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Mlaver E, Sweeney JF. Establishing a culture of highly reliable quality care. Surgery 2024; 175:1229-1231. [PMID: 37953142 DOI: 10.1016/j.surg.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 11/14/2023]
Abstract
Reliability is the likelihood that a process will perform a required function without failure, consistent over time and personnel changes. In the rapidly evolving healthcare landscape, reliably delivering excellent surgical care demands a comprehensive and systematic approach. Accomplishing this task is beyond the reach of any individual clinician, administrator, or leader. The team must work together to establish a highly reliable quality care culture that serves as the foundation for safe, patient-centered practice. High reliability thus inherently relies on transdisciplinary collaboration, with every level of clinical, administrative, and regulatory team members actively communicating, supporting each other, and building trust in each other's expertise. Here, we discuss the fundamentals of establishing a highly reliable quality care culture. We outline the key principles of a highly reliable organization - preoccupation with failure, sensitivity to operations, reluctance to oversimplify, commitment to resilience, and deference to expertise - and the characteristics of teams that can effectively implement these principles. We discuss the importance of standardization, continuous process and outcome measurement, and setting collective goals. And finally, we exemplify these fundamentals through a brief case study. In outlining these foundational concepts for today's care, we also look forward to the impact of big data, artificial intelligence, and interconnectedness on our future continuous quality improvement efforts. Within the myriad complexities of surgical care, there are bound to be adverse outcomes, but by instilling a culture of highly reliable quality care, we can do our best to minimize their frequency, mitigate their harm, and optimize outcomes.
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Affiliation(s)
- Eli Mlaver
- Department of Surgery, Emory University School of Medicine, Atlanta, GA.
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA. https://twitter.com/EmorySurgery
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Smith SR, Blair CM, Lovasik BP, Little LA, Sweeney JF, Sarmiento JM. Use of Perioperative Advanced Practice Providers to Reduce Cost and Readmission in the Postoperative Hepatopancreatobiliary Population: Results of a Simulation Study. J Am Coll Surg 2024; 238:313-320. [PMID: 37930898 DOI: 10.1097/xcs.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND Postoperative healthcare use and readmissions are common among the hepatopancreatobiliary (HPB) population. We evaluated the surgical volume required to sustain advanced practice providers (APPs) in the perioperative setting for cost reduction. STUDY DESIGN Using decision analysis modeling, we evaluated costs of employing dedicated perioperative APP navigators compared with no APPs navigators. Simulated subjects could: (1) present to an emergency department, with or without readmission, (2) present for direct readmission, (3) require additional office visits, or (4) require no additional care. We informed our model using the most current available published data and performed sensitivity analyses to evaluate thresholds under which dedicated perioperative APP navigators are beneficial. RESULTS Subjects within the APP navigator cohort accumulated $1,270 and a readmission rate of 6.9%, compared with $2,170 and 13.5% with no APP navigators, yielding a cost savings of $905 and 48% relative reduction in readmission. Based on these estimated cost savings and national salary ranges, a perioperative APPs become financially self-sustaining with 113 to 139 annual HPB cases, equating to 2 to 3 HPB cases weekly. Sensitivity analyses revealed that perioperative APP navigators were no longer cost saving when direct readmission rates exceeded 8.9% (base case 3.7%). CONCLUSIONS We show that readmissions are reduced by nearly 50% with an associated cost savings of $900 when employing dedicated perioperative APPs. This position becomes financially self-sufficient with an annual HPB case load of 113 to 139 cases. High-volume HPB centers could benefit from postdischarge APP navigators to optimize outcomes, minimize high-value resource use, and ultimately save costs.
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Affiliation(s)
- Savannah R Smith
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Catherine M Blair
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Brendan P Lovasik
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Lori A Little
- Winship Cancer Institute (Little, Sarmiento), Emory University, Atlanta, GA
| | - John F Sweeney
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Juan M Sarmiento
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
- Winship Cancer Institute (Little, Sarmiento), Emory University, Atlanta, GA
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Codner JA, Mlaver E, Solomon G, Saeed M, Di M, Shaffer VO, Dente CJ, Sweeney JF, Patzer RE, Sharma J. Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative. Surg Infect (Larchmt) 2024; 25:63-70. [PMID: 38157325 DOI: 10.1089/sur.2023.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.
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Affiliation(s)
- Jesse A Codner
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Eli Mlaver
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Gina Solomon
- Georgia Trauma Commission, Atlanta, Georgia, USA
| | - Muhammad Saeed
- Department of Surgery, Augusta University, Augusta, Georgia, USA
| | - Mengyu Di
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | | | - John F Sweeney
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Rachel E Patzer
- Department of Surgery, Emory University, Atlanta, Georgia, USA
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Mlaver E, Lynde GC, Sweeney JF, Sharma J. Generalizability of COBRA: A Parsimonious Perioperative Venous Thromboembolism Risk Assessment Model. J Surg Res 2024; 293:8-13. [PMID: 37690384 PMCID: PMC10843055 DOI: 10.1016/j.jss.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 06/30/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Standardized use of venous thromboembolism (VTE) risk assessment models (RAMs) in surgical patients has been limited, in part due to the cumbersome workflow addition required to use available models. The COBRA score-capturing cancer diagnosis, (old) age, body mass index, race, and American Society of Anesthesiologists Physical Status score-has been reported as a potentially automatable VTE RAM that circumvents the cumbersome workflow addition that most RAMs represent. We aimed to test the ability of the COBRA model to effectively risk-stratify patients across various populations. METHODS Patients were included from the 2014-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Participant Use Data File for two hospitals, representing colorectal, endocrine, breast, transplant, plastic, and general surgery services. COBRA score was calculated for each patient using preoperative characteristics. We calculated negative predictive value (NPV) for VTE outcomes and compared the COBRA score to NSQIP's expected VTE rate for all patients, between the two hospitals, and between subspecialty service lines. RESULTS Of the 10,711 patients included, those with COBRA <4 (31%) had projected median VTE rate of 0.21% (interquartile range, 0.09-0.68%; mean, 0.54%). Patients with higher scores (69%) had median rate of 0.88% (0.26-2.07%; 1.46%); relative rate 2.7. The median projected VTE rates for patients identified as low risk were 0.21% and 0.16% and as high risk were 0.87% and 0.89% at hospitals one and 2, respectively. The median projected VTE rates for patients identified as low risk were 0.17%, 0.61%, and 0.08% and as high risk were 0.52%, 1.43%, and 0.18% among general, colorectal, and endocrine surgery patients, respectively. COBRA had NPV of 0.995 and sensitivity of 0.871 as compared to NPV 0.997 and sensitivity 0.857 of the NSQIP model. CONCLUSIONS The COBRA score is concordant with the traditional gold standard NSQIP VTE RAM and demonstrates interhospital and service-specific generalizability, although performance was limited in especially low-risk patients. The model adequately risk-stratifies surgical patients preoperatively, potentially providing clinical decision support for perioperative workflows.
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Affiliation(s)
- Eli Mlaver
- Department of Surgery, Emory University Hospital, Atlanta, Georgia.
| | - Grant C Lynde
- Department of Anesthesiology, Emory University Hospital, Atlanta, Georgia
| | - John F Sweeney
- Department of Surgery, Emory University Hospital, Atlanta, Georgia
| | - Jyotirmay Sharma
- Department of Surgery, Emory University Hospital, Atlanta, Georgia
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Mou D, Kumarasamy M, Grunewald Z, Cooper K, Fay K, Hall CE, Bibler J, Lin E, Davis S, Sweeney JF, Esper G, Sharma J, Hechenbleikner E. The financial impact of the COVID-19 pandemic on sleeve gastrectomy at a major academic institution. Surg Endosc 2023:10.1007/s00464-023-10183-x. [PMID: 37308762 DOI: 10.1007/s00464-023-10183-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The COVID-19- pandemic significantly impacted metabolic and bariatric surgery (MBS) practices due to large-scale surgery cancellations along with staff and supply shortages. We analyzed sleeve gastrectomy (SG) hospital-level financial metrics before and after the COVID-19 pandemic. METHODS Hospital cost-accounting software (MicroStrategy, Tysons, VA) was reviewed for revenues, costs, and profits per SG at an academic hospital (2017-2022). Actual figures were obtained, not insurance charge estimates or hospital projections. Fixed costs were obtained through surgery-specific allocation of inpatient hospital and operating-room costs. Direct variable costs were analyzed with sub-components including: (1) labor and benefits, (2) implants, (3) drug costs, and 4) medical/surgical supplies. The pre-COVID-19 period (10/2017-2/2020) and post-COVID-19 period (5/2020-9/2022) financial metrics were compared with student's t-test. Data from 3/2020 to 4/2020 were excluded due to COVID-19-related changes. RESULTS A total of 739 SG patients were included. Average length of stay (LOS), Center for Medicaid and Medicare Case Mix Index (CMI), and percentage of patients with commercial insurance were similar pre vs. post-COVID-19 (p > 0.05). There were more SG performed per quarter pre-COVID-19 than post-COVID-19 (36 vs. 22; p = 0.0056). Pre-COVID-19 and post-COVID-19 financial metrics per SG differed significantly for, respectively, revenues ($19,134 vs. $20,983) total variable cost ($9457 vs. $11,235), total fixed cost ($2036 vs. $4018), total profit ($7571 vs. $5442), and labor and benefits cost ($2535 vs. $3734; p < 0.05). CONCLUSIONS The post-COVID-19 period was characterized by significantly increased SG fixed cost (i.e., building maintenance, equipment, overhead) and labor costs (increased contract labor), resulting in precipitous profit decline that crosses the break-even in calendar year quarter (CQ) 3, 2022. Potential solutions include minimizing contract labor cost and decreasing LOS.
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Affiliation(s)
- Danny Mou
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA.
| | - Mathu Kumarasamy
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
- Office of Quality, Emory Healthcare, Atlanta, GA, USA
| | - Zachary Grunewald
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
| | - Kristin Cooper
- Finance Department, Emory Healthcare Hospital, Atlanta, GA, USA
| | - Katherine Fay
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
| | - Carrie E Hall
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
| | - Jennifer Bibler
- Finance Department, Emory Healthcare Hospital, Atlanta, GA, USA
| | - Edward Lin
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
| | - Scott Davis
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
| | - John F Sweeney
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
| | - Gregory Esper
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - Jyotirmay Sharma
- Department of Surgery, Emory University, 1364 Clifton Rd, Atlanta, GA, 30322, USA
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Mustansir F, Jajja MR, Lovasik BP, Sharma J, Lin E, Sweeney JF, Sarmiento JM. Does CPT Modifier 22 Appropriately Reflect a Difficult Pancreaticoduodenectomy? Retrospective Analysis of Operative Outcomes and Cost. J Am Coll Surg 2023; 236:993-1000. [PMID: 36735633 DOI: 10.1097/xcs.0000000000000609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND CPT coding allows addition of a 2-digit modifier code to denote particularly difficult procedures necessitating additional reimbursement, called the modifier 22. The use of modifier 22 in relation to pancreatic surgery and outcomes, specifically pancreaticoduodenectomy (PD), has not been explored. STUDY DESIGN All PDs performed from 2010 to 2019 at a quaternary healthcare system were analyzed for differences in preoperative characteristics, outcomes, and cost based on the use of modifier 22. Adjusted logistic regression analysis was used to identify factors predictive of modifier 22 use. RESULTS A total of 1,284 patients underwent PD between 2010 and 2019; 1,173 with complete data were included, of which 320 (27.3%) were coded with modifier 22. Patients coded with modifier 22 demonstrated a significantly longer duration of surgery (365.9 ± 168.4 vs 227 ± 97.1; p < 0.001). They also incurred significantly higher cost of index admission ($37,446 ± 34,187 vs $28,279 ± 27,980; p = 0.002). An adjusted multivariable analysis (specifically adjusted for surgeon variation) revealed duration of surgery (p < 0.001), neoadjuvant chemotherapy (p = 0.039), class II obesity (p = 0.019), and chronic pancreatitis (p = 0.005) to be predictive of modifier 22 use. CONCLUSIONS Despite the subjective nature of this CPT modifier, modifier 22 is an appropriate marker of intraoperative difficulty. Preoperative and intraoperative characteristics that lead to its addition may be used to further delineate difficult PDs.
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Affiliation(s)
- Fatima Mustansir
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Mohammad Raheel Jajja
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Brendan P Lovasik
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Jyotirmay Sharma
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Edward Lin
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - John F Sweeney
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Juan M Sarmiento
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
- Winship Cancer Institute (Sarmiento), Emory University, Atlanta, GA
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Labib JY, Lovasik BP, Lad N, Saltalamacchia J, Maithel SK, Sarmiento JM, Staley CA, Sweeney JF, Kooby DA. Implications of leukocytosis following distal pancreatectomy splenectomy (DPS) and association with postoperative complications. J Surg Oncol 2022; 126:1012-1020. [PMID: 35765934 DOI: 10.1002/jso.26988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/19/2022] [Accepted: 06/11/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Early identification of complications after distal pancreatectomy splenectomy (DPS) poses challenges, as white blood cell count (WBC) is confounded by physiologic leukocytosis. We examined WBC patterns associated with complications after DPS. METHODS Clinicopathologic data were collected for patients who underwent DPS in our system from 2009 to 2016. We examined WBC, temperature, platelet count (PC), and ratios of these variables as potential early indicators of patients at risk of infections or major complications (MCs). RESULTS 348 patients met study inclusion, of whom 206 (59%) were women and the median patient age was 59 ± 15 years. Infectious and MC rates were 11% and 16%, respectively, with <1% 30-day mortality. Postoperative WBC peaks were higher in patients with infections and MCs compared with no complication (23 vs. 17, p < 0.0001). WBC peak timing occurred postoperative day (POD) 2-3 for uncomplicated cases while peaks occurred POD9 for patients with infections and MCs. DISCUSSION These data define patterns of leukocytosis following DPS. Although differences in infection markers were identified for patients with and without complications, no obvious thresholds were identified. Clinical suspicion for complications after DPS remains our best tool for early identification.
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Affiliation(s)
- Jessica Y Labib
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | - Neha Lad
- Department of Transplant and HPB Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Julia Saltalamacchia
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Shishir K Maithel
- Department of Surgical Oncology, Emory University Winship Cancer Institute, Atlanta, Georgia, USA
| | | | - Charles A Staley
- Department of Surgical Oncology, Emory University Winship Cancer Institute, Atlanta, Georgia, USA
| | - John F Sweeney
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - David A Kooby
- Department of Surgical Oncology, Emory University Winship Cancer Institute, Atlanta, Georgia, USA
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Codner JA, Falconer EA, Ashley DW, Sweeney JF, Saeed MI, Langer JM, Shaffer VO, Finley CR, Solomon G, Sharma J. Georgia Quality Improvement Programs Multi-Institutional Collection of Postoperative Opioid Data Using ACS-NSQIP Abstraction. Am Surg 2022; 88:1510-1516. [PMID: 35333645 DOI: 10.1177/00031348221082286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Excessive postoperative opioid prescribing contributes to opioid misuse throughout the US. The Georgia Quality Improvement Program (GQIP) is a collaboration of ACS-NSQIP participating hospitals. GQIP aimed to develop a multi-institutional opioid data collection platform as well as understand our current opioid-sparing strategy (OSS) usage and postoperative opioid prescribing patterns. METHODS This study was initiated 7/2019, when 4 custom NSQIP variables were developed to capture OSS usage and postoperative opioid oral morphine equivalents (OMEs). After pilot collection, our discharge opioid variable required optimization for adequate data capture and was expanded from a free text option to 4 drop-down selection variables. Data collection then continued from 2/2020-5/2021. Logistic regression was used to determine associations with OSS usage. Average OMEs were calculated for common general surgery procedures and compared to national guidelines. RESULTS After variable optimization, the percentage where a total discharge prescription OME could be calculated increased from 26% to 70% (P < .001). The study included 820 patients over 10 operations. There was a significant variation in OSS usage between GQIP centers. Laparoscopic cases had higher odds of OSS use (1.92 (1.38-2.66)) while OSS use had lower odds in black patients on univariate analysis (.69 (.51-.94)). On average 7 out of the 10 cases had higher OMEs prescribed compared to national guidelines recommendations. CONCLUSION Developing a multi-institutional opioid data collection platform through ACS-NSQIP is feasible. Preselected drop-down boxes outperform free text variables. GQIP future quality improvement targets include variation in OSS use and opioid overprescribing.
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Affiliation(s)
- Jesse A Codner
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Elissa A Falconer
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Dennis W Ashley
- Department of Surgery, 5223Navicent Health Medical Center, Macon, GA, USA
| | - John F Sweeney
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Muhammad I Saeed
- Department of Surgery, 1421Augusta University School of Medicine, Augusta, GA, USA
| | - Jason M Langer
- Department of Surgery, 232321Phoebe Putney Memorial, Albany, GA, USA
| | - Virginia O Shaffer
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Charles R Finley
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Gina Solomon
- Department of Surgery, Georgia Quality Improvement Program, Atlanta, GA, USA
| | - Jyotirmay Sharma
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
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Simpson F, Sweeney JF, Shaffer V, Sharma J. Redesigning a More Actionable, Service Line Specific, Surgical Performance Dashboard for an Academic Referral Hospital by Adding Severity of Post-Operative Complications. Am Surg 2022; 88:571-577. [PMID: 35287494 DOI: 10.1177/00031348211061694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Francis Simpson
- Department of Surgery in Atlanta, 12239Emory University, Atlanta, GA, USA
| | - John F Sweeney
- Department of Surgery in Atlanta, 12239Emory University, Atlanta, GA, USA
| | - Virginia Shaffer
- Department of Surgery in Atlanta, 12239Emory University, Atlanta, GA, USA
| | - Jyotirmay Sharma
- Department of Surgery in Atlanta, 12239Emory University, Atlanta, GA, USA
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Sweeney JF. Invited Commentary. J Am Coll Surg 2021; 232:543-544. [PMID: 33771311 DOI: 10.1016/j.jamcollsurg.2020.12.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
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Affiliation(s)
- Jessica Y Liu
- American College of Surgeons, Chicago, Illinois.,Department of Surgery, Emory University, Atlanta, Georgia
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Chicago, Illinois
| | | | - Karl Bilimoria
- American College of Surgeons, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois.,David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles
| | - John F Sweeney
- Department of Surgery, Emory University, Atlanta, Georgia
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Cox JC, Leeds IL, Sadiraj V, Schnier KE, Sweeney JF. Effects of patients' hospital discharge preferences on uptake of clinical decision support. PLoS One 2021; 16:e0247270. [PMID: 33684144 PMCID: PMC7939268 DOI: 10.1371/journal.pone.0247270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/03/2021] [Indexed: 11/23/2022] Open
Abstract
The Centers for Medicare and Medicaid Services identified unplanned hospital readmissions as a critical healthcare quality and cost problem. Improvements in hospital discharge decision-making and post-discharge care are needed to address the problem. Utilization of clinical decision support (CDS) can improve discharge decision-making but little is known about the empirical significance of two opposing problems that can occur: (1) negligible uptake of CDS by providers or (2) over-reliance on CDS and underuse of other information. This paper reports an experiment where, in addition to electronic medical records (EMR), clinical decision-makers are provided subjective reports by standardized patients, or CDS information, or both. Subjective information, reports of being eager or reluctant for discharge, was obtained during examinations of standardized patients, who are regularly employed in medical education, and in our experiment had been given scripts for the experimental treatments. The CDS tool presents discharge recommendations obtained from econometric analysis of data from de-identified EMR of hospital patients. 38 clinical decision-makers in the experiment, who were third and fourth year medical students, discharged eight simulated patient encounters with an average length of stay 8.1 in the CDS supported group and 8.8 days in the control group. When the recommendation was “Discharge,” CDS uptake of “Discharge” recommendation was 20% higher for eager than reluctant patients. Compared to discharge decisions in the absence of patient reports: (i) odds of discharging reluctant standardized patients were 67% lower in the CDS-assisted group and 40% lower in the control (no-CDS) group; whereas (ii) odds of discharging eager standardized patients were 75% higher in the control group and similar in CDS-assisted group. These findings indicate that participants were neither ignoring nor over-relying on CDS.
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Affiliation(s)
- James C. Cox
- Department of Economics and Experimental Economics Center, Georgia State University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Ira L. Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Vjollca Sadiraj
- Department of Economics and Experimental Economics Center, Georgia State University, Atlanta, Georgia, United States of America
| | - Kurt E. Schnier
- Department of Economics and Business Management, University of California – Merced, Merced, California, United States of America
| | - John F. Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, United States of America
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Davis SS, Williford ML, Isenburg S, Klopman M, Sweeney JF, Boden SD. A scalable tool for adjudication of time sensitive cases during COVID-19 pandemic. Surg Endosc 2020; 35:5626-5634. [PMID: 33078226 PMCID: PMC7571307 DOI: 10.1007/s00464-020-08073-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/30/2020] [Indexed: 11/24/2022]
Abstract
Background During the COVID-19 pandemic, prioritization of care and utilization of scarce resources are daily considerations in healthcare systems that have never experienced these issues before. Elective surgical cases have been largely postponed, and surgery departments are struggling to correctly and equitably determine which cases need to proceed. A resource to objectively prioritize and track time sensitive cases would be useful as an adjunct to clinical decision-making. Methods A multidisciplinary working group at Emory Healthcare developed and implemented an adjudication tool for the prioritization of time sensitive surgeries. The variables identified by the team to form the construct focused on the patient’s survivability according to actuarial data, potential impact on function with delay in care, and high-level biology of disease. Implementation of the prioritization was accomplished with a database design to streamline needed communication between surgeons and surgical adjudicators. All patients who underwent time sensitive surgery between 4/10/20 and 6/15/20 across 5 campuses were included. Results The primary outcomes of interest were calculated patient prioritization score and number of days until operation. 1767 cases were adjudicated during the specified time period. The distribution of prioritization scores was normal, such that real-time adjustment of the empiric algorithm was not required. On retrospective review, as the patient prioritization score increased, the number of days to the operating room decreased. This confirmed the functionality of the tool and provided a framework for organization across multiple campuses. Conclusions We developed an in-house adjudication tool to aid in the prioritization of a large cohort of canceled and time sensitive surgeries. The tool is relatively simple in its design, reproducible, and data driven which allows for an objective adjunct to clinical decision-making. The database design was instrumental in communication optimization during this chaotic period for patients and surgeons.
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Affiliation(s)
- S Scott Davis
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia. .,Department of Surgery, Emory School of Medicine, 1365 Clifton Road, Suite A4200, 30322, Atlanta, GA, Georgia.
| | - Michael L Williford
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Matthew Klopman
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Scott D Boden
- Department of Orthopedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Abstract
INTRODUCTION Standardization of preoperative venous thromboembolism (VTE) risk assessment remains challenging due to variation in risk assessment models (RAMs) and the cumbersome workflow addition that most RAMs represent. We aimed to develop a parsimonious RAM that is automatable and actionable within the preoperative workflow. METHODS We performed a case-controlled review of all 18 VTE cases reported over a 12-month period and 171 matched controls included in an institutional National Surgical Quality Improvement Project (NSQIP) data set. We examined the predictive value of the Caprini, Padua, and NSQIP RAMs. We identified the 5 most impactful risk factors in VTE development by contribution to the known RAMs. We compared the predictive ability of cancer, age, body mass index, black race, and American Society of Anesthesiologists Physical Status (ASA-PS) score, to the Caprini, Padua, and NSQIP RAMs for VTE outcomes. Finally, we evaluated concordance between each of the models. RESULTS The Caprini Score was found to be 88.9% sensitive and 32.7% specific using a threshold of 5. The Padua score was found to be 61.1% sensitive and 47.4% specific using a threshold of 4. The novel 5-factor RAM was found to be 94.4% sensitive and 38.0% specific using a threshold of 4. The Caprini and Padua models were discordant in 26% of patients. DISCUSSION Cumbersome manual data entry contributes to the ongoing challenge of standardized VTE risk assessment and prophylaxis. Universally documented information and patient demographics can be utilized to create clinical decision support tools that can improve the efficiency of perioperative workflow and improve the quality of care.
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Affiliation(s)
- Eli Mlaver
- 1371 Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Grant C Lynde
- 1371 Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - John F Sweeney
- 1371 Department of Surgery, Emory University, Atlanta, GA, USA
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Affiliation(s)
- John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Lovasik BP, Blair CM, Little LA, Sellers M, Sweeney JF, Sarmiento JM. Reduction in Post-Discharge Return to Acute Care in Hepatopancreatobiliary Surgery: Results of a Quality Improvement Initiative. J Am Coll Surg 2020; 231:231-238. [DOI: 10.1016/j.jamcollsurg.2020.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
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Tariq M, Jajja MR, Maxwell DW, Galindo RJ, Sweeney JF, Sarmiento JM. Diabetes development after distal pancreatectomy: results of a 10 year series. HPB (Oxford) 2020; 22:1034-1041. [PMID: 31718897 DOI: 10.1016/j.hpb.2019.10.2440] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/05/2019] [Accepted: 10/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Limited literature is available on the postoperative development of impaired glucose tolerance (IGT) and new-onset diabetes mellitus (NODM) following Distal Pancreatectomy (DP). We aimed to study the post-surgical clinical evolution of IGT/DM and its association with preoperative glycemic profiles of patients undergoing DP. METHODS Pre- and postoperative glycemic laboratories were measured in patients undergoing DP by the senior author from 2007-2017. Multivariate risk factor analysis was performed to determine risk factors for new-onset IGT/DM after DP. Kaplan-Meier curves were constructed for development of NODM postoperatively. RESULTS Of 216 included patients, n = 63, n = 68 and n = 85 were preoperatively diagnosed with no-diabetes (No-DM), pre-diabetes (Pre-DM), and diabetes (DM), respectively. At 2-year follow-up, n = 37, n = 80 and n = 99 were classified as No-DM, Pre-DM or DM, respectively. Pre-diabetics had a higher risk of developing postoperative dysglycemia (RR 2.230, 95% CI 1.732-2.870, p = 0.001). Preoperative OGTT>130, HbA1c >6.0, and chronic pancreatitis were risk factors for postoperative DM. CONCLUSION 40% of patients undergoing DP were unaware of their dysglycemic status (pre-DM or DM) pre-operatively. At 2-year follow-up, 36% non-diabetic and 57% pre-diabetic patients had developed NODM. Appropriate pre-operative diabetic assessment is warranted for all patients undergoing pancreatic resections.
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Affiliation(s)
- Marvi Tariq
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohammad R Jajja
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel W Maxwell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.
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Shaffer VO, Baptiste CD, Liu Y, Srinivasan JK, Galloway JR, Sullivan PS, Staley CA, Sweeney JF, Sharma J, Gillespie TW. Improving Quality of Surgical Care and Outcomes: Factors Impacting Surgical Site Infection after Colorectal Resection. Am Surg 2020. [DOI: 10.1177/000313481408000823] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Surgical site infections (SSIs) result in patient morbidity and increased costs. The purpose of this study was to determine reasons underlying SSI to enable interventions addressing identified factors. Combining data from the American College of Surgeons National Surgical Quality Improvement Project with medical record extraction, we evaluated 365 patients who underwent colon resection from January 2009 to December 2012 at a single institution. Of the 365 patients, 84 (23%) developed SSI. On univariate analysis, significant risk factors included disseminated cancer, ileostomy, patient temperature less than 36°C for greater than 60 minutes, and higher glucose level. The median number of cases per surgeon was 36, and a case volume below the median was associated with a higher risk of SSI. On multivariate analysis, significant risks associated with SSI included disseminated cancer (odds ratio [OR], 4.31; P < .001); surgery performed by a surgeon with less than 36 cases (OR, 2.19; P = .008); higher glucose level (OR, 1.06; P 5.017); and transfusion of five units or more of blood (OR, 3.26; P 5.029). In this study we found both modifiable and unmodifiable factors associated with increased SSI. Identifying modifiable risk factors enables targeting specific areas to improve the quality of care and patient outcomes.
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Affiliation(s)
| | | | - Yuan Liu
- From Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | | | - Joe Sharma
- From Emory University School of Medicine, Atlanta, Georgia
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Maxwell DW, Jajja MR, Galindo RJ, Zhang C, Nadeem SO, Sweeney JF, Blair CM, Sarmiento JM. Post-Pancreatectomy Diabetes Index: A Validated Score Predicting Diabetes Development after Major Pancreatectomy. J Am Coll Surg 2020; 230:393-402.e3. [DOI: 10.1016/j.jamcollsurg.2019.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 01/22/2023]
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20
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Enofe N, Howard DH, Kumarusamy MA, Sullivan PS, Srinivasan JK, Staley CA, Esper GJ, Sweeney JF, Sharma J, Shaffer VO. Decreasing Hospital Readmission in Ileostomy Patients: A Follow-Up Study of a Novel Pilot Program. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Maxwell DW, Jajja MR, Hashmi SS, Lin E, Srinivasan JK, Sweeney JF, Sarmiento JM. The hidden costs of open hepatectomy: A 10-year, single institution series of right-sided hepatectomies. Am J Surg 2019; 219:110-116. [PMID: 31495449 DOI: 10.1016/j.amjsurg.2019.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/29/2019] [Accepted: 08/19/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Incisional ventral hernias(IVH) are a common complication following open abdominal surgery. The aim of this study was to uncover the hidden costs of IVH following right-sided hepatectomy. METHODS Outcomes and hospital billing data for patients undergoing open(ORH) and laparoscopic right-sided hepatectomies(LRH) were reviewed from 2008 to 2018. RESULTS Of 327 patients undergoing right-sided hepatectomies, 231 patients were included into two groups: ORH(n = 118) and LRH(n = 113). Median follow-up-times and time-to-hernia were 24.9-months(0.3-128.4 months) and 40.5-months(0.4-81.4 months), respectively. The incidence of hernias at 1, 3, 5, and 10 years was 6/231(2.6%), 13/231(5.6%), 15(6.5%), and 17/231(7.4%); ORH = 14, LRH = 3, p = 0.003), respectively. In terms of IVH repair(IVHR), total operative costs ($10,719.27vs.$4,441.30,p < 0.001) and overall care costs ($20,541.09vs.$7,149.21,p = 0.044) were significantly greater for patients undergoing ORH. Patients whom underwent ORHs had longer hospital stays and more complications following IVHR. Risk analysis identified ORH(RR-10.860), male gender(RR-3.558), BMI ≥30 kg/m2(RR-5.157), and previous abdominal surgery(RR-6.870) as predictors for hernia development (p < 0.030). CONCLUSION Evaluation of pre-operative hernia risk factors and utilization of a laparoscopic approach to right-sided hepatectomy reduces incisional ventral hernia incidence and cost when repair is needed.
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Affiliation(s)
- Daniel W Maxwell
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Mohammad Raheel Jajja
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Salila S Hashmi
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Edward Lin
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - John F Sweeney
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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22
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Maxwell DW, Jajja MR, Tariq M, Mahmooth Z, Galindo RJ, Sweeney JF, Sarmiento JM. Development of Diabetes after Pancreaticoduodenectomy: Results of a 10-Year Series Using Prospective Endocrine Evaluation. J Am Coll Surg 2019; 228:400-412.e2. [PMID: 30690075 DOI: 10.1016/j.jamcollsurg.2018.12.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Limited literature is available on the development of impaired glucose tolerance and diabetes mellitus after pancreaticoduodenectomy. The primary aim was to define the diabetic phenotype and correlate preoperative glycemic laboratory results to new-onset diabetes after pancreaticoduodenectomy. STUDY DESIGN In this prospective study, perioperative fasting and postprandial (oral glucose tolerance test) plasma glucose, glycated hemoglobin, insulin, and c-peptide were measured in consecutive patients undergoing pancreaticoduodenectomy by the senior author from 2006 to 2017. American Diabetes Association definitions were used for glycemic classifications. Multivariate risk factor analysis was performed. RESULTS Of 774 identified patients, 371 diabetics were excluded and 403 patients were included: 167 and 236 were preoperatively classified as nondiabetic and prediabetic, respectively. The incidence rates of diabetes at 120 months post pancreaticoduodenectomy were 9.0% (nondiabetics), 22.0% (prediabetics), and 16.6% (overall). Patients in whom diabetes developed demonstrated a 3-fold larger difference between oral glucose tolerance test and fasting glucose (Δ), and 2-fold larger Δinsulin and Δc-peptide values. Tiered multivariate analysis identified glycated hemoglobin >5.4% with a relative risk (RR) of 2.944 (p = 0.047) as an independent predictor of impaired glucose tolerance and diabetes mellitus. Analysis of patients stratified by preoperative classification identified fasting glucose >95 mg/dL (nondiabetics, RR 1.925; p = 0.002), and glycated hemoglobin ≥5.4% (prediabetics, RR 3.125; p = 0.040) as independent risk factors for diabetes. Compared with nondiabetics, prediabetics classified by any laboratory results demonstrated an RR of 2.471 (p = 0.001) for diabetes developing postoperatively. There was no association between primary pathology, advancing age, or BMI and increased risk of diabetes development. CONCLUSIONS Diabetes will develop after pancreaticoduodenectomy in approximately 16.6% of patients. A preoperative glycated hemoglobin >5.4% independently predicts new-onset diabetes. Pre- and postoperative endocrine analysis remains paramount for proper patient risk stratification.
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Affiliation(s)
| | - Mohammad Raheel Jajja
- Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA
| | - Marvi Tariq
- Department of Surgery, Emory University, Atlanta, GA
| | | | | | | | - Juan M Sarmiento
- Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA.
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Morse BC, Jhunjhunwala R, Dente CJ, Dougherty S, Nicholas JM, Gelbard RB, Sweeney JF, Wyrzykowski AD. Value Analysis in Acute Care Surgery: Evaluation of Individual Surgeon Performance for Emergent Cholecystectomy. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shah MM, Hunter BW, Sweeney JF, Lin E, Perez SD, Parker C, Davis SS. Operating Room Efficiency in Bariatric Surgery: The Effect of Team Member Experience on Operative Times in Laparoscopic Roux-en-Y Gastric Bypass. Bariatr Surg Pract Patient Care 2017. [DOI: 10.1089/bari.2017.0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mihir M. Shah
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University, Atlanta, Georgia
| | - Ben W. Hunter
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University, Atlanta, Georgia
| | - John F. Sweeney
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University, Atlanta, Georgia
| | - Edward Lin
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University, Atlanta, Georgia
| | - Sebastian D. Perez
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University, Atlanta, Georgia
| | - Cheryl Parker
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University, Atlanta, Georgia
| | - Steven Scott Davis
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University, Atlanta, Georgia
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25
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Cooper WO, Guillamondegui O, Hines OJ, Hultman CS, Kelz RR, Shen P, Spain DA, Sweeney JF, Moore IN, Hopkins J, Horowitz IR, Howerton RM, Meredith JW, Spell NO, Sullivan P, Domenico HJ, Pichert JW, Catron TF, Webb LE, Dmochowski RR, Karrass J, Hickson GB. Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications. JAMA Surg 2017; 152:522-529. [PMID: 28199477 DOI: 10.1001/jamasurg.2016.5703] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Unsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves. Objective To examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations. Design, Setting, and Participants This retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016. Exposures Unsolicited patient observations for the patient's surgeon in the 24 months preceding the date of the operation. Main Outcomes and Measures Postoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest. Results Among the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile. Conclusions and Relevance Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.
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Affiliation(s)
- William O Cooper
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oscar Guillamondegui
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - O Joe Hines
- Division of General Surgery, University of California, Los Angeles Medical Center
| | - C Scott Hultman
- Department of Surgery, University of North Carolina, Chapel Hill
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California
| | - John F Sweeney
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ilene N Moore
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph Hopkins
- Department of Medicine, Stanford University, Stanford, California
| | - Ira R Horowitz
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Russell M Howerton
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - J Wayne Meredith
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Nathan O Spell
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Patricia Sullivan
- Department of Quality and Patient Safety, University of Pennsylvania Health System, Philadelphia
| | - Henry J Domenico
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James W Pichert
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas F Catron
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynn E Webb
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roger R Dmochowski
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee2Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jan Karrass
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gerald B Hickson
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee12Center for Quality, Safety and Risk Prevention, Vanderbilt University Medical Center, Nashville, Tennessee
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Short HL, Parakati I, Heiss KF, Wulkan ML, Sweeney JF, Raval MV. Challenge of balancing duration of stay and readmissions in children's operation. Surgery 2017; 162:950-957. [PMID: 28709646 DOI: 10.1016/j.surg.2017.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgeons balance competing interests of minimizing duration of stay with readmissions. Complications that occur early after discharge often result in readmissions. This study examines the relationship between duration of stay, timing of complications, and readmission risk. METHODS Cases from the 2012-2014 National Surgical Quality Improvement Project-Pediatric were organized into 30 procedural groups. Procedures where duration of stay approximated the median day of complication were identified. A theoretical model was applied to minimize readmissions by extending duration of stay. RESULTS From 30 procedure groups, 3 were identified where duration of stay approximated median day of compilations: complicated appendectomy, antireflux operation, and abdominal operation without bowel resection. The complicated appendectomy readmission rate drops from 12.2% to 8.2%, increasing duration of stay from 3 to 8 days at the cost of 16,428 additional hospital days among 4,740 patients (3.5 days/patient). Readmission optimization tapers after duration of stay of 8 days. Similar findings were observed for antireflux operation and abdominal operation without bowel resection with readmission optimization at duration of stay of 5 days (2.6 days/patient) and 7 days (5.3 days/patient), respectively. CONCLUSION Our theoretical model aimed at balancing readmissions by extending duration of stay to capture early complications results in a substantial increase in hospital days illustrating the conflict between competing quality metrics and limited resources.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Isaac Parakati
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
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Shaffer VO, Owi T, Kumarusamy MA, Sullivan PS, Srinivasan JK, Maithel SK, Staley CA, Sweeney JF, Esper G. Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program. J Am Coll Surg 2017; 224:425-430. [PMID: 28232058 DOI: 10.1016/j.jamcollsurg.2016.12.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population. STUDY DESIGN An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected. RESULTS Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group. CONCLUSIONS Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.
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Affiliation(s)
| | - Tari Owi
- Emory Healthcare Brain Health Center, Atlanta, GA
| | | | | | | | - Shishir K Maithel
- Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | - Charles A Staley
- Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | | | - Greg Esper
- Department of Neurology, Office of Quality and Project Management, Emory University, Atlanta, GA
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Ramonell KM, Fang S, Perez SD, Srinivasan JK, Sullivan PS, Galloway JR, Staley CA, Lin E, Sharma J, Sweeney JF, Shaffer VO. Development and Validation of a Risk Calculator for Renal Complications after Colorectal Surgery Using the National Surgical Quality Improvement Program Participant Use Files. Am Surg 2016. [DOI: 10.1177/000313481608201234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Postoperative acute renal failure is a major cause of morbidity and mortality in colon and rectal surgery. Our objective was to identify preoperative risk factors that predispose patients to postoperative renal failure and renal insufficiency, and subsequently develop a risk calculator. Using the National Surgical Quality Improvement Program Participant Use Files database, all patients who underwent colorectal surgery in 2009 were selected (n = 21,720). We identified renal complications during the 30-day period after surgery. Using multivariate logistic regression analysis, a predictive model was developed. The overall incidence of renal complications among colorectal surgery patients was 1.6 per cent. Significant predictors include male gender (adjusted odds ratio [OR]: 1.8), dependent functional status (OR: 1.5), preoperative dyspnea (OR: 1.5), hypertension (OR: 1.6), preoperative acute renal failure (OR: 2.0), American Society of Anesthesiologists class ≥3 (OR: 2.2), preoperative creatinine >1.2 mg/dL (OR: 2.8), albumin <3.5 g/dL (OR: 1.8), and emergency operation (OR: 1.5). This final model has an area under the curve (AUC) of 0.79 and was validated with similar excellent discrimination (area under the curve: 0.76). Using this model, a risk calculator was developed with excellent predictive ability for postoperative renal complications in colorectal patients and can be used to aid clinical decision-making, patient counseling, and further research on measures to improve patient care.
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Affiliation(s)
- Kimberly M. Ramonell
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Shuyang Fang
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sebastian D. Perez
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jahnavi K. Srinivasan
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Patrick S. Sullivan
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - John R. Galloway
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Charles A. Staley
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Edward Lin
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jyotirmay Sharma
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - John F. Sweeney
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Virginia O. Shaffer
- From the Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Ramonell KM, Fang S, Perez SD, Srinivasan JK, Sullivan PS, Galloway JR, Staley CA, Lin E, Sharma J, Sweeney JF, Shaffer VO. Development and Validation of a Risk Calculator for Renal Complications after Colorectal Surgery Using the National Surgical Quality Improvement Program Participant Use Files. Am Surg 2016; 82:1244-1249. [PMID: 28234192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Postoperative acute renal failure is a major cause of morbidity and mortality in colon and rectal surgery. Our objective was to identify preoperative risk factors that predispose patients to postoperative renal failure and renal insufficiency, and subsequently develop a risk calculator. Using the National Surgical Quality Improvement Program Participant Use Files database, all patients who underwent colorectal surgery in 2009 were selected (n = 21,720). We identified renal complications during the 30-day period after surgery. Using multivariate logistic regression analysis, a predictive model was developed. The overall incidence of renal complications among colorectal surgery patients was 1.6 per cent. Significant predictors include male gender (adjusted odds ratio [OR]: 1.8), dependent functional status (OR: 1.5), preoperative dyspnea (OR: 1.5), hypertension (OR: 1.6), preoperative acute renal failure (OR: 2.0), American Society of Anesthesiologists class ≥3 (OR: 2.2), preoperative creatinine >1.2 mg/dL (OR: 2.8), albumin <3.5 g/dL (OR: 1.8), and emergency operation (OR: 1.5). This final model has an area under the curve (AUC) of 0.79 and was validated with similar excellent discrimination (area under the curve: 0.76). Using this model, a risk calculator was developed with excellent predictive ability for postoperative renal complications in colorectal patients and can be used to aid clinical decision-making, patient counseling, and further research on measures to improve patient care.
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Affiliation(s)
- Kimberly M Ramonell
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Abstract
The recent regulatory changes enacted by the Centers for Medicare and Medicaid Services (CMS) have identified hospital readmission rates as a critical healthcare quality metric. This research focuses on the utilization of pay-for-performance (P4P) mechanisms to cost effectively reduce hospital readmission rates and meet the regulatory standards set by CMS. Using the experimental economics laboratory we find that both of the P4P mechanisms researched, bonus and bundled payments, cost-effectively meet the performance criteria set forth by CMS. The bundled payment mechanism generates the largest reduction in patient length of stay (LOS) without altering the probability of readmission. Combined these results indicate that utilizing P4P mechanisms incentivizes cost effective reductions in hospital readmission rates.
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Affiliation(s)
- James C Cox
- Experimental Economics Center (ExCEN) and Department of Economics, Andrew Young School of Policy Studies, Georgia State University. Cox: 14 Marietta St. NW, Room 436; Atlanta GA 30303; ; 404-413-0200. Sadiraj: 14 Marietta St., NW, Room 453; Atlanta GA 30303; ; 404-413-0193
| | - Vjollca Sadiraj
- Experimental Economics Center (ExCEN) and Department of Economics, Andrew Young School of Policy Studies, Georgia State University. Cox: 14 Marietta St. NW, Room 436; Atlanta GA 30303; ; 404-413-0200. Sadiraj: 14 Marietta St., NW, Room 453; Atlanta GA 30303; ; 404-413-0193
| | - Kurt E Schnier
- School of Social Sciences, Humanities and Arts, University of California, Merced; 5200 North Lake Road; Merced CA 95343; ; 209-205-6461
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine; 201 Dowman Drive; Atlanta GA 30322; ; 404-727-5800
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Abstract
This paper reports research on improving decisions about hospital discharges - decisions that are now made by physicians based on mainly subjective evaluations of patients' discharge status. We report an experiment on uptake of our clinical decision support software (CDSS) which presents physicians with evidence-based discharge criteria that can be effectively utilized at the point of care where the discharge decision is made. One experimental treatment we report prompts physician attentiveness to the CDSS by replacing the default option of universal "opt in" to patient discharge with the alternative default option of "opt out" from the CDSS recommendations to discharge or not to discharge the patient on each day of hospital stay. We also report results from experimental treatments that implement the CDSS under varying conditions of time pressure on the subjects. The experiment was conducted using resident physicians and fourth-year medical students at a university medical school as subjects.
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Affiliation(s)
- James C. Cox
- Corresponding author: James C. Cox. Experimental Economics Center (ExCEN) and Department of Economics, Andrew Young School of Policy Studies, Georgia State University. Phone: 404-413-0200 FAX: 404-413-0195
| | - Vjollca Sadiraj
- Experimental Economics Center (ExCEN) and Department of Economics, Andrew Young School of Policy Studies, Georgia State University
| | - Kurt E. Schnier
- School of Social Sciences, Humanities and Arts, University of California, Merced
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Leeds IL, Sadiraj V, Cox JC, Gao XS, Pawlik TM, Schnier KE, Sweeney JF. Discharge decision-making after complex surgery: Surgeon behaviors compared to predictive modeling to reduce surgical readmissions. Am J Surg 2016; 213:112-119. [PMID: 28029373 DOI: 10.1016/j.amjsurg.2016.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 02/28/2016] [Accepted: 03/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Little is known about how information available at discharge affects decision-making and its effect on readmission. We sought to define the association between information used for discharge and patients' subsequent risk of readmission. METHODS 2009-2014 patients from a tertiary academic medical center's surgical services were analyzed using a time-to-event model to identify criteria that statistically explained the timing of discharges. The data were subsequently used to develop a time-varying prediction model of unplanned hospital readmissions. These models were validated and statistically compared. RESULTS The predictive discharge and readmission regression models were generated from a database of 20,970 patients totaling 115,976 patient-days with 1,565 readmissions (7.5%). 22 daily clinical measures were significant in both regression models. Both models demonstrated good discrimination (C statistic = 0.8 for all models). Comparison of discharge behaviors versus the predictive readmission model suggested important discordance with certain clinical measures (e.g., demographics, laboratory values) not being accounted for to optimize discharges. CONCLUSIONS Decision-support tools for discharge may utilize variables that are not routinely considered by healthcare providers. How providers will then respond to these atypical findings may affect implementation.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, The Johns Hopkins Hospital, 600 N Wolfe Street, Tower 110, Baltimore, MD 21287, USA; Department of Surgery, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA.
| | - Vjollca Sadiraj
- Department of Economics and Experimental Economics Center, Georgia State University, 14 Marietta Street NW, Atlanta, GA 30303, USA
| | - James C Cox
- Department of Economics and Experimental Economics Center, Georgia State University, 14 Marietta Street NW, Atlanta, GA 30303, USA
| | - Xiaoxue Sherry Gao
- Department of Economics and Experimental Economics Center, Georgia State University, 14 Marietta Street NW, Atlanta, GA 30303, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins Hospital, 600 N Wolfe Street, Tower 110, Baltimore, MD 21287, USA
| | - Kurt E Schnier
- School of Social Sciences, Humanities and Arts, University of California - Merced, 5200 N Lake Road, Merced, CA 95343, USA
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA
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Knechtle WS, Perez SD, Raval MV, Sullivan PS, Duwayri YM, Fernandez F, Sharma J, Sweeney JF. Solving the Value Equation: Assessing Surgeon Performance Using Risk-Adjusted Quality-Cost Diagrams and Surgical Outcomes. Am J Med Qual 2016; 32:532-540. [DOI: 10.1177/1062860616662704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Quality-cost diagrams have been used previously to assess interventions and their cost-effectiveness. This study explores the use of risk-adjusted quality-cost diagrams to compare the value provided by surgeons by presenting cost and outcomes simultaneously. Colectomy cases from a single institution captured in the National Surgical Quality Improvement Program database were linked to hospital cost-accounting data to determine costs per encounter. Risk adjustment models were developed and observed average cost and complication rates per surgeon were compared to expected cost and complication rates using the diagrams. Surgeons were surveyed to determine if the diagrams could provide information that would result in practice adjustment. Of 55 surgeons surveyed on the utility of the diagrams, 92% of respondents believed the diagrams were useful. The diagrams seemed intuitive to interpret, and making risk-adjusted comparisons accounted for patient differences in the evaluation.
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Affiliation(s)
| | | | | | | | | | | | - Joe Sharma
- Emory University School of Medicine, Atlanta, GA
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Tian Y, Sweeney JF, Wulkan ML, Heiss KF, Raval MV. The necessity of sociodemographic status adjustment in hospital value rankings for perforated appendicitis in children. Surgery 2016; 159:1572-1582. [PMID: 26782350 DOI: 10.1016/j.surg.2015.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 11/07/2015] [Accepted: 12/10/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hospitals are increasingly focused on demonstration of high-value care for common surgical procedures. Although sociodemographic status (SDS) factors have been tied to various surgical outcomes, the impact of SDS factors on hospital value rankings has not been well explored. Our objective was to examine effects of SDS factors on high-value surgical care at the patient level, and to illustrate the importance of SDS adjustment when evaluating hospital-level performance. METHODS Perforated appendicitis hospitalizations were identified from the 2012 Kids' Inpatient Database. The primary outcome of interest was high-value care as defined by evaluation of duration of stay and cost. SDS factors included race, health insurance type, median household income, and patient location. The impact of SDS on high-value care was estimated using regression models after accounting for hospital-level variation. Risk-adjusted value rankings were compared before and after adjustment for SDS. RESULTS From 9,986 hospitalizations, 998 high-value encounters were identified. African Americans were less likely to experience high-value care compared with white patients after adjusting for all SDS variables. Although private insurance and living in nonmetro counties were associated independently with high-value care, the effects were attenuated in the fully adjusted models. For the 136 hospitals ranked according to risk-adjusted value status, 59 hospitals' rankings improved after adjustment and 53 hospitals' rankings declined. CONCLUSION After adjustment for patient and hospital factors, SDS has a small but significant impact on risk-adjusted hospital performance ranking for pediatric appendicitis. Adjustment for SDS should be considered in future comparative performance assessment.
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Affiliation(s)
- Yao Tian
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
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Leeds IL, Sadiraj V, Cox JC, Gao SX, Pawlik TM, Schnier KE, Sweeney JF. Discharge Decision-Making after Complex Surgery: Surgeon Behavior Compared to Predictive Modeling to Reduce Surgical Readmissions. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Hagopian TM, Vitiello GA, Hart AM, Perez SD, Sweeney JF, Pettitt BJ. Does the amount of time medical students spend in the operating room during the general surgery core clerkship affect their career decision? Am J Surg 2015; 210:167-72. [DOI: 10.1016/j.amjsurg.2014.10.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 09/30/2014] [Accepted: 10/03/2014] [Indexed: 10/23/2022]
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Lorentz CA, Leung AK, DeRosa AB, Perez SD, Johnson TV, Sweeney JF, Master VA. Predicting Length of Stay Following Radical Nephrectomy Using the National Surgical Quality Improvement Program Database. J Urol 2015; 194:923-8. [PMID: 25986510 DOI: 10.1016/j.juro.2015.04.112] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE Length of stay is frequently used to measure the quality of health care, although its predictors are not well studied in urology. We created a predictive model of length of stay after nephrectomy, focusing on preoperative variables. MATERIALS AND METHODS We used the NSQIP database to evaluate patients older than 18 years who underwent nephrectomy without concomitant procedures from 2007 to 2011. Preoperative factors analyzed for univariate significance in relation to actual length of stay were then included in a multivariable linear regression model. Backward elimination of nonsignificant variables resulted in a final model that was validated in an institutional external patient cohort. RESULTS Of the 1,527 patients in the NSQIP database 864 were included in the training cohort after exclusions for concomitant procedures or lack of data. Median length of stay was 3 days in the training and validation sets. Univariate analysis revealed 27 significant variables. Backward selection left a final model including the variables age, laparoscopic vs open approach, and preoperative hematocrit and albumin. For every additional year in age, point decrease in hematocrit and point decrease in albumin the length of stay lengthened by a factor of 0.7%, 2.5% and 17.7%, respectively. If an open approach was performed, length of stay increased by 61%. The R(2) value was 0.256. The model was validated in a 427 patient external cohort, which yielded an R(2) value of 0.214. CONCLUSIONS Age, preoperative hematocrit, preoperative albumin and approach have significant effects on length of stay for patients undergoing nephrectomy. Similar predictive models could prove useful in patient education as well as quality assessment.
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Affiliation(s)
- C Adam Lorentz
- Departments of Urology and Surgery (SDP, JFS), Emory University, Atlanta, Georgia
| | - Andrew K Leung
- Departments of Urology and Surgery (SDP, JFS), Emory University, Atlanta, Georgia
| | - Austin B DeRosa
- Departments of Urology and Surgery (SDP, JFS), Emory University, Atlanta, Georgia
| | - Sebastian D Perez
- Departments of Urology and Surgery (SDP, JFS), Emory University, Atlanta, Georgia
| | - Timothy V Johnson
- Departments of Urology and Surgery (SDP, JFS), Emory University, Atlanta, Georgia
| | - John F Sweeney
- Departments of Urology and Surgery (SDP, JFS), Emory University, Atlanta, Georgia
| | - Viraj A Master
- Departments of Urology and Surgery (SDP, JFS), Emory University, Atlanta, Georgia.
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Mori M, Liao A, Hagopian TM, Perez SD, Pettitt BJ, Sweeney JF. Medical students impact laparoscopic surgery case time. J Surg Res 2015; 197:277-82. [PMID: 25963166 DOI: 10.1016/j.jss.2015.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/22/2015] [Accepted: 04/03/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Medical students (MS) are increasingly assuming active roles in the operating room. Laparoscopic cases offer unique opportunities for MS participation. The aim of this study was to examine associations between the presence of MS in laparoscopic cases and operation time and postoperative complication rates. MATERIALS AND METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program were linked to operative records for nonemergent, inpatient, and laparoscopic general surgery cases at our institution from January, 2009-January, 2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of MS. Demographics, comorbidities, intraoperative variables, and postoperative complication rates were analyzed. RESULTS Seven hundred laparoscopic cases were included. Controlling for wound class, procedure group, and surgeon, MS were associated with an additional 28 min of total operative time. The most significant increase occurred between the skin incision and skin closure. No significant association between the presence of MS and postoperative complications was observed. CONCLUSIONS This is the first retrospective analysis to examine the effect of MS presence during laparoscopic procedures. Increase in the operation time associated with the presence of MS should be examined further, to optimize the educational experience without incurring increased cost due to increased operation time.
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Affiliation(s)
- Makoto Mori
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - Albert Liao
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - Thomas M Hagopian
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sebastian D Perez
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - Barbara J Pettitt
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, Georgia.
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Revenig LM, Canter DJ, Kim S, Liu Y, Sweeney JF, Sarmiento JM, Kooby DA, Maithel SK, Hill LL, Master VA, Ogan K. Report of a Simplified Frailty Score Predictive of Short-Term Postoperative Morbidity and Mortality. J Am Coll Surg 2015; 220:904-11.e1. [PMID: 25907870 DOI: 10.1016/j.jamcollsurg.2015.01.053] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/31/2015] [Accepted: 01/31/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Frailty is an objective method of quantifying a patient's fitness for surgery. Its clinical use is limited by the time needed to complete, as well as a lack of evidence-based interventions to improve outcomes in identified frail patients. The purpose of this study was to critically analyze the components of the Fried Frailty Criteria, among other preoperative variables, to create a simplified risk assessment amenable to a busy clinical setting, while maintaining prognostic ability for surgical outcomes. STUDY DESIGN We performed a prospective evaluation of patients that included the 5-component Fried Frailty Criteria, traditional surgical risk assessments, biochemical laboratory values, and clinical and demographic data. Thirty-day postoperative outcomes were the outcomes of interest. RESULTS There were 351 consecutive patients undergoing major intra-abdominal operations enrolled. Analysis demonstrated that shrinking and grip strength alone hold the same prognostic information as the full 5-component Fried Frailty Criteria for 30-day morbidity and mortality. The addition of American Society of Anesthesia (ASA) score and serum hemoglobin creates a composite risk score, which facilitates easy classification of patients into discrete low (ref), intermediate (odds ratio [OR] 1.974, 95% CI 1.006 to 3.877, p = 0.048), and high (OR 4.889, 95% CI 2.220 to 10.769, p < 0.001) risk categories, with a corresponding stepwise increase in risk for 30-day postoperative complications. Internal validation by bootstrapping confirmed the results. CONCLUSIONS This study demonstrated that 2 components of the Fried Frailty Criteria, shrinking and grip strength, hold the same predictive value as the full frailty assessment. When combined with American Society of Anesthesiologists score and serum hemoglobin, they form a straightforward, simple risk classification system with robust prognostic information.
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Affiliation(s)
- Louis M Revenig
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - Daniel J Canter
- Department of Urology, Einstein Health Network and the Urologic Institute of Southeastern Pennsylvania, Philadelphia, PA
| | | | - Yuan Liu
- Winship Cancer Institute, Atlanta, GA
| | - John F Sweeney
- Department of General Surgery, Emory University School of Medicine, Atlanta, GA
| | - Juan M Sarmiento
- Department of General Surgery, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | - David A Kooby
- Department of Surgical Oncology, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | - Shishir K Maithel
- Department of Surgical Oncology, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | - Laureen L Hill
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - Viraj A Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | - Kenneth Ogan
- Department of Urology, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Atlanta, GA.
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Hagopian TM, Vitiello GA, Hart AM, Perez SD, Pettitt BJ, Sweeney JF. Do medical students in the operating room affect patient care? An analysis of one institution's experience over the past five years. J Surg Educ 2014; 71:817-824. [PMID: 24931415 DOI: 10.1016/j.jsurg.2014.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 04/20/2014] [Accepted: 04/30/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Medical students are active learners in operating rooms during medical school. This observational study seeks to investigate the effect of medical students on operative time and complications. METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program was linked to operative records for nonemergent, inpatient general surgery cases at our institution from 1 January 2009 to 1 January 2013. Cases were grouped into 13 distinct procedure groups. Hospital records provided information on the presence of medical students. Demographics, comorbidities, intraoperative variables, and postoperative complications were analyzed. RESULTS Overall, 2481 cases were included. Controlling for wound class, procedure group, and surgeon, medical students were associated with an additional 14 minutes of operative time. No association between medical students and postoperative complications was observed. CONCLUSIONS The educational benefits gained by the presence of medical students do not appear to jeopardize the quality of patient care.
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Affiliation(s)
- Thomas M Hagopian
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Gerardo A Vitiello
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra M Hart
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sebastian D Perez
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Barbara J Pettitt
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
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Rutz DR, Squires MH, Maithel SK, Sarmiento JM, Etra JW, Perez SD, Knechtle W, Cardona K, Russell MC, Staley CA, Sweeney JF, Kooby DA. Cost comparison analysis of open versus laparoscopic distal pancreatectomy. HPB (Oxford) 2014; 16:907-14. [PMID: 24931314 PMCID: PMC4238857 DOI: 10.1111/hpb.12288] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 05/05/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND In comparison with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) is associated with fewer complications and shorter hospital stays, but comparative cost data for the two approaches are limited. METHODS Records of all distal pancreatectomies carried out from January 2009 to June 2013 were reviewed and stratified according to operative complexity. Patient factors and outcomes were recorded. Total variable costs (TVCs) were tabulated for each patient, and stratified by category [e.g. 'floor', 'operating room' (OR), 'radiology']. Costs for index admissions and 30-day readmissions were compared between LDP and ODP groups. RESULTS Of 153 procedures, 115 (70 LDP, 45 ODP) were selected for analysis. The TVC of the index admission was US$3420 less per patient in the LDP group (US$10 480 versus US$13 900; P = 0.06). Although OR costs were significantly greater in the LDP cohort (US$5756 versus US$4900; P = 0.02), the shorter average hospitalization in the LDP group (5.2 days versus 7.7 days; P = 0.01) resulted in a lower overall cost. The total cost of index hospitalization combined with readmission was significantly lower in the LDP cohort (US$11 106 versus US$14 803; P = 0.05). CONCLUSIONS In appropriately selected patients, LDP is more cost-effective than ODP. The increased OR cost associated with LDP is offset by the shorter hospitalization. These data clarify targets for further cost reductions.
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Affiliation(s)
- Daniel R Rutz
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Malcolm H Squires
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Joanna W Etra
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Sebastian D Perez
- Department of Surgery, Division of General and Gastrointestinal Surgery, Emory UniversityAtlanta, GA, USA
| | - William Knechtle
- Department of Surgery, Division of General and Gastrointestinal Surgery, Emory UniversityAtlanta, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - Charles A Staley
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA
| | - John F Sweeney
- Department of Surgery, Division of General and Gastrointestinal Surgery, Emory UniversityAtlanta, GA, USA
| | - David A Kooby
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory UniversityAtlanta, GA, USA,Correspondence: David A. Kooby, Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA 30322, USA. Tel: + 1 404 778 3805. Fax: + 1 404 778 4255. E-mail:
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Canter DJ, Revenig L, Ogan K, Kooby DA, Maithel S, Sweeney JF, Sarmiento JM, Liu Y, Kim S, Master VA. Eye of the beholder?: A prospective study examining the correlation between patients' and surgeons' subjective assessment of surgical frailty. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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43
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Squires MH, Staley CA, Knechtle W, Winer JH, Russell MC, Perez S, Sweeney JF, Maithel SK, Staley CA. Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications. Ann Surg Oncol 2014; 22:1739-45. [PMID: 25249258 DOI: 10.1245/s10434-014-4025-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications. METHODS Clinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed. RESULTS A total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550 min. Tumor histology included appendiceal (n = 40; 62 %), colorectal (n = 16; 25 %), goblet cell (n = 5; 8 %), and mesothelioma (n = 3; 5 %). Median length-of-stay was 13 days. Complications occurred in 42 patients (66 %), including 13 (20 %) with major (Clavien grade III-IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was $49,248 and reimbursement was $63,771, for a hospital profit of $14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less ($30,713 vs $80,747; p < 0.001), resulting in a net loss of $17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of $36,285, compared with a net loss of $54,274 in Medicare/Medicaid patients. CONCLUSIONS CRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.
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Affiliation(s)
- Malcolm H Squires
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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44
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Sanni A, Perez S, Medbery R, Urrego HD, McCready C, Toro JP, Patel AD, Lin E, Sweeney JF, Davis SS. Postoperative complications in bariatric surgery using age and BMI stratification: a study using ACS-NSQIP data. Surg Endosc 2014; 28:3302-9. [PMID: 25115863 DOI: 10.1007/s00464-014-3606-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/03/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery results in long-term weight loss and significant morbidity reduction. Morbidity and mortality following bariatric surgery remain low and acceptable. This study looks to define the trend of morbidity and mortality as it relates to increasing age and body mass index (BMI) in patients undergoing bariatric surgery. METHODS We queried the ACS/NSQIP 2010-2011 Public Use File for patients who underwent elective laparoscopic adjustable banding (LAGB), sleeve gastrectomy (LSG) and gastric bypass (LGBP). Total morbidity and 30-day mortality were evaluated. Logistic regression models were created to estimate the effect of increasing age and BMI on morbidity for these bariatric procedures. RESULTS A total of 20,308 laparoscopic bariatric procedures were reviewed (11617 LGBP, 3069 LSG and 5622 LAGB). Overall mortality and morbidity rates were 0.11 and 3.84%, respectively. The odds of postoperative complications increased by 2% with each additional year of age (OR 1.02, 95% CI 1.02-1.03) and every point increase in BMI (OR 1.02, 95% CI 1.01-1.03). Multiple logistic regression identified COPD, Diabetes, Hypertension, and Dyspnea as major risk factors for postoperative morbidity. Postoperative complications were three times more likely after LGBP (OR 2.87, 95% CI 2.31-3.57) and two times more likely after LSG (OR 2.06, 95% CI 1.57-2.72) when compared to patients undergoing LAGB. CONCLUSION Morbidity and mortality increase on a predictable trend with increasing age and BMI. There is increased risk of morbidity for stapling procedures when compared to gastric banding, but this must be considered in context of surgical efficacy when choosing a bariatric procedure. These data can be used in preoperative counseling and evaluation of surgical candidacy of bariatric surgical patients.
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Affiliation(s)
- Aliu Sanni
- Emory Endosurgery/Bariatrics Unit, Department of Surgery, Emory University, 1365 Clifton Road. Building A Suite 5040, Atlanta, GA, 30322, USA,
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45
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Shaffer VO, Baptiste CD, Liu Y, Srinivasan JK, Galloway JR, Sullivan PS, Staley CA, Sweeney JF, Sharma J, Gillespie TW. Improving quality of surgical care and outcomes: factors impacting surgical site infection after colorectal resection. Am Surg 2014; 80:759-763. [PMID: 25105393 PMCID: PMC4370349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Surgical site infections (SSIs) result in patient morbidity and increased costs. The purpose of this study was to determine reasons underlying SSI to enable interventions addressing identified factors. Combining data from the American College of Surgeons National Surgical Quality Improvement Project with medical record extraction, we evaluated 365 patients who underwent colon resection from January 2009 to December 2012 at a single institution. Of the 365 patients, 84 (23%) developed SSI. On univariate analysis, significant risk factors included disseminated cancer, ileostomy, patient temperature less than 36°C for greater than 60 minutes, and higher glucose level. The median number of cases per surgeon was 36, and a case volume below the median was associated with a higher risk of SSI. On multivariate analysis, significant risks associated with SSI included disseminated cancer (odds ratio [OR], 4.31; P < .001); surgery performed by a surgeon with less than 36 cases (OR, 2.19; P = .008); higher glucose level (OR, 1.06; P = .017); and transfusion of five units or more of blood (OR, 3.26; P = .029). In this study we found both modifiable and unmodifiable factors associated with increased SSI. Identifying modifiable risk factors enables targeting specific areas to improve the quality of care and patient outcomes.
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46
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Toro JP, Patel AD, Lytle NW, Sweeney JF, Medbery RL, Scott Davis S, Lin E, Sarmiento JM. Detecting performance variance in complex surgical procedures: analysis of a step-wise technique for laparoscopic right hepatectomy. Am J Surg 2014; 209:418-23. [PMID: 25682098 DOI: 10.1016/j.amjsurg.2014.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 02/24/2014] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Laparoscopic right hepatectomy (LRH) is a technically challenging operation. Our aim is to evaluate a standardized technique of LRH and determine variances in performance. METHODS The procedure was deconstructed into 7 major step-wise components. All LRH followed the same surgical sequence, and used the same devices and operating room set-up. Thirty randomly selected video recordings of the procedure underwent intraoperative time analysis. The variances measured by standard deviation of each step were calculated (mean in minutes ± standard deviation). RESULTS Mean total operative time was 114 ± 25 min. The steps with the least variance were inferior vena cava dissection (8 ± 3) and right hepatic vein ligation (9 ± 5). The longest and also the step with the greatest variance was parenchymal transection (35 ± 12). CONCLUSIONS LRH can be performed consistently using a standardized step-wise technique. Parenchymal transection had most variation, and this could be explained by intrinsic liver factors. Surgical performance improvement should begin with deconstructing the operation into definable steps to identify areas for change.
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Affiliation(s)
- Juan P Toro
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA
| | - Ankit D Patel
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA
| | - Nathaniel W Lytle
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA
| | - John F Sweeney
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA
| | - Rachel L Medbery
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA
| | - Steven Scott Davis
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA
| | - Edward Lin
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
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47
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Urrego H, Sanni A, Toro JP, Lytle N, McCready C, Davis SS, Sweeney JF, Lin E, Patel AD. Out by 3:30—A Study in Robotic Bariatric Surgery Efficiency. Bariatr Surg Pract Patient Care 2014. [DOI: 10.1089/bari.2014.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hernan Urrego
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Aliu Sanni
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Juan P. Toro
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, SOMA Clinic, Medellin, Antioquia, Colombia
| | - Nathaniel Lytle
- Department of General Surgery, Kaiser Permanente, Atlanta, Georgia
| | - Craig McCready
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - S. Scott Davis
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - John F. Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Edward Lin
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ankit D. Patel
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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48
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Toro JP, Lin E, Patel AD, Davis SS, Sanni A, Urrego HD, Sweeney JF, Srinivasan JK, Small W, Mittal P, Sekhar A, Moreno CC. Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy. J Am Coll Surg 2014; 219:430-8. [PMID: 25026879 DOI: 10.1016/j.jamcollsurg.2014.02.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/26/2014] [Accepted: 02/26/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Variable gastric morphology has been identified on routine upper gastrointestinal series after laparoscopic sleeve gastrectomy. This test might give us useful information beyond the presence of leak and obstruction. The aim of this study is to standardize a morphologic classification of gastric sleeve based on water-soluble contrast upper gastrointestinal series, and to determine possible clinical implications. STUDY DESIGN One hundred morbidly obese patients underwent laparoscopic sleeve gastrectomy and had routine upper gastrointestinal on postoperative day 1 or 2. Images were reviewed by 4 radiologists who were blinded to outcomes, and sleeve shape was classified as upper pouch, lower pouch, tubular, or dumbbell. Inter-observer agreement was calculated. Clinical outcomes including weight loss, satiety control, and reflux symptoms were recorded. Comparisons were determined by 1-way ANOVA and t-test. RESULTS Mean age was 46 ± 12 years and mean BMI was 45.1 ± 6 kg/m(2). Overall inter-observer agreement level for the sleeve shape classification was 76.3%. Sleeve shapes were tubular in 37%, dumbbell in 32%, lower pouch in 22%, and upper pouch in 8%. Mean excess body weight loss at 1, 3, and 6 months was 16.8%, 29.9%, and 39.1%, respectively. Excess body weight loss was not associated with sleeve shape. Mean hunger score was 213 ± 97, and patients with dumbbell shape had higher hunger scores (p = 0.003). Mean reflux score was 5.7 ± 8. Upper pouch shape was associated with greater severity of reflux symptoms (p = 0.02). CONCLUSIONS This study suggests a standardized radiographic classification of gastric sleeve morphology. Although sleeve shape is not correlated with weight loss, gastric sleeves with retained fundus result in lower satiety control and higher severity of reflux symptoms. An adequate resection of the gastric fundus might avoid this potential complication.
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Affiliation(s)
- Juan P Toro
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA
| | - Edward Lin
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA.
| | - Ankit D Patel
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA
| | - S Scott Davis
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA
| | - Aliu Sanni
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA
| | - Hernan D Urrego
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA
| | - John F Sweeney
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA
| | - Jahnavi K Srinivasan
- Emory Endosurgery Unit, Emory Bariatric Center, Emory University School of Medicine, Atlanta, GA
| | - William Small
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Pardeep Mittal
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Aarti Sekhar
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
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Toro JP, Lytle NW, Patel AD, Davis SS, Christie JA, Waring JP, Sweeney JF, Lin E. Efficacy of Laparoscopic Pyloroplasty for the Treatment of Gastroparesis. J Am Coll Surg 2014; 218:652-60. [DOI: 10.1016/j.jamcollsurg.2013.12.024] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 12/10/2013] [Indexed: 12/12/2022]
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50
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Medbery RL, Chadid TS, Sweeney JF, Knechtle SJ, Kooby DA, Maithel SK, Lin E, Sarmiento JM. Laparoscopic vs open right hepatectomy: a value-based analysis. J Am Coll Surg 2014; 218:929-39. [PMID: 24680574 DOI: 10.1016/j.jamcollsurg.2014.01.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/30/2013] [Accepted: 01/07/2014] [Indexed: 02/09/2023]
Abstract
BACKGROUND Current literature lacks sufficient data on outcomes after extensive laparoscopic liver resections. We hypothesized that laparoscopic right hepatectomy (LRH) is associated with better clinical outcomes and less overall hospital costs than open right hepatectomy (ORH), supporting the notion that major laparoscopic hepatic resections carry increased value when compared with the open approach. STUDY DESIGN We reviewed medical records of all patients at our institution who underwent elective LRH (n = 48) or ORH (n = 57) from May 16, 2008 to March 1, 2012. Patient demographics, preoperative comorbidities, operative details, and postoperative outcomes were compared between the 2 groups. Hospital billing data were collected for each case to determine the average hospital costs per case. RESULTS Average operative duration, estimated blood loss, intravenous fluid resuscitation requirements, high-grade postoperative complications, the need for postoperative admission to the ICU, and hospital length of stay were significantly less within the LRH cohort. Thirty-day mortality and readmission rates were equivalent between the 2 groups. Despite higher operative costs for LRH ($16,605 vs $10,411, p < 0.001), total postoperative costs were significantly less ($9,075 for LRH vs $16,341 for ORH, p < 0.001), resulting in equivalent overall costs ($25,679 for LRH vs $26,751 for ORH, p = 0.65). CONCLUSIONS Although overall costs between LRH and ORH are equivalent, clinical outcomes after LRH are comparable to those after ORH, supporting the value of laparoscopy in extensive right hepatic resections. Efforts to reduce operative costs of LRH, while maintaining optimal patient outcomes, should be the focus of surgeons and hospitals moving forward.
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Affiliation(s)
- Rachel L Medbery
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Tatiana S Chadid
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - John F Sweeney
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Stuart J Knechtle
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Edward Lin
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Juan M Sarmiento
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA.
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