Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.

BACKGROUND: The Veterans Affairs' (VA) National Surgical Quality Improvement Program (NSQIP) has been associated with significant reductions in postoperative morbidity and mortality. We sought to determine if NSQIP methods and risk models were applicable to private sector (PS) hospitals and if implementation of the NSQIP in the PS would be associated with reductions in adverse postoperative outcomes. METHODS: Data from patients (n = 184,843) undergoing major general or vascular surgery between October 1, 2001, and September 30, 2004, in 128 VA hospitals and 14 academic PS hospitals were used to develop prediction models based on VA patients only, PS patients only, and VA plus PS patients using logistic regression modeling, with measures of patient-related risk as the independent variables and 30-day postoperative morbidity or mortality as the dependent variable. RESULTS: Nine of the top 10 predictors of postoperative mortality and 7 of the top 10 for postoperative morbidity were the same in the VA and PS models. The ratios of observed to expected mortality and morbidity in the PS hospitals based on a model using PS data only versus VA + PS data were nearly identical (correlation coefficient = 0.98). Outlier status of PS hospitals was concordant in 26 of 28 comparisons. Implementation of the NSQIP in PS hospitals was associated with statistically significant reductions in overall postoperative morbidity (8.7%, P = 0.002), surgical site infections (9.1%, P = 0.02), and renal complications (23.7%, P = 0.004). CONCLUSIONS: The VA NSQIP methods and risk models in general and vascular surgery were fully applicable to PS hospitals. Thirty-day postoperative morbidity in PS hospitals was reduced with the implementation of the NSQIP.

Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in men.

BACKGROUND: We used data from the Patient Safety in Surgery Study to compare patient populations, operative characteristics, and unadjusted and risk-adjusted 30-day postoperative mortality and morbidity between the Veterans Affairs (VA) (n = 94,098) and private (n = 18,399) sectors for general surgery operations in men. STUDY DESIGN: This is a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in male patients undergoing major general surgery operations at 128 VA medical centers and 14 university medical centers from October 1, 2001, to September 30, 2004. Multiple logistic regression analysis was used to identify preoperative predictors of postoperative mortality and morbidity. An indicator variable for VA versus private-sector medical center was added to the model to determine if risk-adjusted outcomes were significantly different in the two systems. RESULTS: The unadjusted 30-day mortality rate was higher in the VA compared with the private sector (2.62% versus 2.03%, p = 0.0002); unadjusted morbidity rate was lower in the VA compared with the private sector (12.24% versus 13.99%, p < 0.0001). After risk adjustment, odds ratio for mortality for the VA versus private sector was 1.23 (95% CI, 1.08-1.41). For morbidity after risk adjustment, the indicator variable for health-care system just missed statistical significance (p = 0.0585). Thirty-day postoperative mortality was comparable in the VA and private sector for very common operations but was higher in the VA for less common, more complex operations. CONCLUSIONS: In general surgery operations in men, the VA appeared to have a higher risk-adjusted mortality rate compared with the private sector, but differences in mortality ascertainment in the two sectors might account for some of this effect. The higher mortality in the VA could be the result of higher mortality in the less common, more complex operations. There is a trend toward lower risk-adjusted morbidity in the VA compared with the private sector.

Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in women.

BACKGROUND: In 1985, Congress mandated that the Department of Veterans Affairs (VA) compare its risk-adjusted surgical results with those in the private sector. The National Surgical Quality Improvement Program was developed as a result, in the VA system, and subsequently trialed in 14 university medical centers in the private sector. This report examines the results of the comparison between patient characteristics and outcomes of female general surgical patients in the two health care environments. STUDY DESIGN: Preoperative patient characteristics and laboratory variables, operative variables, and unadjusted postoperative outcomes were compared between VA and the private sector populations. In addition, stepwise logistic regression models were developed for 30-day postoperative mortality and morbidity. Finally, the effect of being treated in a VA or private sector hospital was assessed by adding an indicator variable to the models and testing it for statistical significance. RESULTS: Data from 5,157 female general surgical VA patients who underwent eligible procedures were compared with those from 27,467 patients in the private sector. Unadjusted 30-day mortality was virtually identical in the two groups (1.3%). The unadjusted morbidity rate was slightly, but notably, higher in the private sector (10.9%) as compared with that observed in the VA (8.5%, p < 0.0001). Predictive models were generated for mortality and morbidity combining both groups; top variables in these models were similar to those described previously in the National Surgical Quality Improvement Program. The indicator variable for system of care (VA versus private sector) was not statistically significant in the mortality model, but substantially favored the VA in the morbidity model (odds ratio=0.80, 95% CI=0.71, 0.90). CONCLUSIONS: The data demonstrate that in female general surgical patients, risk-adjusted mortality rates are comparable in the VA and the private sector, but risk-adjusted morbidity is higher in the private sector. Rates of urinary tract infections in the two populations may account for much of the latter difference.

Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: vascular surgical operations in women.

BACKGROUND: Women with peripheral vascular disease requiring vascular operations are less well studied than their male counterparts. The surgical outcomes of female vascular patients in the Department of Veterans Affairs (VA) and private sector hospitals have not previously been compared, and their preoperative risk profile, postoperative morbidity, and mortality need to be better elucidated. STUDY DESIGN: Patients undergoing vascular operations at 14 private sector and 128 VA hospitals, from October 2001 through September 2004, had their preoperative characteristics, operative data, and 30-day postoperative morbidity and mortality compared, as part of the Patient Safety in Surgery (PSS) Study. Logistic regression analysis was performed to develop predictive models for morbidity and mortality, which allowed for a comparison of risk-adjusted outcomes between the two hospital groups. RESULTS: There were 458 vascular surgical operations performed in women in the VA, and 3,535 vascular operations were performed in women in the private sector. Eighteen of 45 preoperative comorbidities and laboratory variables differed considerably between the institutions, and 16 of 18 were adverse among the private sector patients. The unadjusted 30-day mortality rate was higher in the private sector compared with the VA (5.2% versus 2.4%, p=0.008); the unadjusted morbidity rate was higher in the private sector compared with the VA sector (23.4% versus 13.3%, p < 0.0001). After risk adjustment, there was no marked difference between the VA and the private sector in mortality (p=0.12), but the difference in morbidity rates remained pronounced, with an odds ratio of 0.60 for VA versus private sector (95% CI=0.44, 0.81). CONCLUSIONS: Compared with their VA counterparts, women undergoing vascular operations at private sector hospitals had a higher incidence of preoperative comorbidities; after risk adjustment, mortality did not differ substantially. Despite risk adjustment, the incidence of postoperative morbidity in the VA patients was considerably lower, suggesting unidentified differences in the hospital populations, their processes of care, or both.

Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: vascular surgical operations in men.

BACKGROUND: In response to a Congressional mandate to compare risk-adjusted surgical outcomes from Department of Veterans Affairs (VA) hospitals with those from private-sector hospitals, the National Surgical Quality Improvement Program was initiated in the VA system and then was developed in a select group of university medical centers in the private sector. This article analyzes risk-adjusted outcomes after vascular surgical operations in men performed at VA hospitals as compared with private-sector hospitals. STUDY DESIGN: This is a prospective cohort study of a sample of vascular surgical operations in men performed at 128 VA medical centers as compared with 14 university medical centers from October 1, 2001 to September 30, 2004. Patient and operative characteristics, and both unadjusted and risk-adjusted 30-day postoperative morbidity and mortality outcomes were compared. RESULTS: Data from 30,058 vascular operations in men at VA hospitals were compared with 5,174 cases performed at private-sector hospitals. The unadjusted 30-day mortality rate was notably lower in the VA system as compared with the private-sector group (3.4% versus 4.2%, p = 0.004). After risk-adjustment, there was no marked difference in mortality between the two hospital types. The unadjusted 30-day morbidity rate was also considerably lower in the VA hospitals as compared with the private sector (17.3% versus 22.3%, p < 0.0001). After risk-adjustment, morbidity in the VA system remained considerably lower than in the private sector, with an odds ratio of 0.84 (95% CI, 0.78 to 0.92). CONCLUSIONS: In vascular surgical operations in men, the VA hospitals demonstrated a lower risk-adjusted 30-day morbidity rate than the private-sector group. There is no marked difference in adjusted mortality rates between the two types of institutions.

Total energy expenditure and carbohydrate oxidation are increased in the human immunodeficiency virus lipodystrophy syndrome.

To determine whether total energy expenditure (TEE) is increased in the human immunodeficiency virus (HIV) lipodystrophy syndrome, we compared energy expenditure (EE) and substrate oxidation rates in 12 HIV-infected men with lipodystrophy, 7 HIV-infected men without lipodystrophy, and 14 healthy controls. TEE and nutrient oxidation rates were assessed by whole-room indirect calorimetry. Resting energy expenditure (REE) was measured by indirect calorimetry using the open-circuit technique. Body composition was assessed by dual-energy x-ray absorptiometry (DEXA). Insulin sensitivity was measured using the insulin-modified frequently sampled intravenous glucose tolerance test. TEE adjusted for lean body mass (LBM) was significantly higher in the HIV-infected group with lipodystrophy compared to HIV-infected patients without lipodystrophy (2,873.3 +/- 69 v 2,573.9 +/- 92 kcal/d, P =.02) and compared to healthy controls (2,873.3 +/- 69 v 2,404.0 +/- 64 kcal/d, P <.001). REE and sleeping metabolic rate (SMR) adjusted for LBM were also significantly higher in the HIV-infected group with lipodystrophy compared to both HIV-infected and healthy controls. Carbohydrate oxidation rates adjusted for LBM were higher in men with HIV lipodystrophy as compared to healthy controls (362.5 +/- 23 v 250.0 +/- 22 g/d, P = <.01) and tended to be higher as compared to HIV-infected controls (362.5 +/- 23.6 v 297.3 +/- 31 g/d, P =.1). In conclusion, TEE and carbohydrate oxidation are increased in the HIV lipodystrophy syndrome. The increase in TEE appears to be due to increases in REE. The pathogenesis of elevated EE in HIV lipodystrophy and other forms of lipodystrophy remains to be determined.

The effect of mechanical strain on soft (cardiovascular) and hard (bone) tissues: common pathways for different biological outcomes.

Mechanical stress plays a pivotal role in developing and maintaining tissues functionalities. Cells are constantly subjected to strain and compressive forces that are sensed by specialized membrane mechanosensors and converted in biochemical signals able to differently influence cellular behavior in terms of surviving, differentiation and extracellular matrix remodeling. This review focuses on the effects of mechanical strain on soft and hard tissues. Unexpectedly, different cells share almost the same membrane mechanosensors and the relative intracellular pathways, but to ultimately obtain very different biological effects. The events occurring in cardiovascular and bone tissues are treated in details, showing that integrins, cadherins, growth factor receptors and ions channels specifically expressed in the different tissues are the major actors of the sight. However, MAPkinases and RhoGTPases are mainly involved in the biochemical intracellular signaling directed to nuclear modifications.

The role of shear stress on mechanically stimulated engineered vascular substitutes: influence on mechanical and biological properties.

Vascular tissue engineering represents a promising field in the replacement of diseased vessels. The biological properties of three-dimensional (3D) collagen scaffolds indicate this material as a valid choice for vascular tissue engineering. Unfortunately, mechanical properties still remain unsatisfactory, due to a low burst pressure resistance and a plastic deformation. The use of a bioreactor to apply appropriate mechanical stresses have already shown a remodelling effect on the extracellular matrix and the behaviour of cells. In this study, we have shown the effect of the mechanical stress on elastin synthesis, which has a direct effect on the mechanical properties of the tissue-engineered vessel. We measured and compared the stress-strain curves, the elastic modulus and tenacity of a collagen tubular scaffold in the presence of C2C12 murine myoblasts cells, before and after the maturation in the bioreactor, applying a shear stress of 5 dynes/cm(2) for 3 days. Interesting evidence concerning the extracellular matrix structure, which significantly modify the biomechanical characteristics of the cellular scaffold, were observed, underlying the importance of focusing more effort in the research field of physiologically-guided 3D tissue-engineered substitutes.

Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions.

BACKGROUND: Since the Institute of Medicine patient safety reports, a number of survey-based measures of organizational climate safety factors (OCSFs) have been developed. The goal of this study was to measure the impact of OCSFs on risk-adjusted surgical morbidity and mortality. STUDY DESIGN: Surveys were administered to staff on general/vascular surgery services during a year. Surveys included multiitem scales measuring OCSFs. Additionally, perceived levels of communication and collaboration with coworkers were assessed. The National Surgical Quality Improvement Program was used to assess risk-adjusted morbidity and mortality. Correlations between outcomes and OCSFs were calculated and between outcomes and communication/collaboration with attending and resident doctors, nurses, and other providers. RESULTS: Fifty-two sites participated in the survey: 44 Veterans Affairs and 8 academic medical centers. A total of 6,083 surveys were returned, for a response rate of 52%. The OCSF measures of teamwork climate, safety climate, working conditions, recognition of stress effects, job satisfaction, and burnout demonstrated internal validity but did not correlate with risk-adjusted outcomes. Reported levels of communication/collaboration with attending and resident doctors correlated with risk-adjusted morbidity. CONCLUSIONS: Survey-based teamwork, safety climate, and working conditions scales are not confirmed to measure organizational factors that influence risk-adjusted surgical outcomes. Reported communication/collaboration with attending and resident doctors on surgical services influenced patient morbidity. This suggests the importance of doctors' coordination and decision-making roles on surgical teams in providing high-quality and safe care. We propose risk-adjusted morbidity as an effective measure of surgical patient safety.

Implementation of youth development programs: promise and challenges.

PURPOSE: The Community Coalition Partnership Program for the Prevention of Teen Pregnancy provided a unique laboratory for observing how youth development projects were implemented in 13 community-based settings. This article focuses on the scope of these efforts, the content of the projects, and their expected outcomes. METHODS: The investigators inventoried all youth development activities created within the grantee communities between 1997 and 2000 and then surveyed 28 site representatives by telephone. The scope and content of the identified youth development programs were compared with national registries of other such programs. RESULTS: The youth development efforts implemented by the 13 grantees were diverse, multi-faceted, and broad in scope. Most were short-term, but reflected a broad base of support for youth development principles among various community partners. Of the array of youth development efforts developed, more than two-thirds targeted three program areas: community services/outreach, education/training programs, or mentoring programs-a pattern found among youth development programs throughout the country. CONCLUSIONS: Within this partnership, youth development was a better-received framework for mobilizing community partners than were more traditional pregnancy prevention approaches. Communities were successful in creating diverse programs that may have benefits for individual youth, service agencies, and the community at large.

Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.

OBJECTIVE: The objective of this study was to identify the determinants of 30-day postoperative mortality and long-term survival after major surgery as exemplified by 8 common operations. SUMMARY BACKGROUND DATA: The National Surgical Quality Improvement Program (NSQIP) database contains pre-, intra-, and 30-day postoperative data, prospectively collected in a standardized fashion by a dedicated nurse reviewer, on major surgery in the Veterans Administration (VA). The Beneficiary Identification and Records Locator Subsystem (BIRLS) is a VA file that depicts the vital status of U.S. veterans with 87% to 95% accuracy. METHODS: NSQIP data were merged with BIRLS to determine the vital status of 105,951 patients who underwent 8 types of operations performed between 1991 and 1999, providing an average follow up of 8 years. Logistic and Cox regression analyses were performed to identify the predictors of 30-day mortality and long-term survival, respectively. RESULTS: The most important determinant of decreased postoperative survival was the occurrence, within 30 days postoperatively, of any one of 22 types of complications collected in the NSQIP. Independent of preoperative patient risk, the occurrence of a 30-day complication in the total patient group reduced median patient survival by 69%. The adverse effect of a complication on patient survival was also influenced by the operation type and was sustained even when patients who did not survive for 30 days were excluded from the analyses. CONCLUSIONS: The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA. Quality and process improvement in surgery should be directed toward the prevention of postoperative complications.

Long-term weight loss and breakfast in subjects in the National Weight Control Registry.

OBJECTIVE: To examine breakfast consumption in subjects maintaining a weight loss in the National Weight Control Registry (NWCR). RESEARCH METHODS AND PROCEDURES: A cross-sectional study in which 2959 subjects in the NWCR completed demographic and weight history questionnaires as well as questions about their current breakfast consumption. All subjects had maintained a weight loss of at least 13.6 kg (30 lb) for at least 1 year; on average these subjects had lost 32 kg and kept it off for 6 years. RESULTS: A large proportion of NWCR subjects (2313 or 78%) reported regularly eating breakfast every day of the week. Only 114 subjects (4%) reported never eating breakfast. There was no difference in reported energy intake between breakfast eaters and non-eaters, but breakfast eaters reported slightly more physical activity than non-breakfast eaters (p = 0.05). DISCUSSION: Eating breakfast is a characteristic common to successful weight loss maintainers and may be a factor in their success.