Quality Improvement Program Research Articles

Application of machine learning algorithms to predict 30-day hospital readmission following cement augmentation for osteoporotic vertebral compression fractures

ObjectiveOsteoporosis is a common skeletal disease that greatly increases the risk of pathologic fractures and accounts for approximately 700,000 vertebral compression fractures (VCFs) annually in the United States. Cement augmentation procedures such as balloon kyphoplasty (KP) and percutaneous vertebroplasty (VP) have demonstrated efficacy in the treatment of VCFs, however, some studies report rates of readmission as high as 10.8% following such procedures. The purpose of this study was to employ Machine Learning (ML) algorithms to predict 30-day hospital readmission following cement augmentation procedures for the treatment of VCFs using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. MethodsACS-NSQIP was queried to identify patients undergoing either KP or VP from 2011 to 2014. Three ML algorithms were constructed and tasked with predicting post-operative readmissions within this cohort of patients. Results: Postoperative pneumonia, ASA Class 2 designation, age, partially-dependent functional status, and a history of smoking were independently identified as highly predictive of readmission by all ML algorithms. Among these variables postoperative pneumonia (p < 0.01), ASA Class 2 designation (p < 0.01), age (p = 0.002), and partially-dependent functional status (p < 0.01) were found to be statistically significant. Predictions were generated with an average AUC value of 0.757 and an average accuracy of 80.5%. ConclusionsPostoperative pneumonia, ASA Class 2 designation, partially-dependent functional status, and age are perioperative variables associated with 30-day readmission following cement augmentation procedures. The use of ML allows for quantification of the relative contributions of these variables toward producing readmission.

Outcomes of Combined Opioids and Benzodiazepines Consumption in Elderly Trauma: A Retrospective Cohort Study.

Acute substance intoxication is associated with traumatic injury and worse hospital outcomes. The objective of this study was to evaluate the association between simultaneous opioids and benzodiazepines (OB) use and hospital outcomes in elderly trauma patients. We performed a retrospective analysis using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) 2017 database. We included trauma patients (age ≥ 65years) examined by urine toxicology within 24hours of presentation. The primary outcome was in-hospital mortality. Secondary outcomes included hospital and ICU lengths of stay (HLOS AND ICULOS), in-hospital complications (eg, ventilator-associated pneumonia), unplanned intubation, and duration of mechanical ventilation. Patients were stratified being both positive for opioids and benzodiazepines (OB+) or not (OB-) based on having positive or negative drug screen for both drugs, respectively. A 1:1 propensity score matching was performed controlling for demographics (eg, age and sex), comorbidities (eg, alcoholism), and injury characteristics. Of 77,311 tested patients, 849 OB+ were matched to OB- patients. Compared to OB- group, OB+ patients were more likely to have unplanned intubation (26 [3.1%] vs 8 [0.9%], P = 0.002) and had prolonged HLOS (≥2days: 683 [84.0%] vs 625 [77.8%], P = 0.002). There were no differences in all other outcomes (P > 0.05). The OB intake is associated with higher incidence of unplanned intubation and longer HLOS in elderly trauma patients. Early identification of elderly trauma patient with OB+ can help provide necessary pharmacologic and behavioral interventions to treat their substance use and potentially improve outcomes.

Identifying Independent Predictors of Short-Term Postoperative Morbidity in Patients Undergoing Cranioplasty.

The present study intends to identify independent predictors of short-term postoperative complications and health utilization in patients undergoing cranioplasty. Demographic, clinical, and intraoperative characteristics were collected for each patient undergoing cranioplasty in the National Surgery Quality Improvement Program database from 2011 to 2020. The 30-day outcomes analyzed were medical complications, wound complications, return to the operating room, extended hospital stay, and non-home discharge. Bivariate analyses were initially used to identify variables that yielded a P value less than 0.2 which were subsequently analyzed in a multivariate logistic regression to identify independent predictors of the aforementioned outcomes. In total, 2316 patients undergoing cranioplasty were included in the analysis. Increased operative time and totally dependent functional status significantly increased odds of returning to the operating room. Increased age, operative time, cranioplasty size >5cm, and various comorbidities were associated with increased odds of non-home discharge. Bleeding disorders were independently associated with increased odds of wound complications. Increased age, operative time, cranioplasty size >5cm, and several medical history features predisposed to medical complications. Demographic characteristics, including age and race, along with various operative and medical history characteristics were associated with increased odds of extended length of stay. Identification of risk factors can help guide preoperative risk management in cranioplasty.

Undercounting diagnoses in Australian general practice: a data quality study with implications for population health reporting

BackgroundDiagnosis can often be recorded in electronic medical records (EMRs) as free-text or using a term with a diagnosis code. Researchers, governments, and agencies, including organisations that deliver incentivised primary care quality improvement programs, frequently utilise coded data only and often ignore free-text entries. Diagnosis data are reported for population healthcare planning including resource allocation for patient care. This study sought to determine if diagnosis counts based on coded diagnosis data only, led to under-reporting of disease prevalence and if so, to what extent for six common or important chronic diseases.MethodsThis cross-sectional data quality study used de-identified EMR data from 84 general practices in Victoria, Australia. Data represented 456,125 patients who attended one of the general practices three or more times in two years between January 2021 and December 2022. We reviewed the percentage and proportional difference between patient counts of coded diagnosis entries alone and patient counts of clinically validated free-text entries for asthma, chronic kidney disease, chronic obstructive pulmonary disease, dementia, type 1 diabetes and type 2 diabetes.ResultsUndercounts were evident in all six diagnoses when using coded diagnoses alone (2.57–36.72% undercount), of these, five were statistically significant. Overall, 26.4% of all patient diagnoses had not been coded. There was high variation between practices in recording of coded diagnoses, but coding for type 2 diabetes was well captured by most practices.ConclusionIn Australia clinical decision support and the reporting of aggregated patient diagnosis data to government that relies on coded diagnoses can lead to significant underreporting of diagnoses compared to counts that also incorporate clinically validated free-text diagnoses. Diagnosis underreporting can impact on population health, healthcare planning, resource allocation, and patient care. We propose the use of phenotypes derived from clinically validated text entries to enhance the accuracy of diagnosis and disease reporting. There are existing technologies and collaborations from which to build trusted mechanisms to provide greater reliability of general practice EMR data used for secondary purposes.

Inpatient versus Outpatient Alveolar Bone Grafting: A Nationwide Cost Analysis.

To compare postoperative outcomes and costs between inpatient and outpatient ABG in the United States. Retrospective cohort. Multi-institutional/national. Patients who underwent ABG (n = 6649) were identified in the National Surgical Quality Improvement Program Pediatric database from 2012-2021. Inpatient and outpatient cohorts were matched using coarsened exact matching. Thirty-day readmission, reoperation, and complications. A modified Markov model was developed to estimate the cost difference between cohorts. One-way and probabilistic sensitivity analyses were performed. After matching, 3718 patients were included, of which 1859 patients were in each hospital-setting cohort. The inpatient cohort had significantly higher rates of reoperations (0.6% vs. 0.2%; p = 0.032) and surgical site infections (0.8% vs. 0.2%; p = 0.018). The total cost of outpatient ABG was estimated to be $10,824 vs. $20,955 for inpatient ABG, resulting in $10,131 cost savings per patient. Probabilistic sensitivity analysis revealed that all 10,000 simulations resulted in consistent cost savings for the outpatient cohort that ranged from $8000 to $24,000. Outpatient ABG has become increasingly more popular over the past ten years, with a majority of cases being performed in the ambulatory setting. If deemed safe for the individual patient, outpatient ABG may confer a lower risk of nosocomial complications and offer significant cost savings to the healthcare economy.

A Nationwide Analysis of the Impact of Cardiopulmonary Anomalies on Cleft Palate Surgical Outcomes.

To increase awareness and improve perioperative care of patients with cleft palate (CP) and coexisting cardiopulmonary anomalies. Retrospective cohort. Multi-center. Patients who underwent surgical repair of CP between 2012-2020 identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric Data File. Chi-squared analysis and Student's t-test were implemented to make associations between congenital heart disease (CHD) and congenital pulmonary disease (CPD) and postoperative complications. Multiple logistic regression was performed to identify associations between CP and CHD/CPD while controlling for age, gender, and ASA class. C2 values were used to assess the logistic regressions, with a significance level of 0.05 indicating statistical significance. Length of stay (LOS), perioperative complications (readmission, reoperation, reintubation, wound dehiscence, cerebrovascular accidents, and mortality). 9 96 181 patients were identified in the database, 17 786 of whom were determined to have CP, of whom 16.0% had congenital heart defects (CHD) and 13.2% had congenital pulmonary defects (CPD). Patients with CHD and CPD were at a significantly greater risk of increased LOS and all but one operative complication rate (wound dehiscence) relative to patients with CP without a history of CHD and CPD. This study suggests that congenital cardiopulmonary disease is associated with increased adverse outcomes in the setting of CP repair. Thus, heightened clinical suspicion for coexisting congenital anomalies in the presence of CP should prompt referring providers to perform a comprehensive and multidisciplinary evaluation to ensure cardiopulmonary optimization prior to surgical intervention.

Process evaluation of a data-driven quality improvement program within a cluster randomised controlled trial to improve coronary heart disease management in Australian primary care.

This study evaluates primary care practices' engagement with various features of a quality improvement (QI) intervention for patients with coronary heart disease (CHD) in four Australian states. Twenty-seven practices participated in the QI intervention from November 2019 -November 2020. A combination of surveys, semi-structured interviews and other materials within the QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living with heart disease (QUEL) study were used in the process evaluation. Data were summarised using descriptive statistical and thematic analyses for 26 practices. Sixty-four practice team members and Primary Health Networks staff provided feedback, and nine of the 63 participants participated in the interviews. Seventy-eight percent (40/54) were either general practitioners or practice managers. Although 69% of the practices self-reported improvement in their management of heart disease, engagement with the intervention varied. Forty-two percent (11/26) of the practices attended five or more learning workshops, 69% (18/26) used Plan-Do-Study-Act cycles, and the median (Interquartile intervals) visits per practice to the online SharePoint site were 170 (146-252) visits. Qualitative data identified learning workshops and monthly feedback reports as the key features of the intervention. Practice engagement in a multi-featured data-driven QI intervention was common, with learning workshops and monthly feedback reports identified as the most useful features. A better understanding of these features will help influence future implementation of similar interventions. Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12619001790134.

Short-Term Morbidity and Mortality after Distal Femur Open Reduction Internal Fixation in the Geriatric Population.

Distal femur fractures remain a significant cause of morbidity and mortality for elderly patients. There is a lack of large population studies investigating short-term outcomes after distal femur c in elderly patients. The purpose of this study is to assess the incidence of and risk factors for various short-term outcomes after distal femur open reduction internal fixation (ORIF) in the geriatric population. The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database was used to identify all primary distal femur ORIF cases in patients 60+ years old between January 1, 2015 and December 31, 2020 using Current Procedural Terminology (CPT) codes 27511, 27513, and 27514. Demographic, medical, and surgical variables were extracted for all patients. Propensity score matching was used to match cases in the two age groups based on various demographic and medical comorbidity variables. Several 30-day outcome measures were compared between the 60-79-year-old and 80+-year-old groups both before and after matching. Subsequent multivariate logistic regression was used to identify independent risk factors for 30-day outcome measures in the matched cohort. A total of 2913 patients were included in the final cohort: 1711 patients in the 60-79-year-old group and 1202 patients in the 80+-year-old group. Most patients were female (n = 2385; 81.9%). Prior to matching, the older group had a higher incidence of 30-day mortality (1.9% vs. 6.2%), readmission (3.7% vs. 9.7%, p = 0.024), and non-home discharge (74.3% vs. 89.5%, p < 0.001). Additionally, the older group had a higher rate of blood loss requiring transfusion (30.9% vs. 42.3%, p < 0.001) and medical complications (10.4% vs. 16.4%, p < 0.001), including myocardial infarction (0.7% vs. 2.7%, p < 0.001), pneumonia (2.7% vs. 4.6%, p = 0.008), and urinary tract infection (4.1% vs. 6.1%, p = 0.0188). After matching, the older group consistently had a higher incidence of mortality, non-home-discharge, blood loss requiring transfusion, and myocardial infarction. Various independent risk factors were identified for 30-day morbidity and mortality, including American Society of Anesthesiologists (ASA) classification, body mass index (BMI) status, operative duration, and certain medical comorbidities. Geriatric patients undergoing distal femur ORIF are at significant risk for 30-day morbidity and mortality. After matching, octogenarians and older patients specifically are at increased risk for mortality, non-home discharge, and surgical complications compared to patients aged 60-79 years old. Multiple factors, such as BMI status, ASA classification, operative time, and certain medical comorbidities, are independently associated with poor 30-day outcomes.

A Comparison of Clinical Outcomes of Colectomies for Pediatric and Adult Patients With Inflammatory Bowel Disease.

Background: Crohn's disease (CD) and ulcerative colitis (UC) are prevalent in adult and pediatric populations, but their differences are not well studied using national data. We compared the clinical outcomes of these patients using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases.Methods: Colectomy cases for CD and UC, the 2 major forms of inflammatory bowel disease (IBD), were compared between adult and pediatric patients using the 2017-2019 ACS NSQIP databases. Various clinical factors were analyzed, with postoperative complications being the primary outcome of interest.Results: We identified 542 pediatric and 5174 adult CD patients and 360 pediatric and 1292 adult UC patients. Adults with CD or UC were more likely to be on steroids preoperatively (CD: 60.15% vs 24.54%; UC: 65.63% vs 51.39%). Children with IBD were more likely to have preoperative transfusions (CD: 1.48% vs .33%; UC: 8.33% vs .62%), systemic inflammatory response syndrome (CD: 3.51% vs .93%; UC: 12.78% vs 3.10%), or sepsis (CD: 1.85% vs .66%; UC: 1.39% vs .31%). Unplanned reoperations were more common among pediatric patients in both disease states compared to adults (CD: 6.27% vs 4.10%; UC: 11.11% vs 4.26%), with P-values for all factors described as ≤.02. Multivariate logistic regression found pediatric age to be associated with higher odds of needing a reoperation among UC patients but not CD patients.Conclusion: Pediatric patients were sicker at the time of surgery, and those with either disease were more likely to require a reoperation within 30days.

Modern Trends in Surgical Site Infection Rates for Colorectal Surgery: A National Surgical Quality Improvement Project Study 2013-2020.

There are few studies investigating trends in global surgical site infection rates in colorectal surgery in the last decade. This study seeks to describe changes in rates of different surgical site infections from 2013-2020, identify risk factors for SSI occurrence and evaluate the association of minimally invasive surgery and infection rates in colorectal resections. A retrospective analysis of the National Surgical Quality Improvement Program database 2013-2020 identifying patients undergoing open or laparoscopic colorectal resections by procedure codes was performed. Patient demographic information, comorbidities, procedures, and complications data were obtained. Univariable and multivariable logistic regression were performed. This was a retrospective study. A total of 279,730 patients received colorectal resection from 2013 - 2020. Primary outcome measure was rate of surgical site infection, divided into superficial, deep incisional and organ space infections. There was a significant decrease in rates of superficial infections (p < 0.01) and deep incisional infections (p < 0.01) from 5.9% in 2013 to 3.3% in 2020 and from 1.4% in 2013 to 0.6% in 2020, respectively, but a rise in organ space infections (p < 0.01) from 5.2% in 2013 to 7.1% in 2020. Use of minimally invasive techniques was associated with decreased odds of all surgical site infections compared to open techniques (p < 0.01) in multivariate analysis and adoption of minimally invasive techniques increased from 59% in 2013 to 66% in 2020. Study is limited by retrospective nature and variables available for analysis. Superficial and deep infection rates have significantly decreased, likely secondary to improved adoption of minimally invasive techniques and infection prevention bundles. Organ space infection rates continue to increase. Additional research is warranted to clarify current recommendations for mechanical bowel prep and oral antibiotic use as well as to study novel interventions to decrease postoperative infection occurrence. See Video Abstract.

Dependent functional status is an independent risk factor for 30-day mortality and morbidities following colectomy for volvulus: An ACS-NSQIP study from the United States

ObjectivesColonic volvulus is a common cause of bowel obstructions and surgery is the definitive treatment. Functional status is often associated with adverse postoperative outcomes but its effect on colectomy for volvulus remained under-explored. This study sought to analyze the effect of functional status on the 30-day outcomes of colectomy for volvulus. Materials and methodNational Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2022 was utilized. Only patients with volvulus as the primary indication for colectomy were included. Thirty-day postoperative outcomes were compared between patients with dependent functional status (DFS) and independent functional status (IFS), adjusted for demographics, baseline characteristics, preoperative preparation, indication for surgery, and operative approaches by multivariable logistic regression. ResultsThere were 1,476 patients with DFS (945 partially DFS and 531 fully DFS) and 8,824 (85.67 %) IFS patients who underwent colectomy for volvulus. After multivariable analysis, DFS patients had higher risks of mortality (aOR=1.671, 95 CI=1.37–2.038, p < 0.01), pulmonary complications (aOR=2.166, 95 CI=1.85–2.536, p < 0.01), sepsis (aOR=1.31, 95 CI=1.107–1.551, p < 0.01), prolonged postoperative nothing by mouth (NPO) or nasogastric tube (NGT) use (aOR=1.436, 95 CI=1.269–1.626, p < 0.01), discharge not to home (aOR=3.774, 95 CI=3.23–4.411, p < 0.01), and 30-day readmission (aOR=1.196, 95 CI=1.007–1.42, p = 0.04). Moreover, DFS patients had a longer length of stay (p = 0.01). ConclusionDFS was identified as an independent risk factor for increased mortality and complications after colectomy for volvulus. Given the substantial overlap between DFS patients and those who have colonic volvulus, these insights can contribute to preoperative risk assessments and postoperative care in these patients.

Early safety of endoscopic sleeve gastroplasty in super obesity (BMI > 50)

BackgroundThe prevalence of super obesity (BMI > 50) continues to rise. However, the adoption of bariatric surgery in this population remains very low. There are limited studies evaluating the utility of endoscopic sleeve gastroplasty (ESG) in super obesity. ObjectivesThe purpose of this study is to evaluate the short-term safety profile of ESG in patients with super obesity using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. SettingUnited States. MethodsWe retrospectively analyzed patients who underwent ESG and sleeve gastrectomy (SG) from 2016 to 2021. Patients with BMI >50 who underwent ESG were compared to ESG patients with BMI <50 and also SG patients with BMI >50. Primary outcomes included the incidence of severe adverse events (AEs), hospital readmission, reintervention, and reoperation within 30 days of the primary procedure. Secondary outcomes included procedure time, hospital length of stay, and total body weight loss at 30 days. ResultsThere were no significant differences in AE, reoperations, hospital readmissions, or reinterventions for patients with super obesity undergoing ESG, compared to patients with BMI below 50. Mean total body weight loss was greater in patients with super obesity. There were no significant differences in AEs for patients with super obesity who underwent ESG versus SG, although ESG patients had more hospital readmissions, reinterventions, and reoperations. ConclusionsESG may be performed safely, with comparable safety to SG, in patients with BMI as high as 70. However, further studies are needed to validate the feasibility and long-term efficacy prior to clinical implementation.

Analysis of program outcomes attainment for diploma in civil engineering at Universiti Teknologi MARA Pahang

Analysis of program outcomes involves the assessment of the learning objectives based on cognitive, psychomotor, and affective domains and their attainment is measured using both direct and indirect approaches. This study aims to assess the program outcomes attainment for the civil engineering diploma program at Universiti Teknologi MARA Pahang. The program outcomes attainment in this study was obtained from two categories of students based on cohort 20174 using the Plan ID 6541, namely i) 257 graduated on-time students and ii) 365 overall students including extended students. The attainments were analyzed quantitatively using key performance indicators for each program outcome and program performance indicators for the overall attainment of program outcomes. Based on the key performance indicator, the results reveal that nine program outcomes are indicated as excellent while three program outcomes are indicated as good. Meanwhile, based on the program performance indicator, this cohort is indicated as well performed where 9 out of 12 program outcomes recorded above 70% average attainment. Various effective continuous quality improvement (CQI) program can be identified by the school’s committee based on these findings to further enhance the program outcomes attainment.

NSQIP audit of enhanced recovery after surgery protocols for radical cystectomy.

11009 Background: Utilization of enhanced recovery after surgery (ERAS) protocols for radical cystectomy (RC) has been associated with improved postoperative recovery and shorter hospital stays. The multiple components within ERAS leads itself to heterogenous implementation across different institutions. We aimed to assess the impact of increasing compliance to ERAS components on postoperative outcomes in patients who underwent RC. Methods: The National Surgical Quality Improvement Program database included 3,708 patients who underwent RC from 2019 to 2021. ERAS components of interest included regional anesthesia block, no bowel prep, no prolonged NGT or NPO status, VTE prophylaxis with mechanical and pharmacologic means, and antibiotic duration &lt; 24 hours. Baseline characteristics and complications were stratified by number of ERAS components utilized (≤ 3, 4, or 5). Statistical endpoints included thirty-day complications, length of stay (LOS), and readmissions. Optimal RC outcome was defined as absence of any postoperative complication, reoperation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable analyses with Bonferroni correction were performed to assess the association between ERAS compliance and outcomes. Results: Of the 3,708 patients who underwent RC with ERAS components utilized, 1,506 (41%) received ≤ 3 interventions, 1454 (39%) received 4, and 748 (20%) received 5. Baseline characteristics were relatively similar across the three groups. On multivariable analysis adjusted for multiple hypothesis testing, when compared to patients who received ≤ 3 interventions, patients who received 4 and 5 interventions had lower rates of any complication (OR 0.71; 99% CI [0.58 - 0.88], OR 0.74 [0.57 - 0.95], respectively), and shorter LOS (β -1.32 [-1.69, -0.95], β -1.74 [-2.19, -1.28], respectively). Moreover, patients with increased ERAS compliance experienced increased odds of an optimal outcome (OR 1.68 [1.38 – 2.05], OR 1.97 [1.55 – 2.51], respectively). Conclusions: Greater adherence to ERAS protocol interventions yielded superior post-operative outcomes for patients who underwent RC. This large-scale analysis supports that ERAS protocols are beneficial in a dose-dependent fashion and should be utilized. [Table: see text]

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

Factors associated with increased 30-day re-operation risk in anterior cruciate ligament reconstruction

BackgroundRevision surgery following isolated anterior cruciate ligament reconstruction (ACLR) has often focused on mid- to long-term revisions due to re-rupture, while short-term 30-day revision is a rare, but underappreciated entity. This study aims to characterize incidence and risk factors for reoperations following isolated ACLR. MethodsThis is a retrospective case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (NSQIP) database from 2005 to 2017. Current Procedural Terminology codes were used to identify elective isolated ACLR patients. Patients undergoing reoperations were analyzed using bivariate analysis against their respective perioperative variables. Multivariate stepwise logistic regression was used to identify independent risk factors for reoperations after ACLR. Results12,790 patients were included in the study. 37.0% of patients were female. Mean age was 32.2+/-10.7 years and mean body mass index (BMI) was 27.8+/-6.5 kg/m2, with 28.9% of patients with BMI > 30. The most frequently reported reason for reoperation based on CPT and ICD-9/10 codes was postoperative infection (0.5%). Overall reoperation rate was approximately 0.5%. Multivariate analysis identified operative time >1.5 h (OR 2.6 [95% CI; 1.5–4.4]), dependent functional status (OR 14.0 [1.4–141.6]), and adjunctive anesthesia (OR 2.4 [95% CI; 1.1–5.0]) as independent risk factors for reoperation. Female sex was a protective factor against reoperations (OR 0.6 [0.3–0.98]). ConclusionPrimary, isolated ACLR is associated with extremely low rates of short-term reoperations. Operative time >1.5 h, dependent functional status, and adjunctive anesthesia were independent risk factors for reoperation and female sex was a protective factor against reoperation. Level of EvidenceLevel III. Retrospective cohort study.

Insulin Dependence Negatively Impacts Outcomes in Anterior Cervical Discectomy with Fusions: A Ten-Year Retrospective Analysis

Background ContextAlthough anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing diabetic patient population, there is a paucity of literature focusing on insulin-dependence as a risk-factor for post-operative ACDF complications. PurposeTo evaluate the differential impact of insulin dependence on perioperative outcomes including total length of stay, surgical, and medical complications within thirty days following ACDF. Study Design/SettingA retrospective cohort, large multicenter database study. Patient SampleThe American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551. Outcome MeasuresPerioperative surgical and medical complications. MethodsThe study population was divided into three groups 1) insulin-dependent diabetes mellitus (IDDM), 2) insulin-independent diabetes mellitus (NIDDM), and 3) no diabetes mellitus (non-DM). One-way analysis of variance for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the three groups. Multivariable logistic regression analysis assessed the effect of diabetes mellitus status on post-operative medical and surgical outcomes. ResultsA total of 85,758 ACDF procedures were identified between 2011 and 2021, of which 5,178 were IDDM, 9,652 were NIDDM, and 70,982 were non-DM. The rates of surgical and medical complication varied between the three groups. IDDM patients had the highest rates of at least one medical complication (6.1%). Only IDDM increased the risk for medical complications (OR: 1.320, 95% CI [1.144-1.518]) and extended hospital length of stay (LOS) (OR: 1.244, 95% CI [1.071-1.441]) following a multivariate logistic regression analysis. ConclusionPatients with IDDM were at an increased risk for postoperative medical complications and extended hospital LOS. Personalized postoperative management, guided by risk assessment is indicated for this population. These findings can be used to improve risk stratification and informed consent for DM patients who are insulin dependent.

Results of a quality improvement program to increase complete lung cancer biomarker testing rates by focusing on system, physician, and other factors associated with adverse health outcomes.

e23249 Background: Complete biomarker testing (CBT) is an underutilized standard of care for patients with advanced lung adenocarcinoma, but limited tissue samples may lead to incomplete testing. Especially if quantity is not sufficient (QNS) requiring additional samples, a prolonged time-to-initiation of treatment (TTT) has been shown to negatively impact clinical outcomes. Bon Secours Mercy Health (BSMH) Youngstown, Ohio reviewed biomarker testing data and found: 1) only 41% of patients received CBT, and 2) in the case of QNS when liquid biopsies were utilized, the time from diagnosis to results took an average of 42 days. BSMH worked in collaboration with OncoLens and Q Synthesis to address these issues and reduce the TTT. To our knowledge, there is also no data on interventions that can increase CBT across large health systems and simultaneously tackle both physician and other factors associated with known health disparities. Methods: A multidisciplinary team developed a new workflow for patients diagnosed with advanced NSCLC. The pilot involved collecting both tissue and blood at the time of needle biopsy and working with a single reference lab for testing. Physicians and nurses in radiology and pulmonology were in-serviced on the new workflow. As patients were being prepared for a biopsy procedure, nurses collected two tubes of blood for liquid biopsy. After the procedure, both the tissue and blood were sent to pathology and if pathology confirmed an advanced NSCLC diagnosis, both samples were sent to the reference lab for testing. The lab developed a new process to hold blood and test it only when the tissue was QNS. If QNS, tissue testing for PD- L1 was prioritized, and additional biomarker tests were completed with the blood sample. If tissue quantity was sufficient, unused blood was discarded. The lab charged for a single test regardless of whether the test was performed on tissue and/or blood. Results: The QI project ran from Sept 2021 - Dec 2022 and achieved four improvements: 1) a 39.6% increase in CBT in patients with advanced NSCLC (80.6% post-intervention), 2) a decrease of 15.7 days from diagnosis to complete liquid biopsy test results (27.2 days post-intervention, 3) increased CBT rates across all but one physician by an average of 55% (-5% to 220%), and 4) increased CBT by 8% in females and patients with Medicare, Medicaid or other noncommercial/underinsured/uninsured payors. Conclusions: This QI project demonstrated that CBT of advanced NSCLC can be improved by programs that are tailored to large health systems and individual physicians. Gains are also seen in patient populations at risk of adverse outcomes.

Quality Improvement Project to Reduce Admission Hypothermia of Preterm Infants Born at Less than 32 Weeks or 1,500 g

Purpose: Hypothermia upon admission to the neonatal intensive care unit (NICU) contributes significantly to various neonatal complications, particularly in preterm infants. This study aimed to assess the impact of quality improvement (QI) interventions, including using plastic bags and head caps, and adjusting delivery room temperatures, on improving the admission body temperature and reducing hypothermia in infants born at less than 32 weeks or weighing 1,500 g.Methods: This study retrospectively analyzed the medical records of infants born at less than 32 weeks or weighing 1,500 g who admitted to the NICU at Samsung Medical Center from January 2022 to February 2024. The QI program that was initiated in April 2023 focused on managing admission temperatures using plastic bags and head caps, and maintaining delivery room temperatures at ≥25 °C. The admission temperature and short-term outcomes pre- and post-QI were compared.Results: In a study of 270 patients, implementing QI initiatives significantly raised the admission temperature from 36.2±0.5 to 36.4±0.4 °C (p&lt;0.01), particularly impacting infants weighing ≥1,000 g, in whom mild hypothermia occurrences dropped from 76.3% to 43.9% (p&lt;0.01). This improvement in temperature management significantly decreased both mild and severe hypothermia rates post-QI. Additionally, implementing all three initiatives was more effective than when two or fewer initiatives were implemented.Conclusion: Simple and cost-effective QI interventions can increase admission temperatures and decrease hypothermia in neonates. Further research is essential to explore the long-term outcomes and develop effective hypothermia management strategies in neonatal care.

Screening for Bacterial Vaginosis Prior to Delivery: A Cost-Effectiveness Study.

The objective of this study was to compare the cost and effectiveness of three strategies for screening and/or treating bacterial vaginosis (BV) during pregnancy prior to delivery: (1) the current standard of care was neither test nor treat for BV (Treat None); (2) test all patients for BV at 36 weeks' gestation; treat if positive (Test Treat); and (3) treat all patients undergoing cesarean delivery with intravenous metronidazole at time of surgery (Treat All Cesarean). Effectiveness was defined as avoidance of postpartum surgical site infection (SSI). A decision analytic cost-effectiveness model was designed from a third-party payer perspective using clinical and cost estimates obtained from the literature, American College of Surgeons National Surgical Quality Improvement Program participant use file (2005-2019), 2019 National Vital Statistics, Medicare costs, and wholesale drug costs. Cost estimates were inflated to 2020 U.S. dollars. For this study, effectiveness was defined as avoidance of postpartum SSIs. The base case analysis that is the current standard of care of not routinely testing and treating patients for BV (Treat None) was the most expensive and least effective strategy, with a mean cost of $59.16 and infection rate of 3.71%. Empirically treating all patients for BV without testing (Treat All Cesarean) was the most effective and the least expensive strategy, with a mean cost of $53.50 and an infection rate of 2.75%. Testing all patients for BV and treating those positive for BV (Test Treat) was also relatively inexpensive and effective, with an infection rate of 2.94% and mean cost of $57.05. Compared with Treat None, we would expect the Treat All Cesarean strategy to reduce the infection rate by 26%. These findings suggest that treating pregnant patients with intravenous metronidazole at time of cesarean delivery could be an effective and cost-saving strategy. Testing and treating for BV could also be considered a reasonable strategy, as it has the added benefit of preserving antibiotic stewardship. In no analysis was the standard of care strategy of neither testing nor treating for BV before delivery the preferred strategy. · BV colonization may increase surgical site infection risk after cesarean section.. · Treatment of BV before or during delivery may be cost-saving strategies as treatment could prevent costs associated with infection.. · Further study is needed to best balance the risk of surgical site infection with antibiotic stewardship..