Inter-Hospital Transfer Is an Independent Risk Factor for Hospital-Associated Infection.

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs.

A retrospective study of the effects of minimally invasive colorectal surgery on Patient Safety Indicators across a five-hospital system.

BACKGROUND: The Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals. METHODS: A health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13. RESULTS: There were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15. CONCLUSION: Understanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued.

Surgical Wound Misclassification to Clean From Clean-Contaminated in Common Abdominal Operations.

BACKGROUND: Wound classification helps predict wound-related complications and is useful in stratifying surgical site infection reporting. We sought to evaluate misclassification among commonly performed surgeries that are at least clean-contaminated. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried from 2005 to 2016 by Current Procedural Terminology codes identifying common surgeries that are, by definition, not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Univariate analysis and multivariate logistic regression were performed. RESULTS: Of the 1,208,544 operative cases reviewed, 22,925 (1.90%) were misclassified as clean. Hysterectomy was the most commonly misclassified operation (3.11%), and colectomy the least (0.82%). Misclassification was higher in laparoscopic cases (1.92% versus 1.82%; P < 0.01). Misclassification increased from 2005 to 2016 (0.22% versus 3.11%; P < 0.01). Misclassified patients were younger (46.7 versus 47.7 y; P < 0.01); had lower rates of hypertension, chronic obstructive pulmonary disease, smoking history, and steroid use (P < 0.01); and had shorter length of stay (2.2 versus 3.2 d; P < 0.01), lower 30-d readmission rates (3.7% versus 5.0%; P < 0.01), and less surgical site infections (1.7% versus 3.4%; P < 0.01). Open hysterectomy was the most significant positive predictor for misclassification (odds ratio 3.34; P < 0.01). Open appendectomy was the most significant negative predictor (odds ratio 0.20; P < 0.01). CONCLUSIONS: There is an increasing trend of misclassifying wounds as clean. Misclassified patients have better outcomes, and misclassification may be affected by patient characteristics, operative approach, and type of procedure rather than reflecting the true infectious burden. Further research is warranted.

Different Harm and Mortality in Critically Ill Medical vs Surgical Patients: Retrospective Analysis of Variation in Adverse Events in Different Intensive Care Units.

BACKGROUND: Institutional harm reduction campaigns are essential in improving safe practice in critical care. Our institution embarked on an aggressive project to measure harm. We hypothesized that critically ill surgical patients were at increased risk of harm compared with medical intensive care patients. METHODS: Three years of administrative data for patients with at least 1 Intensive Care Unit day at an urban tertiary care center were assembled. Data were accessed from the Henry Ford Health System No Harm Campaign in Detroit, MI. Harm was defined as any unintended physical injury resulting from medical care. Patients were deemed surgical if they had at least 1 procedure in the operating room. Univariate analysis was used to compare surgical patients with nonsurgical. Logistic regression was used for risk adjustment in predicting harm and death. RESULTS: The study included 19,844 patients, of whom 7483 (37.7%) were surgical. The overall mortality was 7.8% (n = 1554). More surgical patients experienced harm than did nonsurgical patients (2923 [39.1%] vs 2798 [22.6%], odds ratio [OR] = 2.2, p < 0.001). Surgical patients were less likely to die (6.2% vs 8.8%, p < 0.001). Surgical patients were more likely to experience harm (OR = 2.1) but had lower mortalities (OR = 0.45) vs other harmed patients (OR = 3.8; all p < 0.001). CONCLUSION: Most harm in surgically critically ill patients is procedure related. Preliminary data show that harm is associated with death, yet both surgical and African American patients experience more harm with a lower mortality rate.

Is Esophagectomy for Benign Conditions Benign?

BACKGROUND: Outcomes data on esophagectomy performed for benign conditions is scarce. Using the National Surgical Quality Improvement Program database, we sought to analyze outcomes of esophagectomy performed for benign conditions. METHODS: The National Surgical Quality Improvement Program database was queried for all esophagectomies performed from 2005 to 2015. Outcomes for benign conditions were analyzed and compared with outcomes for malignant conditions. RESULTS: Esophagectomy was performed in 7,477 patients during the study period. Of those, 6,762 underwent esophagectomy for malignant conditions and 715 for benign conditions. For patients with benign conditions, reconstruction was performed using gastric conduit in 631 and colon/intestine in 84. The anastomosis was intrathoracic in 420 and cervical in 295. Benign esophagectomies were more likely to be emergent (10.1% vs 0.4%, p < 0.001). In addition, these patients had a longer hospital length of stay (17.2 days vs 14.5 days, p < 0.001) and higher occurrence of Clavien-Dindo grade IV complications (25% vs 20%, p = 0.003). Mortality was similar at 4%. In patients with benign conditions, reconstruction with colon/intestine had higher occurrence of Clavien-Dindo Grade IV complications (37% vs 23%, p = 0.006), surgical wound infections (33% vs 16%, p < 0.001), and death (10% vs 4%, p = 0.017) compared with gastric reconstruction. Site of anastomosis did not affect outcomes. CONCLUSIONS: Benign esophagectomies are associated with significant morbidity. Although the site of the anastomosis does not alter outcomes, use of colon/intestine conduit should be pursued with caution.

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Return to Operating Room: A National Surgical Quality Improvement Program Study.

OBJECTIVE: Because of the health care initiative on quality improvement projects in academic medicine, this study explores the impact of different postgraduate years (PGYs) on unexpected re-operation rates. METHODS: Using the National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open vascular, cranial, and functional. Comparison groups were cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Comorbidity disease burden was measured by frailty index. The primary outcome measure was 30-day unintended return to the operating room. RESULTS: Of the 9782 cases, re-operations were higher for those cases featuring a senior resident (5.6%) compared with mid-level resident (4.1%) and junior resident (3.8%) (P = 0.001). Although senior residents operated on patients with a statistically significantly higher neurologic disease burden, greater relative value units, longer operative times, and more 30-day postoperative adverse events, the level of resident training did not have an impact on revision surgery after multivariable logistical regression. The strongest predictors of return to the operating room included the frailty index (adjusted odds ratio [ORadj] = 5.18, P < 0.001), functional subspecialty (ORadj = 2.65, P < 0.001), and Wound Class 4 - dirty/infected wound (ORadj = 2.33, P = 0.016). CONCLUSIONS: Resident participation in neurosurgical cases does not affect 30-day unplanned re-operation rates, which were affected by frailty index, functional subspecialty, and wound class.

Rate of Urologic Injury with Robotic Hysterectomy.

STUDY OBJECTIVE: To evaluate rates of urologic injury in patients who underwent robotic hysterectomy compared with laparoscopic, vaginal, and open hysterectomy. DESIGN: A retrospective analysis (Canadian Task Force classification II-2). SETTING: Henry Ford Health System, 2013 to 2016. PATIENTS: Women who underwent robotic, vaginal, laparoscopic, and open abdominal hysterectomy. INTERVENTIONS: Robotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, vaginal hysterectomy, and abdominal hysterectomy. MEASUREMENTS AND MAIN RESULTS: To identify patients with urologic injury, a departmental database for quality improvement was searched for reported urologic injuries. In addition, patients who had urology consultation within 90 days of hysterectomy were screened for injury. A total of 3114 hysterectomies were identified by retrospective chart review. One thousand eighty-eight robotic, 782 laparoscopic, 304 vaginal, and 940 abdominal hysterectomies were analyzed for urologic complications. A total of 27 injuries were confirmed (7 during laparoscopic hysterectomy, 10 during robotic hysterectomy, 1 during vaginal hysterectomy, and 9 during abdominal hysterectomy). The overall rate of urologic injury was 0.87% with a 0.55% risk of bladder injury and a 0.32% risk of injury to the ureter. When the route of hysterectomy was taken into account, the risk of urologic injury was 0.92% for robotic hysterectomy, 0.90% for laparoscopic hysterectomy, 0.33% for vaginal hysterectomy, and 0.96% for open hysterectomy. The mean body mass index (BMI) for all patients was 32.7 kg/m2; injured patients had a mean BMI of 34.6 kg/m2, and noninjured patients had a mean BMI of 32.0 kg/m2 (p = .10). CONCLUSION: Rates of urologic injury with robotic hysterectomy are similar to those of laparoscopic hysterectomy in our population. BMI was not significantly different in patients who had urologic injuries. Surgeon volume was not associated with risk for urologic injury.

Surgical site infection after transoral versus posterior approach for atlantoaxial fusion: a matched-cohort study.

OBJECTIVE In the past, spine surgeons have avoided the transoral approach to the atlantoaxial segment because of concerns for unacceptable patient morbidity. The objective of this study was to measure 30-day postoperative complications, especially surgical site infection (SSI), after transoral versus posterior approach to atlantoaxial fusion. METHODS The source population was provided by the American College of Surgeons National Surgical Quality Improvement Program database, which was queried for all patients who underwent atlantoaxial fusion for degenerative/spondylotic disease and/or trauma between 2005 and 2014. To eliminate bias from unequal sample sizes, patients who underwent the transoral approach were matched with patients who underwent the posterior approach (generally 1:5 ratio) based on age ± 5 years and modified frailty index score (a measure of preoperative comorbidity burden). Because of rare SSI incidence, adjusted odds ratios (ORadj) of SSI were calculated using penalized maximum likelihood estimation. RESULTS A total of 318 patients were included in the study. There were no statistically significant differences between the transoral cohort (n = 56) and the posterior cohort (n = 262) in terms of 30-day postoperative individual complications, including SSI (1.79% vs 1.91%; p = 0.951) and composite complications (10.71% vs 6.87%; p = 0.323). Controlling for sex and smoking, the odds of SSI in the transoral approach were almost equal to the odds in the posterior approach (ORadj 1.17; p = 0.866). While the unplanned reoperation rate of 5.36% after transoral surgery was higher than the 1.53% rate after posterior surgery, the difference approached, but did not reach, statistical significance (p = 0.076). CONCLUSIONS Transoral versus posterior surgery for atlantoaxial fusion did not differ in 30-day unexpected outcomes. Therefore, spinal pathology, rather than concern for postoperative complications, should adjudicate the technical approach to the atlantoaxial segment.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program Analysis.

BACKGROUND: Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear. OBJECTIVE: To elucidate factors associated with increased mortality risk in patients with unplanned postoperative reintubation. DESIGN: Retrospective study. Patients older than 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Multiple regression models were used to examine the impact on mortality of factors that included the modified frailty index (mFI) we developed, American Society of Anesthesiologists (ASA) score, age decile, and days to reintubation. MAIN OUTCOME MEASURE: Mortality. RESULTS: A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). On postoperative day 1, 4434 patients were reintubated and 878 (19.8%) died. On postoperative day 7 and beyond, 6329 patients were reintubated and 2215 (35.0%) died. Increasing mFI resulted in increasing incidence of mortality (mFl of 0 = 20.5% mortality vs mFl of 0.37-0.45 = 41.7% mortality). As ASA score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality (40-49 years, 17.9% vs 80-89 years, 42.1%). After adjustment for confounding factors, mFI, ASA score, age decile, and increasing number of days to reintubation were independently and significantly associated with increased mortality in the study population. CONCLUSION: Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.

Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery.

OBJECTIVE Limited tools exist to stratify perioperative risk in patients undergoing spinal procedures. The modified frailty index (mFI) based on the Canadian Study of Health and Aging Frailty Index (CSHA-FI), constructed from standard demographic variables, has been applied to various other surgical populations for risk stratification. The authors hypothesized that it would be predictive of postoperative morbidity and mortality in patients undergoing spine surgery. METHODS The 2006-2010 National Surgical Quality Improvement Program (NSQIP) data set was accessed for patients undergoing spine surgeries based on Current Procedural Terminology (CPT) codes. Sixteen preoperative clinical NSQIP variables were matched to 11 CSHA-FI variables (changes in daily activities, gastrointestinal problems, respiratory problems, clouding or delirium, hypertension, coronary artery and peripheral vascular disease, congestive heart failure, and so on). The outcomes assessed were 30-day occurrences of adverse events. These were then summarized in groups: any infection, wound-related complication, Clavien IV complications (life-threatening, requiring ICU admission), and mortality. RESULTS A total of 18,294 patients were identified. In 8.1% of patients with an mFI of 0 there was at least one morbid complication, compared with 24.3% of patients with an mFI of ≥ 0.27 (p < 0.001). An mFI of 0 was associated with a mortality rate of 0.1%, compared with 2.3% for an mFI of ≥ 0.27 (p < 0.001). Patients with an mFI of 0 had a 1.7% rate of surgical site infections and a 0.8% rate of Clavien IV complications, whereas patients with an mFI of ≥ 0.27 had rates of 4.1% and 7.1% for surgical site infections and Clavien IV complications, respectively (p < 0.001 for both). Multivariate analysis showed that the preoperative mFI and American Society of Anesthesiologists classification of ≥ III had a significantly increased risk of leading to Clavien IV complications and death. CONCLUSIONS A higher mFI was associated with a higher risk of postoperative morbidity and mortality, providing an additional tool to improve perioperative risk stratification.

Lower Extremity Microembolism in Open vs. Endovascular Abdominal Aortic Aneurysm Repair.

Although previous studies have documented the occurrence of microembolization during abdominal aortic aneurysm (AAA) repair by both open and endovascular approaches, no study has compared the downstream effects of these two repair techniques on lower extremity hemodynamics. In this prospective cohort study, 20 patients were treated with endovascular aneurysm repair (EVAR) (11 Zenith, 8 Excluder, and 1 Medtronic) and 18 patients with open repair (OR) (16 bifurcated grafts, 2 tube grafts). Pre- and postoperative ankle-brachial indices (ABIs) and toe-brachial indices (TBIs) were measured preoperatively and on postoperative day (POD) 1 and 5. Demographics and preoperative ABIs/TBIs were identical in EVAR (0.97/0.63) and OR (0.96/0.63) patients (p = 0.21). There was a significant decrease in ABIs/TBIs following both EVAR (0.83/0.52, p = 0.01) and OR (0.73/0.39, p = 0.003) on POD #1, although this decrease was greater following OR than EVAR (p = 0.002). This difference largely resolved by POD #5 (p = 0.41). In the OR group, TBIs in the limb in which flow was restored first was significantly reduced compared to the contralateral limb (0.50 vs. 0.61, p = 0.03). In the EVAR group, there was also a difference in TBIs between the main body insertion side and the contralateral side (0.50 vs. 0.59, p = 0.02). Deterioration of lower extremity perfusion pressures occurs commonly after AAA repair regardless of repair technique. Toe perfusion is worse in the limb opened first during OR and on the main body insertion side following EVAR, suggesting that microembolization plays a major role in this deterioration. The derangement following OR is more profound than after EVAR on POD #1, but recovers rapidly. This finding suggests that microembolizarion may be worse with OR or alternatively that other factors associated with OR (e.g., the hemodynamic response to surgery with redistribution of flow to vital organs peri-operatively) may play a role.

Prolonged Length of Stay after Esophageal Resection: Identifying Drivers of Increased Length of Stay Using the NSQIP Database.

BACKGROUND: Although influence of technical complications in association to hospital length of stay has been studied extensively in esophageal resection, nontechnical factors responsible for prolonged length of stay have not been reported. Using the NSQIP dataset, we hypothesized that we would be able to identify factors associated with prolonged length of stay after esophagectomy. STUDY DESIGN: National Surgical Quality Improvement Program data from 2005 to 2012 were reviewed for CPT codes for esophagectomy. Outlier status for length of stay was defined as >75th percentile. Logistic regression was used to predict outlier status and linear regression to discern factors contributing to longer lengths of stay. RESULTS: A total of 3,538 cases were reviewed. The 75th percentile for length of stay was 17 days. Preoperative predictors of hospital stay outliers include emergency surgery and frailty index (odds ratios = 3.7 and 3.6; p < 0.001). Deep organ space infection and progressive renal insufficiency had the highest likelihood of prolonged length of stay (odds ratios = 5.2 and 5.1; p < 0.001). Failure to wean off of ventilator in 48 hours, urinary tract infection, and pneumonia were associated with length of stay outlier (odds ratios = 3.7, 2.7, and 2.7; all p < 0.001). CONCLUSIONS: Urinary tract infection and pneumonia after esophagectomy are associated with longer hospital stays. Although meticulous surgical technique remains paramount, our study demonstrates that postoperative nontechnical complications factor into prolonged hospital stays. Focus on such factors can lead to reductions in hospital stays.

Use of a simplified frailty index to predict Clavien 4 complications and mortality after hepatectomy: analysis of the National Surgical Quality Improvement Project database.

BACKGROUND: An aging surgical population places an increasing burden on surgeons to accurately risk stratify and counsel patients. Preoperative frailty assessments are a promising new modality to better evaluate patients but can often be time consuming. Data regarding frailty and hepatectomy outcomes have not been published to date. METHOD: Using the National Surgical Quality Improvement Project database, we examined hepatectomy patients 2005 to 11 and correlated frailty scores with outcomes of major morbidity, mortality, and extended length of stay, using a previously validated modified frailty index score. Frailty was compared against age, American Society of Anesthesiologists class, and other common risk variables. RESULTS: Multivariate regression identified frailty as the strongest predictor of Clavien 4 complications (OR = 40.0, 95% CI = 15.2 to 105.0), and mortality (OR = 26.4, 95% CI = 7.7 to 88.2). As the frailty score increased, there was a statistically significant increase in Clavien 4 complications, mortality, and extended length of stay (P < .001 for all). CONCLUSIONS: Frailty is a significant factor in morbidity and mortality after hepatectomy. Use of the modified frailty index allows for feasibility of data collection in a busy clinical setting.

Predictors of Clavien 4 Complications and Mortality After Necrosectomy: Analysis of the NSQIP Database.

BACKGROUND: Acute severe pancreatitis is one of the most common gastrointestinal reasons for admission to hospitals in the USA. Up to 20 % of these patients will progress to necrotizing pancreatitis requiring intervention. The aim of this study is to identify specific preoperative factors for the development of Clavien 4 complications and mortality in patients undergoing pancreatic necrosectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use files were reviewed from 2007 to 2012 to identify patients who underwent a pancreatic necrosectomy. Postoperative complications were stratified into Clavien 4 (ICU level complications) and Clavien 5 (mortality). Univariate and multivariate analyses were performed. RESULTS: A total of 1156 patients underwent a pancreatic necrosectomy from 2007 to 2012. Overall, 42 % of patients experienced a Clavien 4 complication. Mortality rate was 9.5 %. Nonindependent functional status and ASA class were highly significant (p < 0.001) in univariate analysis. Frailty and emergency surgery status (p < 0.001), as well as increased blood urea nitrogen (BUN) and alkaline phosphatase and decreased albumin (p < 0.05) demonstrated independent significance of Clavien 4 complications and mortality in multivariate analysis. CONCLUSION: This study identified specific preoperative variables that place patients at increased risk of Clavien 4 complications and mortality after necrosectomy. Identification of high-risk patients can aid in selection of appropriate treatment strategies and allow for informed preoperative discussion regarding surgical risk.

Tobacco Use and Body Mass Index as Predictors of Outcomes in Patients Undergoing Breast Reduction Mammoplasty.

BACKGROUND: Breast reduction mammoplasty accounts for more than 60,000 procedures annually, but the literature is still sparse on outcomes, especially beyond the single institution perspective. The aim of this study was to seek a broader view by study breast reduction outcomes in the National Surgical Quality Improvement Program database. METHODS: The National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010. The principal outcomes measured were wound complications, surgical site infections, and reoperations. Univariate and multivariate analysis was performed to identify significant relationships. RESULTS: A total of 2779 patients were identified. The mean age was 42.7 (14.1) years and the mean body mass index (BMI) was 31.6 (7.0) kg/m2. Tobacco use was associated with a higher rate of reoperation (P = 0.02). Body mass index was identified as an independent risk factor for wound complications (odds ratio, 1.85, P = 0.005). Patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (P = 0.02). CONCLUSIONS: This study represents the largest sample on breast reduction in the literature. Age and surgeon specialty did not correlate with negative results. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes.

Wound healing in plastic surgery: does age matter? An American College of Surgeons National Surgical Quality Improvement Program study.

BACKGROUND: Increasing age has traditionally been associated with impairment in wound healing after operative interventions. This is based mostly on hearsay and anecdotal information. This idea fits with the authors' understanding of biology in older organisms. This dictum has not been rigorously tested in clinical practice. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried for all patients undergoing plastic surgery from 2005 to 2010. Variables extracted included basic demographics, comorbidities, previous steroid and tobacco use, wound classification at the end of the surgery, and development of postoperative surgical-site infections. Multivariate analyses were used to investigate the impact of aging in wound dehiscence. RESULTS: A total of 25,967 patients were identified. Overall, the incidence of wound dehiscence was 0.75 percent (n = 196). When patients younger than 30 years were compared to older patient groups, no difference in the probability of developing wound dehiscence was noted. Specifically, the groups of patients aged 61 to 70 years and older than 70 years did not have statistically significant wound healing deficiencies [adjusted OR, 0.63 (95 percent CI, 0.11 to 3.63), adjusted p = 0.609; 2.79 (0.55 to 14.18), adjusted p = 0.217, for 61 to 70 years and older than 70 years, respectively]. Factors independently associated with wound dehiscence included postoperative abscess development, paraplegia, quadriplegia, steroid and tobacco use, deep surgical-site infection development, increasing body mass index, and wound classification at the end of surgery. CONCLUSIONS: In patients undergoing plastic surgery, wound dehiscence is a rare complication (0.75 percent). Aging is not associated with an increased incidence of wound dehiscence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Assessing Risk of Critical Care Complications and Mortality in the Elective Bariatric Surgery Population Using a Modified Frailty Index.

BACKGROUND: The rate of surgical complications from bariatric procedures remains low despite an increase in volume. When serious complications occur, they are associated with an increased risk of mortality. The aim of this study is to determine if frail bariatric patients have an increased rate of Clavien level 4 and 5 complications. This study was conducted in participating hospitals in the National Surgical Quality Improvement Program (NSQIP). METHODS: The NSQIP participant use files were used to identify 104,952 patients undergoing elective bariatric procedures from 2005 to 2012. A previously described modified frailty index (mFI) was calculated based on available NSQIP variables, with a higher index suggesting more frail patients. Postoperative adverse events were stratified to Clavien levels 4 and 5 utilizing a pre-existing mapping scheme. RESULTS: Overall, 1 % of patients undergoing elective bariatric surgery experienced Clavien level 4 complications, and 0.2 % experienced a Clavien level 5 complication (mortality). Univariate analysis demonstrated that frailty was significant for both Clavien level 4 and 5 complications (p < 0.001). The mean mFI for those with Clavien level 4 complications, 0.15, was significantly higher than those without Clavien 4 complications, 0.09 (p < 0.001). Those experiencing mortality had a mean mFI of 0.17 compared to a mean mFI of 0.09 in those without mortality (p < 0.001). Frailty retained the highest odds ratio for both Clavien 4 and 5 complications in multivariate analysis compared to American Society of Anesthesiologist (ASA) class, age, sex, body mass index (BMI), and procedure type. CONCLUSIONS: Frailty may be used during patient selection to stratify bariatric surgery patients at high risk for critical care level complications.

Quantifying surgical complexity with machine learning: looking beyond patient factors to improve surgical models.

OBJECTIVE: To investigate the use of machine learning to empirically determine the risk of individual surgical procedures and to improve surgical models with this information. METHODS: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data from 2005 to 2009 were used to train support vector machine (SVM) classifiers to learn the relationship between textual constructs in current procedural terminology (CPT) descriptions and mortality, morbidity, Clavien 4 complications, and surgical-site infections (SSI) within 30 days of surgery. The procedural risk scores produced by the SVM classifiers were validated on data from 2010 in univariate and multivariate analyses. RESULTS: The procedural risk scores produced by the SVM classifiers achieved moderate-to-high levels of discrimination in univariate analyses (area under receiver operating characteristic curve: 0.871 for mortality, 0.789 for morbidity, 0.791 for SSI, 0.845 for Clavien 4 complications). Addition of these scores also substantially improved multivariate models comprising patient factors and previously proposed correlates of procedural risk (net reclassification improvement and integrated discrimination improvement: 0.54 and 0.001 for mortality, 0.46 and 0.011 for morbidity, 0.68 and 0.022 for SSI, 0.44 and 0.001 for Clavien 4 complications; P < .05 for all comparisons). Similar improvements were noted in discrimination and calibration for other statistical measures, and in subcohorts comprising patients with general or vascular surgery. CONCLUSION: Machine learning provides clinically useful estimates of surgical risk for individual procedures. This information can be measured in an entirely data-driven manner and substantially improves multifactorial models to predict postoperative complications.

The differential effects of surgical harm in elderly populations. Does the adage: "they tolerate the operation, but not the complications" hold true?

BACKGROUND: Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old. METHODS: Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY). RESULTS: A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm ($24,000) and decreased cost with age above 80 (-$7,000). CONCLUSIONS: In the elderly surgical population, there is more harm and harm events are associated with higher mortality rates, but less additional cost and LOS. Differing goals or aggressiveness of care may explain cost avoidance in the elderly.

Accuracy of national surgery quality improvement program models in predicting postoperative morbidity in patients undergoing colectomy.

BACKGROUND: The National Surgery Quality Improvement Program (NSQIP) is the standard for assessment of acuity-adjusted outcomes in surgery. The validity of NSQIP has not been well established in colorectal surgery. Technical and process variables, which NSQIP may not consider, affect morbidity rate. OBJECTIVE: A retrospective observational study was undertaken to determine the accuracy of NSQIP models in predicting morbidity for patients undergoing laparoscopic or open colectomy. METHODS: NSQIP participant use files for 2005 to 2008 were obtained. Data were selected using Current Procedural Terminology coding for open or laparoscopic colectomy. NSQIP-generated predicted morbidities were used to create area under the receiver operator curves (AUROCs). RESULTS: AUROCs demonstrated an accurate predictive model if the value was above 0.8 and indicated a marginal predictor mode if below 0.7. The AUROC for the general NSQIP model was 0.817 (confidence interval [CI] = 0.815-0.819, p < 0.001). AUROC for the combined laparoscopic and open colectomy group was 0.703 (CI = 0.698-0.709, p value < 0.001). AUROCs for the individual laparoscopic and open colectomy groups were 0.627 (CI = 0.615-0.640, p < 0.001) and 0.701 (CI = 0.695-0.707, p < 0.001). CONCLUSION: This study demonstrates that although NSQIP-generated morbidities used to create AUROCs are accurate for patients in an overall surgical model, predictive models for morbidity are marginal for laparoscopic and open abdominal colectomies. NSQIP risk models tend to emphasize comorbidities rather than intraoperative details or technical aspects of colonic resections.