American College Of Surgeons National Surgical Quality Improvement Program Data Research Articles

A comparison of the national surgical quality improvement program and the society of thoracic surgery cardiac surgery preoperative risk models: A cohort study.

Cardiac surgery prediction models and outcomes from the ACS-NSQIP have not been reported. We sought to develop preoperative prediction models and estimates of postoperative outcomes for cardiac surgery using the ACS-NSQIP and compare these to the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD). In a retrospective analysis of the ACS-NSQIP data (2007-2018), cardiac operations were identified using cardiac surgeon primary specialty and sorted into cohorts of coronary artery bypass grafting (CABG) only, valve surgery only, and valve+CABG operations using CPT codes. Prediction models were created using backward selection of the 28 nonlaboratory preoperative variables in ACS-NSQIP. Rates of 9 postoperative outcomes and performance statistics of these models were compared to published STS 2018 data. Of 28,912 cardiac surgery patients, 18,139 (62.8%) were CABG only, 7,872 (27.2%) were valve only, and 2,901 (10.0%) were valve+CABG. Most outcome rates were similar between the ACS-NSQIP and STS-ACSD, except for lower rates of prolonged ventilation and composite morbidity and higher reoperation rates in ACS-NSQIP (all P<0.0001). For all 27 comparisons (9 outcomes x 3 operation groups), the c-indices for the ACS-NSQIP models were lower by an average of ~0.05 than the reported STS models. The ACS-NSQIP preoperative risk models for cardiac surgery were almost as accurate as the STS-ACSD models. Slight differences in c-indexes could be due to more predictor variables in STS-ACSD models or the use of more disease- and operation-specific risk variables in the STS-ACSD models.

PD02-06 EFFECT OF RESIDENT INVOLVEMENT IN UROLOGICAL SURGERY ON SHORT-TERM PATIENT OUTCOMES: A META-ANALYSIS AND SYSTEMATIC REVIEW

You have accessJournal of UrologyEducation Research I (PD02)1 Sep 2021PD02-06 EFFECT OF RESIDENT INVOLVEMENT IN UROLOGICAL SURGERY ON SHORT-TERM PATIENT OUTCOMES: A META-ANALYSIS AND SYSTEMATIC REVIEW Nazia Hossain, Hussien Mohamed, and Avi-Chai Robinson Nazia HossainNazia Hossain More articles by this author , Hussien MohamedHussien Mohamed More articles by this author , and Avi-Chai RobinsonAvi-Chai Robinson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001966.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The effect on patient outcomes with and without resident involvement in urological surgery remains controversial. This study aims to systematically determine the effect of resident involvement on patient outcomes in urological surgery. METHODS: This paper followed the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers searched PubMed, Embase, and the Cochrane Library to find studies assessing the impact of resident involvement on patient outcomes in urology cases. Eight patient variables were compared between cohorts to investigate participant similarity. Fifteen outcome variables potentially impacted by resident involvement were compared via meta-analysis. Study quality was assessed using the Newcastle-Ottawa Scale for cohort analysis and given a quality label based on Agency for Healthcare Research and Quality standards. Several papers relied on data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), which reports 30-day patient outcomes. Sensitivity analysis was done to assess for patient overlap between papers that used ACS-NSQIP data. RESULTS: Fifteen studies were included in the meta-analysis, comprising a total of 95,326 patients. The resident-involved group had an overall lower amount of patients with diabetes (odds ratio [OR], 0.84; [95% CI], [0.74, 0.94]), hypertension ([OR], 0.84; [95% CI], [0.82, 0.87]) and smoking ([OR], 0.81; [95% CI], [0.76, 0.86]). Residents were also less involved in operations where patients had a Class 3 or 4 American Society of Anesthesiologists (ASA) scores ([OR], 0.96; [95% CI], [0.93, 1.00]). However, the resident-involved group had more negative post-operative outcomes. The resident-involved surgery group had higher rates of postoperative septic ([OR], 1.37; [95% CI], [1.16, 1.62]) and deep vein thrombosis (DVT) ([OR], 1.36; [95% CI], [1.07, 1.74]). The resident group also had longer operative times when results were reported dichotomously ([OR], 1.78; [95% CI], [1.64, 1.93]). CONCLUSIONS: Based on the results, resident involvement in urological surgery seems to have a negative effect on patient outcomes, specifically increased rates of septic shock, DVT and longer operative time despite resident involvement in cases with healthier patients. However, the data is limited due to the lack of high-quality, propensity-scored studies. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e39-e39 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nazia Hossain More articles by this author Hussien Mohamed More articles by this author Avi-Chai Robinson More articles by this author Expand All Advertisement Loading ...

Laparoscopic Versus Robotic Proctectomy Outcomes: An ACS-NSQIP Analysis

BackgroundThe robotic platform is increasingly used in colorectal surgery. Recent upgrades in the robotic platform and introduction of proctectomy-specific reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) warrant updated evaluation of minimally invasive proctectomy outcomes. The aim of this study was to compare outcomes in robotic versus laparoscopic proctectomy using ACS-NSQIP data. Materials and methodsThe ACS-NSQIP data set was used to identify adult patients undergoing elective robotic and laparoscopic proctectomy in 2016 and 2017. Demographics, preoperative and intraoperative data, and postoperative outcomes were collected. Propensity-weighted analysis was used to estimate the effect of robotic versus laparoscopic surgery on outcomes. ResultsOf 3845 patients meeting inclusion criteria, 2681 (70%) underwent a laparoscopic approach and 1164 (30%) underwent a robotic approach. Patients undergoing a robotic procedure were more likely to be older, have higher American Society of Anesthesiologists scores, low rectal tumors, and have undergone chemotherapy or radiation before surgery. After propensity adjustment, a robotic approach was associated with a decrease in conversion to open operation (estimated mean difference, −6.7%; P < 0.01), length of stay (−0.6 d; P = 0.01), occurrence of postoperative ileus (−3.7%; P = 0.01), and an increase in operative time (20.3 min; P < 0.01). ConclusionsUsing data from a national cohort, we found that compared with laparoscopy, robotic proctectomy is associated with decreased conversion to open operation, longer operation time, decreased length of stay, and decreased postoperative ileus. Our study identified several advantages to a robotic approach; however, further work is needed to assess cost-effectiveness in conjunction with clinical outcomes.

Reduced post-operative urinary tract infection using the National Surgical Quality Improvement Program.

The incidence of post-operative urinary tract infection (UTI) is frequently unknown or underestimated. Failure to recognize a clinical problem results in no action occurring to improve outcomes. The aims of this study were firstly to define the incidence of post-operative UTI in general surgery patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Secondly to design and implement an intervention to reduce the incidence of post-operative UTI and assess the extent of improvement. ACS-NSQIP data were collected and analysed from June 2015 to June 2016 and reported in the Semi Annual Report (SAR). A quality improvement programme was designed and implemented to manage the high incidence of UTI. The outcomes were assessed by the subsequent ACS-NSQIP SAR. The SAR in 2016 reported that Nepean Hospital as a significant outlier with an incidence of post-operative UTI of 3.62% (odds ratio 2.21, confidence limits 1.51-3.44, P < 0.001). A hospital-wide policy for catheter insertion in surgical patients was developed including: education, workshops, accreditation for aseptic technique for catheter insertion, reduced rates of insertion, reduced duration of use and improved catheter care. There was a significant improvement in the incidence of UTI (1.21%) reported by the 2018 SAR (odds ratio 1.01, confidence limits 0.64-1.60, P = 0.68). ACS-NSQIP identified a 2.2-fold increased risk of post-operative UTI. There was no increased risk of UTI after the programme to reduce UTI was introduced.

Management of Degenerative Spondylolisthesis: Analysis of a Questionnaire Study, Correlation With a National Sample, and Perioperative Outcomes of Treatment Options.

Surgical treatment for lumbar degenerative spondylolisthesis has been shown to provide better long-term outcomes than conservative treatment. However, there is variation in surgical approaches employed by surgeons. This study investigates current surgical practice patterns and compares perioperative outcomes of 3 common surgical treatments for this pathology. A survey was administered to surgeons who attended the Lumbar Spine Research Society (LSRS) meeting in 2014. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2005 to 2014 to characterize the same responses. The 2 data sets were compared. Perioperative outcomes of those in the ACS-NSQIP posterior fusion subcohorts were characterized and compared. Posterior surgical approaches utilized by surgeons who responded to the LSRS survey were similar to those captured by ACS-NSQIP where 72% of those with degenerative spondylolisthesis were fused. Of those that were fused, 8% had an uninstrumented posterior fusion, 33% had an instrumented posterior fusion, and 59% had an instrumented posterior fusion with interbody. On multivariate analysis, there was no difference in risk of postoperative adverse events, readmission, or length of stay between these 3 common types of fusion. Practice patterns for the posterior management of lumbar degenerative spondylolisthesis were similar between LSRS survey responses and ACS-NSQIP data. The ACS-NSQIP perioperative outcome measures assessed were similar regardless of surgical technique. These findings highlight that cost-benefit considerations and longer-term outcomes have to be the measures by which surgical technique is chosen for degenerative spondylolisthesis.

Trends and Perioperative Outcomes Across Major Benign Prostatic Hyperplasia Procedures from the ACS-NSQIP 2011-2015.

There are currently several different surgical options for patients with benign prostatic hyperplasia (BPH). The literature has demonstrated equivalent or superior results for holmium laser enucleation of prostate (HoLEP) but with exceptional long-term durability compared to other minimally invasive options. Despite this, HoLEP is not widely practiced. Herein, we investigate trends and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to support a need for further adoption of HoLEP. Using ACS-NSQIP data from 2011 to 2015, trends, baseline characteristics, and perioperative outcomes were collected for major BPH procedures: transurethral resection of prostate (TURP), TURP for regrowth, photovaporization of prostate (PVP), HoLEP, and simple prostatectomy. The most common procedure performed every year was TURP with PVP performed about half as often, while HoLEP (4%-5%) was performed about as infrequently as simple prostatectomy (3%). More African American men underwent simple prostatectomy except in 2011. International normalized ratio (INR) was highest every year for PVP. Hospital stay and transfusion rates were lowest with PVP and HoLEP. Transfusion rates for simple prostatectomy were high (16.0%-25.4%). Lower rates of readmission, reoperation, and urinary tract infection were seen in some years with HoLEP. Given the previously reported favorable outcomes and long-term durability of HoLEP, these ACS-NSQIP data further support that HoLEP should be more often practiced for patients undergoing surgery for BPH.

Preoperative steroids do not improve outcomes for intramedullary spinal tumors: a NSQIP analysis of 30-day reoperation and readmission rates.

Intramedullary spinal cord tumors (IMSCTs) account for 8-10% of all spinal cord tumors and affect patients of all ages. Although uncommon, IMSCTs carry risk of neurological morbidity and mortality, with 5-year survival rates ranging from 50% to 80%. In this study, we utilize the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine the effect of steroid administration on 30-day outcomes following surgery for IMSCTs. ACS-NSQIP data for patients undergoing surgery for intramedullary tumors from 2005 to 2015 was reviewed. Patients were selected based on current procedural terminology (CPT) codes 63285 (Laminectomy, intradural, intramedullary, cervical), 63286 (Laminectomy, intradural, intramedullary, thoracic), and 63287 (Laminectomy, intradural, intramedullary, thoracolumbar). ICD-9 and ICD-10 codes were chosen based on the diagnosis of a tumor. The 30-day clinical outcome data, including reoperations and readmission rates, were collected and compared. A total of 259 patients were reviewed. One hundred eighty-one patients had benign intramedullary tumors and 78 had malignant intramedullary tumors. The majority of IMSCTs were at the thoracic level (n=100), followed by the cervical (n=99), and thoracolumbar (n=39) levels. Thirty-one patients were on corticosteroid therapy prior to surgery. Patients with preoperative steroid administration had no significant difference in reoperation and readmission rates. No significant differences were noted between steroid vs. non-steroid therapy for discharge destination, length of hospital stay, or other postoperative complications. Contrary to previous reports, corticosteroid use prior to surgery for IMSCTs does not have a significant impact on 30-day risk of readmission, reoperation, and risk of postoperative complications.

Factors associated with an increased risk of perioperative cardiac arrest in emergent and elective craniotomy and spine surgery

ObjectiveCardiac arrest following neurosurgery is a devastating complication associated with significant postoperative morbidity and mortality. There are no published studies that have used a large and robust multicenter database to specifically examine demographic and surgical risk factors associated with cardiac arrests following craniotomy and spine surgeries, respectively. Patients and methodsWe retrospectively analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the period between January 1, 2007 and December 31, 2013, focusing on cardiac arrest associated with craniotomy and spine surgery from the intraoperative period to 30days after surgery. A total of 73,584 neurosurgical patients were analyzed (59,609 spine surgeries and 13,975 craniotomies). ResultsThere was an increased risk of cardiac arrest for both craniotomy and spine surgeries in patients with American Society of Anesthesiologists (ASA) Physical Status class 4 or 5, Black and Asian patients compared to White patients and patients totally dependent versus independent based on the ACS-NSQIP risk calculator. The risk of cardiac arrest for craniotomy was 66.5 per 10,000 anesthetics and for spine surgery was 21.3 per 10,000 anesthetics. Cardiac arrest associated with emergent non-traumatic craniotomy was 36.5% and with emergent non-traumatic spine surgery was only 17.3%. We found that 18% of cardiac arrests for craniotomy and 25% of cardiac arrests for spine surgery occurred from the intraoperative period through postoperative day (POD) 0. Both craniotomy and spine surgery patients who had a cardiac arrest were more likely to have acute kidney injury (AKI), failure to wean from the ventilator, postoperative dialysis, myocardial infarction (MI), venous thromboembolism (VTE) and sepsis in the postoperative period. The overall mortality rate for both craniotomy and spine surgeries who had a cardiac arrest from the intraoperative period to 30days postoperative was 61.8% versus 1.2% in the no cardiac arrest control group. ConclusionsIdentification of patient and surgery specific characteristics from ACS-NSQIP data associated with cardiac arrest following craniotomy and spine surgery may lead to initiatives to reduce morbidity and mortality in the neurosurgical patient population.

Analysis of the impact of pre-operative biliary drainage and intraoperative drain placement on outcomes after pancreaticoduodenectomy using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

Objective: We analyzed the outcomes of patients who had preoperative biliary drainage and/or intraoperative drains placed during pancreaticoduodenectomy compared to their non-intervention controls using ACS-NSQIP data. Methods: Retrospective review of 2014 NSQIP data was performed on patients undergoing pancreaticoduodenectomy. Demographic characteristics, length of stay, operative time, and 30-day postoperative complications were compared between study groups. Results: Patients without preoperative biliary drainage [1406/2968 (47%)] had more pancreatic fistulas (20.6% vs 15.9%, p=0.001), less SSI (6.5% vs 12.5%, p<0.001), less wound disruption (1.2% vs 2.2%, p=0.043), more pulmonary embolus (1.7% vs 0.6%, p=0.006), less transfusion requirement (18.1% vs 24.6%, p<0.001), less postoperative sepsis (7.5% vs 11.5%, p<0.001), shorter operative time (370 min vs 380 min, p=0.029) and decreased overall morbidity (53.6% vs 59.9%, p=0.001) compared to controls. Patients who did not have a drain placed at surgery (ND) [393/3108 (13%)] had less pancreatic fistulas (9.2% vs 19.5%, p<0.001), less transfusion requirements (15.4% vs 22.2%, p<0.001), more pneumonia (8.7% vs 4.1%, p<0.001), more post-operative shock (5.6% vs 3.5%, p=0.037), shorter LOS (9.7 d vs 11.3 d, p=0.003), shorter operative time (361 min vs 377 min, p=0.024) and decreased overall morbidity (47.6% vs 58.2%, p<0.001) compared to controls. Multivariate analysis revealed intraoperative drain placement (OR 2.03, p<0.001) and preoperative biliary drainage (OR 1.35, p=0.002) as independent predictors of overall morbidity. Conclusion: In this retrospective review of ACS-NSQIP data, both preoperative biliary drainage and intraoperative drainage of anastomoses in pancreaticoduodenectomies were independent predictors of overall morbidity.

Detection of clinically important colorectal surgical site infection using Bayesian network

BackgroundDespite extensive efforts to monitor and prevent surgical site infections (SSIs), real-time surveillance of clinical practice has been sparse and expensive or nonexistent. However, natural language processing (NLP) and machine learning (i.e., Bayesian network analysis) may provide the methodology necessary to approach this issue in a new way. We investigated the ability to identify SSIs after colorectal surgery (CRS) through an automated detection system using a Bayesian network. Materials and methodsPatients who underwent CRS from 2010 to 2012 and were captured in our institutional American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) comprised our cohort. A Bayesian network was applied to detect SSIs using risk factors from ACS-NSQIP data and keywords extracted from clinical notes by NLP. Two surgeons provided expertise informing the Bayesian network to identify clinically meaningful SSIs (CM-SSIs) occurring within 30 d after surgery. ResultsWe used data from 751 CRS cases experiencing 67 (8.9%) SSIs and 78 (10.4%) CM-SSIs. Our Bayesian network detected ACS-NSQIP-captured SSIs with a receiver operating characteristic area under the curve of 0.827, but this value increased to 0.892 when using surgeon-identified CM-SSIs. ConclusionsA Bayesian network coupled with NLP has the potential to be used in real-time SSI surveillance. Moreover, surgeons identified CM-SSI not captured under current NSQIP definitions. Future efforts to expand CM-SSI identification may lead to improved and potentially automated approaches to survey for postoperative SSI in clinical practice.

American College of Surgeons National Surgical Quality Improvement Program as a quality-measurement tool for advanced cancer patients.

Multiple studies have shown the significantly increased post-operative morbidity and mortality of patients undergoing palliative operations. It has been proposed by some authors that the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database can be used reliably to develop risk-calculators or as an aid for clinical decision-making in advanced cancer patients. ACS-NSQIP is a population-based database that by design only captures outcomes data for the first 30-day following an operation. We considered the suitability of these data as a tool for decision-making in the advanced cancer patient. Six-year retrospective review of a single institution's ACS-NSQIP database for cases identified as "Disseminated Cancer". Procedures performed with palliative intent were identified and analyzed. Of 7,763 patients within the ACS-NSQIP database, 138 (1.8%) were identified as having "Disseminated Cancer". Of the remaining 7,625 entries only 4,486 contained complete survival data for analysis. Thirty-day mortality within the "Disseminated Cancer" group was higher when compared to all other surgical patients (7.9% vs. 0.9%, P<0.001). Explicit chart review of these 138 patients revealed that 32 (23.2%) had undergone operations with palliative intent. Overall survival for palliative and non-palliative operations was significantly different (104 vs. 709 days, P<0.001). When comparing palliative to non-palliative procedures using ACS-NSQIP data, we were unable to detect a difference in 30-day mortality (9.4% vs. 7.5%, P=0.72). Calculations utilizing ACS-NSQIP data fail to demonstrate the increased mortality associated with palliative operations. Patients diagnosed with advanced cancer are not adequately represented within the database due to the limited number of cases collected. Also, more suitable outcomes measures for palliative operations such as pain relief, functional status, and quality of life, are not captured. Therefore, the sole use of thirty-day morbidity and mortality data contained in the ACS-NSQIP database is insufficient to make sound decisions for surgical palliation.

Measuring risk-adjusted value using Medicare and ACS-NSQIP: is high-quality, low-cost surgical care achievable everywhere?

To evaluate the relationship between risk-adjusted cost and quality for colectomy procedures and to identify characteristics of "high value" hospitals (high quality, low cost). Policymakers are currently focused on rewarding high-value health care. Hospitals will increasingly be held accountable for both quality and cost. Records (2005-2008) for all patients undergoing colectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Cost was derived from hospital payments by Medicare. Quality was derived from the occurrence of 30-day postoperative major complications and/or death as recorded in ACS-NSQIP. Risk-adjusted cost and quality metrics were developed using hierarchical multivariable modeling, consistent with a National Quality Forum-endorsed colectomy measure. The study population included 14,745 colectomy patients in 169 hospitals. Average hospitalization cost was $21,350 (SD $20,773, median $16,092, interquartile range $14,341-$24,598). Thirty-four percent of patients had a postoperative complication and/or death. Higher hospital quality was significantly correlated with lower cost (correlation coefficient 0.38, P < 0.001). Among hospitals classified as high quality, 52% were found to be low cost (representing highest value hospitals) whereas 14% were high cost (P = 0.001). Forty-one percent of low-quality hospitals were high cost. Highest "value" hospitals represented a mix of teaching/nonteaching affiliation, small/large bed sizes, and regional locations. Using national ACS-NSQIP and Medicare data, this study reports an association between higher quality and lower cost surgical care. These results suggest that high-value surgical care is being delivered in a wide spectrum of hospitals and hospital types.

Safety of one-step conversion of gastric band to sleeve: a comparative analysis of ACS-NSQIP data

BackgroundThe conversion rate of laparoscopic adjustable gastric banding (LAGB) to laparoscopic sleeve gastrectomy (LSG) has increased during recent years. The safety profile of one-step conversion of LAGB to LSG is not clear from the current literature. MethodsUsing the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), morbidly obese patients undergoing primary LSG and conversion of LAGB to LSG in one-step between 2010 and 2012 were identified. Perioperative outcomes (including 30-day composite rate comprised of 18 postoperative adverse events) were compared between groups using a univariate cross-sectional analysis. ResultsData of 11,320 patients (10,997 primary LSG and 323 LAGB to LSG) were analyzed. The LAGB-to-LSG group had better preoperative health status, including significantly lower body mass index, American Society of Anesthesiologists scores, and prevalence of diabetes and hypertension. Operative time for the LAGB–to-LSG group (130.0±53.7 min) was significantly longer than primary LSG group (98.5±42.8 min, P<.001). The 30-day composite adverse event rate was 6.8% in the LAGB-to-LSG group and 5.4% in the primary LSG group (P = .29). The rate of minor complications, including urinary tract infection and wound infection were significantly higher in the revisional surgery group. Thirty-day rates of other postoperative complications, reoperation, readmission, mortality, and length of hospital stay were comparable between the 2 groups. ConclusionsThis national data suggests that conversion of LAGB to LSG in a single stage has comparable safety to primary LSG. In this study, improved preoperative health status of patients in the revisional group may serve as an equalizer with regards to postoperative outcomes of conversion to LSG.

Limitations of ACS‐NSQIP in Reporting Complications for Patients Undergoing Pancreatectomy: Underscoring the Need for a Pancreas‐Specific Module

Large centralized databases are used with increasing frequency for reporting hospital-specific and nationwide trends and outcomes after various surgical procedures in order to improve quality of surgical care. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) is a risk-adjusted, case-weighted complication tracking initiative that reports 30-day outcomes from more than 400 academic and community institutions in the US. However, the accuracy of event reporting specific to pancreatic surgery has never been examined in depth. We retrospectively reviewed medical records of patients, the information on whose postoperative course was originally reported through ACS-NSQIP between 2006 and 2010. Preoperative characteristics, operative data, and postoperative events were recorded after review of electronic medical records including physician and nursing notes, operative room records and anesthesiologist reports. Fidelity of reported clinical events was assessed. Accuracy, sensitivity, and specificity were calculated for each variable of interest. Two hundred and forty-nine pancreatectomies were reviewed, including 145 (58.2 %) Whipple procedures, 19 (7.6 %) total pancreatectomies, 65 (26.1 %) distal pancreatectomies, and 15 (6.0 %) central or partial resections. Median age was 65.7, males comprised 41.5 % of the group, and 74.3 % of patients were Caucasian. The overall rate of complications reported by NSQIP was 44.0 %, compared with 45.0 % in our review, however discordance was observed in 27.3 % of the time, including 34 cases of reporting a complication where there was not one, and 34 cases of missed complication. The most frequently reported event was postoperative bleeding requiring transfusion, however this was also the event most commonly misclassified. Additionally, three procedures unrelated to the index operation were recorded as reoperation events. While a pancreas-specific module does not yet exist, ACS-NSQIP reports a 7.6 % rate of organ-space surgical site infections; when compared with our institutional rate of Grades B and C postoperative fistula (10.4 %), we observed discordance 4.4 % of the time. Delayed gastric emptying, a common post-pancreatectomy morbidity, was not captured at all. Additionally, there were significant inaccuracies in reporting urinary tract infections, postoperative pneumonia, wound complications, and postoperative sepsis, with discordance rates of 4.4, 3.2, 3.6, and 6.8 %, respectively. ACS-NSQIP data are an important and valuable tool for evaluating quality of surgical care, however pancreatectomy-specific postoperative events are often misclassified, underscoring the need for a hepatopancreatobiliary-specific module to better capture key outcomes in this complex and unique patient population.

Combining Safety and Trainee Education in Surgical Oncology: We All Win

This timely article by Castleberry et al. brings focus to safety concerns in performing large and complex operations in cancer patients. The authors reviewed de-identified data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (PUFs) to study the overall 30-day postoperative mortality and morbidity rates and failure-torescue rate in patients undergoing oncologic operations for colorectal, hepatopancreaticobiliary, and gastroesophageal primary cancers. The primary purpose of the study was to assess the impact of surgical trainee involvement on riskadjusted 30-day morbidity and mortality in patients undergoing these procedures. The risk-adjusted results showed a 6.2 % (27.2 vs. 21 %) higher morbidity with trainee involvement but a 0.2 % (1.9 vs. 2.1 %) lower 30-day mortality rate and a 1.7 % (5.9 vs. 7.6 %) lower failure-to-rescue rate with trainee involvement. These absolute differences are small but were statistically significant due to the large study population of 77,862 patients. It is interesting that these differences were consistent across all types of oncologic procedures performed. There are many limitations of this data: only NSQIP participating hospitals were included, only 30-day mortality was recorded (there is not an insignificant number of patients undergoing hepatopancreaticobiliary and gastroesophageal procedures who may have delayed mortality between postoperative days 30–90). The reason for trainee involvement or no involvement was not recorded. The total number of trainees in a given operation was not recorded, and only the most senior PGY trainee who was present was recorded. Overall, this study suggests that trainee involvement does not worsen (and may even improve) perioperative mortality in patients undergoing complex oncologic procedures but may lead to a modest increase in postoperative morbidity. Another recent study on trainee involvement in open versus laparoscopic partial colectomy, also using ACS-NSQIP data, had similar results. These are encouraging studies as we go forward in our surgical teaching and training. We now place patient safety very appropriately as one of our top quality standards in patient care and the transparent involvement of trainees in the care of these patients in our teaching hospitals will be essential going forward. The ‘‘cost’’ of surgical resident and fellow training cannot be at the expense of poorer patient outcomes. It will be very interesting to see if future studies from these NSQIP hospitals (or other teaching hospitals) will be able to analyze longitudinal data and report any differences in cancer recurrence and cancer-specific survival with trainee involvement. The dynamics of how we teach in the operating room are rapidly expanding and changing. The high cost of medical care, the focus on reducing medical errors, and the ACGMEmandated resident work hour restrictions have brought out some of the best and most creative new approaches to teaching and learning from surgical educators. Surgical simulators allow all levels of residents to complete virtually and repetitively many of the essential steps in complex procedures before ever performing the actual surgeries. Instead of only one trainee performing and staying for an entire operation, many programs now encourage junior residents to observe and perform parts of operations (i.e., placing videoendoscopic ports or performing a laparotomy This article is an editorial about ‘‘Resident Education in the Era of Patient Safety: A nationwide analysis of outcomes and complications in resident-assisted oncologic surgery.’’ by Anthony Castleberry et al. available at doi: 10.1245/s10434-013-3079-2.

A Comparison of Clinical Registry Versus Administrative Claims Data for Reporting of 30-Day Surgical Complications

To compare the recording of 30-day postoperative complications between a national clinical registry and Medicare inpatient claims data and to determine whether the addition of outpatient claims data improves concordance with the clinical registry. Policymakers are increasingly discussing use of postoperative complication rates for value-based purchasing. There is debate regarding the optimal data source for such measures. Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient and outpatient claims data sets. We assessed the ability of (1) Medicare inpatient claims and (2) Medicare inpatient and outpatient claims to detect a core set of ACS-NSQIP 30-day postoperative complications: superficial surgical site infection (SSI), deep/organ-space SSI, any SSI (superficial and/or deep/organ-space), urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, venous thromboembolism (DVT and/or pulmonary embolism), and myocardial infarction. Agreement of patient-level complications by ACS-NSQIP versus Medicare was assessed by κ statistics. A total of 117,752 patients from more than 200 hospitals were studied. The sensitivity of inpatient claims data for detecting ACS-NSQIP complications ranged from 0.27 to 0.78; the percentage of false-positives ranged from 48% to 84%. Addition of outpatient claims data improved sensitivity slightly but also greatly increased the percentage of false-positives. Agreement was routinely poor between clinical and claims data for patient-level complications. This analysis demonstrates important differences between ACS-NSQIP and Medicare claims data sets for measuring surgical complications. Poor accuracy potentially makes claims data suboptimal for evaluating surgical complications. These findings have meaningful implications for performance measures currently being considered.

An Evaluation of Surgical Site Infections by Wound Classification System Using the ACS-NSQIP

Surgical wound classification has been the foundation for infectious risk assessment, perioperative protocol development, and surgical decision-making. The wound classification system categorizes all surgeries into: clean, clean/contaminated, contaminated, and dirty, with estimated postoperative rates of surgical site infection (SSI) being 1%-5%, 3%-11%, 10%-17%, and over 27%, respectively. The present study evaluates the associated rates of the SSI by wound classification using a large risk adjusted surgical patient database. A cross-sectional study was performed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset between 2005 and 2008. All surgical cases that specified a wound class were included in our analysis. Patient demographics, hospital length of stay, preoperative risk factors, co-morbidities, and complication rates were compared across the different wound class categories. Surgical site infection rates for superficial, deep incisional, and organ/space infections were analyzed among the four wound classifications using multivariate logistic regression. A total of 634,426 cases were analyzed. From this sample, 49.7% were classified as clean, 35.0% clean/contaminated, 8.56% contaminated, and 6.7% dirty. When stratifying by wound classification, the clean, clean/contaminated, contaminated, and dirty wound classifications had superficial SSI rates of 1.76%, 3.94%, 4.75%, and 5.16%, respectively. The rates of deep incisional infections were 0.54%, 0.86%, 1.31%, and 2.1%. The rates for organ/space infection were 0.28%, 1.87%, 2.55%, and 4.54%. Using ACS-NSQIP data, the present study demonstrates substantially lower rates of surgical site infections in the contaminated and dirty wound classifications than previously reported in the literature.

Pancreatectomy risk calculator: an ACS-NSQIP resource

BackgroundThe morbidity of pancreatoduodenectomy remains high and the mortality may be significantly increased in high-risk patients. However, a method to predict post-operative adverse outcomes based on readily available clinical data has not been available. Therefore, the objective was to create a ‘Pancreatectomy Risk Calculator’ using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. MethodsThe 2005–2008 ACS-NSQIP data on 7571 patients undergoing proximal (n= 4621), distal (n= 2552) or total pancreatectomy (n= 177) as well as enucleation (n= 221) were analysed. Pre-operative variables (n= 31) were assessed for prediction of post-operative mortality, serious morbidity and overall morbidity using a logistic regression model. Statistically significant variables were ranked and weighted to create a common set of predictors for risk models for all three outcomes. ResultsTwenty pre-operative variables were statistically significant predictors of post-operative mortality (2.5%), serious morbidity (21%) or overall morbidity (32%). Ten out of 20 significant pre-operative variables were employed to produce the three mortality and morbidity risk models. The risk factors included age, gender, obesity, sepsis, functional status, American Society of Anesthesiologists (ASA) class, coronary heart disease, dyspnoea, bleeding disorder and extent of surgery. ConclusionThe ACS-NSQIP ‘Pancreatectomy Risk Calculator’ employs 10 easily assessable clinical parameters to assist patients and surgeons in making an informed decision regarding the risks and benefits of undergoing pancreatic resection. A risk calculator based on this prototype will become available in the future as on online ACS-NSQIP resource.

Identification of Specific Quality Improvement Opportunities for the Elderly Undergoing Gastrointestinal Surgery

Specific complications occur more frequently in elderly patients undergoing major gastrointestinal (GI) tract operations that may represent opportunities for quality improvement. Retrospective cohort study. One hundred twenty-one hospitals participating in American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Using the ACS-NSQIP participant use file (2005-2006), patients undergoing upper gastrointestinal tract (n = 4115), hepatobiliary or pancreatic (n = 3364), and colorectal (n = 17 268) operations at 121 hospitals were examined. Risk-adjusted 30-day outcomes were assessed using regression modeling adjusting for patient characteristics, comorbidities, and surgical procedures. The elderly were defined as those older than 75 years. Between January 1, 2005, and December 31, 2006, a total of 24,747 [corrected] patients who underwent major GI tract operations were identified from the ACS-NSQIP data file. In the elderly, overall perioperative morbidity was 1.2 to 2 times higher and mortality was 2.9 to 6.7 times higher than in younger patients after adjusting for differences in preoperative comorbidities. Irrespective of procedure type, the elderly were significantly more likely to experience cardiac (acute myocardial infarction and cardiac arrest), pulmonary (pneumonia, pulmonary embolism, and respiratory failure), and urologic (urinary tract infection and renal failure) complications. However, surgical site infections, postoperative bleeding events, deep venous thromboses, and rates of return to the operating room did not differ significantly by age. Morbidity and mortality are markedly higher in older patients. Quality measures for the elderly currently address only myocardial infarction, surgical site infection, and deep venous thrombosis. If care for the elderly is to be improved, quality improvement initiatives need to be expanded to include postoperative pulmonary and renal complications.