National Surgical Quality Improvement Research Articles

Preoperative risk factors for anastomotic leak after esophagectomy with gastric reconstruction: A 6-year national surgical quality improvement (NSQIP) database analysis

BackgroundAnastomotic leak is a serious complication after esophagectomy that has been associated with worse outcomes. However, identifying patients at increased risk for anastomotic leak remains challenging. MethodsPatients were included from the 2016 to 2021 National Surgical Quality Improvement Project database who underwent elective esophagectomy with gastric reconstruction for cancer. A multivariable logistic regression model was used to identify risk factors associated with anastomotic leak. ResultsA total of 4,331 patients were included in the study, of whom 647 patients experienced anastomotic leak (14.9%). Multivariable logistic regression revealed higher odds of anastomotic leak with smoking (adjusted odds ratio 1.24, confidence interval 1.02–1.51, P = .031), modified frailty index-5 score of 1 (adjusted odds ratio 1.44, confidence interval 1.19–1.75, P = .002) or 2 (adjusted odds ratio 1.52, confidence interval 1.19-1.94, P = .000), and a McKeown esophagectomy (adjusted odds ratio 1.44, confidence interval 1.16–1.80, P = .001). Each 1,000/μL increase in white blood cell count was associated with a 7% increase in odds of anastomotic leak (adjusted odds ratio 1.07, confidence interval 1.03–1.10, P = .0005). Higher platelet counts were slightly protective, and each 10,000/ μL increase in platelet count was associated with 2% reduced odds of anastomotic leak (adjusted odds ratio 0.98, confidence interval 0.97–0.99, P = .001). ConclusionIn this study, smoking status, frailty index, white blood cell count, McKeown esophagectomy, and platelet counts were all associated with the occurrence of anastomotic leak. These results can help to inform surgeons and patients of the true risk of developing anastomotic leak and potentially improve outcomes by providing evidence to improve preoperative characteristics, such as frailty.

Preoperative Serum Albumin Level Predicts Length of Stay and Perioperative Adverse Events Following Vertebral Corpectomy and Posterior Stabilization for Metastatic Spine Disease.

Retrospective review of a prospectively collected national database. To determine the association between preoperative serum albumin levels and perioperative adverse events (AEs) following vertebral corpectomy and posterior stabilization for metastatic spine disease. The 2010 to 2019 American College of Surgeons' National Surgical Quality Improvement (ACS-NSQIP) database was used to identify all patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Receiver operative characteristic (ROC) curve analysis was used to determine preoperative serum albumin cut-off values for predicting perioperative AEs. Low preoperative serum albumin was defined as serum albumin below this cut-off value. A total of 301 patients were included in the study. ROC curve analysis demonstrated serum albumin < 3.25g/dL as a cut-off value for predicting perioperative AEs. The low serum albumin group had a higher overall perioperative AEs (P = .041), longer post-operative LOS (P < .001), higher 30-day reoperation rate (P = .014), and a higher in-hospital mortality rate (P = .046). Multivariate analysis demonstrated that low preoperative serum albumin was associated with higher perioperative AEs. Low serum albumin level is associated with higher perioperative AEs, longer postoperative LOS, and higher rates of 30-day reoperation and in-hospital mortality among patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Strategies to improve preoperative nutritional status in patients undergoing this procedure may improve these perioperative outcome measures within this surgical population. III.

Surgery on the Day of Admission Decreases Postoperative Complication Rates for Patients With Central Cord Syndrome: An Analysis of National Surgical Quality Improvement (NSQIP) Data From 2010 to 2020.

Retrospective review. This study was undertaken to determine what constitutes "early optimal timing" of surgical management of central cord syndrome (CCS) with respect to a reduction of medical complications. Data varies on the optimal time for surgical treatment of CCS with some studies favoring early intervention and others advocating that surgery can or should be delayed for 2-6 weeks. This IRB-approved study was a retrospective cross-sectional review of surgical management outcomes for patients diagnosed with CCS using the National Surgical Quality Improvement Program database, which consists of anonymized medical record data from the year 2010 to 2020. Patient data included age, sex, American Society of Anesthesiologists score, current procedural terminology codes, length of stay, and postoperative complications. Patients were grouped into admission-day surgery, next-day surgery, and late-surgery groups. A total of 738 patients who underwent surgery to treat CCS were identified in the National Surgical Quality Improvement Program database from 2010 to 2020 and included in this study. Admission-day surgery compared with next-day surgery was associated with a decreased postoperative complication rate after multivariate analysis (odds ratio: 0.52; 95% CI: 0.28-0.97; P =0.0387) as well as shorter length of stay ( P <0.0001). Complication rates between the next-day-surgery cohort and late-surgery cohort did not differ after multivariate analysis (odds ratio: 1.02; 95% CI: 0.63-1.65; P =0.9451), but the length of stay was shorter for next-day surgery ( P <0.0001). Two-year rolling averages for the admission-day-surgery rate and next-day-surgery rate show a compound annual growth rate of 2.52% and 4.10%, respectively. In patients admitted for surgical treatment of CCS, those who receive admission-day surgery have significantly reduced 30-day complication rates as well as shorter length of stays. Therefore, we advocate that "early surgery" should be defined as surgery on the day of admission and should occur in as timely a manner as possible. Prior studies, which define "early surgery" as within 24 hours might, unfortunately, fall short of reaching the optimal threshold for the reduction of 30-day medical complications associated with the treatment of patients with CCS.

Have all races experienced reductions in complication rates following total hip arthroplasty? A NSQIP analysis between 2011 and 2019.

Despite numerous articles in the orthopedic literature evaluating racial and ethnic disparities, inequalities in total joint arthroplasty outcomes remain. While the National Surgical Quality Improvement (NSQIP) database has been previously utilized to highlight these disparities, no previous analysis has evaluated how the rate of various perioperative complications has changed over recent years when segregating by patient race. Specifically, we evaluated if all races have experienced decreases in (1) medical complications, (2) wound complications, (3) venous thromboembolism (VTE), and (4) readmission/reoperation rates following total hip arthroplasty (THA) over recent years? Current Procedural Terminology (CPT) code 27,130 (total hip arthroplasty) was utilized to identify all THA procedures conducted between 2011 and 2019. Patients were segregated according to race and various demographics were collected. Linear regression was utilized to evaluate changes in each complication rate between 2011 and 2019. A multivariate regression was then conducted for each complication to evaluate whether race independently was associated with each outcome. Our analysis included a total of 212,091 patients undergoing primary THA. This included 182,681 (85.76%) White, 19,267 (9.04%) Black, 5928 (2.78%) Hispanic, and 4215 (1.98%) Asian patients. We found that for urinary tract infection (UTI), acute renal failure, superficial SSI, and readmission rates, White patients experienced significant reductions between 2011 and 2019. However, this was not consistent across all races. Black race was associated with a significantly increased risk of acute renal failure (OR: 2.03, 95% CI: 1.17-3.34; p = 0.008), renal insufficiency (OR: 2.33, 95% CI: 1.62-3.28; p < 0.001), deep vein thrombosis (DVT) (OR: 1.34, 95% CI: 1.07-1.66; p = 0.01), and pulmonary embolism (PE) (OR: 1.76, 95% CIL: 1.36-2.24; p < 0.001). Our analysis highlights specific complications for which further interventions are necessary to reduce inequalities across races. These include medical optimization, increased patient education, and continued efforts at understanding how social factors may impact-related care inequalities. Future study is needed to evaluate specific interventions that can be applied at the health systems level to ensure all patients undergoing THA receive the highest quality of care regardless of race.

Post-Operative Day Zero Discharge after Laparoscopic Appendectomy Does Not Worsen High-Yield Outcomes: A NSQIP Database Observational Study

Background: Post-operative day zero (POD-0) discharge after laparoscopic appendectomy for uncomplicated appendicitis has been studied primarily in single-center or pediatric studies. A larger study from a national sample addressing high-yield outcomes can update and supplement current literature and evaluate early discharge rates. Methods: This is a retrospective, observational National Surgical Quality Improvement (NSQIP) database study of laparoscopic appendectomies for uncomplicated appendicitis performed 2016–2019, with discharge POD-0 or post-operative day one (POD-1). Study outcomes included any or serious complication, unplanned readmission, and unplanned return to operating room (OR). Unadjusted outcomes comparisons were estimated via chi-square tests. Multivariate logistic regression models were constructed to adjust for potential confounders (sex, ethnicity, frailty, ASA score, tobacco use and diabetes). Results: A total of 25,629 patients were included in this analysis. More patients were discharged POD-1 (n = 15,229) than POD-0 (n = 10,440). Rate of any or serious complication was lower in patients discharged POD-0 than POD-1 (any complication: 2.0 vs. 2.8, p = 0.0002, serious complication: 1.4 vs. 2.1, p < 0.0001). Unplanned return to OR and unplanned readmission rates were not different between POD-0 and POD-1 discharged groups (p = 0.9 and p = 0.6, respectively). These findings were robust to adjustment for covariates in logistic regression modeling. Conclusions: This study found that unplanned readmission and other outcomes do not appear to be adversely affected by early discharge after laparoscopic appendectomy for uncomplicated appendicitis, confirming prior evidence on the topic in a large, national sample. It also found that early discharge does not appear to be used in most of these patients.

P90. Racial disparities in surgical access and outcomes for oncologic spinal pathology: a multicenter study

BACKGROUND CONTEXT Racial disparities in access to spine surgery and differences in perioperative outcomes have become increasingly evident over the past several years within the United States. However, there is a paucity of evidence concerning racial disparities in surgical access and perioperative outcomes for oncologic spinal pathologies. PURPOSE To determine the association between patient race and access to inpatient spine surgery and perioperative outcomes among patients with oncologic spinal pathologies. STUDY DESIGN/SETTING Retrospective analysis of prospectively collected data. PATIENT SAMPLE The 2010 to 2019 National Surgical Quality Improvement (NSQIP) database was used to identify all black and white patients undergoing surgery for primary or metastatic spine tumors. OUTCOME MEASURES Preoperative health care utilization data including method of hospital admission and rate of emergency surgery were investigated. Postoperative outcomes measures including postoperative length of stay (LOS), 30-day reoperation, 30-day readmission, discharge disposition and major perioperative complications were also investigated. METHODS Patients were stratified by race (black vs white). Two-tailed student t-test was used to analyze continuous data and the Chi Square Test was used to analyze categorical data. A p-value < 0.05 was considered statistically significant. RESULTS A total of 7,320 patients (879 blacks, 6,441 whites) were included in this study. Blacks were more likely to be transferred from an outside emergency room or hospital for definitive care compared to whites (17.3% vs 13.3%; p < 0.01) and a higher rate of emergency surgery was performed among blacks versus whites (14.6% vs 8.2%; p < 0.01). Blacks had a longer post-operative LOS (10.2± 9.2 days vs 7.7 ± 7.4 days; p < 0.01) and higher rates of one or more major perioperative complications (36.8% vs 29.6%; p < 0.01). Blacks also had higher rates of 30-day readmission (14.2% vs 10.4%; p < 0.01) and 30-day re-operation (6.9% vs 4.8%; p < 0.01) as well as higher rates of discharge to a facility (48.2% vs 33.5%). There were no differences in in-hospital mortality rates between blacks and whites (0.8% vs 1.0%; p=0.45). CONCLUSIONS There are significant racial disparities in both access to spine surgery and perioperative outcomes between blacks and whites undergoing surgery for oncologic spinal pathologies. Blacks are more likely to undergo emergency surgery, have longer postoperative LOS, and have higher rates of perioperative complications, 30-day readmission and 30-day reoperation. Renewed efforts to eliminate these disparities are needed on a national level. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Racial disparities in access to spine surgery and differences in perioperative outcomes have become increasingly evident over the past several years within the United States. However, there is a paucity of evidence concerning racial disparities in surgical access and perioperative outcomes for oncologic spinal pathologies. To determine the association between patient race and access to inpatient spine surgery and perioperative outcomes among patients with oncologic spinal pathologies. Retrospective analysis of prospectively collected data. The 2010 to 2019 National Surgical Quality Improvement (NSQIP) database was used to identify all black and white patients undergoing surgery for primary or metastatic spine tumors. Preoperative health care utilization data including method of hospital admission and rate of emergency surgery were investigated. Postoperative outcomes measures including postoperative length of stay (LOS), 30-day reoperation, 30-day readmission, discharge disposition and major perioperative complications were also investigated. Patients were stratified by race (black vs white). Two-tailed student t-test was used to analyze continuous data and the Chi Square Test was used to analyze categorical data. A p-value < 0.05 was considered statistically significant. A total of 7,320 patients (879 blacks, 6,441 whites) were included in this study. Blacks were more likely to be transferred from an outside emergency room or hospital for definitive care compared to whites (17.3% vs 13.3%; p < 0.01) and a higher rate of emergency surgery was performed among blacks versus whites (14.6% vs 8.2%; p < 0.01). Blacks had a longer post-operative LOS (10.2± 9.2 days vs 7.7 ± 7.4 days; p < 0.01) and higher rates of one or more major perioperative complications (36.8% vs 29.6%; p < 0.01). Blacks also had higher rates of 30-day readmission (14.2% vs 10.4%; p < 0.01) and 30-day re-operation (6.9% vs 4.8%; p < 0.01) as well as higher rates of discharge to a facility (48.2% vs 33.5%). There were no differences in in-hospital mortality rates between blacks and whites (0.8% vs 1.0%; p=0.45). There are significant racial disparities in both access to spine surgery and perioperative outcomes between blacks and whites undergoing surgery for oncologic spinal pathologies. Blacks are more likely to undergo emergency surgery, have longer postoperative LOS, and have higher rates of perioperative complications, 30-day readmission and 30-day reoperation. Renewed efforts to eliminate these disparities are needed on a national level.

Same-day Hospital Discharge after Minimally Invasive Hysterectomy in a Gynecologic Oncology Practice: Feasibility, Safety, Predictors of Admission, and Adverse Outcomes

(1) Determine the feasibility and safety of same-day hospital discharge (SDHD) after minimally invasive hysterectomy (MIH) in a gynecologic oncology practice and (2) detail predictors of immediate postoperative hospital admission and multiple 30-day adverse outcomes. Retrospective cohort study. University of Pittsburgh Medical Center Magee-Womens Hospital. MIH by a gynecologic oncologist between January 2017 and July 2019. Clinicopathologic, operative, and medical characteristics, as well as 30-day postoperative complications, emergency department (ED) encounters, and hospital readmissions were extracted. Admitted and SDHD patients were compared using descriptive, chi-square, Fisher's exact, t test, and logistic regression analyses. Univariate and multivariable analyses (MVA) revealed predictors of postoperative hospital admission, 30-day readmission, and a 30-day composite adverse event variable (all-reported postoperative complications, ED encounter, and/or readmission). A total of 1124 patients were identified, of which 77.3% had cancer or precancer; 775 patients (69.0%) underwent SDHD. On MVA, predictors of postoperative admission included older age, distance from hospital, longer procedure length, operative complications, start time after 2 PM, radical hysterectomy, minilaparotomy, adhesiolysis, cardiac disease, cerebrovascular disease, venous thromboembolism, diabetes, and neurologic disorders (p <.05). Moreover, 30-day adverse outcomes were rare (complication 8.7% National Surgical Quality Improvement Program/11.9% all-reported; ED encounter 5.0%; readmission 3.6%). SDHD patients had fewer all-reported complications (10.3% vs 15.5%, p=.01), no difference in ED encounters (4.6% vs 5.7%, p=.44), and fewer observed readmissions (2.8% vs 5.2%, p=.05). Predictors of readmission were identified on univariate; MVA was not feasible given the low number of events. Longer procedure length and cardiac and obstructive pulmonary disease were predictors of the composite adverse event variable (p <.05). SDHD is feasible and safe after MIH within a representative gynecologic oncology practice. Clinicopathologic, medical, and surgical predictors of multiple adverse outcomes were comprehensively described. By identifying patients at high risk of postoperative adverse events, we can direct SDHD selection in the absence of standardized institutional and/or national consensus guidelines and identify patients for prehabilitation and increased perioperative support.

Comparative Effectiveness of Risk-adjusted Cumulative Sum and Periodic Evaluation for Monitoring Hospital Perioperative Mortality.

National surgical quality improvement (QI) programs use periodic, risk-adjusted evaluation to identify hospitals with higher than expected perioperative mortality. Rapid, accurate identification of poorly performing hospitals is critical for avoiding potentially preventable mortality and represents an opportunity to enhance QI efforts. Hospital-level analysis using Veterans Affairs (VA) Surgical Quality Improvement Program data (2011-2016) to compare identification of hospitals with excess, risk-adjusted 30-day mortality using observed-to-expected (O-E) ratios (ie, current gold standard) and cumulative sum (CUSUM) with V-mask. Various V-mask slopes and radii were evaluated-slope of 2.5 and radius of 1.0 was used as the base case. Hospitals identified by CUSUM and quarterly O-E were identified midway into a quarter [median 47 days; interquartile range (IQR): 24-61 days before quarter end] translating to a median of 129 (IQR: 60-187) surgical cases and 368 (IQR: 145-681) postoperative inpatient days occurring after a CUSUM signal, but before the quarter end. At hospitals identified by CUSUM but not O-E, a median of 2 deaths within a median of 5 days triggered a signal. In some cases, these clusters extended beyond CUSUM identification date with as many as 8 deaths undetected using O-E. Sensitivity and negative predictive values for CUSUM relative to O-E were 71.9% (95% confidence interval: 66.2%-77.1%) and 95.5% (94.4%-96.4%), respectively. CUSUM evaluation identifies hospitals with clusters of mortality in excess of expected more rapidly than periodic analysis. CUSUM represents an analytic tool national QI programs could utilize to provide participating hospitals with data that could facilitate more proactive implementation of local interventions to help reduce potentially avoidable perioperative mortality.

Fenestrated Endovascular Aneurysm Repair Affords Fewer Renal Complications than Open Surgical Repair for Juxtarenal Abdominal Aortic Aneurysms in Patients with Chronic Renal Insufficiency

ObjectiveAlthough fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. MethodsAll adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons – National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012–2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the “Cook Zenith Fenestrated” endograft. OSR cases were defined as those that required proximal clamp positions “above one renal” or “between SMA & renals.” Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. ResultsThere were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001). ConclusionFor patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.

Relationship Between Perioperative Outcomes Used for Profiling Hospital Noncardiac Surgical Quality

BackgroundRisk-adjusted morbidity and mortality are commonly used by national surgical quality improvement (QI) programs to measure hospital-level surgical quality. However, the degree of hospital-level correlation between mortality, morbidity, and other perioperative outcomes (like reoperation) collected by contemporary surgical QI programs has not been well-characterized. Materials and MethodsVeterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) data (2015-2016) were used to evaluate hospital-level correlation in performance between risk-adjusted 30-d mortality, morbidity, major morbidity, reoperation, and 2 composite outcomes (1- mortality, major morbidity, or reoperation; 2- mortality or major morbidity) after noncardiac surgery. Correlation between outcomes rates was evaluated using Pearson's correlation coefficient. Correlation between hospital risk-adjusted performance rankings was evaluated using Spearman's correlation. ResultsBased on a median of 232 [IQR 95-331] quarterly surgical cases abstracted by VASQIP, statistical power for identifying 30-d mortality outlier hospitals was estimated between 3.3% for an observed-to-expected ratio of 1.1 and 45.7% for 3.0. Among 230,247 Veterans who underwent a noncardiac operation at 137 VA hospitals, there were moderate hospital-level correlations between various risk-adjusted outcome rates (highest r = 0.40, mortality and composite 1; lowest r = 0.32, mortality and morbidity). When hospitals were ranked based on performance, there was low-to-moderate correlation between rankings on the various outcomes (highest ρ = 0.47, mortality and composite 1; lowest ρ = 0.37, mortality and major morbidity). ConclusionsModest hospital-level correlations between perioperative outcomes suggests it may be difficult to identify high (or low) performing hospitals using a single measure. Additionally, while composites of currently measured outcomes may be an efficient way to improve analytic sample size (relative to evaluations based on any individual outcome), further work is needed to understand whether they provide a more robust and accurate picture of hospital quality or whether evaluating performance across a portfolio of individual measures is most effective for driving QI.

Incidence, predictors, and timing of post-operative stroke following elective total hip arthroplasty and total knee arthroplasty

BackgroundPostoperative stroke is a rare but potentially devastating complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of the current study was to determine the incidence, independent risk factors, and timing of stroke following THA and TKA utilizing the National Surgical Quality Improvement (NSQIP) database.MethodsPatients who underwent elective primary THA and TKA were identified in the 2005–2016 NSQIP database. Thirty-day postoperative strokes were identified, timing was characterized, and an incidence curve was created. Multivariate analyses determined the independent predictors of these strokes.ResultsOf 333,117 patients identified, 286 (0.09%) experienced a stroke. Given that THA vs TKA was not a univariate predictor of stroke, the two procedures were considered together. The majority (65%) of strokes occurred before discharge. Of the strokes observed, 25% occurred by postoperative day one, 50% by postoperative day two, and 75% by postoperative day nine. Independent risk factors for postoperative stroke were: age (60–69 years old odds ratio [OR] = 4.2; 70–79 years old OR = 8.1; ≤80 years old OR = 16.1), higher American Society of Anesthesiologists (ASA) score (ASA≥3 OR = 1.7), and smoking [OR = 1.6).ConclusionThe incidence of stroke after THA/TKA was low at 0.09%, with the majority occurring prior to discharge and half occurring by postoperative day two. Patients who were older, sicker, or who were smokers were at greater risk of postoperative stroke. These findings can be used to council patients and to optimize patient care.Level of evidenceLevel III, Retrospective comparative study.

Inaccuracies in Postoperative Inpatient Stays Assumed in the Valuation of Surgical RVUs.

The aim of this study was to assess the accuracy of inpatient postoperative visits assumed in the valuation of surgical relative value units (RVUs). Medicare reimburses physicians based on the number of RVUs assigned to a service. For surgical procedures with a 10- or 90-day global period, the RVU valuation is based, in part, on a presumed number of inpatient postoperative visits whether or not those visits occur. The Centers for Medicare and Medicaid Services (CMS) have recently proposed changing all surgical procedures to a 0-day global period. We combined 2017 National Surgical Quality Improvement (NSQIP) data with physician time and RVU files from CMS. We then compared the number of inpatient postoperative visits assumed in the valuation to actual length of stay (LOS) information from the surgical registry. The analysis included 10 specialties and 601 distinct current procedural terminology codes. The number of patient observations underlying NSQIP LOS estimates ranged from 50 to 57,904. Eighty-three percent of procedures had median NSQIP LOS values that were shorter than the values assumed in the global period. These differences varied by specialty, with the largest discrepancy in neurosurgery. Procedures in this sample were last reviewed, on average, in 2000, with procedures reviewed more recently having more accurate valuations with respect to LOS. The number of postoperative visits assumed in the valuation of surgical RVUs is grossly inaccurate. Holding all else equal, removing global periods from surgical RVUs would dramatically reduce surgeon compensation.

Specific causes and predictors of readmissions following acute and chronic subdural hematoma evacuation

Patients treated with craniotomy for subdural hematoma (SDH) evacuation have a higher readmission incidence when compared to other neurosurgical patients. Factors predictive of readmission following craniotomy for SDH are incompletely understood. The National Surgical Quality Improvement (NSQIP) database was queried for all patients treated by craniotomy for SDH of any etiology (e.g. acute, chronic, spontaneous, traumatic) during the study period (2012–2014). Patients requiring repeat hospitalization within 30 days of surgery were identified and classified by reason for readmission. Binary logistic regression analysis was used to identify predictors of readmission. 1024 patients met inclusion criteria, among whom 109 (10.6%) were readmitted within 30 days. The most common causes of readmission were recurrent SDH (n = 27; 33.3%), seizure (n = 8; 9.9%), new neurological deficit (n = 6; 7.4%), stroke (n = 6; 7.4%), and altered mental status (AMS) (n = 6; 7.4%). Multivariable modeling identified hypertension requiring medication (OR = 2.78, P = 0.013) and abnormal INR (OR = 2.66, P = 0.035) as significantly associated with readmission following chronic SDH, while postoperative UTI (OR = 3.64, P = 0.01) and stroke (OR = 4.86, P = 0.018) were significant predictors of readmission following acute SDH. Readmission was associated with recurrent hemorrhage after chronic/spontaneous SDH, while seizures, AMS, and neurological deficits drove readmissions after acute/traumatic SDH. Careful management of anticoagulation and antihypertensive medications may be helpful in reducing the risk of readmission following craniotomy for chronic SDH.

A Comparison of 30-Day Perioperative Complications for Open Operative Care of Distal Upper-Extremity Fractures Treated by Orthopedic Versus Plastic Surgeons: A Study of the National Surgical Quality Improvement (NSQIP) Database

PurposeTo determine whether surgeon specialty affects complications after open operative care of distal upper-extremity fractures.MethodsWe performed a retrospective cross-sectional study using the American College of Surgeons National Surgical Quality Improvement Database from 2005 to 2016. Patients were included if they received open operative treatment by an orthopedic or a plastic surgeon for distal radius/ulna, carpal, metacarpal, or phalangeal fracture. Univariate analysis and multivariable analysis of perioperative complications were performed to identify differences between the 2 specialties. Major complications assessed were 30-day reoperation and mortality. We also assessed transfusion, thromboembolic, surgical site infections, cardiac, pulmonary, and renal complications.ResultsA total of 20,512 patients were included. Most cases performed by orthopedic surgeons (71.2%) were for distal radius/ulna fractures, whereas the majority of cases performed by plastic surgeons were for metacarpal (41.0%) and phalangeal (37.9%) fractures. No difference was identified in most perioperative complications between specialties. Plastic surgeons had a higher incidence of surgical site infections (1.2% vs 0.5%) on univariate analysis. However, when controlling for variables such as patient demographics and comorbidities in multivariable analysis, surgical specialty was not significantly associated with surgical site infection. Rather, surgery on phalangeal bones (adjusted odds ratio [aOR] = 2.745; 95% confidence interval [CI], 1.559–4.833), higher wound class (wound class 3 aOR = 3.630; 95% CI, 2.003–6.577), and smoking (aOR = 1.970; 95% CI, 1.279–3.032) were independent risk factors for surgical site infection. Plastic surgeons were found to operate on proportionally more smokers, patients with higher wound class, and phalangeal fractures (37.9% of all fracture cases) compared with orthopedic surgeonsConclusionsOrthopedic and plastic surgeons achieve equivalent outcomes from a safety perspective after open operative treatment of upper-extremity fractures in terms of mortality and 30-day reoperation, which suggests that both specialties can safely perform call-related operative upper-extremity fracture care. Plastic surgeons operated on more smokers, patients with higher wound class, and phalangeal fractures, all of which were associated with increased incidence of surgical site infection, revealing differences in practice composition from their orthopedic colleagues.Type of study/level of evidenceTherapeutic III.

Use of radiation therapy in neoadjuvany treatment for pancreatic adenocarcinoma decreases risk of postoperative pancreatic fistula: A nsqip analysis

Presenter: Christopher Mangieri MD | Wake Forest University Background: Neoadjuvant therapy for pancreatic cancer decreases the risk of post-operative pancreatic fistula (POPF). However, there is a paucity of published data specifying which neoadjuvant regimen is most protective against POPF development. We evaluated the differences between neoadjuvant chemotherapy (CT), radiation therapy (RT), and chemotherapy/radiation therapy (CRT) in regard to effect on POPF rates. We hypothesize combined therapy decreases POPF. Methods: The main and targeted pancreatectomy National Surgical Quality Improvement (NSQIP) registries for 2014-2016 were retrospectively reviewed. Cases that did not contain information on the use of neoadjuvant therapy or POPF development were excluded. Additionally, cases that did not identify a malignant etiology were excluded. Linear regression analysis of NSQIP factors that have previously been shown to be associated with or suspected to be associated with POPF was performed. Factors included neoadjuvant therapy, sex, age, BMI, diabetes, smoking, steroid therapy, preoperative weight loss, preoperative albumin level, perioperative blood transfusions, wound classification, ASA classification, duct size (6mm), gland texture (soft, intermediate, hard), and anastomotic technique. Factors identified to be statistically significant with the development of POPF were then compared between cases that received neoadjuvant CT, RT, and CRT. Results: 10,117 cases were analyzed. Development of POPF was significantly associated with lack of neoadjuvant therapy, male sex, higher BMI, non-diabetic status, post-operative blood transfusion, decreased duct size, and soft gland texture. Neoadjuvant therapy, BMI, duct size, and gland texture had the strongest associations with development of POPF (all p values < 0.0001). Overall 1,765 cases (17.45%) underwent neoadjuvant therapy. 1,031 cases underwent CT, 62 cases underwent RT, and 672 cases underwent CRT. The POPF rates were 20.1%, 11.15%, 4.84%, and 8.18% for cases that received no neoadjuvant therapy, CT, RT, and CRT respectively (p value < 0.0001). Comparison of POPF rates between groups receiving only neoadjuvant therapy demonstrated persistent significant differences with the inclusion of radiation therapy (p value 0.039). Decreasing POPF rates correlated significantly with firmer gland texture with the hard gland rates being 54.84%, 54.17%, 42.48%, and 29.01% in the RT, CRT, CT, and no therapy groups respectively (p value < 0.001). Comparison of the neoadjuvant treatment groups revealed no statistically significant differences between duct size, diabetic status, post-operative transfusions, and BMI. Conclusion: To our knowledge this is the largest analysis of specific neoadjuvant regimens in regard to the development of POPF following pancreaticoduodenectomy. The addition of radiation therapy to neoadjuvant regimens provides the strongest protective effect. This is potentially due to increased fibrosis in the pancreatic parenchyma from the radiation therapy resulting in a firmer gland. These findings provide additional support to alleviate concerns the use of neoadjuvant therapy with radiation will increase adverse outcomes after pancreaticoduodenectomy.

Analysis of the impact of chronic corticosteroid use on free flap reconstruction.

Systemic corticosteroids negatively impact wound healing, potentially increasing postoperative wound complication rates. In this study, the authors utilize the American College of Surgeons (ACS) National Surgical Quality Improvement (NSQIP) database to investigate the impact of chronic steroid usage on postoperative complications following microvascular free tissue transfer procedures. The ACS NSQIP database was queried for all free flap procedures performed between 2005 and 2016. Patients with a history of chronic steroid use (n = 159) were compared to patients with no history of chronic steroid use (n = 3,405). The two cohorts were compared by univariate analysis, followed by multivariate binary logistic regression for all complications noted to be statistically significant on univariate analysis. Patients treated with systemic corticosteroids were more likely to be smokers, have a history of diabetes, hypertension, bleeding disorders, hypoalbuminemia, anemia, and have a wound infection at time of surgery. There were increased rates of bleeding requiring transfusion (37.7 vs. 27.5% p = .005), overall surgical complications (48.4 vs. 36.7%, p = .003) and overall complication rates (56.0 vs. 42.3%, p = .001) in these patients. On multivariate analysis, chronic steroid use was not associated with increased risk of surgical complications (OR = 2.540, p = .056, 95% CI 0.975-6.622), overall complications (OR = 2.303, p = .086, 95% CI 0.888-5.973), or wound complications. However, chronic steroid usage conferred nearly a four times increased risk for major bleeding complications (OR = 3.995, p = .009, 95% CI 1.415-11.279). Chronic corticosteroid use does not increase rates of wound complications, reoperation, or readmission. However, this population may be at increased risk for major bleeding requiring blood transfusion following free flap reconstruction.

The Impact of Body Mass Index (BMI) on 30-day Outcomes Following Posterior Spinal Fusion in Neuromuscular Scoliosis.

Retrospective. Assess the impact of varying severity of BMI on 30-day outcomes following posterior spinal fusions in neuromuscular scoliosis. Obesity in the pediatric population is shown to be associated with adverse outcomes across varying specialties. The weight-outcome relationship in neuromuscular scoliosis has not been thoroughly investigated. The 2012-2016 American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) database was queried using Current Procedural Terminology codes 22800, 22802, and 22804 to identify patients undergoing posterior spinal fusion for neuromuscular scoliosis only. BMI was classified into four groups based on the Center for Disease Control (CDC) BMI-for-age percentile chart - Normal weight (BMI ≥5th to <85th percentile), Underweight (<5th percentile), Overweight (≥85th to <95th percentile) and Obese (≥95th percentile). Multivariate regression models were built to understand the impact of varying BMI severity classes on 30-day outcomes. A total of 1291 patients underwent posterior spinal fusion for neuromuscular scoliosis. A total of 695 (53.8%) were normal weight, 286 (22.2%) were underweight, 145 (11.2%) were overweight, and 165 (12.8%) were obese. Obese patients versus normal weight patients were at a significantly higher risk of surgical site infections (OR 2.15; P = 0.035), wound dehiscence (OR 1.58; P = 0.037), urinary tract infections (OR 3.41; P = 0.010), and 30-day readmissions (OR 1.94; P = 0.029). Of note, overweight versus normal weight individuals had higher odds of cardiopulmonary complications (OR 8.82; P = 0.024). No significant associations were seen for varying BMI and other 30-day outcomes. Obese neuromuscular patients undergoing PSF have higher odds of experiencing adverse outcomes, particularly surgical site infections, urinary tract infections, and readmissions. Providers should promote prevention strategies, such as dietary modification and/or early physical activity in these high-risk patients to minimize the risks of experiencing complications in the acute postoperative period. 3.

P80. The impact of body mass index (BMI) on postoperative outcomes following posterior spinal fusion in neuromuscular scoliosis

BACKGROUND CONTEXT Obesity in the pediatric population is shown to be associated with adverse outcomes across varying specialties. The weight-outcome relationship in neuromuscular scoliosis has not been thoroughly investigated. PURPOSE To assess the impact of varying severity of BMI on 30-day outcomes following posterior spinal fusions in neuromuscular scoliosis. STUDY DESIGN/SETTING Retrospective review of prospectively collected data from a national pediatric surgical registry. PATIENT SAMPLE The 2012-2016 American College of Surgeons – National Surgical Quality Improvement (ACS-NSQIP) database was queried using Current Procedural Terminology codes 22800, 22802 and 22804 and International Classification of Diseases 9th Edition (ICD-9) diagnoses codes to identify patients undergoing posterior spinal fusion for neuromuscular scoliosis only. BMI was classified into four groups based on the Center for Disease Control (CDC) BMI-for-age percentile chart – normal weight (BMI ≥5th to OUTCOME MEASURES Thirty-day outcomes studied included prolonged length of stay >4 days, surgical site infections (superficial/deep/organ-space), wound dehiscence, pneumonia, unplanned intubation, cardiopulmonary complications (cardiac arrest or pulmonary embolism), renal complications (acute renal failure or progressive renal insufficiency), urinary tract infection, CNS complications (coma, stroke, seizure), venous thromboembolism, sepsis, bleeding requiring transfusion, re-operations, re-admissions and mortality outcomes. METHODS Pearson's Chi-square tests were used to assess for baseline differences and 30-day outcomes among the four BMI groups. Each 30-day outcome variable was then entered into a multivariate regression model while adjusting for clinically relevant baseline demographic and clinical characteristics (age, gender, steroid use, ventilator dependence, asthma, gastric disorder, developmental delay, seizure disorder, nutritional support requirement, length of fusion, primary vs revision procedure, use of osteotomy, and pelvic fixation) between the groups, to study the independent impact of varying severity of BMI on 30-day outcomes. RESULTS A total of 1,291 patients underwent posterior spinal fusion for neuromuscular scoliosis. A total of 695 (53.8%) were normal weight, 286 (22.2%) were underweight, 145 (11.2%) were overweight and 165 (12.8%) were obese. Obese patients vs normal weight patients were at a significantly higher risk of surgical site infections (OR 2.15; p=0.035), wound dehiscence (OR 1.58; p=0.037), urinary tract infections (OR 3.41; p=0.010) and 30-day readmissions (OR 1.94; p=0.029). Of note, overweight vs normal weight individuals had higher odds of cardiopulmonary complications (OR 8.82; p=0.024). No significant associations were seen for varying BMI and other 30-day complications, length of stay and mortality. CONCLUSIONS Obese neuromuscular patients undergoing PSF have higher odds of experiencing adverse outcomes, particularly surgical site infections, urinary tract infections and readmissions. Providers should promote prevention strategies, such as dietary modification and/or early physical activity in these high-risk patients to minimize the risks of experiencing complications in the acute post-operative period. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Head and Neck Reconstruction: Does Surgical Specialty Affect Complication Rates?

Reconstruction of head and neck defects resulting from resection of head and neck masses is performed by both plastic surgeons and otolaryngologists. The American College of Surgeons National Surgical Quality Improvement (NSQIP) database allows one to directly compare the outcomes for a given procedure based upon specialty. The purpose of this study is to compare outcomes and resource utilization of microvascular head and neck reconstruction between plastic surgery and otolaryngology. Institutional review board approval was obtained and NSQIP was queried from 2005 to 2015 with inclusion of Current Procedural Terminology codes for free tissue transfer performed for head and neck reconstruction. Outcomes were compared between cases having otolaryngology and plastic surgery as performing the free flap reconstruction. During 2005 to 2015, a total of 2,322 flaps were performed, 893 by plastic surgery and 1,429 by otolaryngology. Average length of stay (LOS) was 13.7 and 11.4 days for plastic surgery and otolaryngology, respectively. It was found that plastic surgery performed more osteocutaneous flaps than otolaryngology. Higher rates of superficial surgical site infection, deep surgical site infections, wound dehiscence, myocardial infarction, bleeding complications, sepsis, unplanned return to the operating room, and unplanned readmission were observed for patients treated by otolaryngology (p < 0.05). This study shows plastic surgery patients have superior outcomes with regards to free tissue transfers of the head and neck when compared with otolaryngology patients. Although plastic surgery patients experienced a longer LOS, the significantly lower complication rate supports an overall more optimal resource utilization. Future studies may elucidate potential cost savings in patients treated by plastic surgery.

Impact of patient handover structure on neonatal perioperative safety.

ObjectiveTo compare the incidence, severity, preventability, and contributing factors of non-routine events - deviations from optimal care based on the clinical situation - associated with team-based, nurse-to-nurse, and mixed handovers in a large cohort of surgical neonates.Study DesignA prospective observational study and one-time cross-sectional provider survey were conducted at one urban academic children’s hospital. 130 non-cardiac surgical cases in 109 neonates who received pre- and post-operative NICU care.ResultsThe incidence of clinician-reported NREs was high (101/130 cases, 78%) but did not differ significantly across acuity-tailored neonatal handover practices. National Surgical Quality Improvement – Pediatric occurrences of major morbidity were significantly higher (p<0.001) in direct team handovers than indirect nursing or mixed handovers.ConclusionsNREs occur at a high rate and are of variable severity in neonatal perioperative care. NRE rates and contributory factors were homogenous across handover types. Surveyed clinicians recommend structured handovers for all patients at every transfer point regardless of acuity.