The United States experience with diagnosing and treating esophageal cancer during the SARS-CoV-2 pandemic: A retrospective cohort study.

The downstream effects on healthcare delivery during the initial wave of the COVID-19 pandemic remain unclear. The purpose of this study was to determine how the healthcare environment surrounding the pandemic affected the oncologic care of patients diagnosed with esophageal cancer. This was a retrospective cohort study evaluating patients in the National Cancer Database (2019-2020). Patients with esophageal cancer diagnoses were divided into pre-pandemic (2019) and pandemic (2020) groups. Patient demographics, cancer-related variables, and treatment modalities were compared. Among 26,231 esophageal cancer patients, 14,024 patients (53.5%) were in the pre-pandemic cohort and 12,207 (46.5%) were in the pandemic cohort. After controlling for demographics, patients diagnosed during the pandemic were more likely to have poorly differentiated tumors (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.08-1.42), pathologic T3 disease compared to T1 (OR 1.25, 95% CI 1.02-1.53), positive lymph nodes on pathology (OR 1.36, 95% CI 1.14-1.64), and to be pathologic stage IV (OR 1.51, 95% CI 1.29-1.76). After controlling for oncologic characteristics, patients diagnosed during the pandemic were more likely to require at least two courses of systemic therapy (OR 1.78, 95% CI 1.48-2.14) and to be offered palliative care (OR 1.13, 95% CI 1.04-1.22). While these patients were offered curative therapy at lower rates, this became non-significant after risk-adjustment (p = .15). The pandemic healthcare environment was associated with significantly increased risk-adjusted rates of patients presenting with advanced esophageal cancer. While this led to significant differences in treatment, most of these differences became non-significant after controlling for oncologic factors.

Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Health Care System.

OBJECTIVE: We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. BACKGROUND: The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported. METHODS: This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders. RESULTS: There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05). CONCLUSIONS: Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.

The deimplementation of laboratory testing in low-risk patients as recommended by the American society of anesthesiologists: An ACS-NSQIP longitudinal analysis.

BACKGROUND: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low-risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low-risk versus higher-risk patients before and after release of these guidelines. METHODS: The ACS-NSQIP database, 2005-2018, was separated into low-risk versus higher-risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low- and higher-risk patients. A difference-in-differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery. RESULTS: Of 7,507,991 patients, 972,431 (13.0%) were defined as low-risk and 6,535,560 (87.0%) higher-risk. Use of any preoperative laboratory test declined in low-risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%-91.9% in higher-risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk-adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76-0.78) in low-risk versus 0.93 (0.92-0.94) in higher-risk patients. In low-risk patients, lack of any preoperative testing was not associated with worse outcomes. CONCLUSIONS: While a majority of low-risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low-risk patients.

Mucosal Ulceration in Gastrointestinal Stromal Tumor is an Independent Predictor of Progression-Free Survival.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Known prognostic features of GISTs include tumor mitotic rate, size, and location, yet one common feature of primary GISTs for which prognostic significance is unknown, is mucosal ulceration. This study aims to investigate the significance of mucosal ulceration in GISTs. MATERIALS AND METHODS: A retrospective study was conducted of 513 patients at a tertiary referral center with a suspected or documented diagnosis of primary GIST between the years of 2000 and 2020. Ulceration was confirmed by definitive documentation in the endoscopic or histopathologic report. The significance of ulceration in GIST was compared to other prognostic factors. RESULTS: Of the 513 patients reviewed, 310 primary GIST patients with known ulceration and disease status were identified. Of those, 27.4% (n = 85) demonstrated mucosal ulceration. Mucosal ulceration in GISTs is associated with GI bleeding, mitotic rate, tumor size, and exon 11 mutations. After a median follow-up of 35.4 (interquartile range = 17.1-62.2) mo, patients with ulcerated GISTs experienced higher rates of tumor progression (40.0% versus 14.2%, P < 0.0001). In multivariate analysis, ulceration of GISTs was highly associated with disease progression (P < 0.0001) and progression-free survival (hazard ratio = 2.4 [1.2-4.7], P = 0.01). CONCLUSIONS: Mucosal ulceration in GISTs is associated with GI bleeding, mitotic rate, tumor size, and exon 11 mutations. Overall, ulceration in GISTs is associated with elevated risk of tumor progression and is an independent prognostic factor. In multivariate analysis, ulceration in GIST remains an independent risk factor for disease progression.

Preoperative Prediction of Unplanned Reoperation in a Broad Surgical Population.

INTRODUCTION: Unplanned reoperation is an undesirable outcome with considerable risks and an increasingly assessed quality of care metric. There are no preoperative prediction models for reoperation after an index surgery in a broad surgical population in the literature. The Surgical Risk Preoperative Assessment System (SURPAS) preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict unplanned reoperation has not been assessed. This study's objective was to determine whether the SURPAS model could accurately predict unplanned reoperation. METHODS: This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database, 2012-2018. An unplanned reoperation was defined as any unintended operation within 30 d of an initial scheduled operation. The 8-variable SURPAS model and a 29-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program nonlaboratory preoperative variables, were developed using multiple logistic regression and compared using discrimination and calibration metrics: C-indices (C), Hosmer-Lemeshow observed-to-expected plots, and Brier scores (BSs). The internal chronological validation of the SURPAS model was conducted using "training" (2012-2017) and "test" (2018) datasets. RESULTS: Of 5,777,108 patients, 162,387 (2.81%) underwent an unplanned reoperation. The SURPAS model's C-index of 0.748 was 99.20% of that for the full model (C = 0.754). Hosmer-Lemeshow plots showed good calibration for both models and BSs were similar (BS = 0.0264, full; BS = 0.0265, SURPAS). Internal chronological validation results were similar for the training (C = 0.749, BS = 0.0268) and test (C = 0.748, BS = 0.0250) datasets. CONCLUSIONS: The SURPAS model accurately predicted unplanned reoperation and was internally validated. Unplanned reoperation can be integrated into the SURPAS tool to provide preoperative risk assessment of this outcome, which could aid patient risk education.

Does Work Relative Value Unit Measure Surgical Complexity for Risk Adjustment of Surgical Outcomes?

INTRODUCTION: The purpose of this study was to determine whether the work relative value unit (workRVU) of a patient's operation can be useful as a measure of surgical complexity for the risk adjustment of surgical outcomes. METHODS: We retrospectively analyzed the American College of Surgeon's National Surgical Quality Improvement Program database (2005-2018). We examined the associations of workRVU of the patient's primary operation with preoperative patient characteristics and associations with postoperative complications. We performed forward selection multiple logistic regression analysis to determine the predictive importance of workRVU. We then generated prediction models using patient characteristics with and without workRVU and compared c-indexes to assess workRVU's additive predictive value. RESULTS: 7,507,991 operations were included. Patients who were underweight, functionally dependent, transferred from an acute care hospital, had higher American Society of Anesthesiologists class or who had medical comorbidities had operations with higher workRVU (all P < 0.0001). The subspecialties with the highest workRVU were neurosurgery (mean = 22.2), thoracic surgery (mean = 21.1), and vascular surgery (mean = 18.8) (P < 0.0001). For all postoperative complications, mean workRVU was higher for patients with the complication than those without (all P < 0.0001). For eight of 12 postoperative complications, workRVU entered the logistic regression models as a predictor variable in the 1st to 4th steps. Addition of workRVU as a preoperative predictive variable improved the c-index of the prediction models. CONCLUSIONS: WorkRVU was associated with sicker patients and patients experiencing postoperative complications and was an important predictor of postoperative complications. When added to a prediction model including patient characteristics, it only marginally improved prediction. This is possibly because workRVU is associated with patient characteristics.

Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations.

BACKGROUND: Operations performed outpatient offer several benefits. The prevalence of outpatient operations is growing. Consequently, the proportion of patients with multiple comorbidities undergoing outpatient surgery is increasing. We compared 30-day mortality and overall morbidity between outpatient and inpatient elective operations. METHODS: Using the 2005-2018 ACS-NSQIP database, we evaluated trends in percent of hospital outpatient operations performed over time, and the percent of operations done outpatient versus inpatient by CPT code. Patient characteristics were compared for outpatient versus inpatient operations. We compared unadjusted and risk-adjusted 30-day mortality and morbidity for inpatient and outpatient operations. RESULTS: A total of 6,494,298 patients were included. The proportion of outpatient operations increased over time, from 37.8% in 2005 to 48.2% in 2018. We analyzed the 50 most frequent operations performed outpatient versus inpatient 25-75% of the time (n = 1,743,097). Patients having outpatient operations were younger (51.6 vs 54.6 years), female (70.3% vs 67.3%), had fewer comorbidities, and lower ASA class (I-II, 69.3% vs. 59.9%). On both unadjusted and risk-adjusted analysis, 30-day mortality and overall morbidity were less likely in outpatient versus inpatient operations. CONCLUSION: In this large multi-specialty analysis, we found that patients undergoing outpatient surgery had lower risk of 30-day morbidity and mortality than those undergoing the same inpatient operation. Patients having outpatient surgery were generally healthier, suggesting careful patient selection occurred even with increasing outpatient operation frequency. Patients and providers can feel reassured that outpatient operations are a safe, reasonable option for selected patients.

Using the Surgical Risk Preoperative Assessment System to Define the "High Risk" Surgical Patient.

BACKGROUND: Defining a "high risk" surgical population remains challenging. Using the Surgical Risk Preoperative Assessment System (SURPAS), we sought to define "high risk" groups for adverse postoperative outcomes. MATERIALS AND METHODS: We retrospectively analyzed the 2009-2018 American College of Surgeons National Surgical Quality Improvement Program database. SURPAS calculated probabilities of 12 postoperative adverse events. The Hosmer Lemeshow graphs of deciles of risk and maximum Youden index were compared to define "high risk." RESULTS: Hosmer-Lemeshow plots suggested the "high risk" patient could be defined by the 10th decile of risk. Maximum Youden index found lower cutoff points for defining "high risk" patients and included more patients with events. This resulted in more patients classified as "high risk" and higher number needed to treat to prevent one complication. Some specialties (thoracic, vascular, general) had more "high risk" patients, while others (otolaryngology, plastic) had lower proportions. CONCLUSIONS: SURPAS can define the "high risk" surgical population that may benefit from risk-mitigating interventions.

Associations Between Preoperative Risk, Postoperative Complications, and 30-Day Mortality.

BACKGROUND: Comorbidities and postoperative complications increase mortality, making early recognition and management critical. It is useful to understand how they are associated with one another. This study assesses associations between comorbidities, complications, and mortality. METHODS: We calculated associations between comorbidities, complications, and 30-day mortality using the 2012-2018 ACS-NSQIP database. We examined the association between mortality and number of complications which complications were most associated with mortality. RESULTS: 5,777,108 patients were included. 30-day mortality was 0.95%. For most comorbidities or postoperative complications, patients with these had higher mortality than patients without. Having ≥ 1 complication increased mortality risk by 32.5-fold (6.5% vs. 0.2%). Mortality rate significantly increased with increasing number of complications, particularly after two or more complications. Bleeding and sepsis were associated with the most deaths. CONCLUSION: The 30-day mortality rate was < 1% but was 32-fold higher in patients with complications and increased rapidly for patients with ≥ 2 complications. Bleeding and sepsis were the most prominent complications associated with mortality.

A Pilot Study of Patient-Reported Outcome Measures Across a Broad Sample of Surgical Patients.

BACKGROUND: Patient-reported outcomes (PROs) have the potential to aid in surgical decision-making, predict surgical outcomes, assess recovery, and evaluate long-term success. We performed a pilot study testing the ability to use PROs in a broad surgical population in preparation for wide spread use. MATERIAL AND METHODS: Surgical patients completed five Patient-Reported Outcome Measurement Information System (PROMIS) measures during their preoperative encounter in the preanesthesia clinic and again postoperatively via emailed link. Preoperative to postoperative changes in PROMIS scores, factors related to completion of postoperative measures, intercorrelations between PROMIS measures, and numbers of patients with normal function, and mild, moderate, and severe deficits in PROMIS scores were analyzed. RESULTS: A total of 393 patients undergoing surgery in 8 specialties completed preoperative PROMIS measures; 239 (60.8%) completed them postoperatively. Physical function (P < 0.0001), pain (P < 0.0001), and cognitive function (P = 0.03) PROMIS scores significantly worsened after surgery but not mental PROMIS scores (P = 0.48). Hispanic and sicker patients had lower completion rates of postoperative measures. Intercorrelations were very high (>0.80) among the physical function and self-efficacy for activities of daily living PROMIS measures. Physical function and pain PROMIS measures had the largest number of patients in the "severe" range after surgery. CONCLUSIONS: Patients across a broad surgical population completed PROMIS measures successfully, both preoperatively and postoperatively, although the postoperative completion rate was lower than other studies reported in the literature. PROMIS scores were reflective of the effects of surgery. Some of the PROMIS measures were highly correlated suggesting that some measures could be eliminated or replaced with measures assessing other important effects of surgery. Consideration could be made to alert health care providers about patients having PROs in the "severe" range for potential intervention.

Predictors of Acute Kidney Injury Following Aortic Arch Surgery.

BACKGROUND: Acute kidney injury (AKI) following open aortic arch surgery is a frequent complication associated with increased morbidity and mortality. The primary purpose of this study was to evaluate risk factors for postoperative AKI in patients who underwent open aortic arch surgery utilizing hypothermic circulatory arrest (HCA). MATERIALS AND METHODS: Included were 295 patients undergoing surgery between January 2011 and March 2018. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines. Preoperative and intraoperative variables were stratified by no AKI versus any AKI, and bivariate analysis was performed. Multivariable logistic regression analysis used statistically and clinically significant characteristics from the bivariate analysis. RESULTS: Of the 295 patients, 93 (32%) developed AKI. In the bivariate analysis, significant predictors of AKI included the following: history of hypertension (P < 0.001), diabetes (P = 0.03), operative urgency (P = 0.009), cardiopulmonary bypass (CPB) time (P < 0.0001), HCA time (0.02), total intraoperative transfusions (P = 0.002), and concomitant procedures (coronary artery bypass grafting, or mitral/tricuspid interventions, P = 0.0009). In the multivariable analysis, significant predictors of AKI were history of hypertension (P = 0.03) and CPB time (P = 0.02). Age, operative urgency, circulatory arrest time, and any intraoperative transfusion were not significant in the multivariable analysis. CONCLUSION: In conclusion, given that CPB time is the only modifiable risk factor identified in the analysis, approaches to reducing bypass time should continue to be the focus of decreasing risk for postoperative AKI in HCA cases.

Intermediate-Acting Nondepolarizing Neuromuscular Blocking Agents and Risk of Postoperative 30-Day Morbidity and Mortality, and Long-term Survival.

BACKGROUND: Nondepolarizing neuromuscular blocking drugs (NNMBDs) are commonly used as an adjunct to general anesthesia. Residual blockade is common, but its potential adverse effects are incompletely known. This study was designed to assess the association between NNMBD use with or without neostigmine reversal and postoperative morbidity and mortality. METHODS: This is a retrospective observational study of 11,355 adult patients undergoing general anesthesia for noncardiac surgery at 5 Veterans Health Administration (VA) hospitals. Of those, 8984 received NNMBDs, and 7047 received reversal with neostigmine. The primary outcome was a composite of respiratory complications (failure to wean from the ventilator, reintubation, or pneumonia), which was "yes" if a patient had any of the 3 component events and "no" if they had none. Secondary outcomes were nonrespiratory complications, 30-day and long-term all-cause mortality. We adjusted for differences in patient risk using propensity matched (PM) followed by assessment of the association of interest by logistic regression between the matched pairs as our primary analysis and multivariable logistic regression (MLR) as a sensitivity analysis. RESULTS: Our primary aim was to assess the adverse outcomes in the patients who had received NNMBDs with and without neostigmine. Administration of an NNMBD without neostigmine reversal compared with NNMBD with neostigmine reversal was associated with increased odds of respiratory complications (PM odds ratio [OR], 1.75 [95% confidence interval [CI], 1.23-2.50]; MLR OR, 1.71 [CI, 1.24-2.37]) and a marginal increase in 30-day mortality (PM OR, 1.83 [CI, 0.99-3.37]; MLR OR, 1.78 [CI, 1.02-3.13]). However, there were no statistically significant associations with nonrespiratory complications or long-term mortality. Patients who were administered an NNMBD followed by neostigmine had no differences in outcomes compared with patients who had general anesthesia without an NNMBD. CONCLUSIONS: The use of NNMBDs without neostigmine reversal was associated with increased odds of our composite respiratory outcome compared with patients reversed with neostigmine. Based on these data, we conclude that reversal of NNMBDs should become a standard practice if extubation is planned.

Surgical Risk Preoperative Assessment System (SURPAS): I. Parsimonious, Clinically Meaningful Groups of Postoperative Complications by Factor Analysis.

OBJECTIVE: To use factor analysis to cluster the 18 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) perioperative complications into a reproducible, smaller number of clinically meaningful groups of postoperative complications, facilitating and streamlining future study and application in live clinical settings. BACKGROUND: The ACS NSQIP collects and reports on eighteen 30-day postoperative complications (excluding mortality), which are variably grouped in published analyses using ACS NSQIP data. This hinders comparison between studies of this widely used quality improvement dataset. METHODS: Factor analysis was used to develop a series of complication clusters, which were then analyzed to identify a parsimonious, clinically meaningful grouping, using 2,275,240 surgical cases in the ACS NSQIP Participant Use File (PUF), 2005 to 2012. The main outcome measures are reproducible, data-driven, clinically meaningful clusters of complications derived from factor solutions. RESULTS: Factor analysis solutions for 5 to 9 latent factors were examined for their percent of total variance, parsimony, and clinical interpretability. Applying the first 2 of these criteria, we identified the 7-factor solution, which included clusters of pulmonary, infectious, wound disruption, cardiac/transfusion, venous thromboembolic, renal, and neurological complications, as the best solution for parsimony and clinical meaningfulness. Applying the last (clinical interpretability), we combined the wound disruption with the infectious clusters resulting in 6 clusters for future clinical applications. CONCLUSIONS: Factor analysis of ACS NSQIP postoperative complication data provides 6 clinically meaningful complication clusters in lieu of 18 postoperative morbidities, which will facilitate comparisons and clinical implementation of studies of postoperative morbidities.

Surgical Risk Preoperative Assessment System (SURPAS): III. Accurate Preoperative Prediction of 8 Adverse Outcomes Using 8 Predictor Variables.

OBJECTIVE: To develop accurate preoperative risk prediction models for multiple adverse postoperative outcomes applicable to a broad surgical population using a parsimonious common set of risk variables and outcomes. SUMMARY BACKGROUND DATA: Currently, preoperative assessment of surgical risk is largely based on subjective clinician experience. We propose a paradigm shift from the current postoperative risk adjustment for cross-hospital comparison to patient-centered quantitative risk assessment during the preoperative evaluation. METHODS: We identify the most common and important predictor variables of postoperative mortality, overall morbidity, and 6 complication clusters from previously published prediction analyses that used forward selection stepwise logistic regression. We then refit the prediction models using only the 8 most common and important predictor variables, and compare the discrimination and calibration of these models to the original full-variable models using the c-index, Hosmer-Lemeshow analysis, and Brier scores. RESULTS: Accurate risk models for 30-day outcomes of mortality, overall morbidity, and 6 clusters of complications were developed using a set of 8 preoperative risk variables. C-indexes of the 8 variable models are between 97.9% and 99.2% of those of the full models containing up to 28 variables, indicating excellent discrimination using fewer predictor variables. Hosmer-Lemeshow analyses showed observed to expected event rates to be nearly identical between parsimonious models and full models, both showing good calibration. CONCLUSIONS: Accurate preoperative risk assessment of postoperative mortality, overall morbidity, and 6 complication clusters in a broad surgical population can be achieved with as few as 8 preoperative predictor variables, improving feasibility of routine preoperative risk assessment for surgical patients.

Surgical Risk Preoperative Assessment System (SURPAS): II. Parsimonious Risk Models for Postoperative Adverse Outcomes Addressing Need for Laboratory Variables and Surgeon Specialty-specific Models.

OBJECTIVE: To develop parsimonious prediction models for postoperative mortality, overall morbidity, and 6 complication clusters applicable to a broad range of surgical operations in adult patients. SUMMARY BACKGROUND DATA: Quantitative risk assessment tools are not routinely used for preoperative patient assessment, shared decision making, informed consent, and preoperative patient optimization, likely due in part to the burden of data collection and the complexity of incorporation into routine surgical practice. METHODS: Multivariable forward selection stepwise logistic regression analyses were used to develop predictive models for 30-day mortality, overall morbidity, and 6 postoperative complication clusters, using 40 preoperative variables from 2,275,240 surgical cases in the American College of Surgeons National Surgical Quality Improvement Program data set, 2005 to 2012. For the mortality and overall morbidity outcomes, prediction models were compared with and without preoperative laboratory variables, and generic models (based on all of the data from 9 surgical specialties) were compared with specialty-specific models. In each model, the cumulative c-index was used to examine the contribution of each added predictor variable. C-indexes, Hosmer-Lemeshow analyses, and Brier scores were used to compare discrimination and calibration between models. RESULTS: For the mortality and overall morbidity outcomes, the prediction models without the preoperative laboratory variables performed as well as the models with the laboratory variables, and the generic models performed as well as the specialty-specific models. The c-indexes were 0.938 for mortality, 0.810 for overall morbidity, and for the 6 complication clusters ranged from 0.757 for infectious to 0.897 for pulmonary complications. Across the 8 prediction models, the first 7 to 11 variables entered accounted for at least 99% of the c-index of the full model (using up to 28 nonlaboratory predictor variables). CONCLUSIONS: Our results suggest that it will be possible to develop parsimonious models to predict 8 important postoperative outcomes for a broad surgical population, without the need for surgeon specialty-specific models or inclusion of laboratory variables.

Association between Intraoperative Hypotension and Hypertension and 30-day Postoperative Mortality in Noncardiac Surgery.

BACKGROUND: Although deviations in intraoperative blood pressure are assumed to be associated with postoperative mortality, critical blood pressure thresholds remain undefined. Therefore, the authors estimated the intraoperative thresholds of systolic blood pressure (SBP), mean blood pressure (MAP), and diastolic blood pressure (DBP) associated with increased risk-adjusted 30-day mortality. METHODS: This retrospective cohort study combined intraoperative blood pressure data from six Veterans Affairs medical centers with 30-day outcomes to determine the risk-adjusted associations between intraoperative blood pressure and 30-day mortality. Deviations in blood pressure were assessed using three methods: (1) population thresholds (individual patient sum of area under threshold [AUT] or area over threshold 2 SDs from the mean of the population intraoperative blood pressure values), (2). absolute thresholds, and (3) percent change from baseline blood pressure. RESULTS: Thirty-day mortality was associated with (1) population threshold: systolic AUT (odds ratio, 3.3; 95% CI, 2.2 to 4.8), mean AUT (2.8; 1.9 to 4.3), and diastolic AUT (2.4; 1.6 to 3.8). Approximate conversions of AUT into its separate components of pressure and time were SBP < 67 mmHg for more than 8.2 min, MAP < 49 mmHg for more than 3.9 min, DBP < 33 mmHg for more than 4.4 min. (2) Absolute threshold: SBP < 70 mmHg for more than or equal to 5 min (odds ratio, 2.9; 95% CI, 1.7 to 4.9), MAP < 49 mmHg for more than or equal to 5 min (2.4; 1.3 to 4.6), and DBP < 30 mmHg for more than or equal to 5 min (3.2; 1.8 to 5.5). (3) Percent change: MAP decreases to more than 50% from baseline for more than or equal to 5 min (2.7; 1.5 to 5.0). Intraoperative hypertension was not associated with 30-day mortality with any of these techniques. CONCLUSION: Intraoperative hypotension, but not hypertension, is associated with increased 30-day operative mortality.

Feasibility and acceptability of a decision aid designed for people facing advanced or terminal illness: a pilot randomized trial.

BACKGROUND: Patients nearing the end of their lives face an array of difficult decisions. OBJECTIVE: This study was designed to assess the feasibility and acceptability of a decision aid (DA) designed for patients facing advanced or terminal illness. DESIGN: We conducted a pilot randomized clinical trial of Health Dialog's Looking Ahead: choices for medical care when you're seriously ill DA (booklet and DVD) applied to patients on a hospital-based palliative care (PC) service. SETTING: University of Colorado Hospital - December 2009 and May 2010. PARTICIPANTS: All adult, English-speaking patients or their decision makers were potentially eligible. Patients were not approached if they were in isolation, did not speak English or if any provider felt that they were not appropriate because of issues such as family conflict or actively dying. INTERVENTION: All participants received a standard PC consultation. Participants in the intervention arm also received a copy of the DA. Measurements Primary outcomes included decision conflict and knowledge. Participants in the intervention arm also completed an acceptability questionnaire and qualitative exit interviews. RESULTS: Of the 239 patients or decision makers, 51(21%) enrolled in the trial. The DA had no significant effect on decision conflict or knowledge. Exit interviews indicated it was acceptable and empowering, although they wished they had access to the DA earlier. CONCLUSIONS: While the DA was acceptable, feasibility was limited by late-life illness challenges. Future trials of this DA should be performed on patients earlier in their illness trajectory and should include additional outcome measures such as self-efficacy and confidence.

The association between participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and postoperative outcomes: A comprehensive analysis of 7,474,298 patients.

INTRODUCTION: Prior publications about the association between participation in the American College of Surgeons National Surgical Quality Improvement Program and improved postoperative outcomes have reported mixed results. We aimed to perform a comprehensive analysis of preoperative characteristics and unadjusted and risk-adjusted postoperative complication rates over time in the American College of Surgeons National Surgical Quality Improvement Program dataset. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program database, 2005 to 2018, to analyze preoperative patient characteristics and unadjusted and risk-adjusted rates of adverse postoperative outcomes by year. Expected events were calculated using multiple logistic regression, with each complication as the dependent variable and the 28 non-laboratory preoperative American College of Surgeons National Surgical Quality Improvement Program variables as the independent variables. Annual observed-to-expected ratios for each outcome were used to risk-adjust outcomes over time. RESULTS: The analytic cohort included 7,474,298 operations across 9 surgical specialties. Both the preoperative patient risk and the unadjusted rate of postoperative complications decreased over time. While the observed-to-expected ratio for mortality remained around 1, the observed-to-expected ratios for the other outcomes decreased over time from 2005 to 2018, except for the following cardiac complications: overall morbidity 1.11 (95% confidence interval: 1.10-1.13) to 0.97 (0.96-0.98); pulmonary 1.18 (1.15-1.21) to 0.91 (0.89-0.92); infection 1.19 (1.16-1.21) to 1.01 (1.00-1.01); urinary tract infection 1.29 (1.23-1.34) to 0.87 (0.86-0.89); venous thromboembolism 1.10 (1.03-1.16) to 0.92 (0.90-0.94) ; cardiac 0.76 (0.70-0.81) to 1.04 (1.01-1.07); renal 1.14 (1.08-1.21) to 0.96 (0.93-0.99); stroke 1.12 (1.00-1.25) to 0.98 (0.94-1.03); and bleeding 1.35 (1.33-1.36) to 0.80 (0.79-0.81). CONCLUSION: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program have experienced a decrease in risk-adjusted postoperative surgical complications over time in all areas except for mortality and cardiac complications.

The Effect of Social Vulnerability on Initial Stage and Treatment for Non-Small Cell Lung Cancer.

OBJECTIVE: The Social Vulnerability Index (SVI) is a composite metric for social determinants of health. The objective of this study was to determine if SVI influences stage at presentation for non-small cell lung cancer (NSCLC) patients and subsequent therapies. MATERIALS AND METHODS: NSCLC patients from our local contribution to the National Cancer Database (2011-2021) were grouped into low SVI (<75 %ile) and high SVI (>75 %ile) cohorts. Demographics, cancer-related variables, and treatment modalities were compared. Multivariable logistic regression was performed to control for the impact of demographics on cancer presentation and for the impact of oncologic variables on treatment outcomes. RESULTS: Of 1,662 NSCLC patients, 435 (26 %) were defined as high SVI. Compared to the 1,227 (74 %) low SVI patients, highly vulnerable patients were more likely to be male (53.3 % vs 46.0 %, p = 0.009), non-White (17.2 % vs 9.7 %, p < 0.0001), have comorbidities (29.4 % vs 23.1 %, p = 0.009) and present at a higher AJCC clinical T, M and overall stage (all p < 0.05). These findings persisted on multivariable analysis, with highly vulnerable patients having 1.5x the odds (95 %CI: 1.23-1.86, p < 0.001) of presenting at more advanced stage. Patients with high SVI were less likely to be recommended for and receive surgery (40.9 % vs 53.2 %, p < 0.001), and this finding persisted after controlling for stage at presentation (OR 1.37, 95 %CI 1.04-1.80). CONCLUSIONS: Highly vulnerable patients present at a more advanced clinical stage and are less likely to be recommended and receive surgery, even after controlling for stage at presentation. Further investigation into these findings is warranted to achieve more equitable oncologic care.