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Romatoski K, Davids JS, Sachs TE, Hagopian EJ. Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery: a report from the 2024 GI Surgery Summit. J Gastrointest Surg 2024:S1091-255X(24)00542-0. [PMID: 39043323 DOI: 10.1016/j.gassur.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/19/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The 2024 GI Surgery Summit brought together Society for Surgery of the Alimentary Tract (SSAT), Society of Surgical Oncology (SSO), and Society of University Surgeons (SUS) members to assess the current state of gastrointestinal (GI) surgery. This report reviews the key discussions and recommendations after the dedicated plenary session that addressed challenges in providing high-quality, accessible GI surgery for all patients. METHODS The Summit took place from January 14 to 16. During the plenary session "Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery," leaders, rising leaders, and members of SSAT, SSO, and SUS met and discussed challenges in providing high-quality, accessible GI surgery. RESULTS Actionable recommendations to address the challenges in providing high-quality, accessible GI surgical care were made, including engaging communities and patients, building alliances across hospitals and surgeons, and establishing standards of GI surgical care. CONCLUSION Surgeons, hospital systems, and surgical societies can improve healthcare access and outcomes for all GI surgical patients.
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Affiliation(s)
- Kelsey Romatoski
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jennifer S Davids
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Ellen J Hagopian
- Department of Surgery, University of Toledo Medical Center, Toledo, OH, United States; Department of Medical Education and Surgery, University of Toledo College of Medicine & Life Sciences, Toledo, OH, United States.
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Dall CP, Liu X, Faraj KS, Srivastava A, Kaufman SR, Shahinian VB, Hollenbeck BK. Teaching Hospitals and Textbook Outcomes After Major Urologic Cancer Surgery. Urology 2024:S0090-4295(24)00451-5. [PMID: 38878826 DOI: 10.1016/j.urology.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/22/2024] [Accepted: 06/04/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE To assess textbook outcomes by hospital teaching status following major surgery for urologic cancers. METHODS We used 100% national Medicare Provider Analysis and Review files from 2017-2020 to assess rates of textbook outcomes in patients undergoing bladder (ie, radical cystectomy), kidney (ie, radical or partial nephrectomy), and prostate (ie, radical prostatectomy) surgery for genitourinary malignancies. The extent of integration of learners into each hospital's workforce-defined as major, minor, and non teaching hospitals-was the primary exposure. A textbook outcome, measured at the patient level, was defined as the absence of in-hospital mortality and mortality within 30days of surgery, no readmission 30days following discharge, no postoperative complication, and no prolonged length of stay. RESULTS Textbook outcomes were achieved in 51% (8564/16,786) of patients after bladder cancer surgery, 70% (39,938/57,300) of patients after kidney cancer surgery, and 82% (50,408/61,385) of patients after prostate cancer surgery. After adjusting for patient- and hospital-level characteristics, teaching hospitals had higher rates of textbook outcomes in those undergoing bladder (50.7% vs 44.0%; P = .001), kidney (72.0% vs 69.7%; P = .02), and prostate (85.3% vs 81.0%; P <.001) surgery. This effect was attenuated, but not eliminated, by surgical volume in additional sensitivity analyses for bladder (OR: 1.20, 95% CI: 1.00-1.42; P = .04) and prostate (OR: 1.15, 95% CI: 1.00-1.32; P = .04) surgery. There were no significant differences in kidney cancer surgery outcomes after adjusting for hospital volume (OR: 1.03, 95% CI: 0.93-1.14; P = .6). CONCLUSION Undergoing major cancer surgery at a teaching hospital was associated with an increased likelihood of achieving a textbook outcome. This effect was attenuated by volume but persisted for bladder and prostate surgery.
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Affiliation(s)
- Christopher P Dall
- Department of Urology, Massachusetts General Hospital, Boston, MA; Department of Urology, Brigham and Women's Hospital, Boston, MA.
| | - Xiu Liu
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Kassem S Faraj
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Arnav Srivastava
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Brent K Hollenbeck
- Department of Urology, Massachusetts General Hospital, Boston, MA; Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Escalante GO, Sun J, Schnell S, Guderian E, Mack CA, Argenziano M, Kurlansky P. Hospital characteristics associated with failure to rescue in cardiac surgery. JTCVS OPEN 2023; 16:509-521. [PMID: 38204725 PMCID: PMC10775121 DOI: 10.1016/j.xjon.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 01/12/2024]
Abstract
Objective The study objective was to examine the association between hospital processes of care and failure to rescue in a diverse, multi-institutional cardiac surgery network. Methods Failure to rescue was defined as an operative mortality after 1 or more of 4 complications: prolonged ventilation, stroke, renal failure, and unplanned reoperation. Society of Thoracic Surgeons data from 20,950 consecutive patients in the Columbia HeartSource network who underwent 1 of 7 cardiac operations-coronary artery bypass grafting, aortic valve replacement ± coronary artery bypass grafting, mitral valve repair or replacement ± coronary artery bypass grafting-were analyzed to calculate failure to rescue rates. Hospital-specific characteristics were ascertained by survey method. Multivariable mixed-effects logistic models assessed the association of these hospital characteristics with failure to rescue while adjusting for patient-related factors known to be associated with mortality. Results Failure to rescue rates at affiliate hospitals ranged from 5.45% to 21.74% (median, 12.5%; interquartile range, 6.9%). When controlling for Society of Thoracic Surgeons-predicted risk of mortality with hospital as a random effect, 4 hospital characteristics were found to be associated with lower failure to rescue rates; the presence of cardiac-trained anesthesiologists (odds ratio, 0.41; CI, 0.31-0.55, P < .001), availability of extracorporeal membrane oxygenation mechanical circulatory support (odds ratio, 0.41; CI, 0.31-0.54, P < .001), ratio of intensive care unit beds to intensivists (odds ratio, 0.87; CI, 0.76-0.99, P = .039), and total number of intensive care unit beds (odds ratio, 0.97; CI, 0.96-0.99, P = .002). Conclusions In a diverse multi-institutional cardiac surgical network, we were able to identify specific hospital processes of care associated with failure to rescue, even when adjusting for patient-related predictors of operative mortality.
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Affiliation(s)
| | - Jocelyn Sun
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
| | - Susan Schnell
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Emily Guderian
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Charles A. Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Michael Argenziano
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
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Wells CI, Varghese C, Boyle LJ, McGuinness MJ, Keane C, O'Grady G, Gurney J, Koea J, Harmston C, Bissett IP. "Failure to Rescue" following Colorectal Cancer Resection: Variation and Improvements in a National Study of Postoperative Mortality. Ann Surg 2023; 278:87-95. [PMID: 35920564 DOI: 10.1097/sla.0000000000005650] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To examine variation in "failure to rescue" (FTR) as a driver of differences in mortality between centres and over time for patients undergoing colorectal cancer surgery. BACKGROUND Wide variation exists in postoperative mortality following colorectal cancer surgery. FTR has been identified as an important determinant of variation in postoperative outcomes. We hypothesized that differences in mortality both between hospitals and over time are driven by variation in FTR. METHODS A national population-based study of patients undergoing colorectal cancer resection from 2010 to 2019 in Aotearoa New Zealand was conducted. Rates of 90-day FTR, mortality, and complications were calculated overall, and for surgical and nonoperative complications. Twenty District Health Boards (DHBs) were ranked into quartiles using risk- and reliability-adjusted 90-day mortality rates. Variation between DHBs and trends over the 10-year period were examined. RESULTS Overall, 15,686 patients undergoing resection for colorectal adenocarcinoma were included. Increased postoperative mortality at high-mortality centers (OR 2.4, 95% CI 1.8-3.3) was driven by higher rates of FTR (OR 2.0, 95% CI 1.5-2.8), and postoperative complications (OR 1.4, 95% CI 1.3-1.6). These trends were consistent across operative and nonoperative complications. Over the 2010 to 2019 period, postoperative mortality halved (OR 0.5, 95% CI 0.4-0.6), associated with a greater improvement in FTR (OR 0.5, 95% CI 0.4-0.7) than complications (OR 0.8, 95% CI 0.8-0.9). Differences between centers and over time remained when only analyzing patients undergoing elective surgery. CONCLUSION Mortality following colorectal cancer resection has halved over the past decade, predominantly driven by improvements in "rescue" from complications. Differences in FTR also drive hospital-level variation in mortality, highlighting the central importance of "rescue" as a target for surgical quality improvement.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Luke J Boyle
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | | | - Celia Keane
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Jason Gurney
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Jonathan Koea
- Department of General Surgery, Waitemata District Health Board, Takapuna, New Zealand
| | - Chris Harmston
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Northland District Health Board, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
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Naar L, Maurer LR, Dorken Gallastegi A, El Hechi MW, Rao SR, Coughlin C, Ebrahim S, Kadambi A, Mendoza AE, Saillant NN, Renne BCB, Velmahos GC, Kaafarani HMA, Lee J. Hospital Academic Status and the Volume-Outcome Association in Postoperative Patients Requiring Intensive Care: Results of a Nationwide Analysis of Intensive Care Units in the United States. J Intensive Care Med 2022; 37:1598-1605. [PMID: 35437045 DOI: 10.1177/08850666221094506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sowmya R Rao
- MGH Biostatistics Center, Harvard Medical School; Department of Global Health, 27118Boston University School of Public Health, Boston, MA, USA
| | - Catherine Coughlin
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Senan Ebrahim
- Hikma Health, San Jose, CA, USA
- 1811Harvard Medical School, Boston, MA, USA
| | - Adesh Kadambi
- Hikma Health, San Jose, CA, USA
- 7938University of Toronto, Toronto, ON, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Christian B Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jarone Lee
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Grönroos-Korhonen MT, Koskenvuo LE, Mentula PJ, Koskensalo SK, Leppäniemi AK, Sallinen VJ. Failure to rescue after reoperation for major complications of elective and emergency colorectal surgery: A population-based multicenter cohort study. Surgery 2022; 172:1076-1084. [DOI: 10.1016/j.surg.2022.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/23/2022] [Accepted: 04/29/2022] [Indexed: 02/07/2023]
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Center-Level Procedure Volume Does Not Predict Failure-to-Rescue After Severe Complications of Oncologic Colon and Rectal Surgery. World J Surg 2021; 45:3695-3706. [PMID: 34448919 PMCID: PMC8572842 DOI: 10.1007/s00268-021-06296-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 11/22/2022]
Abstract
Background The relationship between hospital surgical volume and outcome after colorectal cancer surgery has thoroughly been studied. However, few studies have assessed hospital surgical volume and failure-to-rescue (FTR) after colon and rectal cancer surgery. The aim of the current study is to evaluate FTR following colorectal cancer surgery between clinics based on procedure volume. Methods Patients undergoing colorectal cancer surgery in Sweden from January 2015 to January 2020 were recruited through the Swedish Colorectal Cancer Registry. The primary endpoint was FTR, defined as the proportion of patients with 30-day mortality after severe postoperative complications in colorectal cancer surgery. Severe postoperative complications were defined as Clavien–Dindo ≥ 3. FTR incidence rate ratios (IRR) were calculated comparing center volume stratified in low-volume (≤ 200 cases/year) and high-volume centers (> 200 cases/year), as well as with an alternative stratification comparing low-volume (< 50 cases/year), medium-volume (50–150 cases/year) and high-volume centers (> 150 cases/year). Results A total of 23,351 patients were included in this study, of whom 2964 suffered severe postoperative complication(s). Adjusted IRR showed no significant differences between high- and low-volume centers with an IRR of 0.97 (0.75–1.26, p = 0.844) in high-volume centers in the first stratification and an IRR of 2.06 (0.80–5.31, p = 0.134) for high-volume centers and 2.15 (0.83–5.56, p = 0.116) for medium-volume centers in the second stratification. Conclusion This nationwide retrospectively analyzed cohort study fails to demonstrate a significant association between hospital surgical volume and FTR after colorectal cancer surgery. Future studies should explore alternative characteristics and their correlation with FTR to identify possible interventions for the improvement of quality of care after colorectal cancer surgery.
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