Harnessing the full potential of hospital-based data to support surgical quality improvement.

Surgical departments commonly rely on third-party quality improvement registries. As electronic health data become increasingly integrated and accessible within an institution, alternatives to these platforms arise. We present the conceptualization and implementation of an in-house quality improvement platform that provides real-time reports, is less onerous on clinicians and is tailored to an institution's priorities of care.

Efficacy of intraoperative cell salvage in decreasing perioperative blood transfusion rates in first-time cardiac surgery patients: a retrospective study.

BACKGROUND: Evidence regarding the safety and efficacy of intraoperative cell salvage (ICS) in transfusion reduction during cardiac surgery remains conflicting. We sought to evaluate the impact of routine ICS on outcomes following cardiac surgery. METHODS: We conducted a retrospective analysis of patients who underwent nonemergent, first-time cardiac surgery 18 months before and 18 months after the implementation of routine ICS. Perioperative transfusion rates, postoperative bleeding, clinical and hematological outcomes, and overall cost were examined. We used multivariable logistic regression modelling to determine the risk-adjusted effect of ICS on likelihood of perioperative transfusion. RESULTS: A total of 389 patients formed the final study population (186 undergoing ICS and 203 controls). Patients undergoing ICS had significantly lower perioperative transfusion rates of packed red blood cells (pRBCs; 33.9% v. 45.3% p = 0.021), coagulation products (16.7% v. 32.5% p < 0.001) and any blood product (38.2% v. 52.7%, p = 0.004). Patients receiving ICS had decreased mediastinal drainage at 12 h (mean 320 [range 230-550] mL v. mean 400 [range 260-690] mL, p = 0.011) and increased postoperative hemoglobin (mean 104.7 ± 13.2 g/L v. 95.0 ± 11.9 g/L, p < 0.001). Following adjustment for other baseline and intraoperative covariates, ICS emerged as an independent predictor of lower perioperative transfusion rates of pRBCs (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.87), coagulation products (OR 0.41, 95% CI 0.24-0.71) and any blood product (OR 0.47, 95% CI 0.29-0.77). Additionally, ICS was associated with a cost benefit of $116 per patient. CONCLUSION: Intraoperative cell salvage could represent a clinically cost-effective way of reducing transfusion rates in patients undergoing cardiac surgery. Further research on systematic ICS is required before recommending it for routine use.

CONTEXTE: Les résultats d'études portant sur l'innocuité et l'efficacité de l'autotransfusion peropératoire (ATPO) comme mesure de réduction du besoin de transfusion durant une chirurgie cardiaque sont contradictoires. Nous avons cherché à évaluer l'incidence du recours systématique à l'ATPO sur les issues de chirurgies cardiaques. MÉTHODES: Nous avons mené une analyse rétrospective portant sur des patients ayant subi une première chirurgie cardiaque non urgente 18 mois avant et 18 mois après l'introduction de l'ATPO systématique. Les taux de transfusion périopératoire et d'hémorragie postopératoire, les résultats cliniques et hématologiques et le coût total ont été analysés. Nous avons utilisé un modèle de régression logistique multivariée pour déterminer l'incidence ajustée en fonction du risque du recours à l'ATPO sur la probabilité qu'une transfusion périopératoire soit nécessaire. RÉSULTATS: L'échantillon à l'étude était composé de 389 patients (186 dans le groupe ATPO et 203 dans le groupe témoin). Par rapport au groupe témoin, les patients ayant reçu une ATPO ont eu besoin significativement moins souvent d'une transfusion de concentrés de globules rouges (33,9 % c. 45,3 %; p = 0,021), de produits coagulants (16,7 % c. 32,5 %; p < 0,001) et de produits sanguins, tous types confondus (38,2 % c. 52,7 %; p = 0,004). Chez les patients ayant reçu une ATPO, on a constaté un volume de drainage médiastinal après 12 h plus faible (moyenne : 320 mL [étendue de 230-550] c. 400 mL [étendue de 260-690]; p = 0,011) et une hémoglobine postopératoire plus élevée (moyenne : 104,7 ± 13,2 g/L c. 95,0 ± 11,9 g/L; p < 0,001). Après des ajustements pour tenir compte d'autres covariables des mesures de base et peropératoires, nous avons conclu que le recours à l'ATPO était un facteur prédicteur indépendant de taux de transfusion périopératoire plus faibles de concentré de globules rouges (rapport de cotes [RC] : 0,52; intervalle de confiance [IC] à 95 % : 0,31-0,87), de produits coagulants (RC : 0,41; IC à 95 % : 0,24-0,71) et de produits sanguins, tous types confondus (RC : 0,47; IC à 95 % : 0,29-0,77). De plus, l'ATPO a été associée à des économies de 116 $ par patient. CONCLUSION: L'autotransfusion peropératoire pourrait constituer un moyen cliniquement efficace en fonction des coûts de réduire les taux de transfusion des patients subissant une chirurgie cardiaque. D'autres recherches sur le recours systématique à l'ATPO devront être menées avant qu'on puisse recommander son utilisation de routine.

Increased Distance From the Tertiary Cardiac Center Is Associated With Worse 30-Day Outcomes After Cardiac Operations.

BACKGROUND: Numerous studies have examined the effect of geographic place of residence on access to cardiovascular care, but few have examined their effect on outcomes after cardiac operations. This study examined the effect of geographic place of residence on in-hospital and 30-day outcomes after cardiac operations. METHODS: We performed a retrospective analysis of all patients undergoing nonemergency cardiac operations at a single institution between April 2004 and March 2011. Geographic place of residence was defined as the driving distance from the patient's home to the tertiary cardiac care center divided into the following categories: 0 to 50 km, 50 to 100 km, 100 to 150 km, 150 to 200 km, 200 to 250 km, and more than 250 km. Multivariable logistic regression was used to determine the independent effect of driving distance on in-hospital and 30-day outcomes. RESULTS: The final study population included 4,493 patients, of whom 3,897 (86.7%) had 30-day follow-up. After adjusting for differences among patient groups, no consistent relationship existed between distance and in-hospital outcomes. However, increased distance beyond 100 km was significantly associated with a greater risk of adverse outcomes at 30 days (0 to 50 km: referent; 50 to 100 km: odds ratio, 1.16 [95% confidence interval, 0.83 to 1.62]; 100 to 150 km: 1.32 [1.05 to 1.65], 150 to 200 km: 1.68 [1.33 to 2.11], 200 to 250 km: 1.41 [1.06 to 1.88], and >250 km: 1.30 [1.04 to 1.63]). CONCLUSIONS: Patients who live at an increased distance from the tertiary cardiac care center are more likely to have worse 30-day outcomes after cardiac operations. Further study is required to determine the mechanisms underlying this relationship and how such inequalities may be minimized.

Mammographic microcalcifications and breast cancer tumorigenesis: a radiologic-pathologic analysis.

BACKGROUND: Microcalcifications (MCs) are tiny deposits of calcium in breast soft tissue. Approximately 30% of early invasive breast cancers have fine, granular MCs detectable on mammography; however, their significance in breast tumorigenesis is controversial. This study had two objectives: (1) to find associations between mammographic MCs and tumor pathology, and (2) to compare the diagnostic value of mammograms and breast biopsies in identifying malignant MCs. METHODS: A retrospective chart review was performed for 937 women treated for breast cancer during 2000-2012 at St. Michael's Hospital. Demographic information (age and menopausal status), tumor pathology (size, histology, grade, nodal status and lymphovascular invasion), hormonal status (ER and PR), HER-2 over-expression and presence of MCs were collected. Chi-square tests were performed for categorical variables and t-tests were performed for continuous variables. All p-values less than 0.05 were considered statistically significant. RESULTS: A total of 937 patient charts were included. About 38.3% of the patients presented with mammographic MCs on routine mammographic screening. Patients were more likely to have MCs if they were HER-2 positive (52.9%; p < 0.001). There was a significant association between MCs and peri-menopausal status with a mean age of 50 (64%; p = 0.012). Patients with invasive ductal carcinomas (40.9%; p = 0.001) were more likely to present with MCs than were patients with other tumor histologies. Patients with a heterogeneous breast density (p = 0.031) and multifocal breast disease (p = 0.044) were more likely to have MCs on mammograms. There was a positive correlation between MCs and tumor grade (p = 0.057), with grade III tumors presenting with the most MCs (41.3%). A total of 52.2% of MCs were missed on mammograms which were visible on pathology (p < 0.001). CONCLUSION: This is the largest study suggesting the appearance of MCs on mammograms is strongly associated with HER-2 over-expression, invasive ductal carcinomas, peri-menopausal status, heterogeneous breast density and multifocal disease.

Incidence of febrile neutropenia in early stage breast cancer patients receiving adjuvant FEC-D treatment.

PURPOSE: The purpose of this study is to determine the incidence of febrile neutropenia (FN) among women receiving FEC-D (flurouracil 500 mg/m(2), epirubicin 100 mg/m(2), and cyclophosphamide 500 mg/m(2) every 3 weeks for three cycles followed by docetaxel 100 mg/m(2) every 3 weeks for three cycles) chemotherapy for early stage breast cancer (ESBC) and the impact of primary granulocyte colony-stimulating factor (G-CSF) prophylaxis in a non-clinical trial setting. PATIENTS AND METHODS: A retrospective chart review of women referred for ESBC to The Moncton Hospital between 2005 and 2010 evaluated patient and disease characteristics, adjuvant chemotherapy receipt, G-CSF usage, FN incidence, hospital admission rates, and length of stay. Association of variables with FN was examined, and exploratory multivariable logistic regression modeling examined the impact of baseline variables on risk of FN. RESULTS: Of 520 patients enrolled in the database, 251 (48.3 %) received adjuvant chemotherapy for ESBC. Most (66.9 %) received FEC-D. Overall, 55 (21.9 %) patients developed FN. Forty-four (26.2 %) patients on FEC-D developed FN. Forty of 129 (31.0 %) FEC-D patients who did not receive primary G-CSF prophylaxis developed FN, versus 4 of 39 (10.3 %) receiving G-CSF. Receipt of FEC-D or TC (docetaxel 75 mg/m(2) and cyclophosphamide 600 mg/m(2) every 3 weeks for four or six cycles) was associated with odds ratios of 6.5 or 6.77, respectively, for the development of FN. Receipt of trastuzumab with chemotherapy was associated with an odds ratio of 3.48 for developing FN versus no trastuzumab. Primary G-CSF prophylaxis led to a 63 % reduction in the odds ratio of developing FN. CONCLUSIONS: Incidence of FN with FEC-D treatment is considerably higher in clinical practice than reported in phase III trials. Consistent with ASCO guidelines, prophylactic G-CSF should be considered for all ESBC patients receiving adjuvant FEC-D.