Development and implementation of an institutional enhanced recovery program data process.

Background: With increasing implementation of enhanced recovery programs (ERPs) in clinical practice, standardised data collection and reporting have become critical in addressing the heterogeneity of metrics used for reporting outcomes. Opportunities exist to leverage electronic health record (EHR) systems to collect, analyse, and disseminate ERP data. Objectives: (i) To consolidate relevant ERP variables into a singular data universe; (ii) To create an accessible and intuitive query tool for rapid data retrieval. Method: We reviewed nine established individual team databases to identify common variables to create one standard ERP data dictionary. To address data automation, we used a third-party business intelligence tool to map identified variables within the EHR system, consolidating variables into a single ERP universe. To determine efficacy, we compared times for four experienced research coordinators to use manual, five-universe, and ERP Universe processes to retrieve ERP data for 10 randomly selected surgery patients. Results: The total times to process data variables for all 10 patients for the manual, five universe, and ERP Universe processes were 510, 111, and 76 min, respectively. Shifting from the five-universe or manual process to the ERP Universe resulted in decreases in time of 32% and 85%, respectively. Conclusion: The ERP Universe improves time spent collecting, analysing, and reporting ERP elements without increasing operational costs or interrupting workflow. Implications: Manual data abstraction places significant burden on resources. The creation of a singular instrument dedicated to ERP data abstraction greatly increases the efficiency in which clinicians and supporting staff can query adherence to an ERP protocol.

Perceptions of opioid use and prescribing habits in oncologic surgery: A survey of the society of surgical oncology membership.

BACKGROUND: The objective of this study was to assess current perceptions surrounding opioid prescribing in surgical oncology to inform perioperative quality improvement initiatives. METHODS: After the Society of Surgical Oncology (SSO) approval, a survey was distributed to its membership. Five sample procedures were used to assess provider perceptions and prescribing habits. Data were summarized and compared by self-reported demographics. RESULTS: One hundred and seventy-five participants completed the survey: 149 (85%) faculty, 24 (14%) trainees, and 2 (1%) advanced practice providers. Most participants (76%) practiced in academic programs and 21% practiced in non-US locations. Few differences were identified based on clinical role, academic rank, or practice years. Compared with non-US providers, US providers expected higher pain scores at discharge, recommended greater opioid prescriptions, and estimated more days of opioid use for almost every procedure. More non-US providers believed discharge opioids should not be distributed to patients who are opioid-free in their last 24 inpatient hours (80% vs 50%, P = .001). All providers ranked education as "very important" for reducing opioid prescriptions. CONCLUSIONS: Compared with their international counterparts, US surgical oncology providers expected greater opioid needs and recommended higher prescription numbers. Educating providers on multimodal opioid-sparing bundles, accelerated weaning protocols, and standardized discharge prescribing habits could have a positive impact the US opioid epidemic.

Implementation of a sentinel lymph node mapping algorithm for endometrial cancer: surgical outcomes and hospital charges.

INTRODUCTION: The purpose of this study was to compare operative times, surgical outcomes, resource utilization, and hospital charges before and after the implementation of a sentinel lymph node (SLN) mapping algorithm in endometrial cancer. METHODS: All patients with clinical stage I endometrial cancer were identified pre- (2012) and post- (2017) implementation of the SLN algorithm. Clinical data were summarized and compared between groups. Total hospital charges incurred on the day of surgery were extracted from the hospital financial system for each patient and all charges were adjusted to 2017 US dollars. RESULTS: A total of 203 patients were included: 71 patients in 2012 and 130 patients in 2017. There was no difference in median age, body mass index, or stage. In 2012, 35/71 patients (49.3%) underwent a lymphadenectomy. In 2017, SLN mapping was attempted in 120/130 patients (92.3%) and at least one SLN was identified in 110/120 (91.7%). Median estimated blood loss was similar between groups (100 mL vs 75 mL, p=0.081). There was a significant decrease in both median operative time (210 vs 171 min, p=0.007) and utilization of intraoperative frozen section (63.4% vs 14.6%, p<0.0001). No significant differences were noted in intraoperative (p=1.00) or 30 day postoperative complication rates (p=0.30). The median total hospital charges decreased by 2.73% in 2017 as compared with 2012 (p=0.96). DISCUSSION: Implementation of an SLN mapping algorithm for high- and low-risk endometrial cancer resulted in a decrease in both operative time and intraoperative frozen section utilization with no change in surgical morbidity. While hospital charges did not significantly change, further studies are warranted to assess the true cost of SLN mapping.

Postoperative Urinary Tract Infection Quality Assessment and Improvement: The S.T.O.P. UTI Program and Its Impact on Hospitalwide CAUTI Rates.

BACKGROUND: Postoperative urinary tract infection (UTI) is a frequent complication that diminishes patient experience and incurs substantial costs. The purpose of this project was to develop a urinary tract care assessment tool that would lead to actionable quality improvement initiatives. METHODS: Multidisciplinary teams at a single institution developed the S.T.O.P. UTI algorithm to assess elements related to urinary catheter care: Sterile catheter placement, Timely catheter removal, Optimal collection bag position, and Proper urine sampling for urinalysis and culture. Based on this evaluation, a targeted intervention was applied to address deficient areas in surgical patients. UTI rates were monitored. RESULTS: The assessment revealed that best practice for sterile placement was being performed but that time to removal, optimal positioning, and proper sampling could be improved. Providers were educated on best practice for catheter removal, nurses placed a reminder note on the chart, personnel were taught about optimal catheter positioning, and nursing assistants were educated on best practices for collection of urine. From 2012 to 2015, non-risk-adjusted UTI rates in surgical patients decreased from 2.90% to 0.46% (p = 0.0003), and the American College of Surgeons National Surgical Quality Improvement Program risk-adjusted comparison improved from the 8th to the 4th decile. Simultaneously, hospitalwide catheter-associated UTI rates also decreased, from 2.24/1,000 catheter-days in 2014 to 0.70/1,000 catheter-days in 2016 (p < 0.001). CONCLUSION: The S.T.O.P. UTI algorithm is a tool that hospitals can use to systematically assess UTI processes. The program can identify areas for improvement specific to an institution, directing the allocation of quality improvement resources to decrease both surgical and medical UTIs.

Complex General Surgical Oncology Fellowship Applicants: Trends over Time and the Impact of Board Certification Eligibility.

BACKGROUND: Complex general surgical oncology (CGSO) fellowships recently obtained Accreditation Council for Graduate Medical Education (ACGME) accreditation and board certification eligibility. We aimed to characterize the applicant pool and identify factors predictive of matching into our program. METHODS: We conducted a retrospective review of CGSO fellowship applications to a major cancer center from 2008 to 2018. Data were analyzed for trends over time, including a comparison of pre- versus post-American Board of Surgery (ABS) certification eligibility. RESULTS: A total of 846 applications were reviewed. Most applicants (86.2%) trained in a US residency program; 58.4% performed ≥ 1 research year during residency; 29.6% had a dual degree. Fewer applicants (34.5%) were female, a trend which did not change over time. Post-ABS, applicants were more likely to complete ≥ 1 year between residency and fellowship (20.9% versus 13.2%, p = 0.003), to be in practice at the time of application (12.2% versus 6.6%, p = 0.005), and to reapply (5.5% versus 1.0%, p < 0.001). Post-ABS applicants listed more peer-reviewed publications (8 [interquartile range (IQR) 4, 15] versus 5 [IQR 2, 10]; p < 0.001). On multivariable analysis, factors associated with matching into our program included: US allopathic medical school graduation [odds ratio (OR) 4.6, 95% confidence interval (CI) 1.8-11.7], Alpha Omega Alpha (AOA) Honor Medical Society distinction (OR 2.7, 95% CI 1.6-4.7), dual degree (OR 2.0, 95% CI 1.1-3.4), and performance of a clinical/research rotation at our institution (OR 4.9, 95% CI 2.2-10.7). CONCLUSIONS: After establishment of CGSO board certification eligibility, applicants were more likely to apply while in practice and to reapply. A number of factors, including having a dual degree and rotating at our institution, were associated with matriculation.

Educating Surgical Oncology Providers on Perioperative Opioid Use: Results of a Departmental Survey on Perceptions of Opioid Needs and Prescribing Habits.

BACKGROUND: Patients undergoing oncologic surgery are at risk for persistent postoperative opioid use. As a quality improvement initiative, this study sought to characterize provider perceptions regarding opioid-prescribing after oncologic procedures. METHODS: Surgical oncology attending physicians, clinical fellows, and advanced practice providers (APPs) at a high-volume cancer center were surveyed before and after educational sessions focusing on the opioid epidemic with review of departmental data. RESULTS: The pre-education response rates were 72 (70%) of 103: 22 (65%) of 34 attending physicians, 19 (90%) of 21 fellows, and 31 (65%) of 48 APPs. For five index operations (open abdominal resection, laparoscopic colectomy, wide local excision, thyroidectomy, port), the fellows answered that patients should stop receiving opioids sooner than recommended by the attending surgeons or APPs. For four of five procedures, the APPs recommended higher discharge opioid prescriptions than the attending surgeons or fellows. Almost half of the providers (n = 46, 45%) responded to both the pre- and post-education surveys. After the intervention, the providers recommended lower numbers of opioid pills and indicated that patients should be weaned from opioids sooner for all the procedures. Compared with pre-education, more providers agreed post-education that discharge opioid prescriptions should be based on a patient's last 24 h of inpatient opioid use (83 vs 91%; p = 0.006). The providers who did not attend a session showed no difference in perceptions or recommendations at the repeat assessment. CONCLUSIONS: Variation exists in perioperative opioid-prescribing among provider types, with those most involved in daily care and discharge processes generally recommending more opioids. After education, providers lowered discharge opioid recommendations and thought patients should stop receiving opioids sooner. The next steps include assessing for quantitative changes in opioid-prescribing and implementing standardized opioid prescription algorithms.

Comparative Effectiveness of Computed Tomography- Versus Ultrasound-Guided Percutaneous Radiofrequency Ablation Among Medicare Patients 65 Years of Age or Older With Hepatocellular Carcinoma.

BACKGROUND: For patients with hepatocellular carcinoma (HCC) not eligible for surgical resection, radiofrequency ablation (RFA) is a promising technique that reduces the risk of disease progression. OBJECTIVES: To evaluate whether the trend of image guidance for RFA is moving toward the more expensive computed tomography (CT) technology and to determine the clinical benefits of CT guidance over the ultrasound (US) guidance. METHODS: A cohort of 463 patients was identified from the Surveillance, Epidemiology, and End Results and Medicare-linked database. The temporal trends in use of image guidance were assessed using the Cochrane-Armitage test. The associations between modality of image guidance and survival, complications, and costs were assessed using the Cox regression model, the logistic regression model, and the generalized linear model, respectively. RESULTS: The use of CT-guided RFA increased sharply, from 20.7% in 2002 to 75.9% in 2011. Compared with CT-guided RFA, those who received US-guided RFA had comparable risk of periprocedural and delayed postprocedural complications. Stratified analyses by tumor size also showed no statistically significant difference. In adjusted survival analysis, no statistically significant difference was observed in overall and cancer-specific survival. Nevertheless, the cost of CT-guided RFA ($2847) was higher than that of US-guided RFA ($1862). CONCLUSIONS: Despite its rapid adoption over time, CT-guided RFA incurred higher procedural costs than US-guided RFA but did not significantly improve postprocedural complications and survival. Echoing the American Board of Internal Medicine's Choosing Wisely campaign and the American Society of Clinical Oncology's Value of Cancer Care initiative, findings from our study call for critical evaluation of whether CT-guided RFA provides high-value care for patients with HCC.

Continuous Quality Improvement Measured With Time-Driven Activity-Based Costing in an Outpatient Cancer Surgery Center.

PURPOSE: As health care costs rise, continuous quality improvement and increased efficiency are crucial to reduce costs while providing high-quality care. Time-driven activity-based costing (TDABC) can help identify inefficiencies in processes of cancer care delivery. This study measured the process performance of Port-a-Cath placement in an outpatient cancer surgery center by using TDABC to evaluate patient care process. METHODS: Data were collected from the Anesthesia Information Management System database and OneConnect electronic health record (EHR) for Port-a-Cath cases performed throughout four phases: preintervention (phase I), postintervention, stabilization, and pre-new EHR (phases II and III), and post-new EHR (phase IV). TDABC methods were used to map and calculate process times and costs. RESULTS: Comparing all phases, as measured with TDABC methodology, a decrease in post-anesthesia care unit (PACU) length of stay (LOS) was identified (83 minutes v 67 minutes; P < .05). The decrease in PACU LOS correlated with increased efficiency and decreasing process costs and PACU nurse resource use by fast tracking patients for Port-a-Cath placement. Port-a-Cath placement success and the functionality of ports remained the same as patient experience improved. CONCLUSION: TDABC can be used to evaluate processes of care delivery to patients with cancer and to quantify changes made to those processes. Patients' PACU LOS decreased on the basis of the 2013 Port-a-Cath process improvement initiative and after implementation of a new EHR, over the course of 3 years, as quantified by TDABC. TDABC use can lead to improved efficiencies in patient care delivery that are quantifiable and measurable.

Reviewing the review: a qualitative assessment of the peer review process in surgical journals.

BACKGROUND: Despite rapid growth of the scientific literature, no consensus guidelines have emerged to define the optimal criteria for editors to grade submitted manuscripts. The purpose of this project was to assess the peer reviewer metrics currently used in the surgical literature to evaluate original manuscript submissions. METHODS: Manuscript grading forms for 14 of the highest circulation general surgery-related journals were evaluated for content, including the type and number of quantitative and qualitative questions asked of peer reviewers. Reviewer grading forms for the seven surgical journals with the higher impact factors were compared to the seven surgical journals with lower impact factors using Fisher's exact tests. RESULTS: Impact factors of the studied journals ranged from 1.73 to 8.57, with a median impact factor of 4.26 in the higher group and 2.81 in the lower group. The content of the grading forms was found to vary considerably. Relatively few journals asked reviewers to grade specific components of a manuscript. Higher impact factor journal manuscript grading forms more frequently addressed statistical analysis, ethical considerations, and conflict of interest. In contrast, lower impact factor journals more commonly requested reviewers to make qualitative assessments of novelty/originality, scientific validity, and scientific importance. CONCLUSION: Substantial variation exists in the grading criteria used to evaluate original manuscripts submitted to the surgical literature for peer review, with differential emphasis placed on certain criteria correlated to journal impact factors.

Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy.

BACKGROUND: Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs. STUDY DESIGN: Three unique risk-stratified pancreatectomy clinical pathways-low-risk pancreatoduodenectomy, high-risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk-stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated. RESULTS: The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk-stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low-risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high-risk pancreatoduodenectomy. The rates of 90-day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation. CONCLUSION: Implementation of risk-stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low-risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high-risk pancreatoduodenectomy.

Can postoperative process of care utilization or complication rates explain the volume-cost relationship for cancer surgery?

BACKGROUND: Past studies identify an association between provider volume and outcomes, but less is known about the volume-cost relationship for cancer surgery. We analyze the volume-cost relationship for 6 cancer operations and explore whether it is influenced by the occurrence of complications and/or utilization of processes of care. METHODS: Medicare hospital and inpatient claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Regressions were first estimated to quantify the association of provider volume with costs, excluding measures of complications and processes of care as explanatory variables. Next, these variables were added to the regressions to test whether they weakened any previously observed volume-cost relationship. RESULTS: Higher hospital volume is associated with lower patient costs for esophagectomy but not for other operations. Higher surgeon volume reduces costs for most procedures, but this result weakens when processes of care are added to the regressions. Processes of care that are frequently implemented in response to adverse events are associated with 14% to 34% higher costs. Utilization of these processes is more prevalent among low-volume versus high-volume surgeons. CONCLUSION: Processes of care implemented when complications occur explain much of the surgeon volume-cost relationship. Given that surgeon volume is readily observed, better outcomes and lower costs may be achieved by referring patients to high-volume surgeons. Increasing patient access to surgeons with lower rates of complications may be the most effective strategy for avoiding costly processes of care, controlling expenditure growth.

Selective Perioperative Administration of Pasireotide is More Cost-Effective Than Routine Administration for Pancreatic Fistula Prophylaxis.

BACKGROUND: In a randomized trial, pasireotide significantly decreased the incidence and severity of postoperative pancreatic fistula (POPF). Subsequent analyses concluded that its routine use is cost-effective. We hypothesized that selective administration of the drug to patients at high risk for POPF would be more cost-effective. STUDY DESIGN: Consecutive patients who did not receive pasireotide and underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) between July 2011 and January 2014 were distributed into groups based on their risk of POPF using a multivariate recursive partitioning regression tree analysis (RPA) of preoperative clinical factors. The costs of treating hypothetical patients in each risk group were then computed based upon actual institutional hospital costs and previously published relative risk values associated with pasireotide. RESULTS: Among 315 patients who underwent pancreatectomy, grade B/C POPF occurred in 64 (20%). RPA allocated patients who underwent PD into four groups with a risk for grade B/C POPF of 0, 10, 29, or 60% (P < 0.001) on the basis of diagnosis, pancreatic duct diameter, and body mass index. Patients who underwent DP were allocated to three groups with a grade B/C POPF risk of 14, 26, or 44% (P = 0.05) on the basis of pancreatic duct diameter alone. Although the routine administration of pasireotide to all 315 patients would have theoretically saved $30,892 over standard care, restriction of pasireotide to only patients at high risk for POPF would have led to a cost savings of $831,916. CONCLUSION: Preoperative clinical characteristics can be used to characterize patients' risk for POPF following pancreatectomy. Selective administration of pasireotide only to patients at high risk for grade B/C POPF may maximize the cost-efficacy of prophylactic pasireotide.

Cost-effectiveness of palliative surgery versus nonsurgical procedures in gastrointestinal cancer patients.

Palliative care is an essential component to multidisciplinary cancer care. Improved symptom control, quality of life (QOL), and survival have resulted from its utilization. Cost-effectiveness and utility analyses are significant variables that should be considered in comparing benefits and costs of medical interventions to determine if certain treatments are economically justified. This is a review on the cost-effectiveness of palliative surgery compared to other nonsurgical palliative procedures in patients with unresectable gastrointestinal cancers. J. Surg. Oncol. 2016;114:316-322. © 2016 Wiley Periodicals, Inc.

Preoperative Assessment and Optimization of the Future Liver Remnant.

Liver resection of benign, primary, and metastatic tumors is challenging and places patients at risk for postoperative liver insufficiency. The magnitude of this risk largely depends on the volume and function of the future liver remnant (FLR). It is, therefore, critical that hepatobiliary surgeons are well versed in measurement of liver volume and function as well as various techniques for preoperative liver volume augmentation. The absolute volume of FLR required to avoid postoperative liver insufficiency depends on patient, disease, and anatomic factors. Rapid expansion of the FLR can safely be achieved with portal venous embolization of the contralateral liver segments.

Rapid assessment of technical competency: the 8-min suture test.

BACKGROUND: Although simulation training and evaluation have become increasingly popular for teaching minimally invasive surgery, tools to measure open surgical skills remain underdeveloped. As there is increasing demand for objective measures of technical competency at the completion of surgical training (postgraduate year [PGY]-6 and -7), this project was designed to assess the feasibility, reliability, and validity of a novel open surgical skills evaluation tool, the 8-min suture test (8MST). METHODS: During an annual surgical skills laboratory session, fellows and residents were asked to complete a simulated end-to-end vascular anastomosis. They were limited to 8 min to perform the anastomosis between two 12-mm Dacron grafts mounted on a customized platform. Their real-time and video-recorded performance was scored by two blinded evaluators and compared with their faculty-rated technical performance on clinical rotations completed around the time of 8MST administration. RESULTS: PGY-6 and PGY-7 trainees were compared across several domains including 8MST total score (4.6 versus 5.5, P = 0.030), 8MST setup score (2.3 versus 2.4, P = 0.797), 8MST technical score (2.3 versus 3.1, P = 0.026), and clinical performance score (3.1 versus 3.6, P = 0.006). Comparison of 8MST total score to the clinical performance score identified a strong relationship with a Pearson r = 0.55 (P < 0.001) and r(2) = 0.30. Additionally, 8MST displayed high inter-rater reliability and test-retest reliability. CONCLUSIONS: The 8MST is a rapid, feasible, inexpensive, reliable, and valid test for assessment of surgical trainee technical abilities.