Affairs Surgical Quality Improvement Program Research Articles

Social Determinants of Long-Term Opioid Use Following Total Knee Arthroplasty.

Total knee arthroplasty (TKA) risks persistent pain and long-term opioid use (LTO). The role of social determinants of health (SDoH) in LTO is not well established. We hypothesized that SDoH would be associated with postsurgical LTO after controlling for relevant demographic and clinical variables. This study utilized data from the Veterans Affairs Surgical Quality Improvement Program, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services, including Veterans aged ≥ 65 who underwent elective TKA between 2013 and 2019 with no postsurgical complications or history of significant opioid use. LTO was defined as > 90 days of opioid use beginning within 90 days postsurgery. SDoH variables included the Area Deprivation Index, rurality, and housing instability in the last 12 months identified via medical record screener or International Classification of Diseases, Tenth Revision codes. Multivariable risk adjustment models controlled for demographic and clinical characteristics. Of the 9,064 Veterans, 97% were male, 84.2% white, mean age was 70.6 years, 46.3% rural, 11.2% living in highly deprived areas, and 0.9% with a history of homelessness/housing instability. Only 3.7% (n = 336) developed LTO following TKA. In a logistic regression model of only SDoH variables, housing instability (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.09-5.22) and rurality conferred significant risk for LTO. After adjusting for demographic and clinical variables, LTO was only associated with increasing days of opioid supply in the year prior to surgery (OR = 1.52, 95% CI: 1.43-1.63 per 30 days) and the initial opioid fill (OR = 1.07; 95% CI: 1.06-1.08 per day). Our primary hypothesis was not supported; however, our findings do suggest that patients with housing instability may present unique challenges for postoperative pain management and be at higher risk for LTO.

Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non–Veterans Affairs Care Settings

Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking. To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals. This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older. Surgical care in VA or private-sector hospitals. Postoperative 30-day mortality and failure to rescue (FTR). Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures. Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

Microbiology of Infective Endocarditis in United States Veterans - Association Between Causative Organism and Short- and Long-Term Outcomes.

Previous studies have elucidated the relationship between causative organism and outcomes in infective endocarditis, however this relationship has not been studies in United States Veterans. The aim of this manuscript is to evaluate the association between causative organism and short-term and long-term outcomes in United States (US) Veterans with infective endocarditis (IE) requiring surgical management between 2010-2020. We analyzed 489 patients with surgically treated IE from the Veterans Affairs (VA) Surgical Quality Improvement Program and the VA Informatics and Computing Infrastructure databases. Patients were divided into groups using causative organism identified from blood or intraoperative cultures - Staphylococcus, Streptococcus, Gram-negative rods, Enterococcus, Polymicrobial, and Unknown/Culture Negative. Other identified organisms were excluded from analysis. Cox proportional hazard models were used to calculate risk for stroke/transient ischemic attack (TIA), myocardial infarction (MI), and death based on group. The models were adjusted for covariates using backward elimination. Continuous variables were compared using ANOVA or Kruskal-Wallis H tests, and categorical variables were compared using Chi square tests. Mean follow-up was 4.0 ± 6.3 years. Gram negative rods (GNRs) were associated with greater risk of long-term mortality (adjusted hazard ratios (aHR) 2.15, 95% CI: 1.20-3.86, p = 0.01). Enterococcus was associated with long-term risk of MI (aHR 2.05, 95% CI: 1.07-3.94, p = 0.03). Resistant organisms, such as methicillin-resistant staphylococcus aureus, were associated with long-term risk of MI (aHR 2.51, 95% CI: 1.14-5.45, p = 0.02). Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation (48 hrs) (aHR 1.76, 95% CI: 1.05-2.97, p = 0.034), tracheostomy (aHR 5.64, 95% CI: 2.35-13.55, p < 0.001), and prolonged ICU stay (5 days) (aHR 1.39, 95% CI: 1.01-1.91, p = 0.043). In US Veterans, polymicrobial infections had notably worse perioperative outcomes but similar long-term outcomes in comparison to monomicrobial infections. GNR infections were associated with increased long-term mortality. Enterococcus and resistant organisms were associated with increased long-term risk of MI. Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation, tracheostomy, and prolonged ICU stay.

Comparing Outcomes in Patients Undergoing Colectomy at Veteran Affairs Hospitals and Non-Veteran Affairs Hospitals: A Multiinstitutional Study

IntroductionThe Veteran Affairs Surgical Quality Improvement Program (VASQIP) and National Surgical Quality Improvement Program (NSQIP) are large databases designed to measure surgical outcomes for their respective populations. We sought to compare surgical outcomes in patients undergoing colectomies at Veterans Affairs (VA) hospitals versus non-VA hospitals. MethodsAfter institutional review baord approval, records for 271,523 colectomies from NSQIP and 11,597 from VASQIP between the years 2015 and 2019 were compiled. Demographics, comorbidity, 30-d mortality, and other outcomes were examined using Chi-squared, analysis of variance, Mann Whitney U, and Fisher's Exact Test within SPSS version 26. ResultsVASQIP patients were more likely to be male (94.3% versus 48.4%, P < 0.001) and older (median 63, 52-72 versus 67, 60-72 P < 0.001). Veterans were also more likely to have diabetes (25.3% versus 15.8%, P < 0.001), chronic obstructive pulmonary disease (15.4% versus 5.5%, P < 0.001), and congestive heart failure (17.0% versus 1.3%, P < 0.001). Veterans had slightly better 30-d mortality (2.4% versus 2.8%, P = 0.003), less organ space infections (2.8% versus 5.8%, P < 0.001), or postoperative sepsis (3.4% versus 5.3%). Non-VA patients were more likely to be having emergent surgery (13.4% versus 9.6%, P < 0.001) or undergo a laparoscopic approach (57.9% versus 50.2%, P < 0.001). Non-VA patients had shorter postoperative length of stay (5.99 d versus 7.32 d, P < 0.001) and were less likely to return to the operating room (5.3% versus 8.4%, P < 0.001) ConclusionsDespite increased comorbidity, VA hospitals and hospitals enrolled in NSQIP have managed to achieve markedly similar rates of 30-d mortality following colectomy. Further study is needed to better understand the differences between both the populations and surgical outcomes between VA hospitals and non-VA hospitals.

Predicting wound complications following lower extremity revascularization

ObjectiveThe aim of this study was to create a simple risk score to identify factors associated with wound complications after infrainguinal revascularization. MethodsThe Veterans Affairs Surgical Quality Improvement Program national data set was queried from 2005 to 2021 to identify 22,114 patients undergoing elective open revascularization for peripheral arterial disease (claudication, rest pain, tissue loss) or peripheral aneurysm. Emergency and trauma cases were excluded. The data set was divided into a two-thirds derivation set and one-third validation set to create a risk prediction model. The primary end point was wound complication (wound dehiscence, superficial/deep wound surgical site infection). Eight independent risk factors for wound complications resulted from the model and were assigned whole number integer risk scores. Summary risk scores were collapsed into categories and defined as low (0-3 points), moderate (4-7 points), high (8-11 points), and very high (>12 points). ResultsThe wound complication rate in the derivation data set was 9.7% (n = 1428). Predictors of wound complication included age ≤73 (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.08-1.46), body mass index ≥35 kg/m2 (OR, 1.99; 95% CI, 1.68-2.36), non-Hispanic White (vs others: OR, 1.48; 95% CI, 1.30-1.69), diabetes (OR, 1.23; 95% CI, 1.10-1.37), white blood cell count >9900/mm3 (OR, 1.18; 95% CI, 1.03-1.35), absence of coronary artery disease (OR, 1.27; 95% CI, 1.03-1.35), operative time >6 hours (OR, 1.20; 95% CI, 1.05-1.37), and undergoing a femoral endarterectomy in conjunction with bypass (OR, 1.34; 95% CI, 1.14-1.57). In both the derivation and validation sets, wound complications correlated with risk category. Among the defined categories in the derivation set, wound complication rates were 4.5% for low-risk patients, 8.5% for moderate-risk patients, 13.8% for high-risk patients, and 23.8% for very high-risk patients, with similar results for the internal validation data set. Operative indication did not independently associate with wound complications. Patients with wound complications had higher rates of reoperation and graft failure. ConclusionsThis risk prediction model uses easily obtainable clinical metrics that allow for informed discussion of wound complication risk for patients undergoing open infrainguinal revascularization.

Why Not This Case? Differences Between Resident and Attending Operative Cases at Teaching Hospitals

IntroductionPrevious studies have focused on outcomes pertaining to resident operative autonomy, but there has been little academic work examining the types of patients and cases where autonomy is afforded. We sought to describe the differences between surgical patient populations in teaching cases where residents are and are not afforded autonomy. MethodsWe examined all general and vascular operations at Veterans Affairs teaching hospitals from 2004 to 2019 using Veterans Affairs Surgical Quality Improvement Program. Level of resident supervision is prospectively recorded by the operating room nurse at the time of surgery: attending primary (AP): the attending performs the case with or without a resident; attending resident (AR): the resident performs the case with the attending scrubbed; resident primary (RP): resident operating with supervising attending not scrubbed. Resident (R) cases refer to AR + RP. Patient demographics, comorbidities, level of supervision, and top cases within each group were evaluated. ResultsA total of 618,578 cases were analyzed; 154,217 (24.9%) were AP, 425,933 (68.9%) AR, and 38,428 (6.2%) RP. Using work relative value unit as a surrogate for complexity, RP was the least complex compared to AP and AR (10.4/14.4/14.8, P < 0.001). RP also had a lower proportion of American Society of Anesthesiologists 3 and 4 + 5 patients (P < 0.001), were younger (P < 0.001), and generally had lower comorbidities. The most common RP cases made up a higher proportion of all RP cases than they did for AP/AR and demonstrated several core competencies (hernia, cholecystectomy, appendectomy, amputation). R cases, however, were generally sicker than AP cases. ConclusionsIn the small proportion of cases where residents were afforded autonomy, we found they were more focused on the core general surgery cases on lower risk patients. This selection bias likely demonstrates appropriate attending judgment in affording autonomy. However, this cohort consisted of many “sicker” patients and those factors alone should not disqualify resident involvement.

Venous Thromboembolism Chemoprophylaxis Adherence Rates After Major Cancer Surgery

Venous thromboembolism (VTE) represents a major source of preventable morbidity and mortality and is a leading cause of death in the US after cancer surgery. Previous research demonstrated variability in VTE chemoprophylaxis prescribing, although it is unknown how these rates compare with performance in the Veterans Health Administration (VHA). To determine VTE rates after cancer surgery, as well as rates of inpatient and outpatient (posthospital discharge) chemoprophylaxis adherence within the VHA. This retrospective cohort study within 101 hospitals of the VHA health system included patients aged 41 years or older without preexisting bleeding disorders or anticoagulation usage who underwent surgical treatment for cancer with general surgery, thoracic surgery, or urology between January 1, 2015, and December 31, 2022. The VHA Corporate Data Warehouse, Pharmacy Benefits Management database, and the Veterans Affairs Surgical Quality Improvement Program database were used to identify eligible patients. Data analysis was conducted between January 2022 and July 2023. Inpatient surgery for cancer with general surgery, thoracic surgery, or urology. Rates of postoperative VTE events within 30 days of surgery and VTE chemoprophylaxis adherence were determined. Multivariable Poisson regression was used to determine incidence-rate ratios of inpatient and postdischarge chemoprophylaxis adherence by surgical specialty. Overall, 30 039 veterans (median [IQR] age, 67 [62-71] years; 29 386 men [97.8%]; 7771 African American or Black patients [25.9%]) who underwent surgery for cancer and were at highest risk for VTE were included. The overall postoperative VTE rate was 1.3% (385 patients) with 199 patients (0.7%) receiving a diagnosis during inpatient hospitalization and 186 patients (0.6%) receiving a diagnosis postdischarge. Inpatient chemoprophylaxis was ordered for 24 139 patients (80.4%). Inpatient chemoprophylaxis ordering rates were highest for patients who underwent procedures with general surgery (10 102 of 10 301 patients [98.1%]) and lowest for patients who underwent procedures with urology (11 471 of 17 089 patients [67.1%]). Overall, 3142 patients (10.5%) received postdischarge chemoprophylaxis, with notable variation by specialty. These findings indicate the overall VTE rate after cancer surgery within the VHA is low, VHA inpatient chemoprophylaxis rates are high, and postdischarge VTE chemoprophylaxis prescribing is similar to that of non-VHA health systems. Specialty and procedure variation exists for chemoprophylaxis and may be justified given the low risks of overall and postdischarge VTE.

Risk-Adjusted Cumulative Sum for Early Detection of Hospitals With Excess Perioperative Mortality

National surgical quality improvement programs lack tools for early detection of quality or safety concerns, which risks patient safety because of delayed recognition of poor performance. To compare the risk-adjusted cumulative sum (CUSUM) with episodic evaluation for early detection of hospitals with excess perioperative mortality. National, observational, hospital-level, comparative effectiveness study of 697 566 patients. Identification of hospitals with excess, risk-adjusted, quarterly 30-day mortality using observed to expected ratios (ie, current criterion standard in the Veterans Affairs Surgical Quality Improvement Program) was compared with the risk-adjusted CUSUM. Patients included in the study underwent a noncardiac operation at a Veterans Affairs hospital, had a record in the Veterans Affairs Surgical Quality Improvement Program (January 1, 2011, through December 31, 2016), and were aged 18 years or older. Number of hospitals identified as having excess risk-adjusted 30-day mortality. The cohort included 697 566 patients treated at 104 hospitals across 24 quarters. The mean (SD) age was 60.9 (13.2) years, 91.4% were male, and 8.6% were female. For each hospital, the median number of quarters detected with observed to expected ratios, at least 1 CUSUM signal, and more than 1 CUSUM signal was 2 quarters (IQR, 1-4 quarters), 8 quarters (IQR, 4-11 quarters), and 3 quarters (IQR, 1-4 quarters), respectively. During 2496 total quarters of data, outlier hospitals were identified 33.3% of the time (830 quarters) with at least 1 CUSUM signal within a quarter, 12.5% (311 quarters) with more than 1 CUSUM signal, and 11.0% (274 quarters) with observed to expected ratios at the end of the quarter. The CUSUM detection occurred a median of 49 days (IQR, 25-63 days) before observed to expected ratio reporting (1 signal, 35 days [IQR, 17-54 days]; 2 signals, 49 days [IQR, 26-61 days]; 3 signals, 58 days [IQR, 44-69 days]; ≥4 signals, 49 days [IQR, 42-69 days]; trend test, P < .001). Of 274 hospital quarters detected with observed to expected ratios, 72.6% (199) were concurrently detected by at least 1 CUSUM signal vs 42.7% (117) by more than 1 CUSUM signal. There was a dose-response relationship between the number of CUSUM signals in a quarter and the median observed to expected ratio (0 signals, 0.63; 1 signal, 1.28; 2 signals, 1.58; 3 signals, 2.08; ≥4 signals, 2.49; trend test, P < .001). This study found that with CUSUM, hospitals with excess perioperative mortality can be identified well in advance of standard end-of-quarter reporting, which suggests episodic evaluation strategies fail to detect out-of-control processes and place patients at risk. Continuous performance evaluation tools should be adopted in national quality improvement programs to prevent avoidable patient harm.

A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty

IntroductionThe Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers. MethodsWe conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality. ResultsAmong 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality. ConclusionsWhile RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.

Anterior cervical discectomy and fusion and pneumonia: use of the VASQIP database

Background: Anterior cervical discectomy and fusion (ACDF) may alleviate cervical radiculopathy and myelopathy, with risks including dysphagia, cerebrospinal fluid leakage, neurological injury, and post operative pneumonia (POP). The incidence of POP among non-veteran patients who underwent ACDF surgery was 0.45%. Military veterans may have higher overall complication rates after undergoing ACDF. We aimed to describe the incidence and risk factors of POP among military veterans undergoing ACDF. Methods: This study was a retrospective analysis of the United States Veteran Affairs Surgical Quality Improvement Program database. We assessed the patients who underwent ACDF between January 2001 and December 2017. Bivariate and multivariate statistical analyses were performed to identify the rates of POP and the factors that may increase POP risk. Results: Among the 18,468 patients, 195 (1.06%) experienced POP. Independent risk factors included male sex, chronic steroid use, preoperative sepsis, diabetes, poor overall health, inpatient surgery, and emergency surgery. Multilevel ACDF was associated with a higher POP rate (P&lt;0.001). In the multivariate analysis, patients with a history of severe chronic obstructive pulmonary disease (COPD) were more than twice as likely to experience POP than those without severe COPD (P&lt;0.001). An additional hour in surgery was associated with 16% higher odds of POP (P&lt;0.001). Conclusions: The incidence of POP following ACDF is greater than the nonveteran population, which may be contributed by several factors including COPD, inpatient surgery and length of surgery. The identification of veterans as a high-risk population can potentially help guide decision making when ACDF is considered. Level of Evidence: III.

Palliative Care Consults and Frailty Screening in High-Risk Vascular Surgery Patients

Palliative care has increasingly been integrated into the management of high-risk surgery because of the beneficial effect on patient quality of life. However, the utilization of palliative care in vascular surgery remains unclear due to a lack of data. The purpose of this study was to determine the palliative care consult rate in high-risk vascular surgery patients. A retrospective chart review was performed at a single Veteran Affairs Medical Center from 2013 to 2021. High-risk vascular surgery patients were identified by using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) risk score of >4%, which predicted 30-day mortality. Patient demographics, operative procedures, and clinical outcomes were collected. A total of 126 patients underwent a high-risk vascular surgery operation. The surgical procedures consisted of 78 amputations, 19 bypasses, 18 endovascular aneurysm repair/stents, and 11 thrombectomy/arterial repair. Palliative care was consulted in 44 patients (35%) during the hospitalization: 8 patients (18%) had preoperative consults, whereas 36 patients (82%) had postoperative consults. The overall 30-day mortality was 15%, and the 1-year mortality rate was 34%. The 30-day and 1-year mortality rates were higher in those patients who received palliative care consultation (36% and 64%, respectively) compared with those without consult (0% and 21%, respectively). The palliative care consults had a higher referral rate in more frail patients, by Revised Analysis Index (RAI): n = 13 of 57 (23%) nonfrail (RAI <20), n = 14 of 44 (32%) frail (RAI = 21-32), and n = 17 of 25 (68%) very frail (RAI >33). The majority of the palliative care consults were obtained for goals of care discussion (80%) compared with withdrawal of care (20%). Palliative care is generally underused for vascular surgery patients, but our data demonstrated a palliative care consult rate of 35% in high-risk vascular surgery patients. A frailty screening program can further stratify high-risk vascular surgery patients who would benefit from an early palliative care consult.

Association of Resident Independence With Short-term Clinical Outcome in Core General Surgery Procedures

Prior studies evaluating the effect of resident independence on operative outcome draw from case mixes that cross disciplines and overrepresent cases with low complexity. The association between resident independence and clinical outcome in core general surgical procedures is not well defined. To evaluate the level of autonomy provided to residents during their training, trends in resident independence over time, and the association between resident independence in the operating room and clinical outcome. Using the Veterans Affairs Surgical Quality Improvement Program database from 2005 to 2021, outcomes in resident autonomy were compared using multivariable logistic regression and propensity score matching. Data on patients undergoing appendectomy, cholecystectomy, partial colectomy, inguinal hernia, and small-bowel resection in a procedure with a resident physician involved were included. Resident independence was graded as the attending surgeon scrubbed into the operation (AS) or the attending surgeon did not scrub (ANS). Outcomes of interest included rates of postoperative complication, severity of complications, and death. Of 109 707 patients who met inclusion criteria, 11 181 (10%) underwent operations completed with ANS (mean [SD] age of patients, 61 [14] years; 10 527 [94%] male) and 98 526 (90%) operations completed with AS (mean [SD] age of patients, 63 [13] years; 93 081 [94%] male). Appendectomy (1112 [17%]), cholecystectomy (3185 [11%]), and inguinal hernia (5412 [13%]) were more often performed with ANS than small-bowel resection (527 [6%]) and colectomy (945 [4%]). On multivariable logistic regression adjusting for procedure type, age, body mass index, functional status, comorbidities, American Society of Anesthesiologists class, wound class, case priority, admission status, facility type, and year, factors associated with a complication included increasing age (adjusted odds ratio [aOR], 1.19 [95% CI, 1.16-1.22]), emergent case priority (aOR, 1.41 [95% CI, 1.33-1.50]), and resident independence (aOR, 1.12 [95% CI, 1.03-1.22]). On propensity score matching, AS cases were score matched 1:1 to ANS cases based on the variables listed above. Comparing matched cohorts, there was no difference in complication rates (817 [7%] vs 784 [7%]) or death (91 [1%] vs 102 [1%]) based on attending physician involvement. Core general surgery cases performed by senior-level trainees in such a way that the attending physician is not scrubbed into the case are being done safely with no significant difference in rates of postoperative complication.

Comparison of Postoperative Outcomes of Laparoscopic vs Open Inguinal Hernia Repair

Advocates of laparoscopic surgery argue that all inguinal hernias, including initial and unilateral ones, should be repaired laparoscopically. Prior work suggests outcomes of open repair are improved by using local rather than general anesthesia, but no prior studies have compared laparoscopic surgery with open repair under local anesthesia. To evaluate postoperative outcomes of open inguinal hernia repair under general or local anesthesia compared with laparoscopic repair. This retrospective cohort study identified 107 073 patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent unilateral initial inguinal hernia repair from 1998 to 2019. Data were analyzed from October 2021 to March 2022. Patients were divided into 3 groups for comparison: (1) open repair with local anesthesia (n = 22 333), (2) open repair with general anesthesia (n = 75 104), and (3) laparoscopic repair with general anesthesia (n = 9636). Operative time and postoperative morbidity were compared using quantile regression and inverse probability propensity weighting. A 2-stage least-squares regression and probabilistic sensitivity analysis was used to quantify and address bias from unmeasured confounding in this observational study. Of 107 073 included patients, 106 529 (99.5%) were men, and the median (IQR) age was 63 (55-71) years. Compared with open repair with general anesthesia, laparoscopic repair was associated with a nonsignificant 0.15% (95% CI, -0.39 to 0.09; P = .22) reduction in postoperative complications. There was no significant difference in complications between laparoscopic surgery and open repair with local anesthesia (-0.05%; 95% CI, -0.34 to 0.28; P = .70). Operative time was similar for the laparoscopic and open general anesthesia groups (4.31 minutes; 95% CI, 0.45-8.57; P = .048), but operative times were significantly longer for laparoscopic compared with open repair under local anesthesia (10.42 minutes; 95% CI, 5.80-15.05; P < .001). Sensitivity analysis and 2-stage least-squares regression demonstrated that these findings were robust to bias from unmeasured confounding. In this study, laparoscopic and open repair with local anesthesia were reasonable options for patients with initial unilateral inguinal hernias, and the decision should be made considering both patient and surgeon factors.

Laparoscopic and robotic paraesophageal hernia repair in United States veterans: Clinical outcomes and risk factors associated with reoperation recurrence

BackgroundDespite surgical advances, rates of paraesophageal hernia recurrence remain high. We evaluate outcomes of paraesophageal hernia repair in United States veterans, safety of robotic technology, and risk factors for reoperation for recurrence. MethodsThe Veterans Affairs Surgical Quality Improvement Program database was queried for patients undergoing laparoscopic or robotic paraesophageal hernia repair from 2010 to 2021. The effect of patient and operative characteristics on outcomes was evaluated. Results2,444 patients underwent paraesophageal hernia repair. 62 (2.5%) had a reoperation for recurrence. Emergent priority (aOR 18.3 [5.9–56.2]) and younger age (aOR 0.7 [0.5–0.9]) were associated with increased risk of reoperation. On comparison of propensity matched cohorts, repairs done robotically took longer (4.17 vs. 3.57 h, p < 0.001) but had 30-day outcomes and rates of reoperation for recurrence equivalent to laparoscopic repairs (p > 0.05). ConclusionEmergent priority and younger age are associated with increased risk of reoperation for recurrent paraesophageal hernia. Robotic approaches take longer but are safe.

Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality

The volume of cases that residents perform independentlyhave decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.

Large Surgical Databases with Direct Data Abstraction: VASQIP and ACS-NSQIP.

Direct data abstraction from a patient's chart by experienced medical professional data abstractors has been the historical gold standard for quality and accuracy in clinical medical research. The limiting challenge to population-wide studies for quality and public health purposes is the high personnel costs associated with very large-scale efforts of this type. Two historically related programs that are at least partially able to successfully circumvent this problem and provide high-quality data relating to surgical procedures and the early postoperative period are reviewed in this article. Both utilize similar data abstraction efforts by specially trained and qualified medical abstractors of a sample subset of the total procedures performed at participating hospitals.The Veterans Affairs Surgical Quality Improvement Program (VASQIP), detailed by Nicholas J. Giori, MD, PhD, in the first section of this article, makes use of trained abstractors and has undergone recent additions and updates, including the development of an associated total hip registry for the VA system. The data elements and data integrity provided by both of these programs establish important benchmarks for other "big data" efforts, which often attempt to use alternative less-expensive methods of data collection in order to achieve more widespread or even nationwide data collection.In the second section, Elizabeth B. Habermann, PhD, MPH, provides a detailed review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the data elements collected, and examples of the range of quality improvement and outcomes studies in orthopaedic surgery that it has made possible, along with information on data that have not been collected and the resulting limitations. The ACS NSQIP was actually modeled after the very similar earlier effort started by the United States Department of Veterans Affairs (VA).

Implementation of Frailty Assessment Improves Veterans Affairs Surgical Quality Improvement Program Risk Assessment in General and Vascular Surgery Patients

INTRODUCTION: Frailty has been recognized as an important factor in preoperative risk evaluation. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) Surgical Risk Calculator, derived from chart elements, predicts surgical risk and incorporates many factors now recognized as markers of frailty. We examined the impact on VASQIP Surgical Risk prediction after implementation of a robust frailty assessment. METHODS: A prospective frailty assessment quality improvement project was implemented in general surgery (GenS) and vascular surgery (VascS) for new and preoperative VA patients starting October 2020. We examined the effectiveness of this assessment by comparing VASQIP Surgical Risk prediction with and without use of frailty assessment data. For comparison purposes, 3 operative case complexity groups were identified. RESULTS: A total of 205 patients were screened: 145 (71%) GenS and 60 (29%) VascS. Frailty screening identified issues not captured on routine surgical assessment in 77 (38%) patients; 20 (26%) of these patients were less than 65 years of age. The most common frailty factors captured include cognitive impairment (46% GenS, 47% VascS), dyspnea (19% GenS, 20% VascS), and impaired functional status (14% GenS, 13% VascS). Frailty identification increased VASQIP risk prediction with significant differences post–frailty assessment (p < 0.005; Table 1). Risk of 30-day surgical site infection, ICU admission, and postoperative admission also increased: 1% to 1.2%, 23% to 27.4%, and 72% to 79%, respectively (p < 0.001). Increasing case complexity was associated with higher score differences (p < 0.0001; Table 1). Table 1. - VASQIP Surgical Risk Score Comparison Variable 30-d mortality risk: pre-/postscreen * 180-d mortality risk: pre-/postscreen * 30-d morbidity risk: pre-/postscreen * p Value † Entire group 0.24%/0.31% 1.03%/1.17% 3.55%/3.84% <0.0001 Cases with differences 0.33%/0.61% 1.27%/2.21% 4.18%/4.77% <0.0001 Low case complexity 0.13%/0.15% 0.53%/0.66%‡ 1.78%/1.78%‡ <0.005‡ Moderate case complexity 0.17%/0.20% 0.85%/1.14% 2.14%/2.62% <0.0001 High case complexity 0.30%/0.38% 1.11%/1.42% 4.8%/6.14% <0.0001 Vascular surgery 0.51%/0.62% 1.20%/1.52% 4.24%/4.29% <0.005 General surgery 0.14%/0.18% 0.71%/1.01% 2.80%/3.48% <0.0001 *Median risk percentage displayed. Risk scores calculated with VASQIP Surgical Risk Calculator.†Wilcoxon Signed Ranks Test performed.‡Only 30-day mortality is <0.005; 180-day morality and 30-day morbidity differences were not statistically significant. CONCLUSION: Implementation of frailty assessment, in general, and vascular surgery patients significantly improves VASQIP Surgical Risk prediction. These findings emphasize the prevalence of frailty and the importance of presurgical frailty assessment for both geriatric and nongeriatric patients.

General Surgery Resident Complement and Operative Autonomy – Size Matters

Operative autonomy has progressively decreased for surgery residents. This study investigates the effect of general surgery resident complement size at Veterans Affairs (VA) hospitals on operative autonomy for the residents. We hypothesize that smaller complements of residents would result in fewer opportunities for operative autonomy. Retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Operative cases within the VASQIP database from July 1, 2004 to September 30, 2019 were analyzed. All general surgery procedures performed at teaching VA hospitals from January 2004 to September 2019 were included. The level of resident operative autonomy is defined as follows: attending primary surgeon with or without a resident (AP), resident primary surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Resident complement is based on funded resident positions at each VA hospital during the academic year 2017-2018 and stratified into 3 groups: small (≤4), medium (>4-<7), and large (≥7). The primary outcome was the proportion of operative autonomy for each resident complement group. Secondary outcomes were level of autonomy over time, and mortality and morbidity for RP procedures. Categorical data were compared with Chi-squared test. Four hundred sixty-one thousand seven hundred thirty-four procedures across 92 VA hospitals with general surgery residents were included in the analysis. There were 126,062 cases performed at 29 small resident complement hospitals, 135,539 at 28 medium resident complement hospitals, and 200,133 at 35 large resident complement hospitals. The percentage of RP procedures was higher with increasing resident complement (2.1% vs 6.8% vs 9.9%, p < 0.001). RP procedures have decreased over time in all groups, but the relative decrease was less pronounced as resident complement increased (79.5% vs 73.3% vs 64.7%, p < 0.001). There was no significant difference in adjusted 30-day all-cause mortality between groups. Increased resident complement at VA hospitals is associated with increased resident autonomy in resident primary procedures. Resident autonomy has decreased over time regardless of complement size, but it is less dramatic at sites with more residents. Increasing resident complement at a site may improve operative autonomy, leading to an improved educational experience for surgical residents.

Declining Surgical Resident Operative Autonomy in Acute Care Surgical Cases

IntroductionSurgical resident operative autonomy has decreased markedly over time, reducing resident readiness for independent practice. We sought to examine operative resident autonomy for emergency acute care surgery (ACS) compared to elective cases and associated patient outcomes at veterans affairs hospitals. MethodsThe Veterans Affairs Surgical Quality Improvement Program database was queried for ACS cases (emergency general, vascular, and thoracic) at veterans affairs hospitals from 2004 to 2019. Cases are coded prospectively for the level of supervision: attending primary surgeon (AP); attending scrubbed with resident surgeon (AR); resident primary (RP), attending not scrubbed. Baseline demographics, operative variables, and outcomes were compared. ResultsA total of 61,275 ACS cases and 605,146 elective cases were performed during the study period. The ACS had a higher proportion of RP cases (7.2% versus 5.7%, P < 0.001). The proportion of ACS RP cases decreased from 9.9% to 4.1% (58.6%); elective RP cases decreased from 8.9% to 2.9% (67.4%). The most common ACS RP surgeries were appendectomy, amputations, and cholecystectomy. RP cases had lower American Society of Anesthesia class and lower median work relative value units than AP and AR. There was no difference between mortality rates of RP compared to AP (adjusted odds ratio [OR] 0.94 [0.80-1.09] or AR 0.94 [0.81-1.08]). While there was no difference in complications between the RP and AP (OR 1.01 [0.92-1.12]), there were significantly more complications in AR compared to RP (OR 1.20 [1.10-1.31]). ConclusionsMore autonomy is granted for ACS cases compared to elective cases. While both decreased over time, the decrease is less for ACS cases. Resident autonomy does not negatively impact outcomes, even in emergent cases.

Resident Involvement in Inguinal Hernia Repair Is Safe but Associated With Increased Operative Time

Understanding how resident participation in surgery affects outcomes is critical for academic surgeons. The purpose of this study was to evaluate if resident participation was associated with adverse outcomes for inguinal hernia repair. We used the Veterans Affairs Surgical Quality Improvement Program to look at 61,737 patients aged ≥18y who had open inguinal hernia repairs from 1998 to 2018. Propensity weighting was used to compare postoperative complications and operative time for patients having surgery performed by an attending alone versus attending with a postgraduate year (PGY) 1, 3, or 5 residents. There were 29,806 hernias (48%) repaired by an attending, 12,024 (19%) by an intern, 9008 (15%) by a PGY-3 resident, and 10,898 (18%) by a PGY-5 resident. After propensity weighting, there was a 0.13% (95% CI -0.11% to 0.38%, P=0.29) increase in complications with PGY-1 participation compared to cases performed by attendings alone, a 0.3% increase (95% CI 0.01% to 0.59%, P=0.04) for PGY-3 residents, and a 0.4% increase (95% CI 0.11% to 0.69%, P=0.007) for PGY-5 residents. There was also an increase in operative time of 26min (95% CI 25 to 27, P<0.001) with PGY-1 participation, 19min (95% CI 18 to 20, P<0.001) with PGY-3 participation, and 23min (95% CI 22 to 24, P<0.001) with PGY-5 participation. Resident involvement in inguinal hernia surgery was associated with a significant increase in operative time but had a minimal impact on postoperative complications. Although resident participation in hernia surgery is safe, surgical programs should focus on enhancing operative efficiency for residents.