Background Centralization of care to “centers of excellence” in Europe has led to improved oncologic outcomes; however, little is known regarding the impact of nonmandated regionalization of rectal ...cancer care in the United States. Methods The Statewide Planning and Research Cooperative System (SPARCS) was queried for elective abdominoperineal and low anterior resections for rectal cancer from 2000 to 2011 in New York with the use of International Classification of Diseases, Ninth Revision codes. Surgeon volume and hospital volume were grouped into quartiles, and high-volume surgeons (≥10 resections/year) and hospitals (≥25 resections/year) were defined as the top quartile of annual caseload of rectal cancer resection and compared with the bottom 3 quartiles during analyses. Bivariate and multilevel regression analyses were performed to assess factors associated with restorative procedures, 30-day mortality, and temporal trends in these endpoints. Results Among 7,798 rectal cancer resections, the overall rate of no-restorative proctectomy and 30-day mortality decreased by 7.7% and 1.2%, respectively, from 2000 to 2011. In addition, there was a linear increase in the proportion of cases performed by both high-volume surgeons and high-volume hospitals and a decrease in the number of surgeons and hospitals performing rectal cancer surgery. High-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies (odds ratio 0.65, 95% confidence interval 0.48–0.89) and mortality (odds ratio 0.43, 95% confidence interval 0.21–0.87) rates. No patterns of significant improvement within the volume strata of the surgeon and hospitals were observed over time. Conclusion This study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes. These findings have implications regarding the policy of health care delivery in the United States, supporting referral to high-volume centers of excellence.
Background Expert panels of colorectal surgeons consistently rank anastomotic leak as among the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases ...do not collect data on anastomotic leaks and rely on reported organ space surgical site infections (OSI) as a proxy for identifying anastomotic leaks. This study questions the validity of using OSI as a surrogate for anastomotic leak. Methods The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 12 hospitals that prospectively collects colectomy-specific metrics, including anastomotic leak, in addition to standard National Surgical Quality Improvement Program (NSQIP) data, including OSIs. Cases with an organ space infection and/or anastomotic leak were selected from the 2010–2011 UNYSQI database. Patient characteristics and outcomes were compared for cases with organ space infections and anastomotic leaks. Results Overall, 3% of colectomies had a reported organ space infection and 4% had an anastomotic leak. Among cases having anastomotic leaks, only 25% were also coded as having an organ space infection, leaving 75% of anastomotic leaks not captured by the NSQIP database (κ = 0.272; P ≤ .001). Conclusion Organ space infection is a poor surrogate for anastomotic leak, resulting in grossly underestimated leak rates and seemingly represents different postoperative courses. Procedure-specific quality measures for colorectal surgery should include data collection on anastomotic leaks to provide accurate data for use in improving patient care.
Background There is currently little information regarding the impact of procedure volume on outcomes after open inguinal hernia repair in the United States. Our hypothesis was that increasing ...procedure volume is associated with lesser rates of reoperation and resource use. Methods The database of the Statewide Planning and Research Cooperative System was queried for elective open initial inguinal hernia repairs performed in New York State from 2001 to 2008 via the use of International Classification of Diseases, 9th Revision and Current Procedural Terminology codes. Surgeon and hospital procedure volumes were grouped into tertiles based on the number of open inguinal hernia repairs performed per year. Bivariate, hierarchical mixed effects Cox proportional-hazards, and negative binomial regression analyses were performed assessing for factors associated with reoperation for recurrence, procedure time, and downstream total charges. Results Among 151,322 patients who underwent open inguinal hernia repair, the overall rate of reoperation for recurrence within 5 years was 1.7% with a median time to reoperation of 1.9 years. An inverse relationship was seen between surgeon volume and reoperation rate, procedure time, and health care costs ( P < .001). After we controlled for surgeon, facility, operative and patient characteristics, low-volume surgeons (<25 repairs/year) had greater rates of reoperation (hazard ratio 1.23,95% confidence interval 95% CI 1.11–1.36), longer procedure times (incidence rate ratio 1.22, 95% CI 1.21–1.24), and greater downstream costs (incidence rate ratio 1.13,95% CI 1.10–1.17) than high-volume surgeons (≥25 repairs/year). Conclusion Surgeon volume <25 cases per year for open inguinal hernia repair was independently associated with greater rates of reoperation for recurrence, worse operative efficiency, and greater health care costs. Referral to surgeons who perform ≥25 inguinal hernia repairs per year should be considered to decrease reoperation rates and resource use.
Background Despite the recent major changes in vascular and general surgery training, there has been a paucity of literature examining the effect of these changes on training and surgical outcomes. ...Amputations represent a common cross-section in core competencies for general surgery and vascular surgery trainees. This study evaluates the effect of trainee participation on outcomes after above-knee and below-knee amputations. Methods The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010) was queried using Current Procedural Terminology codes (American Medical Association, Chicago, Ill) for below-knee amputation (27880, 27882) and above knee-amputation (27590, 27592). Resident involvement was defined using the NSQIP variable and was narrowed to postgraduate year 1 to 5. Variables associated with resident involvement were identified, and mortality, morbidity, intraoperative transfusion, and operative time (75th percentile vs the bottom three quartiles) were evaluated as distinct categoric end points in logistic regression. Included in the model were variables with a P value <.1 on χ 2 or independent t -test, as appropriate. Significance was defined at P < .05. Results Residents were involved in 6587 of 11,038 amputations (62%). After adjustment for preoperative and intraoperative factors on logistic regression, there was a significant increase in major morbidity (odds ratio OR, 1.27; 95% confidence interval CI, 1.14-1.42; P < .001), intraoperative transfusion (OR, 1.78; 95% CI, 1.50-2.11; P < .001), and operative time (OR, 1.64 95% CI, 1.46-1.84; P < .001) in resident cases. Conclusions Resident involvement was associated with increased odds of major morbidity after amputation and also with increased operative time and risk for intraoperative transfusions.
Background Hospitals and surgeons simultaneously are pressured to decrease readmissions and duration of stay. We hypothesized that readmissions after endocrine surgery could be predicted by using a ...novel risk-score. Methods The National Surgical Quality Improvement Program database was queried for cervical endocrine operations performed during 2011 and 2012. The primary end point was unplanned readmission within 30 days. Multivariable logistic regression was used to create and validate a scoring system to predict unplanned readmissions. Results Overall, 34,046 cases were included with a readmission rate of 2.8% ( n = 947). The most frequent reasons for readmission were hypocalcemia (32.4%) surgical-site infection (8.4%), and hematoma (8.0%) (2012 data only). The readmission risk score was created using the following factors: thyroid malignancy, hypoalbuminemia, renal insufficiency, American Society of Anesthesiologists class, and duration of stay >1 day. Predicted readmission rate by number of risk factors was 1.7 % for 0 risk factors, 3.2% for 1 risk factor (5–11 points), 5.8% for 2 risk factors, 10.5% for 3 risk factors, and 18.0% for 4 risk factors. The model had good predictive ability with c = 0.646. Conclusion Readmissions after cervical endocrine operations can be predicted. This risk score could be used to direct resource use for preoperative, inpatient, and outpatient care delivery to reduce readmissions.
Risk score for unplanned vascular readmissions Iannuzzi, James C., MD, MPH; Chandra, Ankur, MD; Kelly, Kristin N., MD ...
Journal of vascular surgery,
05/2014, Letnik:
59, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Objective Vascular surgery patients have high readmission rates, and identification of high-risk groups that may be amenable to targeted interventions is an important strategy for readmission ...prevention. This study aimed to determine predictors of unplanned readmission and develop a risk score for predicting readmissions after vascular surgery. Methods The National Surgical Quality Improvement Program database for 2011 was queried for major vascular surgical procedures. The primary end point was unplanned 30-day readmissions. The data were randomly split into two-thirds for development and one-third for validation. Multivariable logistic regression was used to create and validate a point score system to predict unplanned readmissions. Results Overall, 24,929 patients were included, with 2507 readmissions (10.1%). A point-based scoring system was developed with the use of factors predictive for readmission, including procedure type; discharge destination; race; non-elective presentation; pulmonary, renal, and cardiac comorbidities; diabetes; steroid use; hypoalbuminemia; anemia; venothromboembolism before discharge; graft failure before discharge; and bleeding disorder. The point score stratified patients into 3 groups: low risk (0-3 points) with a readmission rate of 5.4%, moderate risk (4-7 points) with a readmission rate of 8.6%, and high risk (≥8 points) with a readmission rate of 16.4%. The model had a C-statistic = 0.67. Conclusions Through the use of patient, operative, and predischarge events, this novel vascular surgery-specific readmission score accurately identified patients at high risk for 30-day unplanned readmission. This model could help direct discharge and home health care resources to patients at high risk, ultimately reducing readmissions and improving efficiency.
Background Evidence suggests that statins may decrease inflammation, airway hyperreactivity, and hypercoagulability while improving revascularization mediated by cholesterol-independent pathways. ...This study evaluated whether the preoperative use of statins is associated with decreased postoperative major noncardiac complications in noncardiac procedures. Study design This was a single-institution study of noncardiac operations performed from 2005 to 2010. The use of statins was identified from electronic medical records and merged with local National Surgical Quality Improvement Program data. Preoperative statin exposure was defined as statin use before operation, as documented by admission medication reconciliation and outpatient or pharmacy records. The primary end point was major noncardiac complications, and secondary end points included respiratory, infectious (sepsis and organ space infection) and complications of venous thromboembolism (VTE). Multivariable logistic regression was performed for each end point while we controlled for clinical covariates meeting P < .10 on bivariate analysis. Results Preoperative statin use was present in 10.5% ( n = 814) of 7,777 total cases. Procedure type included general operation ( n = 2,605, 33.5%), breast/endocrine ( n = 739, 9.5%), colorectal ( n = 1,533, 19.7%), hepatobiliary/pancreatic ( n = 397, 5.1%), orthopedic ( n = 205, 2.6%), skin/ear-nose- throat (145, 1.9%), thoracic ( n = 53, 0.7%), upper gastrointestinal ( n = 651, 8.4%), and vascular cases (1,449, 18.6%). On multivariable analysis, the use of statins was associated with decreased major, noncardiac complications (odds ratio OR 0.62, 95% confidence interval 95% CI 0.49–0.92, P < .001), respiratory complications (OR 0.63, 95% CI 0.50–0.79, P = .017), VTE (OR 0.41, 95% CI 0.18–0.98, P = .044), and infectious complications (OR 0.65, 95% CI 0.45–0.94, P = .023). Conclusion The preoperative use of statins is independently associated with decreased risk of major complications. This effect is likely driven by reduction in respiratory, VTE, and infectious complication rates. These results warrant future clinical trials to assess the perioperative benefit of statin use in noncardiac procedures.
Abstract Background The surgical care pathway is characterized by multiple transitions, from preoperative assessment to inpatient stay, discharge from hospital, and follow-up care. Breakdowns in one ...phase can affect subsequent phases, which in turn can cause delays, cancellations, and complications. Efforts to improve care transitions focused primarily on post-discharge care coordination and inpatient education for medically complex patients have not demonstrated consistent effects. This study aimed to understand the expectations and perceptions of postoperative inpatients regarding transition from hospital to home in an effort to reduce patient burden. Materials and methods Patients who underwent a colorectal resection at a large academic medical center and were discharged home were eligible to participate in the study. Patients were recruited during their postoperative hospital stays and interviewed over the phone within a week after discharge about their perceptions of care, values, and attitudes. Overall, we recruited 16 patients with benign ( n = 8) and malignant ( n = 8) indications. Recruitment continued until theme saturation. Results Factors that shaped patients' understanding of postsurgical recovery and that motivated them to seek provider attention post-discharge fell into three major groups: patient expectations versus reality, availability and role of informal caregivers in the postoperative recovery process, and communication as a key to patient confidence and trust. Conclusions For patients and caregivers, postoperative planning starts long before surgery and hospital admission. Providers should consider these dynamics in designing interventions to improve care transitions, patient satisfaction, and long-term outcomes. This study was limited to colorectal surgical patients treated in a single institution and may be not generalizable to other surgical procedures, non-academic settings or different regions.
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