A Statewide Approach to Reducing Re-excision Rates for Women With Breast-conserving Surgery.

OBJECTIVE: Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates. BACKGROUND: Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target. METHODS: Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided. RESULTS: In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91). CONCLUSIONS: Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings.

Prevalence of High-Grade Anal Dysplasia and Anal Cancer in Veterans Living With HIV and CD4/CD8 Ratio as a Marker For Increased Risk: A Regional Retrospective Cohort Study.

BACKGROUND: The Department of Veterans Affairs cares for the largest population of patients with HIV of any healthcare system in the United States. Screening for anal dysplasia/cancer is recommended for all veterans with HIV. Exams are invasive, burdensome, and resource intensive. We currently lack markers of disease to tailor screening. OBJECTIVE: The purpose of this study was to establish the prevalence of advanced anal disease (high-grade dysplasia and anal cancer) and to determine whether CD4/CD8 ratio correlates with risk. DESIGN: This was a retrospective regional cohort study of veterans with HIV. SETTINGS: The study was conducted at eight medical centers between 2001 and 2019. PATIENTS: Patients with advanced disease were compared with patients with nonadvanced anal pathology. MAIN OUTCOME MEASURES: Logistic regression modeling was used to estimate adjusted odds of disease as a function of CD4/CD8. Lowest (nadir) CD4/CD8 and nearest CD4/CD8 ratio in each cohort were evaluated. RESULTS: A total of 2267 veterans were included. Fifteen percent had anal pathology (112 with advanced disease (37 cancer and 75 high-grade), 222 with nonadvanced disease). Nadir and nearest ratio were lower in patients with advanced disease versus nonadvanced (0.24 vs 0.45 (p < 0.001) and 0.50 vs 0.88 (p < 0.001)). In adjusted models, a 1-unit increase in nadir or nearest ratio conferred decreased risk of advanced disease (OR = 0.19 (95% CI, 0.07-0.53); p < 0.001; OR = 0.22 (95% CI, 0.12-0.43); p < 0.001). Using a minimum sensitivity analysis, a cutoff nadir ratio of 0.42 or nearest ratio of 0.76 could be used to risk stratify. LIMITATIONS: This was a retrospective analysis with a low screening rate. CONCLUSIONS: In a regional cohort of veterans with HIV, 15% were formally assessed for anal dysplasia. Advanced anal disease was present in 33% of those screened, 5% of the HIV-positive population. A strong predictor of advanced disease in this cohort is the CD4/CD8 ratio, which is a promising marker to stratify screening practices. Risk stratification using CD4/CD8 has the potential to decrease burdensome invasive examinations for low-risk patients and to intensify examinations for those at high risk. See Video Abstract at http://links.lww.com/DCR/B528. PREVALENCIA DE DISPLASIA ANAL DE ALTO GRADO Y CNCER ANAL EN VETERANOS QUE VIVEN CON EL VIH Y LA RELACIN CD / CD COMO MARCADOR DE MAYOR RIESGO UN ESTUDIO DE COHORTE REGIONAL RETROSPECTIVE: ANTECEDENTES:El Departamento de Asuntos de Veteranos atiende a la población más grande de pacientes con el virus de inmunodeficiencia humana (VIH) de cualquier sistema de salud en los Estados Unidos. Se recomienda la detección de displasia / cáncer anal para todos los veteranos con VIH. Los exámenes son invasivos, onerosos y requieren muchos recursos. Actualmente carecemos de marcadores de enfermedad para adaptar la detección.OBJETIVO:Establecer la prevalencia de enfermedad anal avanzada (displasia de alto grado y cáncer anal) y determinar si la relación CD4 / CD8 se correlaciona con el riesgo.DISEÑO:Estudio de cohorte regional retrospectivo de veteranos con VIH.AJUSTE:Ocho centros médicos entre 2001-2019.PACIENTES:Se comparó a pacientes con enfermedad avanzada con pacientes con patología anal no avanzada.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó un modelo de regresión logística para estimar las probabilidades ajustadas de enfermedad en función de CD4 / CD8. Se evaluó la relación CD4 / CD8 más baja (nadir) y la relación CD4 / CD8 más cercana en cada cohorte.RESULTADOS:Se incluyeron un total de 2267 veteranos. El 15% tenía patología anal (112 enfermedad avanzada (37 cáncer, 75 de alto grado), 222 enfermedad no avanzada). El nadir y el cociente más cercano fueron menores en los pacientes con enfermedad avanzada frente a los no avanzados (0,24 frente a 0,45 (p <0,001) y 0,50 frente a 0,88 (p <0,001)), respectivamente. En modelos ajustados, el aumento de una unidad en el nadir o el cociente más cercano confirió una disminución del riesgo de enfermedad avanzada (OR 0,19 (IC del 95%: 0,07, 0,53, p <0,001)) y (OR 0,22 (IC del 95%: 0,12, 0,43, p <0,001))), respectivamente. Utilizando un análisis de sensibilidad mínima, se podría utilizar un cociente del nadir de corte de 0,42 o el cociente más cercano de 0,76 para estratificar el riesgo.LIMITACIONES:Análisis retrospectivo con una tasa de detección baja.CONCLUSIONES:En una cohorte regional de veteranos con VIH, el 15% fueron evaluados formalmente por displasia anal. La enfermedad anal avanzada estuvo presente en el 33% de los examinados, el 5% de la población VIH +. Un fuerte predictor de enfermedad avanzada en esta cohorte es la relación CD4 / CD8, que es un marcador prometedor para estratificar las prácticas de detección. La estratificación del riesgo usando CD4 / CD8 tiene el potencial de disminuir los exámenes invasivos onerosos para los pacientes de bajo riesgo e intensificar los exámenes para los de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B528.

Overprescription of Opioids Following Outpatient Anorectal Surgery: A Single-Institution Study.

BACKGROUND: Surgeons contribute to the opioid epidemic by overprescribing opioids for postoperative pain. Excess, unused opioids may be diverted for misuse/abuse. OBJECTIVE: This study aimed to characterize opioid prescribing and use among patients undergoing outpatient anorectal procedures and to assess the adequacy of postoperative pain management. DESIGN: This is a retrospective cohort study, prospective cross-sectional survey. SETTINGS: Patients were treated by colorectal surgeons in an academic medical center between January 2018 and September 2019. PATIENTS: Six hundred twenty-seven patients undergoing an outpatient anorectal procedure were included. MAIN OUTCOME MEASURES: The primary outcomes measured were the opioids prescribed at discharge, opioid prescription refills, patient-reported outcomes regarding opioid use, and the adequacy of postoperative pain management in terms of pain intensity and pain interference. Opioids were standardized to 5-mg oxycodone pills. Patient-reported outcomes were assessed by using previously validated instruments. RESULTS: The majority of patients underwent fistula surgery (n = 234) followed by examination under anesthesia (n = 183), hemorrhoidectomy (n = 131), incision and drainage (n = 51), and pilonidal excision (n = 28). Most patients received opioids (78% fistula, 49% examination under anesthesia, 87% hemorrhoidectomy, 71% incision and drainage, 96% pilonidal). Patients undergoing examination under anesthesia received the fewest opioid pills (median 10; range 3-50) followed by patients undergoing fistula surgery (median13, range 1-50), incision and drainage (median 15, range 3-120), pilonidal excisions (median 15, range 3-60), and hemorrhoidectomies (median 28, range 3-60). Regardless of procedure, the majority of patients used fewer than 5 opioid pills postoperatively. Patients undergoing pilonidal excisions had the largest number of excess unused pills (median 14, range 0-30) followed by patients undergoing fistula surgery and incision and drainage (median 7, ranges 0-30 and 5-17), hemorrhoidectomy (median 6, range 0-50), and examination under anesthesia (median 2, range 0-23). Whereas patients undergoing hemorrhoidectomy reported higher pain levels following discharge, most reported minimal interference with day-to-day activities due to pain regardless of the procedure performed. LIMITATIONS: The limitations of this study included recall bias and sample bias. CONCLUSIONS: The majority of patients do not need more than five to ten 5-mg oxycodone equivalents to achieve adequate pain management after outpatient anorectal surgical procedures. See Video Abstract at http://links.lww.com/DCR/B347. EXCESO DE PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE UNA CIRUGÍA ANORRECTAL AMBULATORIA: UN ESTUDIO DE UNA SOLA INSTITUCIÓN: Cirujanos contribuyen a la epidemia de opioides al recetar en exceso opioides para el dolor postoperatorio. El exceso de opioides no utilizados puede ser desviado por para mal uso o abuso.Caracterizar la prescripción y el uso de opioides entre pacientes sometidos a procedimientos anorrectales ambulatorios y evaluar la efectividad del tratamiento del dolor postoperatorio.Estudio de cohorte retrospectivo, encuesta transversal prospectiva.pacientes tratados por cirujanos colorrectales en un centro médico académico entre enero de 2018 y septiembre de 2019.se incluyeron 627 pacientes que se sometieron a un procedimiento anorrectal ambulatorio.Opioides recetados al alta, reabastecimientos de prescripción de opioides, resultados informados por el paciente con respecto al uso de opioides y efectividad del manejo del dolor postoperatorio en términos de intensidad del dolor y trastornos secundarios a dolor. Los opioides se estandarizaron con píldoras de oxicodona de 5 mg. Los resultados informados por los pacientes se evaluaron utilizando instrumentos previamente validados.La mayoría de los pacientes fueron sometidos a cirugía de fístula (n = 234) seguida de un examen bajo anestesia (EUA; n = 183), hemorroidectomía (n = 131), incisión y drenaje (I&D) (n = 51) y escisión pilonidal (n = 28). La mayoría de los pacientes recibieron opioides (78% fístula, 49% EUA, 87% hemorroidectomía, 71% I&D, 96% pilonidal). Las EUA recibieron la menor cantidad de píldoras opioides (mediana 10, rango 3-50) seguidas de fístula (mediana 13, rango 1-50), I y D (mediana 15, rango 3-120), pilonidales (mediana 15, rango 3-60) y hemorroides. (mediana 28, rango 3-60). Independientemente del procedimiento, la mayoría de los pacientes usaron menos de cinco píldoras opioides después de la operación. Los pacientes pilonidales tuvieron el mayor número de píldoras no utilizadas en exceso (mediana 14, rango 0-30) seguido de fístula e I&D (mediana 7, rangos 0-30 y 5-17, respectivamente), hemorroidectomía (mediana 6, rango 0-50) y EUA (mediana 2, rango 0-23). Si bien los pacientes con hemorroidectomía informaron niveles de dolor más altos después del alta, la mayoría de pacientes informaron un mínimo de interferencia con las actividades diarias debido al dolor, independientemente del procedimiento realizado.Sesgo de recuerdo autoinformado, sesgo de muestra.La mayoría de los pacientes no necesitan más de cinco a diez equivalentes de oxicodona de 5 mg para lograr un manejo adecuado del dolor después de procedimientos quirúrgicos anorrectales ambulatorios. Consulte Video Resumen en http://links.lww.com/DCR/B347. (Traducción-Dr. Adrian Ortega).

Natural history and cost analysis of surgical bypass versus endoscopic stenting for the palliative management of malignant gastric outlet obstruction.

BACKGROUND: Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes. METHODS: Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured. RESULTS: A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028). CONCLUSION: In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention.

Anal Intraepithelial Neoplasia Screening With Anal Pap Tests: Follow-up and Corresponding Histology.

BACKGROUND: Anal cytology is used as a screening tool in the detection of precancerous anal squamous lesions. Follow-up clinical examination after abnormal anal cytology is recommended. The objective of this study was to determine how often abnormal cytology was followed by a clinical examination at our institution and how often cytology predicted histologic outcome. MATERIALS AND METHODS: A retrospective chart review was performed (2008-2018) on patients with anal cytology, demonstrating either low-grade or high-grade squamous intraepithelial lesion. Clinical examination within 1 y (digital rectal examination, anoscopy, or high-resolution anoscopy) was recorded. The probability of anal intraepithelial neoplasm on biopsy after dysplasia on cytology was calculated, and McNemar's test was used to determine if there was correspondence between cytology and histology. RESULTS: A total of 327 anal cytology results demonstrated dysplasia (75% low grade and 25% high grade) in 182 patients. Seventy-five percent of dysplastic anal cytology were followed by clinical examination within 1 y, and 50% were biopsied. The probability of dysplasia on histology after dysplasia on cytology was 72% (95% confidence interval: 64%-78.5%). Twenty-eight percent of low-grade cytology results were upgraded to advanced disease (high-grade or invasive cancer) on histology. A low-grade cytology result was unable to preclude high-grade histology in our population. CONCLUSIONS: There is room for improvement at our institution to consistently follow-up with clinical examination after abnormal anal cytology. Our data suggest this is especially important considering anal cytology is an imperfect predictor of histologic anal intraepithelial neoplasia and invasive disease. Clinical examination is a critical component of anal dysplasia screening and follow-up.

Analysis of 90-day cost for open versus minimally invasive distal pancreatectomy.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear. METHODS: Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments. RESULTS: 693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p<0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p<0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p<0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000. CONCLUSION: MIDP is associated with >$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP.

Using Both Clinical Registry and Administrative Claims Data to Measure Risk-adjusted Surgical Outcomes.

OBJECTIVE: To examine the validity of hybrid quality measures that use both clinical registry and administrative claims data, capitalizing on the strengths of each data source. BACKGROUND: Previous studies demonstrate substantial disagreement between clinical registry and administrative claims data on the occurrence of postoperative complications. Clinical data have greater validity than claims data for quality measurement but can be burdensome for hospitals to collect. METHODS: American College of Surgeons National Surgical Quality Improvement Program records were linked to Medicare inpatient claims (2005-2008). National Quality Forum-endorsed risk-adjusted measures of 30-day postoperative complications or death assessed hospital quality for patients undergoing colectomy, lower extremity bypass, or all surgical procedures. Measures use hierarchical multivariable logistic regression to identify statistical outliers. Measures were applied using clinical data, claims data, or a hybrid of both data sources. Kappa statistics assessed agreement on determinations of hospital quality. RESULTS: A total of 111,984 patients participated from 206 hospitals. Agreement on hospital quality between clinical and claims data was poor. Hybrid models using claims data to risk-adjust complications identified by clinical data had moderate agreement with all clinical data models, whereas hybrid models using clinical data to risk-adjust complications identified by claims data had routinely poor agreement with all clinical data models. CONCLUSIONS: Assessments of hospital quality differ substantially when using clinical registry versus administrative claims data. A hybrid approach using claims data for risk adjustment and clinical data for complications may be a valid alternative with lower data collection burden. For quality measures focused on postoperative complications to be meaningful, such policies should require, at a minimum, collection of clinical outcomes data.

Variation in Hospital Use of Postacute Care After Surgery and the Association With Care Quality.

BACKGROUND: Little is known about hospital use of postacute care after surgery and whether it is related to measures of surgical quality. RESEARCH DESIGN: We used data merged between a national surgery registry, Medicare inpatient claims, the Area Resource File, and the American Hospital Association Annual Survey (2005-2008). Using bivariate and multivariate analyses, we calculated hospital-level, risk-adjusted rates of postacute care use for both inpatient facilities (IF) and home health care (HHC), and examined the association of these rates with hospital quality measures, including mortality, complications, readmissions, and length of stay. RESULTS: Of 112,620 patients treated at 217 hospitals, 18.6% were discharged to an IF, and 19.9% were discharged with HHC. Even after adjusting for differences in patient and hospital characteristics, hospitals varied widely in their use of both IF (mean, 20.3%; range, 2.7%-39.7%) and HHC (mean, 22.3%; range, 3.1%-57.8%). A hospital's risk-adjusted postoperative mortality rate or complication rate was not significantly associated with its use of postacute care, but higher 30-day readmission rates were associated with higher use of IF (24.1% vs. 21.2%, P=0.03). Hospitals with longer average length of stay used IF less frequently (19.4% vs. 24.4%, P<0.01). CONCLUSIONS: Hospitals vary widely in their use of postacute care. Although hospital use of postacute care was not associated with risk-adjusted complication or mortality rates, hospitals with high readmission rates and shorter lengths of stay used inpatient postacute care more frequently. To reduce variations in care, better criteria are needed to identify which patients benefit most from these services.

Comparison between clinical registry and medicare claims data on the classification of hospital quality of surgical care.

OBJECTIVE: To compare the classification of hospital statistical outlier status as better or worse performance than expected for postoperative complications using Medicare claims versus clinical registry data. BACKGROUND: Controversy remains as to the most favorable data source for measuring postoperative complications for pay-for-performance and public reporting polices. METHODS: Patient-level records (2005-2008) were linked between the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Medicare inpatient claims. Hospital statistical outlier status for better or worse performance than expected was assessed using each data source for superficial surgical site infection (SSI), deep/organ-space SSI, any SSI, urinary tract infection, pneumonia, sepsis, deep venous thrombosis, pulmonary embolism, venous thromboembolism, and myocardial infarction by developing hierarchical multivariable logistic regression models. Kappa statistics and correlation coefficients assessed agreement between the data sources. RESULTS: A total of 192 hospitals with 110,987 surgical patients were included. Agreement on hospital rank for complication rates between Medicare claims and ACS-NSQIP was poor-to-moderate (weighted κ: 0.18-0.48). Of hospitals identified as statistical outliers for better or worse performance by Medicare claims, 26% were also identified as outliers by ACS-NSQIP. Of outliers identified by ACS-NSQIP, 16% were also identified as outliers by Medicare claims. Agreement between the data sources on hospital outlier status classification was uniformly poor (weighted κ: -0.02-0.34). CONCLUSIONS: Despite using the same statistical methodology with each data source, classification of hospital outlier status as better or worse performance than expected for postoperative complications differed substantially between ACS-NSQIP and Medicare claims.

Measuring risk-adjusted value using Medicare and ACS-NSQIP: is high-quality, low-cost surgical care achievable everywhere?

OBJECTIVE: To evaluate the relationship between risk-adjusted cost and quality for colectomy procedures and to identify characteristics of "high value" hospitals (high quality, low cost). BACKGROUND: Policymakers are currently focused on rewarding high-value health care. Hospitals will increasingly be held accountable for both quality and cost. METHODS: Records (2005-2008) for all patients undergoing colectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Cost was derived from hospital payments by Medicare. Quality was derived from the occurrence of 30-day postoperative major complications and/or death as recorded in ACS-NSQIP. Risk-adjusted cost and quality metrics were developed using hierarchical multivariable modeling, consistent with a National Quality Forum-endorsed colectomy measure. RESULTS: The study population included 14,745 colectomy patients in 169 hospitals. Average hospitalization cost was $21,350 (SD $20,773, median $16,092, interquartile range $14,341-$24,598). Thirty-four percent of patients had a postoperative complication and/or death. Higher hospital quality was significantly correlated with lower cost (correlation coefficient 0.38, P < 0.001). Among hospitals classified as high quality, 52% were found to be low cost (representing highest value hospitals) whereas 14% were high cost (P = 0.001). Forty-one percent of low-quality hospitals were high cost. Highest "value" hospitals represented a mix of teaching/nonteaching affiliation, small/large bed sizes, and regional locations. CONCLUSIONS: Using national ACS-NSQIP and Medicare data, this study reports an association between higher quality and lower cost surgical care. These results suggest that high-value surgical care is being delivered in a wide spectrum of hospitals and hospital types.

Reliability of evaluating hospital quality by colorectal surgical site infection type.

OBJECTIVE: To determine whether risk-adjusted colorectal SSI rates are statistically reliable as hospital quality measures. BACKGROUND: Policymakers use surgical site infections (SSI) for public reporting of hospital quality and pay-for-performance because they are a relatively common and costly cause of patient morbidity. METHODS: Patients who underwent a colorectal procedure in 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program. We developed hierarchical multivariate logistic models for (1) superficial SSI, (2) deep/organ-space SSI, and (3) "any SSI" and compared how each model ranked hospital-level risk-adjusted performance. Statistical reliability of hospital quality measurements was estimated on a scale from 0 to 1; with 0 indicating that apparent variation between a hospital's quality measurement and the average hospital is statistically unreliable, and 1 indicating that any observed variation is due to a real difference in performance. RESULTS: Mean reliability of hospital-level quality measurements was 0.650 for superficial, 0.404 for deep/organ-space, and 0.586 for "any SSI." Lower reliability was accounted for by relatively little variation in risk-adjusted SSI rates between hospitals and insufficient numbers of colorectal cases submitted by individual hospitals. In 2009, we estimate that 22.1% of all US hospitals performed a sufficient number of colorectal cases to report superficial SSI rates at a high standard of statistical reliability and 1.0% did for deep/organ-space SSI. CONCLUSIONS: As currently constructed, colorectal SSI quality measures might not meet a high standard of statistical reliability for most hospitals, limiting their ability to confidently differentiate high and low performance. Despite an expectation of improving statistical power, combining superficial and deep/organ-space SSI into an "any SSI" measure worsens reliability.

Association between occurrence of a postoperative complication and readmission: implications for quality improvement and cost savings.

OBJECTIVE: To estimate the effect of preventing postoperative complications on readmission rates and costs. BACKGROUND: Policymakers are targeting readmission for quality improvement and cost savings. Little is known regarding mutable factors associated with postoperative readmissions. METHODS: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Risk factors, procedure, and 30-day postoperative complications were determined from ACS-NSQIP. The 30-day postoperative readmission and costs were determined from Medicare. Occurrence of a postoperative complication included surgical site infections and cardiac, pulmonary, neurologic, and renal complications. Multivariate regression models predicted the effect of reducing complication rates on risk-adjusted readmission rates and costs by procedure. RESULTS: The 30-day postoperative readmission rate was 12.8%. Complication rates for readmitted and nonreadmitted patients were 53% and 16% (P < 0.001). Patients with a postoperative complication had higher predicted probability of readmission and cost of readmission than patients without a complication. For the 20 procedures accounting for the greatest number of readmissions, reducing ACS-NSQIP complication rates by a relative 5% could result in prevention of 2092 readmissions per year and a savings to Medicare of $31.0 million per year. Preventing all ACS-NSQIP complications for these procedures could result in prevention of 41,846 readmissions per year and a savings of $620.3 million per year. CONCLUSIONS: This study provides substantial evidence that efforts to reduce postoperative readmissions should begin by focusing on postoperative complications that can be reliably and validly measured. Such an approach will not eliminate all postoperative readmissions but will likely have a major effect on readmission rates.

Validity and feasibility of the american college of surgeons colectomy composite outcome quality measure.

OBJECTIVE: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure. BACKGROUND: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target. METHODS: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds. RESULTS: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%-26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008. CONCLUSIONS: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.

A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications.

OBJECTIVES: To compare the recording of 30-day postoperative complications between a national clinical registry and Medicare inpatient claims data and to determine whether the addition of outpatient claims data improves concordance with the clinical registry. BACKGROUND: Policymakers are increasingly discussing use of postoperative complication rates for value-based purchasing. There is debate regarding the optimal data source for such measures. METHODS: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient and outpatient claims data sets. We assessed the ability of (1) Medicare inpatient claims and (2) Medicare inpatient and outpatient claims to detect a core set of ACS-NSQIP 30-day postoperative complications: superficial surgical site infection (SSI), deep/organ-space SSI, any SSI (superficial and/or deep/organ-space), urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, venous thromboembolism (DVT and/or pulmonary embolism), and myocardial infarction. Agreement of patient-level complications by ACS-NSQIP versus Medicare was assessed by κ statistics. RESULTS: A total of 117,752 patients from more than 200 hospitals were studied. The sensitivity of inpatient claims data for detecting ACS-NSQIP complications ranged from 0.27 to 0.78; the percentage of false-positives ranged from 48% to 84%. Addition of outpatient claims data improved sensitivity slightly but also greatly increased the percentage of false-positives. Agreement was routinely poor between clinical and claims data for patient-level complications. CONCLUSIONS: This analysis demonstrates important differences between ACS-NSQIP and Medicare claims data sets for measuring surgical complications. Poor accuracy potentially makes claims data suboptimal for evaluating surgical complications. These findings have meaningful implications for performance measures currently being considered.

Impact of Care Coordination on the Content of Communication Between Surgeons and Patients With Rectal Cancer.

Management of patients with rectal cancer can be complex, requiring significant care coordination and decisions that balance functional and oncologic outcomes. Objective: To characterize care coordination occurring during surgical consultation for rectal cancer and consequences of using face-to-face time in clinic for care coordination. Methods: Secondary analysis was performed on audio recordings of clinic visits with colorectal surgeons to discuss surgery for rectal cancer at 5 academic medical centers. Analysis included the content of communication related to types of care coordination, specific details and conditions under which care coordination was conducted, and consequences. Results: The cohort included 18 patients seen by 8 surgeons. Care coordination consumed much of the conversation; on average 23.7% (SD 14.6) of content. Communication about care coordination included gathering information from work-up already performed, logistics for completing further work-up, gathering multidisciplinary opinions, and logistics for treatment planning. Obtaining imaging results was particularly challenging and surgeons went to great lengths to gather this information. To mitigate information gaps, surgeons asked patients about critical clinical details. Patients expressed remorse when they could not provide needed information, relay technical details, or had missing reports. Surgeons voiced frustration at the system related to the need to gather information from multiple sources and coordinate logistics. Surgeons worked to inform patients about their disease and discuss important lifestyle and cancer-related tradeoffs. However, the ability to solicit patient input and engage in shared decision making was often limited by incomplete data or conditioned on approval by a multidisciplinary tumor board. Conclusion: Much of the conversation between surgeons and patients with rectal cancer is consumed by care coordination. Organizing care coordination outside of the clinic visit would likely improve the experience for both patients and surgeons, addressing both clinician burnout and variation in management and outcomes.

Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery.

BACKGROUND: Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS). STUDY DESIGN: In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement. RESULTS: In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds. CONCLUSIONS: Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.

Groin herniorrhaphy in patients with cirrhosis and after liver transplantation.

We report on 43 groin herniorrhaphy operations, 18 in 18 patients with documented cirrhosis and 25 in 24 patients after liver transplantation (LT), over a 10-year period at UCLA. Average follow up was 33 months. Most patients were males (84%) with reducible inguinal hernias (70%). Child's class of cirrhotic patients was B in 66 per cent and A and C in 17 per cent each; 7 patients (39%) went on to LT. Compared with post-LT patients, patients with cirrhosis had significantly lower platelets and significantly higher bilirubin, international normalized ratio, and Model for Endstage Liver Disease scores. Mesh was used in 33 per cent of the cirrhotic group and 48 per cent of the LT group. There were four minor wound complications but no deaths, major complications, infections, or ascitic leaks in either group. Two hernias recurred in the cirrhosis group (11%) and none after LT. We conclude that with proper patient selection, groin herniorrhaphy with or without mesh is a safe and durable procedure in patients with cirrhosis and after LT. This is the first large series of groin herniorrhaphy after LT.

Should classification as an ACS-NSQIP high outlier be used to direct hospital quality improvement efforts?

BACKGROUND: ACS-NSQIP classifies hospitals as "high outliers" if their performance is significantly worse than expected. We determined how often hospitals return to as-expected performance after being newly identified as outliers. METHODS: Outlier status was identified in ACS-NSQIP semi-annual reports (SARs) 2008-2011 for 13 postoperative adverse events. Pearson correlation and R2 measured the relationship between frequency of changes in outlier status, frequency of outlier identification, and adverse event rate. RESULTS: Among 284 hospitals, 75% were classified as high outliers for an adverse event at least once. New high outliers frequently did not remain outliers in the next SAR. Of new outliers, mortality had the highest percentage return to as-expected performance (62.7%), while surgical site infection had the lowest (20.5%). The likelihood of an outlier hospital returning to as-expected performance was inversely related to the percentage of hospitals classified as outliers. The percentage of hospitals classified as outliers for an event explained 60% of variation in outlier hospitals returning to as-expected performance. CONCLUSIONS: Outlier status may be less meaningful for adverse events with relatively few outlier hospitals.