Non-inferiority of retrospective data collection for assessing perioperative morbidity

PREPARE trial: a protocol for a multicentre randomised trial of frailty-focused preoperative exercise to decrease postoperative complication rates and disability scores

INTRODUCTION

Frailty is a strong predictor of adverse postoperative outcomes. Prehabilitation may improve outcomes after surgery for older people with frailty by addressing physical and physiologic deficits. The objective of this trial is to evaluate the efficacy of home-based multimodal prehabilitation in decreasing patient-reported disability and postoperative complications in older people with frailty having major surgery.

METHODS AND ANALYSIS

We will conduct a multicentre, randomised controlled trial of home-based prehabilitation versus standard care among consenting patients >60 years with frailty (Clinical Frailty Scale>4) having elective inpatient major non-cardiac, non-neurologic or non-orthopaedic surgery. Patients will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of >3 weeks of prehabilitation (exercise (strength, aerobic and stretching) and nutrition (advice and protein supplementation)). The study has two primary outcomes: in-hospital complications and patient-reported disability 30 days after surgery. Secondary outcomes include survival, lower limb function, quality of life and resource utilisation. A sample size of 750 participants (375 per arm) provides >90% power to detect a minimally important absolute difference of 8 on the 100-point patient-reported disability scale and a 25% relative risk reduction in complications, using a two-sided alpha value of 0.025 to account for the two primary outcomes. Analyses will follow intention to treat principles for all randomised participants. All participants will be followed to either death or up to 1 year.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Clinical Trials Ontario (Project ID: 1785) and our ethics review board (Protocol Approval #20190409-01T). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media.

TRIAL REGISTRATION NUMBER

NCT04221295.

Using the Postoperative Morbidity Survey to Measure Morbidity After Cranial Neurosurgery

BACKGROUND

The incidence of morbidity after cranial neurosurgery is significant, reported in up to a quarter of patients depending on methodology used. The Postoperative Morbidity Survey (POMS) is a reliable method for identifying clinically relevant postsurgical morbidity using 9 organ system domains. The primary aim of this study was to quantify early morbidity after cranial neurosurgery using POMS. The secondary aims were to identify non-POMS-defined morbidity and association of POMS with postoperative hospital length of stay (LOS).

MATERIALS AND METHODS

A retrospective electronic health care record review was conducted for all patients who underwent elective or expedited major cranial surgery over a 3-month period. Postsurgical morbidity was quantified on postoperative days (D) 1, 3, 5, 8, and 15 using POMS. A Poisson regression model was used to test the correlation between LOS and total POMS scores on D1, 3 and 5. A further regression model was used to test the association of LOS with specific POMS domains.

RESULTS

A total of 246 patients were included. POMS-defined morbidity was 40%, 30%, and 33% on D1, D3, and D8, respectively. The presence of POMS morbidity on these days was associated with longer median (range) LOS: D1 6 (1 to 49) versus 4 (2 to 45) days; D3 8 (4 to 89) versus 6 (4 to 35) days; D5 14 (5 to 49) versus 8.5 (6 to 32) days; D8 18 (9 to 49) versus 12.5 (9 to 32) days (P<0.05). Total POMS score correlated with overall LOS on D1 (P<0.001), D3 (P<0.001), and D5 (P<0.001). A positive response to the "infectious" (D1, 3), "pulmonary" (D1), and "renal" POMS items (D1) were associated with longer LOS.

CONCLUSION

Although our data suggests that POMS is a useful tool for measuring morbidity after cranial neurosurgery, some important morbidity items that impact on LOS are missed. A neurosurgery specific tool would be of value.

Development and Validation of an Electronic Postoperative Morbidity Score

BACKGROUND

Electronic health records are being adopted due to numerous potential benefits. This requires the development of objective metrics to characterize morbidity, comparable to studies performed in centers without an electronic health record. We outline the development of an electronic version of the postoperative morbidity score for integration into our electronic health record.

METHODS

Twohundred and three frail patients who underwent elective surgery were reviewed. We retrospectively defined postoperative morbidity score on postoperative day 3. We also recorded potential electronic surrogates for morbidities that could not be easily extracted in an objective format. We compared discriminative capability (area under the receiver operator curve) for patients having prolonged length of stay or complex discharge requirements.

RESULTS

One hundred thirty-nine patients (68%) had morbidity in ≥1 postoperative morbidity score domain. Initial electronic surrogates were overly sensitive, identifying 173 patients (84%) as having morbidity. We refined our definitions using backward logistic regression against "gold-standard" postoperative morbidity score. The final electronic postoperative morbidity score differed from the initial version in its definition of cardiac and neurological morbidity. There was no significant difference in the discriminative capability between electronic postoperative morbidity score and postoperative morbidity score for either outcome (area under the receiver operator curve: 0.66 vs 0.66 for complex discharge requirement, area under the receiver operator curve: 0.66 vs 0.67 for a prolonged length of stay; P> .05 for both). Patients with postoperative morbidity score or electronic postoperative morbidity score-defined morbidity on day 3 had increased risk of prolonged length of stay (P < .001 for both).

CONCLUSIONS

We present a variant of postoperative morbidity score based on objective electronic metrics. Discriminative performance appeared comparable to gold-standard definitions for discharge outcomes. Electronic postoperative morbidity score may allow characterization of morbidity within our electronic health record, but further study is required to assess external validity.

SNAP-2 EPICCS: the second Sprint National Anaesthesia Project-EPIdemiology of Critical Care after Surgery: protocol for an international observational cohort study

INTRODUCTION

The admission of high-risk patients to critical care after surgery is a recommended standard of care. Nevertheless, poor compliance against this recommendation has been repeatedly demonstrated in large epidemiological studies. It is unclear whether this is due to reasons of capacity, equipoise, poor quality clinical care or because hospitals are working creatively to create capacity for augmented care on normal surgical wards. The EPIdemiology of Critical Care after Surgery study aims to address these uncertainties.

METHODS AND ANALYSIS

One-week observational cohort study in the UK and Australasia. All patients undergoing inpatient (overnight stay) surgery will be included. All will have prospective data collection on risk factors, surgical procedure and postoperative outcomes including the primary outcome of morbidity (measured using the Postoperative Morbidity Survey on day 7 after surgery) and secondary outcomes including length of stay and mortality. Data will also be collected on critical care referral and admission, surgical cancellations and critical care occupancy. The epidemiology of patient characteristics, processes and outcomes will be described. Inferential techniques (multilevel multivariable regression, propensity score matching and instrumental variable analysis) will be used to evaluate the relationship between critical care admission and postoperative outcome.

ETHICS AND DISSEMINATION

The study has received ethical approval from the National Research Ethics Service in the UK and equivalent in Australasia. The collection of patient identifiable data without prior consent has been approved by the Confidentiality Advisory Group (England and Wales) and the Public Privacy and Patient Benefit Panel (Scotland). In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences.

Postoperative complications in individuals aged 70 and over undergoing elective surgery for colorectal cancer

AIM

This study aims to describe the nature, incidence, severity and outcomes of in-hospital postoperative complications (POCs) in older patients undergoing elective surgery for colorectal cancer.

METHOD

Patients ≥ 70 years old were identified from a prospectively collected database (2009-2015) focusing on the implementation of geriatric screening and assessment in patients with cancer. Medical and surgical POCs were retrieved retrospectively from the medical records, and the severity of the POCs was graded by the Clavien-Dindo (CD) grading system. The following outcomes were analysed comparing patients with and without CD ≥ 2 and CD ≥ 3 POCs: length of stay (LOS), transfer to the intensive care unit, 30-day readmission rates, 30-day and 1-year mortality.

RESULTS

In the 190 patients included, medical POCs (40.5%) were more frequent than surgical POCs (17.9%), and 37.9% experienced CD ≥ 2 POCs. The most common medical POCs were infections (26.8%), transient confusion or altered mental function (12.1%), cardiac arrhythmia (4.7%), and ileus/gastroparesis/prolonged recovery of transit (4.7%). The most common surgical POCs were surgical site infections (12.1%), wound dehiscence/bleeding (4.7%), anastomotic leak (3.7%) and surgical site bleeding (3.7%). The reoperation rate was 7.9%. CD ≥ 2 POCs led to 11 intensive care unit admissions and increased median postoperative LOS by 114% (P < 0.0001 for both), but did not significantly alter 30-day readmission and 30-day and 1-year mortality rates. CD ≥ 3 POCs increased LOS by 162% (P < 0.0001) and showed an increased 1-year mortality (P = 0.07).

CONCLUSION

This study shows that in-hospital medical and surgical complications after surgery for colorectal cancer in patients ≥ 70 years old are frequent and that complications lead to less favourable outcomes.