Contribution of acute kidney injury toward morbidity and mortality in burns: a contemporary analysis.

BACKGROUND: Severe acute kidney injury (AKI) that requires dialytic support, a relatively uncommon complication in severely burned adults, is associated with a substantially increased mortality rate. It is not known whether milder forms of AKI have prognostic importance in burns. METHODS: We performed an observational cohort analysis of consecutive patients with major burns admitted to the burn care unit of a tertiary-care center from 1998 to 2003. Our main outcome measures were AKI stratified by the Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage kidney disease (RIFLE) classification and mortality. RESULTS: AKI occurred in 81 of 304 patients (26.6%) with burns on 10% or greater total-body surface area. Risk factors for AKI on multivariate analysis were inhalational injury, catheter infection, and sepsis. Patients with AKI stratified by using the RIFLE classification had greater mortality, greater requirement of artificial ventilation, and longer durations of intensive care unit and hospital stays. Mortality was not significantly different among those with the "Risk" and "Injury" strata of RIFLE AKI compared with those without AKI, but mortality increased significantly with the "Failure" (60%) strata. In multivariate analysis, age, greater total-body surface area, inhalational injury, and the RIFLE classification of Failure were each independent predictors of death. CONCLUSION: In conclusion, the mortality of patients with burns with severe AKI remains high and unchanged in the modern era of critical care medicine. The RIFLE classification added prognostic information regarding morbidity in patients with milder forms of AKI.

Relationship of processes and structures of care in general surgery to postoperative outcomes: a hierarchical analysis.

BACKGROUND: The majority of studies relating processes and structures of surgical care to outcomes focus on mortality alone, even though morbidity outcomes are frequent, costly, and can have an adverse effect on a patient's short- and longterm survival and quality of life. The purpose of this study was to identify the important processes and structures of surgical care that relate to 30-day, risk-adjusted postoperative morbidity in general surgery. STUDY DESIGN: Department of Veterans Affairs general surgery patients operated on in the period October 1, 2003 to September 30, 2004 at medical centers that participated in the Patient Safety in Surgery (PSS) Study and responded to a process and structure of care survey were included in this study. The patient's risk information was combined with key process and structure variables in a hierarchical maximum likelihood analysis to predict 30-day postoperative morbidity. RESULTS: A number of hospital-level processes and structures of care were identified that predicted 30-day postoperative morbidity. The dominant factor was university affiliation. Affiliated hospitals showed an increase in risk of morbidity even after adjustment for patient risk. CONCLUSIONS: Risk-adjusted morbidity is higher in Veterans Affairs hospitals that are affiliated with university medical centers. These findings mandate additional study to identify the exact factors responsible for this increased morbidity.

Breast cancer surgery in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study.

BACKGROUND: Breast cancer is a common diagnosis. We compare perioperative characteristics and outcomes between male and female patients undergoing treatment for breast cancer and between hospital systems (Department of Veterans Affairs [VA] and private sector [PS]) as part of the Patient Safety in Surgery (PSS) Study. STUDY DESIGN: We performed an analysis of a prospectively collected clinical database. Data collected from 128 VA hospitals and 14 PS academic medical centers as part of the Patient Safety in Surgery Study for fiscal years 2002 through 2004 were used. Analysis included calculation of crude and adjusted odds ratios for morbidity. RESULTS: A total of 3,823 patients were included. Female VA patients at baseline had higher rates of smoking, steroid use, COPD, acute renal failure, dialysis, weight loss > 10%, preoperative chemotherapy, and abnormal laboratory values than female PS patients did. Male patients were older than the female patients in both hospital systems. Mortality rates were very low and similar among groups. All VA patients in this study had substantially longer lengths of stay than the patients in the PS. The unadjusted overall complication rate was 5.21%; the VA female patients experienced an unadjusted complication rate twice that of the PS female patients. When adjusted for confounding variables and differences in preoperative comorbidities, the odds ratio comparing VA with PS females was no longer markedly different (1.404; 95% CI, 0.894, 2.204). CONCLUSIONS: VA patients with breast cancer have higher incidences of most comorbidities than patients in the PS. Differences in complication rates females disappear when adjustment is made for the higher rates of comorbidities in the VA patients.

Relationship of processes and structures of care in general surgery to postoperative outcomes: a descriptive analysis.

BACKGROUND: The systematic collection of quantitative data on structures and processes from surgical services participating in the National Surgical Quality Improvement Program (NSQIP) has not been a focus to date. Efficient collection of useful measures of structures and processes may improve understanding of surgical outcomes and strategies for improving the quality of surgical care, as NSQIP continues to expand. The purpose of this article was to describe results of a quantitative survey designed to measure surgical care structures and processes within NSQIP sites. STUDY DESIGN: A cross-sectional survey was mailed to 123 Department of Veteran Affairs (VA) and 14 private sector sites participating in the Agency for Healthcare Research and Quality (AHRQ)-funded Patient Safety in Surgery (PSS) Study. The survey included questions about organizational structures and processes of preoperative, intraoperative, and postoperative general surgical care services. For this study, we included only data from 90 VA sites that returned a survey (73% response rate). We used descriptive statistics and examined the bivariate association of structures and processes items or scales with risk-adjusted observed-to-expected (O/E) ratios of surgical morbidity and mortality. RESULTS: Examination of frequency or means and standard deviations of items and scales revealed substantial variation in the structures and processes of surgical care services in participating VA sites, with correlation analyses demonstrating that, of 35 process and structure variables, there was a statistically significant relationship with the hospital's observed-to-expected ratio for 14 variables for morbidity, but only 4 variables for mortality. CONCLUSIONS: This descriptive analysis provides support for the potential importance of measuring organizational structures and processes of care in addition to risk-adjusted morbidity and mortality.

Liver resection in veterans affairs and selected university medical centers: results of the patient safety in surgery study.

BACKGROUND: A congressional mandate, which led to the formation of the National Surgical Quality Improvement Program, is now being fulfilled with the publication of general and vascular surgical outcomes comparisons between Veterans Affairs (VA) and university medical centers. A series of National Surgical Quality Improvement Program articles evaluate the effect of hospital type (VA versus university hospitals) on procedure-specific outcomes. This article focuses on liver resections. STUDY DESIGN: This is a prospective cohort study of a sample of patients undergoing liver resections at 128 VA medical centers compared with 14 university medical centers from October 1, 2001, to September 30, 2004. Preoperative and intraoperative characteristics were evaluated to identify possible variables related to morbidity and mortality and possible confounders of the hospital effect. These variables were then used to identify the effect that the hospital setting might have on surgical outcomes after liver resections. RESULTS: Data from 237 liver resections at VA hospitals were compared with 783 procedures performed at university hospitals. The unadjusted 30-day morbidity rate tended to be higher in the VA (university 22.6% versus VA 27.9%; p = 0.10). After risk adjustment, results were equivalent (odds ratio = 0.94; p = 0.77). Unadjusted 30-day mortality rate was significantly higher in VA hospitals (6.8% versus 2.6%; p = 0.002). After risk adjustment, there was no longer a significant difference in mortality between the two hospital systems (odds ratio = 1.62; p = 0.33). CONCLUSIONS: For liver resections, the National Surgical Quality Improvement Program and Patient Safety in Surgery Study data suggest that there is no significant difference in risk-adjusted morbidity or mortality rates between VA and the university medical centers.

Pancreatic resection in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study.

BACKGROUND: Pancreatectomy is a high-risk, technically demanding operation associated with substantial perioperative morbidity and mortality. This study aims to describe the 30-day morbidity and mortality for pancreatectomy and to compare outcomes between private-sector and Veterans Affairs hospitals using multiinstitutional data. STUDY DESIGN: This is a retrospective review of patients who underwent pancreatic resection for neoplasia at private-sector (PS) and Veterans Affairs (VA) hospitals participating in the National Surgical Quality Improvement Program Patient Safety in Surgery Study in fiscal years 2002 to 2004. The variables reviewed were demographics, preoperative medical conditions, intraoperative variables, and outcomes. Using logistic regression to control for differences in patient comorbidities, 30-day mortality and morbidity rates between PS and VA hospitals were compared. RESULTS: A total of 1,069 patients underwent pancreatectomy for neoplasia at 97 participating hospitals. Six hundred ninety-two patients were treated at PS hospitals and 377 at VA hospitals. The average number of patients treated at each hospital was 11.0, with a range of 1 to 83 during the 3-year study period. There were 842 patients who underwent pancreaticoduodenectomy (CPT 4815x) and 227 who underwent distal/subtotal pancreatectomy (CPT 4814x). Significant differences were observed between PS patients and VA patients with regard to comorbidities and patient demographics. The 30-day unadjusted morbidity rate was 33.8% overall, 42.2% at VA hospitals versus 29.1% at PS hospitals (p < 0.0001). Unadjusted and adjusted odds ratio (OR) for postoperative morbidity comparing VA with PS hospitals was 1.781 (95% CI, 1.369-2.318) and 1.581 (95% CI, 1.064-2.307). The 30-day unadjusted operative mortality rate was 3.8% overall, 6.4% at VA hospitals and 2.5% at PS hospitals (p = 0.0015). Unadjusted and adjusted OR for postoperative mortality was 2.909 (95% CI, 1.525-5.549) and 2.533 (95% CI, 1.020-6.290), respectively. Similar outcomes were observed when looking at pancreaticoduodenectomy (CPT 4815x) when analyzed independent of other types of pancreatic resections. CONCLUSION: Pancreatectomies are high-risk operations with substantial perioperative morbidity and mortality. Risk-adjusted outcomes for patients treated at PS hospitals were found to be superior to those for patients treated at VA hospitals in the study.

Adrenalectomy in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study.

BACKGROUND: Data from the Patient Safety in Surgery Study were used to compare preoperative risk factors, intraoperative variables, and surgical outcomes of adrenalectomy procedures performed in 81 Veterans Affairs (VA) hospitals with those performed in 14 private-sector (PS) hospitals. STUDY DESIGN: This study is a retrospective review of prospectively collected data on all patients undergoing adrenalectomy in the VA and PS for fiscal years 2002 through 2004. Bivariate analysis compared VA and PS preoperative risk factors, intraoperative variables, and 30-day morbidity and mortality. Regression risk-adjustment analysis was used to compare 30-day postoperative morbidity in the VA and PS. RESULTS: During the 3 years studied, 178 VA patients and 371 PS patients underwent adrenalectomy procedures with a median per site of 2 (range 1-9) and 21 (range 8-70) procedures per VA and PS hospital, respectively. The VA patients had considerably more comorbidities than PS patients. The unadjusted 30-day morbidity rate was significantly higher in VA (16.29%) than PS (6.74%) hospitals (p = 0.0003); after controlling for the higher rate of comorbidities, the adjusted odds ratio for morbidity in the VA versus the PS hospitals was no longer significant (odds ratio = 1.328; 95% CI, 0.488-3.613). Unadjusted mortality rate was VA 2.81%, PS 0.27%, p = 0.0074. The low event rate overall precluded risk adjustment for mortality. CONCLUSIONS: The VA adrenalectomy population has more preoperative risk factors and substantially higher unadjusted 30-day postoperative morbidity and mortality rates than the PS population. After risk adjustment, there is no significant difference in morbidity between the VA and the PS. A larger study population is needed to compare risk-adjusted mortality between the VA and PS.

Bariatric operations in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study.

BACKGROUND: The objectives of this study were to evaluate outcomes and predictors of morbidity in patients undergoing Roux-en-Y gastric bypass (RYGB) during the Patient Safety in Surgery (PSS) Study. STUDY DESIGN: National Surgical Quality Improvement Program data on PSS patients undergoing RYGB were analyzed for unadjusted and adjusted outcomes. Gender groups acted differently and were analyzed separately. Multivariable regression modeling was used to analyze hospital type as a predictor of risk. Stepwise logistic regression was performed to determine patient factors predictive of postoperative morbidity. RESULTS: A total of 2,438 patients (2,064 private sector [PS], 374 Veterans Affairs [VA]) were identified for analysis. Adjusted odds ratio for postoperative morbidity for VA versus PS female patients was 1.14 (95% CI, 0.63-2.05), and for male patients 2.29 (95% CI, 1.28-4.10). Stepwise logistic regression showed that independent risk factors predictive of morbidity were open procedure, higher American Society of Anesthesiologists class, higher body mass index, diabetes, alcohol consumption, leukocytosis, SGOT > 40 U/L, smoking history, and older age. Importantly, male gender was not significant (p = 0.13) in the regression analysis. Subsequent and unrelated to this study, the VA has restructured its bariatric surgical program, including regionalization of centers, with a substantial lowering of associated mortality and morbidity. CONCLUSIONS: The VA male subset showed higher risk-adjusted postoperative morbidity compared with the PS male subset. The VA and PS female subsets had equivalent risk-adjusted postoperative morbidity. A systematic approach to quality-improvement processes resulted in improved bariatric surgical outcomes in the VA. Male gender might not be an independent risk factor in RYGB patients.

Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery.

CONTEXT: Elderly patients are at high risk of both abnormal hematocrit values and cardiovascular complications of noncardiac surgery. Despite nearly universal screening of patients for abnormal preoperative hematocrit levels, limited evidence demonstrates the adverse effects of preoperative anemia or polycythemia. OBJECTIVE: To evaluate the prevalence of preoperative anemia and polycythemia and their effects on 30-day postoperative outcomes in elderly veterans undergoing major noncardiac surgery. DESIGN: Retrospective cohort study using the VA National Surgical Quality Improvement Program database. Based on preoperative hematocrit levels, we stratified patients into standard categories of anemia (hematocrit <39.0%), normal hematocrit (39.0%-53.9%), and polycythemia (hematocrit > or =54%). We then estimated increases in 30-day postoperative cardiac event and mortality risks in relation to each hematocrit point deviation from the normal category. SETTING AND PATIENTS: A total of 310,311 veterans aged 65 years or older who underwent major noncardiac surgery between 1997 and 2004 in 132 Veterans' Affairs medical centers across the United States. MAIN OUTCOME MEASURES: The primary outcome measure was 30-day postoperative mortality; a secondary outcome measure was composite 30-day postoperative mortality or cardiac events (cardiac arrest or Q-wave myocardial infarction). RESULTS: Thirty-day mortality and cardiac event rates increased monotonically, with either positive or negative deviations from normal hematocrit levels. We found a 1.6% (95% confidence interval, 1.1%-2.2%) increase in 30-day postoperative mortality associated with every percentage-point increase or decrease in the hematocrit value from the normal range. Additional analyses suggest that the adjusted risk of 30-day postoperative mortality and cardiac morbidity begins to rise when hematocrit levels decrease to less than 39% or exceed 51%. CONCLUSIONS: Even mild degrees of preoperative anemia or polycythemia were associated with an increased risk of 30-day postoperative mortality and cardiac events in older, mostly male veterans undergoing major noncardiac surgery. Future studies should determine whether these findings are reproducible in other populations and if preoperative management of anemia or polycythemia decreases the risk of postoperative mortality.

National Surgical Quality Improvement Program analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse outcomes.

BACKGROUND: The increase in obesity coupled with greater acceptance of the field of bariatric surgery has resulted in a substantial rise in the number of weight-loss operations. Because obese individuals are at high risk for surgical complications, concern about the safety of bariatric procedures exists. Earlier investigations of the clinical features associated with surgical complications have produced conflicting results. We sought to identify risk factors for surgical complications in a large, nationally representative population of US veterans. STUDY DESIGN: We analyzed data on bariatric procedures performed at 12 Veterans' Affairs medical centers approved to perform weight-loss operations between 1998 and 2004. Detailed pre-, intra-, and postoperative information and longterm mortality data were prospectively collected using the National Surgical Quality Improvement Program methodology. We used multivariable logistic regression to identify clinical features associated with postoperative complications. RESULTS: Among 575 bariatric patients assessed between 1998 and 2004, 74% were men with a mean age of 51 years. Thirty-day mortality was 1.4%. Overall complication rate was 19.7%. Of those with complications, one-half were of considerable clinical importance, as they were associated with prolonged length of stay. Clinical features that were predictive of adverse events in our multivariable analyses were superobesity, weight>350 pounds, and smoking. A more than 20 pack-year history of smoking was also associated with difficulty in weaning from a ventilator postoperatively. CONCLUSIONS: We identified smoking and superobesity as preoperative risk factors associated with postoperative complications. Future studies should examine the effect of preoperative weight loss and smoking cessation on bariatric procedure outcomes.

Comparative analysis of vagotomy and drainage versus vagotomy and resection procedures for bleeding peptic ulcer disease: results of 907 patients from the Department of Veterans Affairs National Surgical Quality Improvement Program database.

BACKGROUND: The purpose of this study was to determine postoperative outcomes and risk factors for morbidity and mortality in patients requiring surgery for bleeding peptic ulcer disease (PUD). Vagotomy and drainage procedures are technically simpler but are usually associated with higher ulcer recurrence rates. In contrast, vagotomy and resection approaches offer lower ulcer recurrences but represent much more challenging operations and are associated with considerable morbidity and mortality. STUDY DESIGN: Data collected through the Department of Veterans Affairs National Surgical Quality Improvement Program database from 1991 to 2001 were submitted for stepwise logistic regression analysis for prediction of 30-day postoperative morbidity and mortality, rebleeding, and postoperative length of stay. The study population included all patients operated on for bleeding PUD within an 11-year period. RESULTS: The 30-day morbidity, mortality, and rebleeding rates were comparable between surgical groups. Age, American Society of Anesthesiologists class, presence of ascites, coma, diabetes, functional status, hemiplegia, and history of steroid use were predictors of postoperative death. Risk factors for rebleeding included dependent functional status, history of congestive heart failure, smoking, steroid use, and preoperative transfusions. Having a resective procedure, American Society of Anesthesiologists class, hemiplegia, history of COPD, and requiring ventilator-assisted respirations before surgery were positively associated with increased length of hospital stay. CONCLUSIONS: No differences were observed in 30-day mortality, morbidity, or rebleeding rates between surgical groups. Having a resective procedure was a predictor of prolonged postoperative stay. Dependent status and chronic use of steroids were predictors of both rebleeding and postoperative mortality.

Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals.

BACKGROUND: There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system. METHODS: Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood. RESULTS: A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant. CONCLUSIONS: Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.

Predictors of long-term mortality after bariatric surgery performed in Veterans Affairs medical centers.

HYPOTHESIS: The purpose of this study was to examine patient factors associated with mortality among veterans who undergo bariatric surgery. DESIGN: Prospective study that uses data from the Veterans Affairs (VA) National Surgical Quality Improvement Program. SETTING: Group Health Center for Health Studies, the VA North Texas Health Care System, the Denver VA Medical Center, and the Durham VA Medical Center. PATIENTS: We identified 856 veterans who had undergone bariatric surgery in 1 of 12 VA bariatric centers from January 1, 2000, through December 31, 2006. MAIN OUTCOME MEASURES: The risk of death was estimated via Cox proportional hazards. RESULTS: The 856 veterans had a mean body mass index (BMI) of 48.7, a mean age of 54 years, and a mean DCG score of 0.76; 73.0% were men, 83.9% were white, and 7.0% had an ASA class equal to 4. Fifty-four veterans (6.3%) had died by the end of 2006. In our Cox models, patients with a BMI greater than 50 (superobesity; hazard ratio [HR], 1.8; P = .04) or a DCG score greater than or equal to 2 (HR, 3.4; P < .001) had an increased risk of death. CONCLUSION: Superobese veterans and those with a greater burden of chronic disease had a greater risk of death after bariatric surgery from 2000 through 2006.

Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program.

BACKGROUND: Numerous series demonstrate the benefits of laparoscopic versus open adrenalectomy, but fail to adjust for confounding factors. This study uses the Veterans Affairs National Surgical Quality Improvement Program database to compare these two approaches, adjusting for baseline differences. STUDY DESIGN: Laparoscopic (n=358) and open (n=311) adrenalectomy data were collected at 123 Department of Veterans Affairs and 14 university hospitals from October 1, 2001 to September 30, 2004. Preoperative characteristics, operative data, and 30-day outcomes were compared using the chi-square or Fisher's exact test for categorical variables and the t-test for continuous variables. Unadjusted odds ratio (OR) and 95% confidence interval (CI) were computed for the effect of operative approach on postoperative morbidity. Adjusted odds ratios and 95% CI were computed for this same effect, adjusting for variables that were predictive of outcomes or imbalanced at baseline. Data are reported as means +/-SD, unless otherwise indicated. RESULTS: Patients undergoing open adrenalectomy were more likely to be older (57.8+/-11.9 years versus 53.5+/-13.2 years, p < 0.0001), harbor malignancy (44.5% versus 13.5%, p < 0.0001), have higher American Society of Anesthesiologists classifications (p=0.0037), smoke (35.4% versus 22.6%, p=0.0003), and have lower serum albumin levels (3.9+/-0.5 g/dL versus 4.0+/-0.5 g/dL, p=0.0241). Open procedures had increased operative times (3.9+/-1.8 hours versus 2.9+/-1.3 hours, p < 0.0001), transfusion requirements (0.7+/-1.8 U versus 0.1+/-0.5 U, p<0.0001), reoperations (4.8% versus 1.4%, p=0.0094), length of stay (9.4+/-11.0 days versus 4.1+/-4.7 days, p < 0.0001) and 30-day morbidity rates (17.4% versus 3.6%, p < 0.0001) with unadjusted and adjusted odds ratio (95% CI) of 5.52 (2.94, 10.33), and 3.97 (1.92, 8.22), respectively. Open procedures resulted in more pneumonia, unplanned intubation, unsuccessful ventilator wean, systemic sepsis, cardiac arrest, renal insufficiency, and wound infections. CONCLUSIONS: Even after adjustment for confounding factors, 30-day morbidity was much higher for patients having open adrenalectomy.

Mortality after nonemergent major surgery performed on Friday versus Monday through Wednesday.

OBJECTIVE: To determine whether nonemergent major surgery leads to higher mortality when performed on Friday versus early weekdays. SUMMARY BACKGROUND DATA: Adults admitted emergently to acute-care hospitals on weekends experience higher mortality than those admitted on weekdays. METHODS: Cohort study of 188,212 patients undergoing nonemergent major surgery at 124 Veterans Affairs hospitals from 2000 to 2004. Risk-adjusted 30-day mortality was compared for operations performed on Fridays versus Mondays through Wednesdays. Data were derived from the Veterans Affairs' National Surgical Quality Improvement Program database. Patients were divided into 3 groups: floor (admitted postoperatively to regular floor), ICU (admitted postoperatively to intensive care unit), and outpatient (not admitted postoperatively). A stepwise logistic regression analysis was used to test the effect of day of surgery (Friday vs. Monday-through-Wednesday) on 30-day mortality in the presence of characteristics that were significant in bivariate analysis. RESULTS: In the floor group (n = 89,786), operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through Wednesdays (2.94% vs. 2.18%; odds ratio, 1.36; 95% confidence interval, 1.24-1.49; P < 0.001). After adjusting for patient characteristics, odds ratio of 30-day mortality for operations on Fridays, when compared with Mondays through Wednesdays, was 1.17 (95% confidence interval, 1.05-1.26; P = 0.003). Within the ICU (n = 14,271) and outpatient (n = 84,155) groups, nonsignificant differences in 30-day mortality were observed for operations on Fridays versus Mondays through Wednesdays. CONCLUSIONS: For patients admitted to regular hospital floors after nonemergent major surgery, mortality is increased if surgery is performed on Friday versus Monday through Wednesday.

Morbidity and mortality following breast cancer surgery in women: national benchmarks for standards of care.

BACKGROUND: Most reports on postoperative (OP) morbidity and mortality following breast cancer surgery (BCS) are limited by relatively small sample size resulting in a lack of national benchmarks for quality of care. This paper reports the 30-day morbidity and mortality following BCS in women using a large prospective multi-institutional database. METHODS: The National Surgical Quality Improvement Program Patient Safety in Surgery, prospectively collected inpatient and outpatient 30 day postoperative morbidity and mortality data on patients undergoing surgery at 14 university and 4 community centers. Using the procedure CPT code, the database was queried for all women undergoing mastectomy (MT) or lumpectomy with an axillary procedure (L-ANP). Morbidity and mortality were categorized as mortality, wound, cardiac, renal, pulmonary, and central nervous system. Logistic regression models for the prediction of wound complications were developed. Preoperative variables having bivariate relationships with postoperative wound complications with P < or = 0.20 were submitted for consideration. RESULTS: We identified 1660 and 1447 women who underwent MT and l-ANP, respectively. The mean age was 55.9 years. The majority of procedures were under general anesthesia. The 30-day postoperative mortality for MT and l-ALNP were 0.24% and 0%, respectively. The most frequent morbid complication was wound infection, more commonly occurring in the mastectomy (4.34%) group versus the lumpectomy group (1.97%). Cardiac and pulmonary complications occurred infrequently in the mastectomy group (cardiac: MT, 0.12%; and pulmonary: MT, 0.66%). There were no cardiac or pulmonary complications in the lumpectomy group. CNS morbidities were rare in both surgical groups (MT, 0.12%; and l-ALNP, 0.07%). Development of a UTI was more common in women who underwent a mastectomy (0.66%) when compared with women that had a lumpectomy (0.14%). The only significant predictors of a wound complication were morbid obesity (BMI >30), having had a MT, low preoperative albumin and hematocrit greater than 45%. CONCLUSION: Morbidity and mortality rates following BCS in women are low, limiting their value in assessing quality of care. Mastectomy carries higher complication rate than l-ANP with wound infection being the most common.

Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP).

OBJECTIVE: We hypothesize that the systems of care within academic medical centers are sufficiently disrupted with the beginning of a new academic year to affect patient outcomes. METHODS: This observational multiinstitutional cohort study was conducted by analysis of the National Surgical Quality Improvement Program-Patient Safety in Surgery Study database. The 30-day morbidity and mortality rates were compared between 2 periods of care: (early group: July 1 to August 30) and late group (April 15 to June 15). Patient baseline characteristics were first compared between the early and late periods. A prediction model was then constructed, via stepwise logistic regression model with a significance level for entry and a significance level for selection of 0.05. RESULTS: There was 18% higher risk of postoperative morbidity in the early (n = 9941) versus the late group (n = 10313) (OR 1.18, 95%, CI 1.07-1.29, P = 0.0005, c-index 0.794). There was a 41% higher risk for mortality in the early group compared with the late group (OR 1.41, CI 1.11-1.80, P = 0.005, c-index 0.938). No significant trends in patient risk over time were noted. CONCLUSION: Our data suggests higher rates of postsurgical morbidity and mortality related to the time of the year. Further study is needed to fully describe the etiologies of the seasonal variation in outcomes.

Causes of high mortality in colorectal surgery: a review of episodes of care in Veterans Affairs hospitals.

BACKGROUND: The episode of care for colorectal surgery in 8 outlier Veterans Affairs Hospitals with high mortality and the volume outcome relationship in 118 Hospitals are examined. METHODS: A total of 103 deaths were reviewed. Mean age was 74 with 63% of the patients undergoing emergency surgery; 54% of the patients had malignant disease and 21% had metastatic disease. RESULTS: Nineteen percent of the patients had a delay in diagnosis, 22% had delay in surgery and 14% should have received a different surgery usually less radical. In addition, system related issues were identified in 19% of the cases and practitioner related issues in 20% of the cases. The Spearman rank correlation between colorectal surgery volume and unadjusted mortality was 0.114 (P = 0.22). CONCLUSION: Colorectal surgery death is prevalent in elderly patients undergoing emergency surgery for malignancy or metastatic disease and is not related to hospital volume. Timely diagnosis, less radical surgery while optimizing system based pathways might improve outcome.

Risk factors for adverse outcomes following surgery for small bowel obstruction.

OBJECTIVE: To construct risk indices predicting adverse outcomes following surgery for small bowel obstruction (SBO). METHODS: The VA National Surgical Quality Improvement Program contains prospectively collected data on more than 1 million patients. Patients undergoing adhesiolysis only or small bowel resection for SBO from 1991 to 2002 were selected. Independent variables included 68 presurgical and 12 intraoperative risk factors; dependent variables were 21 adverse outcomes including death. Stepwise logistic regression was used to construct models predicting 30-day morbidity and mortality and to derive risk index values. Patients were then divided into risk classes. RESULTS: Of the 2002 patients, 1650 underwent adhesiolysis only and 352 underwent small bowel resection. Thirty-seven percent undergoing adhesiolysis only and 47% undergoing small bowel resection had more than 1 complication (P < 0.001). The overall 30-day mortality was 7.7% and did not differ significantly between the groups. Odds of death were highest for dirty or infected wounds, ASA class 4 or 5, age >80 years, and dyspnea at rest. Morbidity ranged from 22%, among patients with 0 to 7 risk points, to 62% for those with >19 risk points. Mortality ranged from 2% among patients with 0 to 12 risk points to 28% for those with >31 risk points. CONCLUSIONS: Morbidity and mortality after surgery for SBO in VA hospitals are comparable with those in other large series. The morbidity rate, but not the mortality rate, is significantly higher in patients requiring small bowel resection compared with those requiring adhesiolysis only (P < 0.001). The risk indices presented provide an easy-to-use tool for clinicians to predict outcomes for patients undergoing surgery for SBO.