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Chamseddine H, Sawma T, Slika H, Panossian V, Haddad F, Hoballah JJ. Effect of Chronic Steroid Use on Postoperative Wound Complications in Patients Undergoing Arterial Bypass Surgery for Lower Extremity Peripheral Arterial Disease. Ann Vasc Surg 2024; 108:187-194. [PMID: 38960095 DOI: 10.1016/j.avsg.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 03/14/2024] [Accepted: 04/20/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND While existing literature reports adverse effects of chronic steroid use on surgical wound outcomes, there remains lack of data exploring the effect of steroids on postoperative outcomes following lower extremity arterial bypass surgery. This study aims to explore the effect of chronic steroid use on surgical outcomes in patients undergoing open revascularization for lower extremity arterial occlusive disease. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2020, all patients receiving aortoiliac or infrainguinal arterial bypass for peripheral arterial disease (PAD) were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and 30-day outcomes were compared using χ2 test and independent t-test, and the association of chronic steroid use with wound complications was studied using multivariable logistic regression analysis. RESULTS A total of 44,675 patients undergoing open lower extremity revascularization (LER) were identified, of which 1,807 patients were on chronic steroids, and 42,868 patients were not on chronic steroids. On multivariable logistic regression analysis, being on chronic steroids was associated with higher rates of deep surgical site infections (SSIs) (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.03-1.83), any SSI (OR 1.22, 95% CI 1.04-1.43), and wound dehiscence (OR 1.42, 95% CI 1.03-1.96). Chronic steroid users also had significantly increased odds of developing sepsis (OR 1.56, 95% CI 1.19-2.04), pneumonia (OR 1.44, 95% CI 1.08-1.91), urinary tract infection (UTI) (OR 1.54, 95% CI 11.13-2.09), deep vein thrombosis (DVT) (OR 1.60, 95% CI 1.01-2.53), 30-day readmission (OR 1.30, 95% CI 1.12-1.50), reoperation (OR 1.17, 95% CI 1.01-1.37), and mortality (OR 1.33, 95% CI 1.01-1.76) compared with nonchronic steroid users. CONCLUSIONS This study confirms that chronic corticosteroid use is associated with higher risk of SSIs in patients undergoing lower extremity arterial bypass surgery. These patients typically have various underlying health issues, emphasizing the need for personalized treatment and management to reduce steroid-related postoperative complications and improve survival.
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Affiliation(s)
- Hassan Chamseddine
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Tedy Sawma
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hasan Slika
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Vahe Panossian
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fady Haddad
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamal J Hoballah
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Wang CC, Bharadwa S, Foley OW, Domenech I, Vega B, Towner M, Barber EL. Low serum creatinine levels are associated with major post-operative complications in patients undergoing surgery with gynecologic oncologists. Int J Gynecol Cancer 2024; 34:1060-1069. [PMID: 38627036 DOI: 10.1136/ijgc-2024-005308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVE Serum creatinine is a byproduct of muscle metabolism, and low creatinine is postulated to be associated with diminished muscle mass. This study examined the association between low pre-operative serum creatinine and post-operative outcomes. METHODS This retrospective cohort study utilized the 2014-2021 National Surgical Quality Improvement Program to identify patients undergoing surgery with gynecologic oncologists. Patients with missing pre-operative creatinine, end-stage renal disease, sepsis, septic shock, dialysis, or pregnancy were excluded. Pre-operative creatinine was categorized into markedly low (≤0.44 mg/dL), mildly low (0.45-0.64 mg/dL), normal (0.65-0.84 mg/dL), and four categories of elevated levels (0.85-1.04, 1.05-1.24, 1.25-1.44, and ≥1.45 mg/dL). Outcomes included major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, and thromboembolic complications. Also examined were 30-day readmissions, reoperations, and mortality. Logistic regressions assessed the association between creatinine and complications, with stratification by albumin and sensitivity analysis with propensity score matching. RESULTS Among 84 786 patients, 0.8% had markedly low, 19.6% mildly low, and 50.2% normal creatinine; the remainder had elevated creatinine. As creatinine decreased, the risks of major complications increased in a dose-dependent manner on univariable and multivariable analyses. A total of 9.6% (n=63) markedly low patients experienced major complications, second to creatinine ≥1.45 mg/dL (9.9%, n=141). On multivariable models, both markedly and mildly low creatinine were associated with higher odds of major complications (OR 1.715, 95% CI 1.299 to 2.264 and OR 1.093, 95% CI 1.001 to 1.193) and infections (OR 1.575, 95% CI 1.118 to 2.218 and OR 1.165, 95% CI 1.048 to 1.296) versus normal. Markedly low creatinine had similar ORs to creatinine ≥1.45 mg/dL and was further associated with higher odds of cardiovascular and pulmonary complications (OR 2.301, 95% CI 1.300 to 4.071), readmissions (OR 1.403, 95% CI 1.045 to 1.884), and mortality (OR 2.718, 95% CI 1.050 to 7.031). After albumin stratification, associations persisted for markedly low creatinine. Propensity-weighted analyses demonstrated congruent findings. CONCLUSIONS Low creatinine levels are associated with major post-operative complications in gynecologic oncology in a dose-dependent manner. Low creatinine can offer useful information for pre-operative risk stratification, surgical counseling, and peri-operative management.
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Affiliation(s)
- Connor C Wang
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sonya Bharadwa
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Olivia W Foley
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Issac Domenech
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brenda Vega
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary Towner
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Emma L Barber
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Zhang C, Bews K, Klemen ND, Etzioni D, Habermann EB, Thiels C. Thrombotic and Hemorrhagic Outcomes After Elective Surgery in Preoperatively Anticoagulated Patients. Mayo Clin Proc 2024; 99:1038-1045. [PMID: 38960494 DOI: 10.1016/j.mayocp.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To better understand the incidence and timing of thrombotic and hemorrhagic complications in anticoagulated patients undergoing elective surgery. METHODS Using institutional American College of Surgeons National Surgical Quality Improvement Program data, we identified patients receiving preoperative anticoagulation undergoing elective surgery between 2011 and 2021. Medical records review supplemented National Surgical Quality Improvement Program data to detail complication and anticoagulation type and timing. Outcomes for postoperative hemorrhage, acute venous thromboembolism (VTE), and cerebrovascular accident (CVA) were collected. RESULTS A total of 1442 patients met inclusion criteria, and 84 patients (5.8%) experienced 1 or more complications. There were 4 CVA (0.3%), 16 VTE (1.1%), and 68 bleeding (4.7%) events postoperatively. Three patients (75%) with CVA, 10 patients (62.5%) with VTE, and 18 patients (26.5%) with postoperative bleeding had resumed therapeutic anticoagulation before the complication. In terms of long-term sequelae in the CVA cohort, there was 1 mortality (25%), and an additional patient (25%) continues to experience long-term physical and mild cognitive impairments. Patients who experienced postoperative VTE required only anticoagulation adjustments. In patients who experienced bleeding complications, 6 (8.8%) required intensive care unit admissions, and there was 1 mortality (1.5%). CONCLUSION Despite the increased use of anticoagulation over time, balancing postoperative bleeding and thrombotic risks remains challenging. Bleeding complications were most common in preoperatively anticoagulated patients undergoing elective surgery. Earlier postoperative resumption of anticoagulation is unlikely to prevent thrombotic events as 65% of patients had already resumed therapeutic anticoagulation.
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Affiliation(s)
- Chi Zhang
- Department of Surgery, Mayo Clinic, Phoenix, AZ; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Katherine Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Goheer HE, Samuel LT, Flynn AJ, Hendrix CG, Newcomb AH, Carmouche JJ. Insulin dependence negatively impacts outcomes in anterior cervical discectomy with fusions: a ten-year retrospective analysis. Spine J 2024:S1529-9430(24)00260-2. [PMID: 38843957 DOI: 10.1016/j.spinee.2024.05.011] [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: 11/03/2023] [Revised: 04/18/2024] [Accepted: 05/15/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND CONTEXT Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing diabetic patient population, there is a paucity of literature focusing on insulin-dependence as a risk-factor for post-operative ACDF complications. PURPOSE To evaluate the differential impact of insulin dependence on perioperative outcomes including total length of stay, surgical, and medical complications within thirty days following ACDF. STUDY DESIGN/SETTING A retrospective cohort, large multicenter database study. PATIENT SAMPLE The American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551. OUTCOME MEASURES Perioperative surgical and medical complications. METHODS The study population was divided into 3 groups 1) insulin-dependent diabetes mellitus (IDDM), 2) non-insulin-dependent diabetes mellitus (NIDDM), and 3) no diabetes mellitus (non-DM). One-way analysis of variance for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the 3 groups. Multivariable logistic regression analysis assessed the effect of diabetes mellitus status on post-operative medical and surgical outcomes. RESULTS A total of 85,758 ACDF procedures were identified between 2011 and 2021, of which 5,178 were IDDM, 9,652 were NIDDM, and 70,982 were non-DM. The rates of surgical and medical complication varied between the 3 groups. IDDM patients had the highest rates of at least one medical complication (6.1%). Only IDDM increased the risk for medical complications (OR: 1.320, 95% CI [1.144-1.518]) and extended hospital length of stay (LOS) (OR: 1.244, 95% CI [1.071-1.441]) following a multivariate logistic regression analysis. CONCLUSION Patients with IDDM were at an increased risk for postoperative medical complications and extended hospital LOS. Personalized postoperative management, guided by risk assessment is indicated for this population. These findings can be used to improve risk stratification and informed consent for DM patients who are insulin dependent.
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Affiliation(s)
- Haseeb E Goheer
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, 2331 Franklin Road Southwest, Roanoke, VA 24014, USA; Department of Orthopaedic Surgery, Larkin Community Hospital, 7031 SW 62nd Avenue, Miami, FL 33143, USA
| | - Aidan J Flynn
- Department of Psychology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250, USA
| | - Christopher G Hendrix
- Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, 2331 Franklin Road Southwest, Roanoke, VA 24014, USA
| | - Alden H Newcomb
- Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, 2331 Franklin Road Southwest, Roanoke, VA 24014, USA
| | - Jonathan J Carmouche
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA; Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, 2331 Franklin Road Southwest, Roanoke, VA 24014, USA.
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Cizmic A, Häberle F, Wise PA, Müller F, Gabel F, Mascagni P, Namazi B, Wagner M, Hashimoto DA, Madani A, Alseidi A, Hackert T, Müller-Stich BP, Nickel F. Structured feedback and operative video debriefing with critical view of safety annotation in training of laparoscopic cholecystectomy: a randomized controlled study. Surg Endosc 2024; 38:3241-3252. [PMID: 38653899 PMCID: PMC11133174 DOI: 10.1007/s00464-024-10843-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The learning curve in minimally invasive surgery (MIS) is lengthened compared to open surgery. It has been reported that structured feedback and training in teams of two trainees improves MIS training and MIS performance. Annotation of surgical images and videos may prove beneficial for surgical training. This study investigated whether structured feedback and video debriefing, including annotation of critical view of safety (CVS), have beneficial learning effects in a predefined, multi-modal MIS training curriculum in teams of two trainees. METHODS This randomized-controlled single-center study included medical students without MIS experience (n = 80). The participants first completed a standardized and structured multi-modal MIS training curriculum. They were then randomly divided into two groups (n = 40 each), and four laparoscopic cholecystectomies (LCs) were performed on ex-vivo porcine livers each. Students in the intervention group received structured feedback after each LC, consisting of LC performance evaluations through tutor-trainee joint video debriefing and CVS video annotation. Performance was evaluated using global and LC-specific Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores. RESULTS The participants in the intervention group had higher global and LC-specific OSATS as well as global and LC-specific GOALS scores than the participants in the control group (25.5 ± 7.3 vs. 23.4 ± 5.1, p = 0.003; 47.6 ± 12.9 vs. 36 ± 12.8, p < 0.001; 17.5 ± 4.4 vs. 16 ± 3.8, p < 0.001; 6.6 ± 2.3 vs. 5.9 ± 2.1, p = 0.005). The intervention group achieved CVS more often than the control group (1. LC: 20 vs. 10 participants, p = 0.037, 2. LC: 24 vs. 8, p = 0.001, 3. LC: 31 vs. 8, p < 0.001, 4. LC: 31 vs. 10, p < 0.001). CONCLUSIONS Structured feedback and video debriefing with CVS annotation improves CVS achievement and ex-vivo porcine LC training performance based on OSATS and GOALS scores.
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Affiliation(s)
- Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Frida Häberle
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Philipp A Wise
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Müller
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Gabel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Pietro Mascagni
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France
| | - Babak Namazi
- Center for Evidence-Based Simulation, Baylor University Medical Center, Dallas, USA
| | - Martin Wagner
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniel A Hashimoto
- Penn Computer Assisted Surgery and Outcomes (PCASO) Laboratory, Department of Surgery, Department of Computer and Information Science, University of Pennsylvania, Philadelphia, USA
| | - Amin Madani
- Surgical Artificial Intelligence Research Academy (SARA), Department of Surgery, University Health Network, Toronto, Canada
| | - Adnan Alseidi
- Department of Surgery, University of California - San Francisco, San Francisco, USA
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Beat P Müller-Stich
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany.
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Janczewski LM, Silver CM, Schlick CJR, Odell DD, Bentrem DJ, Yang AD, Bilimoria KY, Merkow RP. Association of pathologic factors with postoperative venous thromboembolism after gastrointestinal cancer surgery. J Gastrointest Surg 2024; 28:813-819. [PMID: 38553295 DOI: 10.1016/j.gassur.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/20/2023] [Accepted: 03/02/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) chemoprophylaxis is the standard of care after gastrointestinal (GI) cancer surgery; however, variation in risk based on pathologic factors (eg, stage and histology) is unclear. This study aimed to evaluate the association of pathologic factors with VTE after GI cancer surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program procedure targeted datasets were queried for patients who underwent colorectal, pancreatic, primary hepatic, and esophageal cancer surgery between 2017 and 2020. Disease-specific and pathologic factors associated with postoperative VTE were evaluated using multivariable logistic regression. RESULTS Among 70,934 patients who underwent GI cancer surgery, the incidence rates of 30-day postoperative VTE were 3.3% for pancreatic cancer, 3.2% for esophageal cancer, 2.7% for primary hepatic, and 1.3% for colorectal cancer. T stage was associated with VTE for colorectal cancer (T4 vs T1; odds ratio [OR], 1.79; 95% CI, 1.24-2.60), pancreatic cancer (all T stages vs T1; P < .05), and primary hepatic cancer (T4 vs T1; OR, 2.80; 95% CI, 1.55-5.08). N stage was associated with VTE for colorectal cancer (N2 vs N0; OR, 1.33; 95% CI, 1.04-1.68) and pancreatic cancer (N2 vs N0; OR, 1.36; 95% CI, 1.03-1.81). M stage was associated with VTE for colorectal cancer (OR, 1.47; 95% CI, 1.17-1.85) and esophageal cancer (OR, 2.54; 95% CI, 1.24-5.19). Histologic subtype was not associated with VTE, except for pancreatic neuroendocrine tumors vs adenocarcinoma (OR, 1.34; 95% CI, 1.03-1.74). CONCLUSION Pathologic factors were associated with higher 30-day VTE risk after GI cancer surgery. Acknowledging the association of pathologic factors on VTE is an important first step to considering a more tailored approach to chemoprophylaxis.
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Affiliation(s)
- Lauren M Janczewski
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Casey M Silver
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Cary Jo R Schlick
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - David D Odell
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - David J Bentrem
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States; Department of Surgery, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, United States
| | - Anthony D Yang
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Ryan P Merkow
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, United States.
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Khalid A, Amini N, Pasha SA, Demyan L, Newman E, King DA, DePeralta D, Gholami S, Deutsch GB, Melis M, Weiss MJ. Impact of postoperative pancreatic fistula on outcomes in pancreatoduodenectomy: a comprehensive analysis of American College of Surgeons National Surgical Quality Improvement Program data. J Gastrointest Surg 2024:S1091-255X(24)00483-9. [PMID: 38821210 DOI: 10.1016/j.gassur.2024.05.035] [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: 03/29/2024] [Revised: 05/09/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is a major surgical procedure associated with significant risks, particularly postoperative pancreatic fistula (POPF). Studies have highlighted the importance of certain risk factors for POPF, which are crucial for surgical decision-making and the management of high-risk patients undergoing PD. This study aimed to assess the surgical outcomes of patients undergoing PD who met the International Study Group of Pancreatic Surgery - Class D (ISGPS-D) criteria. METHODS This study analyzed American College of Surgeons National Surgical Quality Improvement Program data (2014-2021) for patients undergoing ISGPS-D PD, classified as having a soft pancreatic texture and a pancreatic duct of ≤3 mm. This study focused on mortality rates and the correlation between several factors and POPF (ISGPS grade B/C). RESULTS From 5964 patients who underwent PD and met the ISGPS-D criteria, the 30-day mortality rate was 1.98%. Males had a higher incidence of POPF than females (57.42% vs 47.35%, respectively; P < .001). Patients with POPF experienced significantly higher rates of major postoperative complications (Clavien-Dindo grade ≥ IIIa), including thrombosis, pneumonia, sepsis, delayed gastric emptying, wound disruption, infections, and acute renal failure. There was a marked increase in the 30-day readmission and mortality rates in patients with POPF (30.0% vs 17.6% and 3.2% vs 1.4%, respectively; all P < .001). Multivariate analysis highlighted female sex as a protective factor against mortality (odds ratio [OR], 0.47; P < .001) and extended hospital stay (>10 days) as a predictor of increased mortality risk (OR, 2.37; P < .001). CONCLUSION This study underscored the significant association between POPF and increased postoperative morbidity and mortality rates. Future efforts should concentrate on refining surgical techniques and improving preoperative assessments to mitigate the risks associated with POPF in patients undergoing PD.
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Affiliation(s)
- Abdullah Khalid
- Northwell Health, North Shore/Long Island Jewish General Surgery, Manhasset, New York, United States.
| | - Neda Amini
- Northwell Health, North Shore/Long Island Jewish General Surgery, Manhasset, New York, United States
| | - Shamsher A Pasha
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Lyudmyla Demyan
- Northwell Health, North Shore/Long Island Jewish General Surgery, Manhasset, New York, United States
| | - Elliot Newman
- Northwell Health Lenox Hill Hospital, New York, New York, United States
| | - Daniel A King
- Northwell Health Cancer Institute, New Hyde Park, New York, United States
| | - Danielle DePeralta
- Northwell Health Cancer Institute, New Hyde Park, New York, United States
| | - Sepideh Gholami
- Northwell Health Cancer Institute, New Hyde Park, New York, United States
| | - Gary B Deutsch
- Northwell Health Cancer Institute, New Hyde Park, New York, United States
| | | | - Matthew J Weiss
- Northwell Health Cancer Institute, New Hyde Park, New York, United States
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Wang CC, Foley OW, Blank SV, Huh WK, Barber EL. Shifting trends and sicker patients: Reassessing hysterectomy performed for benign indications by gynecologic oncologists. Gynecol Oncol 2024; 184:43-50. [PMID: 38277920 DOI: 10.1016/j.ygyno.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE To assess trends and differences in patient characteristics, complications, and distributions of hysterectomy for benign indications by benign gynecologists (BG) and gynecologic oncologists (GO). METHODS This retrospective cohort study identified patients undergoing hysterectomy for benign indications using the National Surgical Quality Improvement Program data from 2014 to 2021. Exclusions were made for gynecologic or disseminated cancers, ascites, non-gynecologic surgeons, and cesarean hysterectomies. Primary outcome was major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, andthromboembolic complications. Thirty-day readmissions, reoperations, and mortality were also analyzed. Propensity score matching was performed in a 1:1 match of GO to BG patients and was compared. Linear regressions assessed trends. RESULTS Among 198,767 patients, 18% (n = 37,707) underwent hysterectomy for benign indications with GO. GO patients exhibited more risk factors for complications and differed significantly from BG patients in comorbidities and perioperative characteristics. Overall, GO patients had higher major complication rates (3.1% vs 2.2%, p < 0.001) and for several other composite complications. After matching, compared to BG, GO-performed hysterectomies had similar rates of major complications (3.0% vs 3.0%, p = 0.55) and no differences in other composite complications, except fewer reoperations (1.2 % vs 1.5%, p < 0.01) and wound complications (0.4% vs 0.5%, p = 0.02) in GO patients. Over the eight years, the percentage of GO-performed hysterectomy (β = 0.41, R2 = 0.71,p < 0.01) increased significantly whereas BG-performed surgeries decreased by the same magnitude. BG had a significant decrease in frail patients (β = -0.47, R2 = 0.90, p < 0.01), but GO did not (β = -0.36, R2 = 0.38, p = 0.10). CONCLUSIONS GO are performing more hysterectomies for benign indications on higher-risk patients. However, on a matched cohort, risks of major complications were similar between GO and BG.
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Affiliation(s)
- Connor C Wang
- Northwestern University Feinberg School of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA.
| | - Olivia W Foley
- Northwestern University Feinberg School of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Stephanie V Blank
- Icahn School of Medicine at Mount Sinai, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Warner K Huh
- University of Alabama at Birmingham, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Birmingham, AL, USA
| | - Emma L Barber
- Northwestern University Feinberg School of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
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Jones DW, Simons JP, Osborne NH, Schermerhorn M, Dimick JB, Schanzer A. Earned outcomes correlate with reliability-adjusted surgical mortality after abdominal aortic aneurysm repair and predict future performance. J Vasc Surg 2024:S0741-5214(24)01082-6. [PMID: 38697233 DOI: 10.1016/j.jvs.2024.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/18/2024] [Accepted: 04/25/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Cumulative, probability-based metrics are regularly used to measure quality in professional sports, but these methods have not been applied to health care delivery. These techniques have the potential to be particularly useful in describing surgical quality, where case volume is variable and outcomes tend to be dominated by statistical "noise." The established statistical technique used to adjust for differences in case volume is reliability-adjustment, which emphasizes statistical "signal" but has several limitations. We sought to validate a novel measure of surgical quality based on earned outcomes methods (deaths above average [DAA]) against reliability-adjusted mortality rates, using abdominal aortic aneurysm (AAA) repair outcomes to illustrate the measure's performance. METHODS Earned outcomes methods were used to calculate the outcome of interest for each patient: DAA. Hospital-level DAA was calculated for non-ruptured open AAA repair and endovascular aortic repair (EVAR) in the Vascular Quality Initiative database from 2016 to 2019. DAA for each center is the sum of observed - predicted risk of death for each patient; predicted risk of death was calculated using established multivariable logistic regression modeling. Correlations of DAA with reliability-adjusted mortality rates and procedure volume were determined. Because an accurate quality metric should correlate with future results, outcomes from 2016 to 2017 were used to categorize hospital quality based on: (1) risk-adjusted mortality; (2) risk- and reliability-adjusted mortality; and (3) DAA. The best performing quality metric was determined by comparing the ability of these categories to predict 2018 to 2019 risk-adjusted outcomes. RESULTS During the study period, 3734 patients underwent open repair (106 hospitals), and 20,680 patients underwent EVAR (183 hospitals). DAA was closely correlated with reliability-adjusted mortality rates for open repair (r = 0.94; P < .001) and EVAR (r = 0.99; P < .001). DAA also correlated with hospital case volume for open repair (r = -.54; P < .001), but not EVAR (r = 0.07; P = .3). In 2016 to 2017, most hospitals had 0% mortality (55% open repair, 57% EVAR), making it impossible to evaluate these hospitals using traditional risk-adjusted mortality rates alone. Further, zero mortality hospitals in 2016 to 2017 did not demonstrate improved outcomes in 2018 to 2019 for open repair (3.8% vs 4.6%; P = .5) or EVAR (0.8% vs 1.0%; P = .2) compared with all other hospitals. In contrast to traditional risk-adjustment, 2016 to 2017 DAA evenly divided centers into quality quartiles that predicted 2018 to 2019 performance with increased mortality rate associated with each decrement in quality quartile (Q1, 3.2%; Q2, 4.0%; Q3, 5.1%; Q4, 6.0%). There was a significantly higher risk of mortality at worst quartile open repair hospitals compared with best quartile hospitals (odds ratio, 2.01; 95% confidence interval, 1.07-3.76; P = .03). Using 2016 to 2019 DAA to define quality, highest quality quartile open repair hospitals had lower median DAA compared with lowest quality quartile hospitals (-1.18 DAA vs +1.32 DAA; P < .001), correlating with lower median reliability-adjusted mortality rates (3.6% vs 5.1%; P < .001). CONCLUSIONS Adjustment for differences in hospital volume is essential when measuring hospital-level outcomes. Earned outcomes accurately categorize hospital quality and correlate with reliability-adjustment but are easier to calculate and interpret. From 2016 to 2019, highest quality open AAA repair hospitals prevented >40 perioperative deaths compared with the average hospital, and >80 perioperative deaths compared with lowest quality hospitals.
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Affiliation(s)
- Douglas W Jones
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical Center, University of Massachusetts Chan Medical School, Worcester, MA.
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical Center, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical Center, University of Massachusetts Chan Medical School, Worcester, MA
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10
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Simhal RK, Wang KR, Shah YB, Lallas CD, Shah MS, Chandrasekar T. Peri-operative outcomes following radical prostatectomy in the setting of advanced prostate cancer. BJU Int 2024. [PMID: 38653516 DOI: 10.1111/bju.16370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To compare the peri-operative outcomes of radical prostatectomy (RP) for locally advanced, node-positive, and metastatic prostate cancer (PCa), as determined through pathological staging, using the American College of Surgeons National Surgical Quality Improvement Project. METHODS We identified RP procedures performed between 2019 and 2021. Patients were stratified by pathological staging to compare the effect of locally advanced disease (T3-4), node positivity (N+) and metastasis (M+) vs localised PCa (T1-2 N0 M0). Baseline demographics and 30-day outcomes, including operating time, length of hospital stay (LOS), 30-day mortality, readmissions, reoperations, major complications, minor complications and surgery-specific complications, were compared between groups. RESULTS Pathological staging data were available for 9276 RPs. Baseline demographics were comparable. There was a slightly higher rate of minor complications in the locally advanced cohort, but no significant difference in major complications, 30-day mortality, readmissions, or rectal injuries. Node positivity was associated with longer operating time, LOS, and some slightly increased rates of 30-day complications. RP in patients with metastatic disease appeared to be similarly safe to RP in patients with M0 disease, although it was associated with a longer LOS and slightly increased rates of certain complications. CONCLUSIONS For patients with pathologically determined locally advanced, node-positive, and metastatic PCa, RP appears to be safe, and is not associated with significantly higher rates of 30-day mortality or major complications compared to RP for localised PCa. This study adds to the growing body of literature investigating the role of RP for advanced PCa; further studies are needed to better characterise the risks and benefits of surgery in such patients.
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Affiliation(s)
- Rishabh K Simhal
- Department of Urology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Kerith R Wang
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yash B Shah
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Costas D Lallas
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mihir S Shah
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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11
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van der Graaf SH, Hagens MJ, Veerman H, Roeleveld TA, Nieuwenhuijzen JA, Wit EMK, W J M Wouters M, van der Mierden S, van Moorselaar RJA, Beerlage HP, Vis AN, van Leeuwen PJ, van der Poel HG. A Systematic Review on the Impact of Quality Assurance Programs on Outcomes after Radical Prostatectomy. Eur Urol Focus 2024:S2405-4569(24)00048-8. [PMID: 38631992 DOI: 10.1016/j.euf.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/23/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND OBJECTIVE The implementation of quality assurance programs (QAPs) within urological practice has gained prominence; yet, their impact on outcomes after radical prostatectomy (RP) remains uncertain. This paper aims to systematically review the current literature regarding the implementation of QAPs and their impact on outcomes after robot-assisted RP, laparoscopic RP, and open prostatectomy, collectively referred to as RP. METHODS A systematic Embase, Medline (OvidSP), and Scopus search was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) process, on January 12, 2024. Studies were identified and included if these covered implementation of QAPs and their impact on outcomes after RP. QAPs were defined as any intervention seeking quality improvement through critically reviewing, analyzing, and discussing outcomes. Included studies were assessed critically using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool, with results summarized narratively. KEY FINDINGS AND LIMITATIONS Ten included studies revealed two methodological strategies: periodic performance feedback and surgical video assessments. Despite conceptual variability, QAPs improved outcomes consistently (ie, surgical margins, urine continence, erectile function, and hospital readmissions). Of the two strategies, video assessments better identified suboptimal surgical practice and technical errors. Although the extent of quality improvements did not appear to correlate with the frequency of QAPs, there was an apparent correlation with whether or not outcomes were evaluated collectively. CONCLUSIONS AND CLINICAL IMPLICATIONS Current findings suggest that QAPs have a positive impact on outcomes after RP. Caution in interpretation due to limited data is advised. More extensive research is required to explore how conceptual differences impact the extent of quality improvements. PATIENT SUMMARY In this paper, we review the available scientific literature regarding the implementation of quality assurance programs and their impact on outcomes after radical prostatectomy. The included studies offered substantial support for the implementation of quality assurance programs as an incentive to improve the quality of care continuously.
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Affiliation(s)
- Sophia H van der Graaf
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands.
| | - Marinus J Hagens
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Hans Veerman
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Ton A Roeleveld
- Prostate Cancer Network Netherlands, Amsterdam, The Netherlands; Department of Urology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Esther M K Wit
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Stevie van der Mierden
- Scientific Information Service, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R Jeroen A van Moorselaar
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Harrie P Beerlage
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - André N Vis
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
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Grande L, Gimeno M, Jimeno J, Pera M, Sancho-Insenser J, Pera M. Continuous monitoring of adverse effects improves surgical outcomes. Cir Esp 2024; 102:209-215. [PMID: 38342137 DOI: 10.1016/j.cireng.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 11/23/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND There has been significant debate about the advantages and disadvantages of using administrative databases or clinical registry in healthcare improvement programs. The aim of this study was to review the implementation and outcomes of an accountability policy through a registry maintained by professionals of the surgical department. MATERIALS AND METHODS All patients admitted to the department between 2003 and 2022 were prospectively included. All adverse events (AEs) occurring during the admission, convalescent care in facilities, or at home for a minimum period of 30 days after discharge were recorded. RESULTS Out of 60,125 records, 24,846 AEs were documented in 16,802 cases (27.9%). There was a progressive increase in the number of AEs recorded per admission (1.17 in 2003 vs. 1.93 in 2022) with a 26% decrease in entries with AEs (from 35.0% in 2003 to 25.8% in 2022), a 57.5% decrease in reoperations (from 8.0% to 3.4%, respectively), and an 80% decrease in mortality (from 1.8% to 1.0%, respectively). It is noteworthy that a significant reduction in severe AEs was observed between 2011 and 2022 (56% vs. 15.6%). CONCLUSION A prospective registry of AEs created and maintained by health professionals, along with transparent presentation and discussion of the results, leads to sustained improvement in outcomes in a surgical department of a university hospital.
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Affiliation(s)
- Luis Grande
- Servicio de Cirugía General, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departmento de Cirugía, Universitat Autònoma de Barcelona, Bellaterra (Barcelona), Spain.
| | - Marta Gimeno
- Servicio de Cirugía General, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Jaime Jimeno
- Servicio de Cirugía General, Hospital del Mar, Barcelona, Spain; Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Manuel Pera
- Servicio de Cirugía General, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departmento de Cirugía, Universitat Autònoma de Barcelona, Bellaterra (Barcelona), Spain
| | - Joan Sancho-Insenser
- Servicio de Cirugía General, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departmento de Cirugía, Universitat Autònoma de Barcelona, Bellaterra (Barcelona), Spain
| | - Miguel Pera
- Servicio de Cirugía General, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departmento de Medicina y Ciencias de la Salud (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
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Dencker EE, Bonde A, Troelsen A, Sillesen M. Assessing the utility of natural language processing for detecting postoperative complications from free medical text. BJS Open 2024; 8:zrae020. [PMID: 38593027 PMCID: PMC11003538 DOI: 10.1093/bjsopen/zrae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/29/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Postoperative complication rates are often assessed through administrative data, although this method has proven to be imprecise. Recently, new developments in natural language processing have shown promise in detecting specific phenotypes from free medical text. Using the clinical challenge of extracting four specific and frequently undercoded postoperative complications (pneumonia, urinary tract infection, sepsis, and septic shock), it was hypothesized that natural language processing would capture postoperative complications on a par with human-level curation from electronic health record free medical text. METHODS Electronic health record data were extracted for surgical cases (across 11 surgical sub-specialties) from 18 hospitals in the Capital and Zealand regions of Denmark that were performed between May 2016 and November 2021. The data set was split into training/validation/test sets (30.0%/48.0%/22.0%). Model performance was compared with administrative data and manual extraction of the test data set. RESULTS Data were obtained for 17 486 surgical cases. Natural language processing achieved a receiver operating characteristic area under the curve of 0.989 for urinary tract infection, 0.993 for pneumonia, 0.992 for sepsis, and 0.998 for septic shock, whereas administrative data achieved a receiver operating characteristic area under the curve of 0.595 for urinary tract infection, 0.624 for pneumonia, 0.571 for sepsis, and 0.625 for septic shock. CONCLUSION The natural language processing approach was able to capture complications with acceptable performance, which was superior to administrative data. In addition, the model performance approached that of manual curation and thereby offers a potential pathway for complete real-time coverage of postoperative complications across surgical procedures based on natural language processing assessment of electronic health record free medical text.
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Affiliation(s)
- Emilie Even Dencker
- Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Alexander Bonde
- Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Aiomic Aps, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopaedics, Copenhagen University Hospital, Hvidovre, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen Medical School, Copenhagen, Denmark
| | - Martin Sillesen
- Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen Medical School, Copenhagen, Denmark
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Khadka B, Sharma A, Bhattarai PR, Rayamajhi B, Adhikari H. Role of pre-operative counseling with NSQIP surgical risk calculator in the surgical patients. Surg Open Sci 2024; 18:11-16. [PMID: 38312306 PMCID: PMC10831096 DOI: 10.1016/j.sopen.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/31/2023] [Accepted: 01/10/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Patient satisfaction is important tool to monitor health care performance and quality of health plans, emphasizing effective counseling and consent processes. The objective of the study is to assess patient satisfaction and anxiety with the use of NSQIP surgical risk calculator in comparison to standardized questionnaires. Methodology This is an interventional prospective randomized study. Difference in patient satisfaction is assessed by a 7-point Likert scale and anxiety assessment by 5-point Likert scale of Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire written in Nepalese. Satisfaction scores were compared using analysis of variance (ANOVA), or the Kruskal-Wallis test. P- value <0.05 was considered statistically significant. Results Satisfaction score regarding comfort during counseling and consent process was similar with and without use of NSQIP surgical risk calculator (83.3 % and 76.9 %, respectively). Satisfaction score regarding plan of anesthesia was 63.33 % with the use of NSQIP and 53.8 % without NSQIP tool. 30.76 % of patients with high school education developed negative feelings following counseling when NSQIP tool was not used (p value 0.002). NSQIP usage increased anxiety about anesthesia and surgery and led to higher continual thinking about the procedure.Duration of counseling was 12 min with NSQIP tool use in comparison to 9.67 min following conventional counseling (p value 0.047). Conclusion NSQIP surgical risk calculator is a reliable tool that can be used alongside conventional methods during preoperative period for decision-making and counseling with similar satisfaction scores but a higher incidence of anxiety and continual thinking about procedures.
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15
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Jehan FS, Ganguli S, Saif A, Hase NE, Nayak PS, Nayyar A, Aziz H. Effect of conditions being present at time of surgery (PATOS) on outcomes in liver surgery. Am J Surg 2024; 228:213-217. [PMID: 37839957 DOI: 10.1016/j.amjsurg.2023.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 09/04/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Information about condition(s) being present at time of surgery (PATOS) in the American College of Surgeons (ASC) National Surgical Quality Improvement Program (NSQIP) database can influence the postoperative complication rates after liver surgeries. Here, we compare the postoperative complication rates with and without taking condition(s) being PATOS into account. METHODS We retrospectively reviewed the ACS NSQIP Participant User Files (PUFs) from 2015 through 2019. We analyzed rates of eight different postoperative complications: superficial surgical site infection (SSI), deep SSI, organ space SSI, pneumonia, urinary tract infection, ventilator, sepsis, and septic shock. In addition, we calculated the percent change in event rates after taking into account whether a condition is PATOS. RESULTS Of the 22,463 patients in the ACS NSQIP PUFs for liver surgery, 334 (1.49%) had one or more conditions PATOS. The percentages of patients with PATOS events ranged from 2.03% for superficial SSI to 14.74% for sepsis. For all complications, event rates declined when taking condition(s) PATOS into account. From 2015 through 2019, the observed-to-expected ratios for most complications remained unchanged. CONCLUSION Whether a condition is PATOS is important in reporting postoperative complication rates for patients undergoing liver surgery. When taking whether a condition is PATOS into account, we demonstrated an overall decrease in event rates across all eight postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | - Hassan Aziz
- University of Iowa Hospitals and Clinics, USA.
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16
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Mirzaie AA, Ueland WR, Lambert KA, Delgado AM, Rosen JW, Valdes CA, Scali ST, Huber TS, Upchurch GR, Shah SK. Appraising the Quality of Reporting of Vascular Surgery Studies That Use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database. Vasc Endovascular Surg 2024; 58:76-84. [PMID: 37452561 DOI: 10.1177/15385744231189771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is an important data source for observational studies. While there are guides to ensure appropriate study reporting, there has been no evaluation of NSQIP studies in vascular surgery. We sought to evaluate the adherence of vascular-surgery related NSQIP studies to best reporting practices. METHODS In January 2022, we queried PubMed for all vascular surgery NSQIP studies. We used the REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) statement and the JAMA Surgery (JAMA-Surgery) checklist to assess reporting methodology. We also extracted the Journal Impact Factor (IF) of each article. RESULTS One hundred and fifty-nine studies published between 2002 and 2022 were identified and analyzed. The median score on the RECORD statement was 6 out of 8. The most commonly missed RECORD statement items were describing any validation of codes and providing data cleaning information. The median score on the JAMA-Surgery checklist was 2 out of 7. The most commonly missed JAMA-Surgery checklist items were identifying competing risks, using flow charts to help visualize study populations, having a solid research question and hypothesis, identifying confounders, and discussing the implications of missing data. We found no difference in the reporting methodology of studies published in high vs low IF journals. CONCLUSION Vascular surgery studies using NSQIP data demonstrate poor adherence to research reporting standards. Critical areas for improvement include identifying competing risks, including a solid research question and hypothesis, and describing any validation of codes. Journals should consider requiring authors use reporting guides to ensure their articles have stringent reporting methodology.
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Affiliation(s)
- Amin A Mirzaie
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Walker R Ueland
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Amanda M Delgado
- Office of Academic Affairs, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Jordan W Rosen
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Carlos A Valdes
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Samir K Shah
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
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Tan EJKW, Chen HLR, Chok AY, Tan IEH, Zhao Y, Lee RS, Ang KA, Au MKH, Ong HS, Ho HSS, Poopalalingam R, Tan HK, Kwek KYC. A reduction in hospital length of stay reduces costs for colorectal surgery: an economic evaluation of the National Surgical Quality Improvement Program in Singapore. Int J Colorectal Dis 2023; 38:257. [PMID: 37882868 DOI: 10.1007/s00384-023-04551-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE In 2017, the National Surgical Quality Improvement Program (NSQIP) was introduced in the Department of Colorectal Surgery at Singapore General Hospital as a pilot quality improvement initiative. This study aimed to examine the cost-effectiveness of NSQIP by evaluating its effects on surgical outcomes, length of stay (LOS), and costs. METHODS We retrospectively reviewed patients undergoing colorectal surgery (2017-2020). Patients were divided into two cohorts: pre-NSQIP (2017-2018) and post-NSQIP (2019-2020). Outcomes evaluated were 30-day postoperative complications, LOS, and costs. Total cost-savings from NSQIP intervention's impact on LOS were estimated using a decision model with a one-way sensitivity analysis. Multivariate logistic regression was performed to identify factors for prolonged LOS. RESULTS 1905 patients underwent colorectal surgery, with 996 in the pre-NSQIP cohort and 909 in the post-NSQIP cohort. A significant reduction in overall postoperative complications of 4.7% was observed in the post-NSQIP cohort (36.5% vs. 31.8%, p = 0.029). Patients in the post-NSQIP cohort had a shorter median LOS (8.0 vs. 6.0 days, p < 0.001). The implementation of NSQIP resulted in an 8.5% decrease in prolonged LOS > 6 days (p < 0.001), saving S$0.31 million on LOS. Total costs per case were reduced by 20.8% following NSQIP (S$39,539.05 vs. S$31,311.93, p < 0.001). CONCLUSION Implementing NSQIP has significantly reduced overall postoperative complications, LOS, and costs and achieved cost savings following colorectal surgery.
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Affiliation(s)
- Emile John Kwong Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Hui Lionel Raphael Chen
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Rachel Shiyi Lee
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Kwok Ann Ang
- Finance, Singapore General Hospital, Singapore, 169608, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
- Finance, Singhealth Community Hospitals, Singapore, 168582, Singapore
| | - Hock Soo Ong
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore, 169608, Singapore
| | - Henry Sun Sien Ho
- Department of Urology, Singapore General Hospital, Singapore, 169608, Singapore
| | - Ruban Poopalalingam
- Department of Anesthesiology, Singapore General Hospital, Singapore, 169608, Singapore
| | - Hiang Khoon Tan
- Singapore General Hospital, Singapore, 169608, Singapore
- SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - Kenneth Yung Chiang Kwek
- Singapore General Hospital, Singapore, 169608, Singapore
- Singapore Health Services, Singapore, 168582, Singapore
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Sibley D, Chen M, West MA, Matthew AG, Santa Mina D, Randall I. Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review. Appl Physiol Nutr Metab 2023; 48:639-656. [PMID: 37224570 DOI: 10.1139/apnm-2022-0272] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.
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Affiliation(s)
- Daniel Sibley
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Maggie Chen
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Malcolm A West
- Faculty of Medicine, Cancer Sciences, University of Southampton, UK
- NIHR Southampton Biomedical Research Centre, Perioperative and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew G Matthew
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Ian Randall
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Bondzi-Simpson A, Ribeiro T, Coburn NG, Hallet J. Integrating equity frameworks into surgical quality improvement and health administrative databases: A narrative review. Am J Surg 2023:S0002-9610(23)00394-X. [PMID: 37640638 DOI: 10.1016/j.amjsurg.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/05/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023]
Abstract
Ensuring safe, timely, and effective surgery is critical for high-quality healthcare and is the goal of surgical quality monitoring systems. At the heart of these systems are health administrative databases which house patient clinico-demographic information, healthcare processes and outcomes. Through analysis of monitoring systems outputs, we can identify gaps within healthcare delivery, patient experience, and surgical outcomes. However, gaps in our healthcare can only be measured by the variables we collect. Equity stratifiers are sociodemographic descriptors that can identify patient populations who experience differences in health and healthcare that may be considered unjust or unfair. They include age, education, gender, geographic location, income, Indigenous identity, racialized group, and sex at birth. These equity stratifiers represent measurable components of the social determinants of health housed within health administrative databases and allow for standardized analysis and reporting of health inequity. However, not all databases collect these stratifiers - making granular analysis of patient subgroups who may experience health inequity impossible to measure. Moreover, in databases that do collect this information, a wide range in the classification systems used makes for comparisons across jurisdictions challenging. The focus of this narrative review will be to apply the principles of the equity stratifier framework to examine what measures are collected in surgical quality improvement databases, cancer monitoring systems and provincial/state health administrative databases in the United States of America and Canada. The goal of this narrative review is to 1) inform researchers, surgeons, and policymakers of the current landscape of social variables collected within common health administrative databases. 2) Outline the pros and cons of the current collection system. 3) Issue a call to action for policymakers to incorporate health equity frameworks into the collection and reporting of data.
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Affiliation(s)
- Adom Bondzi-Simpson
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Tiago Ribeiro
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Jehan FS, Hase NE, Ganguli S, Saif A, Nayyar A, Aziz H. Effect of Present at Time of Surgery (PATOS) on Outcomes in Pancreatic Surgery. J Gastrointest Surg 2023; 27:1632-1639. [PMID: 37231243 DOI: 10.1007/s11605-023-05707-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION While there is some data available on the importance of accounting for the effect of present at time of surgery (PATOS) when estimating unadjusted postoperative complication rates, little is known about the impact of PATOS on outcomes in patients undergoing pancreatic surgery specifically. By taking PATOS into account, we hypothesized that unadjusted, observed postoperative complication rates might be reduced, with these reductions being different across outcomes; however, we expected fewer differences in risk-adjusted results, i.e., observed to expected ratios (O/E ratios). METHODS We retrospectively analyzed the ACS NSQIP Participant Use Files (PUFs) from 2015 to 2019. PATOS data were analyzed for the 8 postoperative complications of superficial, deep, and organ space surgical site infection; pneumonia; urinary tract infection; ventilator dependence; sepsis; and septic shock. Postoperative complication rates were compared by ignoring PATOS vs. taking PATOS into account. RESULTS Of the 31,919 patients in the ACS NSQIP PUFs who underwent pancreatic surgery, 1120 (3.51%) patients had one or more PATOS conditions. The event rates after taking PATOS into account declined for all outcomes-superficial surgical site infection (SSI) rates reduced by 2.56%, deep SSI rates reduced by 4.28%, organ space SSI rates reduced by 9.31%, pneumonia rates reduced by 2.91%, urinary tract infection rates declined by 4.69%, and septic shock rates declined by 9.27%. CONCLUSION Our paper highlights that accounting for PATOS is important for estimating unadjusted postoperative complication rates in patients undergoing pancreatic surgery. Risk adjustment is essential to any attempt at quality assessment and benchmarking. Failure to account for PATOS may penalize surgeons who care for the sickest and most complicated patients and subsequently encourage cherry-picking of less risky patients and procedures.
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Affiliation(s)
| | | | | | - Areeba Saif
- McGovern Medical School, UTHealth, Houston, USA
| | - Apoorve Nayyar
- University of Iowa Hospitals and Clinics, 200 Hawkins Dr, C41-S GH, Iowa City, IA, 52242, USA
| | - Hassan Aziz
- University of Iowa Hospitals and Clinics, 200 Hawkins Dr, C41-S GH, Iowa City, IA, 52242, USA.
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Soto JM, Nguyen AV, van Zyl JS, Huang JH. Outcomes After Supratentorial Craniotomy for Primary Malignant Brain Tumor Resection in Adult Patients: A National Surgical Quality Improvement Program Analysis. World Neurosurg 2023; 175:e780-e789. [PMID: 37061032 DOI: 10.1016/j.wneu.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND The rate of complications remains significant after craniotomy for supratentorial primary malignant brain tumors despite recent advances. OBJECTIVE The goal of this study is to characterize factors associated with these complications. METHODS Data were extracted from the National Surgical Quality Improvement Program database from 2016 to 2019. Patients who underwent a craniotomy for resection of supratentorial primary malignant brain tumors were included. Covariates included demographics/comorbidities, preoperative laboratory values, American Society of Anesthesiologists (ASA) classification, operative time, and postoperative complications. Multivariable logistic regression with backward and forward selection was used to evaluate independent predictors of death, prolonged hospitalization, postoperative stroke with neurologic deficit (CVA), and unplanned readmission. Predictive fit of the model was evaluated using the area under the receiver operating curve (AUC). RESULTS Of 8965 included cases, the 30-day postoperative risks were 1.9% for CVA, 10.1% for unplanned readmission, 1.2% for prolonged hospitalization, and 2.4% for death. Age, ASA category, disseminated cancer, preoperative functional dependence, and postoperative respiratory complications were predictors of 30-day mortality (AUC, 0.83; P < 0.001). CVA was best predicted by increased operation time (P < 0.001), age, ASA category, and recent weight loss (AUC, 0.63; P = 0.009). Prolonged hospitalization was predicted by nonelective surgery status, time from admission to surgery, reintubation, and postoperative sepsis (AUC, 0.78; P < 0.001). Unplanned readmission was predicted by chronic steroid use, postoperative thrombotic complications after surgery, organ/space surgical site infection, deep vein thrombosis, postoperative systemic sepsis, and septic shock (AUC, 0.68; P < 0.001). CONCLUSIONS Our study identifies predictors of major 30-day complications after craniotomy for this subset of patients with brain tumor.
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Affiliation(s)
- Jose M Soto
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Anthony V Nguyen
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Johanna S van Zyl
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA.
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Silver CM, Yang AD, Shan Y, Love R, Prachand VN, Cradock KA, Johnson J, Halverson AL, Merkow RP, McGee MF, Bilimoria KY. Changes in Surgical Outcomes in a Statewide Quality Improvement Collaborative with Introduction of Simultaneous, Comprehensive Interventions. J Am Coll Surg 2023; 237:128-138. [PMID: 36919951 DOI: 10.1097/xcs.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes. STUDY DESIGN Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control. RESULTS There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance. CONCLUSIONS Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes.
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Affiliation(s)
- Casey M Silver
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
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Andrew C, Fleischer CM, Camblor PM, Chow V, Briggs A, Deiner S. Postoperative rehospitalization in older surgical patients: an age-stratified analysis. Perioper Med (Lond) 2023; 12:28. [PMID: 37344862 DOI: 10.1186/s13741-023-00313-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/22/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Older adults comprise 40% of surgical inpatients and are at increased risk of postoperative rehospitalization. A decade ago, 30-day rehospitalizations for Medicare patients were reported as 15%, and more than 70% was attributed to medical causes. In the interim, there have been several large-scale efforts to establish best practice for older patients through surgical quality programs and national initiatives by Medicare and the National Health Service. To understand the current state of rehospitalization in the USA, we sought to report the incidence and cause of 30-day rehospitalization across surgical types by age. STUDY DESIGN We performed a retrospective study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset from 2015 to 2019. Our primary exposure of interest was age. Patients were categorized into four groups: 18-49, 50-64, 65-74, and 75 + years old. Reasons for rehospitalization were evaluated using NSQIP defined causes and reported International Classification of Disease (ICD)-9 and ICD-10 codes. Our primary outcome was the incidence of unplanned 30-day rehospitalization and secondary outcome the cause for rehospitalization. Variables were summarized by age group through relative (%) and absolute (n) frequencies; chi-square tests were used to compare proportions. Since rehospitalization is a time-to-event outcome in which death is a competing event, the cumulative incidence of rehospitalization at 30 days was estimated using the procedure proposed by Gray. The same strategy was used for estimating the cumulative incidence for unplanned rehospitalizations. RESULTS A total of 2,798,486 patients met inclusion criteria; 198,542 had unplanned rehospitalization (overall 7.09%). Rehospitalization by age category was 6.12, 6.99, 7.50, and 9.50% for ages 18-49, 50-64, 65-74, and 75 + , respectively. Complications related to the digestive system were the single most common cause of rehospitalization across age groups. Surgical site infection was the second most common cause, with the relative frequency decreasing with age as follows: 21.74%, 19.08%, 15.09%, and 9.44% (p < .0001). Medical causes such as circulatory or respiratory complications were more common with increasing age (2.10%, 4.43%, 6.27%, 8.86% and 3.27, 4.51, 6.07, 8.11%, respectively). CONCLUSION We observed a decrease in overall rehospitalization for older surgical patients compared to studies a decade ago. The oldest (≥ 75) surgical patients had the highest 30-day rehospitalization rates (9.50%). The single most common reason for rehospitalization was the same across age groups and likely attributed to surgery (ileus). However, the aggregate of medical causes of rehospitalization was more common in older patients; surgical and respiratory reasons were twice as common in this group. Rehospitalization increased by age for some surgery types, e.g., lower extremity bypass, more than others, e.g., ventral hernia repair. Future investigations should focus on interventions to reduce medical complications and further decrease postoperative rehospitalization for older surgical patients undergoing high-risk procedures.
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Affiliation(s)
- Caroline Andrew
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christina M Fleischer
- Department of General Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Pablo Martinez Camblor
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755, USA
| | - Vinca Chow
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755, USA
| | - Alexandra Briggs
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755, USA
| | - Stacie Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755, USA.
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Baboudjian M, Abou-Zahr R, Buhas B, Touzani A, Beauval JB, Ploussard G. The BETTY Score to Predict Perioperative Outcomes in Surgical Patients. Cancers (Basel) 2023; 15:cancers15113050. [PMID: 37297012 DOI: 10.3390/cancers15113050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
The aim of this study is to evaluate a new user-friendly scoring system, namely the BETTY score, that aims to predict 30-day patient outcomes after surgery. In this first description, we rely on a population of prostate cancer patients undergoing robot-assisted radical prostatectomy. The BETTY score includes the patient's American Society of Anesthesiologists score, the body mass index, and intraoperative data, including operative time, estimated blood loss, any major intraoperative complications, hemodynamic, and/or respiratory instability. There is an inverse relationship between the score and severity. Three clusters assessing the risk of postoperative events were defined: low, intermediate, and high risk of postoperative events. A total of 297 patients was included. The median length of hospital stay was 1 day (IQR1-2). Unplanned visits, readmissions, any complications, and serious complications occurred in 17.2%, 11.8%, 28.3%, and 5% of cases, respectively. We found a statistically significant correlation between the BETTY score and all endpoints analyzed (all p ≤ 0.01). A total of 275, 20, and 2 patients were classified as low-, intermediate-, and high-risk according to the BETTY scoring system, respectively. Compared with low-risk patients, patients at intermediate-risk were associated with worse outcomes for all endpoints analyzed (all p ≤ 0.04). Future studies, in various surgical subspecialties, are ongoing to confirm the usefulness of this easy-to-use score in routine.
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Affiliation(s)
- Michael Baboudjian
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France
- Department of Urology, North Hospital, Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille (APHM), 13007 Marseille, France
| | - Rawad Abou-Zahr
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France
| | - Bogdan Buhas
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France
| | - Alae Touzani
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France
| | | | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France
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Rajendran L, Choi WJ, Muaddi H, Ivanics T, Feld JJ, Claasen MPAW, Castelo M, Sapisochin G. Association of Viral Hepatitis Status and Post-hepatectomy Outcomes in the Era of Direct-Acting Antivirals. Ann Surg Oncol 2023; 30:2793-2802. [PMID: 36515750 DOI: 10.1245/s10434-022-12937-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The role of viral hepatitis status in post-hepatectomy outcomes has yet to be delineated. This large, multicentred contemporary study aimed to evaluate the effect of viral hepatitis status on 30-day post-hepatectomy complications in patients treated for hepatocellular carcinoma (HCC). METHODS Patients from the National Surgical Quality Improvement Program (NSQIP) database with known viral hepatitis status, who underwent hepatectomy for HCC between 2014 and 2018, were included. Patients were classified as HBV-only, HCV-only, HBV and HCV co-infection (HBV/HCV), or no viral hepatitis (NV). Multivariable models were used to assess outcomes of interest. The primary outcome was any 30-day post-hepatectomy complication. The secondary outcomes were major complications and post-hepatectomy liver failure (PHLF). Subgroup analyses were performed for cirrhotic and noncirrhotic patients. RESULTS A total of 3234 patients were included. The 30-day complication rate was 207/663 (31.2%) HBV, 356/1077 (33.1%) HCV, 29/81 (35.8%) HBV/HCV, and 534/1413 (37.8%) NV (p = 0.01). On adjusted analysis, viral hepatitis status was not associated with occurrence of any 30-day post-hepatectomy complications (ref: NV, HBV odds ratio (OR) 0.89 [95% confidence interval (CI): 0.71-1.12]; HCV OR 0.91 [95% CI: 0.75-1.10]; HBV/HCV OR 1.17 [95% CI: 0.71-1.93]). Similar results were found in cirrhotic and noncirrhotic subgroups, and for secondary outcomes: occurrence of any major complications and PHLF. CONCLUSIONS In patients with HCC managed with resection, viral hepatitis status is not associated with 30-day post-hepatectomy complications, major complications, or PHLF compared with NV. This suggests that clinical decisions and prognostication of 30-day outcomes in this population likely should not be made based on viral hepatitis status.
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Affiliation(s)
- Luckshi Rajendran
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Woo Jin Choi
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hala Muaddi
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
- Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Marco P A W Claasen
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Matthew Castelo
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada.
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.
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Mason EM, Henderson WG, Bronsert MR, Colborn KL, Dyas AR, Madsen HJ, Lambert-Kerzner A, Meguid RA. Preoperative Prediction of Unplanned Reoperation in a Broad Surgical Population. J Surg Res 2023; 285:1-12. [PMID: 36640606 PMCID: PMC9975057 DOI: 10.1016/j.jss.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 11/07/2022] [Accepted: 12/24/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Unplanned reoperation is an undesirable outcome with considerable risks and an increasingly assessed quality of care metric. There are no preoperative prediction models for reoperation after an index surgery in a broad surgical population in the literature. The Surgical Risk Preoperative Assessment System (SURPAS) preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict unplanned reoperation has not been assessed. This study's objective was to determine whether the SURPAS model could accurately predict unplanned reoperation. METHODS This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database, 2012-2018. An unplanned reoperation was defined as any unintended operation within 30 d of an initial scheduled operation. The 8-variable SURPAS model and a 29-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program nonlaboratory preoperative variables, were developed using multiple logistic regression and compared using discrimination and calibration metrics: C-indices (C), Hosmer-Lemeshow observed-to-expected plots, and Brier scores (BSs). The internal chronological validation of the SURPAS model was conducted using "training" (2012-2017) and "test" (2018) datasets. RESULTS Of 5,777,108 patients, 162,387 (2.81%) underwent an unplanned reoperation. The SURPAS model's C-index of 0.748 was 99.20% of that for the full model (C = 0.754). Hosmer-Lemeshow plots showed good calibration for both models and BSs were similar (BS = 0.0264, full; BS = 0.0265, SURPAS). Internal chronological validation results were similar for the training (C = 0.749, BS = 0.0268) and test (C = 0.748, BS = 0.0250) datasets. CONCLUSIONS The SURPAS model accurately predicted unplanned reoperation and was internally validated. Unplanned reoperation can be integrated into the SURPAS tool to provide preoperative risk assessment of this outcome, which could aid patient risk education.
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Affiliation(s)
- Emily M Mason
- Clinical Science Program, University of Colorado Anschutz Medical Campus, Graduate School, Colorado Clinical and Translational Sciences Institute, Aurora, Colorado; Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado
| | - William G Henderson
- Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado
| | - Michael R Bronsert
- Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado
| | - Kathryn L Colborn
- Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado
| | - Adam R Dyas
- Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado
| | - Helen J Madsen
- Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado
| | - Anne Lambert-Kerzner
- Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado
| | - Robert A Meguid
- Department of Surgery, Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado.
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Koretsky MJ, Brovman EY, Urman RD, Tsai MH, Cheney N. A machine learning approach to predicting early and late postoperative reintubation. J Clin Monit Comput 2023; 37:501-508. [PMID: 36057069 DOI: 10.1007/s10877-022-00908-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022]
Abstract
Accurate estimation of surgical risks is important for informing the process of shared decision making and informed consent. Postoperative reintubation (POR) is a severe complication that is associated with postoperative morbidity. Previous studies have divided POR into early POR (within 72 h of surgery) and late POR (within 30 days of surgery). Using data provided by American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), machine learning classification models (logistic regression, random forest classification, and gradient boosting classification) were utilized to develop scoring systems for the prediction of combined, early, and late POR. The risk factors included in each scoring system were narrowed down from a set of 37 pre and perioperative factors. The scoring systems developed from the logistic regression models demonstrated strong performance in terms of both accuracy and discrimination across the different POR outcomes (Average Brier score, 0.172; Average c-statistic, 0.852). These results were only marginally worse than prediction using the full set of risk variables (Average Brier score, 0.145; Average c-statistic, 0.870). While more work needs to be done to identify clinically relevant differences between the early and late POR outcomes, the scoring systems provided here can be used by surgeons and patients to improve the quality of care overall.
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Affiliation(s)
- Mathew J Koretsky
- College of Engineering and Mathematical Sciences, University of Vermont, 82 University Place, Burlington, VT, 05405, USA.
| | - Ethan Y Brovman
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Mitchell H Tsai
- Department of Orthopedics and Rehabilitation, Department of Surgery, University of Vermont Larner College of Medicine, 111 Colchester Avenue, Burlington, VT, 05401, USA
| | - Nick Cheney
- Department of Computer Science, University of Vermont, 82 University Place, Burlington, VT, 05405, USA
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Sahara K, Ruff SM, Miyake K, Toyoda J, Yabushita Y, Homma Y, Kumamoto T, Matsuyama R, Endo I, Pawlik TM. Trends and Variations in Drain Use Following Pancreatoduodenectomy: Is Early Drain Removal Becoming More Common? World J Surg 2023; 47:1772-1779. [PMID: 37000199 DOI: 10.1007/s00268-023-06966-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Although previous studies have noted the potential benefit of early drain removal (EDR) after pancreatoduodenectomy (PD), there is a paucity of data on the timing of drain removal utilizing a national database that reflect the "real world" setting. Given the ongoing controversy related to PD drain use and management, we sought to define trends in drain use among a large national cohort, as well as identify factors associated with EDR following PD. METHODS The ACS NSQIP targeted pancreatectomy database was used to identify patients who underwent PD between 2014 and 2020. The trend in proportion of patients with EDR (removal ≤ POD3) as well as predictors of EDR were assessed. Risk-adjusted postoperative outcomes were evaluated by multivariable regression analysis. RESULTS Among 14,356 patients, 16.2% of patients (N = 2324) experienced EDR, and the proportion of patients with EDR increased by 68% over the study period (2014: 10.9% vs. 2020: 18.3%, p < 0.001). Higher drain fluid amylase on POD1-3 [LogWorth (LW) = 44.3], operative time (LW = 33.2), and use of minimally invasive surgery (LW = 14.0) were associated with EDR. Additionally, EDR was associated with decreased risk of overall and serious morbidity, PD-related morbidity (e.g., pancreatic fistula), reoperation, prolonged length of stay and readmission (all p < 0.05). CONCLUSIONS Routine drain placement remains a common practice among most surgeons. EDR following PD increased over time was associated with lower post-operative complications and shorter LOS. Despite evidence that EDR was safe and may even be associated with lower complications, only 1 in 6 patients were managed with EDR.
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Affiliation(s)
- Kota Sahara
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
- Department of Surgery, Saiseikai Yokohamashi Nanbu Hospital, 3 Chome-2-10 Konandai, Konan Ward, Yokohama, Kanagawa, 234-0054, Japan
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave, Columbus, OH, 43210, USA
| | - Samantha M Ruff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave, Columbus, OH, 43210, USA
| | - Kentaro Miyake
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Junya Toyoda
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave, Columbus, OH, 43210, USA.
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Moazzam Z, Lima HA, Endo Y, Alaimo L, Ejaz A, Dillhoff M, Cloyd J, Pawlik TM. The implications of fragmented practice in hepatopancreatic surgery. Surgery 2023; 173:1391-1397. [PMID: 36907781 DOI: 10.1016/j.surg.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/09/2023] [Accepted: 02/06/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an "optimal" postoperative course. METHODS Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon's volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression. RESULTS A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84-0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54-0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52-0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52-0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54-0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12-1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28-1.46]). CONCLUSION Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/ZoraysM
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/HLimaSurg
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/YutakaEndoSurg
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/LauraAlaimo5
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/AEjaz85
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/mary_dillhoff
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/jcloydmd
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Chakraborty N, Rhodes S, Luchristt D, Bretschneider CE, Sheyn D. Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy? Am J Obstet Gynecol 2023; 228:205.e1-205.e12. [PMID: 36202231 DOI: 10.1016/j.ajog.2022.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/18/2022] [Accepted: 09/28/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND It is well known that, in general, total laparoscopic hysterectomy is associated with less perioperative morbidity compared with total abdominal hysterectomy. However, total laparoscopic hysterectomy is also associated with longer operating times, which itself is an independent predictor of morbidity. Currently, it is unknown whether there is an operative time threshold beyond which total laparoscopic hysterectomy provides a diminishing return and higher risk of morbidity than a shorter abdominal hysterectomy. OBJECTIVE This study aimed to determine whether there is an operative time limit beyond which the benefits of total laparoscopic hysterectomy diminished compared with shorter total abdominal hysterectomy. STUDY DESIGN Targeted hysterectomy-specific data from the National Surgical Quality Improvement Project was used to identify patients undergoing total laparoscopic hysterectomy and total abdominal hysterectomy for benign indications between the years 2014 and 2018. The primary outcomes of interest were any major morbidity, and the length of stay after surgery was analyzed using generalized linear models. The models controlled for demographic data, comorbidities, and hysterectomy-specific information, such as uterine weight, presence of endometriosis, and pelvic inflammatory disease at the time of surgery. Missing data were addressed using multiple imputation analysis. Sensitivity analyses using propensity score matching and generalized additive models were performed to assess the effect of selection bias and nonlinear interactions between covariates and the outcomes, respectively. Common Procedural Terminology codes were used to identify women who underwent total abdominal hysterectomy (n=58,152) or total laparoscopic hysterectomy (n=58,570-58,573). Conventional laparoscopy could not be differentiated from robotic surgery as there is no mechanism for doing so within the National Surgical Quality Improvement Project. Therefore, total laparoscopic hysterectomy also includes robotic-assisted surgery. Additional exclusion criteria included any surgery lasting >360 minutes, as these represent significant outliers in the data and clinical practice; pelvic reconstructive procedure; anti-incontinence surgery; lymphadenectomy; radical hysterectomy; cytoreductive surgery; a pre- or postoperative diagnostic code for gynecologic malignancy; preoperative sepsis or renal failure; emergency surgery; or any concurrent nongynecologic surgery. Patients who underwent ureteral stenting during the procedure with no additional urologic procedures were included, as this may be performed at the time of hysterectomy or to address ureteral injury. RESULTS The mean operating time was similar for both routes, 129±60 minutes for total laparoscopic hysterectomy and 129±64 minutes for total abdominal hysterectomy (P=.45). The complication rate was higher for total abdominal hysterectomy than total laparoscopic hysterectomy (16.6% vs 7.7%; P<.001); and the median length of stay was longer for total abdominal hysterectomy (2 [interquartile range, 2-3] days vs 1 [interquartile range, 0-1] days; P<.001). After adjusting for confounders, an increase of 1 hour in operative time for hysterectomy was associated with a 45% (95% confidence interval, 41%-49%) increase in the risk of major morbidity; furthermore, total abdominal hysterectomy was associated with an additional time detriment, such that there was an additional 61% (95% confidence interval, 53%-68%) increase in the risk of a major morbidity for each additional hour of a total abdominal hysterectomy. There was no time point at which total abdominal hysterectomy was associated with less morbidity or a shorter length of stay than total laparoscopic hysterectomy, even if total laparoscopic hysterectomy was significantly longer than total abdominal hysterectomy. The same conclusions remained true with the propensity-matched analysis and generalized additive model analyses. CONCLUSION Our findings showed that there is no reasonable operative time at which total laparoscopic hysterectomy is associated with a higher rate of complications or longer length of stay than total abdominal hysterectomy.
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Affiliation(s)
- Natalie Chakraborty
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland OH; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Stephen Rhodes
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland OH
| | - Douglas Luchristt
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - C Emi Bretschneider
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland OH.
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Karabacak M, Margetis K. A Machine Learning-Based Online Prediction Tool for Predicting Short-Term Postoperative Outcomes Following Spinal Tumor Resections. Cancers (Basel) 2023; 15:cancers15030812. [PMID: 36765771 PMCID: PMC9913622 DOI: 10.3390/cancers15030812] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Background: Preoperative prediction of short-term postoperative outcomes in spinal tumor patients can lead to more precise patient care plans that reduce the likelihood of negative outcomes. With this study, we aimed to develop machine learning algorithms for predicting short-term postoperative outcomes and implement these models in an open-source web application. Methods: Patients who underwent surgical resection of spinal tumors were identified using the American College of Surgeons, National Surgical Quality Improvement Program. Three outcomes were predicted: prolonged length of stay (LOS), nonhome discharges, and major complications. Four machine learning algorithms were developed and integrated into an open access web application to predict these outcomes. Results: A total of 3073 patients that underwent spinal tumor resection were included in the analysis. The most accurately predicted outcomes in terms of the area under the receiver operating characteristic curve (AUROC) was the prolonged LOS with a mean AUROC of 0.745 The most accurately predicting algorithm in terms of AUROC was random forest, with a mean AUROC of 0.743. An open access web application was developed for getting predictions for individual patients based on their characteristics and this web application can be accessed here: huggingface.co/spaces/MSHS-Neurosurgery-Research/NSQIP-ST. Conclusion: Machine learning approaches carry significant potential for the purpose of predicting postoperative outcomes following spinal tumor resections. Development of predictive models as clinically useful decision-making tools may considerably enhance risk assessment and prognosis as the amount of data in spinal tumor surgery continues to rise.
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Tran KS, Issa TZ, Lee Y, Lambrechts MJ, Nahi S, Hiranaka C, Tokarski A, Lambo D, Adler B, Kaye ID, Rihn JA, Woods BI, Canseco JA, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. Impact of Prolonged Operative Duration on Postoperative Symptomatic Venous Thromboembolic Events After Thoracolumbar Spine Surgery. World Neurosurg 2023; 169:e214-e220. [PMID: 36323348 DOI: 10.1016/j.wneu.2022.10.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion. METHODS We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE. RESULTS We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event. CONCLUSIONS Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.
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Affiliation(s)
- Khoa S Tran
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Skylar Nahi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cannon Hiranaka
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Andrew Tokarski
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dominic Lambo
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Blaire Adler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Rihn
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Hsiao V, Kazaure HS, Drake FT, Inabnet WB, Rosen JE, Davenport DL, Schneider DF. A comparison of NSQIP and CESQIP in data quality and ability to predict thyroidectomy outcomes. Surgery 2023; 173:215-225. [PMID: 36402607 DOI: 10.1016/j.surg.2022.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/22/2022] [Accepted: 05/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Collaborative Endocrine Surgery Quality Improvement Program tracks thyroidectomy outcomes with self-reported data, whereas the National Surgical Quality Improvement Program uses professional abstractors. We compare completeness and predictive ability of these databases at a single-center and national level. METHOD Data consistency in the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program at a single institution (2013-2020) was evaluated using McNemar's test. At the national level, data from the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program (2016-2019) were used to compare predictive capability for 4 outcomes within each data source: thyroidectomy-specific complication, systemic complication, readmission, and reoperation, as measured by area under curve. RESULTS In the single-center analysis, 66 cases were recorded in both the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program. The reoperation variable had the most discrepancies (2 vs 0 in the National Surgical Quality Improvement Program versus the Collaborative Endocrine Surgery Quality Improvement Program, respectively; χ2 = 2.00, P = .16). At the national level, there were 24,942 cases in the National Surgical Quality Improvement Program and 17,666 cases in the Collaborative Endocrine Surgery Quality Improvement Program. In the National Surgical Quality Improvement Program, 30-day thyroidectomy-specific complication, systemic complication, readmission, and reoperation were 13.25%, 2.13%, 1.74%, and 1.39%, respectively, and in the Collaborative Endocrine Surgery Quality Improvement Program 7.27%, 1.95%, 1.64%, and 0.81%. The area under curve of the National Surgical Quality Improvement Program was higher for predicting readmission (0.721 [95% confidence interval 0.703-0.737] vs 0.613 [0.581-0.649]); the area under curve of the Collaborative Endocrine Surgery Quality Improvement Program was higher for thyroidectomy-specific complication (0.724 [0.708-0.737] vs 0.677 [0.667-0.687]) and reoperation (0.735 [0.692-0.775] vs 0.643 [0.611-0.673]). Overall, 3.44% vs 27.22% of values were missing for the National Surgical Quality Improvement Program and the Collaborative Endocrine Surgery Quality Improvement Program, respectively. CONCLUSION The Collaborative Endocrine Surgery Quality Improvement Program was more accurate in predicting thyroidectomy-specific complication and reoperation, underscoring its role in collecting granular, disease-specific variables. However, a higher proportion of data are missing. The National Surgical Quality Improvement Program infrastructure leads to more rigorous data capture, but the Collaborative Endocrine Surgery Quality Improvement Program is better at predicting thyroid-specific outcomes.
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Affiliation(s)
- Vivian Hsiao
- Department of Surgery, University of Wisconsin-Madison, Madison, WI.
| | - Hadiza S Kazaure
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Frederick T Drake
- Department of Endocrine Surgery, Boston Medical Center, Boston, Massachusetts
| | | | | | | | - David F Schneider
- Department of Surgery, University of Wisconsin-Madison, Madison, WI; Division of Endocrine Surgery, University of Wisconsin-Madison, Madison, WI
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Franklin CDH, House AK, Pfeiffer CN. Complications and postoperative non-steroidal anti-inflammatory use of three extracapsular cruciate ligament repair techniques performed in a general practice clinic environment. J Small Anim Pract 2023; 64:21-30. [PMID: 36324226 DOI: 10.1111/jsap.13557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To report complications and postoperative non-steroidal anti-inflammatory use associated with fabellotibial suture, Tightrope and Ligafiba Isotoggle procedures performed on dogs of varying weights within a general practice setting. MATERIALS AND METHODS Clinical records of eligible patients from 2009 to 2018 were retrospectively extracted from five general practice clinics. Data for signalment, patient weight, surgery performed, complications, postoperative use of non-steroidal anti-inflammatory drugs, and timing thereof were extracted and analysed using multinomial logistic regression. Predicted probability tables were generated for complications and non-steroidal anti-inflammatory drug use. RESULTS The study included 370 surgeries, with 97 fabellotibial suture, 158 Tightrope and 42 Ligafiba Isotoggle procedures in patients less than 15 kg, and 43 fabellotibial suture, 16 Tightrope and 30 Ligafiba Isotoggle procedures in patients at least 15 kg. The proportion of patients that can be expected to have no complications was greatest for older dogs (9 years) weighing less than 15 kg (fabellotibial suture, 91%; Tightrope/Ligafiba Isotoggle, 88%), and the highest major medical and surgical complication risks were expected in young dogs (1 year) weighing over 15 kg (fabellotibial suture, 28%; Tightrope/Ligafiba Isotoggle, 59%). The predicted risk of requiring repeated non-steroidal anti-inflammatory drug prescriptions in the 18-month postoperative period for an 15 kg patient was 37% to 39%. CONCLUSION Weight and age were significant factors influencing complications and postoperative non-steroidal anti-inflammatory drug use in fabellotibial suture, Tightrope and Ligafiba Isotoggle surgical patients in a general practice setting. CLINICAL SIGNIFICANCE Clinicians should consider the possibility of complications and requirement for ongoing non-steroidal anti-inflammatory drug use before performing extracapsular procedures in patients weighing more than 15 kg.
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Affiliation(s)
- C D H Franklin
- Peninsula Vet Emergency and Referral Hospital, Mornington, Australia
| | - A K House
- Peninsula Vet Emergency and Referral Hospital, Mornington, Australia
| | - C N Pfeiffer
- Melbourne Veterinary School, University of Melbourne, Parkville, Australia
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Bronsert MR, Henderson WG, Colborn KL, Dyas AR, Madsen HJ, Zhuang Y, Lambert-Kerzner A, Meguid RA. Effect of Present at Time of Surgery on Unadjusted and Risk-Adjusted Postoperative Complication Rate. J Am Coll Surg 2023; 236:7-15. [PMID: 36519901 PMCID: PMC10204068 DOI: 10.1097/xcs.0000000000000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Present at the time of surgery (PATOS) is an important measure to collect in postoperative complication surveillance systems because it may affect a patient's risk of a subsequent complication and the estimation of postoperative complication rates attributed to the healthcare system. The American College of Surgeons (ACS) NSQIP started collecting PATOS data for 8 postoperative complications in 2011, but no one has used these data to quantify how this may affect unadjusted and risk-adjusted postoperative complication rates. STUDY DESIGN This study was a retrospective observational study of the ACS NSQIP database from 2012 to 2018. PATOS data were analyzed for the 8 postoperative complications of superficial, deep, and organ space surgical site infection; pneumonia; urinary tract infection; ventilator dependence; sepsis; and septic shock. Unadjusted postoperative complication rates were compared ignoring PATOS vs taking PATOS into account. Observed to expected ratios over time were also compared by calculating expected values using multiple logistic regression analyses with complication as the dependent variable and the 28 nonlaboratory preoperative variables in the ACS NSQIP database as the independent variables. RESULTS In 5,777,108 patients, observed event rates for each outcome were reduced by between 6.1% (superficial surgical site infection) and 52.5% (sepsis) when PATOS was taken into account. The observed to expected ratios were similar each year for all outcomes, except for sepsis and septic shock in the early years. CONCLUSIONS Taking PATOS into account is important for reporting unadjusted event rates. The effect varied by type of complication-lowest for superficial surgical site infection and highest for sepsis and septic shock. Taking PATOS into account was less important for risk-adjusted outcomes (observed to expected ratios), except for sepsis and septic shock.
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Affiliation(s)
- Michael R Bronsert
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science (Bronsert, Henderson, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
| | - William G Henderson
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science (Bronsert, Henderson, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- the Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO (Henderson, Colborn, Zhuang, Meguid)
| | - Kathryn L Colborn
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Department of Surgery (Colborn, Dyas, Madsen, Zhuang, Meguid), University of Colorado School of Medicine, Aurora, CO
- the Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO (Henderson, Colborn, Zhuang, Meguid)
| | - Adam R Dyas
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Department of Surgery (Colborn, Dyas, Madsen, Zhuang, Meguid), University of Colorado School of Medicine, Aurora, CO
| | - Helen J Madsen
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Department of Surgery (Colborn, Dyas, Madsen, Zhuang, Meguid), University of Colorado School of Medicine, Aurora, CO
| | - Yaxu Zhuang
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Department of Surgery (Colborn, Dyas, Madsen, Zhuang, Meguid), University of Colorado School of Medicine, Aurora, CO
- the Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO (Henderson, Colborn, Zhuang, Meguid)
| | - Anne Lambert-Kerzner
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science (Bronsert, Henderson, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
| | - Robert A Meguid
- From the Surgical Outcomes and Applied Research Program (Bronsert, Henderson, Colborn, Dyas, Madsen, Zhuang, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science (Bronsert, Henderson, Lambert-Kerzner, Meguid), University of Colorado School of Medicine, Aurora, CO
- Department of Surgery (Colborn, Dyas, Madsen, Zhuang, Meguid), University of Colorado School of Medicine, Aurora, CO
- the Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO (Henderson, Colborn, Zhuang, Meguid)
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Collins CR, Abel MK, Shui A, Intinarelli G, Sosa JA, Wick EC. Preparing for participation in the centers for Medicare and Medicaid Services' bundle care payment initiative-advanced for major bowel surgery. Perioper Med (Lond) 2022; 11:54. [PMID: 36494765 PMCID: PMC9733045 DOI: 10.1186/s13741-022-00286-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND As healthcare costs rise, there is an increasing emphasis on alternative payment models to improve care efficiency. The bundled payment represents an alternative reimbursement model gaining popularity within the surgical sphere. We aimed to assess where the largest opportunities for care improvement lay and how best to identify patients at high risk of suffering costly complications. METHODS We utilized itemized CMS claims data for a retrospective cohort of patients between 2014 and 2016 who met inclusion criteria for the Major Bowel Bundled Payment Program and performed a cost analysis to identify opportunities for improved care efficiency. Based on the results of this cost analysis, we identified readmissions as a target for improvement. We then assessed whether the American College of Surgeons' National Surgical Quality Improvement Program surgical risk calculator (ACS NSQIP SRC) could accurately identify patients within our bundled payment population who were at high risk of readmission using a logistic regression model. RESULTS Our study cohort included 252 patients. Readmissions accounted for 12.8% of the average total care episode cost with a coefficient of variation of 2.72, thereby representing the most substantial, non-fixed cost for our bundled payment patients. Patients readmitted within their 90-day care episode were 2.53 times more likely to be high-cost (>$60,000) than patients not readmitted. However, the ACS NSQIP SRC did not accurately predict patients at high risk of readmission within the first 30 days with an AUROC of 0.58. CONCLUSIONS Our study highlights the importance of reducing readmissions as a central component of improving care for bowel surgery bundled payment patients. Preventing such readmissions requires accurate identification of patients at high risk of readmission; however, current risk prediction models lack the adaptability necessary for this task.
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Affiliation(s)
- Caitlin R. Collins
- grid.266102.10000 0001 2297 6811Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA 94143 USA
| | - Mary Kathryn Abel
- grid.266102.10000 0001 2297 6811School of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Amy Shui
- grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA USA
| | - Gina Intinarelli
- grid.266102.10000 0001 2297 6811Office of Population Health, University of California, San Francisco, San Francisco, CA USA
| | - Julie Ann Sosa
- grid.266102.10000 0001 2297 6811Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA 94143 USA
| | - Elizabeth C. Wick
- grid.266102.10000 0001 2297 6811Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA 94143 USA
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Boddapati V, Lee NJ, Mathew J, Held MB, Peterson JR, Vulapalli MM, Lombardi JM, Dyrszka MD, Sardar ZM, Lehman RA, Riew KD. Respiratory Compromise After Anterior Cervical Spine Surgery: Incidence, Subsequent Complications, and Independent Predictors. Global Spine J 2022; 12:1647-1654. [PMID: 33406919 PMCID: PMC9609542 DOI: 10.1177/2192568220984469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Respiratory compromise (RC) is a rare but catastrophic complication of anterior cervical spine surgery (ACSS) commonly due to compressive fluid collections or generalized soft tissue swelling in the cervical spine. Established risk factors include operative duration, size of surgical exposure, myelopathy, among others. The purpose of this current study is to identify the incidence and clinical course of patients who develop RC, and identify independent predictors of RC in patients undergoing ACSS for cervical spondylosis. METHODS A large, prospectively-collected registry was used to identify patients undergoing ACSS for spondylosis. Patients with posterior cervical procedures were excluded. Baseline patient characteristics were compared using bivariate analysis, and multivariate analysis was employed to compare postoperative complications and identify independent predictors of RC. RESULTS 298 of 52,270 patients developed RC (incidence 0.57%). Patients who developed RC had high rates of 30-day mortality (11.7%) and morbidity (75.8%), with unplanned reoperation and pneumonia the most common. The most common reason for reoperations were hematoma evacuation and tracheostomy. Independent patient-specific factors predictive of RC included increasing patient age, male gender, comorbidities such as chronic cardiac and respiratory disease, preoperative myelopathy, prolonged operative duration, and 2-level ACCFs. CONCLUSION This is among the largest cohorts of patients to develop RC after ACSS identified to-date and validates a range of independent predictors, many previously only described in case reports. These results are useful for taking preventive measures, identifying high risk patients for preoperative risk stratification, and for surgical co-management discussions with the anesthesiology team.
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Affiliation(s)
- Venkat Boddapati
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA,Venkat Boddapati, Columbia University Irving
Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA.
| | - Nathan J. Lee
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Mathew
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Michael B. Held
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Joel R. Peterson
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Meghana M. Vulapalli
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph M. Lombardi
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Marc D. Dyrszka
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Zeeshan M. Sardar
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Ronald A. Lehman
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - K. Daniel Riew
- The Spine Hospital, New
York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
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Huttler A, Hong C, Shah DK. Racial and ethnic disparities in the surgical management of tubal ectopic pregnancy. F S Rep 2022; 3:311-316. [PMID: 36568938 PMCID: PMC9783145 DOI: 10.1016/j.xfre.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 12/27/2022] Open
Abstract
Objective To evaluate racial and ethnic disparities in the surgical management of ectopic pregnancy over time. Design Retrospective cohort study. Setting None. Patients Surgically-managed cases of patients with tubal ectopic pregnancy within the American College of Surgeons National Surgical Quality Improvement Program database between 2010 and 2019. Interventions None. Main outcome measures Surgical approach (laparoscopic compared with open) and procedure (salpingectomy compared with salpingostomy/other). Results Of 7791 patients undergoing surgical management of tubal ectopic pregnancy, 21.8% identified as Hispanic, 24.5% as Black, 9.4% as Asian/other, and 44.3% as White. Use of laparoscopy increased 1.3% per year from 81.4% in 2010 to 91.0% in 2019 (95% confidence interval [CI], 0.010-0.016). Odds of undergoing laparoscopic surgery were lower in Black (adjusted odds ratio [aOR] 0.52; 95% CI, 0.45-0.61) and Hispanic patients (aOR 0.52; 95% CI, 0.44-0.61) compared with White patients and remained similar over time. The use of salpingectomy increased by 1.1% per year from 80.6% in 2010 to 94.7% in 2019 (95% CI, 0.009-0.014). Odds of undergoing salpingectomy were higher among Black (aOR 1.78, 95% CI 1.43-2.23) and Hispanic patients (aOR 1.54; 95% CI, 1.24-1.93) and lower among Asian patients (aOR 0.73, 95% CI, 0.56-0.95) compared with White patients. These ratios remained similar for Black and Asian patients over time. Conclusions Despite the increased use of laparoscopy and salpingectomy in the surgical management of ectopic pregnancy over time, Black and Hispanic patients remain less likely to undergo minimally invasive surgery and more likely to undergo salpingectomy compared with White patients.
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Affiliation(s)
- Alexandra Huttler
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania,Reprint requests: Alexandra Huttler, M.D., Department of Obstetrics and Gynecology, Pennsylvania Hospital, 2 Pine East 800 Spruce Street, Philadelphia, Pennsylvania 19107
| | - Christopher Hong
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania,Division of Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Divya Kelath Shah
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, Pennsylvania
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Choi WJ, Ivanics T, Claasen MPAW, Gallinger S, Hansen B, Sapisochin G. Is it safe to administer neoadjuvant chemotherapy to patients undergoing hepatectomy for intrahepatic cholangiocarcinoma? ACS-NSQIP propensity-matched analysis. HPB (Oxford) 2022; 24:1535-1542. [PMID: 35474005 DOI: 10.1016/j.hpb.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/11/2022] [Accepted: 03/14/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of neoadjuvant chemotherapy (NAC) in patients with intrahepatic cholangiocarcinoma (iCCA) is increasing. The objective of this study was to compare the 30-day post-operative complications and length-of-stay (LOS) between patients undergoing hepatectomy for iCCA with and without NAC. METHODS A retrospective study was conducted using the ACS-NSQIP database queried from 2014 to 2018. Patients with NAC receipt were propensity-score matched into 1:3 ratio with controls using the greedy-matching algorithm and a caliper of 0.2. Logistic and Poisson regression models were used to estimate the effect sizes. RESULTS A total of 1508 patients who underwent hepatectomy for iCCA were included. 706 patients remained after matching and balance were achieved. The NAC group had 110 (60.1%) complications vs. 289 (55.3%) complications in the non-NAC group (p = 0.29). NAC was not associated with worse 30-day postoperative complications [OR 1.24, 95% CI: 0.87-1.76; p = 0.24]. Post-operative LOS in the NAC group was 8.56 days (mean, SD 7.4) vs. non-NAC group 9.27 days (mean, SD 8.41, p = 0.32). NAC was not associated with longer post-operative LOS [RR 0.93, 95% CI:0.80, 1.08; p = 0.32]. CONCLUSION NAC may be safely administered without increasing the risk of 30-day complications or post-operative hospital LOS.
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Affiliation(s)
- Woo Jin Choi
- University of Toronto, Department of General Surgery, Toronto, Canada; University Health Network, HPB Surgical Oncology, Toronto, Canada
| | - Tommy Ivanics
- University Health Network, HPB Surgical Oncology, Toronto, Canada; Department of Surgery, Henry Ford Hospital, Detroit, MI, USA; Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Marco P A W Claasen
- University Health Network, HPB Surgical Oncology, Toronto, Canada; Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Steven Gallinger
- University of Toronto, Department of General Surgery, Toronto, Canada; University Health Network, HPB Surgical Oncology, Toronto, Canada
| | - Bettina Hansen
- University Health Network, Center for Liver Disease, Toronto, Canada
| | - Gonzalo Sapisochin
- University of Toronto, Department of General Surgery, Toronto, Canada; University Health Network, HPB Surgical Oncology, Toronto, Canada.
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Ghannam AD, Crandall ML, Woodruff G, Ra J, Kerwin AJ, Awad ZT, Tepas J. National Surgical Quality Improvement Program Adverse Events Combined With Clavien-Dindo Scores Can Direct Quality Improvement Processes in Surgical Patients. J Patient Saf 2022; 18:e900-e902. [PMID: 35135982 DOI: 10.1097/pts.0000000000000987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The burden of postoperative adverse events (AE) weighs immediately on the patient as unanticipated stress and on the healthcare system as unreimbursed cost. Applying the Clavien-Dindo (C-D) system of AE gradation as a surrogate of cost, we analyzed 4 years' data from a single-state National Surgical Quality Improvement Program (NSQIP) collaboration, hypothesizing that trends of AE were consistent over time and that more frequently performed cases would be associated with less and more minor AE. METHODS The NSQIP defined AEs, consisting of 21 listed postoperative occurrences, which were analyzed using deidentified 30-day postoperative data for 2015 to 2018. Each AE was graded using (C-D) severity (1, lowest; 4, highest with survival). The C-D severity weight, as defined in previous multi-institutional studies, was used as a surrogate for cost and unplanned patient burden. Adverse event incidence was calculated as sum AE/case volume, and population burden as total AE burden/case volume. RESULTS There were 12,567 surgical cases recorded by members of the state collaborative. The overall data demonstrated no significant difference in AE incidence; however, the burden of AE increased by 18.8%. The 8 most common Current Procedural Terminology codes had approximately 50% lower AE incidence compared with overall cases; however, the incidence increased by 56.0% and the AE burden/case increased by 48.0%. CONCLUSIONS Although the 8 most common Current Procedural Terminology codes showed a 50% lower AE incidence compared with overall cases, the incidence increased over the study period. Surgical quality initiatives should be patient centered and focus on high burden AE.
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Affiliation(s)
- Alexander D Ghannam
- From the Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Marie L Crandall
- From the Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Grant Woodruff
- From the Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Jin Ra
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Andrew J Kerwin
- From the Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Ziad T Awad
- From the Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Joseph Tepas
- From the Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
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Frailty Is Superior to Age for Predicting Readmission, Prolonged Length of Stay, and Wound Infection in Elective Otology Procedures. Otol Neurotol 2022; 43:937-943. [PMID: 35970157 DOI: 10.1097/mao.0000000000003636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the predictive ability of the 5-point modified frailty index relative to age in elective otology patients. STUDY DESIGN Retrospective database analysis. SETTING Multicenter, national database of surgical patients. PATIENTS We selected all elective surgical patients who received tympanoplasty, tympanomastoidectomy, mastoidectomy, revision mastoidectomy, and cochlear implant procedures from 2016 to 2019 from the National Surgical Quality Improvement database. INTERVENTIONS Therapeutic. MAIN OUTCOME MEASURES Readmission rates, discharge disposition, reoperation rates, and extended length of hospital stay. RESULTS Utilizing receiver operating characteristics with area under the curve (AUC) analysis, nonrobust status was determined to be a superior predictor relative to age of readmission (AUC = 0.628 [p < 0.001] versus AUC = 0.567 [p = 0.047], respectively) and open wound infection relative to age (AUC = 0.636 [p = 0.024] versus AUC = 0.619 [p = 0.048], respectively). Nonrobust otology patients were more likely to have dyspnea at rest and an American Society of Anesthesiology score higher than 2 before surgery (odds ratios, 13.304 [95% confidence interval, 2.947-60.056; p < 0.001] and 7.841 [95% confidence interval, 7.064-8.704; p < 0.001], respectively). CONCLUSION Nonrobust status was found to be a useful predictor of readmission and prolonged length of stay in patients undergoing elective otology procedures, which generally have low complication rate. Given the aging population and corresponding increase in otology disease, it is important to use age-independent risk stratification measures. Frailty may provide a useful risk stratification tool to select surgical candidates within the aging population.
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Wood MD, West NC, Sreepada R, Loftsgard KC, Petersen L, Robillard J, Page P, Ridgway R, Chadha NK, Portales-Casamar E, Görges M. Identifying risk factors, patient reported experience and outcome measures, and data capture tools for an individualized pain prediction tool in pediatrics: a focus group study (Preprint). JMIR Perioper Med 2022; 5:e42341. [DOI: 10.2196/42341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/05/2022] Open
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Li B, Eisenberg N, Howe KL, Forbes TL, Roche-Nagle G. The impact of sex on outcomes following carotid endarterectomy. Ann Vasc Surg 2022; 88:210-217. [PMID: 36029946 DOI: 10.1016/j.avsg.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Previous studies have demonstrated significant sex differences in vascular surgery outcomes. We assessed stroke or death rates following carotid endarterectomy (CEA) in women vs. men. METHODS The Vascular Quality Initiative (VQI) was used to identify all patients who underwent CEA between 2010-2019. Demographic, clinical, and procedural characteristics were recorded and differences between women vs. men were assessed using independent t-test and chi-square test. The primary outcomes were 30-day and 1-year stroke or death. Associations between sex and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis. RESULTS 52,137 women and 79,974 men underwent CEA in VQI sites during the study period. Women were younger (70.3 vs. 70.5 years, p < 0.001) and more likely to have hypertension (89.2% vs. 88.9%, p < 0.05) and diabetes (36.2% vs. 35.8%, p < 0.001), but less likely to be diagnosed with coronary artery disease (23.2% vs. 31.0%, p < 0.001). A greater proportion of men were receiving cardiovascular risk reduction medications and had symptomatic carotid stenosis (28.5% vs. 26.7%, p < 0.001). Women had shorter procedure times (113 vs. 122 minutes, p < 0.001) and were less likely to receive electroencephalography neuromonitoring (27.9% vs. 28.8%, p < 0.001), drain (35.9% vs. 37.3%, p < 0.001), and protamine (67.4% vs. 68.0%, p < 0.01). Stroke or death at 30 days (1.9% vs. 1.8%, p = 0.60) and 1 year (HR 0.98 [95% CI 0.94 - 1.01], p = 0.20) were similar between groups, which persisted in asymptomatic patients (HR 0.97 [95% CI 0.93 - 1.01], p = 0.17) and symptomatic patients (HR 0.99 [95% CI 0.93 - 1.05], p = 0.71). The similarities in 1-year stroke or death rates existed in both the US (HR 0.96 [95% CI 0.92 - 1.01], p = 0.09) and Canada (HR 1.21 [95% CI 0.47 - 3.11], p = 0.70). CONCLUSIONS Despite sex differences in clinical and procedural characteristics, women and men have similar 30-day and 1-year outcomes following carotid endarterectomy.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn L Howe
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Solano QP, Thumma JR, Mullens C, Howard R, Ehlers A, Delaney L, Fry B, Shen M, Englesbe M, Dimick J, Telem D. Variation of ventral and incisional hernia repairs in kidney transplant recipients. Surg Endosc 2022; 37:3173-3179. [PMID: 35962230 DOI: 10.1007/s00464-022-09505-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/23/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION As survivorship following kidney transplant continues to improve, so does the probability of intervening on common surgical conditions, such as ventral or incisional hernia, in this population. Ventral hernia management is known to vary across institutions and this variation has an impact on patient outcomes. We sought to evaluate hospital level variation of ventral or incisional hernia repair (VIHR) in the kidney transplant population. METHODS We performed a retrospective review of 100% inpatient Medicare claims to identify patients who underwent kidney transplant between 2007 and 2018. The primary outcome was 1- and 3-year ventral or incisional risk- and reliability-adjusted VIHR rates. Patient and hospital characteristics were evaluated across risk- and reliability-adjusted VIHR rate tertiles. Models were adjusted for age, sex, race, and Elixhauser comorbidities. RESULTS Overall, 139,741 patients underwent kidney transplant during the study period with a mean age (SD) of 51.6 (13.7) years. 84,717 (60.6%) were male, and 72,657 (52.0%) were white. Median follow up time was 5.4 years. 2098 (1.50%) patients underwent VIHR. the 1 year risk- and reliability-adjusted hernia repair rates were 0.49% (95% Conf idence Interval (CI) 0.48-0.51, range 0.31-0.59) in tertile 1, 0.63% (95% CI 0.62-0.63, range 0.59-0.68) in tertile 2, and 0.98 (95% CI 0.91-1.05, range 0.68-2.94) in tertile 3. Accordingly, compared to hospitals in tertile 1, the odds of post-transplant hernia repair tertile 2 hospitals were 1.78 (95% CI 1.37-2.31) and at tertile 3 hospitals 3.53 (95% CI 2.87-4.33). CONCLUSIONS In a large cohort of Medicare patients undergoing kidney transplant, the overall cumulative incidence of hernia repair varied substantially across hospital tertiles. Patient and hospital characteristics varied across tertile, most notably in diabetes and obesity. Future research is needed to understand if program and surgeon level factors are contributing to the observed variation in treatment of this common disease.
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Affiliation(s)
- Quintin P Solano
- University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Cody Mullens
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Howard
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne Ehlers
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lia Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian Fry
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mary Shen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA
| | - Dana Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. .,Department of Surgery, University of Michigan, Ann Arbor, MI, USA. .,Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA.
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Brajcich BC, Platoff RM, Thompson VM, Hall B, Ko CY, Pitt HA. Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes? HPB (Oxford) 2022; 24:1252-1260. [PMID: 35034836 DOI: 10.1016/j.hpb.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1). METHODS Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1. RESULTS POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84-14.73]) and C (68.0%, OR 10.50 [3.77-29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039). CONCLUSION POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.
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Affiliation(s)
- Brian C Brajcich
- American College of Surgeons, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | | | | | - Bruce Hall
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University in Saint Louis School of Medicine, and BJC Healthcare, St Louis, MO USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA, USA; The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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Look in the Mirror, Not Out the Window. ANNALS OF SURGERY OPEN 2022; 3:e184. [PMID: 36199485 PMCID: PMC9508963 DOI: 10.1097/as9.0000000000000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/14/2022] [Indexed: 11/26/2022] Open
Abstract
Over the past few decades, institutions have developed complex systems to compare themselves to others with the goal of improving healthcare quality. This process of comparison to others, called external benchmarking, has become the standard approach for quality improvement. However, external benchmarking is resource intensive, may not be flexible enough to focus on problems unique to individual institutions, and may lead to complacency for institutions ranking near the top of the quality bell curve for the measured metrics. Our singular focus on external benchmarking could also divert resources from other approaches. Here, we describe how the use of internal benchmarking, in which an institution focuses on improving their own processes over time, can offer unique advantages as well as offset the limitations of external benchmarking. We advocate for investment in both internal and external benchmarking as complimentary tools to improve healthcare quality. Mini-abstract: External benchmarking, the most common approach to benchmarking today, compares outcomes across a group to improve performance. This article discusses internal benchmarking, a complementary approach with several strengths—including reduced data burden, selection of tailored metrics, motivation to improve for all performers, and incentive to look inward for solutions.
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Szapary HJ, Monárrez R, Varady NH, Hanna P, Chen AF, Rodriguez EK. Complications and predictors of morbidity for hip fracture surgery in patients with chronic liver disease. Hip Int 2022:11207000221112923. [PMID: 35836328 DOI: 10.1177/11207000221112923] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the fact that patients with chronic liver disease (CLD) are at increased risk of complications after a fracture of the hip, there remains little information about the risk factors for acute postoperative complications and their overall outcome.The aim of this study was to describe inpatient postoperative complications and identify predictors of postoperative morbidity. METHODS Patients with CLD who had been treated for a fracture of the hip between April 2005 and August 2019 were identified from a retrospective search of an intramural trauma registry based in the Northeastern United States. Medical records were reviewed for baseline demographics, preoperative laboratory investigations, and outcomes. RESULTS The trauma registry contained 110 patients with CLD who had undergone surgery for a fracture of the hip. Of these, patients with a platelet-count of ⩽100,000/µL were 3.81 (95% CI, 1.59-9.12) times more likely to receive a transfusion than those with a platelet-count of >100,000/µL. Those with a Model for End-stage Liver Disease (MELD) score of >9 were 5.54 (2.33-13.16) times more likely to receive a transfusion and 3.97 (1.06-14.81) times more likely to develop postoperative delirium than those with a MELD score of ⩽9.Of patients without chronic kidney disease, those with a creatinine of ⩾1.2 mg/dL were 6.80 (1.79-25.87) times more likely to develop acute renal failure (ARF) than those with a creatinine of <1.2 mg/dL. In a multivariable model, as MELD score was increased, the odds of developing a composite postoperative complication, which included transfusion, ARF, delirium, or deep wound infection, were 1.29 (1.01-1.66). Other tools used to assess surgical risks, Charlson Comorbidity Index, Elixhauser, and American Society of Anesthesiologist scores, were not predictive. CONCLUSIONS Patients with CLD who undergo surgery for a hip fracture have a high rate of postoperative complications which can be predicted by the preoperative laboratory investigations identified in this study and MELD scores, but not by other common comorbidity indices.
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Affiliation(s)
- Hannah J Szapary
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rubén Monárrez
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD, USA
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip Hanna
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward K Rodriguez
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Kim HJ, Zuckerman SL, Cerpa M, Yeom JS, Lehman RA, Lenke LG. Incidence and Risk Factors for Complications and Mortality After Vertebroplasty or Kyphoplasty in the Osteoporotic Vertebral Compression Fracture-Analysis of 1,932 Cases From the American College of Surgeons National Surgical Quality Improvement. Global Spine J 2022; 12:1125-1134. [PMID: 33380221 PMCID: PMC9210253 DOI: 10.1177/2192568220976355] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The purpose was to investigate the incidence of and risk factors for complications associated with vertebroplasty (VP) or kyphoplasty (KP) for osteoporotic vertebral compression fracture (OVCF) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS A cohort of patients undergoing VP/KP was constructed from the 2011-2013 ACS-NSQIP dataset using Current Procedural Terminology (CPT) codes. The incidences of minor complications (i.e. urinary tract infection, pneumonia, renal insufficiency, superficial infection, wound dehiscence), major complications (i.e. reoperation, deep vein thrombosis, pulmonary embolism, sepsis, dialysis, cardiac arrest, deep infection, stroke), and mortality within 30 days post-surgery were investigated, and their risk factors were assessed using logistic regression modeling. RESULTS Of 1932 patients undergoing VP/KP, 166 (8.6%) experienced a complication, including minor complications in 53 (2.7%), major complications in 95 (4.9%), and death in 40 (2.1%). Multivariate logistic regression analysis indicated that the adjusted odds ratios (95% confidence interval [CI]) of mortality was significantly associated with ASA 4: 16.604 (1.956-140.959) and increased creatinine (≥ 1.3 mg/dL): 3.494 (1.128-10.823). History of chronic obstructive pulmonary disease was associated with minor complications. Increased WBC count and hypoalbuminemia (<3.0 g/dL) were also associated with major complications. CONCLUSIONS The major complication and mortality rates associated with VP/KP were 4.9% and 2.1% respectively, higher than previous reports. Increased creatinine and ASA 4 were independently associated with mortality after VP/KP. Therefore, cautious monitoring and counseling is needed for elderly, patients with preexisting kidney disease or ASA 4 undergoing VP/KP.
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Affiliation(s)
- Ho-Joong Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, and Spine Center, Seongnam, Republic of Korea,Division of Spinal Surgery, Department of Orthopedic Surgery, Columbia University, The Spine Hospital at New York-Presbyterian/Allen Hospital, New York, NY, USA
| | - Scott L. Zuckerman
- Division of Spinal Surgery, Department of Orthopedic Surgery, Columbia University, The Spine Hospital at New York-Presbyterian/Allen Hospital, New York, NY, USA
| | - Meghan Cerpa
- Division of Spinal Surgery, Department of Orthopedic Surgery, Columbia University, The Spine Hospital at New York-Presbyterian/Allen Hospital, New York, NY, USA
| | - Jin S. Yeom
- Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, and Spine Center, Seongnam, Republic of Korea
| | - Ronald A. Lehman
- Division of Spinal Surgery, Department of Orthopedic Surgery, Columbia University, The Spine Hospital at New York-Presbyterian/Allen Hospital, New York, NY, USA
| | - Lawrence G. Lenke
- Division of Spinal Surgery, Department of Orthopedic Surgery, Columbia University, The Spine Hospital at New York-Presbyterian/Allen Hospital, New York, NY, USA,Lawrence G. Lenke, MD, Division of Spinal Surgery, Department of Orthopedic Surgery, Columbia University, The Spine Hospital at New York-Presbyterian/Allen Hospital 5141 Broadway, 3 Field West, New York, NY, USA.
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Matthews L, Levett DZH, Grocott MPW. Perioperative Risk Stratification and Modification. Anesthesiol Clin 2022; 40:e1-e23. [PMID: 35595387 DOI: 10.1016/j.anclin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.
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Affiliation(s)
- Lewis Matthews
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom.
| | - Denny Z H Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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National Assessment of Early Discharge After Video-Assisted Thoracoscopic Surgery for Lung Resection. J Surg Res 2022; 276:242-250. [PMID: 35395564 DOI: 10.1016/j.jss.2022.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Video-assisted thoracoscopic surgery (VATS) techniques permit shorter postoperative length of stay (LOS). However, it remains unknown whether earlier discharge increases the risk of adverse postoperative events. We examined whether shorter LOS following elective VATS lung resection was associated with increased rates of readmission or postoperative complications. METHODS Patients who underwent elective thoracoscopic segmentectomy, lobectomy, or bilobectomy for lung neoplasms from 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. Postoperative LOS was treated as an ordinal variable. The examined outcomes were 30-d readmission and 30-d postdischarge death or serious morbidity (DSM). Multivariable logistic regression models evaluated the association of LOS with outcomes. The most common readmission diagnoses were identified for each operation. RESULTS Among 14,418 patients, 12,410 (86.1%) underwent lobectomy, 1764 (12.2%) underwent segmentectomy, and 244 (1.7%) underwent bilobectomy. The median LOS was 3 d for patients undergoing lobectomy (IQR 2-5) and segmentectomy (IQR 2-4), and 4 d for bilobectomy (IQR 3-6). Readmission rates varied with admission time and ranged from 5.0% for patients with LOS ≤1 d to 8.5% for LOS ≥5 d. The most common readmission diagnoses were pneumothorax (19.0%) and wound complications (13.4%). Each one-day increase in LOS was associated with an increased risk of readmission (OR 1.10, 95% CI 1.04-1.17, P < 0.001). No association was seen between earlier discharge and DSM (OR 1.08, 95% CI 0.99-1.18, P = 0.070). CONCLUSIONS Early discharge following VATS lung resection is not associated with increased rates of readmission or postoperative complications among patients undergoing surgery for cancer, and may safely be considered for selected patients with uncomplicated postoperative recovery.
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