National Quality Improvement Program Research Articles

Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients.

The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

The Mediating Effect of Operative Approach on Racial Disparities in Bariatric Surgery Complications

IntroductionA laparoscopic approach to bariatric surgeries confers a favorable side-effect profile as compared to an open approach. However, literature regarding the independent association of race with access to and postoperative outcomes in laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (GS) is scarce. Materials and methodsAll RYGB and GS cases recorded in American College of Surgeons National Quality Improvement Program data from 2012 to 2020 were subjected to propensity score matching to assess the independent association between Black self-identified race on access to a laparoscopic approach and postoperative complications. Finally, a series of logistic regressions enabled evaluation of the mediating effect of operative approach on racial disparities in postoperative complications. Results55,846 cases of RYGB and 94,209 cases of GS were identified. Following propensity score matching, logistic regression identified Black race as an independent predictor of open approach to RYGB (P < 0.001) and GS (P = 0.019). Black patients had increased incidence of any, minor and severe postoperative complications and unplanned readmissions in both RYGB (P < 0.001, P < 0.001, P = 0.0412, and P < 0.001, respectively) and GS (P < 0.001, P < 0.001, P = 0.0037, and P < 0.001, respectively). Open approach to RYGB was identified as a partial mediator of the independent association between Black race and any complication, minor complications, and unplanned readmission. ConclusionsThis methodology identified racial disparities in complications following RYGB and GS. Interestingly, reduced access to a laparoscopic approach mediated racial disparities in complications following RYGB but not GS. Further research might elucidate upstream determinants of health that catalyze these disparities.

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.

EFFECTS OF ACTIVE PATIENT PARTICIPATION IN AN INFLAMMATORY BOWEL DISEASE QUALITY IMPROVEMENT PROGRAM ON HEALTHCARE UTILIZATION OUTCOMES

Although previous studies have shown that participating in a structured national quality improvement program improves healthcare utilization for patients with inflammatory bowel disease (IBD), it is not known whether the extent of active participation influences health outcomes. Patients in the IBD Qorus Learning Health System self-report symptoms and treatment goals prior to clinic visits via electronic surveys, which facilitates disease surveillance and patient-provider co-production of care. This study assesses the relationship between active patient participation and IBD-related healthcare utilization outcomes.

Incidence and risk factors for the development of lower urinary tract fistulas after hysterectomy diagnosed in the immediate post-operative period: an analysis of the national surgery quality improvement program (nsqip) database

Incidence and risk factors for the development of lower urinary tract fistulas after hysterectomy diagnosed in the immediate post-operative period: an analysis of the national surgery quality improvement program (nsqip) database

EFFECTS OF ACTIVE PATIENT PARTICIPATION IN AN INFLAMMATORY BOWEL DISEASE QUALITY IMPROVEMENT PROGRAM ON HEALTHCARE UTILIZATION OUTCOMES

Abstract BACKGROUND Although previous studies have shown that participating in a structured national quality improvement program improves healthcare utilization for patients with inflammatory bowel disease (IBD), it is not known whether the extent of active participation influences health outcomes. Patients in the IBD Qorus Learning Health System self-report symptoms and treatment goals prior to clinic visits via electronic surveys, which facilitates disease surveillance and patient-provider co-production of care. This study assesses the relationship between active patient participation and IBD-related healthcare utilization outcomes. METHODS We reviewed electronic health records and surveys of patients with IBD from a private community gastrointestinal practice participating in Qorus for two years after they submitted the first pre-clinic survey. The study period was from 2016 to 2021. Primary outcomes were times from the first survey to an IBD-related ED visit/hospitalization, urgent message*, and CT-scan use. Participation score was calculated as a ratio of eligible surveys (submitted within two weeks prior to clinic visits) to the number of clinic visits, with a ratio &amp;lt;0.5 representing inactive participation and ≥0.5 representing active participation. Cox proportional hazards regression was performed to determine the relationship between active participation and healthcare utilization, controlling for potential confounders such as IBD subtype, baseline clinical disease activity, steroid use, and six-months-prior IBD-related ED visit/hospitalization and CT scan use. The “survival time” was defined as the time from the first survey to IBD-related healthcare utilization events, loss of follow-up in the electronic health records, or two years, whichever occurred earliest. RESULTS Out of 244 patients, 122 were inactive participants and 122 were active participants. Among inactive participants, 23.8% experienced an IBD-related ED visit/hospitalization, 27.9% sent an urgent message, and 12.3% received a CT scan. Among active participants, 18.9 % experienced an IBD-related ED visit/hospitalization, 21.3% sent an urgent message, and 12.3% received a CT scan (Table 1). Active and inactive (reference) Qorus participants were not statistically different in their healthcare utilization: ED visit/hospitalization (HR 0.61[95% CI 0.34-1.09]), sending an urgent message (HR 0.68 [95% CI 0.40-1.15]), and CT scan use (HR 1.00 [95% CI 0.47-2.13]), after adjusting for confounders (Table 2). CONCLUSION Although active participants show numerically less frequent ED visit/hospitalization and urgent message than inactive participants, there was not a statistically significant association between participation and healthcare utilization. A greater sample size is needed to draw further conclusions to inform future strategies to engage patients and optimize health outcomes.

National PReCePT Programme: a before-and-after evaluation of the implementation of a national quality improvement programme to increase the uptake of magnesium sulfate in preterm deliveries

ObjectiveTo evaluate the effectiveness and cost-effectiveness of the National PReCePT Programme (NPP) in increasing use of magnesium sulfate (MgSO4) in preterm births.DesignBefore-and-after study.SettingMaternity units (N=137) within NHS England and the...

A National Quality Improvement Program on Ultrasound Department in China: A Controlled Cohort Study of 1297 Public Hospitals.

Providing high-quality medical services is of great importance in the imaging department, as there is a growing focus on personal health, and high-quality services can lead to improved patient outcomes. Many quality improvement (QI) programs with good guidance and fine measurement for improvement have been reported to be effective. In order to improve the quality of ultrasound departments in China, we conducted this study of a national quality improvement program. A total of 1297 public hospitals were included in this QI program on ultrasound departments in China from 2017 to 2019. The effect of this QI program was investigated, and potential factors, including hospital level and local economic development, were considered. The outcome indicators, the positive rate and diagnostic accuracy, were improved significantly between the two phases (positive rate, 2017 vs. 2019: 66.21% vs. 73.91%, p < 0.001; diagnostic accuracy, 2017 vs. 2019: 85.37% vs. 89.74%; p < 0.001). Additionally, they were improved in secondary and tertiary hospitals, with the improvement in secondary hospitals being greater. Notably, the enhancement of diagnostic accuracy in low-GDP provinces was almost 20%, which was more significant than the enhancement in high-GDP provinces. However, the important structural indicator, the doctor-to-patient ratio, decreased from 1.05:10,000 to 0.96:10,000 (p = 0.026). This study suggests that the national ultrasound QI program improved the outcome indicators, with secondary-level hospitals improving more than tertiary hospitals and low-GDP provinces improving more than high-GDP regions. Additionally, as there is a growing need for ultrasound examinations, more ultrasound doctors are needed in China.

Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality

BackgroundSurgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery “step-up” approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the “step-up” approach.MethodsThe American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.ResultsThere were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).ConclusionSPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a “step-up” approach. Larger, prospective studies to compare indications and outcomes for “step up” versus open SPN are warranted.

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.

8681 Complications Among Patients Undergoing Mesh Graft Revision Surgery: A Retrospective Cohort Study of the NSQIP Database

<h3>Study Objective</h3> To compare complication rates among patients having urogynecology surgery for revision of a mesh graft placed for management of pelvic organ prolapse. <h3>Design</h3> A retrospective, population-based cohort study was conducted using the American College of Surgeons National Quality Improvement Program (NSQIP) database. A multivariable logistic regression analysis adjusting for age, race, smoking status, ASA category and concomitant procedures was completed. The outcomes were a composite of complications excluding urinary tract infections (UTI), and hospital readmission within 30 days. <h3>Setting</h3> Inpatient and outpatient mesh revision surgeries performed at community and academic hospitals captured in the NSQIP database from 2012 to 2019. <h3>Patients or Participants</h3> Patients undergoing mesh graft revision by urology or gynecology were classified into vaginal, abdominal or laparoscopic approach using Common Procedural Technology (CPT) codes. Patients having revision of a mid-urethral sling were excluded. <h3>Interventions</h3> Mesh graft revision surgery by vaginal, abdominal or laparoscopic approach <h3>Measurements and Main Results</h3> Of 1692 eligible patients, 1561 underwent vaginal, 74 underwent abdominal, and 57 underwent laparoscopic approach graft revision. The complication rate, excluding UTI, was 4.6% in the vaginal approach group, 12.2% in the abdominal approach group and 12.3% in the laparoscopic approach group (p<0.001). Compared to a vaginal approach, the abdominal approach group had higher odds of complications (abdominal: adjusted OR 2.76, 95% CI 1.30 – 5.83; laparoscopic: adjusted OR 1.86, 95% CI 0.73 – 4.72). The abdominal and laparoscopic groups had higher odds of readmission compared to the vaginal approach group (abdominal: adjusted OR 3.11, 95% CI 1.15 – 8.40; laparoscopic: adjusted OR 6.57, 95% CI 2.22 – 19.40). Clavien-Dindo IV complications were rare and only seen after vaginal surgery (0.4%, n=6). <h3>Conclusion</h3> Short term complications were uncommon after vaginal mesh graft revision surgery, and less common than following an abdominal approach.

Comorbidities Associated With Increased Likelihood of Postoperative Surgical Site Infection in Patients Treated for Hand or Finger Fracture and/or Dislocations.

We aimed to determine the relationship between common preoperative comorbidities and subsequent incidence of postoperative surgical site infections (SSIs) in hand and finger fractures and/or dislocations. We queried the American College of Surgeons National Safety and Quality Improvement Program from January 1, 2015 to December 31, 2019. Patients were included in our study if they were treated by open or percutaneous fixation for any hand or finger fracture and/or dislocation. Predictor variables were smoking status, diabetes mellitus status, and obesity (body mass index > 30) status. Primary outcome was incidence of postoperative SSI. There were a total of 9245 patients included in our study, and 148 patients (1.6%) experienced postoperative SSI. Of these, 59 patients (39.9%) were only smokers, 7 patients (4.7%) only had diabetes mellitus, and 55 patients (37.2%) were only obese. Overall, patients experienced greater odds of sustaining a postoperative SSI if they were a smoker or diabetic compared to non-smokers and non-diabetics, respectively. Considering only open fixation modality, patients with comorbidities were not at significantly increased odds of sustaining postoperative SSI. Considering only percutaneous fixation modality, patients experienced significantly greater odds of sustaining postoperative SSI if they were a smoker compared to non-smoker. Common preoperative comorbidities, including smoking status and diabetes mellitus, increase the likelihood of postoperative complication in patients with hand and finger fractures and/or dislocations undergoing surgical treatment. Further investigation into the different relationship of these comorbidities between open and closed fractures with larger sample sizes will be valuable.

Development and Validation of Machine Learning Models to Predict Readmission After Colorectal Surgery

BackgroundReadmission after colorectal surgery is common and often implies complications for patients and costs for hospitals. Previous works have created predictive models using logistic regression for this outcome but have shown limited accuracy. Machine learning has shown promise in improving predictions by identifying non-linear patterns in data. We sought to create a more accurate predictive model for readmission after colorectal surgery using machine learning. MethodsPatients who underwent colorectal surgery were identified in the National Quality Improvement Program (NSQIP) database including years 2012–2019 and split into training, validation, and test sets. The primary outcome was readmission within 30 days of surgery. Three types of machine learning models were created, including random forest (RF), gradient boosting (XGB), and neural network (NN). A logistic regression (LR) model was also created for comparison. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC). ResultsThe dataset included 213,827 patients after application of exclusion criteria. A total of 23,083 (10.8%) of patients experienced readmission. NN obtained an AUROC of 0.751 (95% CI 0.743–0.759), compared with 0.684 (95% CI 0.676–0.693) for LR. RF and XGB performed similarly with AUROCs of 0.749 (95% CI 0.741–0.757) and 0.745 (95% CI 0.737–0.753) respectively. Ileus, index admission length of stay, organ-space surgical site infection present at time of surgery, and ostomy placement were identified as the most contributory variables. ConclusionsMachine learning approaches outperformed traditional statistical methods in the prediction of readmission after colorectal surgery. After external validation, this improved prediction model could be used to target interventions to reduce readmission rate.

Unicompartmental Knee Arthroplasty vs Total Knee Arthroplasty: A Risk-adjusted Comparison of 30-day Outcomes Using National Data From 2014 to 2018

BackgroundWhen clinically indicated, the choice of performing a total knee arthroplasty (TKA) vs a unicompartmental knee arthroplasty (UKA) is dictated by patient and surgeon preferences. Increased understanding of surgical morbidity may enhance this shared decision-making process. This study compared 30-day risk-adjusted outcomes in TKA vs UKA using a national database. MethodsWe analyzed data from the National Safety and Quality Improvement Program database, for patients who received TKA or UKA between 2014-2018. The main outcomes were blood transfusion, operation time, length of stay, major complication, minor complication, unplanned reoperation, and readmission. Comparisons of odds of the outcomes of interest between TKA and UKA patients were analyzed using multivariate regression models accounting for confounders. ResultsWe identified 274,411 eligible patients, of whom 265,519 (96.7%) underwent TKA, while 8892 (3.3%) underwent UKA. Risk-adjusted models that compared perioperative and postoperative outcomes of TKA and UKA showed that the odds of complications such as blood transfusion (adjusted odds ratio [aOR], 19.74; 95% confidence interval [CI]: 8.19-47.60), major (aOR, 1.87; 95% CI: 1.27-2.77) and minor complications (aOR, 1.43; 95% CI: 1.14-1.79), and readmission (aOR, 1.41; 95% CI: 1.16-1.72) were significantly higher among patients who received TKA than among those who received UKA. In addition, operation time (aOR, 7.72; 95% CI: 6.72-8.72) and hospital length of stay (aOR, 1.11; 95% CI: 1.05-1.17) were also higher among the TKA recipients compared to those who received UKA. ConclusionsUKA is associated with lower rates of adverse perioperative outcomes compared to TKA. Clinical indications and surgical morbidity should be considered in the shared-decision process

Unequitable Heart Failure Therapy for Black, Hispanic and American-Indian Patients.

Despite the high prevalence of heart failure among Black and Hispanic populations, patients of colour are frequently under-prescribed guideline-directed medical therapy (GDMT) and American-Indian populations are not well characterised. Clinical inertia, financial toxicity, underrepresentation in trials, non-trustworthy medical systems, bias and structural racism are contributing factors. There is an urgent need to develop evidence-based strategies to increase the uptake of GDMT for heart failure in patients of colour. Postulated strategies include prescribing all GDMT upon first encounter, aggressive outpatient uptitration of GDMT, intervening upon social determinants of health, addressing bias and racism through changing processes or policies that unfairly disadvantage patients of colour, engagement of stakeholders and implementation of national quality improvement programmes.

Minimally invasive versus open distal pancreatectomy: a matched analysis using ACS-NSQIP.

Minimally invasive distal pancreatectomy (MIDP) is gaining popularity due to improved perioperative outcomes over open distal pancreatectomy (ODP). The purpose of this study is to compare outcomes of MIDP and ODP using patients within a nationwide cohort. The American College of Surgeons' National Quality Improvement Program (2014-2018) was used to evaluate incidence of post-operative pancreatic fistula (POPF) as well as 30-day composite major morbidity for patients undergoing MIDP vs. ODP. Matching was performed with a Mahalanobis-distance model for demographic characteristics, preoperative risk factors, and benign versus malignant pathology. Outcomes were assessed via weighted multiple logistic regression. A total of 3940 patients underwent distal pancreatectomy (1978 MIDP, 1962 ODP). After matching, 2985 patients were included (1978 MIDP, 1007 ODP). The rates of major morbidity (8.65% MIDP vs. 9.76% ODP, p = 0.37) were similar between groups. The MIDP group was found to have significantly decreased length of stay (5.6 vs. 7days, p ≤ 0.001), but greater rates (12.54% MIDP vs. 9.35% ODP, p = 0.02) of post-operative fistula. When matched for baseline patient characteristics, MIDP was associated with shorter length of hospitalization with similar rates of morbidity compared to ODP. However, MIDP was associated with significantly increased rates of POPF. Further studies are needed to investigate this difference in POPF rate, and determine how to optimize MIDP surgical technique to reduce thisrisk.

HbA1c, blood pressure, and cholesterol control in adults with diabetes: A report card for Kuwait

ABSTRACTAimTo assess the level of glycemic, blood pressure, and cholesterol control (the ‘ABCs’) nationally amongst adults with diabetes living in Kuwait.Materials and MethodsUsing data from two national cross‐sectional surveys, the levels of risk factor control were assessed in 1,801 adults with diabetes, aged 18–82 years. Glycemic control was defined as HbA1c < 7%, blood pressure control as systolic and diastolic blood pressures of <140/90 mmHg, and non‐HDL cholesterol control as <3.4 mmol/L.ResultsThe percentage of adults with diabetes achieving control was 39.2% (95% CI, 37.0–41.5) for glycemia, 58.4% (95% CI, 56.0–60.7) for blood pressure, and 28.3% (95% CI, 26.3–30.4) for non‐HDL cholesterol. The percentage of adults who were non‐smokers was 77.6% (95%, CI 75.6–79.4). The percentage of adults with diabetes achieving control on all three risk factors was 7.4% (95% CI, 6.3–8.8), and only 5.8% (95% CI, 4.8–7.0) achieved ABC control and were nonsmokers. ABC control was 30% higher in women compared with men. Non‐Kuwaitis were almost twice as likely to have uncontrolled ABC factors compared with Kuwaitis.ConclusionsOnly 1 in 13 people with diabetes in Kuwait achieved good control of glycemia, blood pressure, and cholesterol. Only 2 in 5 achieved glycemic control, 6 in 10 blood pressure control, and 2 in 7 cholesterol control. A national diabetes quality improvement program is urgently needed to improve the quality of care and to prevent long‐term complications.

Association of annual hospital septic shock case volume and hospital mortality

BackgroundThe burden of sepsis remains high in China. The relationship between case volume and hospital mortality among patients with septic shock, the most severe complication of sepsis, is unknown in China.MethodsIn this retrospective cohort study, we analyzed surveillance data from a national quality improvement program in intensive care units (ICUs) in China in 2020. Association between septic shock case volume and hospital mortality was analyzed using multivariate linear regression and restricted cubic splines.ResultsWe enrolled a total of 134,046 septic shock cases in ICUs from 1902 hospitals in China during 2020. In this septic shock cohort, the median septic shock volume per hospital was 33 cases (interquartile range 14–76 cases), 41.4% were female, and more than half of the patients were over 61 years old, with average hospital mortality of 21.2%. An increase in case volume was associated with improved survival among septic shock cases. In the linear regression model, the highest quartile of septic shock volume was associated with lower hospital mortality compared with the lowest quartile (β − 0.86; 95% CI − 0.98, − 0.74; p < 0.001). Similar differences were found in hospitals of respective geographic locations and hospital levels. With case volume modeled as a continuous variable in a restricted cubic spline, a lower volume threshold of 40 cases before which a substantial reduction of the hospital mortality rate was observed.ConclusionsThe findings suggest that hospitals with higher septic shock case volume have lower hospital mortality in China. Further research is needed to explain the mechanism of this volume–outcome relationship.

Does accreditation matter? An analysis of complications of bariatric cases using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and National Quality Improvement Program databases.

Two large nationwide databases collect data on common operations in the United States. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) collects bariatric data, whereas the National Quality Improvement Program (NSQIP) gathers details on a broader range of general surgical cases. Evaluate the differences in rates of complications between both databases regarding Roux-en-Y gastric bypass and sleeve gastrectomy. National databases, United States. We evaluated the MBSAQIP and NSQIP from 2017 to 2019 using the procedure codes 43644 and 43775. Fifteen common complications were evaluated. Propensity-matched analyses (PMAs) were done to control for differences across databases. Significantly different variables after a PMA were included in multivariable models. The data were examined for differences between the 2 databases before and after the PMA, with and without adjustment for operation type. There were 483,361 cases reported in the MBSAQIP and 57,598 in the NSQIP. PMA matched 57,479 cases for each database. Seven complications were different, with higher rates reported in the NSQIP than in the MBSAQIP: myocardial infarction, sepsis, organ/space surgical site infections, deep vein thrombosis, urinary tract infections, pulmonary embolism, ventilator dependence >48 hours, and pneumonia. When adjusting for the procedure performed, sleeve gastrectomy in the NSQIP had higher rates of organ/space surgical site infections, deep vein thrombosis, sepsis, and death. Roux-en-Y gastric bypass in the NSQIP had higher rates of organ/space surgical site infections, ventilator dependence >48 hours, urinary tract infections, myocardial infarction, deep vein thrombosis, and sepsis. When compared with the MBSAQIP, the NSQIP reports higher rates of bariatric complications. Further studies are needed to confirm the reasons behind this.

Routine Preoperative Nutritional Optimization Not Required in Patients Undergoing Breast Reconstruction

Purpose: There are no data describing the need for preoperative nutritional optimization in patients undergoing breast reconstruction surgery. The purpose of this research was to identify if preoperative breast reconstruction patients are grossly nutritionally deficient as defined by preoperative serum albumin and, thus, if routine preoperative nutrition screening and optimization is necessary in this patient population. Methods: Adult patients who underwent breast reconstruction surgery between 2015 and 2019 were identified within the National Safety and Quality Improvement Program database. Variables of interest for this group of patients were collected, and comparisons were made for these variables between three different breast reconstruction modalities (implant-based reconstruction [IBR], expander-based reconstruction [EBR], and free tissue-based reconstruction [FTBR]) with χ2 and ANOVA statistical tests. Results: A total of 14,509 patients were included. There was not a significant difference in preoperative serum albumin measurements between the three reconstruction modalities and mean measurements for the three reconstruction modalities were all within normal limits. Secondarily, when comparing groups, FTBR had higher incidence of superficial surgical site infection (SSI) (4.49% vs. 1.6% vs. 1.56%, respectively; p < 0.00001), deep SSI (1.57% vs. 0.48% vs. 0.94%, respectively; p < 0.00001), and wound disruption (2.16% vs. 0.78% vs. 0.94%, respectively; p < 0.00001) than IBR and EBR. Conclusion: Preoperative nutritional status was found to be grossly appropriate in a large population of breast reconstruction patients. Furthermore, the ordering of routine preoperative serum albumin is unnecessary and represents an extraneous healthcare cost that does not lead to improved outcomes in breast reconstruction. FTBR incurred the greatest risk of surgical complication independent of preoperative nutritional status.