Abstract This article reviews the philosophy and principles of the National Surgical Quality Improvement Program (NSQIP) that the founders of the program had in mind when they developed the program; ...explains how the philosophy and principles led to the design and statistical methods that were chosen for the program; and reviews recently proposed changes to the program and potential problems that these changes may create.
Although deviations in intraoperative blood pressure are assumed to be associated with postoperative mortality, critical blood pressure thresholds remain undefined. Therefore, the authors estimated ...the intraoperative thresholds of systolic blood pressure (SBP), mean blood pressure (MAP), and diastolic blood pressure (DBP) associated with increased risk-adjusted 30-day mortality.
This retrospective cohort study combined intraoperative blood pressure data from six Veterans Affairs medical centers with 30-day outcomes to determine the risk-adjusted associations between intraoperative blood pressure and 30-day mortality. Deviations in blood pressure were assessed using three methods: (1) population thresholds (individual patient sum of area under threshold AUT or area over threshold 2 SDs from the mean of the population intraoperative blood pressure values), (2). absolute thresholds, and (3) percent change from baseline blood pressure.
Thirty-day mortality was associated with (1) population threshold: systolic AUT (odds ratio, 3.3; 95% CI, 2.2 to 4.8), mean AUT (2.8; 1.9 to 4.3), and diastolic AUT (2.4; 1.6 to 3.8). Approximate conversions of AUT into its separate components of pressure and time were SBP < 67 mmHg for more than 8.2 min, MAP < 49 mmHg for more than 3.9 min, DBP < 33 mmHg for more than 4.4 min. (2) Absolute threshold: SBP < 70 mmHg for more than or equal to 5 min (odds ratio, 2.9; 95% CI, 1.7 to 4.9), MAP < 49 mmHg for more than or equal to 5 min (2.4; 1.3 to 4.6), and DBP < 30 mmHg for more than or equal to 5 min (3.2; 1.8 to 5.5). (3) Percent change: MAP decreases to more than 50% from baseline for more than or equal to 5 min (2.7; 1.5 to 5.0). Intraoperative hypertension was not associated with 30-day mortality with any of these techniques.
Intraoperative hypotension, but not hypertension, is associated with increased 30-day operative mortality.
The effectiveness of perioperative β-blockade in patients undergoing noncardiac surgery remains controversial.
To determine the associations of early perioperative exposure to β-blockers with 30-day ...postoperative outcome in patients undergoing noncardiac surgery.
A retrospective cohort analysis evaluating exposure to β-blockers on the day of or following major noncardiac surgery among a population-based sample of 136,745 patients who were 1:1 matched on propensity scores (37,805 matched pairs) treated at 104 VA medical centers from January 2005 through August 2010.
All cause 30-day mortality and cardiac morbidity (cardiac arrest or Q-wave myocardial infarction).
Overall 55,138 patients (40.3%) were exposed to β-blockers. Exposure was higher in the 66.7% of 13,863 patients undergoing vascular surgery (95% CI, 65.9%-67.5%) than in the 37.4% of 122,882 patients undergoing nonvascular surgery (95% CI, 37.1%-37.6%; P < .001). Exposure increased as Revised Cardiac Risk Index factors increased, with 25.3% (95% CI, 24.9%-25.6%) of those with no risk vs 71.3% (95% CI, 69.5%-73.2%) of those with 4 risk factors or more exposed to β-blockers (P < .001). Death occurred among 1.1% (95% CI, 1.1%-1.2%) and cardiac morbidity occurred among 0.9% (95% CI, 0.8%-0.9%) of patients. In the propensity matched cohort, exposure was associated with lower mortality (relative risk RR, 0.73; 95% CI, 0.65-0.83; P < .001; number need to treat NNT, 241; 95% CI, 173-397). When stratified by cumulative numbers of Revised Cardiac Risk Index factors, β-blocker exposure was associated with significantly lower mortality among patients with 2 factors (RR, 0.63 95% CI, 0.50-0.80; P < .001; NNT, 105 95% CI, 69-212), 3 factors (RR, 0.54 95% CI, 0.39-0.73; P < .001; NNT, 41 95% CI, 28-80), or 4 factors or more (RR, 0.40 95% CI, 0.25-0.73; P < .001; NNT, 18 95% CI, 12-34). This association was limited to patients undergoing nonvascular surgery. β-Blocker exposure was also associated with a lower rate of nonfatal Q-wave infarction or cardiac arrest (RR, 0.67 95% CI, 0.57-0.79; P < .001; NNT, 339 95% CI, 240-582), again limited to patients undergoing nonvascular surgery.
Among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative β-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors. Our findings support use of a cumulative number of Revised Cardiac Risk Index predictors in decision making regarding institution and continuation of perioperative β-blockade. A multicenter randomized trial involving patients at a low to intermediate risk by these factors would be of interest to validate these observational findings.
The efficacy of statins in reducing perioperative cardiovascular and other organ system complications in patients undergoing noncardiac surgery remains controversial. Owing to a paucity of randomized ...clinical trials, analyses of large databases may facilitate informed hypothesis generation and more efficient trial design.
To evaluate associations of early perioperative statin use with outcomes in a national cohort of veterans undergoing noncardiac surgery.
This retrospective, observational cohort analysis included 180 478 veterans undergoing elective or emergent noncardiac surgery (including vascular, general, neurosurgery, orthopedic, thoracic, urologic, and otolaryngologic) who were admitted within 7 days of surgery and sampled by the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients were admitted to Department of Veterans Affairs hospitals and underwent 30-day postoperative follow-up. Data were collected from October 1, 2005, to September 30, 2010, and analyzed from November 28, 2013, to October 31, 2016.
Statin use on the day of or the day after surgery.
All-cause 30-day mortality (primary outcome) and standardized 30-day cardiovascular and noncardiovascular outcomes captured by VASQIP. Use of statins and other perioperative cardiovascular medications was ascertained from the Veterans Affairs Pharmacy Benefits Management research database.
A total of 180 478 eligible patients (95.6% men and 4.4% women; mean SD age, 63.8 11.6 years) underwent analysis, and 96 486 were included in the propensity score-matched cohort (96.3% men; 3.7% women; mean SD age, 65.9 10.6 years). At the time of hospital admission, 37.8% of patients had an active outpatient prescription for a statin, of whom 80.8% were prescribed simvastatin and 59.5% used moderate-intensity dosing. Exposure to a statin on the day of or the day after surgery based on an inpatient prescription was noted in 31.5% of the cohort. Among 48 243 propensity score-matched pairs of early perioperative statin-exposed and nonexposed patients, 30-day all-cause mortality was significantly reduced in exposed patients (relative risk, 0.82; 95% CI, 0.75-0.89; P < .001; number needed to treat, 244; 95% CI, 170-432). Of the secondary outcomes, a significant association with reduced risk of any complication was noted (relative risk, 0.82; 95% CI, 0.79-0.86; P < .001; number needed to treat, 67; 95% CI, 55-87); all were significant except for the central nervous system and thrombosis categories, with the greatest risk reduction (relative risk, 0.73; 95% CI, 0.64-0.83) for cardiac complications.
Early perioperative exposure to a statin was associated with a significant reduction in all-cause perioperative mortality and several cardiovascular and noncardiovascular complications. However, the potential for selection biases in these results must be considered.
The objective of this study was to identify the determinants of 30-day postoperative mortality and long-term survival after major surgery as exemplified by 8 common operations.
The National Surgical ...Quality Improvement Program (NSQIP) database contains pre-, intra-, and 30-day postoperative data, prospectively collected in a standardized fashion by a dedicated nurse reviewer, on major surgery in the Veterans Administration (VA). The Beneficiary Identification and Records Locator Subsystem (BIRLS) is a VA file that depicts the vital status of U.S. veterans with 87% to 95% accuracy.
NSQIP data were merged with BIRLS to determine the vital status of 105,951 patients who underwent 8 types of operations performed between 1991 and 1999, providing an average follow up of 8 years. Logistic and Cox regression analyses were performed to identify the predictors of 30-day mortality and long-term survival, respectively.
The most important determinant of decreased postoperative survival was the occurrence, within 30 days postoperatively, of any one of 22 types of complications collected in the NSQIP. Independent of preoperative patient risk, the occurrence of a 30-day complication in the total patient group reduced median patient survival by 69%. The adverse effect of a complication on patient survival was also influenced by the operation type and was sustained even when patients who did not survive for 30 days were excluded from the analyses.
The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA. Quality and process improvement in surgery should be directed toward the prevention of postoperative complications.
Postoperative pulmonary complications (PPCs), a leading cause of poor surgical outcomes, are heterogeneous in their pathophysiology, severity, and reporting accuracy.
To prospectively study clinical ...and radiological PPCs and respiratory insufficiency therapies in a high-risk surgical population.
We performed a multicenter prospective observational study in 7 US academic institutions. American Society of Anesthesiologists physical status 3 patients who presented for noncardiothoracic surgery requiring 2 hours or more of general anesthesia with mechanical ventilation from May to November 2014 were included in the study. We hypothesized that PPCs, even mild, would be associated with early postoperative mortality and use of hospital resources. We analyzed their association with modifiable perioperative variables.
Noncardiothoracic surgery.
Predefined PPCs occurring within the first 7 postoperative days were prospectively identified. We used bivariable and logistic regression analyses to study the association of PPCs with ventilatory and other perioperative variables.
This study included 1202 patients who underwent predominantly abdominal, orthopedic, and neurological procedures. The mean (SD) age of patients was 62.1 (13.8) years, and 636 (52.9%) were men. At least 1 PPC occurred in 401 patients (33.4%), mainly the need for prolonged oxygen therapy by nasal cannula (n = 235; 19.6%) and atelectasis (n = 206; 17.1%). Patients with 1 or more PPCs, even mild, had significantly increased early postoperative mortality, intensive care unit (ICU) admission, and ICU/hospital length of stay. Significant PPC risk factors included nonmodifiable (emergency yes vs no: odds ratio OR, 4.47, 95% CI, 1.59-12.56; surgical site abdominal/pelvic vs nonabdominal/pelvic: OR, 2.54, 95% CI, 1.67-3.89; and age in years: OR, 1.03, 95% CI, 1.02-1.05) and potentially modifiable (colloid administration yes vs no: OR, 1.75, 95% CI, 1.03-2.97; preoperative oxygenation: OR, 0.86, 95% CI, 0.80-0.93; blood loss in milliliters: OR, 1.17, 95% CI, 1.05-1.30; anesthesia duration in minutes: OR, 1.14, 95% CI, 1.05-1.24; and tidal volume in milliliters per kilogram of predicted body weight: OR, 1.12, 95% CI, 1.01-1.24) factors.
Postoperative pulmonary complications are common in patients with American Society of Anesthesiologists physical status 3, despite current protective ventilation practices. Even mild PPCs are associated with increased early postoperative mortality, ICU admission, and length of stay (ICU and hospital). Mild frequent PPCs (eg, atelectasis and prolonged oxygen therapy need) deserve increased attention and intervention for improving perioperative outcomes.
Timing of prophylactic antibiotic administration for surgical procedures is a nationally mandated and publicly reported quality metric sponsored by the Centers for Medicare and Medicaid Services ...Surgical Care Improvement Project. Numerous studies have failed to demonstrate that adherence to the Surgical Care Improvement Project prophylactic antibiotic timely administration measure is associated with decreased surgical site infection (SSI). OBJECTIVE; To determine whether prophylactic antibiotic timing is associated with SSI occurrence.
Retrospective cohort study using national Veterans Affairs patient-level data on prophylactic antibiotic timing for orthopedic, colorectal, vascular, and gynecologic procedures from 2005 through 2009.
National Veterans Affairs Surgical Care Improvement Project data from 112 Veterans Affairs hospitals and matched Veterans Affairs Surgical Quality Improvement Program data.
Patients undergoing hip or knee arthroplasty, colorectal surgical procedures, arterial vascular surgical procedures, and hysterectomy.
Timing of prophylactic antibiotic administration with respect to surgical incision time.
Data for prophylactic antibiotic agent, prophylactic antibiotic timing with respect to surgical incision, and patient and procedure risk variables were assessed for their relationship with the occurrence of a composite superficial or deep incisional SSI within 30 days after the procedure. Nonlinear generalized additive models were used to examine the association between antibiotic timing and SSI.
Of the 32,459 operations, prophylactic antibiotics were administered at a median of 28 minutes (interquartile range, 17-39 minutes) prior to surgical incision, and 1497 cases (4.6%) developed an SSI. Compared with procedures with antibiotic administration within 60 minutes prior to incision, higher SSI rates were observed for timing more than 60 minutes prior to incision (unadjusted odds ratio OR = 1.34; 95% CI, 1.08-1.66) but not after incision (unadjusted OR = 1.26; 95% CI, 0.92-1.72). In unadjusted generalized additive models, we observed a significant nonlinear relationship between prophylactic antibiotic timing and SSI when considering timing as a continuous variable (P = .01). In generalized additive models adjusted for patient, procedure, and antibiotic variables, no significant association between prophylactic antibiotic timing and SSI was observed. Vancomycin hydrochloride was associated with higher SSI occurrence for orthopedic procedures (adjusted OR = 1.75; 95% CI, 1.16-2.65). Cefazolin sodium and quinolone in combination with an anaerobic agent were associated with fewer SSI events (cefazolin: adjusted OR = 0.49; 95% CI, 0.34-0.71; quinolone: adjusted OR = 0.55; 95% CI, 0.35-0.87) for colorectal procedures.
The SSI risk varies by patient and procedure factors as well as antibiotic properties but is not significantly associated with prophylactic antibiotic timing. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.
Abstract Background Previous studies have demonstrated improved in-hospital mortality following hepatic resection for hepatocellular carcinoma (HCC) at teaching hospitals. The objective of this study ...was to evaluate if resection of HCCs at academic cancer programs (ACP) is associated with improved 10-year survival. Study Design Using the NCDB (1998-2011), we evaluated patients undergoing hepatic resection for HCC at ACPs, comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). High volume cancer programs (HVCPs) were defined as performing ≥10 hepatectomies per year. Multivariate Cox proportional hazard models by stepwise selection were applied to estimate hazard ratios (HR) of predictors of survival. The Kaplan-Meier method was used to generate survival curves at each facility type and survival rates were compared using the log-rank test. Results We identified 12,757 patients undergoing hepatic resection for HCC at ACPs (n=8,404), CCPs (n=483), and CCCPs (n=3,870). Sixty-two percent (n=5,191) of patients treated at ACPs were at high volume institutions compared to 11.6% (n=446) and 0% of CCCPs and CCPs, respectively (p<0.0001). On multivariable analysis, patients undergoing hepatic resection at transplant centers (p<0.0001) and HVCPs had significantly improved survival (p<0.0001). Adjusted 10-year survival rates were 28.7% at high volume ACPs, 28.2% at high volume CCCPs, 24.9% at low volume CCCPs, 25.1% at low volume ACPs, and 21.3% at CCPs (p=<0.0001 ). Conclusions Patients undergoing hepatic resection for HCC at HVCPs had a significantly improved 10-year survival. Regionalization of HCC treatment to HVCPs may improve long-term survival.
The ability to secure financing and local government support for construction of wood pellet facilities can be enhanced by articulating the economic benefits of these production facilities. This ...analysis explains how local economies can benefit from wood pellet manufacturing by expressing the economic multiplier effect of wood pellet plant operations in terms of employment, wages and salaries, and value-added in each of the 13 states in the U.S. South. Input-output analysis is conducted using the IMPLAN software and 2012 data. The analysis examines how direct effects (e.g., plant operation expenditures and employment) generate additional indirect effects (e.g., purchases by supporting industries and their employees) and induced effects (e.g., household spending by direct and indirect employees) that result in a total effect or cumulative benefit to the local economy. Moreover, this study also assesses wood fiber availability and development potential of wood pellet mills in each U.S. South state based on the annual pulpwood growth and removal trends. This information can be used to communicate the wider benefit to an economy that results from the establishment of a wood pellet facility.
•Economic impact ranges considerably depending upon size of state economy.•U.S. South could sustain 554 wood pellet mills at a forest growth to drain ratio of 1.•Economic impact of 101,624 jobs generating US$16.17 billion in output for U.S. South.
This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes.
Risk reduction with the implementation of surgical care improvement project process ...measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention.
A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression.
Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications.
This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.
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