Increased Preoperative Stress Test Utilization is Not Associated With Reduced Adverse Cardiac Events in Current US Surgical Practice.

OBJECTIVE: To measure the frequency of preoperative stress testing and its association with perioperative cardiac events. BACKGROUND: There is persistent variation in preoperative stress testing across the United States. It remains unclear whether more testing is associated with reduced perioperative cardiac events. METHODS: We used the Vizient Clinical Data Base to study patients who underwent 1 of 8 elective major surgical procedures (general, vascular, or oncologic) from 2015 to 2019. We grouped centers into quintiles by frequency of stress test use. We computed a modified revised cardiac risk index (mRCRI) score for included patients. Outcomes included in-hospital major adverse cardiac events (MACEs), myocardial infarction (MI), and cost, which we compared across quintiles of stress test use. RESULTS: We identified 185,612 patients from 133 centers. The mean age was 61.7 (±14.2) years, 47.5% were female, and 79.4% were White. Stress testing was performed in 9.2% of patients undergoing surgery, and varied from 1.7% at lowest quintile centers, to 22.5% at highest quintile centers, despite similar mRCRI comorbidity scores (mRCRI>1: 15.0% vs 15.8%; P =0.068). In-hospital MACE was less frequent among lowest versus highest quintile centers (8.2% vs 9.4%; P <0.001) despite a 13-fold difference in stress test use. Event rates were similar for MI (0.5% vs 0.5%; P =0.737). Mean added cost for stress testing per 1000 patients who underwent surgery was $26,996 at lowest quintile centers versus $357,300 at highest quintile centers. CONCLUSIONS: There is substantial variation in preoperative stress testing across the United States despite similar patient risk profiles. Increased testing was not associated with reduced perioperative MACE or MI. These data suggest that more selective stress testing may be an opportunity for cost savings through a reduction of unnecessary tests.

Safety of laparoscopic inguinal hernia repair in the setting of antithrombotic therapy.

INTRODUCTION: There are a paucity of data regarding the safety of laparoscopic inguinal hernia repair in patients on antiplatelet and anticoagulant therapy (APT/ACT). We aim to compare the postoperative outcomes of laparoscopic (LIHR) vs. open repair of inguinal hernias (OIHR) in patients on APT/ACT. METHOD: We conducted a retrospective cohort study using the Vizient Clinical DataBase. We included adults receiving APT/ACT who underwent outpatient, elective, and primary inguinal hernia repair between 2017 and 2019. Subgroup analysis was performed on patients receiving aspirin, non-aspirin antiplatelet, and anticoagulant therapy. Mixed-effects logistic regression was used to assess both the effect of APT/ACT on the probability of receiving LIHR vs OIHR and their respective outcomes. RESULT: A total of 142,052 repairs were included, of which 21,441 (15%) were performed on patients receiving APT/ACT. Mean age was 69 years (± 10.5) and 93% were male. 19% of hernias were bilateral. 40% of operations were performed at teaching hospitals. On multivariable analysis, patients on non-aspirin antiplatelet or anticoagulant therapy were more likely to receive an open procedure (Odds Ratio (OR) = 1.2; 95% Confidence Intervals (CI) [1.1, 1.4] and OR = 1.4; CI [1.3, 1.5], respectively). LIHR was associated with a lower rate of length of stay > 1 day (OR = 0.65; CI [0.5, 0.9]). Rates of 30-day postoperative hematoma, transfusions, stroke, myocardial infarction, deep venous thrombosis, pulmonary embolism, readmission, and emergency department visits were similar between the two operative approaches. CONCLUSION: Patients on APT/ACT represent a substantial proportion of those undergoing inguinal hernia repair. Non-aspirin antiplatelet or anticoagulant therapy are independent predictors of choosing an open repair. Laparoscopic repair appears to be safe in patients receiving APT/ACT under current perioperative management patterns.

Impact of hospital volume on patient safety indicators and failure to rescue following open aortic aneurysm repair.

OBJECTIVE: Failure to rescue (FTR), a patient safety indicator (PSI) defined, codified, and adjudicated by the Agency for Healthcare Research and Quality, is classified as a preventable inpatient death following major complications. FTR has been reported to be a significant driver of postoperative mortality after open abdominal aortic aneurysm (OAAA) repair. The association between hospital volume (HV) and mortality is well known; however, the mechanisms responsible for these improved outcomes and relative contribution to observed interhospital variation is poorly understood. Similarly, HV influence on specific complications predictive of FTR is unknown; therefore, we sought to determine how HV influences risk and contributes to interhospital variation in PSI events leading to FTR and/or in-hospital mortality after OAAA repair. METHODS: The Vizient database (174 academic/nonacademic hospitals) was queried for all OAAA repairs (elective, n = 2827; nonelective, n = 1622) completed from 2012 to 2014. The primary endpoint was combined FTR and/or in-hospital 30-day mortality. Risk-adjusted rates of complications, Agency for Healthcare Research and Quality-designated PSIs, and FTR were determined. Additional modeling identified PSIs associated with FTR, whereas HV effects on PSIs and FTR were evaluated using mixed-effect models accounting for interhospital variation. Proportion of variation attributable to HV was estimated by contrasting hospital random effect variances in the presence/absence of volume effects. RESULTS: The combined overall FTR/in-hospital 30-day mortality rate was 9.3% (n = 414). For elective and nonelective cases, the overall FTR and 30-day mortality rates were: FTR, 1.6%, 4.9%; and 30-day in-hospital mortality, 3.4%, 17.5%, respectively. HV significantly influenced FTR/30-day in-hospital mortality (P < .0001). FTR/30-day mortality odds for hospitals with 3-year volumes of 50, 100, 150, and 200 cases were 1.4, 2.0, 2.7, and 3.0 times lower, respectively, than hospitals performing ≤25 cases/3 years. The proportion of interhospital variation attributed to HV was greatest for FTR/30-day mortality (62%). Procedural volume accounted for 41% and 38% of interhospital variation in postoperative bleeding and myocardial infarction, respectively. Preoperative predictors of FTR included coagulopathy, arrhythmia (nonelective cases); congestive heart failure, obesity (elective cases); and age, neurological disease, hypertension, and valvular disease (all cases). CONCLUSIONS: OAAA FTR/30-day in-hospital mortality strongly correlated with annual case volume with higher volume centers having the lowest risk. Notably, HV accounted for a significant proportion of the observed variation in FTR and specific complications providing direct evidence for how the volume-outcome relationship may influence perioperative mortality. These findings can inform stakeholders to strategically enable them to implement processes of care directed at the most vulnerable patients that are designed to reduce the likelihood of preventable adverse events and death after OAAA repair. Furthermore, these results underscore the need to regionalize OAAA repair and potentially other complex operations, to HV centers because of their improved ability to rescue patients experiencing complications associated with postoperative mortality.

Operating Room Supply Cost and Value of Care after Implementing a Sustainable Quality Intervention.

BACKGROUND: Variability in operating room supply cost is a modifiable cause of suboptimal resource use and low value of care (outcomes vs cost). This study describes implementation of a quality improvement intervention to decrease operating room supply costs. STUDY DESIGN: An automated electronic health record data pipeline harmonized operating room supply cost data with patient and case characteristics and outcomes. For inpatient procedures, predicted mortality and length of stay were used to calculate observed-to-expected ratios and value of care using validated equations. For commonly performed (1 or more per week) procedures, the pipeline generated figures illustrating individual surgeon performance vs peers, costs for each surgeon performing each case type, and control charts identifying out-of-control cases and surgeons with more than 90th percentile costs, which were shared with surgeons and division chiefs alongside guidance for modifying case-specific supply instructions to operating room nurses and technicians. RESULTS: Preintervention control (1,064 cases for 7 months) and postintervention (307 cases for 2 months) cohorts had similar baseline characteristics across all 16 commonly performed procedures. Median costs per case were lower in the intervention cohort ($811 [$525 to $1,367] vs controls: $1,080 [$603 to $1,574], p < 0.001), as was the incidence of out-of-control cases (19 (6.2%) vs 110 (10.3%), p = 0.03). Duration of surgery, length of stay, discharge disposition, and 30-day mortality and readmission rates were similar between cohorts. Value of care was higher in the intervention cohort (1.1 [0.1 to 1.5] vs 1.0 [0.2 to 1.4], p = 0.04). Pipeline runtime was 16:07. CONCLUSIONS: An automated, sustainable quality improvement intervention was associated with decreased operating room supply costs and increased value of care.

Postoperative Clostridium difficile infection has a differential procedure-specific association with surgical outcomes in contemporary United States practice.

BACKGROUND: The Centers for Disease Control and Prevention has made the prevention of in-hospital Clostridium difficile infection a priority. However, whether there is a differential impact of Clostridium difficile on surgical patients remains undefined. Therefore, we quantified the procedure-specific association between postoperative Clostridium difficile and surgical outcomes to define opportunities for targeted quality improvement. METHODS: We studied patients undergoing major cardiac, vascular, general, or oncologic procedures using the Vizient database from 2015 to 2019. Our primary exposure was postoperative Clostridium difficile infection. Our primary outcomes were postoperative length of stay, hospitalization cost, readmission, and in-hospital mortality. We used linear and logistic regression for risk adjustment. RESULTS: The incidence of Clostridium difficile infection was 1.6% (n = 6,506/397,750). Patients with Clostridium difficile were older, more comorbid, and more frequently underwent urgent surgery. The median postoperative length of stay was 7 days (interquartile range: 5-11 days), and it was 66% longer among those with Clostridium difficile (P < .001). Similarly, the median hospitalization cost was $31,000 (interquartile range: $20,000-$49,000), and it was 51% greater among patients with Clostridium difficile (P < .001). Postoperative Clostridium difficile was associated with more readmissions after coronary artery bypass grafting, small bowel resection, colectomy, gastrectomy, pancreatectomy, and infrainguinal bypass (adjusted odds ratio range: 1.4-1.7), but not after open aneurysm repair, suprainguinal bypass, or esophagectomy. Clostridium difficile was associated with increased mortality after coronary artery bypass grafting, small bowel resection, colectomy, and infrainguinal bypass (adjusted odds ratio range: 1.3-2.7), but not after open aneurysm repair, suprainguinal bypass, esophagectomy, gastrectomy, or pancreatectomy. CONCLUSION: Postoperative Clostridium difficile infection was differentially associated with increased length of stay, cost, readmissions, and mortality across specific procedures. This was most apparent after infrainguinal bypass, small bowel resection, colectomy, and coronary artery bypass grafting. Accordingly, a targeted Clostridium difficile reduction effort for these procedures may offer a more effective approach toward reducing infection rates.

Analysis of the Cost Effectiveness of Laparoscopic Pancreatoduodenectomy.

OBJECTIVE: We sought to determine if laparoscopic pancreatoduodenectomy (LPD) is a cost-effective alternative to open pancreatoduodenectomy (OPD). METHODS: Hospital cost data, discharge disposition, readmission rates, and readmission costs from periampullary cancer patient cohorts of LPD and OPD were compared. The surgical cohorts over a 40-month period were clinically similar, consisting of 52 and 50 patients in the LPD and OPD groups, respectively. RESULTS: The total operating room costs were higher in the LPD group as compared to the OPD group (median US$12,290 vs US$11,299; P = 0.05) due to increased costs for laparoscopic equipment and regional nerve blocks (P ≤ 0.0001). Although hospital length of stay was shorter in the LPD group (median 7 vs 8 days; P = 0.025), the average hospital cost was not significantly decreased compared to the OPD group (median $28,496 vs $28,623). Surgery-related readmission rates and associated costs did not differ between groups. Compared to OPD patients, significantly more LPD patients were discharged directly home rather than to other healthcare facilities (88% vs 72%; P = 0.047). CONCLUSION: For the index hospitalization, the cost of LPD is equivalent to OPD. Total episode-of-care costs may favor LPD via reduced post-hospital needs for skilled nursing and rehabilitation.

The impact of interhospital transfers on surgical quality metrics for academic medical centers.

The emergence of pay-for-performance systems pose a risk to an academic medical center's (AMC) mission to provide care for interhospital surgical transfer patients. This study examines quality metrics and resource consumption for a sample of these patients from the University Health System Consortium (UHC) and our Department of Surgery (DOS). Standard benchmarks, including mortality rate, length of stay (LOS), and cost, were used to evaluate the impact of interhospital surgical transfers versus direct admission (DA) patients from January 2010 to December 2012. For 1,423,893 patients, the case mix index for transfer patients was 38 per cent (UHC) and 21 per cent (DOS) greater than DA patients. Mortality rates were 5.70 per cent (UHC) and 6.93 per cent (DOS) in transferred patients compared with 1.79 per cent (UHC) and 2.93 per cent (DOS) for DA patients. Mean LOS for DA patients was 4 days shorter. Mean total costs for transferred patients were greater $13,613 (UHC) and $13,356 (DOS). Transfer patients have poorer outcomes and consume more resources than DA patients. Early recognition and transfer of complex surgical patients may improve patient rescue and decrease resource consumption. Surgeons at AMCs and in the community should develop collaborative programs that permit collective assessment and decision-making for complicated surgical patients.

Esophageal perforation management using a multidisciplinary minimally invasive treatment algorithm.

BACKGROUND: The surgical management of esophageal perforation (EP) often results in mortality and significant morbidity. Recent less invasive approaches to EP management include endoscopic luminal stenting and minimally invasive surgical therapies. We wished to establish therapeutic efficacy of minimally invasive therapies in a consecutive series of patients. STUDY DESIGN: An IRB-approved retrospective review of all acute EPs between 2007 and 2013 at a single institution was performed. Patient demographic, clinical outcomes data, and hospital charges were collected. RESULTS: We reviewed 76 consecutive patients with acute EP presenting to our tertiary care center. Median age was 64 ± 16 years (range 25 to 87 years), with 50 men and 26 women. Ninety percent of EPs were in the distal esophagus, with 67% of iatrogenic perforations occurring within 4 cm of the gastroesophageal junction. All patients were treated within 24 hours of initial presentation with a removable covered esophageal stent. Leak occlusion was confirmed within 48 hours of esophageal stent placement in 68 patients. Median lengths of ICU and hospital stay were 3 and 10 days, respectively (range 1 to 86 days). One-third of the patients were noted to have prolonged intubation (>7 days) and pneumonia that required a tracheostomy. One in-hospital (1.3%) mortality occurred within 30 days. Median total hospital charges for EP were $85,945. CONCLUSIONS: Endoscopically placed removable esophageal stents with minimally invasive repair of the perforation and feeding access is an effective treatment method for patients with EP. This multidisciplinary method enabled us to care for severely ill patients while minimizing morbidity and mortality and avoiding open esophageal surgery.