Reportable infections following colon surgery in a large public healthcare system in New York City: The consequences of being a level 1 trauma center

Surgical Urgency, Patient Comorbidities, and Socioeconomic Factors in Surgical Site Infections in Pediatric Surgery

BACKGROUND

The rise of value-based purchasing has led to decreased compensation for hospital-acquired conditions, including surgical site infections (SSI). This study aims to assess the risk factors for SSI in children and teenagers undergoing gastrointestinal surgery across US hospitals.

METHODS

The 2018-2020 Nationwide Readmissions Database was queried for patients undergoing gastrointestinal surgery under the age of 18. The primary outcome was SSI during index admission or readmission within a year. Comparison groups were elective, trauma, and emergent surgery based on anatomic location and urgency. Univariable comparison used chi-squared tests for relevant variables. Confounders were addressed through multivariable logistic regression with significant variables from univariable analysis.

RESULTS

113 108 total patients met the study criteria. The SSI rate during admission or readmission was 2.9% (n = 3254). Infections during admission and readmission were 1.4% (n = 1560) and 1.5% (n = 1694), respectively. The most common site was organ space (48.6%, n = 1657). Increased infection risk was associated with trauma (OR 1.80 [1.51-2.16] P < .001), emergency surgery (OR 1.31 [1.17-1.47] P < .001), large bowel surgery (OR 2.78 [2.26-3.43] P < .001), and those with three or more comorbidities (OR 2.03 [1.69-2.45] P < .001). Investor-owned hospitals (OR .65 [.56-.76] P < .001) and highest quartile income (OR .80 [.73-.88] P < .001) were associated with decreased infection risk.

CONCLUSIONS

Pediatric patients undergoing gastrointestinal surgery face an elevated risk of SSI, especially in trauma and emergency surgeries, particularly with multiple comorbidities. Meanwhile, a reduced risk is observed in high-income and investor-owned hospital settings. Hospitals and surgeons caring for high risk patients should advocate for risk adjustment in value-based payment systems.

Do risk adjustment calculations used by governmental agencies adequately assess risk for infection after colon surgery?

BACKGROUND

Surgical site infections (SSIs) following colon surgery are associated with clinical and financial consequences. The Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) use risk adjustment variables to determine quality measure scores.

METHODS

Among patients in a large public system, surgical risk variables were compared between patients with and without SSIs. Propensity score matching, using CMS and NYSDOH risk variables, created control groups. Receiver Operating Characteristics (ROC) curves were created using current and augmented risk adjustment variables.

RESULTS

When matched using CMS risk variables, more patients with SSIs had contaminated/dirty wounds, longer duration of surgery, and emergency surgery. The addition of these variables significantly improved the CMS ROC curve. When matching NYSDOH variables, more SSI patients were male, had contaminated/dirty wounds, and tended to be younger. The addition of these variables to the current NYSDOH adjustment criteria did not significantly improve the ROC curve.

DISCUSSION

The CMS adjustment criteria for colon SSIs do not adequately account for complicated surgeries. The inclusion of additional variables significantly improved the performance of CMS risk adjustment.

CONCLUSIONS

Until more robust risk adjustment criteria are developed, the reporting of SSIs following colon surgery as a quality measure should be suspended.