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

Reduced post-operative urinary tract infection using the National Surgical Quality Improvement Program

BACKGROUND

The incidence of post-operative urinary tract infection (UTI) is frequently unknown or underestimated. Failure to recognize a clinical problem results in no action occurring to improve outcomes. The aims of this study were firstly to define the incidence of post-operative UTI in general surgery patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Secondly to design and implement an intervention to reduce the incidence of post-operative UTI and assess the extent of improvement.

METHODS

ACS-NSQIP data were collected and analysed from June 2015 to June 2016 and reported in the Semi Annual Report (SAR). A quality improvement programme was designed and implemented to manage the high incidence of UTI. The outcomes were assessed by the subsequent ACS-NSQIP SAR.

RESULTS

The SAR in 2016 reported that Nepean Hospital as a significant outlier with an incidence of post-operative UTI of 3.62% (odds ratio 2.21, confidence limits 1.51-3.44, P < 0.001). A hospital-wide policy for catheter insertion in surgical patients was developed including: education, workshops, accreditation for aseptic technique for catheter insertion, reduced rates of insertion, reduced duration of use and improved catheter care. There was a significant improvement in the incidence of UTI (1.21%) reported by the 2018 SAR (odds ratio 1.01, confidence limits 0.64-1.60, P = 0.68).

CONCLUSIONS

ACS-NSQIP identified a 2.2-fold increased risk of post-operative UTI. There was no increased risk of UTI after the programme to reduce UTI was introduced.

Post-Discharge Opioid Prescribing Patterns and Risk Factors in Patients Undergoing Elective Colon and Rectal Surgery Without Complications

BACKGROUND

Few studies have examined opioid usage in the post-discharge period. The primary aim of this study was to evaluate the need for post-discharge opioids in a unique set of patients: those undergoing colorectal operations and experiencing no surgical complications. The secondary aim was to examine the accuracy of the Opioid Risk Tool (ORT) to predict the need for additional opioid prescriptions. Our hypotheses were that few patients would require post-discharge opioids and that the ORT would predict patients requiring post-discharge opioids.

METHODS

All patients undergoing elective colorectal surgery between January 2012 and December 2014 that did not experience NSQIP complications within 30 days or receive an opioid prescription in the 2 weeks prior to operation were reviewed. ORT score was calculated for all patients. Patients requiring post-discharge opioids within 1 year were compared to those not receiving additional opioids after discharge.

RESULTS

There were 367 patients that met inclusion criteria and 56 (15%) received post-discharge opioids. Opioid use in the year prior to surgery was the only significant risk factor to receive post-discharge opioids. Opioids were prescribed for three distinct reasons by three groups of prescribers. The ORT did not accurately predict need for post-discharge opioids.

CONCLUSIONS

Even among patients without complications, 15% received post-discharge opioid prescriptions. Previous opioid use within the year prior to surgery was a major risk factor for additional prescriptions. The timing and prescriber's specialty are impacted by the indication for post-discharge opioids. The ORT did not predict which patients would receive post-discharge opioids.

Association of operative time with outcomes in minimally invasive and abdominal myomectomy

OBJECTIVE(S)

To determine the association of operative time (ORT) with perioperative morbidity and whether there is an ORT at which minimally invasive myomectomy becomes inferior to laparotomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Myomectomy cases identified by CPT code from 2005 to 2016.

INTERVENTION(S)

Cases were stratified and analyzed by surgical approach and 90-minute intervals.

MAIN OUTCOME MEASURE(S)

Thirty-day postoperative morbidity.

RESULT(S)

A total of 11,709 myomectomies were identified; 4,673 (39.9%) were minimally invasive, 6,997 (59.8%) were abdominal, and 39 (0.3%) were conversions. The incidence of complications significantly increased with ORT. After adjusting for confounders, mean ORT in minutes (95% confidence interval) was 113 (111-115) for abdominal, 156 (153-159) for minimally invasive, and 172 (148-200) for conversions. Despite shorter ORT, morbidity was greater in abdominal cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%). The minimally invasive approach in general had lower odds of complications (odds ratio, 0.23; 95% confidence interval, 0.19-0.26). However, when minimally invasive surgery ORT reached ≥ 270 minutes, the odds of a composite complication variable increased compared with abdominal cases <90 minutes (odds ratio, 2.30; 95% confidence interval, 1.69-3.13). Of minimally invasive cases, 88% were completed in <270 minutes.

CONCLUSION(S)

ORT was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach.

Impact of the Number of Levels on Adverse Events and Length of Stay Following Posterior Lumbar Fusion Procedures

STUDY DESIGN

Retrospective SUMMARY OF BACKGROUND DATA:: Little is known regarding the impact of the number of operative levels on the risk for adverse events following spinal procedures.

OBJECTIVE

The objective of this study was to test for associations between the number of operative levels and occurrence of adverse events following posterior lumbar fusion (PLF).

METHODS

Patients undergoing 1-, 2-, or 3-level PLFs were identified in the American College of Surgeons National Surgical Quality Improvement Program database. The number of operative levels was tested for association with occurrence of adverse events in the 30-days following the procedure using multivariate regression. Post hoc pairwise comparisons were made between 1- and 2-level and between 2- and 3-level procedures. Analyses were adjusted for differences in baseline characteristics.

RESULTS

In total, 8162 underwent 1-level, 3,527 underwent 2-level, and 718 underwent 3-level procedures. Patients undergoing 2-level procedures had a higher rate of anemia requiring blood transfusion than 1-level procedures (23.4% vs. 8.6%; adjusted relative risk [RR]=2.5; P<0.001). Furthermore, patient undergoing 3-level procedures had a higher rate of anemia requiring blood transfusion than 2-level procedures (29.9% vs. 23.4%; adjusted RR=1.3; P<0.001). In addition, patients undergoing 3-level procedures had a longer length of stay than 2-level procedures (4.6 vs. 3.9 d; P<0.001) and 2-level procedures had a longer length of stay than 1-level procedures (3.9 vs. 3.5 d; P<0.001).

CONCLUSIONS

Increasing the number of operative levels by one level has minimal impact on the rates of most short-term postoperative adverse events following PLF. This is true both for an increase from 1 to 2 levels and from 2 to 3 levels. While surgeons should consider that an increase in the number of operative levels may increase the risk for blood transfusion and will almost certainly prolong the hospital stay, they need not fear a major increase in the rates of postoperative adverse events.

The Uniformed Services University's Surgical Critical Care Initiative (SC2i): Bringing Precision Medicine to the Critically Ill

Precision medicine endeavors to leverage all available medical data in pursuit of individualized diagnostic and therapeutic plans to improve patient outcomes in a cost-effective manner. Its promise in the field of critical care remains incompletely realized. The Department of Defense has a vested interest in advancing precision medicine for those sent into harm's way and specifically seeks means of individualizing care in the context of complex and highly dynamic combat clinical decision environments. Building on legacy research efforts conducted during the Afghanistan and Iraq conflicts, the Uniformed Service University (USU) launched the Surgical Critical Care Initiative (SC2i) in 2013 to develop clinical- and biomarker-driven Clinical Decision Support Systems (CDSS), with the goals of improving both patient-specific outcomes and resource utilization for conditions with a high risk of morbidity or mortality. Despite technical and regulatory challenges, this military-civilian partnership is beginning to deliver on the promise of personalized care, organizing and analyzing sizable, real-time medical data sets to support complex clinical decision-making across critical and surgical care disciplines. We present the SC2i experience as a generalizable template for the national integration of federal and non-federal research databanks to foster critical and surgical care precision medicine.

Role of nutritional indices in predicting outcomes of vascular surgery

BACKGROUND

Malnutrition is frequent among vascular surgery patients, given their age, chronic comorbidities, and poor functional status, and it is believed to increase their operative risk. We aimed to assess the combined use of recent significant weight loss (>10% body mass) and serum albumin levels as a nutritional status index to predict outcomes.

METHODS

We analyzed vascular surgery data from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2012; N = 238,082) to compare operative death (in-hospital and 30-day operative death) across eight nutritional status groups based on weight loss (yes/no) and albumin category: very low albumin level (VL-Alb; <2.50 g/dL), low albumin level (L-Alb; 2.50-3.39 g/dL), normal albumin level (N-Alb; 3.40-4.39 g/dL), and high albumin level (H-Alb; 4.40-5.40 g/dL). Risk-adjusted odds ratios (AOR) with 95% confidence intervals were estimated by multivariable logistic regression (N-Alb [no weight loss], reference).

RESULTS

The study population included 113,936 patients for whom albumin level was available (age, 67 ± 13 years; 60.2% male). Operative death was documented in 5160 (4.53%) patients. The eight-category nutritional status was more predictive of operative death than age alone (C statistic, 0.74 vs 0.63). A high discrimination multivariable model for operative death was derived (C statistic, 0.851). Low albumin level was associated with increased death that worsened in case of weight loss: VL-Alb + WL, AOR = 3.83 (3.03-4.83); VL-Alb, AOR = 3.36 (3.06-3.69); L-Alb + WL, AOR = 2.46 (1.98-3.05); and L-Alb, AOR = 1.99 (1.84-2.15). Weight loss was associated with increased death even if albumin level was normal: N-Alb + WL, AOR = 1.77 (1.34-2.35); and H-Alb + WL, AOR = 1.91 (0.69-5.31). H-Alb was protective (AOR = 0.65 [0.55-0.76]).

CONCLUSIONS

Nutritional status predicts outcomes of vascular surgery. Serum albumin level and weight loss should be incorporated in patients' risk stratification.

The Effect of Race on Early Perioperative Outcomes After Shoulder Arthroplasty: A Propensity Score Matched Analysis

There is a paucity of data on how racial disparities may affect early outcomes following shoulder arthroplasty. The purpose of this study was to evaluate differences in 30-day complications and readmission rates after shoulder arthroplasty based on race. White and black patients who underwent hemiarthroplasty, anatomic or reverse total shoulder arthroplasty (Current Procedural Terminology codes 23470 and 23472) between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Black patients were propensity score matched 1:4 based on preoperative demographics and comorbidities to white patients. Multivariable analysis was performed to assess postoperative complications based on race. Of the 12,663 patients with shoulder arthroplasty identified, 10,717 (84.6%) were white and 559 (4.4%) were black. Overall, 557 black patients were matched to 2228 white patients, for a total cohort of 2785 patients (mean age, 63.9±11.7 years; female, 61.0%). Surgical indications were similar between black and white patients. The 2 races had similar rates of overall complications, major complications, minor complications, readmissions, and discharge to facility. Mortality was significantly higher among black patients compared with white patients (0.6% vs 0.05%; P=.033). Black patients also experienced longer operative time (mean, 126.4 vs 112.5 minutes; P<.001) and length of stay (mean, 2.4 vs 2.1 days; P<.001). There was a significant disparity with underutilization of shoulder arthroplasty for black patients in the American College of Surgeons National Surgical Quality Improvement Program database. Black and white patients undergoing shoulder arthroplasty experienced similar rates of 30-day complications, readmissions, and discharge to facility. However, black patients experienced greater operative time, total length of stay, and mortality compared with white patients. [Orthopedics. 2019; 42(2):95-102.].

Uncovering Cultural Barriers to Quality Improvement Learning in a Trauma Program: An Ethnographic Study

OBJECTIVE

Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center.

STUDY DESIGN

An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences.

SETTING

University of Toronto and Sunnybrook Health Sciences Center.

PARTICIPANTS

Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees.

RESULTS

All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons.

CONCLUSION

Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change.

Concordance Between Registry and Administrative Data in the Determination of Comorbidity: A Multi-institutional Study

OBJECTIVE

To characterize agreement between administrative and registry data in the determination of patient-level comorbidities.

BACKGROUND

Previous research finds poor agreement between these 2 types of data in the determination of outcomes. We hypothesized that concordance between administrative and registry data would also be poor.

METHODS

A cohort of inpatient operations (length of stay 1 day or greater) was obtained from a consortium of 8 hospitals. Within each hospital, National Surgical Quality Improvement Program (NSQIP) data were merged with intra-institutional inpatient administrative data. Twelve different comorbidities (diabetes, hypertension, congestive heart failure, hemodialysis-dependence, cancer diagnosis, chronic obstructive pulmonary disease, ascites, sepsis, smoking, steroid, congestive heart failure, acute renal failure, and dyspnea) were analyzed in terms of agreement between administrative and NSQIP data.

RESULTS

Forty-one thousand four hundred thirty-two inpatient surgical hospitalizations were analyzed in this study. Concordance (Cohen Kappa value) between the 2 data sources varied from 0.79 (diabetes) to 0.02 (dyspnea). Hospital variation in concordance (intersite variation) was quantified using a test of homogeneity. This test found significant intersite variation at a level of P < 0.001 for each of the comorbidities except for dialysis (P = 0.07) and acute renal failure (P = 0.19). These findings imply significant differences between hospitals in their generation of comorbidity data.

CONCLUSION

This study finds significant differences in how administrative versus registry data assess patient-level comorbidity. These differences are of concern to patients, payers, and providers, each of which had a stake in the integrity of these data. Standardized definitions of comorbidity and periodic audits are necessary to ensure data accuracy and minimize bias.

Preoperative platelet counts and postoperative outcomes in cancer surgery: a multicenter, retrospective cohort study

Platelets play roles in malignancy, wound healing, and immunity. Nevertheless, their significance in postoperative outcomes is not established. This is a retrospective cohort study of 100,795 patients undergoing cancer surgery in 2010 and 2014 in >500 hospitals. Patients were stratified into five groups based on preoperative platelet counts. Multivariable logistic regression was used to determine the risk of 30-day mortality, morbidities, readmission, and prolonged hospitalization using the mid-normal group as a reference. We adjusted for demographic variables, comorbidities, and operation complexity. In the 2014 cohort, multivariable analysis showed that mortality was higher in patients with thrombocytopenia (OR 1.49, 95% CI [1.23-1.81]), high-normal platelets (OR 1.29, [1.06-1.55]), and thrombocytosis (OR 1.78, [1.45-2.19]). Composite postoperative morbidity followed a similar trend with thrombocytopenia (OR 1.34, [1.25-1.43]), high-normal counts (OR 1.41, [1.33-1.49]), and thrombocytosis (OR 2.20, [2.05-2.36]). Concordantly, the risks of prolonged hospitalization and 30-day readmission followed the same pattern. These results were validated in a large colon cancer cohort from the 2010 database. In conclusion, platelet count is a prognostic indicator in cancer surgeries. This could be related to the role of platelets in wound healing and immunity on one hand, and propagating malignancy on the other.

Risk of insulin-dependent diabetes mellitus in patients undergoing carotid endarterectomy

OBJECTIVE

There is conflicting evidence regarding the association of diabetes mellitus (DM) and insulin use with outcomes after carotid endarterectomy (CEA). Therefore, we sought to evaluate the risk of insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) on 30-day outcomes after CEA.

METHODS

We identified patients undergoing CEA from the Targeted Vascular module of the National Surgical Quality Improvement Program (2011-2015) and stratified patients on the basis of their preprocedural symptom status. We compared 30-day outcomes between nondiabetics and patients with NIDDM or IDDM, with 30-day stroke/death as the primary end point.

RESULTS

Of 16,739 CEA patients, 9784 (58%) were asymptomatic, of whom 6720 (69%) had no diagnosis of DM, 1109 (11%) had IDDM, and 1955 (20%) had NIDDM. Of the 6955 symptomatic patients, 4982 (72%) had no diagnosis of DM, 810 (12%) had IDDM, and 1163 (17%) had NIDDM. Among asymptomatic patients, patients with IDDM experienced higher rates of 30-day stroke/death compared with those without DM (3.4% vs 1.5%; P < .001), whereas those with NIDDM experienced rates similar to those of patients without DM (2.1% vs 1.5%; P = .1). Moreover, asymptomatic patients with IDDM and an anatomic high-risk criterion experienced a 30-day stroke/death rate of 6.6%. After adjustment, IDDM was associated with 30-day stroke/death in asymptomatic patients compared with patients without DM (odds ratio, 2.3; 95% confidence interval, 1.5-3.4; P < .001), but NIDDM was not (odds ratio, 1.4; 95% confidence interval, 1.0-2.1; P = .1). In comparison, among symptomatic patients, those with IDDM and NIDDM experienced similar rates of 30-day stroke/death as patients without DM (4.9% vs 3.6% and 4.0% vs 3.6%; both P > .1). After adjustment, neither IDDM nor NIDDM was associated with 30-day stroke/death in symptomatic patients compared with symptomatic patients without DM.

CONCLUSIONS

Rates of 30-day stroke/death after CEA in asymptomatic patients with IDDM exceed international vascular societies' guideline thresholds for acceptable outcomes in asymptomatic patients, especially those with anatomic high-risk criteria. Thus, asymptomatic patients with IDDM may not benefit from CEA, although more data are needed about the natural history of carotid disease in this population.

Defying public expectations: Publicly reported hospital scores do not always correlate with clinical outcomes

BACKGROUND

Publicly reported hospital scores are used by patients to make health care-related decisions; however, their relationship to clinical outcomes is unknown.

METHODS

Through the use of the New York Statewide Planning and Research Cooperative System database, the association between two commonly used scores (Healthgrades and Centers for Medicare & Medicaid Services Hospital Compare) and four clinical outcomes was evaluated in several surgical fields (general, colorectal, hepatobiliary, foregut, and bariatric).

RESULTS

After adjusting for patient-level factors, patients from facilities with greater Healthgrades scores were less likely to develop any complication after general surgery operations (P = .0013). Also, greater Healthgrades scores were associated with less 30-day readmissions and emergency department visits for general surgery operations only (P = .0061 and P = .0013, respectively). In addition, greater Healthgrades scores were significantly associated with a lesser hospital length of stay for colorectal, foregut, and general surgery operations. Greater Centers for Medicare & Medicaid Services Hospital Compare scores were significantly associated with less 30-day readmissions and lesser hospital length of stay for specific operative groups.

CONCLUSION

Although some specialties demonstrated a correlation, there was no consistent relationship between publicly reported hospital scores and surgical outcomes that contributed to clinically meaningful use for patients or operations.

Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing

BACKGROUND

Health care value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.

STUDY DESIGN

Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014 to 2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared with median use, accounting for case, patient, and attending-level variables.

RESULTS

There were 111,055 laboratory orders and 7,360 imaging orders linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% CIs > 1, p < 0.05). Compared with the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% CI >1, p < 0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.

CONCLUSIONS

Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared with imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high users and could be used to educate residents on their ordering patterns.

"Real-time" risk models of postoperative morbidity and mortality for liver transplants

AIM

A comprehensive description of morbidity and mortality risk factors for post liver transplant has not been available to date. In this study, we established real-time risk models of postoperative morbidities and mortality in liver transplant recipients using two Japanese nationwide databases.

METHODS

Data from two Japanese nationwide databases were combined and used for this study. We developed real-time prognostic models for morbidity and mortality from a derivation cohort (n = 1472) and validated the findings with an independent cohort (n = 395). Preoperative variables (C1), preoperative and intraoperative variables (C2), and all variables including postoperative morbidities within 30 days (C3) were analyzed to evaluate the independent risk factors for postoperative morbidity and mortality.

RESULTS

We established real-time risk models for morbidity and mortality. Areas under the curve (AUC) of C1 and C2 risk models for mortality were 0.74 (0.63-0.82) and 0.79 (0.69-0.86), respectively. Multivariate logistic analysis using C3 showed that hemoglobin <10 g/dL, operative time (hours), and five postoperative morbidities (prolonged ventilation >48 hours, coma >24 hours, renal dysfunction, postoperative systemic sepsis, and serum total bilirubin ≥10 mg/dL) represented independent risk factors for mortality (AUC = 0.87, 95% confidence interval [CI]: 0.78-0.93).

CONCLUSIONS

Real-time risk models of postoperative morbidities and mortality at various perioperative time points in liver transplant recipients were established. These novel approaches may improve postoperative outcomes of liver transplant recipients. Furthermore, these real-time risk models may be applicable to other surgical procedures.

Post-surgical opioid prescribing patterns and risk factors for additional opioid prescriptions within one year after non-emergent colorectal surgery

BACKGROUND

National opioid concerns resulted in review of prescribing patterns following colorectal surgery.

METHODS

This retrospective cohort study examined prescribing patterns in elective colorectal surgery at a tertiary academic medical center from January 2012 through December 2014.

RESULTS

Forty percent of 4286 patients received additional opioid prescriptions within the year following colorectal surgery. Multivariable analysis demonstrated that a pre-operative opioid prescriptions within 1 year of surgery (OR 2.91; 95% CI, 1.83-4.60), increasing operative time (OR 1.02; 95% CI, 1.00-1.04), or complications (OR 2.18; 95% CI, 1.38-3.43) was associated with additional opioid prescriptions. The median opioid prescription upon discharge was 225 mg morphine milligram equivalents. Discharge opioid amount was not a risk factor.

CONCLUSIONS

Additional opioid prescriptions after surgery occurred in 40% of patients. Pre-operative prescriptions, increasing operative time and complications were associated with additional opioid prescriptions while opioid amount at discharge was not a risk factor.

Return to the Emergency Room with or without Readmission After Endoscopic Transsphenoidal Surgery in Socioeconomically Disadvantaged Patients at an Urban Medical Center

BACKGROUND

Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population.

METHODS

We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program.

RESULTS

Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia.

CONCLUSION

Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.

Risk Factors and Associated Complications of Symptomatic Venous Thromboembolism in Patients with Craniotomy for Meningioma

OBJECTIVE

Patients undergoing surgical resection of meningioma are at increased risk for developing venous thromboembolism (VTE). The aim of this study was to assess occurrence of VTE in patients who underwent surgical resection of meningioma to determine risk factors and associated complications of VTE.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database from 2012 to 2015 was reviewed for patients who had undergone meningioma resection according to primary Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision.

RESULTS

The study included 5036 patients with meningioma. Rate of VTE was 3.38%, with pulmonary embolism rate of 1.47% and deep venous thrombosis rate of 2.42%. During the first 30 days after surgery, patients with VTE had a mortality rate of 5.88% compared with 1.15% for patients without VTE. Multivariate binary logistic regression analysis determined 5 risk factors for VTE,: age ≥60 years, American Society of Anesthesiologists classification III, operative time ≥310 minutes, ventilator dependence, and preoperative transfusions. Univariate analysis revealed a number of complications significantly associated with VTE occurrence, including unplanned intubation, ventilator use for >48 hours, stroke, sepsis, septic shock, pneumonia, urinary tract infection, and transfusions.

CONCLUSIONS

Risk factors of VTE and associated complications were identified. Understanding these risk factors provides physicians with further insight in managing this subgroup of patients in a personalized fashion in the perioperative period to minimize the incidence and morbidity of VTE.

Early Complications and Mortality following Radical Cystectomy: Associations with Malnutrition and Obesity

BACKGROUND

There are conflicting data regarding the impact of obesity on postoperative outcomes following radical cystectomy (RC) and how obesity and malnutrition interact in patients undergoing RC.

OBJECTIVE

To evaluate associations of body mass index (BMI), significant preoperative weight loss, and hypoalbuminemia with 30-day complications and mortality after RC.

METHODS

Review of the American College of Surgeons National Surgical Quality Improvement Program database identified 2,055 patients who underwent RC (2006-12). Univariate and multivariable logistic regression models were developed to assess associations between hypoalbuminemia (<3.5 g/dL), >10% preoperative weight loss, obesity as characterized by BMI (class I: 30-34.9, II: 35-39.9, III: ≥40 kg/m2), and 30-day complications and mortality.

RESULTS

The median BMI of the study cohort was 27.82 kg/m2 with 22.4% classified as having class I, 7.5% class II, and 4.2% class III obesity, respectively. Hypoalbuminemia and >10% weight loss were present in 16.7% and 3.5%, respectively. Among obese patients, 13.4% had hypoalbuminemia. On multivariable analysis, class I (OR 1.43, p = 0.01), class II (OR 1.92, p < 0.001), and class III (OR 2.32, p < 0.001) obesity and hypoalbuminemia (OR 1.47, p = 0.02) were independently associated with 30-day complications, and class III obesity (OR 2.96, p = 0.02) and hypoalbuminemia (OR 2.33, p = 0.03) were independently associated with 30-day mortality.

CONCLUSION

Increasing class of obesity and hypoalbuminemia were independently associated with increased complications following RC. Hypoalbuminemia and class III obesity were associated with early mortality. This study highlights the fact that malnutrition may coexist in obese patients and underscores the need to identify patients with malnutrition who may be candidates for preoperative nutritional optimization.

Short- and long-term outcomes after postsurgical acute kidney injury requiring dialysis

Objective

Prompt assessment of perioperative complications is critical for the comprehensive care of surgical patients. Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality, yet little is known about how long-term outcomes of patients have evolved. The association of AKI-D with postsurgical outcomes has not been well studied.

Methods

We investigated patients from the National Health Insurance Research Database and validated by the multicenter Clinical Trial Consortium for Renal Diseases cohort. All patients with AKI-D 18 years or older undergoing four major surgeries (cardiothoracic, esophagus, intestine, and liver) were retrospectively investigated (N=106,573). Patient demographics, surgery type, comorbidities before admission, and postsurgical outcomes, including the in-hospital, 30-day, and long-term mortality together with dialysis dependence were collected.

Results

AKI-D is the top risk factor for 30-day and long-term mortality after major surgery. Of 1,664 individuals with AKI-D and 6,656 matched controls, AKI-D during the hospital stay was associated with in-hospital (adjusted hazard ratio [aHR]=3.04, 95% CI 2.79–3.31), 30-day (aHR=3.65, 95% CI 3.37–3.94), and long-term (aHR=3.22, 95% CI 3.01–3.44) mortality. Patients undergoing cardiothoracic surgery (CTS) showed less in-hospital (aHR=0.85, 95% CI 0.75–0.97), 30-day (aHR=0.79, 95% CI 0.70–0.89), and long-term (aHR=0.80, 95% CI 0.72–0.90) mortality compared with non-CTS patients with AKI-D. CTS patients had a high risk of 30-day dialysis dependence (subhazard ratio [sHR]=1.67, 95% CI 1.18–2.38), but the risk of long-term dialysis dependence was similar (sHR=1.38, 95% CI 0.96–2.00) after AKI-D by taking mortality as a competing risk. Non-CTS patients had more comorbidities of sepsis, azotemia, hypoalbuminemia, and metabolic acidosis compared with CTS patients.

Conclusion

AKI exhibits paramount effects on postsurgical outcomes that extend well beyond discharge from the hospital. The goal of the perioperative assessment should include the reassurance of enhancing renal function recovery among different surgeries, and optimized follow-up is warranted in attenuating the complications after postsurgical AKI has occurred.

International benchmarking in oesophageal and gastric cancer surgery

Background

Benchmarking on an international level might lead to improved outcomes at a national level. The aim of this study was to compare treatment and surgical outcome data from the Swedish National Register for Oesophageal and Gastric Cancer (NREV) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA).

Methods

All patients with primary oesophageal or gastric cancer who underwent a resection and were registered in NREV or DUCA between 2012 and 2014 were included. Differences in 30‐day mortality were analysed using case mix‐adjusted multivariable logistic regression.

Results

In total, 4439 patients underwent oesophagectomy (2509 patients) or gastrectomy (1930 patients). Estimated resection rates were comparable. Swedish patients were older but had less advanced disease and less co‐morbidity than Dutch patients. Neoadjuvant treatment rates were lower in Sweden than in the Netherlands, both for patients who underwent oesophagectomy (68·6 versus 90·0 per cent respectively; P < 0·001) and for those having gastrectomy (38·3 versus 56·6 per cent; P < 0·001). In Sweden, transthoracic oesophagectomy was performed in 94·7 per cent of patients, whereas in the Netherlands, a transhiatal approach was undertaken in 35·8 per cent. Higher annual procedural volumes per hospital were observed in the Netherlands. Adjusted 30‐day and/or in‐hospital mortality after gastrectomy was statistically significantly lower in Sweden than in the Netherlands (odds ratio 0·53, 95 per cent c.i. 0·29 to 0·95).

Conclusion

For oesophageal and gastric cancer, there are differences in patient, tumour and treatment characteristics between Sweden and the Netherlands. Postoperative mortality in patients with gastric cancer was lower in Sweden.

Anterior Versus Transforaminal Lumbar Interbody Fusion: Perioperative Risk Factors and 30-Day Outcomes

Background

Operative management of lower back pain often necessitates anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF). Specific pathoanatomic advantages and indications exist for both approaches, and few studies to date have characterized comparative early outcomes.

Methods

Adult patients undergoing elective ALIF or TLIF operations were abstracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) years 2011-2014. Univariate analyses were performed by surgery cohort for each outcome and adjusted for demographic/clinical variables (age ≥ 65, sex, race, body mass index, American Society of Anesthesiologists physical classification score, functional status, inpatient/outpatient status, smoking, hypertension, Charlson Comorbidity Index) using multivariable regression. Means, standard errors, mean differences (B), odds ratios (ORs), and associated 95% confidence intervals (CIs) are reported. Significance was assessed at P < .05.

Results

Of 8263 subjects (ALIF: 4325, TLIF: 3938), ALIF subjects were younger, less obese, less physically impaired, and had significantly lower rates of hypertension, diabetes, coagulopathy, and previous cardiac surgery. On multivariable analysis, ALIF associated with shorter operative time (B = -11.80 minutes, 95% CI [-16.48, -7.12]; P < .001). Transforaminal lumbar interbody fusion was associated with increased incidence of urinary tract infections (UTIs; OR = 1.57, 95% CI [1.10, 2.26]; P = .013) and of blood transfusions (OR = 1.19, 95% CI [1.04, 1.37]; P = .012). Multivariate analysis also demonstrated TLIF associated with shorter hospital length of stay (B = -0.27 days, 95% CI [-0.54, -0.01]; P = .041), and fewer cases of pneumonia (OR = 0.55, 95% CI [0.32, 0.94]; P = .029) and prolonged ventilator dependency (OR = 0.33, 95% CI [0.12, 0.84]; P = .021).

Conclusions

Comparatively, ALIF patients experienced decreased operative time and decreased incidence of postoperative UTIs and blood transfusions. Anterior lumbar interbody fusion patients were more likely to suffer postoperative pulmonary complications and longer hospital stays. Our data support the notion that both anterior and transforaminal surgical approaches perform comparably in context of 30-day perioperative outcomes.

Service Quality Gaps in the Provision of Care to Surgical Patients: a Cross-Sectional Study in the Northwest of Iran

Introduction: The evaluation of service quality is a key measurement which provides the necessary information for effective decision making and providing high quality care. This study aimed to investigate the factors affecting the service quality gap for the provision of care from the perspective of surgical patients hospitalized in a teaching hospital in the Northwest of Iran in 2015.

Methods: In this descriptive cross-sectional study a total of 300 patients and 101 nurses were selected by random sampling method. The data regarding patients’ expectations and perceptions of the quality of healthcare services were collected using the SERVQUAL questionnaire. Also, the nurses’ demographic data were assessed using the demographic data tool.

Results: The mean and standard deviation of the patients’ expectations and perceptions of the quality of healthcare services were 66.59)8.52) and 51.81(11.97), respectively. In all dimensions of the quality of healthcare services, the patients’ perceptions were lower than their expectations. The greatest gap was observed in the dimensions of assurance and responsibility and the lowest gap was reported in the domains of reliability and empathy. There were statistically significant relationships between the nurses’ age, work experiences in surgical wards, professional experiences of nurses, patients’ income level and the gap in the quality of healthcare services.

Conclusion: Despite great efforts directed at the field, the healthcare system still faces numerous challenges in the provision of high quality healthcare services to the patients. The health system should support low-income people and employ professional and experienced nurses for improving the quality of healthcare services.

Complications and Obesity in Arthroplasty-A Hip is Not a Knee

BACKGROUND

Obesity has previously been demonstrated to be an independent risk factor for increased complications after total hip and knee arthroplasties (THA and TKA). The purpose of this study was to compare the effects of obesity and body mass index (BMI) to determine whether the magnitude of the effect was similar for both procedures.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent primary THA or TKA between 2010 and 2014. Patients were stratified by procedure and classified as nonobese, obese, or morbidly obese according to BMI. Thirty-day rates of wound complications, deep infection, total complications, and reoperation were compared using univariate and multivariate logistic regression analyses.

RESULTS

We identified 64,648 patients who underwent THA and 97,137 patients who underwent TKA. Obese THA patients had significantly higher rates of wound complications (1.53% vs 0.96%), deep infection (0.31% vs 0.17%), reoperation rate (2.11% vs 1.02%), and total complications (5.22% vs 4.63%) compared with TKA patients. Morbidly obese patients undergoing THA were also found to have significantly higher rates of wound complications (3.25% vs 1.52%), deep infection (0.84% vs 0.23%), reoperation rate (3.65% vs 1.60%), and total complications (7.36% vs 5.57%). Multivariate regression analysis identified increasingly higher odds of each outcome measure as BMI increased.

CONCLUSION

This study demonstrates that the impact of obesity on postoperative complications is more profound for THA than TKA. This emphasizes the importance of considering patient comorbidities in the context of the specific procedure when assessing risks of surgery.

Predictors of complications following breast reduction surgery: A National Surgical Quality Improvement Program study of 16,812 cases

BACKGROUND

Breast reduction is one of the most common procedures performed by plastic surgeons. Despite good outcomes and high patient satisfaction, there are little national data on the predictors that lead to complications in this patient population. We accessed a national outcomes database to examine these factors.

METHODS

This is a retrospective study examining the National Surgical Quality Improvement Program database from 2006 to 2015. Patients who underwent primary breast reduction were identified. Patients who underwent any cancer-related procedures were excluded. We identified patient-related and procedure-related factors for analysis. Univariate and multivariate logistic regression analyses were used to identify independent predictors of complications.

RESULTS

In total, 16,812 individual cases were identified. The overall complication rate for the cohort was 6.2%, and the major complication rate was 3.0%. Diabetes, bleeding disorder, hypertension, obesity, smoking, steroid use, and prolonged operative time were associated with increased risk of complications (p < 0.05). Concurrent body contouring was a predictor of increased major complications; however, liposuction was not.

CONCLUSIONS

Common surgical risk factors are associated with complications in breast reduction surgery. Although liposuction is not an independent risk factor, concurrent body contouring is associated with increased complications. Surgeons should be aware of these associations when discussing breast reduction with patients.

A risk score model of 30-day readmission in ulcerative colitis after colectomy or proctectomy

INTRODUCTION

The Center for Medicare and Medicaid Services established 30-day readmission rate as a key metric in measuring high-value, cost-conscious care; therefore, our aim is to develop a risk score for 30-day readmission in ulcerative colitis (UC) patients undergoing colectomy or proctectomy.

METHODS

This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file (2011-2015). Patients with UC undergoing colectomy or proctectomy were identified using ICD-9, 10, and CPT codes. Stepwise multivariate analyses were used to determine risk factors associated with readmission including pre-operative conditions, laboratory results, operative variables, and post-operative complications. For readmission risk score assessment, a weighted logistic regression model was built and validated using ACS NSQIP 2011-2014 and 2015 data, respectively.

RESULTS

A total of 4797 patients were included with 963 (20%) patients readmitted within 30 days. Potentially modifiable risk factors included deep vein thrombosis, pulmonary embolism, renal insufficiency, wound infection, urinary tract infection, sepsis/septic shock, and pre-existing congestive heart failure. Ten percent of patients with a risk score between 0 and 9 were readmitted, 18.5% with a score between 10 and 19, 52.2% with a score between 20 and 29, and 59.6% in patients with a risk score >29.

CONCLUSIONS

Multiple potentially preventable risk factors are associated with 30-day readmission following colectomy or proctectomy in UC patients. Higher risk scores are associated with increased risk of unplanned readmission.

Delayed Ileal Pouch Anal Anastomosis Has a Lower 30-Day Adverse Event Rate: Analysis From the National Surgical Quality Improvement Program

BACKGROUND

Ulcerative colitis (UC) patients requiring colectomy often have a staged ileal pouch anal anastomosis (IPAA). There are no prospective data comparing timing of pouch creation. We aimed to compare 30-day adverse event rates for pouch creation at the time of colectomy (PTC) with delayed pouch creation (DPC).

METHODS

Using prospectively collected data from 2011-2015 through the National Surgical Quality Improvement Program, we conducted a cohort study including subjects aged ≥18 years with a postoperative diagnosis of UC. We assessed 30-day postoperative rates of unplanned readmissions, reoperations, and major and minor adverse events (AEs), comparing the stage of the surgery where the pouch creation took place. Using a modified Poisson regression model, we estimated risk ratios (RRs) with 95% confidence intervals (CIs) adjusting for age, sex, race, body mass index, smoking status, diabetes, albumin, and comorbidities.

RESULTS

Of 2390 IPAA procedures, 1571 were PTC and 819 were DPC. In the PTC group, 51% were on chronic immunosuppression preoperatively, compared with 15% in the DPC group (P < 0.01). After controlling for confounders, patients who had DPC were significantly less likely to have unplanned reoperations (RR, 0.42; 95% CI, 0.24-0.75), major AEs (RR, 0.72; 95% CI, 0.52-0.99), and minor AEs (RR, 0.48; 95% CI, 0.32-0.73) than PTC.

CONCLUSIONS

Patients undergoing delayed pouch creation were at lower risk for unplanned reoperations and major and minor adverse events compared with patients undergoing pouch creation at the time of colectomy. 10.1093/ibd/izy082_video1izy082.video15776112442001.

What Can Regional Anesthesiology and Acute Pain Medicine Learn from "Big Data"?

Demonstrating value added to patients' experience through regional anesthesiology and acute pain medicine is critical. Evidence supporting improved outcomes can be derived from prospective studies or retrospective cohort studies. Population-based studies relying on existing clinical and administrative databases are helpful when an outcome is rare and detecting a change would require studying large numbers of patients. This article discusses the effect of regional anesthesiology and acute pain medicine interventions on mortality and morbidity, infection rate, cancer recurrence, inpatient falls, local anesthetic systemic toxicity, persistent postsurgical pain, and health care costs.

Impact of Operative Time on Adverse Events Following Primary Total Joint Arthroplasty

BACKGROUND

Little is known regarding the impact of operative time on adverse events following arthroplasty. The present study tests for associations between a 15-minute increase in operative time and the occurrence of adverse events following primary total joint arthroplasty.

METHODS

Patients undergoing primary total hip or knee arthroplasty during 2006-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Operative time (as a continuous variable) was tested for association with perioperative outcomes using multivariate regression. All regressions were adjusted for differences in demographic, comorbidity, and procedural characteristics.

RESULTS

A total of 165,474 patients met inclusion criteria. The mean (±standard deviation) operative time was 91.9 ± 32.5 minutes. Following adjustment for baseline characteristics, an increase in operative time by 15 minutes increased the risk of anemia requiring transfusion by 9% (95% confidence interval [CI] = 8%-10%, P < .001), wound dehiscence by 13% (95% CI = 8%-19%, P < .001), renal insufficiency by 9% (95% CI = 3%-14%, P < .001), sepsis by 10% (95% CI = 6%-14%, P < .001), surgical site infection by 9% (95% CI = 7%-12%, P < .001), and urinary tract infection by 4% (95% CI = 2%-6%, P < .001). Similarly, an increase in operative time by 15 minutes increased the risk of hospital readmission by 5% (95% CI = 4%-6%, P < .001) and of extended hospital length of stay (≥4 days) by 9% (95% CI = 8%-10%, P < .001).

CONCLUSION

The present study suggests that greater operative time increases the risk for multiple postoperative complications following total joint arthroplasty. These data suggest that surgeons should consider steps to minimize operative time without compromising the technical components of the surgical procedure.

What Is the Impact of Smoking on Revision Total Knee Arthroplasty?

BACKGROUND

There is a paucity of literature evaluating the impact of smoking on revision arthroplasty procedures. The purpose of this study was to identify the effect of smoking on complications after revision total knee arthroplasty (rTKA).

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify patients who underwent rTKA between 2006 and 2014. Patients were divided into current smokers and nonsmokers according to the NSQIP definitions. Each cohort was compared in terms of demographic data, preoperative comorbidities, and operative time. Infection end points were created from composite surgical site infection variables defined by the NSQIP database. Multivariate logistic regression analysis was utilized to adjust for confounding variables and calculate adjusted odds ratios (ORs) and associated 95% confidence intervals (95% CIs).

RESULTS

In total, 8776 patients underwent rTKA. Of these patients, 11.6% were current smokers. Univariate analyses demonstrated that smokers had a higher rate of any wound complication (3.8% vs 1.8%, P < .0001), deep infection (2.5% vs 1.0%, P < .0001), pneumonia (1.3% vs 0.4%, P < .0001), and reoperation (5.0% vs 3.1%, P = .001) compared to nonsmokers undergoing revision total knee arthroplasty. Multivariate analysis identified current smokers as being at a significantly increased risk of any wound complication (OR 2.1; 95% CI 1.4-3.1) and deep infection (OR 2.1, 95% CI 1.2-3.6) after rTKA.

CONCLUSION

This study demonstrates that smoking significantly increases the risk of infection, wound complications, and reoperation after rTKA. The results are even more magnified for revision procedures compared to published effects of smoking on primary total knee arthroplasty complications. Further research is needed regarding the impact of smoking cessation on mitigation of these observed risks.

Accelerating surgical quality improvement in Ontario through a regional collaborative: a quality-improvement study

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) collaborative in Ontario, the Ontario Surgical Quality Improvement Network (ON-SQIN), was launched in January 2015. We describe its approaches to support surgical quality improvement and examine its early impact on member hospitals.

METHODS

All Ontario hospitals that participated in the ON-SQIN and NSQIP were included in this quality-improvement study. The primary intervention was the introduction of the ON-SQIN, and the secondary interventions included a community of practice and access to quality-improvement resources and tools. Outcome measures included the level of quality-improvement capacity, collaborative-wide aggregate data on postoperative complications, and self-reported rates of surgical site and urinary tract infections.

RESULTS

Eighteen hospitals that enrolled in the ON-SQIN in 2015 reported an increase in their capacity for quality improvement after 18 months. Analysis of the collaborative-wide aggregate data in a 6-month period (14 748 surgical cases) revealed a substantial reduction of acute renal failure (relative risk 0.48, 95% confidence interval 0.25-0.95) and urinary tract infection (relative risk 0.77, 95% confidence interval 0.61-0.97). Most hospitals that targeted prevention of surgical site infection and urinary tract infection reported reduction of these occurrences during a 1-year period.

INTERPRETATION

The ON-SQIN supported the uptake of the NSQIP in Ontario hospitals and promoted targeted surgical quality-improvement initiatives, resulting in increased quality-improvement capacity and development of the community of practice. Furthermore, our early experience suggests that improvements in surgical care are being realized.

Unplanned reoperation after hepatectomy: an analysis of risk factors and outcomes

BACKGROUND/PURPOSE

Reoperation is being increasingly utilized as a metric for surgical care quality. The aim of this study was to identify the incidence of and risk factors for unplanned reoperation following index hepatectomy.

METHODS

Pre, intra- and post-operative information of patients who underwent partial hepatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2013 were analyzed.

RESULTS

343 (4%) of 9195 patients required reoperation within 30 days of index hepatectomy. The index procedures with the highest incidence of reoperation (%) were trisectionectomy (7%) and right hepatectomy (5%). Patients who underwent reoperation had increased index operative duration (323 ± 174 min versus 243 ± 125 min, p < 0.001), postoperative transfusion (57% versus 23%, p < 0.001), wound complications, cardiorespiratory, renal, thromboembolic, and infectious events. Hemorrhage was the most common indication for reoperation (10%). Male gender, ASA class 4, and right hepatectomy or trisectionectomy were independent predictors of reoperation (OR 1.4 [1.1-1.7], p = 0.007; 2.0 [1.3-3.1], p = 0.003; 1.6 [1.2-2.0], p = 0.001 and 2.5 [1.8-3.4], p < 0.001, respectively). All reoperations occurred during index hospitalization and resulted in longer mean length of stay (19 ± 17 days versus 7 ± 7 days, p < 0.001).

CONCLUSION

Reoperation is associated with several patient characteristics and procedural factors in this national sample. Knowledge of these factors can increase awareness of patients at risk for reoperation.

Unique predictors and economic burden of superficial and deep/organ space surgical site infections following pancreatectomy

BACKGROUND

Surgical site infections (SSIs) are common following pancreatectomy and associated with significant morbidity and economic burden. We sought to identify distinct predictors for superficial versus deep/organ space SSIs and their effects on surgical outcomes.

METHODS

ACS-NSQIP targeted pancreatectomy 2014 and 2015 databases were queried. Univariate and multivariate models were developed for both types of SSI, length of stay (LOS), and readmission. Costs were estimated based on Centers for Medicare & Medicaid Services (CMS) recommendations.

RESULTS

Of 8093 patients, there were 422 (5.2%) superficial and 1005 (12.4%) deep/organ space SSIs. On multivariate analyses, preoperative biliary stenting was predictive only for superficial SSI (OR: 2.21), while BMI of 25-29.9 (OR: 1.25) and BMI ≥30 kg/m2 (OR: 1.53), pancreatic duct size <3 mm (OR: 1.30), and intermediate (OR: 1.67) versus hard gland texture were predictors of deep/organ-space SSI. Superficial and deep/organ space SSIs were independent predictors of prolonged LOS (OR: 1.74 vs 1.80) and readmission (OR: 2.59 vs 6.57). Additional readmission costs per patient secondary to superficial SSI and deep/organ space SSI were $7661.37 and $18,409.42, respectively.

CONCLUSION

Deep/organ space SSI contributes more profoundly to prolonged hospital stay, readmission, and additional costs, suggesting that strategies should focus on preferential prevention of deep/organ space infections.

Venous Thromboembolism Following Total Knee Arthroplasty: Does Race Matter?

BACKGROUND

Venous thromboembolism (VTE) (deep venous thrombosis and pulmonary embolism) is a known complication following total knee arthroplasty (TKA). Recent literature has identified differences in VTE risk based on race with African Americans having higher risk of VTE. This study evaluated the impact of race on VTE following TKA using a large multicenter database.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program to identify patients who underwent primary TKA in 2010-2014. Patients were stratified based on race: Asian, Black/African American, White, and Other. Demographics were compared to determine the impact on 30-day postoperative complications. Multivariate logistic regression analysis was performed to control for confounding demographics and comorbidities between races. Primary outcomes included overall complications and VTE.

RESULTS

In total, 96,230 patients were included. Univariate analysis demonstrated that Blacks had a significantly higher rate of any complication (5.5%), deep venous thrombosis (1.3%), and pulmonary embolism (1.1%) than other races (P = .007, P < .001, and P < .001, respectively). Overall mortality rate did not differ between races (P = .26). Multivariate regression analysis identified that Blacks were significantly more likely to have a VTE than Whites (odds ratio 1.7, 95% confidence interval 1.4-2.0). Overall complications were significantly higher for Blacks than Whites (odds ratio 1.1, 95% confidence interval 1.02-1.3). There were no differences in the rates of VTE or overall complications between Asians/Other races and Whites.

CONCLUSION

Blacks have a significantly higher risk of VTE following primary TKA than other races. Future studies should investigate causes for this disparity.

Examining the Ability of Artificial Neural Networks Machine Learning Models to Accurately Predict Complications Following Posterior Lumbar Spine Fusion

STUDY DESIGN

A cross-sectional database study.

OBJECTIVE

The aim of this study was to train and validate machine learning models to identify risk factors for complications following posterior lumbar spine fusion.

SUMMARY OF BACKGROUND DATA

Machine learning models such as artificial neural networks (ANNs) are valuable tools for analyzing and interpreting large and complex datasets. ANNs have yet to be used for risk factor analysis in orthopedic surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent posterior lumbar spine fusion. This query returned 22,629 patients, 70% of whom were used to train our models, and 30% were used to evaluate the models. The predictive variables used included sex, age, ethnicity, diabetes, smoking, steroid use, coagulopathy, functional status, American Society for Anesthesiology (ASA) class ≥3, body mass index (BMI), pulmonary comorbidities, and cardiac comorbidities. The models were used to predict cardiac complications, wound complications, venous thromboembolism (VTE), and mortality. Using ASA class as a benchmark for prediction, area under receiver operating curves (AUC) was used to determine the accuracy of our machine learning models.

RESULTS

On the basis of AUC values, ANN and LR both outperformed ASA class for predicting all four types of complications. ANN was the most accurate for predicting cardiac complications, and LR was most accurate for predicting wound complications, VTE, and mortality, though ANN and LR had comparable AUC values for predicting all types of complications. ANN had greater sensitivity than LR for detecting wound complications and mortality.

CONCLUSION

Machine learning in the form of logistic regression and ANNs were more accurate than benchmark ASA scores for identifying risk factors of developing complications following posterior lumbar spine fusion, suggesting they are potentially great tools for risk factor analysis in spine surgery.

LEVEL OF EVIDENCE

3.

Incidence, Risk Factors, and Clinical Implications of Pneumonia After Surgery for Geriatric Hip Fracture

BACKGROUND

Little is known regarding the occurrence of pneumonia after hip fracture surgery. The purpose of this study is to determine the incidence, risk factors, and clinical implications of pneumonia after surgery for geriatric hip fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to retrospectively study geriatric patients undergoing surgery for hip fracture during 2006-2014. Independent risk factors for developing pneumonia within 30 days of surgery were identified using multivariate regression.

RESULTS

Of the 29,377 patients meeting inclusion criteria, 13,736 (46.8%) underwent hemiarthroplasty, 9468 (32.2%) intramedullary fixation, 4294 (14.6%) plate and/or screw fixation, 1299 (4.4%) total joint arthroplasty, and 580 (2.0%) percutaneous fixation. In total 1191 patients developed pneumonia, an incidence of 4.1%. The strongest risk factors for pneumonia were male sex, older age (especially ≥90 years), low body mass index, and chronic obstructive pulmonary disease. Patients who developed pneumonia had a higher readmission rate (79.1% vs 8.2%, P < .001), a higher rate of sepsis (16.6% vs 1.7%, P < .001), and a higher mortality rate (29.2% vs 5.7%, P < .001). Among 1602 total mortalities, 348 (17.9%) occurred in patients with pneumonia.

CONCLUSION

Pneumonia is a serious complication after geriatric hip fracture surgery, which increases the readmission and mortality risks. Evidence-based pneumonia prevention programs should be implemented among high-risk patients-males, patients ≥90 years, body mass index <18.5 kg/m², and/or patients with chronic obstructive pulmonary disease-to decrease morbidity and mortality.

Improving quality and safety in paediatric spinal surgery

Aims

The aim of this study was to evaluate improvements in the quality and safety of paediatric spinal surgery following the implementation of a specialist Paediatric Spinal Surgical Team (PSST) in the operating theatre.

Patients and Methods

A retrospective consecutive case study of paediatric spinal operations before (between January 2008 and December 2009), and after (between January 2012 and December 2013) the implementation of PSST, was performed. A comparative analysis of outcome variables including surgical site infection (SSI), operating time (ORT), blood loss (BL), length of stay (LOS), unplanned staged procedures (USP) and transfusion rates (allogenic and cell-saver) was performed between the two groups. The rate of complications during the first two postoperative years was also compared between the groups.

Results

There were 130 patients in the pre-PSST group and 277 in the post-PSST group. The age, gender, body mass index (BMI), preoperative Cobb angle of the major curve and the number of levels involved were similar between the groups. There were statistically significant differences in SSI, ORT, LOS, allogenic blood transfusion volume (ABTV), and USPs between the groups. There was a 94% decrease in the rate of SSI's in the post-PSST group. Patients in the post-PSST group had a mean reduction in ORT of 53 minutes (sd 7.7) (p = 0.013), LOS by 5.4 days (sd 1.8) (p = 0.019), and ABTV by 226.3 ml (sd 28.4) (p < 0.001). There were significantly more USPs in the pre-PSST group (6.2%) compared with the post-PSST group (2.9%) (p = 0.001). Multivariate regression showed that the effect of PSST remained significant for ORT, LOS, BL, ABVT and cell-saver amount transfused (p = 0.0001). The odds of having a SSI were tenfold higher and the odds of receiving a blood transfusion were 2.4 times higher, respectively, in the pre-PSST group (p = 0.004 and p = 0.011). The rate of complications within the first two postoperative years was significantly higher in the pre-PSST group (13.1%) compared with the post-PSST group (4.3%) (p < 0.001).

Conclusion

The implementation of a PSST in the operating theatre significantly improves the outcomes in paediatric spinal surgery. Cite this article: Bone Joint J 2018;100-B:493–8.

Effect of Malnutrition on Radical Nephroureterectomy Morbidity and Mortality: Opportunity for Preoperative Optimization

INTRODUCTION

Nutritional status has been increasingly recognized as an important predictor of prognosis and surgical outcomes for cancer patients. We evaluated the effect of preoperative malnutrition on the development of surgical complications and mortality after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

Using data from the American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30-day postoperative complications and overall mortality after RNU from 2005 to 2015. The preoperative variables suggestive of poor nutritional status included hypoalbuminemia (< 3.5 g/dL), weight loss within 6 months before surgery (> 10%), and a low body mass index.

RESULTS

A total of 1200 patients were identified who had undergone RNU for UTUC. The overall complication rate was 20.5% (n = 246), and mortality rate was 1.75% (n = 21). On univariate analysis, patients who experienced a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4%; P < .001) and weight loss (3.7% vs. 1.0%; P = .003). After controlling for baseline characteristics and comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (odds ratio, 2.09; 95% confidence interval, 1.29-3.38; P = .003). Hypoalbuminemia was also a significant independent predictor of mortality (odds ratio, 4.31; 95% confidence interval, 1.45-12.79; P = .008) on multivariable regression analysis.

CONCLUSION

Our results have shown that hypoalbuminemia is a significant predictor of surgical complications and mortality after RNU for UTUC. This finding supports the importance of patients' preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes.

Thirty-day postoperative morbidity and mortality in elderly women with breast cancer: an analysis of the NSQIP database

PURPOSE

Postoperative complication rates for elderly women undergoing breast cancer surgery have not been well studied. We describe the postoperative complication rates of elderly (≥ 70 years) women with breast cancer and compare them with young (40-69 years) women.

METHODS

Data were extracted from the National Surgical Quality Improvement Program database (2004-2014). We included women with invasive breast cancer who underwent surgery. Outcomes were 30-day postoperative morbidity and mortality (complications), which were compared between young and elderly women. Morbidity was categorized using the Surgical Risk Preoperative Assessment System (SURPAS) clusters.

RESULTS

We identified 100,037 women of which 26.7% were elderly. Compared to young women, elderly women were more likely to have more comorbidities and undergo breast-conserving surgery, but less likely to undergo lymph node surgery, breast reconstruction, and neoadjuvant chemotherapy. While the 30-day overall morbidity rate was not significantly different between young and elderly women (3.9 vs. 3.8%, p = 0.2), elderly women did have significantly higher rates of pulmonary, cardiac (arrest and myocardial infarction), venous thromboembolic, and neurological morbidity. Specific morbidities that showed significantly lower rates among elderly women included wound disruption and deep and organ space surgical site infection. Any cause death was significantly higher in elderly compared to young women (0.2 vs. 0.05%, p < 0.001).

CONCLUSIONS

While some specific 30-day postoperative morbidities were more often seen in elderly women, the overall 30-day postoperative complication rate was very low. These data support the safety of breast cancer surgery in well-selected elderly patients.

Hypoalbuminemia Is Associated With Septic Revisions After Primary Surgery and Postoperative Infection After Revision Surgery

STUDY DESIGN

Retrospective database review.

OBJECTIVE

To determine (1) the relationship between hypoalbuminemia and body mass index (BMI); (2) the association between malnutrition and revision spine surgery for septic reasons; and (3) the association between malnutrition and infection after aseptic revision spine surgery.

SUMMARY OF BACKGROUND DATA

Although malnutrition has been suggested to increase the risk of infection after spine surgery, evidence supporting this hypothesis is conflicting.

METHODS

Patients undergoing revision spine surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2006 to 2014. Hypoalbuminemia (albumin < 3.5 g/dL) was used as a surrogate marker of malnutrition. Multivariate analysis was used to assess the association of hypoalbuminemia with septic versus aseptic revision spine surgery. The association between hypoalbuminemia and deep infection postoperatively within 30 days of aseptic revision surgeries was also assessed.

RESULTS

A total of 3136 patients who underwent revision spine surgery were identified; 2922 (93.2%) underwent surgery for aseptic reasons, and 214 (6.8%) for septic reasons. Hypoalbuminemia was present in all BMI groups including obese patients, though it was highest in underweight patients (22.4%). Patients who underwent surgery for septic reasons had a higher rate of hypoalbuminemia than those undergoing surgery for aseptic reasons (49.1% vs. 8.5%, P < 0.001) with nine times the odds of having hypoalbuminemia (adjusted odds ratio, OR = 9.17, P < 0.001). Of the 2922 patients undergoing revision spine surgery for aseptic reasons, hypoalbuminemia was independently associated with acute deep infection within 30 days of surgery (adjusted OR = 2.85, P = 0.019).

CONCLUSION

Malnutrition is more common in revision spine surgery for septic reasons when compared with aseptic revision surgery. Acute postoperative infection following aseptic revision surgery is also more common in patients with malnutrition. Further study, in the form of prospective trials, will help to increase our understanding of the effects of malnutrition in spine surgery.

LEVEL OF EVIDENCE

3.

Accuracy of the ACS NSQIP Online Risk Calculator Depends on How You Look at It: Results from the United States Gastric Cancer Collaborative

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous throm-boembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.