Surgical Care Outcomes Research Articles

Differences in Surgical Cancer Care Delivery and Outcomes Between Safety-Net and Non-Safety-Net Hospitals in the United States: A Comprehensive Systematic Review.

Studies evaluating the association of safety-net hospitals (SNHs) with outcomes of surgical care in cancer patients have demonstrated mixed results. We sought to systematically investigate the association of SNH status with measures of surgical cancer care delivery and outcomes. A comprehensive review of the literature identified from the MEDLINE/PubMed, Embase, Web of Science, and Cochrane databases was performed according to the PRISMA guidelines. Risk of bias assessment was conducted using the Joanna Briggs Institute's tool. The findings were synthesized qualitatively. Of the 1749 records identified, 33 retrospective studies were included, 79% of which investigated national databases. Risk of bias assessment revealed average score of 78%. Among studies assessing each outcome, lower likelihood of receiving appropriate surgical interventions in SNH patients was reported by 85%; longer intervals to surgery by 100%; and prolonged hospital stays by 73%. Most studies reported no differences in survival (65%) or readmission (67%). Results were mixed regarding complications and mortality. Patient characteristics and shortage of resources and interdisciplinary teams were frequently proposed factors for observed disparities. Cancer patients at SNHs may be less likely to undergo some surgical treatments and experience longer intervals to treatment but achieve largely comparable short- and long-term outcomes to non-SNH patients.

Abdominal vacuum therapy is a component of DAMAGE CONTROL SURGERY tactics for combat trauma to the abdomen

The goal of the study was to improve the outcomes of surgical care and treatment for patients with combat-related abdominal injuries at different levels of medical support during combat operations by using abdominal vacuum therapy as a component of Damage Control Surgery tactics. At the II level of combat medical support within the Damage Control Surgery tactics, abdominal vacuum therapy was applied to 75 wounded male combatants with a combat abdominal injury, aged 37.4±8.3 years (main group). The comparison group consisted of 87 wounded patients aged 37.5±10.2 years, operated on using Damage Control Surgery tactics with drainage of the abdominal cavity and suturing of the skin only. 40.0% of the wounded in the main group and 46.0% of the comparison group were admitted with signs of traumatic shock of various degrees. According to the AdTS scale, 78.7% of the wounded in the main group were admitted in a serious condition, 21.3% – in an extremely serious condition; in the comparison group, 74.7% were in severe condition, 25.3% were in extremely severe condition. In 57.3% of the wounded of the main group, abdominal vacuum therapy was carried out in the irrigation-flow mode. 24.0% used standard bandages for abdominal vacuum therapy, 76.0% used partially improvised ones. The level of negative pressure was set in the range of 40-125 mm Hg in constant mode. Intra-abdominal pressure was measured by a standard method (through the bladder) at admission and after surgery. The assessment of the state of the abdominal cavity in the I and III phases of Damage Control Surgery was carried out according to the Abdominal Cavity Index scale – an integral assessment expressed in points based on factors that can be assessed visually during surgery. The volume of surgical interventions in the 1st phase of the Damage Control Surgery tactic depended on the nature of the damage to the abdominal organs and the condition of the wounded. After the completion of Phase I of Damage Control Surgery tactics, all wounded were evacuated by road medical transport and medical helicopters to the next level of medical support, with abdominal vacuum therapy during evacuation in the main group and Damage Control Resuscitation measures. Under the effect of abdominal vacuum therapy, the reduction of intra-abdominal pressure in the main group was pronounced (Δ=9.2; p<0.01) than in the comparison group (Δ=6.1; p<0.01). Abdominal vacuum therapy during the II phase of the Damage Control Surgery tactic made it possible to clean the abdominal cavity better (p<0.0001) than in the comparison group and provided better preparation for the implementation of the III phase of this tactic. As a result, reliable protection from external factors, active prevention of intra-abdominal pressure and rehabilitation of the abdominal cavity during the application of abdominal vacuum therapy during the II phase of Damage Control Surgery tactics in the main group of wounded after obstructive resections of the small intestine in the I phase made it possible to completely abandon terminal stomas in the III phase (in the comparison group – 5) in favor of the formation of small bowel intestinal anastomoses, and during obstructive colon resections, the number of terminal colostomas in the main group was reduced to 50.0% (in the comparison group -90.9%, р=0.004), also in favor of the formation anastomoses, which significantly improved the functional results of providing assistance to the wounded with a combat abdominal injury. The use of abdominal vacuum therapy during phases I-II of the Damage Control Surgery (DCS) tactics allows for the optimization of the scope of surgical interventions in phase III of Damage Control Surgery and significantly improves the functional outcomes of surgical care and treatment for patients with combat abdominal injuries at various levels of medical support during combat operations.

Transforming perioperative patient safety clinical guidelines recommendations into measurable standards: insights from the SAFEST project

Abstract Adopting evidence-based practices can improve the safety outcomes of surgical care. However, translating evidence into practice is slow in the healthcare field; an effort should be made to overcome this challenge. One approach could be to develop measurable standards to allow the evaluation and prioritization of healthcare improvements. The SAFEST project aimed to transform a list of prioritized clinical guidelines recommendations for adults’ perioperative care into measurable standardized practices (or standards) for hospitals to implement along the perioperative patient journey. Based on a previous systematic review of guidelines and an international expert panel review, we transformed recommendations into standards through an iterative and consensus qualitative approach. First, recommendations were classified according to the perioperative period (pre, intra or post) and based on predefined clinical areas. Second, one or more recommendations were transformed into one standard. Third, for each standard, measurable elements were developed to highlight in practical terms what needs to be implemented and measured, and the source of information and responsible stakeholder were identified. The overall transformation was performed by independent reviewers and the list of measurable standards was approved and finalized through discussion. From an initial list of 101 prioritized clinical practices recommendations, we developed 103 standards with 164 measurable elements. The standards with the related measurable elements, classified based on the perioperative period, were grouped in 12 different areas based on specific topic (e.g., complications preventions). Overall, these measurable standards can enhance dissemination and implementation of patient safety standardized practices in the continuum of care for adults’ patients undergoing surgery.

Timely Access to Essential Surgery, Surgical Workforce, and Surgical Volume: Global Surgery Indicators in Mexico.

The Lancet Commission on Global Surgery seeks to improve surgical care outcomes and equity for the world population through 6 indicators outlined in its 2030 Global Surgery Report. Our study aimed to estimate the percentage of the Mexican population with access to surgical care within the 2-hour distance range (indicator 1), the surgical workforce density (indicator 2), and the number of surgical procedures performed per 100,000 inhabitants (indicator 3) during the year 2020. Knowing these indicators can help to design and implement policies to increase surgical care access coverage and equity in our country. Data related to population distribution, local referral hospitals, and surgical volume were obtained from the 2020 Mexican National Census. Information relating to hospital characteristics and surgical specialists was collected from the Secretariat of Health's public records. We calculated travel time between health care facilities and municipalities using the TrueWay Matrix API and R Studio. Taking into consideration the health care system affiliation, the proportion of the Mexican population with timely access to essential surgery was 81.7%, with 29.3 specialists per 100,000 inhabitants and 726.9 annual procedures performed per 100,000 inhabitants. We identified clusters of municipalities where a low proportion of the population has timely access to essential surgery. These findings illustrate that changes in Mexican policy are required to facilitate more equitable and timely access to essential surgical care among the population.

Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality

The volume of cases that residents perform independentlyhave decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.

Implementation of the Maryland Global Budget Revenue Model and Variation in the Expenditures and Outcomes of Surgical Care: A Systematic Review and Meta-analysis.

To assess the effect of the Global Budget Revenue (GBR) program on outcomes after surgery. There is limited data summarizing the effect of the GBR program on surgical outcomes as compared with traditional fee-for-service systems. The Medline, Embase, Scopus, and Web of Science databases were used to conduct a systematic literature search on April 5, 2022. We identified full-length reports of comparative studies involving patients who underwent surgery in Maryland after implementation of the GBR program. A random effects model calculated the overall pooled estimate for each outcome which included complications, rates of readmission and mortality, length of stay, and costs. Fourteen studies were included in the qualitative synthesis, with 8 unique studies included in the meta-analysis. Our analytical sample was comprised of 170,011 Maryland patients, 78,171 patients in the pre-GBR group, and 91,840 patients in the post-GBR group. The pooled analysis identified modest reductions in costs [standardized mean difference (SMD) -0.34; 95% CI, -0.42, -0.25; P <0.001], complications [odds ratio (OR): 0.57; 95% CI, 0.36-0.92, P =0.02], readmission (OR: 0.78; 95% CI, 0.72-0.85, P <0.001), mortality (OR: 0.58; 95% CI, 0.47-0.72, P <0.001), and length of stay (standardized mean difference: -0.26; 95% CI, -0.32, -0.2, P <0.001) after surgery. Implementation of the GBR program is associated with improved outcomes and reductions in costs among Maryland patients who underwent surgical procedures. This is particularly salient given the increasing need to disseminate and scale population-based payment models that improve patient care while controlling health care costs.

Surgical Cancer Care in the Safety-Net Hospital: A Systematic Review

INTRODUCTION: Care delivery in quaternary medical centers in the United States has been developed to provide quality, high-volume surgical cancer care. For the most vulnerable populations, however, safety-net hospitals (SNHs) remain their home for both complex and routine healthcare needs. The objective of this study was to assess the access to and quality of surgical oncology care in SNHs. METHODS: A comprehensive and systematic review of the literature was conducted using the PubMed, EMBASE, and Cochrane Library databases to identify all studies (2000 to present) describing the delivery of surgical cancer care at SNHs in the United States (PROSPERO #CRD42021290092). These studies described the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs. RESULTS: Of 4,530 records, 37 studies met inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary cancers (16%). Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range 24% to 61% of patients). Although reports comparing overall survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care across SNHs. CONCLUSION: These findings highlight barriers in care facing many cancer patients. Continued efforts should address improved access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals, toward an integrated cancer system.

Addressing Health Concerns Interrupted by the COVID-19 Pandemic

Addressing Health Concerns Interrupted by the COVID-19 Pandemic

Minimally-invasive approach to emergent colorectal surgery in aging adults: A report from the Surgical Care Outcomes Assessment Program

BackgroundDespite known benefits of minimally invasive surgery(MIS) in elective settings, MIS use in emergency colorectal surgery(CRS) is limited. Older adults are more likely to require emergent CRS, and MIS is used less frequently with increasing age. MethodsA retrospective cohort was constructed of emergent CRS cases performed between 2011 and 2019. Discharge(DC) disposition, adverse events, and length of stay(LOS) between MIS and open surgery were compared and stratified by age. Adjustment was made for selected confounders using inverse probability weighting. ResultsOf 6913 emergent CRS cases across 50 hospitals, 1616(23%) were approached MIS. MIS cases were more likely [OR(95%CI)] to DC home [<65yo:1.7(1.3,2.2); 65–74:1.5(1.1,1.9); 75+:1.2(0.9,1.5)] and have fewer adverse events [<65yo:0.6(0.5,0.8); 65–74:0.7(0.5,0.9); 75+:0.7(0.5,0.9)]. LOS was shorter [Mean difference in days(95%CI)] [<65yo: 2.2(-2.9,-1.4); 65–74: 0.9(-2.7,1.0); 75+: 0.7(-1.7,0.2)]. ConclusionsMIS in emergent CRS is associated with increased DC to home, fewer adverse events, and shorter LOS. Benefits persisted with age after adjustment, suggesting an opportunity for improved MIS delivery in older adults.

Evaluating variation in enhanced recovery for colorectal surgery: a report from the Surgical Care Outcomes Assessment Program.

Robust data demonstrate that enhanced recovery protocols (ERPs) decrease length of stay, complications and cost. However, little is known about the reasons for variation in compliance with ERPs. The aim of this work was to confirm the efficacy of ERPs in a regional network, and to determine factors that are associated with ERP delivery in diverse hospital settings. A prospective cohort of patients was created by recording all elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP). The delivery of 12 ERP components was tracked at all sites, and factors associated with ERP component delivery and affecting outcomes were reported. From 2016 to 2019, 9274 elective colorectal operations were performed at 36 hospitals. Indications were 48% cancer, 23% diverticulitis and 8% inflammatory bowel disease. Minimally invasive surgery was used in 71%. The proportion of cases with six or more ERP components received increased from 23% in 2016 to 50% in 2019. An increase in components was associated with a shorter length of stay and fewer combined adverse events and reinterventions. Further, increasing numbers of ERP components provided an incremental benefit to patients even when delivered in a low-volume centre or by a low-volume surgeon, and regardless of patient presentation. At SCOAP hospitals, the delivery of increasing numbers of ERP components was associated with improved perioperative outcomes and decreased complications after elective colorectal surgery. The variation in delivery of these evidence-based components in subsets of our cohort indicates an important opportunity for quality improvement initiatives.

The impact of obesity on minimally invasive colorectal surgery: A report from the Surgical Care Outcomes Assessment Program collaborative

BackgroundOperating on obese patients can increase case complexity and result in worse outcomes. We described the incremental impact of BMI on morbidity and outcomes of colorectal operations and whether laparoscopic and robotic(MIS) approaches mitigate this morbidity differently. MethodsA retrospective cohort of patients undergoing elective colorectal operations in SCOAP was created to examine the association of increasing BMI on surgical outcomes. Additionally, multivariable logistic regression models were constructed. ResultsFrom 2011 to 2019, 22,863 elective colorectal operations (mean age 62, 55% female) were performed at 42 hospitals. Patients had BMI≥30 in 7576(33%) and BMI≥40 in 1180(5%) of operations. After risk adjustment, BMI≥40 was associated with increased conversions(OR1.57,95%CI1.26–1.96), increased combined adverse events(CAE)(OR1.32,95%CI1.15–1.52), and death(OR2.24, 95%CI1.41–3.55)(all p < 0.01). MIS approaches were each associated with lower CAE(lap OR0.49,95%CI0.46–0.53; robot OR0.42,95%CI0.37–0.47), and death(lap OR0.24,95%CI0.18–0.33; robot OR0.18,95%CI0.10–0.35)(all p < 0.01). ConclusionsSevere obesity is associated with increased conversion rates and worse short-term outcomes after colorectal surgery, though this trend is partially mitigated with a minimally invasive approach. These findings support the broad application of MIS for colorectal operations in obese patients.

Evaluating the Regional Uptake of Minimally Invasive Colorectal Surgery: a Report from the Surgical Care Outcomes Assessment Program

BackgroundMinimally invasive surgery (MIS) for colorectal disease has well-known benefits, but many patients undergo open operations. When choosing an MIS approach, robotic technology may have benefits over traditional laparoscopy and is increasingly used. However, the broad adoption of MIS, and specifically robotics, across colorectal operations has not been well described. Our primary hypothesis is that rates of MIS in colorectal surgery are increasing, with different contributions of robotics to abdominal and pelvic colorectal operations. MethodsRates of MIS colorectal operations are described using a prospective cohort of elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP) from 2011 to 2018. The main outcome was proportion of cases approached using open, laparoscopic, and robotic surgery. Factors associated with increased use of MIS approaches were described. ResultsAcross 21,423 elective colorectal operations, rates for MIS (laparoscopic or robotic surgery) increased from 44% in 2011 to 75% in 2018 (p < 0.001). Approaches for abdominal operations (n = 12,493) changed from 2 to 11% robotic, 43 to 63% laparoscopic, and 56 to 26% open (p < 0.001). Approaches for pelvic operations (n = 8930) changed from 3 to 33% robotic, 40 to 42% laparoscopic, and 57 to 24% open(p < 0.001). These trends were similar for high-(100 + operations/year) and low-volume hospitals and surgeons. ConclusionsAt SCOAP hospitals, the majority of elective colorectal operations is now performed minimally invasively. The increase in the MIS approach is primarily driven by laparoscopy in abdominal procedures and robotics in pelvic procedures.

Evaluating the Regional Uptake of Robotic Colorectal Surgery: A Report from the Surgical Care Outcomes Assessment Program Collaborative

Evaluating the Regional Uptake of Robotic Colorectal Surgery: A Report from the Surgical Care Outcomes Assessment Program Collaborative

Automating Electronic Clinical Data Capture for Quality Improvement and Research: The CERTAIN Validation Project of Real World Evidence.

Background:The availability of high fidelity electronic health record (EHR) data is a hallmark of the learning health care system. Washington State’s Surgical Care Outcomes and Assessment Program (SCOAP) is a network of hospitals participating in quality improvement (QI) registries wherein data are manually abstracted from EHRs. To create the Comparative Effectiveness Research and Translation Network (CERTAIN), we semi-automated SCOAP data abstraction using a centralized federated data model, created a central data repository (CDR), and assessed whether these data could be used as real world evidence for QI and research.Objectives:Describe the validation processes and complexities involved and lessons learned.Methods:Investigators installed a commercial CDR to retrieve and store data from disparate EHRs. Manual and automated abstraction systems were conducted in parallel (10/2012-7/2013) and validated in three phases using the EHR as the gold standard: 1) ingestion, 2) standardization, and 3) concordance of automated versus manually abstracted cases. Information retrieval statistics were calculated.Results:Four unaffiliated health systems provided data. Between 6 and 15 percent of data elements were abstracted: 51 to 86 percent from structured data; the remainder using natural language processing (NLP). In phase 1, data ingestion from 12 out of 20 feeds reached 95 percent accuracy. In phase 2, 55 percent of structured data elements performed with 96 to 100 percent accuracy; NLP with 89 to 91 percent accuracy. In phase 3, concordance ranged from 69 to 89 percent. Information retrieval statistics were consistently above 90 percent.Conclusions:Semi-automated data abstraction may be useful, although raw data collected as a byproduct of health care delivery is not immediately available for use as real world evidence. New approaches to gathering and analyzing extant data are required.

Pain and Health-Related Quality of Life After Pediatric Inpatient Surgery

Around 4 million children undergo inpatient surgery in the United States each year, however little is known about the impact of surgery and postoperative pain on children's health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2 to 18 years (mean = 9.6 years), 50% male, 56% white, admitted to surgical services at a children's hospital enrolled in the study. Parent participants reported on sociodemographics, child HRQOL, and pain characteristics at baseline and 1 month after discharge. Although most of the children recovered to baseline by 1 month after hospital discharge, 23% of children had a significant decline in HRQOL. Logistic regression analyses found that increasing child age (odds ratio = 2.1 for age 13–18 years) and the presence of moderate-severe postsurgical pain at 1 month (odds ratio = 5.7) were significantly associated with deterioration in HRQOL from baseline to 1-month follow-up (P < .05 for each variable). Although HRQOL returns to the baseline level for most children, a sizeable proportion have significant deterioration in HRQOL associated with continued postsurgical pain at 1 month after hospital discharge from surgery. PerspectiveThis study addresses an important gap in the literature, examining pain and health-related quality of life in a broad population of children undergoing a wide range of inpatient surgeries. Evaluation of inpatient health services from a patient and family perspective is essential in evaluating outcomes of surgical care.

Alvimopan Use, Outcomes, and Costs: A Report from the Surgical Care Outcomes and Assessment Program Comparative Effectiveness Research Translation Network Collaborative

Alvimopan Use, Outcomes, and Costs: A Report from the Surgical Care Outcomes and Assessment Program Comparative Effectiveness Research Translation Network Collaborative

Outcome Quality Standards in Pancreatic Oncologic Surgery

To identify quality indicators and establish acceptable quality limits (AQLs) in pancreatic oncologic surgery using a formal statistical methodology. Indicators have been identified through systematic literature reviews and guidelines for pancreatic surgery. AQLs were determined for each indicator with confidence intervals of 99.8 and 95 % above and below the weighted average by sample size from the different series examined. Several indicators have been identified with the following results as AQLs: resectability rate >59 %; morbidity, mortality, and pancreatic fistula rate in pancreaticoduodenectomy <55, <5, and <16 %, respectively; morbidity, mortality, and fistula rate in distal pancreatectomy <53, <4, and <31 %, respectively; number of lymph nodes retrieved >15; R1 resection <46 %; survival at 1, 3, and 5 years >54, >19, and >8 %, respectively. A series of different indicators for quality surgical care outcome in pancreatic cancer, as well as their limits, have been determined according to a standard methodology.

A concept paper: Using the outcomes of common surgical conditions as quality metrics to benchmark district surgical services in South Africa as part of a systematic quality improvement programme

The fourth, fifth and sixth Millennium Development Goals relate directly to improving global healthcare and health outcomes. The focus is to improve global health outcomes by reducing maternal and childhood mortality and the burden of infectious diseases such as HIV/AIDS, tuberculosis and malaria. Specific targets and time frames have been set for these diseases. There is, however, no specific mention of surgically treated diseases in these goals, reflecting a bias that is slowly changing with emerging consensus that surgical care is an integral part of primary healthcare systems in the developing world. The disparities between the developed and developing world in terms of wealth and social indicators are reflected in disparities in access to surgical care. Health administrators must develop plans and strategies to reduce these disparities. However, any strategic plan that addresses deficits in healthcare must have a system of metrics, which benchmark the current quality of care so that specific improvement targets may be set.This concept paper outlines the role of surgical services in a primary healthcare system, highlights the ongoing disparities in access to surgical care and outcomes of surgical care, discusses the importance of a systems-based approach to healthcare and quality improvement, and reviews the current state of surgical care at district hospitals in South Africa. Finally, it proposes that the results from a recently published study on acute appendicitis, as well as data from a number of other common surgical conditions, can provide measurable outcomes across a healthcare system and so act as an indicator for judging improvements in surgical care. This would provide a framework for the introduction of collection of these outcomes as a routine epidemiological health policy tool.

Variability in Reexcision Following Breast Conservation Surgery

Health care reform calls for increasing physician accountability and transparency of outcomes. Partial mastectomy is the most commonly performed procedure for invasive breast cancer and often requires reexcision. Variability in reexcision might be reflective of the quality of care. To assess hospital and surgeon-specific variation in reexcision rates following partial mastectomy. An observational study of breast surgery performed between 2003 and 2008 intended to evaluate variability in breast cancer surgical care outcomes and evaluate potential quality measures of breast cancer surgery. Women with invasive breast cancer undergoing partial mastectomy from 4 institutions were studied (1 university hospital [University of Vermont] and 3 large health plans [Kaiser Permanente Colorado, Group Health, and Marshfield Clinic]). Data were obtained from electronic medical records and chart abstraction of surgical, pathology, radiology, and outpatient records, including detailed surgical margin status. Logistic regression including surgeon-level random effects was used to identify predictors of reexcision. Incidence of reexcision. A total of 2206 women with 2220 invasive breast cancers underwent partial mastectomy and 509 patients (22.9%; 95% CI, 21.2%-24.7%) underwent reexcision (454 patients [89.2%; 95% CI, 86.5%-91.9%] had 1 reexcision, 48 [9.4%; 95% CI, 6.9%-12.0%] had 2 reexcisions, and 7 [1.4%; 95% CI, 0.4%-2.4%] had 3 reexcisions). Among all patients undergoing initial partial mastectomy, total mastectomy was performed in 190 patients (8.5%; 95% CI, 7.2%-9.5%). Reexcision rates for margin status following initial surgery were 85.9% (95% CI, 82.0%-89.8%) for initial positive margins, 47.9% (95% CI, 42.0%-53.9%) for less than 1.0 mm margins, 20.2% (95% CI, 15.3%-25.0%) for 1.0 to 1.9 mm margins, and 6.3% (95% CI, 3.2%-9.3%) for 2.0 to 2.9 mm margins. For patients with negative margins, reexcision rates varied widely among surgeons (range, 0%-70%; P = .003) and institutions (range, 1.7%-20.9%; P < .001). Reexcision rates were not associated with surgeon procedure volume after adjusting for case mix (P = .92). Substantial surgeon and institutional variation were observed in reexcision following partial mastectomy in women with invasive breast cancer.

Inefficiency as the major driver of excess costs in lung resection

Risk-adjusted outcomes of surgical care are important for quality and cost assessments. Although cardiac surgery is commonly studied, risk-adjusted analysis of excess costs of lung resection has not been pursued. We used 2002 to 2005 National Inpatient Sample of the Healthcare Cost and Utilization Project data to evaluate adverse outcomes and costs in elective lung resections in hospitals with more than 20 cases during that period. Adverse outcomes were inpatient death or excessive risk-adjusted postoperative stay. Logistic models were defined to predict adverse outcomes. Linear models were designed to predict costs. Hospital-specific adverse outcome rates and costs were measured to define performance outliers. Cost-effective reference hospitals were used to define total excess costs. Among 12,182 patients at 215 hospitals undergoing lung resection, there were 336 inpatient deaths (2.8%) and 880 live discharges with prolonged risk-adjusted postoperative stay (7.2%). Predictive models for mortality and risk-adjusted postoperative stay had C statistics of 0.773 and 0.643, respectively. There were 11 ineffective hospitals (5.1%) with excessive adverse outcomes (P<.005) and 34 inefficient hospitals (15.8%) meeting quality measures but with higher than predicted costs (P<.0005). Ineffective hospitals had costs $1020 per case lower than predicted. Inefficient hospitals had costs $9978 higher than predicted. Inefficiency is the major factor in excess inpatient costs associated with lung resection in this model. Although refinements in databases, including total physician costs and postdischarge adverse event costs, will alter models, excess costs of lung resection appear to be driven by inefficiency, not adverse outcomes.