Evidence Review for the American College of Surgeons Quality Verification Part III: Standardization, Protocols, and Achieving Better Outcomes for Patient Care.

BACKGROUND: After decades of experience supporting surgical quality and safety by the American College of Surgeons, the ACS Quality Verification Program (ACS QVP) was developed to help hospitals improve surgical quality and safety. This review is the final installment of a three-part review aimed to synthesize evidence supporting the main principles of the ACS QVP. STUDY DESIGN: Evidence was systematically reviewed for three principles: standardized team-based care across five phases of surgical care, disease-based management, and external regulatory review. MEDLINE was searched for articles published from inception to January 2019 and two reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 5,237 studies across these three topics were identified. Studies were included if they evaluated the relationship between the standard of interest and patient-level or organization measures within the last twenty years. RESULTS: After applying inclusion criteria, a total of 150 studies in systematic reviews and primary studies were included for assessment. Despite institutional variation in standardized clinical pathways, evidence demonstrated improved outcomes such as reduced length of stay (LOS), costs, and complications. Evidence for multidisciplinary disease-based care protocols was mixed, though trended towards improving patient outcomes such as reduced LOS and readmissions. Similarly, the evidence for accreditation and adherence to external process measures was also mixed, though several studies demonstrated the benefit of accreditation programs on patient outcomes. CONCLUSIONS: The identified literature supports the importance of standardized multidisciplinary and disease-based processes and external regulatory systems to improve quality of care.

Identifying Population-Level and Within-Hospital Disparities in Surgical Care.

BACKGROUND: The lack of consensus on equity measurement and its incorporation into quality-assessment programs at the hospital and system levels may be a barrier to addressing disparities in surgical care. This study aimed to identify population-level and within-hospital differences in the quality of surgical care provision. STUDY DESIGN: The analysis included 657 NSQIP participating hospitals with more than 4 million patients (2014 to 2018). Multilevel random slope, random intercept modeling was used to examine for population-level and in-hospital disparities. Disparities in surgical care by Area Deprivation Index (ADI), race, and ethnicity were analyzed for 5 measures: all-case inpatient mortality, all-case urgent readmission, all-case postoperative surgical site infection, colectomy mortality, and spine surgery complications. RESULTS: Population-level disparities were identified across all measures by ADI, 2 measures for Black race (all-case readmissions and spine surgery complications), and none for Hispanic ethnicity. Disparities remained significant in the adjusted models. Before risk adjustment, in all measures examined, within-hospital disparities were detected in: 25.8% to 99.8% of hospitals for ADI, 0% to 6.1% of hospitals for Black race, and 0% to 0.8% of hospitals for Hispanic ethnicity. After risk adjustment, in all measures examined, less than 1.1% of hospitals demonstrated disparities by ADI, race, or ethnicity. CONCLUSIONS: After risk adjustment, very few hospitals demonstrated significant disparities in care. Disparities were more frequently detected by ADI than by race and ethnicity. The lack of substantial in-hospital disparities may be due to the use of postoperative metrics, small sample sizes, the risk adjustment methodology, and healthcare segregation. Further work should examine surgical access and healthcare segregation.

Pentoxifilina reduz a disfunção hepatocelular na endotoxemia aguda / Pentoxifyline reduces hepatocellular disfunction in acute endotoxemia

A endotoxemia é acompanhada pela produção de citosinas pró-inflamatórias, radicais livres e lesão de órgãos. Os efeitos da pentoxifilina, uma metilxantina e inibidor da fosfodiesterase pentoxifilina em modelo experimental de endotoxemia, especificamente na função e arquitetura hepática. Utilizaram-se 68 ratos Sprague-Dawley divididos em três grupos tratados por via endovenosa com lipopolissacarídeo (5mg/Kg), Lipopolissacarídeo + pentoxifilina (25mg/Kg), ou solução salina (SHAM), sedo avaliados após 2, 4, e 24 horas, conforme os picos de apresentação. ALT e AST foram avaliados em necrose hepática, hemorragia e infiltrado inflamatório parenquimal e sinusoidal. A infiltração de neutrófilos foi medida pela contagem de células coradas positivamente para MOP, NF-KB, p-65 foi verificado pela contagem de núcleos positivos de hepatócitos e células de Kupffer, iNOS foi avaliada pela presença de células de Kupffer positivas. Os níveis de ALT, AST em 4h foram significativamente menores no grupo pentoxifilina/lipopolissacaríde quando comparado com o grupo lipopolissacarídeo. Os animais tratados com pentoxifilina apresentaram significante redução do escore de lesão hepática e da infiltração por neutrófilos. Em adição, ocorreu significante diminuição no número de núcleos positivos de hepatócitos e células de Kupffer para NE-KB p-65,bem como células de Kupffer positivas para iNOS nos animais tratados com pentoxifilina, quando comparados com o grupo lipopolissacarídeo. A pentoxifilina reduziu a resposta inflamatória e a lesão hepática causadas pela endotoxmia.

Influência da pentoxifilina nos níveis citosinas e parâmetros inflamatórios no modelo de endotoxemia aguda / Influence of pentoxifylline on cytokine levels and inflammatory parameters in acute endotoxemia model

A produção excessiva de espécies reativas do oxigênio pelos polimorfonucleares está associada a dano tecidual durante inflamação. A pentoxifilina, um inibidor da fosfodiesterase, diminui a produção de citosinas pró-inflamatórias e o dano tecidual induzido pelo lipopolissacarídeo (LPS)...

Excessive production of reactive oxygen species by PMN is associated with tissue damage during inflammation. Pentoxifylline, a phosphodiesterase inhibitor, decreases proinflammatory cytokine production and tissue injury after LPS challenge...