Unplanned returns to the operating room: a quality improvement methodology for the comparison of institutional outcomes to national benchmarks

OBJECTIVE

Unplanned returns to the operating room (RORs) constitute an important quality metric in surgical practice. In this study, the authors present a methodology to compare a department's unplanned ROR rates with national benchmarks in the context of large-scale quality of care surveillance.

METHODS

The authors identified unplanned RORs within 30 days from the initial surgery at their institution during the period 2014-2018 using an institutional documentation platform that facilitates the collection of reoperation information by providers in the clinical setting. They divided the procedures into 28 groups by Current Procedural Terminology and International Classification of Diseases, 9th and 10th Revision codes. They estimated national benchmarks of unplanned RORs for these procedure groups via querying the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) registry during the period 2014-2018. Finally, they numerically assessed the unplanned ROR rates at their institution compared with those calculated from the ACS NSQIP registry.

RESULTS

Using the above methodology, the authors were able to classify 12,575 of the cases performed in their department during the period of interest, including 6037 (48%) cranial cases and 6538 (52%) spinal or peripheral nerve cases. Among those, 161 (1.3%) presented with complications that required an unplanned ROR within 30 days from the initial surgery. The respective cumulative unplanned ROR rate in the ACS NSQIP registry during the same timeframe was 3.6%. Among 15 categories of cranial procedures, the cumulative unplanned ROR rate was 1.3% in the authors' department and 5.6% in the ACS NSQIP registry. Among 13 categories of spinal and peripheral nerve procedures, the cumulative unplanned ROR rate was 1.3% in the authors' department and 2.8% in the ACS NSQIP registry. Unplanned ROR rates at the authors' institution were lower than the national average for each of the 28 procedure groups of interest. Yearly analysis of institutional ROR rates for the five most commonly performed procedures showed lower reoperation rates compared with the national benchmarks.

CONCLUSIONS

Using an institutional documentation tool and a widely available national database, the authors developed a reproducible and standardized method of comparing their department's outcomes with national benchmarks per procedure subgroup. This methodology accommodates longitudinal quality surveillance across the different subspecialties in a neurosurgical department and may illuminate potential shortcomings of care delivery in the future.

Are children with unilateral sensorineural hearing loss receiving cochlear implants?

INTRODUCTION

The US Food and Drug Administration (FDA) granted its first approval for cochlear implants (CI) in children with bilateral sensorineural hearing loss (SNHL) in 1990. In 2019, the FDA expanded CI indications to include children with unilateral SNHL.

OBJECTIVE

The aim of this study was to assess the prevalence of children with unilateral SNHL in the population of new pediatric CI recipients between 2012 and 2021.

METHODS

A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Pediatric database examined patients under 18 years of age with bilateral or unilateral SNHL who underwent CI between 2012 and 2021. Current Procedural Terminology code 69930 identified patients with 'cochlear device implantation, with or without mastoidectomy.' The percentage of children undergoing CI for unilateral versus bilateral SNHL during the study period was calculated and subjected to statistical analysis.

RESULTS

9863 pediatric CI patients were included with a mean age of 5.1 (95 % CI 5.1-5.2) years at the time of implantation. 7.5 % (N = 739) of patients had unilateral SNHL and 92.5 % (N = 9124) had bilateral SNHL. Children with bilateral SNHL undergoing CI were significantly younger (5.0 years versus 6.9 years for those with unilateral SNHL, p < .001). There was a statistically significant difference in the percentage of children receiving CI for unilateral versus bilateral SNHL (3.3 % in 2012 to 14.3 % in 2021, p < .001) before and after the FDA changes.

CONCLUSIONS

The proportion of CIs placed for unilateral SNHL has increased annually even before 2019 when the FDA expanded its CI indications to include children with unilateral SNHL for the first time.

Risk of hysterectomy at the time of myomectomy: an underestimated surgical risk

OBJECTIVE

To evaluate the risk of hysterectomy at the time of myomectomy and the associated 30-day postoperative morbidity.

DESIGN

Cohort study.

PATIENTS

Patients who underwent myomectomies identified from the American College of Surgeons' National Surgical Quality Improvement Program from 2010 to 2021.

INTERVENTION

Unplanned hysterectomy at the time of a myomectomy procedure.

MAIN OUTCOME MEASURES

The Current Procedural Terminology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Preoperative characteristics and morbidity outcomes were obtained. The univariate analysis was performed using the chi-square and Fisher exact tests, as appropriate. Multivariate logistic regression reported risk factors for individuals who underwent hysterectomy at the time of myomectomy. P values of <.05 were considered statistically significant.

RESULTS

A total of 13,213 individuals underwent myomectomy, and 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed with the laparoscopic approach (7.1%), followed by the abdominal (3.2%) and hysteroscopic (1.9%) approaches. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 minutes), and laparoscopic approach were associated with a significantly increased risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, an increased odds of hysterectomy was noted for white race, longer operative time, ASA class III or higher, obesity, laparoscopic approach, and low fibroid burden. Patients who underwent concurrent hysterectomy had a longer median length of hospital stay (2 vs. 1 day), longer median operative time (161 vs. 126 minutes), increased intraoperative/postoperative blood transfusions (14.5% vs. 9.0%), and higher rates of organ/space surgical site infections (1.5% vs. 0.5%) and return to surgery (2.0% vs. 0.7%) than those who did not (P<.05). The risk of a major complication within 30 days of myomectomy increased in patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted odds ratio, 2.4; 95% confidence interval, 1.8-3.2).

CONCLUSION

The risk of hysterectomy during a myomectomy is higher than previously reported. The patient age of ≥43 years, obesity, white race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counseling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy.

Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing common bile duct exploration

PURPOSE

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator is a risk stratification tool to help predict risks of postoperative complications, which is important for informed decision-making. The purpose of this study was to evaluate the accuracy of the calculator in predicting postoperative complications in patients undergoing common bile duct (CBD) exploration.

METHODS

A retrospective chart review was completed for 305 patients that underwent open and laparoscopic CBD exploration at a single institution from 2010 to 2018. Patient demographics and preoperative risk factors were entered into the calculator, and the predicted complication risks were compared with observed complication rates. Brier score, C-statistic, and Hosmer-Lemeshow regression analysis were used to assess discrimination and calibration.

RESULTS

The observed rate exceeded the predicted rate for any complication (35.1% vs. 21%), return to operating room (5.9% vs. 3.6%), death (3.3% vs. 1%), and sepsis (3% vs. 2.4%). The model performed best in predicting serious complication (Brier 0.087, C-statistic 0.818, Hosmer-Lemeshow 0.695), surgical site infection (Brier 0.068, C-statistic 0.670, Hosmer-Lemeshow 0.292), discharge to rehabilitation facility (Brier 0.041, C-statistic 0.907, Hosmer-Lemeshow 0.638), and death (Brier 0.028, C-statistic 0.898, Hosmer-Lemeshow 0.004). In multivariable analysis, there was no statistically significant predicted complication type that affected the type of surgery.

CONCLUSION

The calculator was accurate in predicting serious complication, surgical site infection, discharge to rehabilitation facility, and death. However, the model displayed poor predictive ability in all other complications that were analyzed.

The Accuracy of the NSQIP Universal Surgical Risk Calculator Compared to Operation-Specific Calculators

Objective

To compare the performance of the ACS NSQIP "universal" risk calculator (N-RC) to operation-specific RCs.

Background

Resources have been directed toward building operation-specific RCs because of an implicit belief that they would provide more accurate risk estimates than the N-RC. However, operation-specific calculators may not provide sufficient improvements in accuracy to justify the costs in development, maintenance, and access.

Methods

For the N-RC, a cohort of 5,020,713 NSQIP patient records were randomly divided into 80% for machine learning algorithm training and 20% for validation. Operation-specific risk calculators (OS-RC) and OS-RCs with operation-specific predictors (OSP-RC) were independently developed for each of 6 operative groups (colectomy, whipple pancreatectomy, thyroidectomy, abdominal aortic aneurysm (open), hysterectomy/myomectomy, and total knee arthroplasty) and 14 outcomes using the same 80%/20% rule applied to the appropriate subsets of the 5M records. Predictive accuracy was evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), and Hosmer-Lemeshow (H-L) P values, for 13 binary outcomes, and mean squared error for the length of stay outcome.

Results

The N-RC was found to have greater AUROC (P = 0.002) and greater AUPRC (P < 0.001) compared to the OS-RC. No other statistically significant differences in accuracy, across the 3 risk calculator types, were found. There was an inverse relationship between the operation group sample size and magnitude of the difference in AUROC (r = -0.278; P = 0.014) and in AUPRC (r = -0.425; P < 0.001) between N-RC and OS-RC. The smaller the sample size, the greater the superiority of the N-RC.

Conclusions

While operation-specific RCs might be assumed to have advantages over a universal RC, their reliance on smaller datasets may reduce their ability to accurately estimate predictor effects. In the present study, this tradeoff between operation specificity and accuracy, in estimating the effects of predictor variables, favors the N-R, though the clinical impact is likely to be negligible.

Impact of surgeon specialty on clinical outcomes following esophagectomy for cancer

BACKGROUND

The impact of surgeon and hospital operative volume on esophagectomy outcomes is well-described; however, studies examining the influence of surgeon specialty remain limited. Therefore, we evaluated the impact of surgeon specialty on short-term outcomes following esophagectomy for cancer.

METHODS

The 2016-2019 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) was queried to identify all patients undergoing esophagectomy for esophageal cancer. Surgeon specialty was categorized as general (GS) or thoracic (TS). Entropy balancing was used to generate sample weights that adjust for baseline differences between GS and TS patients. Weights were subsequently applied to multivariable linear and logistic regressions, which were used to evaluate the independent association of surgeon specialty with 30-day mortality, complications, and postoperative length of stay.

RESULTS

Of 2657 esophagectomies included for analysis, 54.1% were performed by TS. Both groups had similar distributions of age, sex, and body mass index. TS patients more frequently underwent transthoracic esophagectomy, while GS patients more commonly received minimally invasive surgery. After adjustment, surgeon specialty was not associated with altered odds of 30-day mortality (adjusted odds ratio [AOR] 1.10 p = 0.73) or anastomotic leak (AOR 0.87, p = 0.33). However, TS patients exhibited a 40-min reduction in operative duration and faced greater odds of perioperative transfusion, relative to GS.

CONCLUSION

Among ACS NSQIP participating centers, surgeon specialty influenced operative duration and blood product utilization, but not mortality and anastomotic leak. Our results support the relative safety of esophagectomy performed by select GS and TS.

Outpatient compared to inpatient thyroidectomy on 30-day postoperative outcomes: a national propensity matched analysis

BACKGROUND

To address the postoperative outcomes between outpatient and inpatient neck surgery involving thyroidectomy procedures.

METHODS

A cohort analysis of surgical patients undergoing primary, elective, total thyroidectomy from multiple United States medical institutions who were registered with the American College of Surgeons National Surgical Quality Improvement Program from 2015 to 2018. The primary outcome was a composite score that included any 30-day postoperative adverse event.

RESULTS

A total of 55,381 patients who underwent a total thyroidectomy were identified comprising of 14,055 inpatient and 41,326 outpatient procedures. A cohort of 13,496 patients who underwent outpatient surgery were propensity matched for covariates with corresponding number of patients who underwent inpatient thyroidectomies. In the propensity matched cohort, the occurrence of any 30-day after surgery complications were greater in the inpatient group, 424 out of 13,496 (3.1%) compared to the outpatient group, 150 out of 13,496 (1.1%), P < 0.001. Moreover, death rates were greater in the inpatient group, 22 out 13,496 (0.16%) compared to the outpatient group, 2 out of 13,496 (0.01%), P < 0.001. Similarly, hospital readmissions occurred with greater frequency in the inpatient group, 438 out of 13,496 (3.2%) compared to the outpatient group, 310 out of 13,496 (2.3%), P < 0.001.

CONCLUSION

Thyroidectomy procedures performed in the outpatient setting had less rates of adverse events, including serious postoperative complications (e.g., surgical site infection, pneumonia, progressive renal insufficiency). In addition, patients who had thyroidectomy in the outpatient setting had less 30-day readmissions and mortality. Surgeons should recognize the benefits of outpatient thyroidectomy when selecting disposition of patients undergoing neck surgery.

Implication of American Society of Anesthesiologists Physical Status (ASA-PS) on tonsillectomy with or without adenoidectomy outcomes

BACKGROUND

The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T ± A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T ± A.

STUDY DESIGN

A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T ± A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups.

RESULTS

On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p ≤ 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay >1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T ± A.

CONCLUSION

Higher ASA-PS classification is an independent predictor of complications following T ± A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T ± A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

Traumatic Proximal Femoral Fractures during COVID-19 Pandemic in the US: An ACS NSQIP® Analysis

In order to determine the impact of COVID-19 on the treatment and outcomes in patients with proximal femoral fracture’s (PFF), we analyzed a national US sample. This is a retrospective review of American College of Surgery’s (ACS) National Surgical Quality Improvement Program (NSQIP) for patients with proximal femoral fractures. A total of 26,830 and 26,300 patients sustaining PFF and undergoing surgical treatment were sampled during 2019 and 2020, respectively. On multivariable logistic regression, patients were less likely to have ‘presence of non-healing wound’ (p < 0.001), functional status ‘independent’ (p = 0.012), undergo surgical procedures of ‘hemiarthroplasty’(p = 0.002) and ‘ORIF IT, Peritroch, Subtroch with plates and screws’ (p < 0.001) and to be ‘alive at 30-days post-op’ (p = 0.001) in 2020 as compared to 2019. Patients were more likely to have a case status ‘emergent’, ‘loss of ≥10% body weight’, discharge destination of ‘home’ (p < 0.001 for each) or ‘leaving against medical advice’ (p = 0.026), postoperative ‘acute renal failure (ARF)’ (p = 0.011), ‘myocardial infarction (MI)’ (p = 0.006), ‘pulmonary embolism (PE)’ (p = 0.047), and ‘deep venous thrombosis (DVT)’ (p = 0.049) in 2020 as compared to 2019. Patients sustaining PFF and undergoing surgical treatment during pandemic year 2020 differed significantly in preoperative characteristics and 30-day postoperative complications when compared to patients from the previous year.

Postoperative complications in pediatric patients with cerebral palsy

BACKGROUND/PURPOSE

To assess surgical outcomes of patients with cerebral palsy (CP) and if they differ from patients without CP.

METHODS

The NSQIP-Pediatric database from 2012 to 2019 was used to compare differences in presenting characteristics and outcomes between patients with and without CP. Chi-square tests and multivariable logistic regression analysis were used to determine significance.

RESULTS

119,712 patients, 433 (0.4%) with CP, 119,279 (99.6%) without, were identified. Patients with CP had more postoperative complications (19.4% vs. 6.9%, p < 0.001) with an OR of 3.2, (95%CI 2.5-4.1, p < 0.001) on univariable analysis. They underwent fewer laparoscopic procedures (79.1% vs. 90.8%, p < 0.001), had more readmissions (10.2% vs. 3.8%, p < 0.001), reoperations (5.1% vs. 1.2%, p < 0.001), and longer length of stays (LOS) (median 3 versus 1 day, p < 0.001). On multivariable analysis, having CP did not increase the odds of postoperative morbidity (OR 0.99, 95% CI 0.7-1.3), but higher ASA class, congenital lung malformation, gastrointestinal disease, coagulopathy, preoperative inotropic support, oxygen use, nutritional support, and steroid use significantly increase the odds of morbidity, all of which were more common in patients with CP.

CONCLUSION

Patients with CP have more postoperative complications, open procedures, and longer LOS. Patient complexity may account for these differences and risk-directed perioperative planning may improve outcomes.

LEVEL OF EVIDENCE

Level IV.

Laparoscopic Ventral Hernia Repair Postoperative Complications in End Stage Renal Disease Patients

Background:

The prevalence of patients with end stage renal disease (ESRD) requiring general surgical procedures is increasing. Our aim was to explore the effect of ESRD on patients undergoing elective laparoscopic ventral hernia repair.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (2010–2015) database was used to identify patients who underwent elective laparoscopic ventral hernia repair. Multivariable analysis was performed adjusting for risk variables including age, gender, race, comorbidity status, body mass index ≥ 35, and presence of ESRD.

Results:

A total of 8,789 patients undergoing elective laparoscopic ventral hernia repair were identified. Sixty-four patients (0.73%) had ESRD. ESRD was identified as an independent risk factor for postoperative pneumonia (odds ration [OR] 6.91, p = 0.00363), sepsis (OR 18.58, p = 0.000286), and length of stay (IRR 1.63, 95% confidence interval 1.19 – 2.27, p = 0.0036).

Conclusions:

ESRD patients undergoing elective laparoscopic ventral hernia repair had an increased risk of postoperative pneumonia, sepsis, and length of stay. Clinicians should be cognizant of these risks when performing elective operations on ESRD patients.

Specialty-Specific Readmission Risk Models Outperform General Models in Estimating Hepatopancreatobiliary Surgery Readmission Risk

BACKGROUND

Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population.

METHODS

Pancreatectomy and hepatectomy operation-specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC).

RESULTS

A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58).

CONCLUSION

HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies.

Utility of preoperative laboratory testing in ASA 1 & ASA 2 patients undergoing outpatient surgery in the United States

STUDY OBJECTIVE

To assess the utility of preoperative testing in ASA physical status 1 and 2 patients undergoing outpatient surgery across several surgical specialties.

DESIGN

Retrospective cohort study.

PATIENTS

The American College of Surgeons National Surgical Quality Improvement Program database from 2017 to 2018 was queried to extract patients defined as ASA 1 and 2 who underwent outpatient surgeries. A total of 352,775 adult patients underwent outpatient surgery with 186,954 patients had at least one lab drawn within 30 days prior to the surgery.

INTERVENTIONS

ASA physical status 1 and 2 patients who underwent outpatient surgeries.

MEASUREMENTS

The primary independent variable was the utilization of preoperative laboratory testing. The primary outcomes were the occurrence of any medical or surgical complication adverse events within 30 days of discharge. In addition, we also examined hospital readmissions. A P value of 0.025 was used to avoid type I error for each primary outcome.

MAIN RESULTS

In the overall cohort, 186,954 out of 352,775 (53%) of patients had at least one lab test. Hematology was the most common lab test ordered, 172,903 out of 352,755 patients (49%), followed by chemistry (43%), liver function (23%), and coagulation tests (11%). After adjusting for confounding factors, the use preoperative testing was not associated with overall medical complications, OR (95%CI) of 1.09 (1.00 to 1.18), P = 0.05 and overall surgical complications, 1.00 (0.92 to 1.08), P = 0.96 [Bonferroni corrected: medical complications OR (97.5% CI) of 1.09 (0.989 to 1.202), P = 0.0950 and overall surgical complications, 1.00 (0.918 to 1.093), P = 1.00.

CONCLUSION

We detected a low utility of preoperative tests for ASA 1 and 2 patients undergoing a large variety of outpatient procedures. Our results support the elimination of preoperative laboratory test for ASA 1 and 2 undergoing ambulatory surgery.

Determining the Association Between Unplanned Reoperation and Readmission in Selected General Surgery Operations

BACKGROUND

Unplanned reoperations and unplanned readmissions can increase morbidity and mortality. Few studies however, have explored the association of reoperation and readmission among general surgery patients. Our aim was to examine this relationship in selected abdominal operations.

METHODS

Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files from 2014 to 2018 were utilized. Six groups of operations, defined by ACS NSQIP procedure codes for ventral hernia repair, colectomy, appendectomy, proctectomy, small bowel resection, and gastrectomy, were assessed. Patients discharged ≤ 14 days after operation were included in the study. This time period was selected to reduce ACS NSQIP 30 day post-surgery follow-up bias. Unplanned reoperations were defined as those occurring during the index hospitalization. The primary outcome was unplanned readmission that occurred ≤ 14 days from the date of discharge. Logistic regression models were used to examine variables associated with unplanned readmission for each procedure group.

RESULTS

A total of 787,118 patients were included: ventral hernia repair 35.2%, colectomy 30.6%, appendectomy 26.5%, proctectomy 3.7%, small bowel resection 3.2%, and gastrectomy 0.8%. Unplanned reoperation was independently associated with unplanned readmission for ventral hernia repair (OR 2.84, 95% CI 2.28-3.54, P < 0.001), colectomy (OR 1.58, CI 1.42- 1.76, P < 0.001), appendectomy (OR 2.91, CI 2.21-3.84, P < 0.001), and proctectomy (OR 1.41, CI 1.10-1.81, P = 0.006). Other clinically relevant covariates associated with readmission were partially dependent functional status before colectomy (OR 1.34, CI 1.23-1.46, P < 0.001), ventral hernia repair (OR 1.79, CI 1.54-2.09, P < 0.001), and small bowel resection (OR 1.44, CI 1.18-1.77, P < 0.001; and ASA 4/5 classification for colectomy (OR 2.71, CI 2.36-3.11, P < 0.001), proctectomy (OR 2.10, CI 1.48-2.97, P < 0.001), ventral hernia repair (OR 8.19, CI 6.78-9.88, P < 0.001), appendectomy (OR 2.80, CI 2.35-3.34, P < 0.001), and small bowel resection (OR 3.42, CI 2.20-5.32, P < 0.001). ASA 2, ASA 3 classification, age, and sex were also associated with unplanned readmission for most procedures.

CONCLUSIONS

Unplanned reoperations are associated with an increase in unplanned readmission after selected abdominal operations included in this study. This factor should be considered in discharge and follow-up planning to help reduce unplanned readmissions.

Validation study of the ACS NSQIP surgical risk calculator for two procedures in Japan

INTRODUCTION

The ACS NSQIP Surgical Risk Calculator (SRC) assesses risk to support goal-concordant care. While it accurately predicts US outcomes, its performance internationally is unknown. This study evaluates SRC accuracy in predicting mortality following low anterior resection (LAR) and pancreaticoduodenectomy (PD) in NSQIP patients and accuracy retention when applied to native Japanese patients (National Clinical Database, NCD).

METHODS

NSQIP (41,260 LAR; 15,114 PD) and NCD cases (61,220 LAR; 27,901 PD) from 2015 to 2017 were processed through the SRC mortality model. Country-specific calibration and discrimination were assessed with and without an intercept correction applied to the Japanese data.

RESULTS

The SRC exhibited acceptable calibration for LAR and PD when applied to NSQIP data but miscalibration for NCD data. A simple correction to the model intercept, motivated by lower mortality rates in the Japanese data, successfully remediated the miscalibration.

CONCLUSIONS

The SRC may inaccurately predict surgical risk when applied to the native Japanese population. An intercept correction method is suggested when miscalibration is encountered; it is simple to implement and may permit effective international use of the SRC.

The Association of Preoperative Smoking With Postoperative Outcomes in Patients Undergoing Total Hip Arthroplasty

BACKGROUND

Preoperative smoking is an easily modifiable risk factor and has associations with increased postoperative morbidity and mortality. It is important to clarify these risks for specific procedures to provide improved and evidence-based quality of care. The purpose of the present study aims to identify the associations between preoperative smoking and 30-day postoperative outcomes in patients undergoing total hip arthroplasty.

METHODS

We used R statistics to conduct a multivariable logistic regression analysis followed by a propensity score matching analysis to explore the association between preoperative smoking and postoperative outcomes.

RESULTS

A final cohort of 67,897 patients who underwent total hip arthroplasty was selected for analysis. After adjusting for potential confounders, the odds of postoperative pulmonary complications (odds ratio [OR], 1.352; 95% confidence interval [95% CI], 1.075-1.700; P = .01), infectious complications (OR, 1.310; 95% CI, 1.094-1.567; P = .003), and extended hospital stay (OR, 1.17; 95% CI, 1.099-1.251; P < .001) were all significantly higher in the smoking population. After propensity matching these cohorts, both infectious complications (P = .017) and extended hospital stays (P = .001) were significantly higher in smoking patients.

CONCLUSIONS

After controlling for potential confounding variables, our multivariable regression analysis revealed a significant increase in pulmonary and infectious complications as well as significantly longer hospital stays in our smoking population. When using a propensity score matching analysis, an increase in infectious complications as well as extended hospital stay was observed. Given the concerning prevalence of smoking in the United States, our data provide updated information toward a growing mass of literature supporting smoking cessation before surgical operations.

Demographic and Clinical Variables Associated With 30-day Re-Intubation Following Surgical Aortic Valve Replacement

BACKGROUND

A retrospective study was performed to evaluate factors associated with 30-d re-intubation following surgical aortic valve repair. We hypothesized a significant increase in the odds of re-intubation among patients with preoperative comorbidities.

METHODS

The American College of Surgery National Surgical Quality Improvement Program database from 2007 to 2016 was used to evaluate demographic and clinical factors associated with 30-d re-intubation following surgical aortic valve repair. Multivariable logistic regression was used to report factors associated with 30-d re-intubation while controlling for various patient characteristics.

RESULTS

The study population consisted of 5,766 adult subjects who underwent surgical aortic valve repair, of whom 258 (4.47%) were re-intubated within 30 d of surgery. The mean ± SD age was 69 ± 12.98 y, and 3,668 (63.6%) were male. The prevalence of diabetes mellitus, shortness of breath, poor functional status, COPD, congestive heart failure, hypertension, and bleeding disorder was higher among subjects who were re-intubated compared to those who were not (P < .05). Age, severe COPD, congestive heart failure, and bleeding disorder were associated with this outcome.

CONCLUSIONS

Age, COPD, congestive heart failure, and bleeding disorder were associated with 30-d re-intubation in this surgical cohort. If surgical aortic valve repair is deemed non-emergent, patients should be optimized preoperatively and receive careful postoperative planning to reduce the risk of postoperative complications.

Outcomes of Laparoscopic Versus Open Ladd Procedures and Risk Factors for Conversion

Background: Malrotation is a common congenital anomaly that can lead to bowel obstruction and ischemia if not corrected with a Ladd procedure. Controversy exists between open and laparoscopic approaches. We sought to compare postoperative outcomes and determine risk factors for conversion to an open procedure. Methods: The National Surgical Quality Improvement Program (NSQIP)-Pediatric was used to identify patients undergoing Ladd procedures from 2013 to 2018. Propensity score matching was used to account for differences in patient characteristics between open and laparoscopically treated cohorts. Chi-square tests and adjusted logistic regression analysis were used to determine patient outcomes differences between treatment groups and factors associated with conversion. Results: A total of 2437 patients were identified, 1889 (77.5%) open, 548 (22.5%) laparoscopic, and 193 (35.2%) laparoscopic converted to open. Patients undergoing laparoscopic compared with open procedures had shorter length of stay (5 versus 7 days, P < .001) and lower overall complication rates (13.1% versus 18.1%, P = .025), despite longer operative times (108.9 versus 93.7 minutes, P < .001). Patients requiring conversion were more likely to be younger, have an urgent/emergent case, sepsis/septic shock, and nutritional support requirement. Conclusions: After risk adjustment, laparoscopic Ladd procedure is associated with decreased complications and minimal operative time increases compared with an open approach. Risk factors associated with conversion should be considered during operative planning.

The influence of prematurity on neonatal surgical morbidity and mortality

BACKGROUND

As survival rates amongst premature infants have improved, prematurity remains a leading contributor to neonatal surgical morbidity and mortality. This study aims to better assess the influence of prematurity on surgical outcomes.

METHODS

The NSQIP-Pediatric database was used to compare outcomes between preterm and term infants undergoing surgical repair of select congenital anomalies from 2012 to 2017. Prematurity was categorized as extremely preterm (EP) (<29 weeks), very preterm (VP) (29-32 weeks), moderate to late preterm (MLP) (33-36 weeks), and term (≥37 weeks). Significance was determined using Chi-square tests, Fisher exact tests and adjusted logistic regression analysis.

RESULTS

4852 infants were identified with 45 (0.9%) EP, 211 (4.3%) VP, 1492 (30.8%) MLP, and 3104 (64.0%) term. Compared to term, preterm infants have increased odds of surgical morbidity (EP Odds Ratio (OR) 3.2 95% Confidence Interval (CI) 1.6-6.4, VP OR 1.2 95%CI 0.9-1.7, and MLP OR 1.2 95%CI 1.0-1.4). 30-day mortality decreased as neonatal age increased from 22.2% EP to 2.9% term (p < 0.001). Premature populations had higher rates of sepsis, pneumonia, bleeding requiring transfusion and 30-day mortality.

CONCLUSIONS

Prematurity increases morbidity and mortality amongst neonates undergoing surgery. Risk-adjustment for prematurity is needed and premature infants may have unique quality improvement targets.

LEVEL OF EVIDENCE

Level III.

Post-discharge venous thromboembolism after pancreatectomy for malignancy: Predicting risk based on preoperative, intraoperative, and postoperative factors

BACKGROUND AND OBJECTIVES

Extended chemoprophylaxis is recommended for high-risk patients following pancreatectomy for malignancy. However, quantifying risk remains difficult. We sought to (a) identify factors associated with post-discharge venous thromboembolism (VTE) following pancreatectomy for malignancy and (b) develop a post-discharge VTE risk calculator to identify high-risk patients.

METHODS

Patients who underwent pancreatectomy for malignant histology from 2014 to 2018 were identified from the ACS NSQIP pancreatectomy procedure targeted dataset. Preoperative, intraoperative, and postoperative factors known at hospital discharge were evaluated for association with post-discharge VTE via multivariable logistic regression. A post-discharge VTE risk calculator was developed and validated.

RESULTS

Of 19 340 analyzed patients, 280 (1.5%) developed post-discharge VTE. Post-discharge VTE was associated with increasing body mass index (BMI; eg, morbidly obese BMI odds ratio [OR]: 1.99 [95% confidence interval {CI}: 1.30-3.02] vs normal BMI), procedure type (distal pancreatectomy OR: 1.47 [95% CI: 1.02-2.12] vs pancreaticoduodenectomy), pancreatic fistula (OR: 1.59 [95% CI: 1.19-2.13]) and delayed gastric emptying (OR: 1.81 [95% CI: 1.29-2.52]). Patients' predicted probability of post-discharge VTE ranged from 0.7% to 9.0%. Twenty iterations of 10-fold cross-validation demonstrated internal validity.

CONCLUSIONS

Preoperative, intraoperative, and postoperative factors were associated with post-discharge VTE following pancreatectomy for malignancy. This post-discharge VTE risk calculator allows for quantification of individual post-discharge VTE risk, which ranged from 0.7% to 9.0%.

Myomectomy associated blood transfusion risk and morbidity after surgery

OBJECTIVE

To evaluate blood transfusion risks and the associated 30-day postoperative morbidity after myomectomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Women who underwent myomectomies for symptomatic uterine fibroids (N = 3,407).

INTERVENTION(S)

Blood transfusion during or within 72 hours after myomectomy.

MAIN OUTCOME MEASURE(S)

The primary outcomes were rate of blood transfusion with myomectomy and risk factors associated with receiving a transfusion. The secondary outcome was 30-day morbidity after myomectomy.

RESULT(S)

The overall rate of blood transfusion was 10% (hysteroscopy, 6.7%; laparoscopy, 2.7%; open/abdominal procedures, 16.4%). Independent risk factors for transfusion included as follows: black race (adjusted odds ratio [aOR] 2.27, 95% confidence interval [CI] 1.62-3.17) and other race (aOR 1.77, 95% CI 1.20-2.63) compared with white race; preoperative hematocrit <30% compared to ≥30% (aOR 6.41, 95% CI 4.45-9.23); preoperative blood transfusion (aOR 2.81, 95% CI 1.46-5.40); high fibroid burden (aOR 1.91, 95% CI 1.45-2.51); prolonged surgical time (fourth quartile vs. first quartile aOR 11.55, 95% CI 7.05-18.93); and open/abdominal approach (open/abdominal vs. laparoscopic aOR 9.06, 95% CI 6.10-13.47). Even after adjusting for confounders, women who required blood transfusions had an approximately threefold increased risk for experiencing a major postoperative complication (aOR 2.69, 95% CI 1.58-4.57).

CONCLUSION(S)

Analysis of a large multicenter database suggests that the overall risk of blood transfusion with myomectomy is 10% and is associated with an increased 30-day postoperative morbidity. Preoperative screening of women at high risk for transfusion is prudent as perioperative transfusion itself leads to increased major postoperative complications.

Predictors of 30-Day Unplanned Readmissions, Complications, and Mortality Following Operative Management of C2 Fractures

STUDY DESIGN

Retrospective database review.

OBJECTIVES

To determine factors associated with unplanned readmission, complications, and mortality in patients undergoing operative management for C2 fractures.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS NSQIP) was queried between 2007 and 2014. Unplanned readmission, any complication, and mortality were the outcomes of interest. Bivariate statistics were calculated, and multivariate regression models were estimated.

RESULTS

A total of 285 patients were enrolled. Readmission data was available for 199 patients and 11 patients (5.5% of 199 patients) had an unplanned readmission. Overall, 60 patients (21% of 285 patients) had at least 1 complication and 15 patients (5.3% of 285 patients) died. Five factors were associated with complications: transferred from another facility (odds ratio [OR] 3.00, 95% confidence interval [CI]1.51-5.98; P < .01); operative time ≥180 minutes (OR 2.43, 95% CI 1.11-5.36; P = .03); at least 1 patient comorbidity (OR 2.50, 95% CI 1.01-6.18; P < .05); American Society of Anesthesiologists (ASA) class 3 (OR 4.86, 95% CI 1.19-19.88; P = .03); and ASA class 4 (OR 7.24, 95% CI 1.66-31.66; P = .01). The only factor associated with unplanned readmission was having at least one postoperative complication (OR 7.10, 95% CI 1.04-48.59; P < .05), while patients who were partially or totally dependent from a functional standpoint were at increased odds of death (OR 3.98, 95% CI 1.12-14.08; P = .03).

CONCLUSIONS

Patients with functional limitations have increased odds of death, while patients with postoperative complications have increased odds of unplanned readmission. Being transferred from an outside facility, having an operative time ≥180 minutes, having at least one comorbidity, and being classified as ASA class 3 or 4 increase patient odds of complication.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

Background

There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors.

Methods

A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation.

Results

We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood.

Conclusions

The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

Pre-Operative, Intra-Operative, and Post-Operative Factors Associated with Post-Discharge Venous Thromboembolism Following Colorectal Cancer Resection

BACKGROUND

Venous thromboembolism (VTE) is the most common preventable cause of 30-day post-operative mortality, with many events occurring after hospital discharge. High-level evidence supports post-discharge VTE chemoprophylaxis following abdominal/pelvic cancer resection; however, some studies support a more tailored approach. Our objectives were to (1) identify risk factors associated with post-discharge VTE in a large cohort of patients undergoing colorectal cancer resection and (2) develop a post-discharge VTE risk calculator.

METHODS

Patients who underwent colorectal cancer resection from 2012 to 2016 were identified from ACS NSQIP colectomy and proctectomy procedure-targeted modules. Multivariable logistic regression was used to identify factors associated with post-discharge VTE. Incorporating pre-operative, intra-operative, and post-operative variables, a post-discharge VTE risk calculator was constructed and validated.

RESULTS

Of 51,139 patients, 387 (0.76%) developed post-discharge VTE. Pre-operative factors associated with post-discharge VTE included BMI (e.g., morbidly obese OR 2.27, 95% CI 1.65-3.12 vs. normal BMI), and thrombocytosis (OR 1.41, 95% CI 1.03-1.92). Intra-operative factors included operative time (4-6 h OR 1.56, 95% CI 1.12-2.17; > 6 h, OR 1.85, 95% CI 1.21-2.84, vs. < 2 h), and type of operation (e.g., open partial colectomy OR 1.67, 95% CI 1.30-2.16 vs. laparoscopic partial colectomy). Post-operative factors included anastomotic leak (OR 2.05, 95% CI 1.31-3.21) and post-operative ileus (OR 1.39, 95% CI 1.07-1.79). Using the risk calculator, the predicted probability of post-discharge VTE ranged from 0.04 to 10.29%. On a 10-fold cross validation, the calculator's mean C-Statistic was 0.65.

CONCLUSIONS

Patient-specific factors are associated with varying rates of post-discharge VTE. We present the first post-discharge VTE risk calculator designed for use at the time of discharge following colorectal cancer resection.

Spine surgeon specialty differences in single-level percutaneous kyphoplasty

Background

Percutaneous kyphoplasty (PKP) is a procedure performed by a spine surgeon who undergoes either orthopedic or neurosurgical training. The relationship between short-term adverse outcomes and spine specialty is presently unknown. To compare short-term adverse outcomes of single-level PKP when performed by neurosurgeons and orthopedic surgeons in order to develop more concretely preventive strategies for patients under consideration for single-level PKP.

Methods

We evaluated patients who underwent single-level PKP from 2012 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We used univariate analysis and multivariate logistic regression to assess the association between spine surgeon specialty and short-term adverse events, including postoperative complication and unplanned readmission, and to identify different independent risk predictors between two specialties.

Results

Of 2248 patients who underwent single-level PKP procedure, 1229 patients (54.7%) had their operations completed by a neurosurgeon. There were no significant differences in the development of the majority of postoperative complications and the occurrence of unplanned readmission between the neurosurgical cohort (NC) and the orthopedic cohort (OC). A difference in the postoperative blood transfusion rate (0.7% NS vs. 1.7% OC, P = 0.039) was noted and may due to the differences in comorbidities between patients. Multivariate regression analysis revealed different independent predictors of postoperative adverse events for the two spine specialties.

Conclusions

By comparing a large range of demographic feature, preoperative comorbidities, and intraoperative factors, we find that short-term adverse events in single-level PKP patients does not affect by spine surgeon specialty, except that the OC had higher postoperative blood transfusion rate. In addition, the different perioperative predictors of postoperative complications and unplanned readmissions were identified between the two specialties. These findings can lead to better evidence-based patient counseling and provide valuable information for medical evaluation and potentially devise methods to reduce patients’ risk.

Clostridium difficile Colitis Following Revision Total Knee Arthroplasty: Incidence and Risk Factors

BACKGROUND

Clostridium difficile-associated diarrhea (CDAD) is associated with adverse events and financial liability. As institutions continue to adopt CDAD rates as a quality control metric, it is important to identify patients at risk before surgery, including revision total knee arthroplasty (rTKA). This study was conducted to (1) determine the incidence of CDAD within 30 days of rTKA and (2) identify perioperative risk factors for CDAD following rTKA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify 6023 rTKA procedures from 2015-2016. Preoperative and perioperative variables, including patient demographics, lab values, comorbidities, operative time, procedure type, presence of postoperative infections, and rates of CDAD were collected. Chi-square and Fisher's exact tests were used to detect differences between categorical variables, and t-tests were used to compare continuous variables. A stepwise logistic regression model was used to identify the risk factors for CDAD.

RESULTS

The rate of CDAD within 30 days of rTKA was found to be 0.4% (24/6024). The CDAD rate following aseptic revision was 0.2% (12/4893), while the incidence of CDAD after septic revision was 1.1% (12/1130). Preoperative functional dependence (odds ratio [OR] = 5.14; P = .002), septic revision (OR = 2.77; P = .026), and cancer (OR = 14.26; P = .016) were statistically significant independent risk factors for CDAD after rTKA.

CONCLUSION

The incidence of CDAD after rTKA is approximately 0.4% in the United States. Independent risk factors for CDAD include septic revision, preoperative functional dependence, and cancer. Prevention of CDAD in these higher risk patients must be considered before surgery and antibiotic selection for other infections should be managed judiciously.

Perioperative outcomes after tracheoplasty: A NSQIP analysis 2014-2016

OBJECTIVES

Tracheoplasty or tracheal resection and are essential components of the care of patients with severe tracheal stenosis. We aimed to study the perioperative outcomes of patients after tracheoplasty or resection using a national surgical registry.

METHODS

We analyzed the 2014 to 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file for patients who underwent tracheal resection or tracheoplasty (CPT codes 31750, 31760, 31780, and 31781). We analyzed the perioperative outcomes including length of stay (LOS), dehiscence, unplanned reintubations, unplanned surgeries, and 30-day readmission rates. A random 4:1 sample of non-tracheoplasty patients served as the control group.

RESULTS

From 2014 to 2016, 126 patients underwent tracheoplasty. The median age was 56 years (IQR = 45-63). There were 93 (74%) females, 88 (70%) white, and 3.2% (4/126) Hispanic. The median LOS was 7 days (IQR = 5-10 days). Of these, 4.8% (6/126) developed wound infections and 3/126 (2.4%) developed wound dehiscence. Five out of 126 required unplanned reintubation (4.0%) and 16/126 (13%) had an unplanned reoperation. The 30-day unplanned readmission rate was 16% (20/126). The wound infection, unplanned intubations, and readmission rates were significantly higher (P < .005) than the control group.

CONCLUSIONS

The 30-day perioperative outcomes of adult patients undergoing tracheoplasty showed that adverse events are common, but severe adverse events such as death are rare. Continued research into risk mitigation among these patients is warranted.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1514-1519, 2020.

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

STUDY OBJECTIVE

To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.

DESIGN

Retrospective cohort study.

SETTING

Postoperative recovery.

PATIENTS

8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.

INTERVENTIONS

We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.

MEASUREMENTS

Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.

MAIN RESULTS

After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94-11.14), pulmonary complications (OR 1.83, 95% CI 1.4-2.36), extended hospital stay (OR 1.47, 95% CI 1.26-1.72), readmission (OR 1.27, 95% CI 1.01-1.59) and mortality (OR 1.92, 95% CI 1.54-2.39) were all significantly higher in patients with preoperative delirium compared to those without.

CONCLUSIONS

After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.

Thirty-Day Unplanned Reintubation Following Pleurodesis: A Retrospective National Registry Analysis

OBJECTIVE

To examine risk factors associated with 30-day unplanned reintubation after pleurodesis.

DESIGN

A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program surgical outcomes registry.

SETTING

United States hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

PARTICIPANTS

The study comprised 2,358 patients who underwent video-assisted thorascopic surgery for pleurodesis from 2007 to 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The final sample included 2,358 cases, of which 93 (3.9%) required 30-day unplanned reintubation. Cases with 30-day unplanned reintubation, compared to those without, had higher unadjusted rates of American Society of Anesthesiologists physical status (ASA PS) score ≥4 (54.8% v 27.2%), preoperative dyspnea (71% v 57%), congestive heart failure (14% v 5.4%), functional dependence (28% v 10.3%), and diabetes mellitus (29% v 17.8%) (all p < 0.05). Patients with 30-day reintubation experienced higher unadjusted rates of 30-day outcomes including mortality (50.5% v 10.1%), pneumonia (28% v 4.9%), ventilator dependence (50.5% v 10.1%), sepsis (7.5% v 1.9%), myocardial infarction (5.4% v 0.1%), cardiac arrest (18.3% v 0.6%), transfusion (14% v 4.5%), and reoperation (15.1% v 3.2%) (all p < 0.05). The odds of 30-day unplanned reintubation were increased significantly on multivariable analysis for patients with ASA PS score ≥4, functional dependence, disseminated cancer, renal dialysis, and weight loss (all p < 0.05).

CONCLUSION

Given the dearth of population-based studies addressing risk factors of reintubation after pleurodesis, this study suggests further review of preoperative optimization, which is required to improve patient outcomes and safety.

ACS NSQIP Surgical Risk Calculator: Pilot Analysis on Feasibility in an Academic Safety Net Hospital

BACKGROUND

Hospitals are looking for effective methods to track outcomes that are risk-adjusted for patient population characteristics. This is especially relevant for safety net hospitals (SNHs) servicing high-risk populations and in an era of quality-based reimbursement incentives. One such program with these goals is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This is an institution-based quality audit whereby we determined the presence and consistency of charted data required to compute perioperative risk in the ACS NSQIP risk calculator.

MATERIALS AND METHODS

A retrospective chart review of 28 elective colorectal procedures was performed at an urban, academic SNH over a 1-y period. For each case, it was determined whether the required NSQIP variables were readily presented via preoperative documentation. Univariate and bivariate statistics were employed to compare data field completion rates.

RESULTS

Of the 28 reviewed patient charts, none (n = 0) had all preoperative risk documentation required to complete an ACS NSQIP risk analysis. 89.3% of charts (n = 25) had ≤ 55% of required data to complete a risk assessment. However on bivariate analysis, demographic variables were more likely to have been recorded (P < 0.001) than other risk factors.

CONCLUSIONS

Preoperative risk assessment and corresponding charting practices at the SNH reviewed was fragmented and incomplete. There was lack of definitive documentation of risk factors and preoperative interventions used to modulate risk. Under current reimbursement models such as the MACRA Quality Payment Program, these findings are crucial for like-institutions to consider to critically evaluate their own documentation practices.

Revision Total Shoulder Arthroplasty is Associated with Increased Thirty-Day Postoperative Complications and Wound Infections Relative to Primary Total Shoulder Arthroplasty

BACKGROUND

With an increasing volume of primary total shoulder arthroplasties (TSA), the number of revision TSA cases is expected to increase as well. However, the postoperative medical morbidity of revision TSA has not been clearly described.

QUESTIONS/PURPOSES

The purpose of this study was to determine the rate of postoperative complications following revision TSA, relative to primary TSA. In addition, we sought to identify independent predictors of complications, as well as to compare operative time and postoperative length of stay between primary and revision TSA.

METHODS

Patients who underwent primary/revision TSA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Differences in complications, readmission rates, operative time, length of stay, and predictors of complications were evaluated using bivariate and multivariate analyses.

RESULTS

A total of 10,371 primary TSA (95.4%) and 496 revision TSA cases (4.6%) were identified. The overall complication rate was 6.5% in primary and 10.7% in revision TSA patients (p < 0.001). Multivariate analysis identified an increased risk of any complication (odds ratio 1.73, p < 0.001), major complication (2.08, p = 0.001), and wound infection (3.45, p = 0.001) in revision TSA patients, relative to primary cases. Operative time was increased in revision cases (mean ± standard deviation, 125 ± 62.5), relative to primary (115 ± 47.7, p < 0.001). Age > 75, female sex, history of diabetes or chronic obstructive pulmonary disease, and American Society of Anesthesiologists classification ≥ 3 were associated with increased risk of any complication. Smoking history was the only significant predictor of wound infection.

CONCLUSION

Revision TSA, in comparison to primary, poses an increased risk of postoperative complications, particularly wound infections. A history of smoking was an independent predictor of wound infections.

Unplanned Reoperation Following Colorectal Surgery: Indications and Operations

AIM

Prior studies have demonstrated a reoperation rate ranging from 5.8 to 7.6% following colorectal surgery. However, the indications for reoperation have not been extensively evaluated. We aimed to describe the indications for reoperation and associated procedures following colorectal resection.

METHODS

This is a retrospective cohort study of all patients undergoing colorectal resection at a single institution from 2003 to 2013. For patients who returned to the operating room, the primary indication was categorized into mutually exclusive categories and all procedures performed within 30 days of the initial operation were indexed. Univariate and multivariate analyses were performed.

RESULTS

We identified 2793 patients who underwent colorectal operations, of which 407 (14.6%) were emergent. A total of 178 (6.7%) patients returned to the operating room. On multivariate analysis, emergent operation, malnutrition, corticosteroid use, and operative duration were independently associated with reoperation; independent functional status was protective. The most common indications for reoperation were anastomotic leak and bowel obstruction. The most common procedures performed were ostomy creation, bowel resection, and adhesiolysis.

CONCLUSIONS

Reoperation after colorectal surgery is a relatively common occurrence for which we have identified the risk factors, most common indications, and specific procedures performed. This knowledge will help identify areas for improvement.

NSQIP as a Predictor of Length of Stay in Patients Undergoing Free Flap Reconstruction

OBJECTIVE

The National Surgical Quality Improvement Program (NSQIP) calculator was created to improve outcomes and guide cost-effective care in surgery. Patients with head and neck cancer (HNC) undergo ablative and free flap reconstructive surgery with prolonged postoperative courses.

METHODS

A case series with chart review was performed on 50 consecutive patients with HNC undergoing ablative and reconstructive free flap surgery from October 2014 to March 2016 at a tertiary care center. Comorbidities and intraoperative and postoperative variables were collected. Predicted length of stay was tabulated with the NSQIP calculator.

RESULTS

Thirty-five patients (70%) were male. The mean (SD) age was 67.2 (13.4) years. The mean (SD) length of stay (LOS) was 13.5 (10.3) days. The mean (SD) NSQIP-predicted LOS was 10.3 (2.2) days (P = .027).

DISCUSSION

The NSQIP calculator may be an inadequate predictor for LOS in patients with HNC undergoing free flap surgery. Additional study is necessary to determine the accuracy of this tool in this patient population.

IMPLICATIONS FOR PRACTICE

Head and neck surgeons performing free flap reconstructive surgery following tumor ablation may find that the NSQIP risk calculator underestimates the LOS in this population.

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

BACKGROUND

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

METHODS

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

RESULTS

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p < 0.001).

CONCLUSIONS

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification?

BACKGROUND

Total knee arthroplasty (TKA) is often the best answer for end-stage, posttraumatic osteoarthritis after intra-articular and periarticular fractures about the knee. Although TKA in this setting is often considered more technically demanding, outcomes are typically worse for patients. This study examines the intraoperative differences and 30-day outcomes in posttraumatic vs primary TKA cohorts.

METHODS

Patients undergoing TKA were selected from the National Surgical Quality Improvement Program database from 2010 to 2013. Patients were stratified on the basis of concurrent procedures and administrative codes indicating posttraumatic diagnoses. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether posttraumatic arthritis was a risk factor for poor outcomes.

RESULTS

A total of 67,675 primary and 674 posttraumatic TKAs were identified. Posttraumatic TKA patients were on average younger and healthier than the primary TKA population. The posttraumatic TKA group had higher rates of superficial surgical site infections and bleeding requiring transfusion. History of posttraumatic knee osteoarthritis was found to be an independent risk factor for prolonged operative time, increased length of hospital stay, and 30-day hospital readmission.

CONCLUSION

We have demonstrated increased intraoperative times, heightened transfusion requirements and surgical site infections, and higher readmission rates after conversion TKA in the posttraumatic cohort. In contrast to total hip arthroplasty, current diagnosis and reimbursement schemes do not differentiate posttraumatic patients from primary osteoarthritis groups undergoing TKA. We believe that classification reform would improve medical documentation and improve patient care.

Morbid obesity is an independent risk factor for postoperative renal dysfunction in young adults: a review of the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Little information exists on the acute effects of elective surgery on renal function. Our aim was to determine if obesity was an independent risk factor for postoperative renal complications (RCs).

METHODS

A total of 119,142 patients aged 18 to 35 years with body mass index (BMI) ≥18 kg/m(2) obtained from American College of Surgeons National Surgical Quality Improvement Project (2005 to 2010) were classified into standard BMI categories. Association between BMI and preoperative estimated glomerular filtration rate (eGFR; calculated using modification of diet in renal disease formula) was analyzed. Postoperative changes in eGFR and RCs were measured. Multivariate regression analysis was performed adjusting for all variables.

RESULTS

Postoperatively, there was a reduction in eGFR among the overweight (-3.4 mL/min/1.73 m(2), P < .001), obese class I (-3.9 mL/min/1.73 m(2), P = .001), and obese class II (-5.3 mL/min/1.73 m(2), P < .001). The odds of any postoperative RC was significantly higher in obese class III patients (odds ratio = 2.01 95% confidence interval 1.07 to 3.76, P = .029).

CONCLUSIONS

Results seen in patients with BMI greater than 40 indicate that BMI can serve as an independent predictor of RCs.

Total Joint Arthroplasty in Patients with Chronic Renal Disease: Is It Worth the Risk?

26-27% of patients with end stage hip and knee arthritis requiring TJR have chronic renal disease. A multi-center, prospective clinical registry was queried for TJA's from 2006 to 2012, and 74,300 cases were analyzed. Renal impairment was quantified using estimated glomerular filtration rate (eGFR) to stratify each patient by stage of CRD (1-5). There was a significantly greater rate of overall complications in patients with moderate to severe CRD (6.1% vs. 7.6%, P<0.001). In those with CRD (Stage 3-5), mortality was twice as high (0.26% vs. 0.48%, P<0.001). Patients with Stage 4 and 5 CRD had a 213% increased risk of any complication (OR 2.13, 95% CI: 1.73-2.62). Surgeons may use these findings to discuss the risk-benefit ratio of elective TJR in patients with CRD.

The Incidence of and Risk Factors for 30-Day Surgical Site Infections Following Primary and Revision Total Joint Arthroplasty

The authors assessed the incidence of and risk factors associated with 30-day surgical site infections (SSIs) following primary (p) and revision (r) THA and TKA. In total, 23,128 primary and 2170 revision TJAs were identified between 2005 and 2010 in the ACS NSQIP database. The 30-day SSI rates, overall and deep, were 1.1 and 0.1% for pTKA, 1.18 and 0.4% for pTHA, 1.68 and 0.7% for rTKA, and 2.9 and 1.7% for rTHA. After primary TJA, independent risk factors were BMI>40, hypertension, prolonged operative time, electrolyte disturbance and previous infection, and after revision TJA, dyspnea and bleeding disorder were risk factors. This study should help provide benchmark data for SSI following TJA.

How sick are dialysis patients undergoing cholecystectomy? Analysis of 92,672 patients from the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Although cholecystectomy is one of the most common surgical procedures performed in the United States, there is an absence of data on the risks of cholecystectomy in dialysis patients. Our objective was to analyze the outcomes of cholecystectomy in dialysis patients.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we selected all patients who underwent cholecystectomy from 2005 to 2010. Univariate analysis was performed and logistic and linear regression models were used to obtain risk-adjusted outcomes. The main outcomes were morbidity, mortality, and length of stay.

RESULTS

Dialysis was associated with a higher risk of 30-day postoperative morbidity (16.1% vs 3.8%, adjusted odds ratio 1.91, 95% confidence interval 1.18 to 3.10), but not mortality. The average length of stay following any cholecystectomy was 4.1 days longer for dialysis patients (5.5 vs 1.4 days, P < .0001).

CONCLUSION

Patients on dialysis who undergo cholecystectomy are at a higher risk for postoperative morbidity, but not mortality.

Outcomes registries: an untapped resource for use in surgical education

OBJECTIVE

To examine the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for use in profiling the aggregated resident operative experience by postgraduate training year and to demonstrate the extent to which a surgical registry could be used to examine resident exposure to adverse events.

BACKGROUND

Independent data regarding the operative experience and clinical effectiveness across residency programs remain elusive. In the absence of reliable data, the ability to standardize surgical education and reduce variation in practice remains an unachievable goal.

METHODS

We identified general surgery cases using the ACS NSQIP Participant Use File 2011. Resident participation was defined according to postgraduate year (PGY). Descriptive statistical analyses were performed regarding procedure type and clinical outcomes.

RESULTS

Of the total general surgery cases, a PGY 1 to 5 resident participated in 87% (45,423), and 28% (n = 14,559) were performed with PGY 5 residents. Interns were involved with 10% (n = 5448) of the cases. The type of procedures performed varied by PGY, but cholecystectomy was the most common. Overall, 11% (4773) of cases were associated with an adverse event or mortality or both, with a mortality rate of 0.8% (374). The most common adverse event was bleeding (5%).

CONCLUSIONS

The ACS NSQIP captures the breadth of the resident experience in operative case mix and exposure to adverse events. Although the program was originally designed to uncover areas for quality improvement, the findings of our study demonstrate the utility of an outcomes registry as a guide for the development of future educational content in the resident curriculum.

Bariatric surgery in patients with reduced kidney function: an analysis of short-term outcomes

BACKGROUND

With rates of obesity among patients with chronic kidney disease (CKD) mirroring that of the general population, there is growing interest in offering bariatric surgery to these patients. We sought to determine the safety of bariatric surgery in this patient population.

METHODS

Patients who underwent selected laparoscopic bariatric procedures between 2005 and 2011. Estimated glomerular filtration rate (eGFR) was calculated and divided into stages of CKD. Procedures included Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), and laparoscopic sleeve gastrectomy (SG). Univariable analysis and multivariable adjustment was used to compare complication rates across stages of eGFR.

RESULTS

A total of 64,589 patients were included: 64.5% underwent RYGB, 29.8% LAGB, and 5.7% SG. A total of 61.7% of patients had normal eGFR (Stage 1), 32.0% were stage 2, 5.3% were stage 3, and 1.0% were stage 4/5. After adjusting for relevant patient characteristics, there was a trend toward increasing complications from stage 1 to stage 4/5 CKD among RYGB, LAGB, and SG groups, but none were statistically significant. Similarly, major complications generally increased across stages of CKD for each procedure, but was only significant for RYGB comparing stage 3 to stage 1 (OR 1.22; 95% CI: 1.01-1.47; P = .042) and risk difference .96% (95% CI: .03-1.96). Considering only stage 4/5 CKD, overall (P = .114) and major complications (P = .032) were highest in the RYGB group, followed by SG and LAGB.

CONCLUSION

More advanced stages of CKD do not appear to be statistically associated with an increased risk of 30-day postoperative complications.

Patient-specific risk factors are predictive for postoperative adverse events in colorectal surgery: an American College of Surgeons National Surgical Quality Improvement Program-based analysis

BACKGROUND

Pay-for-performance measures incorporate surgical site infection rates into reimbursement algorithms without accounting for patient-specific risk factors predictive for surgical site infections and other adverse postoperative outcomes.

METHODS

Using American College of Surgeons National Surgical Quality Improvement Program data of 67,445 colorectal patients, multivariable logistic regression was performed to determine independent risk factors associated with various measures of adverse postoperative outcomes.

RESULTS

Notable patient-specific factors included (number of models containing predictor variable; range of odds ratios [ORs] from all models): American Society of Anesthesiologists class 3, 4, or 5 (7 of 7 models; OR 1.25 to 1.74), open procedures (7 of 7 models; OR .51 to 4.37), increased body mass index (6 of 7 models; OR 1.15 to 2.19), history of COPD (6 of 7 models; OR 1.19 to 1.64), smoking (6 of 7 models; OR 1.15 to 1.61), wound class 3 or 4 (6 of 7 models; OR 1.22 to 1.56), sepsis (6 of 7 models; OR 1.14 to 1.89), corticosteroid administration (5 of 7 models; OR 1.11 to 2.24), and operation duration more than 3 hours (5 of 7 models; OR 1.41 to 1.76).

CONCLUSIONS

These findings may be used to pre-emptively identify colorectal surgery patients at increased risk of experiencing adverse outcomes.

Anterior and posterior cervical fusion in patients with high body mass index are not associated with greater complications

BACKGROUND CONTEXT

Obesity has been associated with adverse surgical outcomes; however, limited information is available regarding the effect of obesity on cervical spinal fusion outcomes.

PURPOSE

To determine the effect of obesity on complication rates after cervical fusions.

STUDY DESIGN/SETTING

Retrospective cohort analysis of prospectively collected data on cervical fusion surgeries.

PATIENT SAMPLE

Patients in the ACS-NSQIP database from 2005 to 2010 undergoing cervical anterior or posterior fusion.

OUTCOME MEASURES

Primary outcome measures were 30-day postsurgical complications, including mortality, deep-vein thrombosis, pulmonary embolism, septic complications, system-specific complications, and having ≥1 complication overall. Secondary outcomes were time spent in the operating room, blood transfusions, length of stay, and reoperation within 30 days.

METHODS

Patients undergoing anterior or posterior cervical fusions in the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program were selected using Current Procedural Terminology codes. Anterior cervical fusion patients were categorized into four groups on the basis of body mass index (BMI): nonobese (18.5-29.9 kg/m(2)), obese I (30-34.9 kg/m(2)), obese II (35-39.9 kg/m(2)), and obese III (≥40 kg/m(2)). Posterior cervical patients were categorized into two groups based on the basis of BMI: nonobese (18.5-29.9 kg/m(2)) and obese (≥30 kg/m(2)) due to the smaller sample size. Patients in the obese categories were compared with patients in the nonobese categories by the use of χ(2), Fisher's exact test, Student t test, and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative comorbidities. The authors report no sources of funding or conflicts of interest related to this study.

RESULTS

Data were available for 3,671 and 400 patients who underwent anterior or posterior cervical fusion, respectively. Obese class III patients only showed a greater incidence of deep-vein thrombosis after anterior fusions on univariate analysis. Obese patients only showed longer mean surgical times and total operating room times after posterior fusions on univariate analysis. On multivariate analyses, these differences did not remain significant. There were also no differences in multivariate analyses for overall and system-specific complication rates, lengths of hospital stay, reoperation rates, and mortality among the obesity groups when compared with the nonobese groups with anterior or posterior cervical fusions.

CONCLUSIONS

High BMI, regardless of obesity class, does not appear to be associated with increased complications after cervical fusion in the 30-day postoperative period.

The future of quality measurement in the United States

The need to practice cost efficient medicine and provide it in the safest way possible is paving the way for quality improvement (QI) programs to take off. American College of Surgeons National Surgical QI Project and Surgical Care and Outcomes Assessment Program are some of the leading examples and have provided useful data to evaluate our systems and decrease morbidity and mortality. With proven outcomes driving morbidity and mortality rates down, we have to wonder how to refine these measures to make them more relevant to specialty surgeries such as colorectal. On the contrary, participation in programs like these has placed extended requirements on hospitals and physicians. In addition, some of the quality measures may be inaccurately identifying low and high performing hospitals and individuals because of inherent flaws in the database. This could potentially be in conflict with the mission of these programs. What will be presented are some alternatives and different directions QI is moving toward.

Reoperative parathyroidectomy: who is at risk and what is the risk?

BACKGROUND

Persistent and recurrent hyperparathyroidism necessitate reoperation, which is associated with increased procedure-specific complication rates. The effect of reoperative parathyroidectomy on more generalized outcomes is poorly understood. We sought to determine patient, provider, and perioperative characteristics associated with reoperation, as well as to determine the associated risks.

METHODS

All patients receiving a parathyroidectomy in the American College of Surgeons National Surgical Quality Improvement Program database (2008-2011) were identified. Patients receiving initial parathyroidectomy were compared with those receiving reoperative parathyroidectomy. Descriptive statistics and univariate analyses were performed. Multivariate logistic regression models were developed for significant outcome measures.

RESULTS

Of 9114 parathyroidectomies performed, 8738 (95.9%) were initial and 376 (4.1%) were reoperative. The annual rate of reoperation was 3.6%-4.8%. Patients undergoing reoperative parathyroidectomy were more likely to be obese (48.5 versus 40.0%, P = 0.009) and American Society of Anesthesiologist class 3 (40.7 versus 30.3%, P = 0.001) than patients undergoing initial parathyroidectomy. There was no difference in gender, age, or race. Reoperations had a longer median operative time (101 minimum, interquartile range [IQR] [74-146] versus 76 [55-105], P <0.001) and a longer postoperative length of stay (median days until discharge 1, IQR [1-1] versus 1, IQR [0-1], P <0.001). No difference was found in the rates of mortality and common postoperative morbidity as measured in NSQIP. Patients undergoing reoperation were more likely to be readmitted within 30 d (12.7 versus 2.6%, P <0.001). After adjusting for confounders, reoperation continued to be significantly associated with readmission (odds ratio 3.82, confidence interval: 1.63-8.97; P = 0.002).

CONCLUSIONS

Obesity and an American Society of Anesthesiologist 3 classification are independently associated with reoperation. Readmission within 30 d is associated with reoperation and is a target for patient education and quality improvement after this procedure.

Visualizing surgical quality data with treemaps

BACKGROUND

Treemaps are space-constrained visualizations for displaying hierarchical data structures using nested rectangles. The visualization allows large amounts of data to be examined in one display. The objective of this research was to examine the effects of using treemap visualizations to help surgeons assess surgical quality data from the American College of Surgeons created the National Surgical Quality Improvement Program database in a quick and timely manner.

STUDY DESIGN

A controlled human subjects experiment was conducted to assess the ability of individuals to make quick and accurate judgments on surgery data by visualizing a treemap, with data hierarchically displayed by surgeon group, surgeon, and patient. Participants were given 20 task questions to complete involving examining the treemap and comparing surgeons' patients based on outcomes (dead or alive) and length of stay days. The outcomes measured were error (incorrect or correct) and task completion time.

RESULTS

120 participants completed 20 task questions for a total of 2400 responses. The main effects of layout and node size were found to be significant for absolute error, P < 0.0505 and P < 0.0185, respectively. The average judgment time to complete a task was 24 s with an accuracy rate of approximately 68%.

CONCLUSIONS

This study served as a proof of concept to determine if treemaps could be beneficial in assessing surgical data retrospectively by allowing surgeons and healthcare administrators to make quick visual judgments. The study found that factors about the layout design affect judgment performance. Future research is needed to examine whether implementing the treemap within a dashboard system will improve on judgment accuracy for surgical quality questions.

Early discharge and readmission after colorectal resection

BACKGROUND

Emphasis on the provision of high quality, cost-effective healthcare has meant increasing efforts at reducing postoperative length of stay while reducing 30-d readmission rates. The aim of this study was to identify factors associated with early discharge (ED) and to evaluate the effectof ED on readmission after colorectal resection.

MATERIALS AND METHODS

We identified all inpatients aged ≥18 y who underwent a colorectal resection in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File, 2011. ED was defined as a length of stay ≤25th percentile by procedure (rectal resection, open colectomy, and laparoscopic colectomy). Multivariate logistic regression was used to identify factors significantly associated with ED and readmission. A subset analysis was performed by procedure type.

RESULTS

Of 28,532 patients, 2171 (7%) underwent rectal resection, 14,976 (52%) underwent open colectomy, and 11,385 (40%) underwent laparoscopic colectomy with an ED on or before postoperative days 5, 5, and 3, respectively. The overall cohort included patients with a mean age of 61 y. A total of 52% were women and 37% were colorectal cancer patients. Age >65 y, recent steroid use, simultaneous ostomy creation, nonelective surgery, need for reoperation, and a postoperative occurrence before discharge were significantly associated with a reduced likelihood of ED. The overall rate of readmission was 12%. Patients who were discharged early were significantly less likely to be readmitted (odds ratio, 0.77; 95% confidence interval, 0.70-0.84).

CONCLUSIONS

In the appropriate patient population, ED after colorectal surgery may be implemented without any adverse effect on readmission rates.

Safety of laparoscopic and open approaches for repair of the unilateral primary inguinal hernia: an analysis of short-term outcomes

BACKGROUND

Primary laparoscopic repair of unilateral inguinal hernias has not achieved widespread recognition mainly because of concerns over safety.

METHODS

Prospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program between 2005 and 2010. Complications in patients undergoing unilateral first-time, elective laparoscopic unilateral inguinal hernia repair (LIHR) were compared with open inguinal hernia repair (OIHR).

RESULTS

Of 37,645 identified patients, 6,356 (16.9%) underwent LIHR and 31,289 (83.1%) underwent OIHR. Both groups had similar 30-day overall complications, major complications, and mortality rates: 62 (1.0%) vs 307 (1.0%), P = 1.00; 31 (.5%) vs 173 (.5%), P = .57; and 1 (.02%) vs 16 (.05%), P = .34, respectively. Using multivariable logistic regression, overall complications showed no difference, OR 1.01 (95% CI .76 to 1.34; P = .94), as did major complications, OR .90 (95% CI .61 to 1.34; P = .62), although favoring the LIHR group, where OR and CI represent the odss ratio and confidence intervals.

CONCLUSION

These data demonstrate no significant difference between elective unilateral LIHR and OIHR with regard to 30-day morbidity and mortality.