An Online Tool for Global Benchmarking of Risk-Adjusted Surgical Outcomes

Evaluating the Prognostic Accuracy of AMPREDICT in Predicting 1-Year Mortality Following Major Lower Limb Amputation

BACKGROUND

Accurately predicting postoperative outcomes is fundamental to informed clinical decision-making, and alignment of patient and family expectations. The AMPREDICT Decision Support Tool is a predictive tool designed to assess the probability of mortality 1 year after major and minor amputations. We aimed to evaluate the prognostic accuracy of AMPREDICT in our Veteran patient population.

METHODS

Retrospective review of lower extremity amputations completed at the West Los Angeles Veterans Affairs hospital from 2000 to 2020. Staged open amputations and previous minor amputations were excluded. Using the AMPREDICT tool, the probability of mortality 1 year postsurgery for single-stage transfemoral and transtibial amputations was calculated, then compared with observed patient outcomes. Observed to predicted mortality was compared through boxplots, at 1 year after surgery, confidence intervals were calculated, and group means were compared using Student's t-test. Receiver operator curves were constructed to assess discriminatory capacity of the tool. Significance was set at P < 0.05.

RESULTS

Four hundred twenty three patients underwent 650 lower extremity amputations during our study period. Two hundred sixty seven patients underwent single-stage transfemoral or transtibial amputations comprising our study cohort. The average age at amputation was 66 years with an average age of death at 71 years. AMPREDICT tool's prognostic capability varied across the 2 amputations studied. For single-staged transfemoral amputations, prediction aligned closely with observed outcomes, as indicated by a significant P value of 0.0002 (confidence interval 12.73-36.37). For single-stage transtibial amputations, the predictions were also significant, P value 0.0017 (confidence interval 5.25-21.20), although had a wider prediction range.

CONCLUSIONS

Our study confirms the reliability of the AMPREDICT tool in predicting 1-year mortality for patients undergoing major lower limb amputations. The predictive accuracy was found to be statistically significant for both single-staged transfemoral and transtibial amputations. These findings suggest that AMPREDICT may be a valuable tool in the clinical setting for patients undergoing major lower limb amputation.

Surgical risk calculators in veterans following lower extremity amputation

OBJECTIVE

To evaluate the accuracy of multiple risk calculators for 30-day mortality on patients undergoing major lower extremity amputation.

METHODS

The actual 30-day mortality at a single Veterans Affairs institution was compared to the predicted outcome from the following risk calculators: ACS-NSQIP, VASQIP, amputation scoring tool (AST), and POTTER elective.

RESULTS

The overall calculated 30-day mortality was similar to the actual mortality with the VASQIP and POTTER elective risk calculators, while the NSQIP and AST over-estimated the 30-day mortality. The predictive accuracy of the POTTER and NSQIP risk calculators were moderate (AUC >0.7), and fair for the VASQIP and AST.

CONCLUSION

Risk assessment tools can provide adjunctive data on predicted 30-day mortality in patients undergoing major lower extremity amputation. In our study, there were differences in predictability of the risk calculators for lower extremity amputation that should be considered when utilizing a risk assessment tool to improve physician-patient shared decision-making.

Prehabilitation program for African sub-Saharan surgical patients is an unmet need

Approximately 4.2 million people worldwide die within 30 days of surgery each year. Half of these deaths occur in low- and middle-income countries. Postoperative deaths account for 7.7% of all deaths globally, making it the third-highest contributor to deaths, after heart disease and stroke. In sub-Saharan Africa, there is a higher rate of mortality following postoperative complications compared to high-income countries. The WHO has tools to help countries provide safer surgery. However, implementation remains poor in most African countries. Interventions focused on intraoperative or postoperative measures to improve perioperative prognosis may be too late for high-risk patients. Poor preoperative cardiorespiratory functional capacity, poor management of pre-existing comorbidities and risk factors and no assessment of the patient´s surgical risk is associated with adverse postoperative outcomes, including mortality, complications, slower recovery, longer intensive care stay, extended hospital length of stay and reduced postoperative quality of life. To significantly decrease morbidity and mortality following surgery in Africa, we propose the implementation of a comprehensive preoperative intervention, that must include: i) risk assessment of surgical patients to identify those at greater risk of postoperative complications for elective surgery; ii) increase the preoperative functional reserve of these high-risk patients, to enhance their tolerance to surgical stress and improve postoperative recovery; iii) anticipate postoperative care needs and organize tools, resources and establish simple workflows to manage postoperative complications. We believe this approach is simple, feasible and will significantly reduce postoperative burden for both patients, hospitals and society.

Epidemiology and mortality of pediatric surgical conditions: insights from a tertiary center in Uganda

INTRODUCTION/PURPOSE

The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited.

METHODS

Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016.

RESULTS

2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung's, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%).

CONCLUSION

There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.

ACS-NSQIP risk calculator predicts cohort but not individual risk of complication following colorectal resection

OBJECTIVE

Compare the ACS-NSQIP risk calculator with institutional risk for colorectal surgery.

METHODS

Actual and predicted outcomes were compared for both cohort and individuals.

RESULTS

For the cohort, the risk calculator was accurate for 7/8 outcomes; there were more serious complications than predicted (19.4 vs 14.7%, p < 0.05). Risk calculator Brier scores and null Brier scores were comparable.

PATIENTS

with better outcomes than predicted were current smokers (OR 4.3 95% CI 1.2-15.4), ASA ≥ 3 (OR 10.4, 95% CI 2.8-39.2), underwent total/subtotal colectomy (OR 3.5, 95% CI 1.1-12.2) or operated by Surgeon 2 (OR 2.9, 95% CI 1.4-11.6). Patients with serious complications who had low predicted risk had low ASA (OR 10.5, 95% CI 1.3-82.6), and underwent operation by Surgeon 2 (OR 11.8, 95% CI 2.5, 55.2).

LIMITATIONS

Single center study, sample size may bias subgroup analyses.

CONCLUSIONS

The ACS NSQIP calculator did not predict outcome better than sample risk.