Quality Improvement Program Risk Research Articles

Enhanced Recovery With Aggressive Ambulation Decreases Length of Stay in Lung Cancer Surgery

ObjectiveThoracic Enhanced Recovery with Ambulation after Surgery (T-ERAS) protocol at our institution includes ambulation into the operating room and 250-feet ambulation within 1 hour of extubation. We compared the average length of stay (LOS) between T-ERAS patients and that predicted using a validated surgical risk calculator. MethodsWe retrospectively reviewed patients undergoing lung cancer resection with minimally invasive approach from 2012 to 2022. Patients aged ≥ 18 were included if early ambulation was documented. Patient information were entered into the American College of Surgeon's National Surgical Quality Improvement Program Risk Calculator (NSQIP) to obtain the predicted LOS. Descriptive statistics, comparisons of observed versus predicted LOS (O/P ratio), and nonparametric testing were conducted. ResultsOf 940 patients reviewed, 886 met eligibility. For the study cohort, average age was 68, and 514 (58.0%) were female. By procedure, there were 631(71.2%) lobectomy, 204(23.0%) wedge, 26(2.9%) segmentectomy, 20(2.3%) bilobectomy, and 5(0.6%) pneumonectomy. The average LOS observed for the entire cohort was 1.2 days (median 1.0 day) compared to the predicted LOS of 3.4 days with the NSQIP (median 4.0). Overall, 842 (95%) of patients had LOS better than predicted (O/P ratio < 1), 19 (2.1%) had LOS as predicted (O/P ratio = 1), and 25 (2.8%) had LOS longer than predicted (O/P ratio > 1). The mean O/P ratio was 0.34. ConclusionAverage LOS with T-ERAS protocol was 1.2 days compared to the predicted average of 3.6 days in patients undergoing minimally invasive lung cancer resections. Our study provides a potential protocol to shorten the LOS beyond what is predicted by NSQIP.

SP2.9 - National Emergency Laparotomy Audit (NELA) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction calculators are not accurate in predicting 30-day mortality in patients aged 80 and above

Abstract Background 30- to 50000 Emergency Laparotomies (EL) are performed annually in the UK. More than half of patients are aged 70 or over and have a high post-operative complication rate along with a 16-20% risk of 30-day mortality (30-dm). To date, the literature lacks a dedicated risk prediction tool for mortality and morbidity following EL in the elderly population. Methods A multi-center, retrospective study of patients aged ≥80 undergoing EL examined the correlation between predicted 30-dm using NELA and ACS-NSQIP and actual 30-dm. This occurred in two UK centers over a 2-year period. The primary outcome was defined as the correlation between actual 30-dm and NELA or ACS-NSQIP predicted 30-dm. GraphPad Prism 10.1.1. was used for statistical analysis. Results 141 cases were included in the final analysis (Table 1). The actual 30-dm was 17.73%, NELA predicted 30-dm 13.07% (7.21;27.84), and ACS-NSQIP 9.4% (3.8;20.6). NELA correlated positively with ACS-NSQIP predicted 30-dm (R²=0.79; p&amp;lt;0.0001). No association was found between actual 30-dm and predicted NELA 30-dm, R²=0.01; p&amp;lt;0.0001 or ACS-NSQIP, R²=0.01; p&amp;lt;0.0001. All data is expressed as Median + IQR. Conclusion In octo- and nonagenarians, following an emergency laparotomy, both NELA and ACS-NSQIP are not accurate in predicting 30-day mortality.Table 1Male/female ratio0.63Age (years)84 (81;87)BMI (kg/m²)24.27 (21.43;27)Lactate (most recent preoperative value) mmol/L1.7 mmol/L (1.14;3.01)ASA grade3 (2;4)Clinical frailty score3 (3;5)Charlson Comorbidity Index4 (2;5)

FP7.8 - Perioperative risk prediction for Emergency Laparotomy in Adults, using the National Emergency Laparotomy Audit (NELA) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction tools – an Eastern European perspective

Abstract Background Worldwide, emergency laparotomy (EL) is one of the most common procedures. Having an actual 30-day mortality (30-dm) of 10 to 15%, EL has a high mortality rate, particularly in patients &amp;gt;70 years old. Preoperative risk assessment and stratification can improve outcomes. The American-College-of-Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) and the National Emergency Laparotomy Audit (NELA) risk prediction tools are the most used risk calculators, but both can under or overpredict. Methods This is a single-center, retrospective, cohort study that looked at the correlation between actual and predicted 30-dm using NELA and ACS-NSQIP in adults ≥18, following EL, over 2 years, in a single-tertiary-center from Romania. The primary outcome was defined as the correlation between actual 30-dm and NELA or ACS-NSQIP predicted 30-dm. Statistical analysis was performed using GraphPad-Prism 10.1.1. and Stata18. Results 207 cases were analyzed. Male/female ratio was 1.49; age 65 years (50;77); BMI 26.25kg/m² (23.01;28.35); preoperative lactate 1.8 mmol/L (1.5;3.4); ASA grade 3 (2;4) clinical frailty score 4 (3;4); and Charlson Comorbidity Index 5 (3;8). Actual 30-dm was 31.4% with NELA and ACS-NSQIP predicted 30-dm of 5.78% (1.84;21.48) and 5.5% (1.2;24.2) respectively. NELA and ACS-NSQIP predicted 30-dm expressed a strong positive correlation, R²=0.88; p&amp;lt;0.0001. Both NELA and ACS-NSQIP predicted 30-dm showed a significant positive correlation with actual 30-dm: R²=0.33, p&amp;lt;0.0001; and R²=0.41, p&amp;lt;0.0001 respectively. All data is presented as Median + IQR. Conclusion In a Romanian setting both ACS-NSQIP and NELA risk calculators underpredicted 30-dm, despite expressing a strong positive correlation with actual 30-dm.

NELA 1 - Actual and predicted 30-day mortality following emergency laparotomy using National Emergency Laparotomy Audit (NELA) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction tools

Abstract Background Emergency laparotomy (EL) is common, with &amp;gt;30,000 performed annually in the UK. EL has a high 30-day mortality of 9.2%, especially in the elderly. Reliable preoperative risk assessment is essential to aid decision-making and perioperative care arrangements. NELA and ACS-NSQIP risk calculators can both be used to assess risk, and both can under or over-predict mortality. Methods This is a multi-center, retrospective, observational, cohort study investigating the correlation between actual 30-dm (a-30-dm) and predicted 30-dm (p-30-dm) following EL using NELA and ACS-NSQIP in adults over and under 70, over 2-years, in two UK centres. Sample size was calculated at 385 cases. Statistical analysis was carried out using GraphPad Prism 10.1.1. Results 626 cases were analyzed. A-30-dm, NELA, and ACS-NSQIP p-30-dm in the under 70s subgroup were 5.78%, 5.53%, and 3.41% respectively, with NELA and ACS-NSQIP correlating positively with a-30-dm: R²=0.12, p&amp;lt;0.0001 and R²=0.09, p&amp;lt;0.0001. In over 70s, a-30-dm was 13.96%, NELA p-30-dm 14.02% and ACS-NSQIP 9.76%, with a positive correlation between the latter two (R²=0.56, p&amp;lt;0.0001), but a weak one between a-30-dm and NELA (R²=0.04, p&amp;lt;0.0001) or ACS-NSQIP (R²=0.02, p&amp;lt;0.0001). For the entire cohort a-30-dm, NELA and ACS-NSQIP p-30-dm were 9.74%, 9.8%, and 6.59% respectively. NELA and ACS-NSQIP p-30-dm showed a strong positive correlation (R²=0.89; p&amp;lt;0.0001) with only NELA showing a strong positive correlation with a-30-dm (R²=0.31, p&amp;lt;0.0001); and not ACS-NSQIP (R²=0.05, p&amp;lt;0.0001). Conclusion NELA can accurately predict 30-day mortality in patients aged &amp;lt;70 undergoing EL but not &amp;gt;70. ACS-NSQIP and a-30-dm correlated in a very weak manner.

ThP6.15 - 1, 3, and 5-year mortality following emergency laparotomy, can the National Emergency Laparotomy Audit (NELA) or the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) risk calculators predict it? – a retrospective, multi-center, observational, cohort study

Abstract Background Emergency laparotomy (EL) comprises a high-risk group of surgical procedures, associated with a significantly increased risk of death in the following 5 years. EL are performed on a heterogeneous population, of which at least 50% are ≥ 70 years old. Accurate preoperative risk prediction is vital for planning care, patient shared decision, and improving outcomes. To date, no prediction tool can reliably estimate long-term outcomes, including mortality, following an EL. Methods This is a multicenter, retrospective, observational, cohort study that investigated the correlation between actual mortality at 1, 3, and 5 years and predicted 30-day mortality (30-dm) using NELA and ACS-NSQIP risk prediction tools, following EL, in adults aged ≥18, over 2 years, in two UK centers. The sample size was calculated at 385 cases. GraphPad-Prism 10.1.1. was used for statistical analysis. Results 626 cases were analyzed. The male/female ratio was 0.85, age 70 years (55;78); BMI 24.94kg/m² (22;29); preoperative lactate 1.7 mmol/L (1.2;2.6), clinical frailty score 3 (2;4); and Charlson Comorbidity Index 4(2;5) (all data is expressed as median+IQR). The 1, 3, and 5-year survival were 76%, 67%, and 61%, respectively. A perfect positive correlation between NELA and ACS-NSQIP 30-dm and the 1-year actual mortality was found (R²=1). At 3 years only NELA correlated positively to actual mortality (R²=0.23, p&amp;lt;0.05). The 5-year mortality correlated positively with both predictors - NELA: R²=0.61, p&amp;lt;0.001; ACS-NSQIP: R²=0.31, p&amp;lt; 0.05. Conclusion Both NELA and ACS-NSQIP risk calculators can predict mortality at 1,3 and 5 years after an emergency laparotomy, with NELA expressing a stronger correlation.

Evaluation of The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Risk Calculator as A Predictor of Postoperative Complications After Coronary Artery Surgery

Evaluation of The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Risk Calculator as A Predictor of Postoperative Complications After Coronary Artery Surgery

Using risk-adjusted cumulative sum to evaluate surgeon, divisional, and institutional outcomes—a feasibility study

BackgroundFew objective, real-time measurements of surgeon performance exist. The risk-adjusted cumulative sum is a novel method that can track surgeon-level outcomes on a continuous basis. The objective of this study was to demonstrate the feasibility of using risk-adjusted cumulative sum to monitor outcomes after colorectal operations and identify clinically relevant performance variations. MethodsThe National Surgical Quality Improvement Program was queried to obtain patient-level data for 1,603 colorectal operations at a high-volume center from 2011 to 2020. For each case, expected risks of morbidity, mortality, reoperation, readmission, and prolonged length of stay were estimated using the National Surgical Quality Improvement Program risk calculator. Risk-adjusted cumulative sum curves were generated to signal observed-to-expected odds ratios of 1.5 (poor performance) and 0.5 (exceptional performance). Control limits were set based on a false positive rate of 5% (α = 0.05). ResultsThe cohort included data on 7 surgeons (those with more than 20 cases in the study period). Institutional observed versus expected outcomes were the following: morbidity 12.5% (vs 15.0%), mortality 2.5% (vs 2.0%), prolonged length of stay 19.7% (vs 19.1%), reoperation 11.1% (vs 11.3%), and 30-day readmission 6.1% (vs 4.8%). Risk-adjusted cumulative sum accurately demonstrated within- and between-surgeon performance variations across these metrics and proved effective when considering division-level data. ConclusionRisk-adjusted cumulative sum adjusts for patient-level risk factors to provide real-time data on surgeon-specific outcomes. This approach enables prompt identification of performance outliers and can contribute to quality assurance, root-cause analysis, and incentivization not only at the surgeon level but at divisional and institutional levels as well.

Accuracy of the ACS NSQIP Surgical Risk Calculator for Predicting Postoperative Complications in Gastric Cancer Following Open Gastrectomy.

The prediction of complications before gastric surgery is of utmost importance in shared decision making and proper counseling of the patient in order to minimize postoperative complications. Our aim was to evaluate the predictive validity of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator in gastric cancer patients who underwent gastrectomy. Preoperative assessment data of 432 patients were retrospectively reviewed and manually entered into the calculator. The accuracy of the calculator was evaluated using Pearson's chi-squared test, C-statistic, Brier score, and Hosmer-Lemeshow test. The lowest Brier scores were observed in urinary tract infection, renal failure, venous thromboembolism, pneumonia, and cardiac complications. Best results were obtained for predicting sepsis, discharge to rehabilitation facility, and death (low Brier scores, C-statistic >.7, and Hosmer-Lemeshow P > .05). The calculator had a strong performance in predicting sepsis, discharge to the rehabilitation facility, and death. However, it performed poor in predicting the most commonly observed events (any or serious complication and surgical site infection).

Validation of the American College of Surgeons National Surgical Quality Improvement Program risk predictor in an Australian general surgical cohort.

The National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator from the American College of Surgeons is a widely available tool for peri-operative risk prediction. This study investigates its predictive performance in an Australian setting. A single-centre retrospective external validation study was conducted at a tertiary referral centre in New South Wales, Australia. Data from a general surgical cohort in a 2-year period from 2020 to 2021 was collected from the NSQIP database and entered into the NSQIP calculator. The predictive performance of the calculator was analysed across the standard 14 NSQIP postoperative outcome measures at 30 days. There were 2121 patient records analysed using tests of accuracy and in the discrimination and calibration domains. The overall predictive performance of the NSQIP calculator was reasonable. There was greater accuracy at lower-risk predictions. At higher-risk predictions, Readmission, Death, and Discharge to Nursing or Rehab Facility, and Length of Stay were overestimated, whilst other outcomes were underestimated. This study demonstrates reasonable overall performance of the NSQIP calculator in the context of this cohort and provides data to support the need for locally adapted and validated risk prediction tools for use by Australian perioperative physicians.

A retrospective comparison of 90-day outcomes, length of stay, and readmissions between robotic-assisted and laparoscopic colectomy.

Investigations generally assess 30days of perioperative outcomes with robotic-assisted and laparoscopic colectomy. Outcomes beyond 30days serve as a quality metric of surgical services and an assessment of 90days of outcomes may have greater clinical utility. The purpose of this study was to assess 90days of outcomes, length of stay (LOS), and readmissions among patients who underwent a robotic-assisted versus laparoscopic colectomy using a national database. Patients undergoing either robotic-assisted or laparoscopic colectomy were identified using Current Procedural Terminology (CPT) codes within PearlDiver, a national, inpatient records database from 2010 to 2019. Outcomes were defined using the National Surgical Quality Improvement Program (NSQIP) risk calculator and identified using International Classification of Disease (ICD) diagnosis codes. Categorical variables were compared using chi-square tests, and continuous variables were compared using paired t tests. Covariate-adjusted regression models were also constructed to evaluate these associations while accounting for potential confounders. A total of 82,495 patients were assessed in this study. At 90days, patients of the laparoscopic colectomy cohort experienced a higher rate of complications than patients who underwent robotic-assisted colectomy (9.5 vs. 6.6%, p < 0.001). There were no significant differences in LOS (6 vs. 6.5days, p = 0.08) and readmissions (6.1 vs. 6.7%, p = 0.851) at 90days. Patients undergoing robotic-assisted colectomy have a lower risk for morbidity at 90days. Neither approach is superior for LOS nor 90days of readmissions. Both techniques are effective minimally invasive procedures, yet patients may gain a greater risk benefit from robotic colectomy.

Palliative Care Consults and Frailty Screening in High-Risk Vascular Surgery Patients

Palliative care has increasingly been integrated into the management of high-risk surgery because of the beneficial effect on patient quality of life. However, the utilization of palliative care in vascular surgery remains unclear due to a lack of data. The purpose of this study was to determine the palliative care consult rate in high-risk vascular surgery patients. A retrospective chart review was performed at a single Veteran Affairs Medical Center from 2013 to 2021. High-risk vascular surgery patients were identified by using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) risk score of >4%, which predicted 30-day mortality. Patient demographics, operative procedures, and clinical outcomes were collected. A total of 126 patients underwent a high-risk vascular surgery operation. The surgical procedures consisted of 78 amputations, 19 bypasses, 18 endovascular aneurysm repair/stents, and 11 thrombectomy/arterial repair. Palliative care was consulted in 44 patients (35%) during the hospitalization: 8 patients (18%) had preoperative consults, whereas 36 patients (82%) had postoperative consults. The overall 30-day mortality was 15%, and the 1-year mortality rate was 34%. The 30-day and 1-year mortality rates were higher in those patients who received palliative care consultation (36% and 64%, respectively) compared with those without consult (0% and 21%, respectively). The palliative care consults had a higher referral rate in more frail patients, by Revised Analysis Index (RAI): n = 13 of 57 (23%) nonfrail (RAI <20), n = 14 of 44 (32%) frail (RAI = 21-32), and n = 17 of 25 (68%) very frail (RAI >33). The majority of the palliative care consults were obtained for goals of care discussion (80%) compared with withdrawal of care (20%). Palliative care is generally underused for vascular surgery patients, but our data demonstrated a palliative care consult rate of 35% in high-risk vascular surgery patients. A frailty screening program can further stratify high-risk vascular surgery patients who would benefit from an early palliative care consult.

Contemporary association of preoperative malnutrition and outcomes of hiatal hernia repairs in the United States

BackgroundHypoalbuminemia has been used as a surrogate for malnutrition and is associated with worse postoperative outcomes across major operations. Because patients with hiatal hernia often have inadequate caloric intake, we examined the association of serum albumin levels with outcomes after hiatal hernia repair. MethodsAdults undergoing elective and non-elective hiatal hernia repair via any approach were tabulated from the 2012 to 2019 National Surgical Quality Improvement Program. Patients were stratified into the Hypoalbuminemia cohort if serum albumin <3.5 mg/dL using restricted cubic spline analysis. Major adverse events were defined as a composite of all-cause mortality and major complications per the American College of Surgeons National Surgical Quality Improvement Program risk calculator. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were then constructed to assess the association of preoperative albumin with major adverse events, postoperative length of stay, and 30-day readmission. ResultsOf 23,103 patients, 11.7% comprised the Hypoalbuminemia cohort. The Hypoalbuminemia group was older, less commonly of White race, and less likely to have an independent functional status than others. They were also more likely to undergo inpatient, non-elective surgery via laparotomy. After entropy balancing and adjustment, hypoalbuminemia remained associated with increased odds of major adverse events and multiple complications and longer adjusted postoperative length of stay. There was no significant difference in adjusted odds of readmission. ConclusionWe used a quantitative methodology to establish a serum albumin threshold of 3.5 mg/dL associated with increased adjusted odds of major adverse events, increased postoperative length of stay, and postoperative complications after hiatal hernia repair. These results may guide preoperative nutrition supplementation.

Outcomes of Postoperative Overnight High-Acuity Care in Medium-Risk Patients Undergoing Elective and Unplanned Noncardiac Surgery

Postoperative complications are increasing, risking patients' health and health care sustainability. High-acuity postoperative units may benefit outcomes, but existing data are very limited. To evaluate whether a new high-acuity postoperative unit, advanced recovery room care (ARRC), reduces complications and health care utilization compared with usual ward care (UC). In this observational cohort study, adults who were undergoing noncardiac surgery at a single-center tertiary adult hospital, anticipated to stay in hospital for 2 or more nights, were scheduled for postoperative ward care, and at medium risk (defined as predicted 30-day mortality of 0.7% to 5% by the National Safety Quality Improvement Program risk calculator) were included. Allocation to ARRC was based on bed availability. From 2405 patients assessed for eligibility with National Safety Quality Improvement Program risk scoring, 452 went to ARRC and 419 to UC, with 8 lost to 30-day follow-up. Propensity scoring identified 696 patients with matched pairs. Patients were treated between March and November 2021, and data were analyzed from January to September 2022. ARRC is an extended postanesthesia care unit (PACU), staffed by anesthesiologists and nurses (1 nurse to 2 patients) collaboratively with surgeons, with capacity for invasive monitoring and vasoactive infusions. ARRC patients were treated until the morning after surgery, then transferred to surgical wards. UC patients were transferred to surgical wards after usual PACU care. The primary end point was days at home at 30 days. Secondary end points were health facility utilization, medical emergency response (MER)-level complications, and mortality. Analyses compared groups before and after propensity scoring matching. Of 854 included patients, 457 (53.5%) were male, and the mean (SD) age was 70.0 (14.4) years. Days at home at 30 days was greater with ARRC compared with UC (mean [SD] time, 17 [11] vs 15 [11] days; P = .04). During the first 24 hours, more patients were identified with MER-level complications in ARRC (43 [12.4%] vs 13 [3.7%]; P < .001), but after return to the ward, these were less frequent from days 2 to 9 (9 [2.6%] vs 22 [6.3%]; P = .03). Length of hospital stay, hospital readmissions, emergency department visits, and mortality were similar. For medium-risk patients, brief high-acuity care with ARRC allowed enhanced detection and management of early MER-level complications, which was followed by a decreased incidence of subsequent MER-level complications after discharge to the ward and by increased days at home at 30 days.

External Validation of the National Surgical Quality Improvement Program Calculator Utilizing a Single Institutional Experience for Adult Spinal Deformity Corrective Surgery.

Identify the external applicability of the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) risk calculator in the setting of adult spinal deformity (ASD) and subsets of patients based on deformity and frailty status. ASD patients were isolated in our single-center database and analyzed for the shared predictive variables displayed in the NSQIP calculator. Patients were stratified by frailty (not frail <0.03, frail 0.3-0.5, severely frail >0.5), deformity [T1 pelvic angle (TPA) > 30, pelvic incidence minus lumbar lordosis (PI-LL) > 20], and reoperation status. Brier scores were calculated for each variable to validate the calculator's predictability in a single center's database (Quality). External validity of the calculator in our ASD patients was assessed via Hosmer-Lemeshow test, which identified whether the differences between observed and expected proportions are significant. A total of 1606 ASD patients were isolated from the Quality database (48.7 years, 63.8% women, 25.8 kg/m2); 33.4% received decompressions, and 100% received a fusion. For each subset of ASD patients, the calculator predicted lower outcome rates than what was identified in the Quality database. The calculator showed poor predictability for frail, deformed, and reoperation patients for the category "any complication" because they had Brier scores closer to 1. External validity of the calculator in each stratified patient group identified that the calculator was not valid, displaying P values >0.05. The NSQIP calculator was not a valid calculator in our single institutional database. It is unable to comment on surgical complications such as return to operating room, surgical site infection, urinary tract infection, and cardiac complications that are typically associated with poor patient outcomes. Physicians should not base their surgical plan solely on the NSQIP calculator but should consider multiple preoperative risk assessment tools.

Implementation of Frailty Assessment Improves Veterans Affairs Surgical Quality Improvement Program Risk Assessment in General and Vascular Surgery Patients

INTRODUCTION: Frailty has been recognized as an important factor in preoperative risk evaluation. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) Surgical Risk Calculator, derived from chart elements, predicts surgical risk and incorporates many factors now recognized as markers of frailty. We examined the impact on VASQIP Surgical Risk prediction after implementation of a robust frailty assessment. METHODS: A prospective frailty assessment quality improvement project was implemented in general surgery (GenS) and vascular surgery (VascS) for new and preoperative VA patients starting October 2020. We examined the effectiveness of this assessment by comparing VASQIP Surgical Risk prediction with and without use of frailty assessment data. For comparison purposes, 3 operative case complexity groups were identified. RESULTS: A total of 205 patients were screened: 145 (71%) GenS and 60 (29%) VascS. Frailty screening identified issues not captured on routine surgical assessment in 77 (38%) patients; 20 (26%) of these patients were less than 65 years of age. The most common frailty factors captured include cognitive impairment (46% GenS, 47% VascS), dyspnea (19% GenS, 20% VascS), and impaired functional status (14% GenS, 13% VascS). Frailty identification increased VASQIP risk prediction with significant differences post–frailty assessment (p < 0.005; Table 1). Risk of 30-day surgical site infection, ICU admission, and postoperative admission also increased: 1% to 1.2%, 23% to 27.4%, and 72% to 79%, respectively (p < 0.001). Increasing case complexity was associated with higher score differences (p < 0.0001; Table 1). Table 1. - VASQIP Surgical Risk Score Comparison Variable 30-d mortality risk: pre-/postscreen * 180-d mortality risk: pre-/postscreen * 30-d morbidity risk: pre-/postscreen * p Value † Entire group 0.24%/0.31% 1.03%/1.17% 3.55%/3.84% <0.0001 Cases with differences 0.33%/0.61% 1.27%/2.21% 4.18%/4.77% <0.0001 Low case complexity 0.13%/0.15% 0.53%/0.66%‡ 1.78%/1.78%‡ <0.005‡ Moderate case complexity 0.17%/0.20% 0.85%/1.14% 2.14%/2.62% <0.0001 High case complexity 0.30%/0.38% 1.11%/1.42% 4.8%/6.14% <0.0001 Vascular surgery 0.51%/0.62% 1.20%/1.52% 4.24%/4.29% <0.005 General surgery 0.14%/0.18% 0.71%/1.01% 2.80%/3.48% <0.0001 *Median risk percentage displayed. Risk scores calculated with VASQIP Surgical Risk Calculator.†Wilcoxon Signed Ranks Test performed.‡Only 30-day mortality is <0.005; 180-day morality and 30-day morbidity differences were not statistically significant. CONCLUSION: Implementation of frailty assessment, in general, and vascular surgery patients significantly improves VASQIP Surgical Risk prediction. These findings emphasize the prevalence of frailty and the importance of presurgical frailty assessment for both geriatric and nongeriatric patients.

194 ORIEL (Mortality Risk Prediction in Emergency Laparotomy): A Comparison of Mortality Risk Prediction Tools

Abstract Aim Emergency laparotomies carry significant risk of morbidity and mortality. Risk calculation tools are essential to identify high-risk patients and inform clinicians in decision making. As part of a multi-centre research initiative, a retrospective study of all emergency laparotomies in a major trauma centre was conducted to determine the most accurate predictor of thirty-day mortality by comparing four, internationally recognised, risk assessment tools. Method Patients who underwent emergency laparotomy were identified using hospital databases. National Emergency Laparotomy Audit (NELA) was used to record pre- and post-operative mortality scores. The Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM); American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Surgical Outcome Risk Tool (SORT) were used to calculate risk of mortality for each patient. The Receiver Operating Curve (ROC) statistical method was chosen to compare the results of each in order to establish the tool most pertinent to prediction of local mortality. Results 274 patients underwent emergency laparotomies at the Trust between December 2017 to December 2019. Of these, 96.7% (n=265) survived the 30-day post -operative period and 3.3% (n= 9) died. The ROC comparator demonstrated 100% sensitivity for the calculation of NELA, P-POSSUM and ACS-NSQIP and specificity of 77%, 76% and 63% for NELA, ACS-NSQIP and P-POSSUM respectively. SORT was found to be the poorest indicator of post-operative mortality. Conclusions NELA is the most accurate predictor of 30-day mortality in patients who undergo emergency laparotomy. Comparison with the outcomes of other centres will help confirm our results.

Accuracy of National Surgical Quality Improvement Program Risk Calculator Among Elderly Patients Undergoing Pancreas Resection

IntroductionA preoperative goals-of-care discussion is essential in maintaining the autonomy of older adults who require surgery. The purpose of this study was to determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) risk calculator and its association with age for patients who underwent pancreatectomy. MethodsUsing the American College of Surgeons NSQIP database, patients who underwent pancreatectomy between 2012 and 2015 were identified. Age was categorized into three groups: 18-64, 65-79, and 80-89 y. Analysis of variance and Pearson correlation coefficients were employed to assess differences between age categories in predicted and actual mortality and morbidity. Covariate-adjusted logistic regression models were employed to evaluate associations while accounting for potential confounders. ResultsA total of 17,906 patients were included. The correlation between actual and predicted mortality was low (r = 0.14, P < 0.001). This correlation was weakest for the age category 80-89 y (r = 0.04, P = 0.07) and strongest for 65-79 y category (r = 0.14, P > 0.001). The correlation was weakest among patients who underwent pancreatoduodenectomy (r = 0.06, P = 0.08) and in this group mortality was overestimated for older adults in the age group 80-89 (actual mortality: 3.2% versus predicted mortality: 5.6%, P = 0.08). After adjusting for covariates, the interaction term between age and predicted mortality (P = 0.0021) indicated that the relationship between predicted and actual mortality is significantly influenced by patient age. ConclusionsThe NSQIP risk calculator appears to overestimate mortality and morbidity risk for elderly patients undergoing pancreatoduodenectomy. These predictions should be used with caution in preoperative goals-of-care discussions with patients aged 80 y and older.

Predicting complications of spine surgery: external validation of three models

BACKGROUND CONTEXTNumerous prediction tools are available for estimating postoperative risk following spine surgery. External validation and comparison of these tools is critical prior to clinical use. No model for adverse events after spine surgery has undergone decision curve analysis. PURPOSEExternal validation, comparison, and decision curve analysis of 3 previously described models [SpineSage, Risk Assessment Tool (RAT), National Surgical Quality Improvement Program Risk Calculator (NSQIP)] for predicting 30-day postoperative complications after spine surgery STUDY DESIGNRetrospective cohort study. PATIENT SAMPLEThree hundred fifteen patients who underwent spine surgery at a tertiary academic surgical center in New Zealand between January 2019 and April 2020. OUTCOME MEASURESAs defined by each risk prediction tool and objectively using the Comprehensive Complication Index. METHODSWe retrospectively reviewed risk of postoperative complication was calculated for each patient according to the 3 models. Overall model fit, calibration, discrimination, and decision curve analysis for each model were assessed in line with the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines. RESULTS100 (35%) patients experienced complications. SpineSage and RAT were well calibrated, NSQIP systematically underestimated risk. Area under the curve was greatest for SpineSage (0.75) compared with the NSQIP (0.72) and the RAT (0.69). Decision curve analysis showed SpineSage resulted in greatest net benefit across all risk thresholds. CONCLUSIONSOf the models studied, SpineSage most accurately predicted risk and can be expected to perform better than a strategy of treating all patients if patient or surgeon deem complication risk >10% significant. NSQIP may not be suitable for the clinical use in our local population.

Impact of perioperative inflammation on days alive and at home after surgery.

Perioperative inflammation is associated with perioperative complications, including delirium, that are associated with a reduced number of postoperative days alive and at home at 90 days (DAH90). We tested whether inflammation was associated with DAH90 even when adjusting for perioperative factors, and whether inflammation independently was associated with DAH90 when adjusting for delirium. We conducted a prospective cohort study of major, non-intracranial surgical patients who were older than 65 yr (n=134). We measured postoperative delirium incidence and severity, and changes in interleukin (IL)-8 and IL-10 in blood plasma. Our primary outcome, DAH90, was analysed using quantile regression. Before adjusting for delirium, a postoperative day 1 increased IL-8 was associated with fewer DAH90 at the 0.75 quantile (β=-0.082; 95% confidence interval [CI], -0.19 to -0.006) after adjusting for demographic (age and sex) and perioperative factors (cardiovascular surgery, National Surgical Quality Improvement Program risk of death, and operative time). IL-10 was similarly associated with DAH90 at the 0.5 (β=-0.026; 95% CI, -0.19 to -0.001) and 0.75 (β= -0.035; 95% CI, -0.07 to -0.006) quantiles. Neither cytokine was significantly associated with DAH90 once delirium and baseline Trail Making Test B were added to the models. Perioperative inflammation predicts DAH90, but when delirium is added to the model inflammation loses significance as a predictor, whereas delirium is significant. Targeting perioperative inflammation may reduce delirium and moderate hospital readmission and mortality. NCT03124303.

The Veteran Affair Surgical Quality Improvement Program Calculator is a Poor Predictor of Morbidity and Mortality in Octogenarian and Nonagenarian Veterans Undergoing Major Lower Extremity Amputations

Morbidity and mortality for major (above the ankle) lower extremity amputation (LEA) is high in veteran patients and age is a predictor of mortality. The Veteran Affair Surgical Quality Improvement Program (VASQIP) risk assessment tool has been validated for several operations but not for elderly patients undergoing LEA. The present study interrogated the accuracy for the VASQIP calculator for a medium/high-risk operation in a high-risk veteran population (octogenarians and nonagenarians). Variables required from input for the VASQIP calculator were retrospectively obtained for 57 octogenarians and 11 nonagenarians submitting to LEA at our institution from 2009 to 2021. The six-outcome variables provided by the VASQIP calculator (30-day mortality, 180-day mortality, 30-day morbidity, 30-day surgical site infection risk, probability of intensive care unit stay, and probability of hospital stay) were compared to observed morbidity and mortality. The accuracy of the calculator was assessed by area under the receiver operating characteristic curve and reported by the area under the curve (AUC) as previously described. In the 68 patients included in this analysis, the time to death from the last index operation was 422.0±604.9days for octogenarians and 65.6±89.3days for nonagenarians. Predicted versus observed 30-day mortality for octogenarians and nonagenarians was 8.46 vs. 24.56 [AUC=0.739; 95% confidence interval (0.581 to 0.898)] and 24.46 vs. 45.45 [AUC=0.600 (0.171 to 1.000)], respectively. Predicted versus observed 180-day mortality for the same cohorts was 25.22 vs. 47.37 [AUC=0.578 (0.427 to 0.728)] and 45.34 vs. 90.91 [AUC=0.100 (0.000 to 0.286)], respectively. Thirty-day morbidity, 30-day surgical site infection, probability of intensive care unit, and probability of in-hospital stay produced an AUC less than 0.600 for all these outcomes. The VASQIP risk calculator is a poor predictor of short-term outcomes in octogenarians and nonagenarians undergoing major LEA. Most octogenarian and nonagenarian veterans died within 1year, and the mean survival for nonagenarians was less than 3months after LEA. The decision for major LEA in octogenarian and nonagenarian veterans warrants an informed discussion with the patient and family.