Hospital Analgesia Practices and Patient-reported Pain After Colorectal Resection.

OBJECTIVE: The aim of the study was to characterize patient-reported outcomes of analgesia practices in a population-based surgical collaborative. BACKGROUND: Pain control among hospitalized patients is a national priority and effective multimodal pain management is an essential component of postoperative recovery, but there is little understanding of the degree of variation in analgesia practice and patient-reported pain between hospitals. METHODS: We evaluated patient-reported pain scores after colorectal operations in 52 hospitals in a state-wide collaborative. We stratified hospitals by quartiles of average pain scores, identified hospital characteristics, pain management practices, and clinical outcomes associated with highest and lowest case-mix-adjusted pain scores, and compared against Hospital Consumer Assessment of Healthcare Providers and Systems pain management metrics. RESULTS: Hospitals with the lowest pain scores were larger (503 vs 452 beds; P < 0.001), higher volume (196 vs 112; P = 0.005), and performed more laparoscopy (37.7% vs 27.2%; P < 0.001) than those with highest scores. Their patients were more likely to receive local anesthesia (31.1% vs 12.9%; P < 0.001), nonsteroidal anti-inflammatory drugs (33.5% vs 14.4%; P < 0.001), and patient-controlled analgesia (56.5% vs 22.8%; P < 0.001). Adverse postoperative outcomes were less common in hospitals with lowest pain scores, including complications (20.3% vs 26.4%; P < 0.001), emergency department visits (8.2% vs 15.8%; P < 0.001), and readmissions (11.3% vs 16.2%; P = 0.01). CONCLUSIONS: Pain management after colorectal surgery varies widely and predicts significant differences in patient-reported pain and clinical outcomes. Enhanced postoperative pain management requires dissemination of multimodal analgesia practices. Attention to patient-reported outcomes often omitted from surgical outcomes registries is essential to improving quality from the patient's perspective.

Multi-institutional assessment of sphincter preservation for rectal cancer.

BACKGROUND: Sphincter-preserving surgery (SPS) has been proposed as a quality measure for rectal cancer surgery. However, previous studies on SPS rates lack critical clinical characteristics, rendering it unclear if variation in SPS rates is due to unmeasured case-mix differences or surgeons' selection criteria. In this context, we investigate the variation in SPS rates at various practice settings. METHODS: Ten hospitals in the Michigan Surgical Quality Collaborative collected rectal cancer-specific data, including tumor location and reasons for non-SPS, of patients who underwent rectal cancer surgery from 2007 to 2012. Hospitals were divided into terciles of SPS rates (frequent, average, and infrequent). Patients were categorized as 'definitely SPS eligible' a priori if they did not have any of the following: sphincter involvement, tumor <6 cm from the anal verge, fecal incontinence, stoma preference, or metastatic disease. Fixed-effects logistic regression was used to evaluate for factors associated with SPS. RESULTS: In total, 329 patients underwent rectal cancer surgery at 10 hospitals (5/10 higher volume, and 6/10 major teaching). Overall, 72 % had SPS (range by hospital 47-91 %). Patient and tumor characteristics were similar between hospital terciles. On multivariable analysis, only hospital ID, younger age, and tumor location were associated with SPS, but not sex, race, body mass index, American Joint Committee on Cancer (AJCC) stage, preoperative radiation, or American Society of Anesthesiologists (ASA) class. Analysis of the 181 (55 %) 'definitely-eligible' patients revealed an SPS rate of 90 % (65-100 %). CONCLUSIONS: SPS rates vary by hospital, even after accounting for clinical characteristics using detailed chart review. These data suggest missed opportunities for SPS, and refute the general hypothesis that hospital variation in previous studies is due to unmeasured case-mix differences.