Surgical Quality Indicators Research Articles

Surgical quality indicators in low-resource settings: A new evidence-based tool

Worldwide efforts to improve access to surgical care must be accompanied by improvements in the quality of surgical care; however, these efforts are contingent on the ability to measure quality. This report describes a novel, evidence-based tool to measure quality of surgical care in low-resource settings. We defined a widely applicable, multidimensional conceptual framework for quality. The suitability of currently available quality metrics to low-resource settings was evaluated. Then we developed new indicators with sufficient supportive evidence to complete the framework. The complete set of metrics was condensed into four collection sources and tools. The following 15 final evidence-based indicators were defined: (1) Safe structure: morbidity and mortality conference; (2) safe process: use of the safe surgery checklist; (3) (4) safe outcomes: perioperative mortality rate and proportion of cases with complications graded >2 on the Clavien-Dindo scale; (5) effective structure: provider density; (6) effective process: procedure rate; (7) effective outcome: rate of caesarean sections; (8) patient-centered process: use of informed consent; (9) patient-centered outcome: patient hospital satisfaction questionnaire; (10) timely structure: travel time to hospital; (11) timely process: time from emergency department presentation to non-elective abdominal surgery; (12) timely outcome: patient follow-up plan; (13) efficient process: daily operating room usage; (14) equitable outcome: comparative income of patients compared with population; and (15) proportion of patients facing catastrophic expenditure because of surgical care. This tool provides an evidence-based conceptual tool to assess the quality of surgical care in diverse low-resource settings.

Why Certification of Colorectal Cancer Centres Does Not Improve Surgical Quality

To improve treatment results, certification of colorectal cancer centres in Germany assures interdisciplinary treatment according to official treatment guidelines. The treatment results of certified colorectal cancer centres are published annually. Despite certification, the surgical quality indicators of anastomotic leakage, wound infection, and revision surgery have not improved between 2009 and 2015. Patients with anastomotic leakage (AL) after colorectal resection of an adenocarcinoma were analyzed in a Morbidity and Mortality (M+M) conference structured according to the London Protocol. The results were compared to structure and process parameters that are part of the data entry form (DEF) of the Deutsche Krebsgesellschaft (DKG) used for the certification of colorectal cancer centres. Between 2015 and 2017, 387 colorectal resections were performed. Of these, 158 resections were performed due to the diagnosis of a colorectal carcinoma. For 13/149 resections with anastomosis, a leak was diagnosed (8.7%). All patients suffering from an AL were analysed in an M+M conference structured according to the London Protocol. For 10/13 patients, abnormalities in structural and procedural quality were found. As regards procedural quality, this included the application of standards (n = 6/10), communication (n = 3/10) and missing but needed results from examinations (n = 1/10). As regards structural quality, insufficient physical resources were predominant (n = 3/10). Only one of these abnormalities was identified using the DEF. For processes and structures to improve surgical quality, it is required that they have relevant influence on surgical quality. We found that only 1/13 abnormalities detected in the M+M conference structured according to the London Protocol was represented in the DEF. To improve the influence on surgical quality, extensions to the DEF of the Deutsche Krebsgesellschaft should be discussed.

The impact of complete embedding of remaining tissue in gynecological lymph node dissection specimen in surgical pathology on lymph node yield: is it clinically relevant?

The assessment of nodal metastases in gynecological surgical specimen is an important staging parameter, directing further therapeutic procedures. Since the number of lymph nodes (LNs) removed is seen as an indicator of surgical and pathological quality, the demand for higher lymph node (LN) counts is raising. The goal of this prospective study was the comparison between lymph node counts of macroscopically detectable LNs and the LN yield by complete embedding and proceeding of all submitted LN-containing tissue in the pathology laboratory. One hundred six cases of cervical, uterine, or ovarian cancer, treated in three different hospitals within 3years, were analyzed. All tissue submitted to the pathology from the surgically performed LN dissections was completely dissected and embedded in the institute of pathology. Subsequently, the amount of LN of all macroscopically detectable nodes was compared to the final histologically reached numbers of LN. Furthermore the histologically visible area of the LNs and their metastases was analyzed to assess the relation of LN numbers to the whole examined LN area. Complete embedding raises the average number of LN counted by 3 to 7 but did only minimally increase the LN area for microscopical examination by about 5% due to the small area of the additional LNs in the remaining fat tissue. The staging was in no case altered by complete embedding, even when additional nodal metastases were detected in the remaining fat tissue, since this was only seen in cases which had already metastatic nodes. Complete embedding of LN-containing tissue did not provide relevant additional staging information and seems therefore unnecessarily laborious, careful pathological work-up assumed.

Benchmarking quality for renal cancer surgery: Canadian Kidney Cancer information system (CKCis) perspective.

There is a lack of validated quality metrics to evaluate the care of patients receiving surgery for renal cell carcinoma (RCC). To address this, the Kidney Cancer Research Network of Canada defined a list of quality indicators (QI) to assess hospital-level performance. We have case-mix adjusted these QIs to benchmark RCC surgical care at Canadian academic centres. The Canadian Kidney Cancer information system (CKCis) was used to measure six QIs: laparoscopic approach proportion (LA), partial nephrectomy proportion (PN), partial nephrectomy in patients with chronic kidney disease (CKDPN), positive margin rate (PMR), partial nephrectomy complication rate (PNCx), and warm ischemia time (WIT). To benchmark performance, indirect standardization (observed-to-expected ratio) methodology was employed using multivariate regression models. Multivariate models for LA, PN, and CKDPN demonstrated good discrimination and were used for benchmarking. National averages of 74% (70-78%), 73% (70-75%), and 70% (67-74%) for the LA, PN, and CKDPN QIs, respectively, were determined and used to benchmark individual hospital performance. Overall, three (23%), two (15%), and two (15%) hospitals performed below expected for LA, PN, and CKDPN, respectively. Hospital identity was an independent predictor of LA, PN, and CKDPN (p<0.001). Significant variability between CKCis hospitals for three RCC surgical QIs exists. Using the CKCis infrastructure may provide a framework for institution-level audit feedback for quality improvement. Greater CKCis capture rates and further data supporting the construct validity of these QIs are required to extend the use of this dataset to real-world quality initiatives.

Validation of Using Claims Data to Measure Safety of Lumbar Fusion Surgery.

Retrospective analysis of patients undergoing elective lumbar fusion operations, comparing rates of repeat spine surgery based on method of ascertainment. We report the accuracy of a claims-based approach for reporting repeat surgery compared with medical records abstraction as the "gold standard." Previous studies have reported the validity of a claims-based algorithm for grouping patients by surgical indication and classifying operative features, but their accuracy in measuring surgical quality indicators has not been widely examined. We identified a subset of patients undergoing elective lumbar fusion operations at a single institution from 1996 to 2011, excluding those with spinal fracture, spinal cord injury, or cancer. From the medical record we abstracted the incidence of repeat spine operation or rehospitalization at 1 year. We cross-classified each event record with its corresponding value derived from claims. The sensitivity and specificity of the claims-based approach were calculated for reoperation within 30, 90, and 365 days, and all-cause hospital readmission within 30 days. Medical records linked to claims data were obtained for 520 patients undergoing elective lumbar fusion. Reoperation rates based on chart review were 1.0%, 1.3%, 3.6%, compared with 0.8%, 1.7%, and 3.8% based on the final claims methods at 30, 90, and 365 days, respectively. The claims-based algorithm had sensitivities of 80.0%, 100%, and 94.1% and specificities of 100%, 99.6%, 99.2% for repeat surgery within 30, 90, and 365 days, respectively. The sensitivity for all-cause readmission was 50%. Health care quality improvement efforts often rely on administrative data to report surgical safety. We found that claims-based ascertainment of safety at a single institution was very accurate. However, accuracy depended on careful attention to the timing of outcomes, as well as the definitions and coding of repeat surgery, including how orthopedic device removal codes are classified. 3.

Development and Pilot Study of an Essential Set of Indicators for General Surgery Services

IntroductionAt present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose. MethodsA modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators. ResultsTwelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement. ConclusionsCurrently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

PHP89 - Case Duration As A Surgical Quality And Efficiency Indicator In Surgical Residency Training Programs

PHP89 - Case Duration As A Surgical Quality And Efficiency Indicator In Surgical Residency Training Programs

Desarrollo y estudio piloto de un conjunto esencial de indicadores para los servicios de cirugía general

IntroductionAt present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose. MethodsA modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators. ResultsTwelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement. ConclusionsCurrently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

MP63-15 VALIDATION OF PERI-OPERATIVE BLOOD TRANSFUSION AS A SURGICAL QUALITY INDICATOR OF CYSTECTOMY: A POPULATION-BASED STUDY

You have accessJournal of UrologyBladder Cancer: Invasive V1 Apr 2016MP63-15 VALIDATION OF PERI-OPERATIVE BLOOD TRANSFUSION AS A SURGICAL QUALITY INDICATOR OF CYSTECTOMY: A POPULATION-BASED STUDY D. Robert Siemens, Melanie Jaeger, Xuejiao Wei, Francisco Vera-Badillo, and Christopher Booth D. Robert SiemensD. Robert Siemens More articles by this author , Melanie JaegerMelanie Jaeger More articles by this author , Xuejiao WeiXuejiao Wei More articles by this author , Francisco Vera-BadilloFrancisco Vera-Badillo More articles by this author , and Christopher BoothChristopher Booth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.944AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous single-center studies of peri-operative blood transfusion (PBT) at the time of radical cystectomy have suggested a potential association with long-term cancer survival. Here we describe the frequency of PBT at cystectomy in routine clinical practice and evaluate its effect on outcomes in order to explore its utility as a quality indicator of surgical care. METHODS Electronic records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients with bladder cancer who underwent cystectomy and PBT between 2000-2008. Hospital discharge records identified PBT. Modified Poisson regression model was used to determine the factors associated with PBT. A Cox proportional hazards regression model was used to explore the association between PBT and overall (OS) and cancer-specific (CSS) survival. RESULTS Among the 2593 patients with cystectomy in 2000-2008, 62% received an allogenic red blood cell transfusion. The frequency of PBT decreased over the study period (from 68% in 2000 to 54% in 2008, p<0.001). Factors associated with receiving PBT included age (80+ years RR 1.25, 95%CI 1.14-1.39), sex (female RR 1.40, 95%CI 1.33-1.48), greater co-morbidity (RR 1.11, 95%CI 1.03-1.20), T stage (T4 tumor RR 1.24, 95%CI 1.12-1.36) and surgeon volume (lowest quartile RR 1.18, 95%CI 1.08-1.28). Utilization of PBT was associated with inferior early outcomes including median length of stay (11 days vs 9 days, p<0.001), 90-day readmission rate (38% vs 29%, p<0.001) and 90-day mortality (11% vs 4%, p<0.001). OS (32% vs 47%, p<0.001) and CSS (38% vs 54%, p<0.001) at five years were lower among patients with PBT. These differences in long-term survival persisted on multivariate analysis (OS HR 1.33,95% CI 1.20-1.48; CSS HR 1.39, 95% CI 1.23-1.56). CONCLUSIONS Although rates are decreasing, these data suggest very high utilization rate of PBT at time of cystectomy in routine clinical practice. PBT is associated with substantially lower long-term survival. This association persists despite adjustment for provider volume, suggesting that PBT is a valid indicator of surgical care of bladder cancer. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e827 Advertisement Copyright & Permissions© 2016MetricsAuthor Information D. Robert Siemens More articles by this author Melanie Jaeger More articles by this author Xuejiao Wei More articles by this author Francisco Vera-Badillo More articles by this author Christopher Booth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Centralization of Penile Cancer Management in the United States: A Combined Analysis of the American Board of Urology and National Cancer Data Base

To assess the potential benefit of centralization of care in penile cancer. Centralization of care in other disease processes standardizes treatment and improves outcomes. Because penile cancer is a rare malignancy with unchanged mortality rates over the last two decades, we hypothesize that there may be a benefit to centralization. We identified surgeon, patient, and hospital characteristics captured by the National Cancer Data Base (1998-2012) and American Board of Urology case logs (2003-2013) for all penile cancer cases and procedures. Differences in patient demographics, stage of disease, referral patterns, and surgical quality indicators were assessed between academic and community hospitals. Using case logs to evaluate the distribution of penile cancer care, we found that only 4.1% of urologists performed a penile surgery and 1.5% performed a lymph node dissection (LND). Academic centers treated higher-stage cancers and saw more cases/year than community centers, suggesting informal centralization. Two guideline-based quality indicators demonstrated no difference in use of penile-sparing surgery but a higher likelihood of having an LND performed at an academic center (48.4% vs 26.6%). The total lymph node yield was significantly greater at academic centers (18.5 vs 12.5). Regression modeling demonstrated a 2.29 increased odds of having an LND at an academic center. Our data provide the first evidence for centralization of penile cancer in the US. At the time of diagnosis, equal number of patients is treated with penile-sparing surgery but there is greater use of LND and higher lymph node yield at academic centers. Ultimately, longer follow-up is necessary to determine if this improves survival of patients with penile cancer.

Hospital variation in rates of acid-reducing medication use after laparoscopic sleeve gastrectomy

BackgroundPostoperative gastroesophageal reflux is one of the most important long-term complications of sleeve gastrectomy, the most common bariatric procedure. ObjectiveTo assess variation in hospital performance with laparoscopic sleeve gastrectomy using rates of acid-reducing medication use at postoperative 1 year. SettingClinical registry of bariatric surgical patients at academic and community hospitals in Michigan. MethodsWe studied 2923 patients who underwent laparoscopic sleeve gastrectomy across 39 hospitals in the Michigan Bariatric Surgery Collaborative, 2007 to 2014. We compared risk- and reliability-adjusted rates of new-onset reflux—defined by new use of acid-reducing medication—across hospitals and in relation to surgical quality indicators (hospital procedure volume and 30-day complications). ResultsOverall, 20% of patients were newly taking acid-reducing medication at postoperative 1 year. Hospital rates of new medication use varied 3-fold, ranging from 10% (95% CI 7−15%) to 31% (95% CI 23−40%) of patients. Of the 2 hospitals with significantly lower rates of new medication use, 1 was high volume and 1 was medium volume. The 1 hospital with significantly higher rates was medium volume. Rates of acid-reducing medication use did not correlate with hospital volume or perioperative complications. ConclusionAcross Michigan hospitals, rates of new acid-reducing medication use at 1 year after laparoscopic sleeve gastrectomy varied widely and did not correlate with traditional quality indicators. Future research could explore differences in surgical technique to better understand the factors underlying variation in long-term outcomes after sleeve gastrectomy.

French current management and oncological results of locally recurrent rectal cancer

BackgroundThere is a significant worldwide variation in practice regarding the criteria for operative intervention and overall management in patients with locally recurrent rectal cancer (LRRC). A survival benefit has been described for patients with clear resection margins in patients undergoing surgery for LRRC which is seen as an important surgical quality indicator. MethodsA prospective French national database was established in 2008 which recorded procedures undertaken for locally recurrent rectal cancer (LRRC). Overall and Disease-Free Survival (OS, DFS) were assessed retrospectively. We report the variability and the heterogeneity of LRRC management in France as well as 5-year oncological outcomes. ResultsIn this national report, 104 questionnaires were completed at 29 French surgical centres with a high variability of cases-loaded. Patients had preoperative treatment in 86% of cases. Surgical procedures included APER (36%), LAR (25%), Hartmann's procedure (21%) and pelvic exenterations (15.5%). Four patients had a low sacrectomy (S4/S5). There were no postoperative deaths and overall morbidity was 41%. R0 was achieved in 60%, R1 and R2 in 29% and 11%, respectively. R0 resection resulted in a 5-year OS of 35% compared to 12% and 0% for respectively R1 and R2 (OR = 2.04; 95% CI: 1.4–2.98; p < 0.001). OS was similar between R2 and non-resected patients (OR = 1.47; 95% CI: 0.58–3.76; p = 0.418). ConclusionsOur data is in accordance with the literature except the rate of extended resection procedures. This underlines the selective character of operative indications for LRRC in France as well as the care variability and the absence of optimal clinical pathway regarding these patients.

Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery

BackgroundAdverse events (AEs) after outpatient orthopaedic surgery are common, but difficult to detect. Electronic health records facilitate abstraction of large quantities of data, and may allow automated identification of ‘triggers’...

PWE-302 Colorectal cancer lymph node retrieval number is associated with biological and institutional factors: a tertiary centre audit

Introduction Increased numbers of lymph nodes (LN) retrieved within a colorectal cancer resection is positively associated with survival and as such, identification of ≥12 LN is considered to be a surgical quality indicator. Here we audited LN retrieval data to establish both quality compliance and identify factors affecting identification rates. Method All colorectal cancer resections from April 2012–October 2014 at our institution were identified from the hospital’s cancer registry. The primary outcome variable was the number of nodes identified within the resection. Results 398 cases were included with a median LN retrieval number of 16. Greater numbers of nodes were identified in laparoscopic versus open surgery (p Conclusion Local compliance in the identification of ≥12 nodes was achieved. Audit analysis of LN retrieval data provides insight into the biology of colorectal cancer as well as identifying institutional specific predictors of LN yield. Disclosure of interest None Declared. References Berger AC, Sigurdson ER, LeVoyer T, Hanlon A, Mayer RJ, Macdonald JS, et al . Colon cancer survival is associated with decreasing ratio of metastatic to examined lymph nodes. J Clin Oncol. 2005;23(34):8706–12 Buczacki SJA and Davies RJ. Colon resection - is standard technique adequate? Surg Oncol Clin N Am . 2014 Jan;23(1):25–34 Chang GJ, Rodriguez-Bigas MA, Skibber JM, Moyer VA. Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst. 2007;99(6):433–41 Gilchrist RK, David VC. Lymphatic Spread of Carcinoma of the Rectum. Ann Surg. 1938;108(4):621–42 Le Voyer TE, Sigurdson ER, Hanlon AL, Mayer RJ, Macdonald JS, Catalano PJ, et al . Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol. 2003;21(15):2912–9 Lykke J, Roikjaer O, Jess P. The relation between lymph node status and survival in Stage I-III colon cancer: results from a prospective nationwide cohort study. Colorectal Dis. 2013;15(5):559–65

Invited Commentary

The burden of postoperative infection is felt broadly both in patient outcomes and in resource utilization. Over the past decade, the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program have highlighted the full impact of these adverse events [1Rowell K.S. Turrentine F.E. Hutter M.M. Khuri S.F. Henderson W.G. Use of national surgical quality improvement program data as a catalyst for quality improvement.J Am Coll Surg. 2007; 204: 1293-1300Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 2de Lissovoy G. Fraeman K. Hutchins V. Murphy D. Song D. Vaughn B.B. Surgical site infection: incidence and impact on hospital utilization and treatment costs.Am J Infect Control. 2009; 37: 387-397Abstract Full Text Full Text PDF PubMed Scopus (796) Google Scholar]. Although researchers are increasingly turning to national administrative databases to acquire patient samples, these sources are frequently marred by inconsistent or incomplete clinical data. In this issue of The Annals, Robich and colleagues [3Robich M.P. Sabik J.F. Houghtaling P.L. et al.Prolonged effect of postoperative infectious complications on survival after cardiac surgery.Ann Thorac Surg. 2015; 99: 1591-1600Google Scholar] harness their impressive single-institution operative volume to shed light on the long-term clinical impact of postoperative infections after cardiac operations. Performing propensity-matched analysis on a clinically focused dataset, the authors show that patients who experience postoperative infections and are successfully treated retain an increased risk of death after discharge that gradually decreases over time. In particular, the risk-adjusted survival for patients with septicemia, pneumonia, or harvest site infection is inferior to that in propensity-matched, noninfected control patients. Although the authors report a negative survival impact for as long as 1 year after discharge, a large portion of this excess risk is observed within the first 3 months. Notably, noninfected control patients in the matched group also had relatively poor 1-year survival, suggesting that patients who experience infectious adverse events tend to be sicker at baseline. The authors then identified numerous risk factors associated with postoperative infections, including age, immunosuppression, operative duration, diabetes, prolonged ventilation, and others. These results reinforce intuitive associations with valuable, objective evidence. The authors rightly acknowledged that, as with nearly all propensity-matching studies, there may be unaccounted confounders and imperfect matching. Nevertheless, this study and others carry important implications for both perioperative management and follow-up after discharge. The identification of a high-risk patient may suggest roles for antibiotic prophylaxis prolongation up to 48 hours [4Lador A. Nasir H. Mansur N. et al.Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis.J Antimicrob Chemother. 2012; 67: 541-550Crossref PubMed Scopus (83) Google Scholar], fast-track extubation, early mobilization and urinary catheter removal, or surgical techniques aimed at preserving sternal blood supply [5Deo S.V. Shah I.K. Dunlay S.M. et al.Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients.Ann Thorac Surg. 2013; 95: 862-869Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar]. After discharge, these patients should receive aggressive follow-up with a low threshold for readmission. Finally, this study’s results advocate for certain surgical quality indicators to extend beyond the short-term perioperative period, because it is becoming increasingly clear that adverse outcomes months or even years after an operation may nevertheless be associated with adverse events directly related to the operation. Prolonged Effect of Postoperative Infectious Complications on Survival After Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 99Issue 5PreviewWhether patients having infections after cardiac surgery are at a survival disadvantage after hospital discharge is unclear. Our objectives were (1) to identify characteristics of such patients and (2) to determine whether this complication is associated with increased mortality beyond hospital discharge. Full-Text PDF

Physician level reporting of surgical and pathology performance indicators: a regional study to assess feasibility and impact on quality.

There is increased awareness that, to minimize variation in clinician practice and improve quality, performance reporting should be implemented at the provider level. This optimizes physician engagement and creates a sense of professional responsibility for quality and performance measurement at the individual and organizational levels. Individual provider level reporting was implemented within a provincial health region involving 56 clinicians (general surgeons, surgical oncologists, urologists and pathologists). The 2 surgical pathology indicators chosen were colorectal cancer (CRC) lymph node retrieval rate and pT2 prostate cancer margin positivity rate. Surgical resections for all prostate and colorectal cancer performed between Jan. 1, 2011, and Mar. 30, 2012, were included. We used a pre- and postsurvey design to obtain physician perceptions and focus groups with program leadership to determine organizational impact. Survey results showed that respondents felt the data provided in the reports were valid (67%), consistent with expectations (70%), maintained confidentiality (80%) and were not used in a punitive manner (77%). During the study period the pT2 prostate margin positivity rate decreased from 57.1% to 27.5%. For the CRC lymph node retrieval rate indicator, high baseline performance was maintained. We developed a robust process for providing physicians with confidential, individualized surgical and pathology quality indicator reports. Our results reinforce the importance of individual physician feedback as a strategy for improving and sustaining quality in surgical and diagnostic oncology.

Cesarean section surgical site infections in sub-Saharan Africa: a multi-country study from Medecins Sans Frontieres.

BackgroundSurgical site infections (SSI) are a significant cause of post-surgical morbidity and mortality and can be an indicator of surgical quality. The objectives of this study were to measure post-operative SSI after cesarean section (CS) at four sites in three sub-Saharan African countries and to describe the associated risk factors in order to improved quality of care in low and middle income surgical programs.MethodsThis study included data from four emergency obstetric programs supported by Medecins sans Frontieres, from Burundi, the Democratic Republic of Congo (DRC), and Sierra Leone. Women undergoing from August 1 2010 to January 31 2011 were included. CS post-operative SSI data were prospectively collected. Logistic regression was used to model SSI risk factors.FindingsIn total, 1,276 women underwent CS. The incidence of SSI was 7.3 % (range 1.7–10.4 %). 93 % of SSI were superficial. The median length of stay of women without SSI was 7 days (range 3–63 days) compared to 21 days (range 5–51 days) in those with SSI (p < 0.001). In multivariate analysis, younger age, premature rupture of the membranes, and neonatal death were associated with an increased risk of SSI, while antenatal hemorrhage and the Lubutu, DRC project site were associated with a lower risk of developing an SSI.ConclusionsThis study demonstrates that surgery can be performed with a low incidence of SSI, a proxy for surgical safety, in sub-Saharan Africa. Protocols such as perioperative antibiotics and basic infrastructure such as clean water and sterilization can be achieved. Simple data collection tools will assist policymakers with monitoring and evaluation as well as quality control assurance of surgical programs in low and middle income countries.

Obesity was associated with a decreased postoperative recurrence of rectal cancer in a Japanese population.

Obesity contributes to the technical difficulty of rectal surgery and is considered to be a risk factor for postoperative complications. The impact of obesity on the long-term outcomes of rectal cancer surgery remains unclear. A total of 263 consecutive rectal cancer patients who underwent surgery were categorized into two groups according to the body mass index (BMI) based on the Asian BMI classification: non-obese (BMI <25 kg/m(2)) and obese (BMI ≥25 kg/m(2)). The postoperative survival and recurrence rates and oncological surgical quality indicators were compared between groups using the univariate and multivariate analyses. The differences in recurrence patterns were assessed by a competing risk regression analysis. 64 (24%) patients were included in the obese group. The number of retrieved lymph nodes was significantly greater in the non-obese group than in the obese group (22.4 vs. 16.0, P < 0.01). The 5-year disease-free survival (DFS) rates were 86.5 and 68.8% in the obese and non-obese groups, respectively (P = 0.01). The multivariate analysis demonstrated that obesity significantly decreased the postoperative recurrence rate (P = 0.04). Moreover, the BMI was significantly associated with distant metastasis (P = 0.04). Obese rectal cancer patients have high DFS rates and a decreased incidence of distant metastases compared to non-obese patients. The BMI may be a key factor for predicting the postoperative prognosis and determination of an appropriate strategy for the treatment of rectal cancer patients.

Esophagectomy outcomes at a mid-volume cancer center utilizing prospective multidisciplinary care and a 2-surgeon team approach

BackgroundEsophagectomy is associated with high morbidity and mortality, leading to calls for restricted performance at high-volume centers. MethodsPatients with esophageal cancer were evaluated prospectively in a multidisciplinary tumor board from January 2012 - December 2012. A 2-surgeon team was utilized and detailed outcomes were assessed prospectively. ResultsThirty-one patients underwent esophagectomy, 20 patients underwent laparoscopic transhiatal (65%) approach, and 11 patients underwent laparoscopically assisted Ivor-Lewis (35%) approach. Eighty-one percent of the patients were male, with a median age of 64 years (range: 35 to 83 years) and 73% of the patients had adenocarcinoma. Neoadjuvant chemoradiation was performed in 79% of the patients. R0 resection was achieved in 29 (94%) patients, median nodes identified were 15. Major complications (grade III to V) occurred in 13 (42%) patients and did not correlate with surgical techniques, anastomotic leak occurred in 5 (16%) patients, and significant pulmonary complications occurred in 11 (35%) patients. The length of stay at the hospital was 10 days, readmission rate 23%, and 30-day mortality rate 6%. ConclusionsHigh-quality esophagectomy can be performed safely at a mid-volume cancer center. Our outcomes question the reliance on volume alone as an indicator of cancer surgical quality.

Defining quality in surgical training: perceptions of the profession

BackgroundTo improve surgical training standards, it is necessary to first define the elements of high-quality training and methods for measuring them. MethodsSemistructured interviews were conducted with attending (n = 10) and resident (n = 10) general surgeons. An interview topic guide was used to elicit end users' opinions on indicators of training quality and methods to measure them. Interviews were recorded, transcribed verbatim, and coded using a framework to identify emergent themes. Sampling ceased once thematic saturation was achieved. ResultsKey surgical training quality indicators include continuity (80% of participants) and relationship (95%) between trainee and trainer, level of supervision (85%), and an optimal volume (95%) and mix (90%) of operative cases. All surgeons felt that trainee logbook analysis and feedback was essential. The majority (85%) felt that training analysis should be freely available to create accountability for hospitals and attending surgeons (70%) and encourage competition (70%) to drive up standards. Only 30% felt that all attending surgeons should offer training. ConclusionsSurgical training quality needs to be robustly assessed. Transparency in training outcomes will create competition and raise standards of surgical education.