American College Of Surgeons National Quality Improvement Program Research Articles

Concomitant Procedures, Black Race, Male Sex, and General Anesthesia Show Fair Predictive Value for Prolonged Rotator Cuff Repair Operative Time: Analysis of the NSQIP Database Using Machine Learning

PurposeThe purpose of this study is to develop machine learning models using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database to predict prolonged operative time (POT) for rotator cuff repair (RCR). Furthermore, this study aims to use the trained machine learning (ML) models, cross-referenced with traditional multivariate logistic regression (MLR), to determine the key perioperative variables that may predict POT for RCR. MethodsData were obtained from a large, national database (NSQIP) from 2021. Patients with unilateral RCR procedures were included. Demographic, preoperative, and operative variables were analyzed. A multivariable logistic regression (MLR) model and various other machine learning techniques, including random forest (RF) and artificial neural network (ANN), were compared using area under the curve (AUC), calibration, Brier score, and decision curve analysis. Feature importance was identified from the overall best-performing model. ResultsA total of 6,690 patients met inclusion criteria. The random forest (RF) ML model had the highest AUC upon internal validation (0.706) and the lowest Brier score (0.15), outperforming the other models. The RF model also demonstrated strong performance upon assessment of the calibration curves (Slope = 0.86, Intercept = 0.08) and decision curve analysis. The model identified concomitant procedure, specifically labral repair and biceps tenodesis, as the most important variable for determining POT, followed by age <30 years, Black or African American race, male sex, and general anesthesia. ConclusionsDespite the advanced machine learning models used in this study, the NSQIP dataset was only able to fairly predict POT following RCR. The RF model identified concomitant procedures, specifically labral repair and biceps tenodesis, as the most important variables for determining POT. Additionally, demographic factors such as age <30 years, Black race, and general anesthesia were significant predictors. While male sex was identified as important in the RF model, the MLR model indicated that its predictive value is primarily in conjunction with specific procedures like biceps tenodesis and subacromial decompression.

Machine learning used to determine features of importance linked to overnight stay after patellar tendon repair

PurposeThe purpose of this study is to determine if machine learning is an effective method to identify features of patients who may need a longer postoperative stay following a patellar tendon repair. MethodsThe American College of Surgeons National Quality Improvement Program (ACS-NSQIP) was used to collect 1173 patients who underwent patellar tendon repair. Machine learning (ML) was then applied to determine features of importance in this patient population. Several algorithms were used: Random Forest, Artificial Neural Network, Gradient Boosting, and Support Vector Machine. These were then compared to the American Society of Anesthesiologists (ASA) classification system based logistic regression as a control. ResultsRandom Forest (RF) was determined to be the best performing algorithm, with an AUC of 0.72, accuracy of 77.66 %, and precision of 0.79, and recall of 0.96. All other algorithms performed similarly to the control. RF gave the highest permutation feature importance to age (PFI 0.25), BMI (PFI 0.19), ASA classification (PFI 0.14), hematocrit (PFI 0.12), and height (PFI 0.11). ConclusionsThis study shows that machine learning can be used as a tool to identify features of importance for length of postoperative stay in patients undergoing patellar tendon repair. RF was found to be a better performing model than logistic regression at determining patients predisposed to longer length of stay as determined by AUC. This supported the study's hypothesis that ML can provide an effective method for identifying features of importance in patients requiring a longer postoperative stay after patellar tendon repair.

Quality of Surgical Care Within the Criminal Justice Health Care System

Individuals who are incarcerated represent a vulnerable group due to concerns about their ability to provide voluntary and informed consent, and there are considerable legal protections regarding their participation in medical research. Little is known about the quality of surgical care received by this population. To evaluate perioperative surgical care provided to patients who are incarcerated within the Texas Department of Criminal Justice (TDCJ) and compare their outcomes with that of the general nonincarcerated population. This cohort study analyzed data from patients who were incarcerated within the TDCJ and underwent general or vascular surgery at the University of Texas Medical Branch (UTMB) from 2012 to 2021. Case-specific outcomes for a subset of these patients and for patients in the general academic medical center population were obtained from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) and compared. Additional quality metrics (mortality index, length of stay index, and excess hospital days) from the Vizient Clinical Data Base were analyzed for patients in the incarcerated and nonincarcerated groups who underwent surgery at UTMB in 2020 and 2021 to provide additional recent data. Patient-specific demographics, including age, sex, and comorbidities were not available for analysis within this data set. Perioperative outcomes (30-day morbidity, mortality, and readmission rates) were compared between the incarcerated and nonincarcerated groups using the Fisher exact test. The sample included data from 6675 patients who were incarcerated and underwent general or vascular surgery at UTMB from 2012 to 2021. The ACS-NSQIP included data (2012-2021) for 2304 patients who were incarcerated and 602 patients who were not and showed that outcomes were comparable between the TDCJ population and that of the general population treated at the academic medical center with regard to 30-day readmission (6.60% vs 5.65%) and mortality (0.91% vs 1.16%). However, 30-day morbidity was significantly higher in the TDCJ population (8.25% vs 5.48%, P = .01). The 2020 and 2021 data from the Vizient Clinical Data Base included 629 patients who were incarcerated and 2614 who were not and showed that the incarcerated and nonincarcerated populations did not differ with regard to 30-day readmission (12.52% vs 11.30%) or morbidity (1.91% vs 2.60%). Although the unadjusted mortality rate was significantly lower in the TDCJ population (1.27% vs 2.68%, P = .04), mortality indexes, which account for case mix index, were similar between the 2 populations (1.17 vs 1.12). Findings of this cohort study suggest that patients who are incarcerated have equivalent rates of mortality and readmission compared with a general academic medical center population. Future studies that focus on elucidating the potential factors associated with perioperative morbidity and exploring long-term surgical outcomes in the incarcerated population are warranted.

Baseline labs predict adverse postoperative outcomes following metastatic brain tumor resection: Analysis of 5943 patients from a prospective surgical registry (2015–2019)

IntroductionThe present study sought to evaluate the predictive accuracy of preoperative lab values (PLV) on postoperative metastatic brain tumor resection (MBTR) outcomes using data queried from a large prospective international surgical registry, representing over 700 hospitals in 11 countries. MethodsAdult metastatic brain tumor patients (N = 5943) were queried from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database, from 2015 to 2019, using diagnostic and procedural coding. The relationship between preoperative lab values and key indicators of adverse postoperative outcomes following metastatic brain tumor resection were assessed with univariate and multivariate analyses. Adverse postoperative outcomes of interest included: 30-day mortality, Clavien-Dindo Grade IV (CDIV) complications, extended length of stay (eLOS), and discharge to non-home destination (NHD), as well as secondary outcomes: non-Clavien-Dindo Grade IV complications, unplanned reoperation, and unplanned readmission. ResultsIndependent PLV most strongly associated with 30-day mortality were hypernatremia, increased serum creatinine, and thrombocytopenia. Significant predictors of CDIV complications were hypoalbuminemia and thrombocytopenia. eLOS was associated with hypoalbuminemia, anemia, and hyponatremia. The strongest independent predictors of NHD were anemia, hyperbilirubinemia, and hypoalbuminemia. ConclusionSeveral pre-operative lab values independently predicted worse outcomes for metastatic brain tumor resection patients. Hypoalbuminemia, thrombocytopenia, and anemia had the strongest association with the study's adverse postoperative outcomes. These baseline lab values may be considered for preoperative risk stratification of metastatic brain tumor patients.

Accounting for age in prediction of discharge destination following elective lumbar fusion: a supervised machine learning approach

BACKGROUND CONTEXTThe number of elective spinal fusion procedures performed each year continues to grow, making risk factors for post-operative complications following this procedure increasingly clinically relevant. Nonhome discharge (NHD) is of particular interest due to its associations with increased costs of care and rates of complications. Notably, increased age has been found to influence rates of NHD. PURPOSETo identify aged-adjusted risk factors for nonhome discharge following elective lumbar fusion through the utilization of Machine Learning-generated predictions within stratified age groupings. STUDY DESIGNRetrospective Database Study. PATIENT SAMPLEThe American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database years 2008 to 2018. OUTCOME MEASURESPostoperative discharge destination. METHODSACS-NSQIP was queried to identify adult patients undergoing elective lumbar spinal fusion from 2008 to 2018. Patients were then stratified into the following age ranges: 30 to 44 years, 45 to 64 years, and ≥65 years. These groups were then analyzed by eight ML algorithms, each tasked with predicting post-operative discharge destination. RESULTSPrediction of NHD was performed with average AUCs of 0.591, 0.681, and 0.693 for those aged 30 to 44, 45 to 64, and ≥65 years respectively. In patients aged 30 to 44, operative time (p<.001), African American/Black race (p=.003), female sex (p=.002), ASA class three designation (p=.002), and preoperative hematocrit (p=.002) were predictive of NHD. In ages 45 to 64, predictive variables included operative time, age, preoperative hematocrit, ASA class two or class three designation, insulin-dependent diabetes, female sex, BMI, and African American/Black race all with p<.001. In patients ≥65 years, operative time, adult spinal deformity, BMI, insulin-dependent diabetes, female sex, ASA class four designation, inpatient status, age, African American/Black race, and preoperative hematocrit were predictive of NHD with p<.001. Several variables were distinguished as predictive for only one age group including ASA Class two designation in ages 45 to 64 and adult spinal deformity, ASA class four designation, and inpatient status for patients ≥65 years. CONCLUSIONSApplication of ML algorithms to the ACS-NSQIP dataset identified a number of highly predictive and age-adjusted variables for NHD. As age is a risk factor for NHD following spinal fusion, our findings may be useful in both guiding perioperative decision-making and recognizing unique predictors of NHD among specific age groups.

Use of random forest machine learning algorithm to predict short term outcomes following posterior cervical decompression with instrumented fusion

Random Forest (RF) is a widely used machine learning algorithm that can be utilized for identification of patient characteristics important for outcome prediction. Posterior cervical decompression with instrumented fusion (PCDF) is a procedure for the management of cervical spondylosis, cervical spinal stenosis, and degenerative disorders that can cause cervical myelopathy or radiculopathy. An RF algorithm was employed to predict and describe length of stay (LOS), readmission, reoperation, transfusion, and infection rates following elective PCDF using The American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database 2008 through 2018. The RF algorithm was tasked with determining the importance of independent clinical variables in predicting our outcomes of interest and importance of each variable based on the reduction in the Gini index. Application of an RF algorithm to the ACS-NSQIP database yielded a highly predictive set of patient characteristics and perioperative events for five outcomes of interest related to elective PCDF. These variables included postoperative infection, increased age, BMI, operative time, and LOS, and decreased preoperative hematocrit and white blood cell count. Risk factors that were predictive for rate of reoperation, readmission, hospital length of stay, transfusion requirement, and post-operative infection were identified with AUC values of 0.781, 0.791, 0.781, 0.902, and 0.724 respectively. Utilization of these findings may assist in risk analysis during the perioperative period and may influence clinical or surgical decision-making.

Simple Clinical Screening Underestimates Malnutrition in Surgical Patients with Inflammatory Bowel Disease-An ACS NSQIP Analysis.

The present large scale study aimed to assess the prevalence and consequences of malnutrition, based on clinical assessment (body mass index and preoperative weight loss) and severe hypoalbuminemia (<3.1 g/L), in a representative US cohort undergoing IBD surgery. The American College of Surgeons National Quality improvement program (ACS-NSQIP) Public User Files (PUF) between 2005 and 2018 were assessed. A total of 25,431 patients were identified. Of those, 6560 (25.8%) patients had severe hypoalbuminemia, 380 (1.5%) patients met ESPEN 2 criteria (≥10% weight loss over 6 months PLUS BMI < 20 kg/m2 in patients <70 years OR BMI < 22 kg/m2 in patients ≥70 years), and 671 (2.6%) patients met both criteria (severe hypoalbuminemia and ESPEN 2). Patients who presented with malnutrition according to any of the three definitions had higher rates of overall, minor, major, surgical, and medical complications, longer LOS, higher mortality and higher rates of readmission and reoperation. The simple clinical assessment of malnutrition based on BMI and weight loss only, considerably underestimates its true prevalence of up to 50% in surgical IBD patients and calls for dedicated nutritional assessment.

Appraising the Quality of Reporting of American College of Surgeons NSQIP Emergency General Surgery Studies

The quality of emergency general surgery (EGS) studies that use the American College of Surgeons-National Quality Improvement Program (ACS-NSQIP) database is variable. We aimed to critically appraise the methodologic reporting of EGS ACS-NSQIP studies. We searched the PubMed ACS-NSQIP bibliography for EGS studies published from 2004 to 2019. The quality of reporting of each study was assessed according to the number of criteria fulfilled with respect to the 13-item RECORD statement and the 10-item JAMA Surgery checklist. Three criteria in each checklist were not applicable and were therefore excluded. An analysis was conducted comparing studies published in high and low impact factor (IF) journals. We identified a total of 99 eligible studies. Twenty-six percent of studies were published in high IF journals, and 73% of the journals had a policy requiring adherence to reporting statements. The median number of criteria fulfilled for the RECORD statement (out of 10 items) and the JAMA Surgery checklist (out of 7 items) were both equal to 4 (interquartile range [IQR] 3, 5). Sixty-three percent of studies did not explain the methodology for data cleaning, 81% of studies did not describe the population selection process, and 55% did not discuss the implications of missing variables. There were no differences in overall scores between studies published in high and low IF journals. The methodologic reporting of EGS studies using ACS-NSQIP remains suboptimal. Future efforts should focus on improving adherence to the policies to mitigate potential sources of bias and improve the credibility of large database studies.

Obesity is a predictor of increased morbidity after tracheostomy.

The purpose of this study was to analyze the relationship between body mass index (BMI) and 30-day morbidity and mortality risk in patients undergoing tracheostomy using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP). This is a retrospective, cross-sectional, cohort study. Patients were identified with Current Procedural Terminology codes in the ACS-NSQIP database. Patients who underwent tracheostomy from 2005 to 2018 were queried. They were stratified into four BMI classes and matched to normal BMI cohorts. Multivariate logistic regression was used to identify independent predictors for complications, readmissions, and unplanned reoperations within 30days. Among 3784 patients meeting inclusion and exclusion criteria, obesity was shown to be a significant independent risk factor for overall complications (OR 1.439, 95% CI 1.226-1.689, p<0.001), postoperative acute renal failure (OR 10.715, 95% CI 1.213-94.646, p=0.033), and unplanned readmissions (OR 1.702, 95% CI 1.095-2.647, p=0.018). A significantly lower rate of postoperative transfusions was observed for obese patients (OR 0.581, 95% CI 0.432-0.781, p<0.001). Obesity was found to be independently associated with an increased risk of overall complication, developing acute renal failure, and having an unplanned 30-day readmission following tracheostomy. The risk of postoperative transfusion appears to be lower in obese patients. 4.

Quality Indicators of Central Compartment Neck Dissection in Thyroid Surgery.

Quality metrics are an increasingly important means of improving patient care. Variability in the number of lymph nodes removed during central compartment lymph node dissection (CCLND) at the time of thyroidectomy has not been studied. A retrospective cohort study was performed using American College of Surgeons National Quality Improvement Program (ACS-NSQIP) data. Centers in North America and worldwide contributing data to ACS-NSQIP and performing thyroidectomy on adults in inpatient and outpatient settings were included. Adult patients undergoing thyroidectomy with or without CCLND were included. Outcomes of interest were number of nodes removed during CCLND and risks of postoperative hypocalcemia. In total, 6108 patients met inclusion criteria (1565 with CCLND). The median number of lymph nodes removed during CCLND was 2. There was no statistically significant association between postoperative hypocalcemia and CCNLD, regardless of number of nodes removed. However, we were underpowered to detect this association based on the overall low nodal yield of many CCLNDs performed. In many cases where CCLND is documented as part of thyroidectomy, very few lymph nodes are removed. Our ability to draw conclusions regarding the effect of CCLND on postoperative hypocalcemia is restricted due to the limited nature of many CCLNDs performed.

Increased severity of anaemia is associated with 30-day complications following total joint replacement.

The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty. Following adjustment, patients in the THA cohort with moderate to severe anaemia had an increased odds of 6.194 (95% confidence interval (CI) 5.679 to 6.756; p < 0.001) for developing any postoperative complication. Following adjustment, patients in the TKA cohort with moderate to severe anaemia had an increased odds of 5.186 (95% CI 4.811 to 5.590; p < 0.001) for developing any postoperative complication. Among both cohorts, as severity increased, there was an increased risk of postoperative complications. Preoperative anaemia is a risk factor for complications following primary arthroplasty. There is a significant relationship between the severity of anaemia and the odds of postoperative complications. Patients who had moderate to severe anaemia were at increased risk of developing postoperative complications relative to patients with mild anaemia. When considering elective primary THA or TKA in a moderately or severely anaemic patient, surgeons should strongly consider correcting anaemia prior to surgery if possible. Cite this article: Bone Joint J 2020;102-B(4):485-494.

Neck dissection does not add to morbidity or mortality of laryngectomy

ObjectivesTo examine the national rates of complications, readmission, reoperation, death and length of hospital stay after laryngectomy. To explore the risks of neck dissection with laryngectomy using outcomes.MethodsThe American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database was reviewed retrospectively. The database was analyzed for patients undergoing laryngectomy with and without neck dissection. Demographic, perioperative complication, reoperation, readmission, and death variables were analyzed.Results754 patients who underwent total laryngectomy during this time were found. Demographic analysis showed average age was 63 years old, 566 (75.1%) were white, and 598 (79.3%) were male. Of these patients, 520 (69.0%) included a neck dissection while 234 (31.0%) did not. When comparing patients who received a neck dissection to those who did not, there were no significant differences in median length of hospital stay (12.5 days w/vs. 13.3 days w/o, P = 0.99), rates of complication (40% w/vs. 35% w/o, P = 0.23), reoperation (13.5% w/vs. 14% w/o, P = 0.81), readmission (14% w/vs. 18% w/o, P = 0.27), and death (1.3% w/vs. 1.3% w/o, P > 0.99). Furthermore, neck dissection did not increase the risk of complication (P = 0.23), readmission (P = 0.27), reoperation (P = 0.81), death (P = 0.94), or lengthened hospital stay (P = 0.38).ConclusionsConcurrent neck dissection does not increase postoperative morbidity or mortality in patients undergoing total laryngectomies. These results may help physicians make decisions regarding concurrent neck dissection with total laryngectomy.

Prophylactic antibiotic bundle compliance and surgical site infections: an artificial neural network analysis

BackgroundBest practice “bundles” have been developed to lower the occurrence rate of surgical site infections (SSI’s). We developed artificial neural network (ANN) models to predict SSI occurrence based on prophylactic antibiotic compliance.MethodsUsing the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) Tampa General Hospital patient dataset for a six-month period, 780 surgical procedures were reviewed for compliance with SSI guidelines for antibiotic type and timing. SSI rates were determined for patients in the compliant and non-compliant groups. ANN training and validation models were developed to include the variables of age, sex, steroid use, bleeding disorders, transfusion, white blood cell count, hematocrit level, platelet count, wound class, ASA class, and surgical antimicrobial prophylaxis (SAP) bundle compliance.ResultsOverall compliance to recommended antibiotic type and timing was 92.0%. Antibiotic bundle compliance had a lower incidence of SSI’s (3.3%) compared to the non-compliant group (8.1%, p = 0.07). ANN models predicted SSI with a 69–90% sensitivity and 50–60% specificity. The model was more sensitive when bundle compliance was not used in the model, but more specific when it was. Preoperative white blood cell (WBC) count had the most influence on the model.ConclusionsSAP bundle compliance was associated with a lower incidence of SSI’s. In an ANN model, inclusion of the SAP bundle compliance reduced sensitivity, but increased specificity of the prediction model. Preoperative WBC count had the most influence on the model.

International Validation of Reduced Major Morbidity After Minimally Invasive Distal Pancreatectomy Compared With Open Pancreatectomy.

To quantify the nationwide impact of minimally invasive distal pancreatectomy (MIDP) on major morbidity as compared with open distal pancreatectomy (ODP). A recent randomized controlled trial (RCT) demonstrated significant reduction in time to functional recovery after MIDP compared with ODP, but was not powered to assess potential risk reductions in major morbidity. International cohort study using the American College of Surgeons' National Quality Improvement Program (ACS-NSQIP) (88 centers; 2014-2016) to evaluate the association between surgical approach (MIDP vs ODP) and 30-day composite major morbidity (CMM; death or severe complications) with external model validation using Dutch Pancreatic Cancer Group data (17 centers; 2005-2016). Multivariable logistic regression assessed the impact of nationwide MIDP rates between 0% and 100% on postoperative CMM at conversion rates between 0% and 25%, using estimated marginal effects. A sensitivity analysis tested the impact at various scenarios and patient populations. Of 2921 ACS-NSQIP patients, 1562 (53%) underwent MIDP with 18% conversion, and 1359 (47%) underwent ODP. MIDP was independently associated with reduced CMM [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.42-0.60, P < 0.001], confirmed by external model validation (n = 637, P < 0.003). The association between rising MIDP implementation rates and falling postoperative morbidity was linear between 0% (all ODP) and 100% (all MIDP). The absolute risk reduction for CMM was 11% (95% CI 7.3%-15%) at observed conversion rates and improved to 14% (95% CI 11%-18%) as conversion approached 0%. Similar effects were seen across subgroups. This international study predicted a nationwide 11% risk reduction for CMM after MIDP versus ODP, which is likely to improve as conversion rates decrease. These findings confirm secondary outcomes of the recent LEOPARD RCT.

The Practice of Overlapping Colorectal Operations in a Tertiary Care Center Is Safe

Determine the safety of overlapping surgery in a tertiary care colorectal surgery practice. Although overlapping surgery is common in academic centers, reports on outcomes of this practice are limited. The primary aim of this study was to investigate the safety of overlapping surgery in a dedicated tertiary care academic colorectal practice by comparing groups of patients who did or did not have their surgery performed in an overlapping fashion. Retrospective review of 1270 colorectal patients undergoing inpatient colorectal surgery at our institution. Eligible participants were all patients undergoing elective inpatient colorectal surgery by one of the colorectal surgeons at the Mayo Clinic Rochester between January 1, 2012 and December 31, 2015. Patients under the age of 18 or who underwent an emergent procedure were excluded. Data were abstracted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. Additionally, each subject's chart was reviewed and further abstracted. The safety of overlapping surgery on outcomes was assessed using multiple multivariable models. One thousand two hundred seventy patients were included in the study cohort of whom 50.7% were female and the average age was 55.4 years. Overlapping surgery occurred in 576 patients (45%). There were no significant differences in demographic, surgical indications, procedures, or operative complexity between patients undergoing overlapping surgery and those who did not. Overall adverse events were significantly less likely in patients undergoing overlapping surgery compared with those who did not (18.4% vs 23.6%, P = 0.02). We found that overlapping surgery was associated with significantly less adverse events compared with patients not undergoing overlapping surgery using a model that controlled for the effect of the individual surgeon (OR 0.7, 95% CI 0.6 - 0.96; P = .02) and a multivariable propensity score (OR 0.7, 95% CI 0.5- 0.9; P = 01). Overlapping surgery in a tertiary care colorectal practice is safe and not associated with adverse patient outcomes.

Increased Length of Hospital Stay after Endovascular Abdominal Aortic Aneurysm Repair: Role of Pulmonary Complications.

ObjectivesThe average hospital length of stay plays a significant role in healthcare costs, and is also used as a metric of hospital efficiency. An advantage of endovascular abdominal aortic aneurysm repair (EVAR) is the shorter postoperative time period after the surgery. The purpose of this study is to review the factors associated with increased length of stay after EVAR.MethodsThe records from American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database in 2013 were obtained using Procedure Participant User File. Pre-, intra-, and post-operative factors were assessed of patients undergoing EVAR in 2013. Multivariable logistic regression analysis was used to identify independent variables for a hospital length of stay of at least seven days.ResultsA total of 1,991 patients (18.7% female, 81.3% males) underwent EVAR in 2013. Among these patients, 223 (11.2%) had a hospital stay greater than seven days. Variables significantly associated with length of stay in a multivariable model included: total operation time greater than 180 minutes (vs. less than 90 minutes, OR 1.88, CI 1.03-3.41, p = 0.039), postoperative, and intraoperative transfusions (OR 2.60, CI 1.66-4.08, p < 0.001), return to operating room (OR 2.88, CI 1.55-5.38, p < 0.001), rupture indication for surgery (OR 5.59, CI 3.18-9.83, p < 0.001), myocardial infarction (OR 5.85, CI 2.22-15.43, p < 0.001), preoperative transfusion (OR 13.05, CI 4.26-39.99, p < 0.001), and on ventilator greater than 48 hours (OR 49.65, CI 10.72-230.07, p < 0.001).ConclusionsMultiple factors affect length of hospital stay in patients who have undergone EVAR. Patients with postoperative respiratory failure after EVAR have a significantly higher risk for longer hospital stays.

Nationwide Evaluation of Patient Selection for Minimally Invasive Distal Pancreatectomy Using American College of Surgeons' National Quality Improvement Program.

To assess current nationwide case selection factors for minimally invasive distal pancreatectomy (MIDP) and identify actual risk factors for adverse outcomes compared with open distal pancreatectomy (ODP). Patient selection criteria that predict outcomes after MIDP remain unknown. As a result, widespread adoption of this surgical technique may have been delayed and its potential benefits possibly under-exploited. Retrospective cohort study of elective ODP and MIDP performed at 106 centers in 2014, using the pancreas-targeted American College of Surgeons' National Quality Improvement Program (ACS-NSQIP) database. Exclusion criteria were neoadjuvant treatment or pancreatitis as only diagnosis. Primary outcome includes a composite major morbidity metric, reflecting adverse events including mortality and reoperation. Multivariable modeling was used to detect current selection factors and to identify actual risk factors of composite major morbidity. A total of 928 patients underwent ODP (n = 472) or MIDP (n = 456) using a laparoscopic or robot-assisted approach, 24% for pancreatic ductal adenocarcinoma (PDAC). Current selection factors for MIDP were benign disease (odds ratio: OR: 1.56, CI: 1.10-2.21) and body mass index (BMI) 30-40 (OR: 1.41, CI: 1.04-1.91). Current selection factors for ODP were PDAC (OR: 0.45, CI: 0.31-0.64), benign tumor size >5 centimeters (OR: 0.40, CI: 0.23-0.67), and multivisceral procedures (OR: 0.39, CI: 0.26-0.59). Risk factors for composite major morbidity did not differ between ODP and MIDP. A trend was observed between MIDP and a lower risk of composite major morbidity compared with ODP (OR: 0.43, CI: 0.17-1.07). Current selection factors for ODP or MIDP (benign disease, tumor size, and BMI) do not mitigate the risk of major morbidity. We found no evidence that MIDP should be avoided based on tumor etiology or size, BMI, or patient physical status.

Predictors of length of stay, reoperation, and readmission following total laryngectomy.

To identify relevant patient and surgical risk factors associated with prolonged length of stay, return to the operating room, and readmission within 30 days following total laryngectomy using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) STUDY DESIGN: Retrospective database study. Patients undergoing total laryngectomy alone for laryngeal cancer were identified from the ACS-NSQIP database from 2005 to 2014. Multivariate logistic regression was used to identify independent predictors for prolonged length of stay, readmissions, and unplanned reoperations within 30 days. Among 871 patients meeting inclusion and exclusion criteria, the median length of stay was 8.0 days (range, 0-130 days). Totally dependent functional status (P < .01; odds ratio [OR]: 32.62), Black or African American race (P = .029; OR: 1.75), and operative time (P < .0001; OR: 1.15) were associated with prolonged length of stay. The overall rate of return to the operating room within 30 days was 12.4%. Contaminated wound status (P = .025; OR: 3.53), operative time (P = .015; OR: 1.10), steroid use (P < .01; OR: 2.92), and smoking (P = .05; OR: 1.60) were significantly associated with return to the operating room. Unplanned readmission rate was 11.9%, and 47.37% of readmissions were due to wound infection/pharyngocutaneous fistula. Dirty/contaminated wound classification (P = .05; OR: 22.5) was associated with readmission on multivariate analysis. This is the first population-level analysis to be performed on length of stay, readmission, and reoperation for total laryngectomy. Assessing and identifying modifiable risk factors on quality metrics may reduce overall cost and the burden on limited hospital resources. 4. Laryngoscope, 127:1339-1344, 2017.

Wound dehiscence in a sample of 1776 cystectomies: identification of predictors and implications for outcomes.

To investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy (RC). In all, 1776 patient records with Current Procedural Terminology (CPT) codes for radical cystectomy (RC) were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. Stratification was made based on the occurrence of postoperative wound dehiscence, defined as loss of integrity of fascial closure. Descriptive and logistic regression models were used to identify predictors of postoperative wound dehiscence. The implications of wound dehiscence on peri- and postoperative outcomes such as complications, mortality, prolonged length of stay (>11days), and prolonged operative time (>411min), were assessed. Of 1776 patients analysed, 57 (3.2%) had a documented wound dehiscence. In multivariable analyses, chronic obstructive pulmonary disease (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.0-4.0; P = 0.03) and high body mass index (OR 2.3, 95% CI 1.3-4.4; P = 0.008) were significant predictors of wound dehiscence. While female gender had significantly lowerproportions of wound dehiscence, multivariable analyses did notconfirm this (OR 0.4, 95% CI 0.4-1.4; P = 0.75). Our study is the first to identify predictors of wound dehiscence after RC in a large, contemporary multi-institutional cohort. Identifying patients at risk of postoperative wound complications may guide the use of preventative measures at the time of surgery.

MP67-09 PREDICTORS OF WOUND DEHISCENCE IN A PROSPECTIVE DATASET OF 2,556 CYSTECTOMIES

You have accessJournal of UrologyBladder Cancer: Invasive IV1 Apr 2015MP67-09 PREDICTORS OF WOUND DEHISCENCE IN A PROSPECTIVE DATASET OF 2,556 CYSTECTOMIES Christian Meyer, Julian Hanske, Deepansh Dalela, Daniel Pucheril, Marianne Schmid, Jesse Sammon, Mani Menon, Felix Chun, Joachim Noldus, Margit Fisch, and Quoc-Dien Trinh Christian MeyerChristian Meyer More articles by this author , Julian HanskeJulian Hanske More articles by this author , Deepansh DalelaDeepansh Dalela More articles by this author , Daniel PucherilDaniel Pucheril More articles by this author , Marianne SchmidMarianne Schmid More articles by this author , Jesse SammonJesse Sammon More articles by this author , Mani MenonMani Menon More articles by this author , Felix ChunFelix Chun More articles by this author , Joachim NoldusJoachim Noldus More articles by this author , Margit FischMargit Fisch More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2492AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Wound dehiscence is major complication following radical cystectomy. It is a significant cause of readmission, reopearation and potentially delays lifesaving adjuvant therapies. We sought to investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy. METHODS 2556 patient records with Current Procedural Terminology (CPT) codes for cystectomy between 2005 and 2012 were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP). Stratification was made on the basis of the occurrence of postoperative wound dehiscence. This was defined as full disintegrity of the skin and fascial layer. Outcomes of interest included overall complication, mortality, prolonged length of stay and prolonged operative time, the latter two defined as measures above the 75th percentile. Descriptive and logistic regression models were performed to identify predictors of postoperative wound dehiscence. RESULTS Of 2556 patients analyzed, 74 (2.9%) had a documented wound dehiscence. In multivariable analyses, smoking (OR 2.2 p=.002), prolonged operative time (OR 1.6;p=0.05) and BMI were associated with increased odds of postoperative wound dehiscences. Female gender was associated with decreased odds of dehiscence (OR 0.4; p=0.022). Elevated preoperative creatinine (>1.2 mg/dl), chronic steroid use and diabetes were not independent predictors. CONCLUSIONS Our study is the first to identify predictors of wound dehiscence following radical cystectomy in a large multi-institutional prospective cohort. Identifying patients at risk for postoperative wound complications may guide the use preventative measures at the time of surgery. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e853 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Meyer More articles by this author Julian Hanske More articles by this author Deepansh Dalela More articles by this author Daniel Pucheril More articles by this author Marianne Schmid More articles by this author Jesse Sammon More articles by this author Mani Menon More articles by this author Felix Chun More articles by this author Joachim Noldus More articles by this author Margit Fisch More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...