Michigan Surgical Quality Collaborative Research Articles

Association of preoperative thyroid hormone replacement with perioperative complications after major abdominal surgery

ObjectiveTo determine the association between preoperative thyroid hormone replacement and complications following major abdominal surgery. MethodsA retrospective case series was performed of patients enrolled in the Michigan Surgical Quality Collaborative (MSQC) who underwent major abdominal surgery at an academic institution over a 10-year period. The principal explanatory variable was preoperative thyroid hormone replacement. Primary outcomes were morbidity, mortality and length of stay. Results2700 patients were identified. On multivariate analysis correcting for established predictors of operative morbidity, patients on preoperative thyroid replacement had a 1.5- fold increased risk of serious morbidity(p ​= ​0.01), and a 1.7- fold greater risk for serious sepsis(p ​= ​0.04). Thyroid replacement was associated with longer length of stay(p ​< ​0.001). While there was a high degree of missing data for surgical approach (31.1 ​% missing data), results suggest that patients on thyroid hormone replacement were more likely to undergo an open rather than minimally invasive surgery(p ​< ​0.01). Open surgery was associated with greater risk of serious morbidity(p ​= ​0.003) and longer length of stay(p ​< ​0.001). ConclusionsPreoperative thyroid hormone replacement independently predicts operative morbidity and length of stay following major abdominal surgery.

Use of statewide financial incentives to improve documentation of hernia and mesh characteristics in ventral hernia repair.

Documentation of intraoperative details is critical for understanding and advancing hernia care, but is inconsistent in practice. Therefore, to improve data capture on a statewide level, we implemented a financial incentive targeting documentation of hernia defect size and mesh use. The Abdominal Hernia Care Pathway (AHCP), a voluntary pay for performance (P4P) initiative, was introduced in 2021 within the statewide Michigan Surgical Quality Collaborative (MSQC). This consisted of an organizational-level financial incentive for achieving 80% performance on eight specific process measures for ventral hernia surgery, including complete documentation of hernia defect size and location, as well as mesh characteristics and fixation technique. Comparisons were made between AHCP and non-AHCP sites in 2021. Of 69 eligible sites, 47 participated in the AHCP in 2021. There were N = 5362 operations (4169 at AHCP sites; 1193 at non-AHCP sites). At AHCP sites, 69.8% of operations had complete hernia documentation, compared to 50.5% at non-AHCP sites (p < 0.0001). At AHCP sites, 91.4% of operations had complete mesh documentation, compared to 86.5% at non-AHCP sites (p < 0.0001). The site-level hernia documentation goal of 80% was reached by 14 of 47 sites (range 14-100%). The mesh documentation goal was reached by 41 of 47 sites (range 4-100%). Addition of an organizational-level financial incentive produced marked gains in documentation of intra-operative details across a statewide surgical collaborative. The relatively large effect size-19.3% for hernia-is remarkable among P4P initiatives. This result may have been facilitated by surgeons' direct role in documenting hernia size and mesh use. These improvements in data capture will foster understanding of current hernia practices on a large scale and may serve as a model for improvement in collaboratives nationally.

Positive margin rates for colorectal cancer vary significantly by hospital in Michigan: Can we achieve a 0 % positive margin rate?

BackgroundHigh quality surgical care for colorectal cancer (CRC) includes obtaining a negative surgical margin. The Michigan Surgical Quality Collaborative (MSQC) is a statewide consortium of hospitals dedicated to quality improvement; a subset of MSQC hospitals abstract quality of care measures for CRC surgery, including positive margin rate. The purpose of this study was to determine whether positive margin rates vary significantly by hospital, and whether positive margin rates should be a target for quality improvement. MethodsWe performed a retrospective cohort study of patients who underwent CRC resection from 2016 to 2020. The primary outcome was the presence of a positive margin. Univariate and multivariable analyses were performed to test the association of positive margins with patient, hospital, and tumor characteristics. ResultsThe cohort consisted of 4211 patients from 42 hospitals (85 % colon cancer and 15 % rectal cancer). The crude positive margin rate was 6.15 % (95 % CI 4.6–7.4 %); this ranged from 0 % to 22 % at individual hospitals. In multivariable analysis, factors independently associated with positive margins included male sex, underweight BMI, metastatic cancer, rectal cancer (vs. colon), T4 T-stage, N1c/N2 N-stage, and open surgical approach. After adjusting for these factors, there remained significant variation by hospital, with 8 hospitals being statistically-significant outliers. ConclusionsPositive margins rates for CRC vary by hospital in Michigan, even after rigorous adjustment for case-mix. Furthermore, several hospitals achieved near-zero positive margin rates, suggesting opportunities for quality improvement through the identification of best practices among CRC surgery centers.

Trends in surgical approach to hysterectomy and perioperative outcomes in Michigan hospitals from 2010 through 2020.

The objective of this study was to determine the trends in surgical approach to hysterectomy over the last decade and compare perioperative outcomes and complications. This retrospective cohort study used clinical registry data from the Michigan Hospitals that participated in Michigan Surgical Quality Collaborative (MSQC) from January 1st, 2010 through December 30th, 2020. A multigroup time series analysis was performed to determine how surgical approachto hysterectomy [open/TAH, laparoscopic (TLH/LAVH), and robotic-assisted (RA)] has changed over the last decade. Abnormal uterine bleeding, uterine fibroids, chronic pelvic pain, pelvic organ prolapse, endometriosis, pelvic mass, and endometrial cancer were the most common indications for hysterectomy. The open approach to hysterectomy declined from 32.6 to 16.9%, a 1.9-fold decrease, with an average decline of 1.6% per year (95% CI - 2.3 to - 0.9%). Laparoscopic-assisted hysterectomies decreased from 27.2 to 23.8%, a 1.5-fold decrease, with an average decrease of 0.1% per year (95% CI - 0.7 to 0.6%). Finally, the robotic-assisted approach increased from 38.3 to 49.3%, a 1.25-fold increase, with an average of 1.1% per year (95% CI 0.5 to 1.7%). For malignant cases, open procedures decreased from 71.4 to 26.6%, a 2.7-fold decrease, while RA-hysterectomy increased from 19.0 to 58.7%, a 3.1-fold increase. After controlling for the confounding variables age, race, and gynecologic malignancy, RA hysterectomy was found to have the lowest rate of complications when compared to the vaginal, laparoscopic and open approaches. Finally, after controlling for uterine weight, black patients were twice as likely to undergo an open hysterectomy compared to white patients.

239 What Happens After Surgery? Postoperative High-Risk prescribing in Patients with Chronic Opioid Use

OBJECTIVES/GOALS: Patients on chronic opioids face gaps in transitions of care in the time following surgery, increasing the risk for adverse events, specifically high-risk opioid prescribing. The objective of this study is to determine how rates of high-risk prescribing differ between patients with public and private insurance. METHODS/STUDY POPULATION: A retrospective cohort study of 1,435 adult patients with preoperative chronic opioid use on Medicaid or commercial insurance who underwent surgery between November 2017 and February 2021. Patients were identified using the Michigan Surgical Quality Collaborative (MSQC) database, a collection of perioperative data from 70 hospitals across the state of Michigan. Data from the MSQC were merged with Michigan’s prescription drug monitoring program to provide additional information on pre- and postoperative opioid prescribing. Multivariable logistic regression was used to assess high-risk prescribing by the presence of a preoperative usual prescriber and insurance type. RESULTS/ANTICIPATED RESULTS: Overall, 22.7% of patients on private insurance and 23.6% of patients on Medicaid fulfilled criteria for new, postoperative high-risk prescribing. Among criteria for high-risk prescribing, multiple prescribers was the most significant contributor (private insurance: 17.4%, Medicaid: 18.9%). Patients on Medicaid insurance did not have increased odds of new postoperative high-risk prescribing (OR = 1.067, 95% CI: 0.813-1.402). While fewer patients on Medicaid had a preoperative usual prescriber (86.9% and 90.9% respectively, p = 0.015), there was no significant difference between the two insurance types in baseline rates of high-risk prescribing prior to surgery (private insurance: 43.4%, Medicaid: 46.0%, p = 0.352). DISCUSSION/SIGNIFICANCE: While we do not observe disparities in high-risk prescribing between insurance types, rates of high-risk prescribing postoperatively are high across payer types. Further studies to determine the factors driving rates of high-risk opioid prescribing among patients with chronic opioid use are needed to identify areas for future intervention.

8258 Does Uterine Size Matter? the Relationship between Surgeon Volume, Surgical Approach, and Uterine Weight for Benign Hysterectomy.

<h3>Study Objective</h3> To assess the relationship between surgeon volume and surgical approach for benign hysterectomies across increasing uterine weights. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Hospitals in the Michigan Surgical Quality Collaborative (MSQC) registry between July 2012 and April 2021. <h3>Patients or Participants</h3> Patients undergoing benign hysterectomy. <h3>Interventions</h3> Hysterectomy. <h3>Measurements and Main Results</h3> For each hysterectomy, surgeon volume was determined by the number of hysterectomies contributed to the MSQC registry by the surgeon in the calendar year. Cases were classified into tertiles by surgeon volume. Multivariable logistic regression with interaction analysis was used to determine the likelihood of undergoing a minimally-invasive hysterectomy (MIH) by surgeon volume and uterine weight. Of the 59,356 patients, 47,149 (79.4%) patients underwent MIH and 12,207 (20.6%) underwent abdominal hysterectomy. The proportion of minimally-invasive hysterectomy (MIH) decreased with increasing uterine weight. Hysterectomies performed by high- and intermediate-volume surgeons were more likely to be minimally-invasive versus those performed by low-volume surgeons (high-volume: aOR 2.13 [95% CI 1.86-2.44]; intermediate-volume: aOR 1.74 [95% CI 1.52-2.00]). For hysterectomies performed by high-volume surgeons, the propensity for a minimally-invasive approach was amplified for uterine weights between 250-2000g, with the maximum interaction effect between 1000-2000g (aOR 4.23 [95% CI 2.57-6.96]). There was no interaction effect among weights below 250g or above 2000g. <h3>Conclusion</h3> Hysterectomies performed by high-volume surgeons are more likely to be associated with a minimally-invasive approach compared to those performed by low-volume surgeons among all uterine weights, but especially among uteri weighing between 250-1999g.

Association of opioid exposure before surgery with opioid consumption after surgery

ObjectiveTo determine the effect of prescription opioid use in the year before surgery on opioid consumption after surgery.BackgroundRecently developed postoperative opioid prescribing guidelines rely on data from opioid-naïve patients. However,...

Heterogeneity in Surgical Quality Improvement in Michigan.

The aim of this study was to evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012 to 2019 in a collaborative quality improvement network. Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall; however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design. We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012 to 2019. Risk-and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last 2 years and the first 2 years of the study period. There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012 to 2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points). Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.

Implementation of a synoptic operative note for abdominal wall hernia repair: a statewide pilot evaluating completeness and communication of intraoperative details.

BackgroundVariable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption.MethodsIn January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches.ResultsFrom January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value < 0.001). While collection of intraoperative variables improved after synoptic note implementation, low note adoption was reported. Facilitators of improved variable collection were (1) communication with data abstractors and (2) stakeholder acknowledgment of widespread benefit, while barriers included (1) surgeon resistance to practice change, (2) EMR/technology, and (3) interruptions to communication and implementation.ConclusionThis mixed-methods evaluation of a synoptic operative note implementation suggests that sustained communication, particularly with abstractors, was the most impactful intervention. Future implementation efforts may have improved effectiveness with interventions supplementary to surgeon-level direction.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-021-08614-8.

Effects of Pharmacologic Venous Thromboembolism (VTE) Prophylaxis in Benign Minimally Invasive Hysterectomy

Study Objective To evaluate if the addition of pharmacologic prophylaxis (heparin, low molecular weight heparin) for VTE is associated with adverse perioperative outcomes in minimally invasive surgery (MIS) hysterectomy for benign indications compared to mechanical prophylaxis alone. Design Retrospective cohort study. Setting Michigan Surgical Quality Collaborative (MSQC). Patients or Participants Patients who underwent a benign MIS hysterectomy (i.e. laparoscopic, vaginal, laparoscopic-assisted vaginal, or robotic-assisted laparoscopy) performed between July 2012 and June 2015 and received mechanical prophylaxis for thromboembolism. Interventions Patients were divided into cohorts who received mechanical prophylaxis alone (MPpx) or mechanical + pharmacologic prophylaxis (M+Pppx). Propensity score matching was used to minimize confounding due to differences in age, race, body mass index>40, hypertension, congestive heart failure, smoking, functional status, preoperative transfusion, preoperative anemia or thrombocytopenia, length of stay, and hospital teaching status. Outcomes evaluated in the propensity-matched cohorts were estimated blood loss, intraoperative time, postoperative blood transfusion, postoperative VTE, surgical site infection, reoperation, and readmission. Measurements and Main Results There were 1944 matched pairs of patients in the Mppx and M+Pppx cohorts. Intraoperative time was 21 minutes longer (168 minutes ± 63 min vs 189 ± 75 mins, p Conclusion Further research is needed into the addition of pharmacologicprophylaxis to mechanical prophylaxis and its association with longer operative time for benign minimally invasive hysterectomy. Given extremely low rates of VTE in both groups and no difference detected in other significant peri-operative outcomes using a large database, it seems reasonable to question routine use of pharmacologic prophylaxis in these patients.

Colorectal surgery collaboratives: The Michigan experience

The Michigan Surgical Quality Collaborative (MSQC) was one of the first large-scale regional collaborative quality improvement (CQI) organizations, bringing together surgeons and nurses from 70 Michigan hospitals with a goal of improving surgical outcomes. In this article, we describe the evolution of the MSQC, the science of collaborative quality improvement, and the colorectal surgery-focused projects that MSQC has implemented. Colorectal surgery initiatives have focused on (1) surgical site infection reduction, (2) improving quality of care for colorectal cancer, (3) enhanced recovery pathways, (4) technical skills coaching using video review, and (5) opioid use reduction.

Association of Medicaid Eligibility With Surgical Readmission Among Medicare Beneficiaries

The Centers for Medicare & Medicaid Services is beginning to consider adjusting for social risk factors, such as dual eligibility for Medicare and Medicaid, when evaluating hospital performance under value-based purchasing programs. It is unknown whether dual eligibility represents a unique domain of social risk or instead represents clinical risk unmeasured by variables available in traditional Medicare claims. To assess how dual eligibility for Medicare and Medicaid is associated with risk-adjusted readmission rates after surgery. A retrospective cohort study was conducted of 55 651 Medicare beneficiaries undergoing general, vascular, and gynecologic surgery at 62 hospitals in Michigan between January 1, 2014, and December 1, 2016. Representative cohorts were derived from traditional Medicare claims (n = 29 710) and the Michigan Surgical Quality Collaborative (MSQC) clinical registry (n = 25 941), which includes additional measures of clinical risk. Statistical analysis was conducted between April 10 and July 15, 2019. The association between dual eligibility and risk-adjusted 30-day readmission rates after surgery was compared between models inclusive and exclusive of additional measurements of clinical risk. The study also examined how dual eligibility is associated with hospital profiling using risk-adjusted readmission rates. Dual eligibility for Medicare and Medicaid. Risk-adjusted all-cause 30-day readmission after surgery. There were a total of 3986 dual-eligible beneficiaries in the Medicare claims cohort (2554 women; mean [SD] age, 72.9 [6.9] years) and 1608 dual-eligible beneficiaries in the MSQC cohort (990 women; mean [SD] age, 72.9 [6.8] years). In both data sets, higher proportions of dual-eligible beneficiaries were younger, female, and nonwhite than Medicare-only beneficiaries (Medicare claims cohort: female, 2554 of 3986 [64.1%] vs 12 879 of 25 724 [50.1%]; nonwhite, 1225 of 3986 [30.7%] vs 2783 of 25 724 [10.8%]; MSQC cohort: female, 990 of 1608 [61.6%] vs 12 578 of 24 333 [51.7%]; nonwhite, 416 of 1608 [25.9%] vs 2176 of 24 333 [8.9%]). In the Medicare claims cohort, dual-eligible beneficiaries were more likely to be readmitted (15.5% [95% CI, 13.7%-17.3%]) than Medicare-only beneficiaries (13.3% [95% CI, 12.7%-13.9%]; difference, 2.2 percentage points [95% CI, 0.4-3.9 percentage points]). In the MSQC cohort, after adjustment for more granular measures of clinical risk, dual eligibility was not significantly associated with readmission (difference, 0.6 percentage points [95% CI, -1.0 to 2.2 percentage points]). In both the Medicare claims and MSQC cohorts, adding dual eligibility to risk-adjustment models had little association with hospital ranking using risk-adjusted readmission rates. This study suggests that dual eligibility for Medicare and Medicaid may reflect unmeasured clinical risk of readmission in claims data. Policy makers should consider incorporating more robust measures of social risk into risk-adjustment models used by value-based purchasing programs.

16: Bundled interventions and an institutional focus on infection prevention significantly reduces post-hysterectomy infectious morbidity

To determine the impact of bundled interventions to prevent infectious morbidity after hysterectomy. An Infection prevention bundle was developed utilizing elements of previously published checklists as well as several data-driven measures developed from the Michigan Surgical Quality Collaborative (MSQC) to reduce post-hysterectomy infectious morbidity. These Michigan specific interventions included: addition of Metronidazole to first-generation cephalosporins for antibiotic prophylaxis, administration of beta-lactam antibiotics (unless the patient had documented anaphylactic reaction to penicillin), subcuticular closure of open incisions, early removal of Foley catheter. Moreover, an institutional focus on reducing infections consisted of a dedicated multi-disciplinary surgical site infection prevention committee consisting of infection prevention specialists, operating room nursing, surgeons and departmental leadership. Simultaneously, institution-wide efforts to increase handwashing and implement enhanced recovery were launched. All patients undergoing hysterectomy between 10/08/2015 - 10/07/2018 were divided into 3 equal yearly time frames for the analysis. Clinicopathologic data, operative details, and 30-day outcomes were obtained from three sources: electronic medical record, MSQC outcome dataset, and departmental infection prevention committee database. The primary outcome of interest was overall infection rate. This included superficial surgical site infection, deep and organ space infections, Clostridium difficile infection, culture proven urinary tract infections and others. A total of 1,867 hysterectomies were included in the analysis. Baseline demographic and operative details were similar between the patients in the three timeframes. Overall, 30-day infection rate fell from 4.5% (29/644) during year-1 to 2.6% (16/607) during year-2 to 2.1% (13/616) in year-3 (p = 0.036). Details of each category of infection included are presented in Table 1. On multivariate analysis, after adjusting for age, race, body mass index, malignancy and surgical approach, year of surgery remained an independent predictor with lower odds of infection (year-2 vs. year-1: OR 0.364 [95% CI 0.14 – 0.95]; year-3 vs. year-1: OR 0.281[95% CI 0.095 – 0.84]). A systemwide approach of implementing bundled interventions with an emphasis on infection prevention can significantly reduce infectious morbidity after hysterectomy.

Building, scaling, and sustaining a learning health system for surgical quality improvement: A toolkit.

This article describes how to start, replicate, scale, and sustain a learning health system for quality improvement, based on the experience of the Michigan Surgical Quality Collaborative (MSQC). The key components to operationalize a successful collaborative improvement infrastructure and the features of a learning health system are explained. This information is designed to guide others who desire to implement quality improvement interventions across a regional network of hospitals using a collaborative approach. A toolkit is provided (under Supporting Information) with practical information for implementation.

Hospital quality and payment variation for pancreaticoduodenectomy in michigan

Presenter: Adrian Diaz MD, MPH | University of Michigan Background: Previous studies have documented cost variation for inpatient surgical procedures suggesting opportunities for savings, however assessment by claims data is often criticized for lacking clinical granularity and validation. By leveraging linkage between two unique datasets, a clinical registry and a claims based registry, we sought to characterize variation in payments for pancreaticoduodenectomy (PD) across hospitals in Michigan. By linking outcomes to cost this study is able help differentiate between quality problems (e.g. complications) and efficiency problems (e.g. overutilization). Variation in outcomes and utilization may highlight opportunities for collaborative quality improvement and practice standardization. Methods: We linked Michigan Surgical Quality Collaborative (MSQC) clinical registry data for PD performed at 8 Michigan hospitals to the Michigan Value Collaborative (MVC) registry from 2014 to 2018. The MSQC is a regional collaborative that maintains a robust and well-established state-wide clinical registry focused on outcomes and health care use. The MVC is a statewide collaborative focused on improving the value of care in the state of Michigan which maintains a claims-based registry with 30-day price-standardized episodes of care from multiple payers. Payment components between hospitals were compared with identified drivers of variation (e.g., index hospitalization/procedure, readmissions, post-acute care, and professional fees). Results: Among 1,535 PD episodes identified, the 30-day episode payment by hospital ranged between $34,680 and $56,973 with a median of $40,063. Index hospitalization payments were the primary driver of this variation (46%), followed by post-acute discharge payment (34%). Readmissions by hospital ranged from 5% to 22% with a median of 17%; post-operative morbidity ranged from 11% to 35% with a median of 28%. Notably, higher payments were not associated with improved clinical performance (Figure 1). As such, individual hospitals may look at their own complication/cost profiles to understand if they are managing complications as efficiently as possible. Alternatively, hospitals with low morbidity but high costs may be over-utilizing services (e.g. post-acute care). Conclusion: In this analysis, the linkage of clinical registry data with claims-based registry data provides a unique opportunity to study drivers of cost and variation. For patients undergoing PD in Michigan, we found a wide variation in surgical episode spending across hospitals without major difference in clinical performance. Hospital leaders may seek to better understand variation in practices between their hospitals in order to standardize care and reduce variation in post-acute care and other utilization. Similar procedure-specific analyses should be performed for other clinical service lines in order to understand whether variations in quality (e.g., complications) or efficiency (e.g., post-acute care) drive observed differences in spending.

Hospital Variation in Readmissions and Visits to the Emergency Department Following Ileostomy Surgery

BackgroundIleostomy surgery is associated with a high readmission rate, and care pathways to prevent readmissions have been proposed. However, the extent to which readmission rates have improved is unknown. This study examined rates of readmission and emergency department visits (“return to hospital,” or RTH) across hospitals in Michigan. MethodsThis was a retrospective cohort study of patients undergoing colorectal surgery with ileostomy formation from July 2012 to August 2017 in twenty Michigan Surgical Quality Collaborative (MSQC) hospitals. Primary outcome was RTH within 30 days of surgery. Multivariable logistic regression was used to identify risk factors for RTH. RTH rates over time were calculated, and hospitals’ risk-adjusted rates were estimated using a multivariable model. Hospitals were divided into quartiles by risk-adjusted RTH rates, and RTH rates were compared between quartiles. ResultsOf 982 patients, 28.5% experienced RTH. Rates of RTH did not decrease over time. Adjusted hospital RTH rates ranged from 9.4 to 43.3%. The risk-adjusted rate in the best-performing hospital quartile was 17.5% vs. 37.3% in the worst-performing quartile (p < 0.001). Hospitals that were outliers for ileostomy RTH were not outliers for colorectal resection RTH in general. ConclusionsRates of RTH following ileostomy surgery are high and vary between hospitals. This suggests inconsistent or ineffective use of pathways to prevent these events and potential for improvement. There is clear opportunity to standardize care to prevent RTH after ileostomy surgery.

Statewide Clinic Registries: The Michigan Surgical Quality Collaborative.

Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.

Acute Care Surgery Model and Outcomes in Emergency General Surgery

Annually, more than 2 million patients are admitted with emergency general surgery (EGS) conditions. Emergency general surgery cases comprise 11% of all general surgery operations, yet account for 47% of mortalities and 28% of complications. Using the statewide general surgery Michigan Surgical Quality Collaborative (MSQC) data, we previously confirmed that wide variations in EGS outcomes were unrelated to case volume/complexity. We assessed whether patient care model (PCM) affected EGS outcomes. There were 34 hospitals that provided data for PCM, resources, surgeon practice patterns, and comprehensive MSQC patient data from January 1, 2008 to December 31, 2016 (general surgery cases= 126,494; EGS cases= 39,023). Risk and reliability adjusted outcomes were determined using hierarchical multivariable logistic regression analysis with multiple clinical covariates and PCM. The general surgery service (GSS) model was more common (73%) than acute care surgery (ACS, 27%). Emergency general surgery 30-day mortality was 4.1% (intestinal resections 11.6%). The ACS model was associated with a reduction of 31% in mortality (odds ratio [OR] 0.69; 95% CI 0.52-0.92] for EGS cases, related to decreased mortality in the intestinal resection cohort (8.5% ACS vs 12% GSS, p < 0.0001). Morbidity in EGS was 17.4% (9.7% elective); highest (40%) in intestinal resection, and PCM did not affect morbidity. We identified specific variables for an optimal EGS risk adjustment model. This is the first multi-institutional study to identify that an ACS model is associated with a significant 31% mortality reduction in EGS using prospectively collected, clinically obtained, research-quality collaborative data. We identified that new risk adjustment models are necessary for EGS outcomes evaluations.

Documenting pessary offer prior to hysterectomy for management of pelvic organ prolapse.

To (1) determine the proportion of hysterectomy cases with documentation of pessary counseling prior to prolapse surgery and (2) identify variables associated with women offered a pessary. The Michigan Surgical Quality Collaborative (MSQC) is a hysterectomy improvement initiative. Hysterectomies from 2013 to 2015 in which prolapse was the principal diagnosis were included. "Pessary offer" was defined as documentation showing the patient declined, could not tolerate, or failed a pessary trial. Bivariate analyses were used to compare demographics, medical history, surgical route, concomitant procedures (colpopexy or colporrhaphy), and intra- and postoperative complications between women with and without pessary offer. Hierarchical logistic regression was used to determine factors independently associated with pessary offer. Risk-adjusted pessary offer rates by hospital were calculated. The adjusted rate of pessary offer was 25.2%, ranging from 3 to 76% per hospital. Bivariate comparisons showed differences between women with and without pessary offer in age, tobacco use, prior pelvic surgery, insurance status, surgical approach, secondary indication for surgery, concomitant prolapse procedure, teaching hospital status and hospital bed size. In logistic regression, odds of pessary offer increased with age > 55 years (OR 1.45, 95% CI 1.12-1.88, p = 0.006), Medicare insurance (OR 1.65, 95% CI 1.30-2.10, p < 0.0001), and a concomitant procedure (OR 1.5, 95% CI 1.16-1.93, p = 0.002). Postoperative urinary tract infections were more common in patients offered a pessary (6.4% vs. 2.5%, p < 0.0001), but other complications were similar. Overall, only one-quarter of hysterectomies for prolapse in MSQC hospitals had documentation of pessary counseling-suggesting an opportunity to improve documentation, counseling regarding pessary use, or both.

Evaluation of the Methods Used by Medicare's Hospital-Acquired Condition Reduction Program to Identify Outlier Hospitals for Surgical Site Infection

The Hospital Acquired Condition Reduction Program (HACRP) is a national pay-for-performance program that includes a measure of surgical site infection (SSI) after hysterectomy and colectomy. This study compares the HACRP SSI measure with other published methods. This was a retrospective cohort study from the Michigan Surgical Quality Collaborative (MSQC). The outcome was 30-day, adjusted deep and organ space SSI ("complex SSI"). Observed-to-expected ratios of complex SSI for each hospital were calculated using HACRP, National Healthcare Safety Network (NHSN), and MSQC methodologies. C-statistics were compared between models. Hospital rankings were compared, and ladder plots show changes in hospitals' HACRP scores that derive from each algorithm. Complex SSI occurred in 1.1% (190 of 16,672) of hysterectomies and 4.8% (n= 514 of 10,725) of colectomies. The HACRP risk-adjustment model for hysterectomy had a C-statistic of 0.55, significantly lower than NHSN (0.61, p= 0.0461) or MSQC models (0.77, p< 0.0001). For colectomy, C-statistics were 0.57, 0.66 (p < 0.0001) and 0.73 (p<0.0001), respectively. For both operations, there were 5 high-outlier hospitals using HACRP, but fewer (4 or 3) using the other methods. Most hospitals in the bottom quartile were not statistical outliers, but would be flagged under HACRP. More than 50% of hospitals changed ranking position between models, which would result in different scores under HACRP. This study showed that the HACRP SSI measure unfairly places hospitals at risk for financial penalties that are not statistical outliers. Policy makers need to weigh the burden of data collection and the accuracy needed to identify hospitals for financial reward orpenalty.