Clinical review: Can we predict which patients are at risk of complications following surgery?

Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review

BACKGROUND

Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery.

METHODS

A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies.

RESULTS

From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches.

CONCLUSIONS

This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42022369944).

The Postoperative Airway Compromise Score-First Steps to Developing a Postoperative Tool for the Assessment of Upper Airway-Related Complications Following Anterior Cervical Spine Surgery

BACKGROUND

Acute upper airway compromise is a rare but catastrophic complication after anterior cervical discectomy and fusion. This study aims to develop a score to identify patients at risk of acute postoperative airway compromise (PAC).

METHODS

Potential risk factors for acute PAC were selected by a modified Delphi process. Ten patients with acute PAC were identified of 1466 patients who underwent elective anterior cervical discectomy and fusion between July 2014 and May 2019. A comparison group was created by a randomized selection process (non-PAC group). Factors associated with PAC and a P value of < 0.10 were entered into a logistic regression model and coefficients contributed to each risk factor's overall score. Calibration of the model was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Quantitative discrimination was calculated, and the final model was internally validated with bootstrap sampling.

RESULTS

We identified 18 potential risk factors from our Delphi process, of which 6 factors demonstrated a significant association with airway compromise: age >65 years, current smoking status, American Society of Anesthesiologists class >2, history of a bleeding disorder, surgery of upper subaxial cervical spine (above C4), and duration of surgery >179 minutes. The final prediction model included 5 predictors with very strong performance characteristics. These 5 factors formed the PAC score, with a range from 0 to 100. A score of 20 yielded the greatest balance of sensitivity (80%) and specificity (88%).

CONCLUSIONS

The acute PAC score demonstrates strong performance characteristics. The PAC score might help identify patients at risk of upper airway compromise caused by surgical site abnormalities.

Defining the association between the prolonged operative time and 90-day complications in patients undergoing radical cystectomy

Objective

Radical cystectomy is a complex lengthy procedure associated with postoperative morbidity. We aimed to assess the operative time (OT) in patients undergoing radical cystectomy and its impact on 90-day postoperative complications and readmission rates.

Methods

The retrospective cohort study included 296 patients undergoing radical cystectomy and urinary diversion from May 2010 to December 2018 in our institution. The OT of 369 min was set as a cutoff value between short and long OT groups. The primary outcome was 90-day postoperative complication rates. Secondary outcomes were gastrointestinal recovery time, length of hospital stay, and 90-day readmission rates.

Results

The overall incidence of 90-day postoperative complications was 79.7% where 43.2% representing low-grade complications according to the Clavien-Dindo classification (Grade 1 and Grade 2), and 36.5% representing high-grade complications (Grade≥3). Gastrointestinal tract and infectious complications are the most common complications in our data set (45.9% and 45.6%, respectively). On multivariable analysis, prolonged OT was significantly associated with odds of high-grade complications (odds ratio 2.340, 95% confidence interval 1.288-4.250, p=0.005). After propensity score-matched analysis, a higher incidence of major complications was identified in the long OT group 55 (51.4%) compared to 35 (32.7%) in the short OT group (p=0.006). A shorter gastrointestinal tract recovery time was noticed in the short OT group (p=0.009). Prolonged OT was associated with a higher 90-day readmission rate on univariate and multivariate analyses (p<0.001, p=0.001, respectively).

Conclusion

Prolonged OT (>369 min) is associated with an increased risk of postoperative complications and readmission rates. The perception of potential postoperative complications requires careful monitoring of these patients which could translate into better operative outcomes.

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

Swedish registry study showed that 50% of paediatric operations were performed in university hospitals and mortality was low

AIM

To investigate the distribution of paediatric surgery in various hospitals and to study postoperative risk factors of mortality.

METHODS

Retrospective registry-based cohort study of children aged 0-14 years undergoing surgery from 2017 to 2021. Data were extracted from the Swedish Perioperative Registry. A mixed logistic regression was applied for the all-risk mortality analysis.

RESULTS

A total of 126 539 cases were identified, 50% in university, 36% in county and 14% in district hospitals. The dominating operations were appendectomy in 6667, orchidopexy in 5287, inguinal hernia repair in 4200 and gastrostomy in 1152 children. Among children under 1 year of age or American Society of Anesthesiologists Physical Status classification (ASA-PS-Class) 3-5, the majority underwent surgery in university hospitals. The 30-day mortality in university hospitals was 0.5% and in county hospitals 0%. The proportion of emergency surgery was similar in university and county hospitals. Independent risk factors of mortality were being under 1 year of age, ASA-PS-class 4-5, emergency surgery and surgery at university hospitals.

CONCLUSION

Half of all operations in children were performed in university hospitals, with low postoperative mortality despite effective centralisation of high risk patients <1 year of age or ASA-PS-Class 3-5.

Development and validation of an interpretable Markov-embedded multilabel model for predicting risks of multiple postoperative complications among surgical inpatients: a multicenter prospective cohort study

BACKGROUND

When they encounter various highly related postoperative complications, existing risk evaluation tools that focus on single or any complications are inadequate in clinical practice. This seriously hinders complication management because of the lack of a quantitative basis. An interpretable multilabel model framework that predicts multiple complications simultaneously is urgently needed.

MATERIALS AND METHODS

The authors included 50 325 inpatients from a large multicenter cohort (2014-2017). The authors separated patients from one hospital for external validation and randomly split the remaining patients into training and internal validation sets. A MARKov-EmbeDded (MARKED) multilabel model was proposed, and three models were trained for comparison: binary relevance, a fully connected network (FULLNET), and a deep neural network. Performance was mainly evaluated using the area under the receiver operating characteristic curve (AUC). The authors interpreted the model using Shapley Additive Explanations. Complication-specific risk and risk source inference were provided at the individual level.

RESULTS

There were 26 292, 6574, and 17 459 inpatients in the training, internal validation, and external validation sets, respectively. For the external validation set, MARKED achieved the highest average AUC (0.818, 95% CI: 0.771-0.864) across eight outcomes [compared with binary relevance, 0.799 (0.748-0.849), FULLNET, 0.806 (0.756-0.856), and deep neural network, 0.815 (0.765-0.866)]. Specifically, the AUCs of MARKED were above 0.9 for cardiac complications [0.927 (0.894-0.960)], neurological complications [0.905 (0.870-0.941)], and mortality [0.902 (0.867-0.937)]. Serum albumin, surgical specialties, emergency case, American Society of Anesthesiologists score, age, and sex were the six most important preoperative variables. The interaction between complications contributed more than the preoperative variables, and formed a hierarchical chain of risk factors, mild complications, and severe complications.

CONCLUSION

The authors demonstrated the advantage of MARKED in terms of performance and interpretability. The authors expect that the identification of high-risk patients and the inference of the risk source for specific complications will be valuable for clinical decision-making.

Factors Affecting the Duration of Surgery in the Management of Condylar Head Fractures

Prolonged operation times should be avoided due to the associated complications and negative effects on the efficiency of the use of operating room resources. Surgical treatment of mandibular condylar head fractures is a well-established routine procedure at our department, nevertheless, we recognized fluctuating operating times. This study aims to pinpoint the influencing factors, in particular the hypothesis whether the efficiency of intraoperative muscle relaxation may decisively affect the duration of surgery. It analyses 168 mandibular condylar head fractures that were surgically treated in the period from 2007 to 2022 regarding the duration of the surgery and potential factors affecting it. The potential predictors' influence on the dependent variable operation time was mainly calculated as a bivariate analysis or linear regression. Efficiency of relaxation (p ≤ 0.001), fragmentation type (p = 0.031), and fracture age (p = 0.003) could be identified as decisive factors affecting the duration of surgery, as the first surgeon was a constant. In conclusion, surgical intervention should start as soon as possible after a traumatic incident. In addition, a dosage regimen to optimize the efficiency of relaxation should be established in future studies. Fragmentation type and concomitant fractures should also be considered for a more accurate estimation of the operating time.

Prognostic models for surgical-site infection in gastrointestinal surgery: systematic review

BACKGROUND

Identification of patients at high risk of surgical-site infection may allow clinicians to target interventions and monitoring to minimize associated morbidity. The aim of this systematic review was to identify and evaluate prognostic tools for the prediction of surgical-site infection in gastrointestinal surgery.

METHODS

This systematic review sought to identify original studies describing the development and validation of prognostic models for 30-day SSI after gastrointestinal surgery (PROSPERO: CRD42022311019). MEDLINE, Embase, Global Health, and IEEE Xplore were searched from 1 January 2000 to 24 February 2022. Studies were excluded if prognostic models included postoperative parameters or were procedure specific. A narrative synthesis was performed, with sample-size sufficiency, discriminative ability (area under the receiver operating characteristic curve), and prognostic accuracy compared.

RESULTS

Of 2249 records reviewed, 23 eligible prognostic models were identified. A total of 13 (57 per cent) reported no internal validation and only 4 (17 per cent) had undergone external validation. Most identified operative contamination (57 per cent, 13 of 23) and duration (52 per cent, 12 of 23) as important predictors; however, there remained substantial heterogeneity in other predictors identified (range 2-28). All models demonstrated a high risk of bias due to the analytic approach, with overall low applicability to an undifferentiated gastrointestinal surgical population. Model discrimination was reported in most studies (83 per cent, 19 of 23); however, calibration (22 per cent, 5 of 23) and prognostic accuracy (17 per cent, 4 of 23) were infrequently assessed. Of externally validated models (of which there were four), none displayed 'good' discrimination (area under the receiver operating characteristic curve greater than or equal to 0.7).

CONCLUSION

The risk of surgical-site infection after gastrointestinal surgery is insufficiently described by existing risk-prediction tools, which are not suitable for routine use. Novel risk-stratification tools are required to target perioperative interventions and mitigate modifiable risk factors.

Network prediction of surgical complication clusters: a prospective multicenter cohort study

Complicated relationships exist in both occurrence and progression of surgical complications, which are difficult to account for using a separate quantitative method such as prediction or grading. Data of 51,030 surgical inpatients were collected from four academic/teaching hospitals in a prospective cohort study in China. The relationship between preoperative factors, 22 common complications, and death was analyzed. With input from 54 senior clinicians and following a Bayesian network approach, a complication grading, cluster-visualization, and prediction (GCP) system was designed to model pathways between grades of complication and preoperative risk factor clusters. In the GCP system, there were 11 nodes representing six grades of complication and five preoperative risk factor clusters, and 32 arcs representing a direct association. Several critical targets were pinpointed on the pathway. Malnourished status was a fundamental cause widely associated (7/32 arcs) with other risk factor clusters and complications. American Society of Anesthesiologists (ASA) score ⩾3 was directly dependent on all other risk factor clusters and influenced all severe complications. Grade III complications (mainly pneumonia) were directly dependent on 4/5 risk factor clusters and affected all other grades of complication. Irrespective of grade, complication occurrence was more likely to increase the risk of other grades of complication than risk factor clusters.

Complication After Gastrectomy for Gastric Cancer According to Hospital Volume: Based on Korean Gastric Cancer Association-Led Nationwide Survey Data

PURPOSE

This study aimed to analyze the incidence and risk factors of complications following gastric cancer surgery in Korea and to compare the correlation between hospital complications based on the annual number of gastrectomies performed.

MATERIALS AND METHODS

A retrospective analysis was conducted using data from 12,244 patients from 64 Korean institutions. Complications were classified using the Clavien-Dindo classification (CDC). Univariate and multivariate analyses were performed to identify the risk factors for severe complications.

RESULTS

Postoperative complications occurred in 14% of the patients, severe complications (CDC IIIa or higher) in 4.9%, and postoperative death in 0.2%. The study found that age, stage, American Society of Anesthesiologists (ASA) score, Eastern Cooperative Oncology Group (ECOG) score, hospital stay, approach methods, and extent of gastric resection showed statistically significant differences depending on hospital volumes (P<0.05). In the univariate analysis, patient age, comorbidity, ASA score, ECOG score, approach methods, extent of gastric resection, tumor-node-metastasis (TNM) stage, and hospital volume were significant risk factors for severe complications. However, only age, sex, ASA score, ECOG score, extent of gastric resection, and TNM stage were statistically significant in the multivariate analysis (P<0.05). Hospital volume was not a significant risk factor in the multivariate analysis (P=0.152).

CONCLUSIONS

Hospital volume was not a significant risk factor for complications after gastric cancer surgery. The differences in the frequencies of complications based on hospital volumes may be attributed to larger hospitals treating patients with younger age, lower ASA scores, better general conditions, and earlier TNM stages.

Impact of 3D printed models on quantitative surgical outcomes for patients undergoing robotic-assisted radical prostatectomy: a cohort study

BACKGROUND

Three-dimensional (3D) printed anatomic models can facilitate presurgical planning by providing surgeons with detailed knowledge of the exact location of pertinent anatomical structures. Although 3D printed anatomic models have been shown to be useful for pre-operative planning, few studies have demonstrated how these models can influence quantitative surgical metrics.

OBJECTIVE

To prospectively assess whether patient-specific 3D printed prostate cancer models can improve quantitative surgical metrics in patients undergoing robotic-assisted radical prostatectomy (RARP).

METHODS

Patients with MRI-visible prostate cancer (PI-RADS V2 ≥ 3) scheduled to undergo RARP were prospectively enrolled in our IRB approved study (n = 82). Quantitative surgical metrics included the rate of positive surgical margins (PSMs), operative times, and blood loss. A qualitative Likert scale survey to assess understanding of anatomy and confidence regarding surgical approach was also implemented.

RESULTS

The rate of PSMs was lower for the 3D printed model group (8.11%) compared to that with imaging only (28.6%), p = 0.128. The 3D printed model group had a 9-min reduction in operating time (213 ± 42 min vs. 222 ± 47 min) and a 5 mL reduction in average blood loss (227 ± 148 mL vs. 232 ± 114 mL). Surgeon anatomical understanding and confidence improved after reviewing the 3D printed models (3.60 ± 0.74 to 4.20 ± 0.56, p = 0.62 and 3.86 ± 0.53 to 4.20 ± 0.56, p = 0.22).

CONCLUSIONS

3D printed prostate cancer models can positively impact quantitative patient outcomes such as PSMs, operative times, and blood loss in patients undergoing RARP.

Influence of Operative Time in the Results of Elective Endovascular Repair of Abdominal Aortic Aneurysms

BACKGROUND

A prolonged operative time (OT) is a well-recognized risk factor of postoperative complications after many open surgical procedures, although little is known about its impact in less-invasive endovascular procedures. We aimed to define the characteristics related to a prolonged OT in the endovascular treatment of aorto-iliac aneurysms (EVAR) and to evaluate the influence of OT on postoperative outcomes.

METHODS

Retrospective analysis of 284 consecutive patients (mean age 75 years, 95% male) who underwent an elective EVAR between 2000 and 2019. Operative characteristics related to OT and the impact of OT in postoperative results was studied using multiple lineal and logistic regression analyses, respectively.

RESULTS

The mean surgical time was 200 min. OT was associated (regression model) with the implantation of straight endografts (-38 min, P = 0.007), femoral artery surgery (+80 min, P < 0.001), hypogastric preservation procedures (+70 min, P < 0.001), associated peripheral arterial disease (+22 min, P = 0.013), general anesthesia (+34 min, P < 0.001), and aneurysm diameter (+9 min/cm, P = 0.002). During the postoperative period (<30 days or at discharge), 21% presented a complication and 2.8% died. OT was independently associated with a higher incidence of postoperative complications (odds ratio [OR] for each additional 30' of surgery = 1.34, P < 0.001), such as immediate (OR = 1.48, P = 0.003) and 6-month mortality (OR = 1.28, P = 0.025).

CONCLUSIONS

A prolonged OT is an independent risk factor for complications and mortality after EVAR. Surgeons must take this factor into consideration when defining the best therapeutic strategy for abdominal aortic aneurysms.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The new SUMPOT to predict postoperative complications using an Artificial Neural Network

An accurate assessment of preoperative risk may improve use of hospital resources and reduce morbidity and mortality in high-risk surgical patients. This study aims at implementing an automated surgical risk calculator based on Artificial Neural Network technology to identify patients at risk for postoperative complications. We developed the new SUMPOT based on risk factors previously used in other scoring systems and tested it in a cohort of 560 surgical patients undergoing elective or emergency procedures and subsequently admitted to intensive care units, high-dependency units or standard wards. The whole dataset was divided into a training set, to train the predictive model, and a testing set, to assess generalization performance. The effectiveness of the Artificial Neural Network is a measure of the accuracy in detecting those patients who will develop postoperative complications. A total of 560 surgical patients entered the analysis. Among them, 77 patients (13.7%) suffered from one or more postoperative complications (PoCs), while 483 patients (86.3%) did not. The trained Artificial Neural Network returned an average classification accuracy of 90% in the testing set. Specifically, classification accuracy was 90.2% in the control group (46 patients out of 51 were correctly classified) and 88.9% in the PoC group (8 patients out of 9 were correctly classified). The Artificial Neural Network showed good performance in predicting presence/absence of postoperative complications, suggesting its potential value for perioperative management of surgical patients. Further clinical studies are required to confirm its applicability in routine clinical practice.

The impact of the incorporation of a feasible postoperative mortality model at the Post-Anaesthestic Care Unit (PACU) on postoperative clinical deterioration: A pragmatic trial with 5,353 patients

Background

Practical use of risk predictive tools and the assessment of their impact on outcome reduction is still a challenge. This pragmatic study of quality improvement (QI) describes the preoperative adoption of a customised postoperative death probability model (SAMPE model) and the evaluation of the impact of a Postoperative Anaesthetic Care Unit (PACU) pathway on the clinical deterioration of high-risk surgical patients.

Methods

A prospective cohort of 2,533 surgical patients compared with 2,820 historical controls after the adoption of a quality improvement (QI) intervention. We carried out quick postoperative high-risk pathways at PACU when the probability of postoperative death exceeded 5%. As outcome measures, we used the number of rapid response team (RRT) calls within 7 and 30 postoperative days, in-hospital mortality, and non-planned Intensive Care Unit (ICU) admission.

Results

Not only did the QI succeed in the implementation of a customised risk stratification model, but it also diminished the postoperative deterioration evaluated by RRT calls on very high-risk patients within 30 postoperative days (from 23% before to 14% after the intervention, p = 0.05). We achieved no survival benefits or reduction of non-planned ICU. The small group of high-risk patients (13% of the total) accounted for the highest proportion of RRT calls and postoperative death.

Conclusion

Employing a risk predictive tool to guide immediate postoperative care may influence postoperative deterioration. It encouraged the design of pragmatic trials focused on feasible, low-technology, and long-term interventions that can be adapted to diverse health systems, especially those that demand more accurate decision making and ask for full engagement in the control of postoperative morbi-mortality.

Derivation and validation of a national multicenter mortality risk stratification model - the ExCare model: a study protocol

Introduction

Surgical care is essential for proper management of various diseases. However, it can result in unfavorable outcomes. In order to identify patients at higher risk of complications, several risk stratification models have been developed. Ideally, these tools should be simple, reproducible, accurate, and externally validated. Unfortunately, none of the best-known risk stratification instruments have been validated in Brazil. In this sense, the Ex-Care model was developed by retrospective data analysis of surgical patients in a major Brazilian university hospital. It consists of four independent predictors easily collected in the preoperative evaluation, showing high accuracy in predicting death within 30 days after surgery.

Objectives

To update and validate a Brazilian national-based model of postoperative death probability within 30 days based on the Ex-Care model. Also, to develop an application for smartphones that allows preoperative risk stratification by Ex-Care model.

Methods

Ten participating centers will collect retrospective data from digital databases. Variables age, American Society of Anesthesiologists (ASA) physical status, surgical severity (major or non-major) and nature (elective or urgent) will be evaluated as predictors for in-hospital mortality within 30 postoperative days, considered the primary outcome.

Expected results

We believe that the Ex-Care model will present discriminative capacity similar to other classically used scores validated for surgical mortality prediction. Furthermore, the mobile application to be developed will provide a practical and easy-to-use tool to the professionals enrolled in perioperative care.

Influence of Operative Time in the Results of Infrainguinal Bypass for Chronic Limb Threatening Ischemia

BACKGROUND

An increased operative time (OT) has been associated with a higher rate of adverse outcomes after several surgical procedures although scarce evidence exists for infrainguinal bypass surgery (IBS) and its impact beyond the postoperative period. The aim of this study was to define surgical characteristics related to a prolonged OT in IBS for chronic limb threatening ischemia and its influence on postoperative and 1-year outcomes.

MATERIALS AND METHODS

Retrospective study of 249 consecutive patients (mean age 72.4 years, 73.1% male) undergoing IBS for CLI between 2008 and 2018. The characteristics related to the duration of surgery and its impact on outcome were assessed with a multiple linear regression and a multivariate logistic regression, respectively.

RESULTS

Interventions associated with a prolonged OT included the bypass to a below-the-knee artery (additional 36 min, p = 0.002), the need for an alternative vein or a hybrid PTFE-vein graft (additional 37 min, p = 0.02) and inflow associated procedures (additional 47 min, p < 0.001). OT was associated with a higher rate of postoperative complications (OR for each additional 30 min 1.123, 95% CI 1.021-1.234) and need for a sociosanitary facility at discharge (OR 1.143, 95% CI 1.033-1.265). At 1-year of follow-up, OT was related to a higher major amputation rate (OR 1.201, 95% CI 1.036-1.393) and non-significantly to mortality (OR 1.125, 95% CI 0.999-1.268).

CONCLUSIONS

A prolonged OT is a risk factor for adverse outcomes after IBS that extends beyond the immediate postoperative period. Further research is needed to evaluate how an expected high OT might influence decision-making.

Mortality and Complications Following Visceral Surgery: A Nationwide Analysis Based on the Diagnostic Categories Used in German Hospital Invoicing Data

BACKGROUND

The in-hospital mortality after visceral surgery in Germany is unknown.

METHODS

In this retrospective, descriptive analysis, nationwide hospital billing data based on diagnosis-related groups (DRG) over the period 2009-2015 were studied to determine the in-hospital mortality, complications and their management, and deaths after documented severe complications (failure to rescue, FTR) after visceral surgery in Germany. Organ-system subgroups were defined and subdivided into frequent operations (inguinal hernia repair, appendectomy, thyroid operations, cholecystec- tomy), colorectal operations, and complex operations (surgery of the esophagus, pancreas, liver, and stomach).

RESULTS

3 287 199 patients from 1392 hospitals were included in the analysis. The in-hospital mortality after visceral surgery was 1.9%. The lowest mortality was after the frequently performed operations (0.04-0.4%), the highest after complex surgery of the esophagus (8.6%) and stomach (11.7%). Severe complications were most commonly seen after complex surgery of the pan- creas (27.7%), liver (24.3%), esophagus (37.8%), and stomach (36.7%). 90.6% of deaths occurred after colorectal or complex operations, which together accounted for 23% of all operations. The FTR rate was 8.4% after appendectomy and cholecystec- tomy (95% confidence interval [8.34; 8.46]) and 20.3% after esophageal surgery ([19.8; 20.8]).

CONCLUSION

In Germany, in-hospital mortality after visceral surgery is not uncommon, with a frequency of nearly 2%. Improved complication management after complex operations appears necessary. A limitation of this study is the identification of compli- cations from anonymized billing data.

Designing risk prediction models for ambulatory no-shows across different specialties and clinics

Objective

As available data increases, so does the opportunity to develop risk scores on more refined patient populations. In this paper we assessed the ability to derive a risk score for a patient no-showing to a clinic visit.

Methods

Using data from 2 264 235 outpatient appointments we assessed the performance of models built across 14 different specialties and 55 clinics. We used regularized logistic regression models to fit and assess models built on the health system, specialty, and clinic levels. We evaluated fits based on their discrimination and calibration.

Results

Overall, the results suggest that a relatively robust risk score for patient no-shows could be derived with an average C-statistic of 0.83 across clinic level models and strong calibration. Moreover, the clinic specific models, even with lower training set sizes, often performed better than the more general models. Examination of the individual models showed that risk factors had different degrees of predictability across the different specialties. Implementation of optimal modeling strategies would lead to capturing an additional 4819 no-shows per-year.

Conclusion

Overall, this work highlights both the opportunity for and the importance of leveraging the available electronic health record data to develop more refined risk models.

Preoperative predictors of postoperative complications after gastric cancer resection

Risk management is becoming an increasingly important healthcare issue. Gastrectomy with lymphadenectomy is still the mainstay of treatment for localized gastric cancer, but it is sometimes associated with postoperative complications that compromise the patient’s quality of life, tolerability of adjuvant treatment, and prognosis. Parameters based exclusively on preoperative factors can identify patients most at risk of postoperative complications, whereby surgeons can provide the patient with precise informed consent information and optimal perioperative management. Ultimately, these predictive tools can also help minimize medical costs. In this context, many studies have identified factors that predict postoperative complications, including indicators based on body constitution, nutrition, inflammation, organ function and hypercoagulation. This review presents our current understanding and discusses some future perspectives of preoperatively identified factors predictive of complications after resection for gastric cancer.

Pharmacist involvement to improve patient outcomes in lower gastrointestinal surgery: a prospective before and after study

Background Enhanced recovery pathways were first introduced in the UK in 2002 (Enhanced Recovery Partnership Programme in Delivering enhanced recovery-helping patients to get better sooner after surgery. Department of Health, London, 2010). The aims of such pathways are to reduce patient length of stay whilst still providing high quality of care. Objectives To evaluate the impact of pharmacist involvement in enhanced recovery pathways. Setting A large 1200 bed tertiary hospital in the North of England. Methods The pre-post study included all patients admitted for major colorectal surgery during the period 2013-2016. Baseline data were collected on all patients seen pre-operatively in a nurse-led pre-admission clinic. The intervention was introduced where a dedicated surgical pharmacist pre-operatively reviewed patients from the time they were listed for surgery until discharge with a focus on medicines optimisation. Main outcome measure The primary outcome measures were length of stay along with the type and number of post-operative complications. Results 100 patients were included in this study, with 50 patients in the baseline group and 50 patients in the intervention group. There was a significant reduction in the median length of stay (baseline group-10.5 days; intervention group-7.5 days; P < 0.001). The total number of complications was also less in the intervention group (baseline group-125; intervention group-75; P > 0.05) as was the number of patients whom had no complications (P > 0.05). Conclusions Active pharmacist involvement in enhanced recovery protocols is associated with a significantly reduced median length of stay as well as an overall reduction in the total number of post-operative complications.

Performance validation of the ALPPS risk model

BACKGROUND

Based on the International ALPPS registry, we have recently proposed two easily applicable risk models (pre-stage1 and 2) for predicting 90-day mortality in ALPPS but a validation of both models has not been performed yet.

METHODS

The validation cohort (VC) was composed of subsequent cases of the ALPPS registry and cases of centers outside the ALPPS registry.

RESULTS

The VC was composed of a total of 258 patients including 70 patients outside the ALPPS registry with 32 cases of early mortalities (12%). Development cohort (DC) and VC were comparable in terms of patient and surgery characteristics. The VC validated both models with an acceptable prediction for the pre-stage 1 (c-statistic 0.64, P = 0.009 vs. 0.77, P < 0.001) and a good prediction for the pre-stage 2 model (c-statistic 0.77, P < 0.001 vs. 0.85, P < 0.001) as compared to the DC. Overall model performance measured by Brier score was comparable between VC and DC for the pre-stage 1 (0.089 vs. 0.081) and pre-stage 2 model (0.079 vs. 0087).

CONCLUSION

The ALPPS risk score is a fully validated model to estimate the individual risk of patients undergoing ALPPS and to assist clinical decision making to avoid procedure-related early mortality after ALPPS.

Validating the Electronic Cardiac Arrest Risk Triage (eCART) Score for Risk Stratification of Surgical Inpatients in the Postoperative Setting: Retrospective Cohort Study

OBJECTIVE

Assess the accuracy of 3 early warning scores for predicting severe adverse events in postoperative inpatients.

SUMMARY OF BACKGROUND DATA

Postoperative clinical deterioration on inpatient hospital services is associated with increased morbidity, mortality, and cost. Early warning scores have been developed to detect inpatient clinical deterioration and trigger rapid response activation, but knowledge regarding the application of early warning scores to postoperative inpatients is limited.

METHODS

This was a retrospective cohort study of adult patients hospitalized on the wards after surgical procedures at an urban academic medical center from November, 2008 to January, 2016. The accuracies of the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and the electronic cardiac arrest risk triage (eCART) score were compared in predicting severe adverse events (ICU transfer, ward cardiac arrest, or ward death) in the postoperative period using the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 32,537 patient admissions included in the study, 3.8% (n = 1243) experienced a severe adverse outcome after the procedure. The accuracy for predicting the composite outcome was highest for eCART [AUC 0.79 (95% CI: 0.78-0.81)], followed by NEWS [AUC 0.76 (95% CI: 0.75-0.78)], and MEWS [AUC 0.75 (95% CI: 0.73-0.76)]. Of the individual vital signs and labs, maximum respiratory rate was the most predictive (AUC 0.67) and maximum temperature was an inverse predictor (AUC 0.46).

CONCLUSION

Early warning scores are predictive of severe adverse events in postoperative patients. eCART is significantly more accurate in this patient population than both NEWS and MEWS.

Transfer of the care of patients with low risk of mortality in postoperative: experience report

OBJECTIVE

Describe the implementation of care transfer flow chart in postoperative, based on a risk classification model.

METHOD

Experience report on the implementation of a pilot project between the post-anesthetic recovery room and the surgical hospitalization unit, developed between December/2016 and March/2017, aimed at transferring s the care of patients with low risk of postoperative mortality, in a university hospital in the South of Brazil.

RESULTS

The project made it possible to expedite the discharge of the patient from the Post-Anesthetic Recovery Room to the surgical hospitalization unit, to qualify the records regarding nursing care and to optimize the time of nurses in both units for care activities.

CONCLUSION

The implementation of a care transfer flow chart from the risk classification for postoperative patients contributed to a more effective communication, culminating in improvements in patient safety.

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.

Soluble Urokinase Plasminogen Activator Receptor (suPAR) as an Added Predictor to Existing Preoperative Risk Assessments

BACKGROUND

Risk assessment strategies, such as using the American Society of Anesthesiologists (ASA) physical status classification, attempt to identify surgical high-risk patients. Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker reflecting overall systemic inflammation and immune activation, and it could potentially improve the identification of high-risk surgical patients.

METHODS

We included patients acutely admitted to the emergency department who subsequently underwent surgery within 90 days of admission. Patients were stratified into low-risk or high-risk groups, according to ASA classification (ASA_low: ASA I-II; ASA_high: ASA III-VI) and suPAR level, measured at admission (suPAR_high above and suPAR_low below 5.5 ng/ml), respectively. Pre-specified complications were identified in national registries and electronic medical records. The association between ASA classification, suPAR level, CRP and the rate of postoperative complications was analyzed with logistic regression and Cox regression analyses, estimating odds ratios and hazard ratios (HRs).

RESULTS

During 90-day follow-up from surgery, 31 (7.0%) patients died and 158 (35.6%) patients had postoperative complications. After adjusting for age, sex, and ASA classification, the HR for 90-day postoperative mortality was 2.5 (95% CI 1.6-4.0) for every doubling of suPAR level. suPAR was significantly better than CRP at predicting mortality and all complications (P = 0.0036 and P = 0.0041, respectively). Combining ASA classification and suPAR level significantly improved prediction of mortality and the occurrence of a postoperative complication within 90 days after surgery (P < 0.0001).

CONCLUSION

Measuring suPAR levels in acutely admitted patients may aid in identifying high-risk patients and improve prediction of postoperative complications.

Good overall morbidity prediction with the POSSUM scoring system in patients having a total hip or knee replacement - a prospective study in 227 patients

Purpose

The Physiological and Operation Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and P (Portsmouth)-POSSUM predict the risks of complications and mortality 30 days after surgery. The purpose of this study was to evaluate the POSSUM and P-POSSUM scoring systems in patients who underwent surgery for a total hip or knee replacement.

Patients and methods

A total of 227 patients with an elective primary total hip or knee replacement were included. The predicted postoperative morbidity was analyzed in these patients and compared with the observed value 30 days after surgery. Logistic regression analysis was used to assess the correlation of variables and outcome.

Results

The number of patients undergoing total hip or knee replacement was equally distributed with a mean age of 66.4±12.5 years; 57% of patients were females. Postoperative complications occurred in 49 patients, and POSSUM predicted 49 cases with an observed-over-expected ratio of 1.0. The average total POSSUM score was 27.4±4.4 in patients with complications and 26.8±3.5 in patients without complications (P=0.340). Wound infection (n=18), urinary tract infection (n=7), and pulmonary embolus (n=5) were the most common complications. The operation magnitude variable had the highest mean POSSUM score making it the most relevant variable. Age and blood loss and echocardiogram had the largest variance among the assessed variables.

Conclusion

POSSUM accurately predicted morbidities in patients undergoing elective primary total hip or knee replacement. The risk for wound infection, urinary retention, and pulmonary embolus should be considered during hospitalization. The computerized POSSUM system provides case-mix-adjusted morbidity predictions for groups and, hence, serves as a useful tool for surgical audits and large-scale benchmarking.

Prolonged operative duration is associated with complications: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to systematically synthesize the large volume of literature reporting on the association between operative duration and complications across various surgical specialties and procedure types.

METHODS

An electronic search of PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from January 2005 to January 2015 was conducted. Sixty-six observational studies met the inclusion criteria.

RESULTS

Pooled analyses showed that the likelihood of complications increased significantly with prolonged operative duration, approximately doubling with operative time thresholds exceeding 2 or more hours. Meta-analyses also demonstrated a 14% increase in the likelihood of complications for every 30 min of additional operating time.

CONCLUSIONS

Prolonged operative time is associated with an increase in the risk of complications. Given the adverse consequences of complications, decreased operative times should be a universal goal for surgeons, hospitals, and policy-makers. Future study is recommended on the evaluation of interventions targeted to reducing operating time.

A novel risk classification system for 30-day mortality in children undergoing surgery

A simple, objective and accurate way of grouping children undergoing surgery into clinically relevant risk groups is needed. The purpose of this study, is to develop and validate a preoperative risk classification system for postsurgical 30-day mortality for children undergoing a wide variety of operations. The National Surgical Quality Improvement Project-Pediatric participant use file data for calendar years 2012-2014 was analyzed to determine preoperative variables most associated with death within 30 days of operation (D30). Risk groups were created using classification tree analysis based on these preoperative variables. The resulting risk groups were validated using 2015 data, and applied to neonates and higher risk CPT codes to determine validity in high-risk subpopulations. A five-level risk classification was found to be most accurate. The preoperative need for ventilation, oxygen support, inotropic support, sepsis, the need for emergent surgery and a do not resuscitate order defined non-overlapping groups with observed rates of D30 that vary from 0.075% (Very Low Risk) to 38.6% (Very High Risk). When CPT codes where death was never observed are eliminated or when the system is applied to neonates, the groupings remained predictive of death in an ordinal manner.

Perioperative Assessment of Older Surgical Patients using a Frailty Index—Feasibility and Association with Adverse Postoperative Outcomes

This study aimed to examine the feasibility of using a frailty index (FI) based on comprehensive geriatric assessment (CGA), to assess the level of frailty in older surgical patients preoperatively and to evaluate the association of FI-CGA with poorer postoperative outcomes. Two hundred and forty-six patients aged ≥70 years undergoing intermediate- to high-risk surgery in a tertiary hospital were recruited. Frailty was assessed using a 57-item FI-CGA form, with fit, intermediate frail, and frail patients defined as FI ≥0.25, >0.25 to 0.4, and >0.4, respectively. Adverse outcomes were ascertained at 30 days and 12 months post-surgery. Logistic regression models assessed the relationship between FI and adverse outcomes, adjusting for age, gender and acuity of surgery. The mean age of the participants was 79 years (standard deviation [SD] 6.5%), 52% were female, 91% were admitted from the community, 43% underwent acute surgery, and 19% were assessed as frail. The FI-CGA form was reported as being easy to apply, with a low patient refusal rate (2.2%). The majority of items were easy to rate, although inter-rater reliability was not tested. In relation to outcomes, greater frailty was associated with increased 12-month mortality (6.4%, 15.6%, and 23% for fit, intermediate frail, and frail patients respectively, P=0.01) and 12-month hospital readmission (33.9%, 48.9%, and 60% respectively, P=0.004). There were no statistically significant differences between fit, intermediate frail, and frail groups in perioperative adverse events (17.4%, 23.3%, and 19.1% respectively, P=0.577) or 30-day postoperative complications (35.8%, 47.8%, and 46.8% respectively, P=0.183). Our findings suggest that it is feasible to use the FI-CGA to assess frailty preoperatively, and that using the FI-CGA may identify patients at high risk of adverse long-term outcomes.

A calculator for mortality following emergency general surgery based on the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

The complex nature of current morbidity and mortality predictor models do not lend themselves to clinical application at the bedside of patients undergoing emergency general surgery (EGS). Our aim was to develop a simplified risk calculator for prediction of early postoperative mortality after EGS.

METHODS

EGS cases other than appendectomy and cholecystectomy were identified within the American College of Surgeons National Surgery Quality Improvement Program database from 2005 to 2014. Seventy-five percent of the cases were selected at random for model development, whereas 25% of the cases were used for model testing. Stepwise logistic regression was performed for creation of a 30-day mortality risk calculator. Model accuracy and reproducibility was investigated using the concordance index (c statistic) and Pearson correlations.

RESULTS

A total of 79,835 patients met inclusion criteria. Overall, 30-day mortality was 12.6%. A simplified risk model formula was derived from five readily available preoperative variables as follows: 0.034*age + 0.8*nonindependent status + 0.88*sepsis + 1.1 (if bun ≥ 29) or 0.57 (if bun ≥18 and < 29) + 1.16 (if albumin < 2.7), or 0.61 (if albumin ≥ 2.7 and < 3.4). The risk of 30-day mortality was stratified into deciles. The risk of 30-day mortality ranged from 2% for patients in the lowest risk level to 31% for patients in the highest risk level. The c statistic was 0.83 in both the derivation and testing samples.

CONCLUSION

Five readily available preoperative variables can be used to predict the 30-day mortality risk for patients undergoing EGS. Further studies are needed to validate this risk calculator and to determine its bedside applicability.

LEVEL OF EVIDENCE

Prognostic/epidemiological study, level III.

Postoperative complications and clinical outcomes among patients undergoing thoracic and gastrointestinal cancer surgery: A prospective cohort study

Objective

This study sought to determine the influence of postoperative complications on the clinical outcomes of patients who underwent thoracic and gastrointestinal cancer surgery.

Methods

A prospective cohort study was conducted regarding 179 consecutive patients who received thorax or digestive tract surgery due to cancer and were admitted to an oncological intensive care unit. The Postoperative Morbidity Survey was used to evaluate the incidence of postoperative complications. The influence of postoperative complications on both mortality and length of hospital stay were also assessed.

Results

Postoperative complications were found for 54 patients (30.2%); the most common complications were respiratory problems (14.5%), pain (12.9%), cardiovascular problems (11.7%), infectious disease (11.2%), and surgical wounds (10.1%). A multivariate logistic regression found that respiratory complications (OR = 18.68; 95%CI = 5.59 - 62.39; p < 0.0001), cardiovascular problems (OR = 5.06, 95%CI = 1.49 - 17.13; p = 0.009), gastrointestinal problems (OR = 26.09; 95%CI = 6.80 - 100.16; p < 0.0001), infectious diseases (OR = 20.55; 95%CI = 5.99 - 70.56; p < 0.0001) and renal complications (OR = 18.27; 95%CI = 3.88 - 83.35; p < 0.0001) were independently associated with hospital mortality. The occurrence of at least one complication increased the likelihood of remaining hospitalized (log-rank test, p = 0.002).

Conclusions

Postoperative complications are frequent disorders that are associated with poor clinical outcomes; thus, structural and procedural changes should be implemented to reduce postoperative morbidity and mortality.

Deaths Following Cholecystectomy and Herniotomy: An Analysis of Nationwide German Hospital Discharge Data From 2009 to 2013

BACKGROUND

In 2010, 158 000 cholecystectomies and 207 000 herniotomies (without bowel surgery) were performed in Germany as inpatient procedures, generally on a routine, elective basis. Deaths following such operations are rare events. We studied the potential association of death after cholecystectomy or herniotomy with risk factors that could have been detected beforehand, and we examined the types of complications that were documented in these cases.

METHODS

Using nationwide hospital discharge data (DRG statistics) for the years 2009-2013, we analyzed the characteristics of patients who died in the hospital after undergoing a cholecystectomy for cholelithiasis or the repair of an inguinal, femoral, umbilical, or abdominal wall hernia. We compared these data with those of patients who survived and studied the impact of the coded comorbidities on the risk of death.

RESULTS

In Germany, in the years 2009-2013, there were 2957 deaths after a total of 731 000 cholecystectomies (in-hospital mortality, 0.4%) and 1316 deaths after a total of 1 023 000 herniotomies without bowel surgery (0.13%). The patients who died were markedly older than those who did not, and they more commonly had comorbidities. Factors associated with a higher risk of death were age over 65 years, and comorbidities such as congestive heart failure, chronic pulmonary or hepatic disease, or poor nutritional status. Complications were coded much more often for the patients who died than for those who did not.

CONCLUSION

These findings suggest that there is potential for improvement in preoperative risk identification, complication avoidance, and the early recognition and treatment of complications, as well as in safe surgical technique. Measures to lower the mortality associated with herniotomy and cholecystectomy would lessen patients' individual risk and thereby improve patient safety.

Risk factors analysis of thromboembolectomy for acute thromboembolic lower extremity ischemia in native arteries

BACKGROUND

Aim of this study is to report the results of thromboembolectomy (ThEmb) for acute thromboembolic lower limb ischemia (ATLI) in native arteries and to create a predictive score for amputation-free survival (AFS) at 30 days.

METHODS

It is a single center, retrospective analysis of a four years period. All patients had ThEmb: adjunctive procedures included femoral and/or popliteal endarterectomy in 30 (18.3%) cases, PTA-stent in 24 (14.6%), and femoral endarterectomy plus PTA-stent in 12 (7.3%). Fasciotomies were performed in 6 (3.6%) patients. Predictors of AFS identified on univariate screen (inclusion threshold, P<.20) were included in a multivariable model. The resulting significant predictors were assigned an integer score to stratify patients into risk groups.

RESULTS

Authors analyzed 164 limbs in 164 patients. Mean age was 80±10 years (range, 40-99). In-hospital mortality was 9.8% (N.=16); AFS at 30 days was 84.7% (N.=139). The anatomic level (iliac vs. femoropopliteal vs. infrapopliteal) of the occlusion did not affect AFS (P=.326). Multivariable analysis identified six significant predictors of AFS at 30 days: age >85 (P=0.050), chronic obstructive pulmonary disease (P=0.008), chronic renal insufficiency (P=0.019), late (>6 hours) onset (P=0.004), the presence of major neurologic deficit (P=0.023), and an increased (>800IU/L) level of creatine phosphokinase (P=0.001). An integer score generated two risk groups (low-risk 0-2 [70.1% of cohort], and high-risk ≥3 [29.9% of cohort]): stratification of the patients according to risk category yielded significantly different AFS at 30 days (low-risk 5.2% vs. high-risk 38.8%, P<0.0001).

CONCLUSIONS

Among patients selected to undergo ThEmb for ATLI in native arteries, this risk score identified a group of patients with a 40% chance of death or major amputation at 30 days. The score can help to optimize the operative strategy, but further prospective validation is needed.

[Impact of quality measurement, transparency and peer review on in-hospital mortality - retrospective before-after study with 63 hospitals]

BACKGROUND

In 2008 the 'Initiative Qualitätsmedizin' (initiative for quality in medical care, IQM) was established as a voluntary non-profit association of hospital providers of all kinds of ownership. Currently, about 350 hospitals from Germany and Switzerland participate in IQM. Member hospitals are committed to a quality strategy based on measuring outcome indicators using administrative data, peer review procedures to improve medical quality, and transparency by public reporting. This study aims to investigate whether voluntary implementation of this approach is associated with improvements in medical outcome.

METHODS

Within a retrospective before-after study 63 hospitals, which started to participate in IQM between 2009 and 2011, were monitored. In-hospital mortality in these hospitals was studied for 14 selected inpatient services in comparison to the German national average. The analyses examine whether in-hospital mortality declined after participation of the studied hospitals in IQM, independently of secular trends or deviations in case mix when compared to the national average, and whether such findings were associated with initial hospital performance or peer review procedures.

RESULTS

Declining in-hospital mortality was observed in hospitals with initially subpar performance. These declines were statistically significant for treatment of myocardial infarction, heart failure, pneumonia, and septicemia. Similar, but statistically non-significant trends were observed for nine further treatments. Following peer-review procedures significant declines in in-hospital mortality were observed for treatments of myocardial infarction, heart failure, and pneumonia. Mortality declines after peer reviews regarding stroke, hip fracture and colorectal resection were not significant, and after peer reviews regarding mechanically ventilated patients no changes were observed.

CONCLUSION

The results point to a positive impact of the quality approach applied by IQM on clinical outcomes. A more targeted selection of hospitals to be peer-reviewed might further enhance the impact of this approach.

Using Surgeon-Specific Outcome Reports and Positive Deviance for Continuous Quality Improvement

BACKGROUND

Using the thoracic morbidity and mortality classification to document all postoperative adverse events between October 2012 and February 2014, we created surgeon-specific outcome reports (SSORs) to promote self-assessment and to implement a divisional continuous quality improvement (CQI) program, on the construct of positive deviance, to improve individual surgeon's clinical performance.

METHODS

Mixed-methods study within a division of six thoracic surgeons, involving (1) development of real-time, Web-based, risk-adjusted SSORs; (2) implementation of CQI seminars (n = 6; September 2013 to June 2014) for evaluation of results, collegial discussion on quality improvement based on identification of positive outliers, and selection of quality indicators for future discussion; and (3) in-person interviews to identify facilitators and barriers to using SSORs and CQI. Interview transcripts were analyzed using thematic analysis.

RESULTS

Interviews revealed enthusiastic support for SSORs as a means to improve patient care through awareness of personal outcomes with blinded divisional comparison for similar operations and diseases, and apply the learning objectives to continuous professional development and maintenance of certification. Perceived limitations of SSORs included difficulty measuring surgeon expertise, limited understanding of risk adjustment, resistance to change, and belief that knowledge of sensitive data could lead to punitive actions. All surgeons believed CQI seminars led to collegial discussions, whereas perceived limitations included quorum participation and failing to circle back on actionable items.

CONCLUSIONS

Real-time performance feedback using SSORs can motivate surgeons to improve their practice, and CQI seminars offer the opportunity to review and interpret results and address issues in a supportive environment. Whether SSORs and CQI can lead to improvements in rates of postoperative adverse events is a matter of ongoing research.

Pretreatment health measures and complications after surgical management of elderly women with breast cancer

BACKGROUND

Elderly patients with breast cancer are less likely to be offered surgery, partly owing to co-morbidities and reduced functional ability. However, there is little consensus on how best to assess surgical risk in this patient group.

METHODS

The ability of pretreatment health measures to predict complications was investigated in a prospective cohort study of a consecutive series of women aged at least 70 years undergoing surgery for operable (stage I-IIIa) breast cancer at 22 English breast units between 2010 and 2013. Data on treatment, surgical complications, health measures and tumour characteristics were collected by case-note review and/or patient interview. Outcome measures were all complications and serious complications within 30 days of surgery.

RESULTS

The study included 664 women. One or more complications were experienced by 41·0 per cent of the patients, predominantly seroma or primary/minor infections. Complications were serious in 6·5 per cent. More extensive surgery predicted a higher number of complications, but not serious complications. Older age did not predict complications. Several health measures were associated with complications in univariable analysis, and were included in multivariable analyses, adjusting for type/extent of surgery and tumour characteristics. In the final models, pain predicted a higher count of complications (incidence rate ratio 1·01, 95 per cent c.i. 1·00 to 1·01; P = 0·004). Fatigue (odds ratio (OR) 1·02, 95 per cent c.i. 1·01 to 1·03; P = 0·004), low platelet count (OR 4·19, 1·03 to 17·12: P = 0·046) and pulse rate (OR 0·96, 0·93 to 0·99; P = 0·010) predicted serious complications.

CONCLUSION

The risk of serious complications from breast surgery is low for older patients. Surgical decisions should be based on patient fitness rather than age. Health measures that predict surgical risk were identified in multivariable models, but the effects were weak, with 95 per cent c.i. close to unity.