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Vitello DJ, Shah D, Ko B, Brajcich BC, Peters XD, Merkow RP, Pitt HA, Bentrem DJ. Establishing the clinical relevance of grade A post-hepatectomy liver failure. J Surg Oncol 2024; 129:745-753. [PMID: 38225867 PMCID: PMC10922784 DOI: 10.1002/jso.27570] [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: 10/26/2023] [Accepted: 12/09/2023] [Indexed: 01/17/2024]
Abstract
INTRODUCTION The International Study Group of Liver Surgery's criteria stratifies post-hepatectomy liver failure (PHLF) into grades A, B, and C. The clinical significance of these grades has not been fully established. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hepatectomy-targeted database was analyzed. Outcomes between patients without PHLF, with grade A PHLF, and grade B or C PHLF were compared. Univariate and multivariable logistic regression were performed. RESULTS Six thousand two hundred seventy-four adults undergoing elective major hepatectomy were included in the analysis. The incidence of grade A PHLF was 4.3% and grade B or C was 5.3%. Mortality was similar between patients without PHLF (1.2%) and with grade A PHLF (1.1%), but higher in those with grades B or C PHLF (25.4%). Overall morbidities rates were 19.3%, 41.7%, and 72.8% in patients without PHLF, with grade A PHLF, and with grade B or C PHLF, respectively (p < 0.001). Grade A PHLF was associated with increased morbidity (grade A: odds ratios [OR] 2.7 [95% CI: 2.0-3.5]), unplanned reoperation (grade A: OR 3.4 [95% CI: 2.2-5.1]), nonoperative intervention (grade A: OR 2.6 [95% CI: 1.9-3.6]), length of stay (grade A: OR 3.1 [95% CI: 2.3-4.1]), and readmission (grade A: OR 1.8 [95% CI: 1.3-2.5]) compared to patients without PHLF. CONCLUSIONS Although mortality was similar between patients without PHLF and with grade A PHLF, other postoperative outcomes were notably inferior. Grade A PHLF is a clinically distinct entity with relevant associated postoperative morbidity.
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Affiliation(s)
- Dominic J Vitello
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dhavan Shah
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bona Ko
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian C Brajcich
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xane D Peters
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago Prizker School of Medicine, Chicago, Illinois, USA
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Jesse Brown Veterans Administration Medical Center, Chicago, Illinois, USA
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Ma M, Peters XD, Zhang LM, Hornor M, Christensen K, Coleman J, Finlayson E, Flood KL, Katlic M, Lagoo-Deenadayalan S, Robinson TN, Rosenthal RA, Tang VL, Ko CY, Russell MM. Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative. J Am Coll Surg 2023; 237:171-181. [PMID: 37185633 DOI: 10.1097/xcs.0000000000000723] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 05/17/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process. STUDY DESIGN The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed. RESULTS Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults. CONCLUSIONS This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.
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Affiliation(s)
- Meixi Ma
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL (Ma)
| | - Xane D Peters
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, Loyola University Medical Center, Maywood, IL (Peters, Hornor)
| | - Lindsey M Zhang
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of Chicago Medical Center, Chicago, IL (Zhang)
| | - Melissa Hornor
- Department of Surgery, Loyola University Medical Center, Maywood, IL (Peters, Hornor)
| | - Kataryna Christensen
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
| | - JoAnn Coleman
- Sinai Center for Geriatric Surgery, Sinai Hospital, Baltimore, MD (Coleman, Katlic)
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco, San Francisco, CA (Finlayson)
| | - Kellie L Flood
- Department of Medicine, Division of Geriatrics, Hospice, and Palliative Medicine, University of Alabama at Birmingham Medical Center, Birmingham, AL (Flood)
| | - Mark Katlic
- Sinai Center for Geriatric Surgery, Sinai Hospital, Baltimore, MD (Coleman, Katlic)
| | | | - Thomas N Robinson
- Department of Surgery, University of Colorado Denver, Aurora, CO (Robinson)
| | | | - Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA (Tang)
| | - Clifford Y Ko
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA (Ko, Russell)
| | - Marcia M Russell
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA (Ko, Russell)
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Peters XD, Cohen ME, Meng X, Hall BL, Ko CY. Influence of Perioperative COVID-19 Infection on Surgical Outcomes and Risk Adjustment for Quality Assessment in the American College of Surgeons NSQIP. J Am Coll Surg 2023:00019464-990000000-00617. [PMID: 37042523 DOI: 10.1097/xcs.0000000000000711] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Surgical patients with perioperative COVID-19 infection experience higher rates of adverse events than those without COVID, which may lead to imprecision in hospital-level quality assessment. Our objectives were to quantify differences in COVID-19 associated adverse events in a large national sample and examine distortions in surgical quality benchmarking if COVID status is not considered. STUDY DESIGN Data included 793,280 patient records from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from April 1, 2020 to March 31, 2021. Models predicting 30-day Mortality, Morbidity, Pneumonia, Ventilator Dependency > 48 hours, and unplanned intubation were constructed. Risk adjustment variables were selected for these models from standard NSQIP predictors and perioperative COVID status. RESULTS 5,878 (0.66%) had preoperative COVID and 5,215 (0.58%) had postoperative COVID. COVID rates demonstrated some consistency across hospitals (median preoperative 0.84%, IQR=0.14%-0.84%; median postoperative 0.50%, IQR=0.24%-0.78%). Postoperative COVID was always associated with increased adverse events. For postoperative COVID among all cases, there was nearly a six-fold increase in Mortality (1.07% to 6.37%) and15-fold increase in Pneumonia (0.92% to 13.57%), excluding the diagnosis of COVID itself. The effects of preoperative COVID were less consistent. Inclusion of COVID in risk-adjustment models had minimal effects on surgical quality assessments. CONCLUSION Perioperative COVID was associated with a dramatic increase in adverse events. However, quality benchmarking minimally affected. This may be the result of low overall COVID rates or balance in rates established across hospitals over the 1-year observational period. There remains limited evidence for restructuring ACS NSQIP risk-adjustment for the time-limited effects of the COVID pandemic.
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Affiliation(s)
- Xane D Peters
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago IL
- Loyola University Medical Center, Department of Surgery, Maywood IL
| | - Mark E Cohen
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago IL
| | - Xiangiu Meng
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago IL
| | - Bruce L Hall
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago IL
- Washington University in Saint Louis, Department of Surgery and Olin Business School; St. Louis VA Medical Center; and BJC Healthcare, St Louis, MO
| | - Clifford Y Ko
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago IL
- University of California Los Angeles David Geffen School of Medicine; VA Greater Los Angeles Healthcare System, Department of Surgery; Los Angeles CA
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