Quality in surgery: current issues for the future

Surgical Outcome Reporting. Moving From a Comic to a Tragic Opera?

OBJECTIVES

To assess the current quality of surgical outcome reporting in the medical literature and to provide recommendations for improvement.

BACKGROUND

In 1996, The Lancet labeled surgery as a "comic opera" mostly referring to the poor quality of outcome reporting in the literature impeding improvement in surgical quality and patient care.

METHODS

We screened 3 first-tier and 2 second-tier surgical journals, as well as 3 leading medical journals for original articles reporting on results of surgical procedures published over a recent 18-month period. The quality of outcome reporting was assessed using a prespecified 12-item checklist.

RESULTS

Six hundred twenty-seven articles reporting surgical outcomes were analyzed, including 125 randomized controlled trials. Only 1 (0.2%) article met all 12 criteria of the checklist, whereas 356 articles (57%) fulfilled less than half of the criteria. The poorest reporting was on cumulative morbidity burden, which was missing in 94% of articles (n=591) as well as patient-reported outcomes missing in 83% of publications (n=518). Comparing journal groups for the individual criterion, we found moderate to very strong statistical evidence for better quality of reporting in high versus lower impact journals for 7 of 12 criteria and strong statistical evidence for better reporting of patient-reported outcomes in medical versus surgical journals ( P <0·001).

CONCLUSIONS

The quality of outcomes reporting in the medical literature remains poor, lacking improvement over the past 20 years on most key end points. The implementation of standardized outcome reporting is urgently needed to minimize biased interpretation of data thereby enabling improved patient care and the elaboration of meaningful guidelines.

Effect of trauma quality improvement initiatives on outcomes and costs at community hospitals: A scoping review

BACKGROUND

Due to complex geography and resource constraints, trauma patients are often initially transported to community or rural facilities rather than a larger Level I or II trauma center. The objective of this scoping review was to synthesize evidence on interventions that improved the quality of trauma care and/or reduced healthcare costs at non-Level I or II facilities.

METHODS

A scoping review was performed to identify studies implementing a Quality Improvement (QI) initiative at a non-major trauma center (i.e., non-Level I or II trauma center [or equivalent]). We searched 3 electronic databases (MEDLINE, Embase, CINAHL) and the grey literature (relevant networks, organizations/associations). Methodological quality was evaluated using NIH and JBI study quality assessment tools. Studies were included if they evaluated the effect of implementing a trauma care QI initiative on one or more of the following: 1) trauma outcomes (mortality, morbidity); 2) system outcomes (e.g., length of stay [LOS], transfer times, provider factors); 3) provider knowledge or perception; or 4) healthcare costs. Pediatric trauma, pre-hospital and tele-trauma specific studies were excluded.

RESULTS

Of 1046 data sources screened, 36 were included for full review (29 journal articles, 7 abstracts/posters without full text). Educational initiatives including the Rural Trauma Team Development Course and the Advanced Trauma Life Support course were the most common QI interventions investigated. Study outcomes included process metrics such as transfer time to tertiary care and hospital LOS, along with measures of provider perception and knowledge. Improvement in mortality was reported in a single study evaluating the impact of establishing a dedicated trauma service at a community hospital.

CONCLUSIONS

Our review captured a broad spectrum of trauma QI projects implemented at non-major trauma centers. Educational interventions did result in process outcome improvements and high rates of self-reported improvements in trauma care. Given the heterogeneous capabilities of community and rural hospitals, there is no panacea for trauma QI at these facilities. Future research should focus on patient outcomes like mortality and morbidity, and locally relevant initiatives.

Quality and Outcome Assessment for Surgery

ABSTRACT

This forum summarizes the proceedings of the joint European Surgical Association (ESA)/American Surgical Association (ASA) symposium on Quality and Outcome Assessment for Surgery that took place in Bordeaux, France, as part of the celebrations of the 30th anniversary of the ESA. Three presentations focused on a) the main messages from the Outcome4Medicine Consensus Conference, which took place in Zurich, Switzerland, in June 2022, b) the patient perspective, and c) benchmarking were hold by ESA members and discussed by ASA members in a symposium attended by members of both associations.

Improving prehospital trauma care in Rwanda through continuous quality improvement: an interrupted time series analysis

INTRODUCTION

Injury is a major cause of premature death and disability in East Africa, and high-quality pre-hospital care is essential for optimal trauma outcomes. The Rwandan pre-hospital emergency care service (SAMU) uses an electronic database to evaluate and optimize pre-hospital care through a continuous quality improvement programme (CQIP), beginning March 2014.

MATERIALS AND METHODS

The SAMU database was used to assess pre-hospital quality metrics including supplementary oxygen for hypoxia (O2), intravenous fluids for hypotension (IVF), cervical collar placement for head injuries (c-collar), and either splinting (splint) or administration of pain medications (pain) for long bone fractures. Targets of >90% were set for each metric and daily team meetings and monthly feedback sessions were implemented to address opportunities for improvement. These five pre-hospital quality metrics were assessed monthly before and after implementation of the CQIP. Met and unmet needs for O2, IVF, and c-collar were combined into a summative monthly SAMU Trauma Quality Scores (STQ score). An interrupted time series linear regression model compared the STQ score during 14 months before the CQIP implementation to the first 14 months after.

RESULTS

During the 29-month study period 3,822 patients met study criteria. 1,028 patients needed one or more of the five studied interventions during the study period. All five endpoints had a significant increase between the pre-CQI and post-CQI periods (p<0.05 for all), and all five achieved a post-CQI average of at least 90% completion. The monthly composite STQ scores ranged from 76.5 to 97.9 pre-CQI, but tightened to 86.1-98.7 during the post-CQI period. Interrupted time series analysis of the STQ score showed that CQI programme led to both an immediate improvement of +6.1% (p=0.017) and sustained monthly improvements in care delivery-improving at a rate of 0.7% per month (p=0.028).

CONCLUSION

The SAMU experience demonstrates the utility of a responsive, data-driven quality improvement programme to yield significant immediate and sustained improvements in pre-hospital care for trauma in Rwanda. This programme may be used as an example for additional efforts engaging frontline staff with real-time data feedback in order to rapidly translate data collection efforts into improved care for the injured in a resource-limited setting.

Differences in hospital performance for noncancer vs cancer colorectal surgery

BACKGROUND

Considerable hospital-to-hospital variations in surgical outcomes have been reported across surgical procedures. However, it is unclear whether hospital quality rankings are consistent for noncancer and cancer operations. We investigated the differences in hospital performance for noncancer and cancer colorectal resections at 52 hospitals participating in the Michigan Surgical Quality Collaborative (MSQC).

STUDY DESIGN

Patients undergoing colorectal resections between 2008 and 2012 were identified. Hierarchical risk-adjusted models were used to evaluate hospital level 30-day morbidity, major morbidity, extended length-of-stay (LOS > 75(th) percentile), and mortality outcomes. Hospital performance, as ranked by observed-to-expected ratios, was compared by rank-order changes, interquartile ranges (IQR), and Spearman's correlations.

RESULTS

Of the 19,990 colorectal resections, 7,292 (36.5%) were for cancer. We observed wide variations in all risk-adjusted 30-day outcomes between hospitals, but only weak correlations in cancer and noncancer performance within hospitals. Overall hospital performance in mortality after noncancer and cancer operations was not correlated (Spearman's rho: 0.02). Of the best performing hospitals in mortality after noncancer resections, 69% were reclassified to a worse quartile for cancer operations (median rank-change of 12.5 ranks [IQR 5 to 27]). Similarly, hospital performance in morbidity was only moderately correlated (rho: 0.59; p < 0.001). Of the hospitals with lowest morbidity rates for noncancer resections, 31% were reclassified. We noted a similar lack of relationship in major morbidity and extended LOS.

CONCLUSIONS

A hospital's performance ranking in risk-adjusted outcomes after noncancer colorectal resections does not correlate to its performance for cancer-related colorectal resections. Indication for operation should be considered when leveraging risk-adjusted hospital outcomes for quality improvement efforts.

A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery

AIM

Enhanced recovery after surgery (ERAS) programmes have been shown to reduce length of stay and peri-operative morbidity. However, there are comparatively few data on their cost effectiveness. The object of this systematic review was to appraise the current literature to determine the cost effectiveness of ERAS and to characterize how cost is reported and evaluated.

METHOD

An electronic database search identified studies comparing ERAS with standard peri-operative care in colorectal surgery where an evaluation of cost effectiveness was a primary or secondary outcome. Cost data were converted to euros to enable a more standardized comparison of the studies. There were no limits on study design.

RESULTS

Seven articles were included in the analysis. The reporting and evaluation of cost data were inconsistent. Reported cost for ERAS ranged from €1989 to €12,805 per patient. Although not all statistically significant, all studies demonstrated cost reductions with ERAS compared with non-ERAS although they were highly variable, ranging from €153 to €6537 per patient.

CONCLUSION

Although the review has shown ERAS to be cost effective, there are some important inconsistencies and deficiencies regarding the reporting of data. Authors should therefore be encouraged to report cost data to supplement the literature detailing clinical efficacy.

Results of a surgeon-directed quality improvement project on breast cancer surgery outcomes in South-Central Ontario

BACKGROUND

Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario.

METHODS

Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region.

RESULTS

Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons.

CONCLUSIONS

This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

Enhanced recovery after colon surgery in a community hospital system

BACKGROUND

Enhanced recovery after colon surgery has not been widely adopted in the United States and Europe, despite evidence that postoperative complications and hospital length of stay are decreased.

OBJECTIVE

We sought to evaluate the introduction of a comprehensive care process for enhanced recovery after colon surgery in 8 community hospitals.

DESIGN

A system-wide, surgeon-directed, multidisciplinary committee developed a comprehensive enhanced-care quality-improvement program. Surgeons and operations leaders in each hospital developed the internal structure to implement the process.

PATIENTS

Surgeons had the option of entering or not entering patients in the enhanced-care pathway. Other than trauma patients, there were no exclusion criteria.

MAIN OUTCOME MEASURES

To limit selection bias, the study population included all patients undergoing colon resections (those entered and not entered in the care process). Length of stay, postoperative days, hospital costs, 30-day readmission rate, and return to surgery for the study population were compared with a 2-year historical baseline.

RESULTS

Forty-two percent of the study population was entered in the enhanced-care process. The average length of stay and the number of postoperative days in the study population decreased by 1.5 (P < .0001) and 1.3 (P < .0001) days. The rate of readmissions and returns to surgery remained stable (P > .05), and the average hospital cost decreased by $1763 (P = .02). Generalized linear regression analysis demonstrated that the enhanced-care process was a more significant variable than was the surgical approach (laparoscopic vs open surgery) in decreasing length of stay.

LIMITATIONS

The degree of compliance with care process elements and the relative contribution of each element of the care process are unknown.

CONCLUSIONS

A comprehensive enhanced-care colon surgery care process was successfully introduced in a community hospital system, as indicated by the clinical outcome measures.

Quality improvement for pancreatic cancer care: is regionalization a feasible and effective mechanism?

Variability exists in the quality of pancreatic cancer care provided in the United States. High-volume centers have been shown to have improved outcomes for pancreatectomy. Regionalization of pancreatic cancer care to high-volume centers has the potential to improve care and outcomes. Practical limitations such as overloading currently available high-volume centers, extending patient travel times, sharing patients within a multipayer health system, and incorporating patient preferences must be addressed for regionalization to become a reality. The benefits and limitations of regionalization of pancreatic cancer care are discussed in this review. To improve the overall quality of pancreatic cancer care at all hospitals in the United States, a combination of referral of patients with pancreatic cancer to high- and moderate-volume hospitals in conjunction with specific quality-improvement efforts at those institutions is proposed.

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

The history and development of the NSQIP, from its inception in the Veterans Administration Health System to its implementation within the private sector sponsored by the ACS, documents the growth of a program that has substantially improved the quality of surgical care and has had a considerable influence on the culture of quality improvement in the profession. The success of the ACS NSQIP is the result of providing hospitals with rigorous, clinical data, networking opportunities, and resources to improve their risk-adjusted outcomes. In this manner, the ACS NSQIP challenges its hospitals and health care providers to continually improve the care they provide. In addition to reducing the complications and mortality experienced by patients after surgical procedures, hospitals that participate in the ACS NSQIP have seen the financial rewards of their quality improvement efforts. Continued growth of the ACS NSQIP will facilitate achievement of the primary goal surrounding the current health care reform debate: efficient, high-quality care.

Providing specialist services in Australia across barriers of distance and culture

Most of Australia's population live in urban environments and have ready access to high-quality specialist surgical services. The 1% of Australians (210,600 people) who live in the Northern Territory of Australia sparsely occupy more than one-sixth of Australia's land mass and have varied cultural backgrounds. The organization of surgical services in the Northern Territory provides a case study in providing specialist surgical services to disadvantaged, rural and remote populations in a developed country. Historical and current initiatives to overcome barriers of distance include a coordinated network of health clinics, regional hospitals, and specialist surgical facilities staffed by health care practitioners with broad training and a wide scope of practice. Aeromedical services that facilitate patient and medical team transport were among the first worldwide. Recent initiatives to overcome barriers posed by cultural differences include an Indigenous Languages Interpreter Service, dedicated Indigenous health educators, and specialist outreach visits. Specialist services in the Northern Territory are delivered locally by appropriately trained generalists in cooperation with and supported by specialists from larger centers. This cooperative model of delivery of specialist services maximizes population access to the whole range of surgical therapies and encourages the efficient use of both specialists and generalists. Adoption of the principles of this model may lead to increasingly efficient delivery of specialist services in more densely populated regions.

National assessment of melanoma care using formally developed quality indicators

PURPOSE

There is considerable variation in the quality of cancer care delivered in the United States. Assessing care by using quality indicators could help decrease this variability. The objectives of this study were to formally develop valid quality indicators for melanoma and to assess hospital-level adherence with these measures in the United States.

METHODS

Quality indicators were identified from available literature, consensus guidelines, and melanoma experts. Thirteen experts ranked potential measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. Adherence with individual valid indicators and a composite measure of all indicators were assessed at 1,249 Commission on Cancer hospitals by using the National Cancer Data Base (NCDB; 2004 through 2005).

RESULTS

Of 55 proposed quality indicators, 26 measures (47%) were rated as valid. These indicators assessed structure (n = 1), process (n = 24), and outcome (n = 1). Of the 26 measures, 10 are readily assessable by using cancer registry data. Adherence with valid indicators ranged from 11.8% to 96.5% at the patient level and 3.7% to 83.0% at the hospital level. (Adherence required that >OR= 90% of patients at a hospital receive concordant care.) Most hospitals were adherent with 50% or fewer of the individual indicators (median composite score, five; interquartile range, four to seven). Adherence was higher for diagnosis and staging measures and was lower for treatment indicators.

CONCLUSION

There is considerable variation in the quality of melanoma care in the United States. By using these formally developed quality indicators, hospitals can assess their adherence with current melanoma care guidelines through feedback mechanisms from the NCDB and can better direct quality improvement efforts.

Assessment of pancreatic cancer care in the United States based on formally developed quality indicators

BACKGROUND

Pancreatic cancer outcomes vary considerably among hospitals. Assessing pancreatic cancer care by using quality indicators could help reduce this variability. However, valid quality indicators are not currently available for pancreatic cancer management, and a composite assessment of the quality of pancreatic cancer care in the United States has not been done.

METHODS

Potential quality indicators were identified from the literature, consensus guidelines, and interviews with experts. A panel of 20 pancreatic cancer experts ranked potential quality indicators for validity based on the RAND/UCLA Appropriateness Methodology. The rankings were rated as valid (high or moderate validity) or not valid. Adherence with valid indicators at both the patient and the hospital levels and a composite measure of adherence at the hospital level were assessed using data from the National Cancer Data Base (2004-2005) for 49 065 patients treated at 1134 hospitals. Summary statistics were calculated for each individual candidate quality indicator to assess the median ranking and distribution.

RESULTS

Of the 50 potential quality indicators identified, 43 were rated as valid (29 as high and 14 as moderate validity). Of the 43 valid indicators, 11 (25.6%) assessed structural factors, 19 (44.2%) assessed clinical processes of care, four (9.3%) assessed treatment appropriateness, four (9.3%) assessed efficiency, and five (11.6%) assessed outcomes. Patient-level adherence with individual indicators ranged from 49.6% to 97.2%, whereas hospital-level adherence with individual indicators ranged from 6.8% to 99.9%. Of the 10 component indicators (contributing 1 point each) that were used to develop the composite score, most hospitals were adherent with fewer than half of the indicators (median score = 4; interquartile range = 3-5).

CONCLUSIONS

Based on the quality indicators developed in this study, there is considerable variability in the quality of pancreatic cancer care in the United States. Hospitals can use these indicators to evaluate the pancreatic cancer care they provide and to identify potential quality improvement opportunities.

Effect of subjective preoperative variables on risk-adjusted assessment of hospital morbidity and mortality

OBJECTIVE

To examine the influence of American Society of Anesthesiologists Physical Status Classification (ASA) and preoperative Functional Health Status (FHS) variables on risk-adjusted estimates of surgical quality and to assess whether classifications are inflated at some hospitals.

BACKGROUND

ASA and FHS are influential in risk-adjusted comparisons of surgical quality. However, because ASA and FHS are subjective they can be inflated, making patients appear more ill than they actually are, and crediting hospitals for a sicker patient population.

METHODS

We identified 28,751 colorectal surgery patients at 170 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program (ACS NSQIP) during 2006 to 2007. Logistic regression models were developed for morbidity and mortality with and without inclusion of ASA and FHS. Hospital quality rankings from the different models were compared.

RESULTS

Morbidity and mortality rates were 24.3% and 3.9%, respectively. Percents of patients in ASA classes I through V were 3.3%, 46.4%, 41.5%,8.3%, and 0.7% and that were independent or partially or totally dependent were 89.2%, 7.2%, and 3.6%, respectively. Models that included ASA and FHS exhibited slightly better fit (Hosmer-Lemshow statistic) and discrimination(c-statistic) than models without both these variables, though magnitudes of differences were consistent with chance. There was inconsistent evidence for improper assignment of ASA and FHS.

CONCLUSIONS

The small improvements in model quality when both ASA and FHS are present versus absent, suggest that they make a unique contribution to assessing severity of preoperative risk. With little indication that these subjective variables are subject to an important level of institutional bias, it is appropriate that they be used to assess risk-adjusted surgical quality. Periodic monitoring for inappropriate inflation of ASA status is warranted.

Directing Surgical Quality Improvement Initiatives: Comparison of Perioperative Mortality and Long-Term Survival for Cancer Surgery

Purpose

Quality-improvement initiatives are being developed to decrease volume-based variability in surgical outcomes. Resources for national and hospital quality-improvement initiatives are limited. It is unclear whether quality initiatives in surgical oncology should focus on factors affecting perioperative mortality or long-term survival. Our objective was to determine whether differences in hospital surgical volume have a larger effect on perioperative mortality or long-term survival using two methods.

Patients and Methods

From the National Cancer Data Base, 243,103 patients who underwent surgery for nonmetastatic colon, esophageal, gastric, liver, lung, pancreatic, or rectal cancer were identified. Multivariable modeling was used to evaluate 60-day mortality and 5-year conditional survival (excluding perioperative deaths) across hospital volume strata. The number of potentially avoidable perioperative and long-term deaths were calculated if outcomes at low-volume hospitals were improved to those of the highest-volume hospitals.

Results

Risk-adjusted perioperative mortality and long-term conditional survival worsened as hospital surgical volume decreased for all cancer sites, except for liver resections where there was no difference in survival. When comparing low- with high-volume hospitals, the hazard ratios for perioperative mortality were substantially larger than for long-term survival. However, the number of potentially avoidable deaths each year in the United States, if outcomes at low-volume hospitals were improved to the level of highest-volume centers, was significantly larger for long-term survival.

Conclusion

Although the magnitude of the hazard ratios implies that quality-improvement efforts should focus on perioperative mortality, a larger number of deaths could be avoided by focusing quality initiatives on factors associated with long-term survival.

The challenges of resident training in complex hepatic, pancreatic, and biliary procedures

Operations on the liver and pancreas have fallen within the domain of the general surgeon and have been part of general surgery training. The more complex procedures involving these organs are limited in number in most general surgery residencies and do not afford an opportunity for vast experience. Moreover, fellowship programs in hepato-bilio-pancreatic (HPB) surgery and the development of laparoscopic techniques may have further limited the familiarity of general surgery residents with these operations. To determine the experience accrued by finishing general surgery residents, we accessed, through the Residency Review Committee of the Accreditation Council for Graduate Medical Education, the Resident Case Log System used by general surgery residents throughout their training to document operative cases. The number of operations on the gallbladder, bile ducts, pancreas, and liver was examined over the past 16 years (there were missing data for 3 years). Reference years 1995 and 2005 were compared to detect trends. Experience with laparoscopic cholecystectomy has steadily increased and averaged more than 100 cases in 2006. Experience in liver resection, distal pancreatectomy, and partial (Whipple) pancreatectomy has statistically improved from 1995 to 2005, but the numbers of cases are low, generally less than five per finishing resident. Experience in open common bile duct and choledocho-enteric anastomoses has statistically declined from 1995 to 2005, averaging less than four cases per finishing resident. The mode (most frequently performed number) for liver and pancreas resections was either 0 or 1. It is doubtful this experience in HPB surgery engenders confidence in many finishing residents. Attention should be focused on augmenting training in HPB surgery for general surgery residents perhaps through a combination of programmatic initiatives, ex vivo experiences, and minifellowships. Institutional initiatives might consist of defined HPB services with appropriate expertise, infrastructure, process, and outcome measures in which a resident-oriented, competency-based curriculum could be developed.

Relation between hospital volume and outcome of elective surgery for abdominal aortic aneurysm: a systematic review

OBJECTIVES

Our aim was to analyse the relation between hospital volume and peri-operative mortality in abdominal aortic aneurysm surgery.

DESIGN

Systematic review.

METHOD

The Medline, Embase and Cochrane databases were searched to identify all population based studies reporting on the volume outcome relationship published between 1966 and 2006. Two independent observers performed methodological quality assessment and data extraction. Outcome was 30-day or in-hospital mortality in relation to hospital volume.

RESULTS

Twenty-four articles were included. Overall peri-operative mortality ranged from 2.3 to 9.9%. The cut-off values for a high- or low-volume hospital appeared to range from 8 to 50 operations annually. The peri-operative mortality in low volume hospitals (LVH) ranged from 3.0 to 13.8% (median 6.2%) and from 1.8 to 7.4% in high volume hospitals (HVH) (median 4.3%). In 14 studies a significantly lower mortality was found in HVH as opposed to LVH; in 10 articles no such difference between HVH and LVH could be proved.

CONCLUSION

We found some evidence for a relation between the volume of AAA surgery and peri-operative mortality. There seems to be a nonsignificant trend in favour of high volume hospitals. However we could not derive an unequivocal volume threshold for safely performing AAA surgery.