A, Ansaloni L, Gentili N, Danesi V, Montella MT, Altini M. Emilia-Romagna Surgical Colorectal Cancer Audit (ESCA): a value-based healthcare retro-prospective study to measure and improve the quality of surgical care in colorectal cancer. Int J Colorectal Dis 2022; 37:1727-1738. [PMID: 35779080 PMCID: PMC9262771 DOI: 10.1007/s00384-022-04203-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgery is the main treatment for non-metastatic colorectal cancer. Despite huge improvements in perioperative care, colorectal surgery is still associated with a significant burden of postoperative complications and ultimately costs for healthcare organizations. Systematic clinical auditing activity has already proven to be effective in measuring and improving clinical outcomes, and for this reason, we decided to evaluate its impact in a large area of northern Italy. METHODS The Emilia-Romagna Surgical Colorectal Audit (ESCA) is an observational, multicentric, retro-prospective study, carried out by 7 hospitals located in the Emilia-Romagna region. All consecutive patients undergoing surgery for colorectal cancer during a 54-month study period will be enrolled. Data regarding baseline conditions, preoperative diagnostic work-up, surgery and postoperative course will be collected in a dedicated case report form. Primary outcomes regard postoperative complications and mortality. Secondary outcomes include each center's adherence to the auditing (enrolment rate) and evaluation of the systematic feedback activity on key performance indicators for the entire perioperative process. CONCLUSION This protocol describes the methodology of the Emilia-Romagna Surgical Colorectal Audit. The study will provide real-world clinical data essential for benchmarking and feedback activity, to positively impact outcomes and ultimately to improve the entire healthcare process of patients undergoing colorectal cancer surgery. CLINICAL TRIAL REGISTRATION The study ESCA is registered on the clinicaltrials.gov platform (Identifier: NCT03982641).
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Affiliation(s)
- Ilaria Massa
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Federico Ghignone
- U.O. Chirurgia Generale, Hospital “Santa Maria delle Croci”, AUSL, Ravenna, Romagna Italy
| | - Giampaolo Ugolini
- U.O. Chirurgia Generale, Hospital “Santa Maria delle Croci”, AUSL, Ravenna, Romagna Italy
| | - Giorgio Ercolani
- U.O. Chirurgia Generale e Terapie Oncologiche avanzate, Hospital “GB. Morgagni-L.Pierantoni”, AUSL, Forli, Romagna Italy
| | - Isacco Montroni
- U.O Chirurgia Generale, Hospital “degli Infermi”, AUSL, Faenza, Romagna Italy
| | - Patrizio Capelli
- Department of Surgery, Hospital “G. Da Saliceto”, Piacenza, AUSL, Piacenza, Italy
| | - Gianluca Garulli
- U.O. Chirurgia Generale, Hospital “Infermi”, AUSL, Rimini, Romagna Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, AUSL, Cesena, Romagna Italy
| | - Andrea Lucchi
- U.O. Chirurgia Generale, Hospital “Ceccarini”, AUSL, Riccione, Romagna Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Nicola Gentili
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Valentina Danesi
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Maria Teresa Montella
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) “ Dino Amadori”, Meldola, Italy
| | - Mattia Altini
- Healthcare Administration, AUSL of Romagna, Ravenna, Italy
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Ecker BL, Brajcich BC, Ellis RJ, Ko CY, D’Angelica MI. Registry-based randomized clinical trials in surgery: Working with ACS-NSQIP and the AHPBA to conduct pragmatic trials. J Surg Oncol 2022; 125:89-92. [PMID: 34897710 PMCID: PMC8787438 DOI: 10.1002/jso.26742] [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: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 01/03/2023]
Abstract
Randomized controlled trials (RCTs) represent the gold standard for evidence in clinical medicine because of their ability to account for the effects of unmeasured confounders and selection bias by indication. However, their complexity and immense costs limit their application, and thus the availability of high-quality data to guide clinical care. Registry-based RCTs are a type of pragmatic trial that leverages existing registries as a platform for data collection, providing a low-cost alternative for randomized studies. Herein, we describe the tenets of registry RCTs and the development of the first AHPBA/ACS-NSQIP-based registry trial.
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Affiliation(s)
- Brett L. Ecker
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Brian C. Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Ryan J. Ellis
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Clifford Y. Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, Department of Surgery, University of California Los Angeles, Los Angeles, CA,Department of Surgery, University of California Los Angeles David Geffen School of Medicine, 10833 LeConte Avenue., 72-215 CHS, Los Angeles, CA,VA Greater Los Angeles Healthcare System, 11301 Wiltshire Blvd., Los Angeles, CA
| | - Michael I. D’Angelica
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Poorthuis MH, Herings RA, Dansey K, Damen JA, Greving JP, Schermerhorn ML, de Borst GJ. External Validation of Risk Prediction Models to Improve Selection of Patients for Carotid Endarterectomy. Stroke 2022; 53:87-99. [PMID: 34634926 PMCID: PMC8712365 DOI: 10.1161/strokeaha.120.032527] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE The net benefit of carotid endarterectomy (CEA) is determined partly by the risk of procedural stroke or death. Current guidelines recommend CEA if 30-day risks are <6% for symptomatic stenosis and <3% for asymptomatic stenosis. We aimed to identify prediction models for procedural stroke or death after CEA and to externally validate these models in a large registry of patients from the United States. METHODS We conducted a systematic search in MEDLINE and EMBASE for prediction models of procedural outcomes after CEA. We validated these models with data from patients who underwent CEA in the American College of Surgeons National Surgical Quality Improvement Program (2011-2017). We assessed discrimination using C statistics and calibration graphically. We determined the number of patients with predicted risks that exceeded recommended thresholds of procedural risks to perform CEA. RESULTS After screening 788 reports, 15 studies describing 17 prediction models were included. Nine were developed in populations including both asymptomatic and symptomatic patients, 2 in symptomatic and 5 in asymptomatic populations. In the external validation cohort of 26 293 patients who underwent CEA, 702 (2.7%) developed a stroke or died within 30-days. C statistics varied between 0.52 and 0.64 using all patients, between 0.51 and 0.59 using symptomatic patients, and between 0.49 to 0.58 using asymptomatic patients. The Ontario Carotid Endarterectomy Registry model that included symptomatic status, diabetes, heart failure, and contralateral occlusion as predictors, had C statistic of 0.64 and the best concordance between predicted and observed risks. This model identified 4.5% of symptomatic and 2.1% of asymptomatic patients with procedural risks that exceeded recommended thresholds. CONCLUSIONS Of the 17 externally validated prediction models, the Ontario Carotid Endarterectomy Registry risk model had most reliable predictions of procedural stroke or death after CEA and can inform patients about procedural hazards and help focus CEA toward patients who would benefit most from it.
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Affiliation(s)
| | - Reinier A.R. Herings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kirsten Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Johanna A.A. Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Racial and Ethnic Disparities in Obliterative Procedures for the Treatment of Vaginal Prolapse. Female Pelvic Med Reconstr Surg 2021; 27:e710-e715. [PMID: 34807885 DOI: 10.1097/spv.0000000000001116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although racial disparities are well documented for common gynecologic surgical procedures, few studies have assessed racial disparities in the surgical treatment of vaginal prolapse. This study aimed to compare the use of obliterative procedures for the treatment of vaginal prolapse across racial and ethnic groups. STUDY DESIGN This is a retrospective cohort study of surgical cases from 2010 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program, a nationally validated database. Cases were identified by Current Procedural Terminology codes. Modified Poisson regression was used to calculate risk ratios and 95% confidence intervals, adjusting for potential confounders selected a priori. RESULTS We identified 45,865 surgical cases, of which 10% involved an obliterative procedure. In the unadjusted model, non-Hispanic Asian and non-Hispanic Black patients were more likely to undergo an obliterative procedure compared with non-Hispanic White patients (risk ratio [95% confidence interval], 2.4 [2.1-2.7] and 1.2 [1.03-1.3], respectively). These relative risks were largely unchanged when controlling for age, body mass index, diabetes, American Society of Anesthesiologists classification, and concurrent hysterectomy. CONCLUSIONS Although both obliterative and reconstructive procedures have their respective risks and benefits, the proportion of patients undergoing each procedure differs by race and ethnicity. It is unclear whether such disparities may be attributable to differences in preference or inequity in care.
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Labott JR, Brinkmann EJ, Hevesi M, Couch CG, Rose PS, Houdek MT. The ACS-NSQIP surgical risk calculator is a poor predictor of postoperative complications in patients undergoing oncologic distal femoral replacement. Knee 2021; 33:17-23. [PMID: 34536764 DOI: 10.1016/j.knee.2021.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/20/2021] [Accepted: 08/31/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Distal femur replacement (DFR) has become a preferred reconstruction for tumors involving the femur but is associated with known complications. The ACS-NSQIP surgical risk calculator is an online tool developed to estimate postoperative complications in the first 30-days, however, has not been used in patients undergoing DFR. The purpose of this study was determining the utility of the ACS-NSQIP calculator to predict postoperative complications. METHODS 56 (30 male, 26 female) patients who underwent DFR were analyzed using the CPT codes: 27,365 (Under Excision Procedures on the Femur and Knee Joint), 27,447 (Arthroplasty, knee, condyle and plateau), 27,486 (Revision of total knee arthroplasty, with or without allograft), 27,487 (Revision of total knee arthroplasty, with or without allograft) and 27,488 (Repair, Revision, and/or Reconstruction Procedures on the Femur [Thigh Region] and Knee Joint). The predicted rates of complications were compared to the observed rates. RESULTS Complications were noted in 30 (54%) of patients. The predicted risk of complications based off the CPT codes were: 27,356 (14%); 27,447 (5%); 27,486 (7%); 27,487 (8%) and 27,488 (12%). Based on ROC curves, the use of the ACS-NSQIP score were poor predictors of complications (27356, AUC 0.54); (27447, AUC 0.45); (27486, AUC 0.45); (27487, AUC 0.46); (27488, AUC 0.46). CONCLUSIONS Distal femur arthroplasty performed in the setting of oncologic orthopedics is a complex procedure in a "high risk" surgical group. The ACS-NSQIP does not adequately predict the incidence of complications in these patients and cannot be reliably used in the shared decision-making process.
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Affiliation(s)
- Joshua R Labott
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Elyse J Brinkmann
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Mario Hevesi
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Cory G Couch
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Peter S Rose
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Matthew T Houdek
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States.
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Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review. Ann Surg 2021; 274:e489-e506. [PMID: 34784666 DOI: 10.1097/sla.0000000000004751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to review and appraise how quality improvement (QI) skills are taught to surgeons and surgical residents. BACKGROUND There is a global drive to deliver capacity in undertaking QI within surgical services. However, there are currently no specifications regarding optimal QI content or delivery. METHODS We reviewed QI educational intervention studies targeting surgeons or surgical trainees/residents published until 2017. Primary outcomes included teaching methods and training materials. Secondary outcomes were implementation frameworks and strategies used to deliver QI training successfully. RESULTS There were 20,590 hits across 10 databases, of which 11,563 were screened following de-duplication. Seventeen studies were included in the final synthesis. Variable QI techniques (eg, combined QI models, process mapping, and "lean" principles) and assessment methods were found. Delivery was more consistent, typically combining didactic teaching blended with QI project delivery. Implementation of QI training was poorly reported and appears supported by collaborative approaches (including building learning collaboratives, and coalitions). Study designs were typically pre-/post-training without controls. Studies generally lacked clarity on the underpinning framework (59%), setting description (59%), content (47%), and conclusions (47%), whereas 88% scored low on psychometrics reporting. CONCLUSIONS The evidence suggests that surgical QI training can focus on any well-established QI technique, provided it is done through a combination of didactic teaching and practical application. True effectiveness and extent of impact of QI training remain unclear, due to methodological weaknesses and inconsistent reporting. Conduct of larger-scale educational QI studies across multiple institutions can advance the field.
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Benign Hysterectomy Operative Times and 30-day Complications: A Cohort Study. J Minim Invasive Gynecol 2021; 29:429-439. [PMID: 34808382 DOI: 10.1016/j.jmig.2021.11.005] [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: 08/02/2021] [Revised: 10/20/2021] [Accepted: 11/06/2021] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To evaluate the 30-day complication rate among different hysterectomy routes and operative times. DESIGN A retrospective cohort study. SETTING American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011-2019. PATIENTS 216,621 total cases including total abdominal hysterectomies (TAH), total vaginal hysterectomies (TVH), total laparoscopic-assisted vaginal hysterectomies (LAVH), and total laparoscopic hysterectomies (TLH). INTERVENTIONS Eligible cases included benign hysterectomies with operative times between 20 minutes and 500 minutes. We excluded cases involving disseminated cancer, emergency surgery, supracervical approaches, or concomitant procedures. MEASUREMENTS Multivariable logistic regression was used to evaluate the relationship between postoperative complications and operative time for each operative route. Multivariable logistic regression with a linear spline term was used to analyze differences in the association between postoperative complications and operative time below and above threshold operative times. MAIN RESULTS Multivariable logistic regression demonstrated a significant association between operative time and overall complication rates for all hysterectomy routes. Spline logistic regression demonstrated a significant increase in adjusted odds of a complication occurring at or above the thresholds of 100 minutes for TAH. CONCLUSION Patients undergoing a TAH for benign indications had a significantly increased odds of developing a complication within 30 days when operative time exceeded 100 minutes. Operative time may play a larger role in preoperative, intraoperative, and postoperative management than previously recognized for TAH in contrast to other hysterectomy routes.
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Garber D, Wandell GM, Gobillot TA, Merati A, Bhatt NK, Giliberto JP. Safety and Predictors of 30-Day Adverse Events of Laryngeal Framework Surgery: An Analysis of ACS-NSQIP data. Laryngoscope 2021; 132:1414-1420. [PMID: 34726793 DOI: 10.1002/lary.29921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To characterize and identify predictors of 30-day adverse events in patients undergoing laryngeal framework surgery (LFS). STUDY DESIGN This study is a retrospective analysis of the National Surgical Quality Improvement dataset. METHODS LFS cases were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2008 to 2018. Demographic variables, patient comorbidities, and perioperative outcomes (any adverse event, 30-day readmission, 30-day reoperation, and unplanned intubation) were extracted. Patient-specific and surgery-specific factors associated with perioperative adverse events were examined using descriptive statistics and univariate logistic regression (LR). RESULTS Of 283 patients who underwent LFS, 225 underwent laryngoplasty medialization, 56 underwent laryngoplasty medialization with arytenoidectomy or arytenoidopexy via an external approach, and 2 underwent local myocutaneous or fasciocutaneous advancement flap along with laryngoplasty. Medical comorbidities were present in 33.6% of patients and 57.9% were American Society of Anesthesiologists (ASA) Class III/IV (57.9%). LFS was performed as same-day surgery in 30.7% of cases. Fourteen patients (4.9%) suffered an adverse condition within 30 days following surgery. In univariate LR, ASA Class III or IV (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.2-30.1) was the only predictor associated with any adverse event. Arytenoid adduction (AA) was associated with increased risk of reoperation within 30 days of the initial surgery (OR 6.4, 95% CI 1.0-49). CONCLUSIONS LFS is a generally safe procedure with infrequent perioperative adverse events. In the ACS-NSQIP database, ASA classification of III or IV was associated with a higher risk for any 30-day adverse event and AA was associated with a higher risk for 30-day reoperation. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- David Garber
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Grace M Wandell
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Theodore A Gobillot
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Al Merati
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Neel K Bhatt
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - John Paul Giliberto
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
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Chaudhry SA, Rosenfeld ES, Glousman BN, Sparks AD, Lala S, Macsata R, Amdur R, Sidawy AN, Nguyen BN. Dependent functional status rather than age is a better predictor of adverse outcomes after excision of an infected abdominal aortic graft. J Vasc Surg 2021; 75:1413-1421. [PMID: 34606962 DOI: 10.1016/j.jvs.2021.08.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/29/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The optimal management of infected abdominal aortic grafts is complete surgical excision plus in situ or extra-anatomic revascularization in patients who can tolerate this morbid operation. In addition to using age and the presence of comorbidities for risk assessment, physicians form a global clinical impression when deciding whether to offer excision or to manage conservatively. Functional status is a distinct objective measure that can inform this decision. This study examines the relative impact of age and functional status on outcomes of infected abdominal aortic graft excision to guide surgical decision-making. METHODS Current Procedural Terminology code 35907 was used to identify patients undergoing excision of infected abdominal aortic graft in the 2005 to 2017 American College of Surgeons - National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by the upper age quartile (75 years old) as a cutoff, and then by functional status, independent vs dependent (as defined by NSIQIP). The patients were then stratified into four groups: Younger (<75)/Independent, Younger (<75)/Dependent, Older (≥75)/Independent, and Older (≥75)/Dependent. Outcomes measured included 30-day mortality and major organ-system dysfunction. RESULTS There were 814 patients who underwent infected abdominal aortic graft excision: 508 patients (62%) were Younger/Independent, 89 patients (11%) were Younger/Dependent, 176 patients (22%) were Older/Independent, and 41 patients (5%) were Older/Dependent. There was no statistically significant difference in 30-day mortality for Younger/Dependent (odds ratio [OR], 1.66; 95% confidence interval [CI], 0.90-3.09; P = .536) or Older/Independent (OR, 1.31; 95% CI, 0.78-2.19; P = .311) patients when compared with Younger/Independent patients, which suggests that neither old age nor dependent functional status by itself adversely affects mortality. However, when both factors were present, Older/Dependent patients had three times higher mortality when compared with Younger/Independent patients (41.5% vs 13.4%, respectively; OR, 3.13; 95% CI, 1.46-6.71; P = .003). Furthermore, as long as patients presented with independent functional status, old age by itself did not adversely affect major organ-system dysfunction (ORs for Older/Independent vs Younger/Independent were 0.76 [P = .454], 1.04 [P = .874], and 0.90 [P = .692] for cardiac, pulmonary, and renal complications, respectively). On the contrary, even in younger patients, dependent functional status was significantly associated with higher pulmonary complications (Younger/Dependent vs Younger/Independent: OR, 2.22; 95% CI, 1.33-3.73; P = .002) and higher rates of unplanned reoperation (OR, 2.67; 95% CI, 1.62-4.41; P < .0001). CONCLUSIONS Dependent functional status has significant association with adverse outcomes after excision of infected abdominal aortic grafts, whereas old age alone does not. Therefore, this procedure could be considered in appropriately selected elderly patients with otherwise good functional status. However, caution should be applied in dependent patients regardless of age due to the risk of pulmonary complications.
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Affiliation(s)
- Sharjeel A Chaudhry
- Department of Surgery, George Washington University, Washington, DC; Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | | | | | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC
| | - Salim Lala
- Department of Surgery, George Washington University, Washington, DC
| | - Robyn Macsata
- Department of Surgery, George Washington University, Washington, DC
| | - Richard Amdur
- Department of Surgery, George Washington University, Washington, DC
| | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC
| | - Bao-Ngoc Nguyen
- Department of Surgery, George Washington University, Washington, DC.
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Boddapati V, Lee NJ, Mathew J, Vulapalli MM, Lombardi JM, Dyrszka MD, Sardar ZM, Lehman RA, Riew KD. Hybrid Anterior Cervical Discectomy and Fusion and Cervical Disc Arthroplasty: An Analysis of Short-Term Complications, Reoperations, and Readmissions. Global Spine J 2021; 11:1183-1189. [PMID: 32705903 PMCID: PMC8453682 DOI: 10.1177/2192568220941453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Although cervical disc arthroplasty (CDA) has become a well-established and effective treatment for symptomatic cervical degeneration, many patients with multilevel disease are not good candidates for CDA at all levels. For such patients, hybrid surgery (HS)-a combination of adjacent anterior cervical discectomy and fusion (ACDF) and CDA-may be more appropriate. Given the novelty of HS and the relative dearth of studies adequately assessing short-term perioperative complications, this current study sought to assess the short-term morbidity profile of HS, differences in operative duration, length of stay (LOS), and readmission and reoperation rates and reasons relative to a 2-level ACDF cohort. METHODS All patients who underwent HS and 2-level ACDF were identified between 2011 and 2018 using a large, prospectively collected registry. Baseline patient characteristics and postoperative complications were compared using bivariate and/or multivariate analysis. RESULTS A total of 390 patients undergoing HS were identified. Two-level procedures were the most common (74.9%). Patients undergoing HS were more likely to be younger, male, and have fewer comorbidities. There were no differences between HS and 2-level ACDF in rates of any postoperative complication, transfusion, readmissions, and operative duration. However, HS had a decreased LOS (0.5 days), relative to a 2-level ACDF. HS patients had low rates of reoperation (1.28%) with 1 case for hematoma evacuation and another for revision CDA. CONCLUSIONS This study represents one of the largest cohorts of patients undergoing HS reported to date. Patients undergoing HS are not at increased risk of perioperative complications relative to a 2-level ACDF and may benefit from shorter LOS.
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Affiliation(s)
- Venkat Boddapati
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA,Venkat Boddapati, Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY 10032, USA.
| | - Nathan J. Lee
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Mathew
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Meghana M. Vulapalli
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph M. Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Marc D. Dyrszka
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Zeeshan M. Sardar
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Ronald A. Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - K. Daniel Riew
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
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64
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Boyd BAJ, Winkelman WD, Mishra K, Vittinghoff E, Jacoby VL. Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse. Am J Obstet Gynecol 2021; 225:405.e1-405.e7. [PMID: 33984303 DOI: 10.1016/j.ajog.2021.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/28/2021] [Accepted: 05/05/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery. OBJECTIVE This study aimed to evaluate the differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity. STUDY DESIGN This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either vaginal colpopexy or abdominal sacrocolpopexy. Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine whether race and ethnicity are associated with the type of colpopexy (vaginal vs abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity. RESULTS A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were vaginal colpopexy and 10,524 (46%) were abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2262 (21%) were performed via laparotomy and 8262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, and 11% unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (odds ratio, 0.82; 95% confidence interval, 0.68-0.99, and odds ratio, 0.56; 95% confidence interval, 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (odds ratio, 0.68; 95% confidence interval, 0.58-0.79, and odds ratio, 0.31; 95% confidence interval, 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. After a colpopexy, African American women were more likely to need a blood transfusion (odds ratio, 3.04; 95% confidence interval, 1.95-4.73; P≤.001) and have a deep vein thrombosis or pulmonary embolus (odds ratio, 2.46; 95% confidence interval, 1.10-5.48; P=.028), but less likely to present with postoperative urinary tract infections (odds ratio, 0.68; 95% confidence interval, 0.49-0.96; P=.028) than White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had higher odds of developing grade II complications than White women in multivariable models (odds ratio, 1.25; 95% confidence interval, 1.04-1.51; P=.02). CONCLUSION There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. In particular, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. Although complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.
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Affiliation(s)
- Brittni A J Boyd
- Department of Obstetrics, Gynecology, and Reproductive Science, University of California, San Francisco, CA.
| | - William D Winkelman
- Department of Obstetrics and Gynecology, Mount Auburn Hospital, Cambridge, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA
| | - Kavita Mishra
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Vanessa L Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Science, University of California, San Francisco, CA
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Yu J, Houtrow AJ. Moving Pediatric Complex Care Forward: Big Data and National Research Collaborations. Pediatrics 2021; 148:peds.2021-051833. [PMID: 34349031 DOI: 10.1542/peds.2021-051833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Justin Yu
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania .,Departments of Pediatrics
| | - Amy J Houtrow
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.,Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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66
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Lee KC, Sokas CM, Streid J, Senglaub SS, Coogan K, Walling AM, Cooper Z. Quality Indicators in Surgical Palliative Care: A Systematic Review. J Pain Symptom Manage 2021; 62:545-558. [PMID: 33524478 DOI: 10.1016/j.jpainsymman.2021.01.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/09/2021] [Accepted: 01/19/2021] [Indexed: 02/05/2023]
Abstract
CONTEXT Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs. OBJECTIVES To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality. METHODS A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality. RESULTS There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators. CONCLUSION This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.
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Affiliation(s)
- Katherine C Lee
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, California, USA
| | - Claire M Sokas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jocelyn Streid
- Department of Anesthesiology and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven S Senglaub
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Coogan
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Aversa JG, Chatani PD, Copeland AR, Blakely AM, Davis JL, Nilubol N, Babic B, Hernandez JM. The impact of level II evidence on surgical practice: Dual agent bowel prep for elective colorectal surgery. Surgery 2021; 170:703-706. [PMID: 33933279 PMCID: PMC9907358 DOI: 10.1016/j.surg.2021.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 02/27/2021] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Affiliation(s)
- John G Aversa
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD. https://twitter.com/JG_Aversa
| | - Praveen D Chatani
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Amy R Copeland
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Andrew M Blakely
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Naris Nilubol
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Bruna Babic
- Department of Surgery, New York Presbyterian-Queens, Flushing, NY, USA; Department of Surgery, Weill Cornell Medicine, New York, NY
| | - Jonathan M Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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Abstract
OBJECTIVE To establish and define disparities in care for patients presenting with surgical disease who have pre-existing mental health diagnoses. SUMMARY BACKGROUND DATA Mental illness affects approximately 6.7 million Canadians. For them, stigma, comorbid disorders, and sequelae of psychiatric diagnoses can be barriers patients face to receive equitable healthcare. The goal of this review is to define inequities in surgical care for patients with pre-existing mental illness. METHODS We search OVID Medline, Pubmed, EMBASE, and the Cochrane review files using a combination of search terms using a PICO (population, intervention, comparison, outcome) model focusing on surgical care for patients with mental illness. RESULTS The literature on mental illness in surgical patients focused primarily on preoperative and postoperative disparities in surgical care between patients with and without a diagnosis of mental illness. Preoperatively, patients were 7.5-40% less likely to be deemed surgical candidates, were less likely to receive testing, and were more likely to present at later stages of their disease or have delayed surgical care. Similar themes arose in the postoperative period: patients with mental illness were more likely to require ICU admission, were up to 3 times more likely to have a prolonged length of hospital stay, had a 14-270% increased likelihood of having postoperative complications, and had significantly higher healthcare costs. CONCLUSIONS Surgical patients with preexisting psychiatric diagnoses have a propensity for worse perioperative outcomes compared to patients without reported mental illness. Taking a thorough psychiatric history can potentially help surgical teams address disparities and access to care as well as anticipate and prevent adverse outcomes.
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69
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Setting up a quality program: defining the value proposition for anesthesiology. Int Anesthesiol Clin 2021; 59:1-11. [PMID: 34320569 DOI: 10.1097/aia.0000000000000332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Womble TN, Comadoll SM, Dugan AJ, Davenport DL, Ali SZ, Srinath A, Matuszewski PE, Aneja A. Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting? Foot Ankle Surg 2021; 27:581-587. [PMID: 32917527 DOI: 10.1016/j.fas.2020.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/14/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off. METHODS Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA). RESULTS 9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007). CONCLUSIONS Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tanner N Womble
- School of Medicine, University of Kentucky, Lexington, KY, USA
| | - Shea M Comadoll
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Adam J Dugan
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Syed Z Ali
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arjun Srinath
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA.
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Labott JR, Brinkmann EJ, Hevesi M, Wyles CC, Couch CG, Rose PS, Houdek MT. Utility of the ACS-NSQIP surgical risk calculator in predicting postoperative complications in patients undergoing oncologic proximal femoral replacement. J Surg Oncol 2021; 124:852-857. [PMID: 34184278 DOI: 10.1002/jso.26583] [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: 05/01/2021] [Revised: 05/25/2021] [Accepted: 06/12/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Proximal femur replacement (PFR) in the setting of tumor resection is associated with a high rate of postoperative complication. The online American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator is approved by the Center of Medicare and Medicaid services to estimate 30-day postoperative complications. This study was to determine if the ACS-NSQIP can predict postoperative complications following PFR. METHODS We reviewed 103 (61 male and 42 female) patients undergoing PFR using the Current Procedural Terminology (CPT) codes available in the calculator: 27125 (hemiarthroplasty), 27130 (total hip), 27132 (conversion to total hip), 27134 (revision total hip), 27137 (revision acetabulum), 27138 (revision femur), and 27365 (excision tumor hip). The predicted rates of complications were compared with the observed rates. RESULTS Complications occurred in 54 (52%) of patients, with the predicted risk based on CPT codes: 27125 (21.5%); 27130 (7.8%); 27132 (16.6%), 27134 (17.8%), 27137 (14.4%), 274138 (22.7%), and 27365 (16.2%). The calculator was a poor predictor of complications (27125, area under the curve [AUC] 0.576); (27130, AUC 0.489); (27132, AUC 0.490); (27134, AUC 00.489); (27137, AUC 0.489); (27138, AUC 0.471); and (27365, AUC 0.538). CONCLUSION Oncologic PFR is known for complications. The ACS-NSQIP does not adequately predict the incidence of complications, and therefore cannot reliably be used in their shared decision-making process preoperative.
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Affiliation(s)
- Joshua R Labott
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elyse J Brinkmann
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cory G Couch
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Koch KE, Hahn A, Hart A, Kahl A, Charlton M, Kapadia MR, Hrabe JE, Cromwell JW, Hassan I, Gribovskaja-Rupp I. Male sex, ostomy, infection, and intravenous fluids are associated with increased risk of postoperative ileus in elective colorectal surgery. Surgery 2021; 170:1325-1330. [PMID: 34210525 DOI: 10.1016/j.surg.2021.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Postoperative ileus is a common and costly complication after elective colorectal surgery. Effects of intravenous fluid administration remain controversial, and the effect of ostomy construction has not been fully evaluated. Various restrictive intravenous fluid protocols may adversely affect renal function. We aimed to investigate the impact of intestinal reconstruction and intravenous fluid on ileus and renal function after colorectal resection under an enhanced recovery protocol. METHODS A retrospective study of a prospectively maintained institutional database for a tertiary academic medical center following National Surgical Quality Improvement Program standards was reviewed, analyzing elective colorectal resections performed under enhanced recovery protocol from 2015 to 2018. Postoperative ileus was defined as nasogastric decompression, nil per os >3 days postoperatively, or nasogastric tube insertion. Patients with and without ileus were compared. Intravenous fluid and different anastomoses and ostomies were investigated. Acute kidney injury was a secondary outcome, due to the potential of renal damage with restriction of intravenous fluid volume during and after surgery and controversy in current literature in this matter. RESULTS Postoperative ileus occurred in 18.5% of patients (n = 464). Male sex (odds ratio 1.97, 95% confidence interval 1.12-3.52) and postoperative infection (odds ratio 2.13, 95% confidence interval 1.03-4.35) were associated with ileus. Compared to colorectal anastomosis, ileostomy/ileorectal anastomosis had the highest risk of ileus (odds ratio 4.9, 95% confidence interval 2.33-11.3), colostomy second highest (odds ratio 3.3, 95% confidence interval 1.35-8.39), while ileocolic anastomosis did not significantly differ (odds ratio 2.06, 95% confidence interval 0.69-5.85) on multivariate analysis. Each liter of intravenous fluid within the first 72 hours significantly correlated with postoperative ileus (odds ratio 1.41, 95% confidence interval 1.27-1.59). Rates of acute kidney injury did not differ (P = .18). CONCLUSION Each additional liter of intravenous fluid given in the first 72 hours increased the risk of postoperative ileus 1.4-fold. There is substantially higher risk of ileus with male sex, infection, ileostomy/ileorectal anastomosis, and colostomy. Judicious use of intravenous fluid, as described in our enhanced recovery protocol, is not detrimental for renal function in the setting of normal baseline.
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Affiliation(s)
- Kelsey E Koch
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Amy Hahn
- College of Public Health, University of Iowa, Iowa City, IA
| | - Alexander Hart
- College of Public Health, University of Iowa, Iowa City, IA
| | - Amanda Kahl
- College of Public Health, Iowa Cancer Registry, University of Iowa, Iowa City, IA
| | - Mary Charlton
- College of Public Health, University of Iowa, Iowa City, IA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jennifer E Hrabe
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - John W Cromwell
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Imran Hassan
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
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Banco D, Dodson JA, Berger JS, Smilowitz NR. Perioperative cardiovascular outcomes among older adults undergoing in-hospital noncardiac surgery. J Am Geriatr Soc 2021; 69:2821-2830. [PMID: 34176124 DOI: 10.1111/jgs.17320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Older adults undergoing noncardiac surgery have a high risk of major adverse cardiovascular events (MACE). This study aims to estimate the magnitude of increased perioperative risk, and examine national trends in perioperative MACE following in-hospital noncardiac surgery in older adults compared to middle-aged adults. DESIGN Time-series analysis of retrospective longitudinal data. SETTING The United States Agency for Healthcare Research and Quality National Inpatient Sample (NIS). PARTICIPANTS Hospitalizations for major noncardiac surgery among adults age ≥45 years between January 2004 and December 2014. MEASUREMENTS Inpatient perioperative MACE was defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke. In hospital death was determined from the NIS discharge disposition. MI and ischemic stroke were defined by International Classification of Diseases, Ninth Revision codes. RESULTS Of an estimated 55,349,978 surgical hospitalizations, 26,423,039 (47.7%) were for adults age 45-64, 14,231,386 (25.7%) age 65-74, 10,621,029 (19.2%) age 75-84 years, and 4,074,523 (7.4%) age ≥85 years. MACE occurred in 1,601,022 surgical hospitalizations (2.9%). Adults 65-74 (2.8%; aOR 1.16, 95% CI 1.14-1.17), 75-84 years (4.5%; aOR 1.30, 95% CI 1.28-1.32), and ≥85 years (6.9%; aOR 1.55, 95% CI 1.52-1.57) had greater risk of MACE than those 45-64 years (1.7%). From 2004 to 2014, MACE declined among adults 65-74 (3.1-2.5%, p < 0.001), 75-85 years (4.9-3.9%, p < 0.001), and ≥85 years (7.7-6.1%, p < 0.001), but was unchanged for adults age 45-64. Declines in MACE were driven by decreased MI and mortality despite increased stroke. CONCLUSION Older adults accounted for half of hospitalizations, but experienced the majority of MACE. Older adults had greater adjusted odds of MACE than younger individuals. The proportion of perioperative MACE declined over time, despite increases in ischemic stroke. These data highlight risks of noncardiac surgery in older adults that warrant increased attention to improve perioperative outcomes.
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Affiliation(s)
- Darcy Banco
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA.,Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA.,Department of Surgery, New York University School of Medicine, New York, New York, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA.,Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, New York, USA
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74
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Postoperative Admission, Readmission, and Complications for Patients 60 Years and Older Who Are Undergoing an Isolated Sling Procedure for Stress Incontinence: A Database Study. Female Pelvic Med Reconstr Surg 2021; 27:e542-e548. [PMID: 33208653 DOI: 10.1097/spv.0000000000000988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to determine the effect of increasing age on postoperative admission, readmission, and complications for patients 60 years and older who underwent a synthetic or autologous sling procedure for stress incontinence. METHODS A retrospective cohort study of surgical cases from 2012 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Eligible patients were at least 60 years old and underwent an isolated sling procedure for stress incontinence identified by Current Procedural Terminology code 57288. Baseline demographics, preoperative comorbidities, and postoperative complications were obtained. Risk ratios (RRs) and 95% confidence intervals were calculated using log-binomial regressions. RESULTS Of 3,960 eligible patients, 634 (16.0%) were admitted postoperatively. Admission rates differed across age groups (P = 0.04). For example, compared with patients aged 60-64 years, those aged 70-74 years had 1.3 times the risk of admission (95% confidence interval, 1.04-1.6). Other risk factors for admission included diabetes (RR, 1.3) and hypertension (RR, 1.2). Patients who had general anesthesia had 6.3 times the risk of admission compared with those who had monitored anesthesia/intravenous sedation. There were 72 patients (1.8%) readmitted within 30 days. There was no association between age and readmission. Risk factors for readmission included diabetes (RR, 1.8), bleeding disorders (RR, 3.4), severe chronic obstructive pulmonary disease (RR, 3.7), and congestive heart failure (RR, 11.3). There were 192 complications (4.8%), including 45 major complications (1.1%). CONCLUSIONS Among patients 60 years and older, the risk of postoperative admission and readmission for patients undergoing a synthetic or autologous sling procedure is low and complications are uncommon.
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Boddapati V, Held MB, Levitsky M, Charette RS, Neuwirth AL, Geller JA. Risks and Complications After Arthroplasty for Pathological or Impending Pathological Fracture of the Hip. J Arthroplasty 2021; 36:2049-2054.e5. [PMID: 33640182 DOI: 10.1016/j.arth.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/18/2021] [Accepted: 02/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Treatment options for metastatic osseous lesions of the proximal femur include hemiarthroplasty (HA) or total hip arthroplasty (THA) depending on lesion characteristics and patient demographics. Studies assessing short-term outcomes after HA/THA in this patient population are limited. Therefore, the purpose of this present study was to identify short-term rates of morbidity and mortality after HA/THA for pathological proximal femur fractures, as well as readmission and reoperation rates and reasons. METHODS This study utilized a large, prospectively collected registry to identify patients who underwent HA/THA between 2011 and 2018. Patients were stratified by indication for surgery, including pathological fracture, nonpathological fracture, and osteoarthritis. Baseline patient characteristics and postoperative complications were compared using bivariate and/or multivariate analysis. RESULTS In total, 883 patients undergoing HA/THA for a pathological fracture were identified. Relative to an osteoarthritis cohort, these patients tended to be older, had a lower body mass index, and had significantly more preoperative comorbidities. These patients had high rates of total complications (13.93%), including thirty-day mortality (3.29%), unplanned return to the operating room (4.98%), and pulmonary complications (3.85%). Patients with pathological fracture had a longer operative duration relative to osteoarthritis and nonpathological cohorts (+27 and +25 minutes, respectively), despite having high rates of HAs performed. CONCLUSION Patients undergoing hip arthroplasty for pathologic proximal femur fracture have increased morbidity and mortality relative to an osteoarthritis cohort. However, patients with a pathological fracture have similar rates of morbidity and mortality when compared with a nonpathological fracture cohort, but did experience higher rates of perioperative blood transfusion and unplanned readmissions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Venkat Boddapati
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Michael B Held
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Matthew Levitsky
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Ryan S Charette
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Alexander L Neuwirth
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Jeffrey A Geller
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
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Ju YU, Min BW. A Review of Bowel Preparation Before Colorectal Surgery. Ann Coloproctol 2021; 37:75-84. [PMID: 32674551 PMCID: PMC8134921 DOI: 10.3393/ac.2020.04.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 12/30/2022] Open
Abstract
Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.
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Affiliation(s)
- Yeon Uk Ju
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Byung Wook Min
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
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Sahara K, Tsilimigras DI, Moro A, Mehta R, Hyer JM, Paredes AZ, Beane JD, Endo I, Pawlik TM. Variation in Drain Management Among Patients Undergoing Major Hepatectomy. J Gastrointest Surg 2021; 25:962-970. [PMID: 32342262 DOI: 10.1007/s11605-020-04610-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/08/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although previous studies have suggested that drain management is highly variable, data on drain placement and timing of drain removal among patients undergoing hepatic resection remain scarce. The objective of the current study was to define the utilization of drain placement among patients undergoing major hepatic resection. METHODS The ACS NSQIP-targeted hepatectomy database was used to identify patients who underwent major hepatectomy between 2014 and 2017. Association between day of drain removal, timing of discharge, and drain fluid bilirubin on postoperative day (POD) 3 (DFB-3) was assessed. Propensity score matching (PSM) was used to compare outcomes of patients with a drain removed before and after POD 3. RESULTS Among 5330 patients, most patients had an abdominal drain placed at the time of hepatic resection (n = 3075, 57.7%). Of 2495 patients with data on timing of drain removal, only 380 patients (15.2%) had their drain removed by POD 3. Almost 1 in 6 patients (n = 441, 17.7%) were discharged home with the drain in place. DFB-3 values correlated poorly with POD of drain removal (R2 = 0.0049). After PSM, early drain removal (≤ POD 3) was associated with lower rates of grade B or C bile leakage (2.1% vs. 7.1%, p = 0.008) and prolonged length of hospital stay (6.0% vs. 12.7%, p = 0.009) compared with delayed drain removal (> POD 3). CONCLUSIONS Roughly 3 in 5 patients had a drain placed at the time of major hepatectomy and only 1 in 7 patients had the drain removed early. This study demonstrated the potential benefits of early drain removal in an effort to improve the quality of care following major hepatectomy.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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The extent of colorectal resection and short-term outcomes in patients with ulcerative colitis. Updates Surg 2021; 73:1429-1434. [PMID: 33783765 DOI: 10.1007/s13304-021-01040-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE There is limited literature on the impact of the extent of resection on short-term outcomes in patients with ulcerative colitis (UC) in an elective setting. The aim of this study was to better understand the impact of approach and extent of resection on short-term outcomes for patients undergoing total proctocolectomy (TPC) and subtotal colectomy (STC) for UC. METHODS Patients with UC who underwent elective TPC or STC were captured from the ACS-NSQIP® 2011-2018 database and divided into four cohorts: Open TPC (O-TPC), Laparoscopic TPC (L-STC), Open STC (O-STC), and Laparoscopic STC (L-STC). Baseline and perioperative variables were compared between the four groups alongside 30-day mortality and 30-day complication rates. RESULTS Of 3387 patients, 368 (10.9%) underwent O-STC, 406 (12%) underwent O-TPC, 1958 (58%) underwent L-STC, and 655 (19%) underwent L-TPC. Overall rate of prolonged length of stay (LOS) was 27% and 9% needed a blood transfusion. There was no difference in the risk of complications between open TPC and open STC. Those who had open surgery had a higher risk of complications and prolonged LOS. Patients who had L-TPC had prolonged LOS compared to patients who had L-STC, but less compared to those who had O-STC. CONCLUSION Elective surgery for UC is associated with high rates of prolonged LOS and blood transfusion despite MIS approaches. Short-term outcomes and LOS are more impacted by the operative approach than the extent of resection. Despite this laparoscopic TPC has higher rates of prolonged LOS when compared to laparoscopic STC.
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Complication rates and resource utilization after total hip and knee arthroplasty stratified by body mass index. J Orthop 2021; 24:111-120. [PMID: 33679036 DOI: 10.1016/j.jor.2021.02.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/14/2021] [Indexed: 11/22/2022] Open
Abstract
Over 295,000 patients from 2016 to 2018 in a national database were grouped into normal weight (BMI 18.5 to <25 kg/m2), overweight (25 to <30), type-1 obese (30 to <35), type-2 obese (35 to <40), and type-3 obese (40 or higher). Differences in resource utilization and complication rates across BMI categories were compared. In comparison to normal weight patients, overweight and obese patients undergoing TJA were at risk for increased resource utilization and various early complications. Patients undergoing TKA with a BMI up to 45 kg/m2 are at similar risk for 30-day postoperative complications when compared to type-1 obese patients.
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Takahashi A, Yamamoto H, Kakeji Y, Marubashi S, Gotoh M, Seto Y, Miyata H. Estimates of the effects of centralization policy for surgery in Japan: does centralization affect the quality of healthcare for esophagectomies? Surg Today 2021; 51:1010-1019. [PMID: 33660105 DOI: 10.1007/s00595-021-02245-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/17/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE This study compared the quality of healthcare before and after implementation of a policy restructuring the healthcare delivery system and estimated the impact of centralization. METHODS We used the National Clinical Database to study patients undergoing esophagectomies from 2011 to 2016. We compared the effect of centralization based on the patient background, surgical mortality, and year of surgery. Difference-in-difference methods based on the generalized estimating equation logistic regression model were used for before-and-after comparisons after adjusting for patient-level expected surgical mortality. RESULTS In total, 34,640 cases were identified. More cases with risk factors were noted in ultra-low-volume hospitals, where 38.4% of cases in underpopulated areas were treated, than in higher volume facilities, and the operative mortality, readmission within 30 days and length of stay were worse among patients treated in these hospitals. In centralized prefectures, the number of cases per hospital increased over time (7.2 in 2011 to 9.5 in 2016) while the crude operative mortality tended to decrease (3.4% in 2011 to 1.8% in 2016). The difference-in-difference estimator was 0.856 (95% confidence interval: 0.639-1.147, p = 0.298). CONCLUSION The centralization of ultra-low-volume hospitals did not lead to a deterioration in the quality of care but rather an improving trend.
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Affiliation(s)
- Arata Takahashi
- Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan.,Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Yamamoto
- Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan.,Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Kakeji
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | | | - Mitsukazu Gotoh
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan. .,Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Held MB, Boddapati V, Sarpong NO, Cooper HJ, Shah RP, Geller JA. Operative Duration and Short-Term Postoperative Complications after Unicompartmental Knee Arthroplasty. J Arthroplasty 2021; 36:905-909. [PMID: 33012597 DOI: 10.1016/j.arth.2020.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/24/2020] [Accepted: 09/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prolonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration: < 90 minutes, between 90 and 120 minutes, and >120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics. RESULTS We identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the "any complication" rate between cohorts. However, operative duration >120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non-home discharge (OR: 2.14, CI: 1.65-2.77, P < .001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration <90 minutes. There was no difference in mortality rates. CONCLUSION Increased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non-home discharge, surgical site infection, reoperation, and blood transfusion.
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Affiliation(s)
- Michael B Held
- Columbia University Medical Center, Department of Orthopaedic Surgery, New York, NY
| | - Venkat Boddapati
- Columbia University Medical Center, Department of Orthopaedic Surgery, New York, NY
| | - Nana O Sarpong
- Columbia University Medical Center, Department of Orthopaedic Surgery, New York, NY
| | - Herbert J Cooper
- Columbia University Medical Center, Department of Orthopaedic Surgery, New York, NY
| | - Roshan P Shah
- Columbia University Medical Center, Department of Orthopaedic Surgery, New York, NY
| | - Jeffrey A Geller
- Columbia University Medical Center, Department of Orthopaedic Surgery, New York, NY
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DesPain RW, Parker WJ, Kindvall AT, Learn PA, Elster EA, Jessie EM, Rodriguez CJ, Bradley MJ. Comparison of Outcomes Between the National Surgical Quality Improvement Program and an Emergency General Surgery Registry. J Healthc Qual 2021; 43:76-81. [PMID: 32195744 DOI: 10.1097/jhq.0000000000000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The National Surgical Quality Improvement Program (NSQIP) has become a prevalent tool for quality improvement. At our tertiary military hospital, NSQIP collects 20% of eligible cases. We implemented an emergency general surgery (EGS) registry to prospectively review all EGS cases. We compared our EGS registry with NSQIP, hypothesizing that NSQIP sampling under-represents EGS outcomes. METHODS A formal EGS Process Improvement Program was implemented in 2016. From 2016 to 2018, the four most common operations were laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction, and nonelective hernia repair. Outcomes were compared between the EGS registry and NSQIP abstracted cases. RESULTS In 2016, the EGS registry identified 11/112 (9.8%) patients with a complication. National Surgical Quality Improvement Program abstracted 16% of EGS cases with 16.7% (3/18) of patients having a complication. In 2017, the EGS registry identified 10/87 (11.5%) cases with complications. National Surgical Quality Improvement Program abstracted 23% of EGS with zero complications. In 2018, the EGS registry identified 9.5% of 74 cases with complications. National Surgical Quality Improvement Program abstracted 15% of EGS cases with zero complications. CONCLUSIONS National Surgical Quality Improvement Program did not capture many important EGS outcomes. In 2 of 3 years, NSQIP did not identify a single complication for EGS. National Surgical Quality Improvement Program alone may be insufficient to target EGS improvements.
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The American College of Surgeons National Quality Improvement Program Incompletely Captures Implant-Based Breast Reconstruction Complications. Ann Plast Surg 2021; 84:271-275. [PMID: 31663932 DOI: 10.1097/sap.0000000000002051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Implant-based breast reconstruction (IBR) accounts for 70% of postmastectomy reconstructions in the United States. Improving the quality of surgical care in IBR patients through accurate measurements of outcomes is necessary. The purpose of this study is to compare the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from our institution to our complete institutional health records database. METHODS Data were collected and recorded for all patients undergoing IBR at our institution from 2015 to 2017. The data were completely identified and compared with our institutional NSQIP database for demographics and complications. RESULTS The electronic health records data search identified 768 IBR patients in 3 years and NSQIP reported on 229 (30%) patients. Demographics were reported similarly among the 2 databases. Rates of tissue expander/implant infections (5.9% vs 1.8%; P = 0.003) and wound dehiscence (3.5% vs 0.4%; P = 0.003) were not reported similarly between our database and NSQIP. However, the rates of hematoma (2.7% vs 1.8%) and skin flap necrosis (2.5% vs 1.8%) were comparable between the two databases. In our database, 43% of all complications presented after 30 days of surgery, beyond NSQIP's capture period. CONCLUSIONS Databases built on partial sampling, such as the NSQIP, may be useful for demographic analyses, but fall short of providing data for complications after IBR, such as infections and wound dehiscence. These results highlight the utility and importance of complete databases. National comparisons of clinical outcomes for IBR should be interpreted with caution when using partial databases.
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Chandrasekar T, Boorjian SA, Capitanio U, Gershman B, Mir MC, Kutikov A. Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass. Eur Urol 2021; 80:575-588. [PMID: 33558091 DOI: 10.1016/j.eururo.2021.01.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced. OBJECTIVE To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process. EVIDENCE ACQUISITION A collaborative critical review of the medical literature was conducted. EVIDENCE SYNTHESIS We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making. CONCLUSIONS Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care. PATIENT SUMMARY With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.
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Affiliation(s)
- Thenappan Chandrasekar
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.
| | | | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Maria Carmen Mir
- Department of Urology, Fundación Instituto Valenciano Oncologia, Valencia, Spain
| | - Alexander Kutikov
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Comparison of machine learning techniques to predict unplanned readmission following total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:e50-e59. [PMID: 32868011 DOI: 10.1016/j.jse.2020.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Machine learning (ML) techniques have been shown to successfully predict postoperative complications for high-volume orthopedic procedures such as hip and knee arthroplasty and to stratify patients for risk-adjusted bundled payments. The latter has not been done for more heterogeneous, lower-volume procedures such as total shoulder arthroplasty (TSA) with equally limited discussion around strategies to optimize the predictive ability of ML algorithms. The purpose of this study was to (1) assess which of 5 ML algorithms best predicts 30-day readmission, (2) test select ML strategies to optimize the algorithms, and (3) report on which patient variables contribute most to risk prediction in TSA across algorithms. METHODS We identified 9043 patients in the American College of Surgeons National Surgical Quality Improvement Database who underwent primary TSA between 2011 and 2015. Predictors included demographics, comorbidities, laboratory data, and intraoperative variables. The outcome of interest was 30-day unplanned readmission. Five ML algorithms-support-vector machine (SVM), logistic regression, random forest (RF), an adaptive boosting algorithm, and neural network-were trained on the derivation cohort (2011-2014 TSA patients) to predict 30-day unplanned readmission rates. After training, weights for each respective model were fixed and the classifiers were evaluated on the 2015 TSA cohort to simulate a prospective evaluation. C-statistic and f1 scores were used to assess the performance of each classifier. After evaluation, features were removed independently to assess which features most affected classifier performance. RESULTS The derivation and validation cohorts comprised 5857 and 3186 primary TSA patients, respectively, with similar demographics, comorbidities, and 30-day unplanned readmission rates (2.9% vs. 2.7%). Of the ML algorithms, SVM performed the worst with a c-statistic of 0.54 and an f1-score of 0.07, whereas the random-forest classifier performed the best with the highest c-statistic of 0.74 and an f1-score of 0.18. In addition, SVM was most sensitive to loss of single features, whereas the performance of RF did not dramatically decrease after loss of single features. Within the trained RF classifier, 5 variables achieved weights >0.5 in descending order: high bilirubin (>1.9 mg/dL), age >65, race, chronic obstructive pulmonary disease, and American Society of Anesthesiologists' scores ≥3. In our validation cohort, we observed a 2.7% readmission rate. From this cohort, using the RF classifier we were then able to identify 436 high-risk patients with a predicted risk score >0.6, of whom 36 were readmitted (readmission rate of 8.2%). CONCLUSION Predictive analytics algorithms can achieve acceptable prediction of unplanned readmission for TSA with the RF classifier outperforming other common algorithms.
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Are outpatient three- and four-level anterior cervical discectomies and fusion safe? Spine J 2021; 21:231-238. [PMID: 33049410 DOI: 10.1016/j.spinee.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management. PURPOSE The present study aimed to investigate the safety of outpatient three- and four-level ACDF. STUDY DESIGN Retrospective cohort study PATIENT SAMPLE: The National Surgical Quality Improvement Program - a large, prospectively-collected registry - was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting. OUTCOME MEASURES The rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status. METHODS Baseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF. RESULTS In total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not. CONCLUSIONS This present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.
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Preoperative Assessment of Geriatric Surgical Patients: Update on Clinical Scales Used for Elective General and Digestive Surgery. Surg Laparosc Endosc Percutan Tech 2021; 31:368-375. [PMID: 33399357 DOI: 10.1097/sle.0000000000000896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Higher life expectancy in the general population entails a growing interest in the surgical management of diseases affecting elderly patients. Preoperative assessment when planning surgery needs to carefully evaluate physical and functional status of the patient. This review aims to describe the most commonly used scales in the evaluation of elderly patients scheduled for surgery and provides a useful tool to decide the scales that would be better to assess these specific patients. METHODS According to the PRISMA statement of publications published, we have carried out a systematic review focused on elderly patients who underwent surgical procedures in General and Surgery. Using Medline, Embase, and Cochrane library, a systematic search of the literature from 1992 to 2018 was performed. This enabled us to retrieve information from the selected articles on scales to evaluate medical fitness, functional status, or both, in the elderly or frail patients. RESULTS We reviewed 102 articles and selected the most frequently used assessment scales or indexes. After this extensive analysis, we selected 4 functional scales (Katz Index, Barthel Scale, Karnofsky Performance Score, and Vulnerable Elders Survey), 4 clinical scales (American Society of Anaesthesiologists Index, Charlson Comorbidity Index, Pfeiffer Test, and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity Scale) and finally, 2 mixed scales (American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator and Edmonton Frail Scale). CONCLUSIONS No consensus on the use of a unified assessment scale for elderly patients exists. However, with this review, we provide a brief guideline about the most useful and used scales to perform a comprehensive assessment of geriatric patients undergoing surgery.
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The Surgical Approach to Abdominal Sacrocolpopexy and Concurrent Hysterectomy: Trends for the Past Decade. Female Pelvic Med Reconstr Surg 2021; 27:e196-e201. [DOI: 10.1097/spv.0000000000000891] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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89
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Perioperative Adverse Events for Stress Urinary Incontinence Surgery: A National Analysis. Female Pelvic Med Reconstr Surg 2021; 27:e187-e190. [PMID: 32427624 DOI: 10.1097/spv.0000000000000887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of the study was to compare perioperative morbidity of stress urinary incontinence surgery using data from a nationwide cohort. METHODS This is a retrospective cohort study of the American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2016. Stress urinary incontinence surgery was defined using current procedural terminology (CPT) for abdominal retropubic colposuspension (CPT 51840, 51841), laparoscopic retropubic colposuspension (CPT 51990, 51992), and suburethral sling (CPT 57288). Patients were excluded if they underwent any concomitant surgery except for cystoscopy (CPT 52000). Surgical approach and perioperative morbidity were examined using suburethral sling as the referent population. Patient characteristics, operative data, and 30-day postoperative events were collected. RESULTS Overall, 19,093 women underwent a stress urinary incontinence surgery: 317 abdominal retropubic colposuspension, 357 laparoscopic retropubic colposuspension, and 18,419 suburethral sling. Patients undergoing abdominal retropubic suspension had more inpatient procedures compared with suburethral sling and laparoscopic retropubic colposuspension (65% vs 10.4% and 17.6%, P < 0.001) and longer length of stay (1.6 ± 2.9 vs 0.3 ± 2.7 and 0.3 ± 0.6, respectively, P < 0.001). Abdominal retropubic colposuspension had the longest odds ratio time compared with suburethral sling (72.0 ± 64.6 vs 38.1 ± 34.2 minutes, P < 0.001). Composite morbidity was significantly higher for abdominal retropubic colposuspension compared with suburethral sling and laparoscopic retropubic colposuspension (7.9% vs 3.4% and 2.0%, P < 0.001). After adjusting for comorbidities, composite morbidity was higher for abdominal retropubic suspension (P = 0.007) compared with suburethral sling. CONCLUSIONS Compared with suburethral sling, laparoscopic retropubic colposuspension had the lowest 30-day comorbidity and abdominal retropubic colposuspension had the highest 30-day comorbidity.
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Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical Function and Perioperative Complication in Major Abdominal Colorectal Operations. J Am Coll Surg 2020; 232:451-459. [PMID: 33383215 DOI: 10.1016/j.jamcollsurg.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) is a validated tool for capturing a patient's perception of their physical capacity. The goal of this study was to determine whether preoperative PF correlates with a risk of postoperative complications. STUDY DESIGN Patients from a single-institution American College of Surgeons NSQIP database undergoing elective colorectal abdominal operations from January 2018 to June 2019 with a preoperative PROMIS-PF T-score were eligible for this retrospective study. Patients were divided into moderate to severe (score <40) and minimal to mild (score ≥40) physical disability cohorts. Primary outcomes were any complication and any Clavien-Dindo grade III or higher complication. Multivariate logistic regression was performed. RESULTS In total, 249 patients were included: 78 (31%) with self-scored moderate to severe disability and 171 (69%) with minimal to mild disability. Patients who scored as moderate to severe disability had a higher frequency of comorbidities and an open operative approach compared with patients with minimal to mild disability. These patients then had higher rates of any complication (37.2% vs 19.9%; p = 0.0036) and Clavien-Dindo grade III or higher complications (14.1% vs 7.6%; p = 0.017). After adjusting for patient factors, surgical procedure, and approach, patients scoring as moderate to severe disability were 2.00 times more likely (95% CI, 1.05 to 3.84; p = 0.036) to have any complication and 2.76 times more likely (95% CI, 1.07 to 7.14; p = 0.036) to have a Clavien-Dindo grade III or higher complication. CONCLUSIONS Moderate to severe PF disability score is associated with increased risk of postoperative complications among patients undergoing colorectal operations. PROMIS-PF T-score can be a useful tool to identify patients who would benefit from targeted preoperative interventions, such as patient education, nutritional optimization, and prehabilitation.
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Lockett MA, Mauldin PD, Zhang J, Marsden JE, Taber DJ, Gebregziabher M, Chung C, Hebbar P, Adams L, Baliga PK. Facilitated Regional Collaboration and In-Hospital Surgical Complication. J Am Coll Surg 2020; 232:536-543. [PMID: 33383216 DOI: 10.1016/j.jamcollsurg.2020.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Surgical quality improvement efforts are challenging due to the multidisciplinary nature of care, difficulties obtaining reliable data, and variability in quality metrics. The objective of this analysis was to assess whether participation in a regional collaborative quality initiative was associated with decreased in-hospital surgical complication in South Carolina. STUDY DESIGN In-hospital surgical complication rates were determined using a statewide all-payer claims data set. Retrospective, univariate, and longitudinal multivariable analyses were performed and adjustments were made to account for aggregated hospital-level patient characteristics. RESULTS The analysis included 275,387 general surgery cases performed in South Carolina hospitals between January 2016 and December 2018. Eight hospitals involved in the South Carolina Surgical Quality Collaborative (SCSQC) performed 56,179 cases and 51 non-SCSQC hospitals performed 219,208 cases. Univariate analysis revealed SCSQC hospitals performed operations in older patients (p < 0.0001) and patients with higher mean Charlson Comorbidity Index scores (p < 0.0001). SCSQC hospitals had higher mean in-hospital surgical complication rates at the surgery level compared with non-SCSQC hospitals (8.3% vs 7.0%; p < 0.0001). However, in multivariable analyses, the rate ratio for in-hospital surgical complication in SCSQC hospitals was 0.994 (95% CI, 0.989 to 0.998; p = 0.008) per month compared with non-SCSQC hospitals. This suggests a 21.6% (95% CI, 7.2% to 39.6%) proportional decrease in the rate of in-hospital surgical complication during 3 years associated with participation in the regional collaborative quality initiative. CONCLUSIONS Structured collaboration between facilities, reliable data abstraction support, timely data review, and active member participation resulted in outcomes improvements for participating hospitals compared with hospitals that did not participate in a regional collaborative quality initiative.
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Affiliation(s)
- Mark A Lockett
- Medical University of South Carolina, College of Medicine, Charleston, SC.
| | - Patrick D Mauldin
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Jingwen Zhang
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Justin E Marsden
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - David J Taber
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | | | - Catherine Chung
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Preetha Hebbar
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Larry Adams
- Health Sciences South Carolina, Columbia, SC
| | - Prabhakar K Baliga
- Medical University of South Carolina, College of Medicine, Charleston, SC
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Howard R, Johnson E, Berlin NL, Fan Z, Englesbe M, Dimick JB, Telem DA. Hospital and surgeon variation in 30-day complication rates after ventral hernia repair. Am J Surg 2020; 222:417-423. [PMID: 33323274 DOI: 10.1016/j.amjsurg.2020.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/29/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ventral hernia repair is an extremely common operation, however the variability in patient outcomes between individual hospitals and surgeons is unclear. We analyzed variability in 30-day complication rates and identified specific complications that contributed to this variability. METHODS Retrospective, cross-sectional analysis of 30-day complication rates following ventral hernia repair across 73 hospital and 978 surgeons between January 1, 2014 and December 31, 2018. RESULTS Data were collected on 19,007 patients who underwent VIHR at 73 hospitals across 978 surgeons. Adjusted complication rate among hospitals was 6.2% (range 4.3%-12.8%) and among surgeons was 6.2% (range 3.5%-26.8%). Variation between lowest and highest quartile surgeons was greatest for acute kidney injury (0.12% vs. 1.71%, P < 0.001), superficial surgical site infection (0.33% vs. 3.62%, P < 0.001), sepsis (0.27% vs. 2.47%, P < 0.001), and catheter-associated urinary tract infection (0.02% vs. 0.30%, P < 0.001). CONCLUSION After adjusting for a number of patient-specific clinical variables, there is significant variation in 30-day complication rates after ventral hernia repair. This represents a significant opportunity to improve patient outcomes.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
| | - Emily Johnson
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; National Clinical Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
| | - Zhaohui Fan
- Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
| | | | - Justin B Dimick
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Dana A Telem
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA.
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Trends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006–2016. Clin Neurol Neurosurg 2020; 199:106310. [DOI: 10.1016/j.clineuro.2020.106310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023]
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Zhang LM, Ma M, Russell MM, Ko CY. Surgical quality— what have we done and where are we going? SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Single-level Posterolateral Fusion (PLF) Alone and Posterior Interbody Fusion (PLIF/TLIF) Alone Lead to a Decreased Risk of Short-term Complications Compared to Combined PLF With PLIF/TLIF Procedures: A Matched Analysis. Spine (Phila Pa 1976) 2020; 45:E1391-E1399. [PMID: 32796465 DOI: 10.1097/brs.0000000000003615] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of a database cohort. OBJECTIVE To compare short-term outcome measures and complications between single-level posterolateral fusion (PLF), single-level posterior interbody fusion (PLIF/TLIF), and combined single-level PLF+PLIF/TLIF. SUMMARY OF BACKGROUND DATA Both PLF and interbody fusion are well-established procedures for degenerative spinal disease. However, there is lack of consensus as to the ideal surgical approach for specific applications. Additionally, the difference in risk of complications with traditional PLF, interbody fusion with posterior approach, and circumferential fusion is still contested. METHODS The ACS NSQIP database was used to identify 24,228 patients who underwent either a single-level PLF, single-level PLIF/TLIF, or combined single-level PLF+PLIF/TLIF between 2014 and 2017. To control for potential confounding variables, exact matching was used to pair individuals from each treatment group based on several factors, including sex, age, body mass index, various comorbidities, and American Society of Anesthesiologists classification. After appropriate matching, the rate of various short-term outcome measures and complications were compared between the three treatment groups. RESULTS After exact matching, 13,251 patients were included in the final analysis. The rates of non-home discharge, overall surgical complications, and bleeding requiring transfusion were significantly lower in the PLF group and PLIF/TLIF group relative to the PLF+PLIF/TLIF group (P < 0.001 for all comparisons). The rate of deep venous thrombosis was lower in the PLIF/TLIF group relative to the PLF group (P = 0.006). There were no significant differences in other medical complications, unplanned readmission, reoperation, or return to the OR between any of the treatment groups. CONCLUSIONS The combination of single-level PLF+PLIF/TLIF is associated with higher rates of short-term complications relative to either single-level PLF or PLIF/TLIF alone. The associated risks of this therapy should be considered when considering surgical management for lumbar disease. LEVEL OF EVIDENCE 3.
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Grass F, Storlie CB, Mathis KL, Bergquist JR, Asai S, Boughey JC, Habermann EB, Etzioni DA, Cima RR. Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution. Surg Infect (Larchmt) 2020; 22:523-531. [PMID: 33085571 DOI: 10.1089/sur.2020.208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John R Bergquist
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shusaku Asai
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Judy C Boughey
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David A Etzioni
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Schlick CJR, Yuce TK, Yang AD, McGee MF, Bentrem DJ, Bilimoria KY, Merkow RP. A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery. Surgery 2020; 169:240-247. [PMID: 33077197 DOI: 10.1016/j.surg.2020.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis. METHODS Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed. RESULTS Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors. CONCLUSION Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.
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Affiliation(s)
- Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL.
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Accelerating Surgical Site Infection Abstraction With a Semi-automated Machine-learning Approach. Ann Surg 2020; 276:180-185. [DOI: 10.1097/sla.0000000000004354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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99
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Merkow RP, Shan Y, Gupta AR, Yang AD, Sama P, Schumacher M, Cooke D, Barnard C, Bilimoria KY. A Comprehensive Estimation of the Costs of 30-Day Postoperative Complications Using Actual Costs from Multiple, Diverse Hospitals. Jt Comm J Qual Patient Saf 2020; 46:558-564. [PMID: 32888813 PMCID: PMC8822472 DOI: 10.1016/j.jcjq.2020.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The cost of surgical care is largely measured by charges or payments, both of which are inadequate. Actual cost data from the hospital's perspective are required to accurately quantify the financial return on investment of engaging in quality improvement. The objective of this study was to define the cost of individual, 30-day postoperative complications using robust cost data from a diverse group of hospitals. METHODS Using clinical data derived from the American College of Surgeons National Surgical Quality Improvement Program, this retrospective study assessed postoperative complications for patients who underwent surgery at one of four hospitals in 2016. Actual direct and indirect 30-day costs were obtained, and the adjusted cost per complication was determined. RESULTS From the 6,387 patients identified, the three complications associated with the highest independent adjusted cost per event were prolonged ventilation ($48,168; 95% confidence interval [CI]: $21,861-$74,476), unplanned intubation ($26,718; 95% CI: $15,374-$38,062), and renal failure ($18,528; CI: $17,076-$19,981). The three complications associated with the lowest independent adjusted cost per event were urinary tract infection (-$372; 95% CI: -$1,336-$592), superficial surgical site infection ($2,473; 95% CI: -$256-$5,201) and venous thromboembolism ($7,909; 95% CI: -$17,903-$33,721). After colectomy, the adjusted independent cost of anastomotic leak was $10,195 (95% CI: $5,941-$14,449), while the cost of postoperative ileus was $10,205 (95% CI: $6,259-$14,149). CONCLUSION The actual hospital costs of complications were estimated using cost data from four diverse hospitals. These data can be used by hospitals to estimate the financial benefit of reducing surgical complications.
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Affiliation(s)
- Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ying Shan
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Aakash R. Gupta
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anthony D. Yang
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | - David Cooke
- Northwestern Memorial HealthCare, Chicago, IL
| | | | - Karl Y. Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Northwestern Memorial HealthCare, Chicago, IL
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Zhang J, Li YI, Pieters TA, Towner J, Li KZ, Al-Dhahir MA, Childers F, Li YM. Sepsis and septic shock after craniotomy: Predicting a significant patient safety and quality outcome measure. PLoS One 2020; 15:e0235273. [PMID: 32941422 PMCID: PMC7498000 DOI: 10.1371/journal.pone.0235273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 06/12/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Sepsis and septic shock are important quality and patient safety metrics. This study examines incidence of Sepsis and/or septic shock (S/SS) after craniotomy for tumor resection, one of the most common neurosurgical operations. METHODS Multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify patients undergoing craniotomy for tumor (CPT 61510, 61521, 61520, 61518, 61526, 61545, 61546, 61512, 61519, 61575) from 2012-2015. Univariate and multivariate logistic regression models were used to identify risk factors for S/SS. RESULTS There were 18,642 patients that underwent craniotomy for tumor resection. The rate of sepsis was 1.35% with a mortality rate of 11.16% and the rate of septic shock was 0.65% with a 33.06% mortality rate versus an overall mortality rate of 2.46% in the craniotomy for tumor cohort. The 30-day readmission rate was 50.54% with S/SS vs 10.26% in those without S/SS. Multiple factors were identified as statistically significant (p <0.05) for S/SS including ascites (OR = 33.0), ventilator dependence (OR = 4.5), SIRS (OR = 2.8), functional status (OR = 2.3), bleeding disorders (OR = 1.7), severe COPD (OR = 1.6), steroid use (OR = 1.6), operative time >310 minutes (OR = 1.5), hypertension requiring medication (OR = 1.5), ASA class ≥ 3 (OR = 1.4), male sex (OR = 1.4), BMI >35 (OR = 1.4) and infratentorial location. CONCLUSIONS The data indicate that sepsis and septic shock, although uncommon after craniotomy for tumor resection, carry a significant risk of 30-day unplanned reoperation (35.60%) and mortality (18.21%). The most significant risk factors are ventilator dependence, ascites, SIRS and poor functional status. By identifying the risk factors for S/SS, neurosurgeons can potentially improve outcomes. Further investigation should focus on the creation of a predictive score for S/SS with integration into the electronic health record for targeted protocol initiation in this unique neurosurgical patient population.
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Affiliation(s)
- Jingwen Zhang
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yan Icy Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Bioinformatics, University of Nanjing Medical University, Nanjing, China
| | - Thomas A. Pieters
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
| | - James Towner
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Kevin Z. Li
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Mohammed A. Al-Dhahir
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Faith Childers
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Yan Michael Li
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
- Department of Neurosurgery, Minimally Invasive Brain and Spine Institute, SUNY Upstate Medical University, Syracuse, NY, United States of America
- * E-mail:
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