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.

The association between patient preoperative disposition and outcomes after diagnostic lung biopsy.

Background: Surgical diagnostic lung biopsy (DLB) is performed to guide the management of pulmonary disease with unclear etiology. However, the utilization of surgical DLB in critically ill patients remains unclear. The purpose of this study was to determine if patient preoperative disposition impacts complication rates after DLB. Methods: This was retrospective cohort study using electronic health record (EHR) data at one academic institution [2013-2021]. Patients who underwent DLB were identified using current procedural terminology (CPT) codes and cohorted based on preoperative disposition. The primary outcome was 30-day mortality; secondary outcomes were overall morbidity, individual complications, and changes to medical therapy. Complication rates were compared using chi-squared tests, Fisher's exact tests, or analysis of variance (ANOVA). Multivariable logistic regression was performed to generate risk-adjusted odds ratios (ORs) for each complication. Results: Of 285 patients, 238 (83.5%) presented from home, 26 (9.1%) from inpatient floor units, and 21 (7.4%) from intensive care units (ICUs). Patients requiring ICU had the highest 30-day rates of mortality, overall morbidity, and all individual complications (all P<0.05). After risk adjustment, non-ICU inpatients had higher odds of postoperative ventilator use, prolonged ventilation, and ICU need than outpatients (all P<0.05). Preoperative ICU disposition was associated with increased OR of 30-day mortality [OR, 70.92; 95% confidence interval (CI): 5.55-906.32] and overall morbidity (OR, 7.27; 95% CI: 1.93-27.42) compared to patients with other preoperative dispositions. There were no differences in changes to medical therapy between the cohorts. Conclusions: Patients requiring ICU before DLB had significantly higher risk-adjusted rates of mortality and postoperative complications than outpatients and other inpatients. A clear benefit from tissue diagnosis should be defined prior to performing DLB on critically ill patients.

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 Effect of Laparoscopic Gastric Ischemic Preconditioning Prior to Esophagectomy on Anastomotic Stricture Rate and Comparison with Esophagectomy-Alone Controls.

BACKGROUND: Benign anastomotic stricture is a recognized complication following esophagectomy. Laparoscopic gastric ischemic preconditioning (LGIP) prior to esophagectomy has been associated with decreased anastomotic leak rates; however, its effect on stricture and the need for subsequent endoscopic intervention is not well studied. METHODS: This was a case-control study at an academic medical center using consecutive patients undergoing oncologic esophagectomies (July 2012-July 2022). Our institution initiated an LGIP protocol on 1 January 2021. The primary outcome was the occurrence of stricture within 1 year of esophagectomy, while secondary outcomes were stricture severity and frequency of interventions within the 6 months following stricture. Bivariable comparisons were performed using Chi-square, Fisher's exact, or Mann-Whitney U tests. Multivariable regression controlling for confounders was performed to generate risk-adjust odds ratios and to identify the independent effect of LGIP. RESULTS: Of 253 esophagectomies, 42 (16.6%) underwent LGIP prior to esophagectomy. There were 45 (17.7%) anastomotic strictures requiring endoscopic intervention, including three patients who underwent LGIP and 42 who did not. Median time to stricture was 144 days. Those who underwent LGIP were significantly less likely to develop anastomotic stricture (7.1% vs. 19.9%; p = 0.048). After controlling for confounders, this difference was no longer significant (odds ratio 0.46, 95% confidence interval 0.14-1.82; p = 0.29). Of those who developed stricture, there was a trend toward less severe strictures and decreased need for endoscopic dilation in the LGIP group (all p < 0.20). CONCLUSION: LGIP may reduce the rate and severity of symptomatic anastomotic stricture following esophagectomy. A multi-institutional trial evaluating the effect of LGIP on stricture and other anastomotic complications is warranted.

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.

Timing of recovery of quality of life after robotic anatomic lung resection.

Patient-reported outcomes (PROs) are an underreported aspect of surgical recovery. The purpose of our study was to track PROs after robotic anatomic lung to determine the timing to recovery of baseline patient baseline quality of life. This was a prospective cohort study at an academic medical center (4/2021-12/2022). Patients who underwent robotic anatomic lung resection were asked to complete PROMIS-29 surveys at the preoperative clinic visit, postoperative clinic visit, 30 days and 90 days postoperatively via in-person and email-based electronic surveys. The PROPr score, a summary of health-related quality of life, and mental and physical health z-scores were estimated for each patient using published methods and compared by postoperative timing. 75 patients completed the preoperative survey and at least one postoperative survey; 56 completed postoperative clinic surveys, 54 completed 30-day postoperative surveys, and 40 completed 90-day postoperative surveys. All three PROMIS scores decreased between the preoperative and first postoperative visit (all p < 0.05). PROPr scores increased over time but remained significantly worse than baseline by 90 days (-0.08 difference between 90 days and preoperative, p = 0.02). While PROMIS summary z-scores for physical health remained - 0.29 lower at 90 days postoperatively, this did not reach statistical significance (p = 0.06). Mental health scores returned to baseline by 90 days postoperatively (p = 0.41). While some PROs returned to baseline by 90 days postoperatively, overall quality-of-life scores remained significantly below preoperative baselines. These findings are important to share with patients during the informed consent process to achieve patient centered care more effectively.

Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population.

OBJECTIVE: The purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. SUMMARY BACKGROUND DATA: Growing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. METHODS: This was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012-2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. RESULTS: Overall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p â€‹< â€‹0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p â€‹< â€‹0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant. CONCLUSIONS: High SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population.

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.

National trends in technique use for esophagectomy: Does primary surgeon specialty matter?

BACKGROUND: Cardiothoracic surgeons and general surgeons (including surgical oncologists) perform most esophagectomies. The purpose of this study was to explore whether specialty-driven differences in surgical techniques and the use of minimally invasive surgical approaches exist and are associated with postoperative outcomes after esophagectomy. METHODS: This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program esophagectomy-targeted participant user file (2016-2018). Patients who underwent esophagectomy were sorted into cardiothoracic and general surgeon cohorts based on surgeon specialty. Perioperative characteristics and postoperative outcomes were compared using the χ2 analysis or independent t test. Multivariable logistic regression controlling for perioperative variables was performed to generate risk-adjusted rates of postoperative outcomes compared by surgical specialty. RESULTS: Of 3,247 patients included, 1,792 (55.2%) underwent esophagectomy by cardiothoracic surgeons and 1,455 (44.5%) by general surgeons as the primary surgeon. Cardiothoracic surgeons were more likely to use traditional minimally invasive surgical (P = .0004) or open approaches (P < .0001) and less likely to use robotic (P = .04) or a hybrid robotic and traditional approaches (P < .0001). Cardiothoracic surgeons performed more Ivor Lewis esophagectomies and fewer transhiatal and McKeown esophagectomies (P < .0001). After risk adjustment, there were no differences in rates of postesophagectomy complications, such as anastomotic leaks or positive margins, between cardiothoracic surgeons and general surgeons (all P > .05). However, cardiothoracic surgeons were more likely than general surgeons to treat anastomotic leaks with surgery rather than procedural interventions (odds ratio = 1.76; 95% confidence interval, 1.24-2.52). CONCLUSION: Cardiothoracic surgeons and general surgeons use minimally invasive surgical subtypes differently when performing esophagectomy. However, there were no risk-adjusted differences in postoperative complications when compared by surgical subspecialty. Esophagectomy is being performed safely by surgeons with different specialties and training pathways.

Social vulnerability is associated with post-operative morbidity following robotic-assisted lung resection.

Background: The social vulnerability index (SVI) is a neighborhood-based metric used to determine an individual's susceptibility to socioeconomic hardship, with high SVI indicating high susceptibility. SVI has previously been associated with surgical outcomes. We aimed to determine if SVI influences morbidity following robotic-assisted lung resection. Methods: This was a retrospective cohort study at one academic medical center (1/1/2021-11/30/2022). Patients undergoing robotic-assisted lung resection were grouped into low (<75th percentile) and high (≥75th percentile) SVI cohorts. The primary outcome was 30-day overall morbidity; secondary outcomes were individual 30-day post-operative outcomes. Univariate analysis was performed using Chi-squared or Mann-Whitney-U tests, and multivariable logistic regression was performed to generate risk-adjusted odds ratios (ORs) of postoperative complications. Results: We included 320 patients, of which 40 patients (12.5%) in the high-SVI group and 280 (87.5%) in the low-SVI group. High SVI patients were more likely to be non-Caucasian and of Hispanic ethnicity, but there were no other differences in perioperative characteristics (all P>0.05). High SVI patients were more likely to experience a post-operative complication (42.5% vs. 24.6%, P=0.017), surgical site infection (SSI) (12.5% vs. 4.3%, P=0.047), hemothorax (5.0% vs. 0.0%, P=0.015), intensive care need (15.0% vs. 4.6%, P=0.021), sepsis (10.0% vs. 1.1%, P=0.006) and unplanned reoperation (5.0% vs. 0.4%, P=0.042). After risk-adjustment, the association of increased overall morbidity with high SVI persisted (OR =2.53; 95% confidence interval: 1.19-5.35). Conclusions: High SVI was associated with increased risk-adjusted odds of morbidity after robotic-assisted lung resection. Highly vulnerable patients should be allocated perioperative resources to help mitigate the increased risk of these complications.

Analyzing the impact of the Coronavirus disease 2019 pandemic on initial oncologic presentation and treatment of non-small cell lung cancer in the United States.

BACKGROUND: A significantly lower rate of non-small cell lung cancer (NSCLC) screening, greater healthcare avoidance, and changes to oncologic recommendations were some consequences of the Coronavirus disease 2019 (COVID-19) pandemic affecting the medical environment. We sought to determine how the healthcare environment during the COVID-19 pandemic affected the oncologic treatment of patients diagnosed with non-small cell lung cancer (NSCLC). METHODS: This was a retrospective cohort study evaluating patients with NSCLC in the National Cancer Database (2019-2020). Patients were divided into prepandemic (2019) and pandemic (2020) cohorts, and patient, oncologic, and treatment variables were compared. Multivariable logistic regression was performed to control for the impact of demographic characteristics on oncologic variables and the impact of oncologic variables on treatment variables. RESULTS: The study population comprised 250,791 patients, including 114,533 patients (45.7%) in the pandemic cohort. There were 15% fewer new NSCLC diagnoses during the pandemic compared with prepandemic. Patients diagnosed during the pandemic had more advanced clinical TNM stage on presentation (P < .0001) and were more likely to have tumors in overlapping lobes or in a main bronchus (P = .0002). They were less likely to receive cancer treatment (P < .0001) and to undergo primary resection (P < .0001) and more likely to receive adjuvant systemic therapy (P = .004) and a combination of palliative treatment regimens (P < .0001). After risk adjustment, all these differences remained statistically significant (P < .05). CONCLUSIONS: The COVID-19 pandemic was associated with increased clinical stage at presentation for patients with NSCLC, which impacted subsequent treatment strategies. However, treatment differed minimally when controlling for cancer stage. Future studies will examine the impact of these differences on overall survival and cancer-free survival.

Perioperative hypothermia in robotic-assisted thoracic surgery: Incidence, risk factors, and associations with postoperative outcomes.

OBJECTIVE: Inadvertent perioperative hypothermia has been associated with poor surgical outcomes. The purpose of this study was to evaluate the incidence and associated postoperative complications of inadvertent perioperative hypothermia in patients undergoing robotic-assisted thoracic surgery lung resections. METHODS: This was a single-center, retrospective cohort study evaluating all consecutive patients who underwent robotic-assisted thoracic surgery lung resection between January 1, 2021, and November 30, 2022. Temperatures were measured at 5 time points: preprocedure unit, anesthesia induction, 30 minutes postinduction, extubation, and recovery room arrival. Temperature changes were calculated at each interval. Adjusted and unadjusted comparison was performed between those who experienced varying levels of inadvertent perioperative hypothermia (Hypothermia I: <36 °C, Hypothermia II: <35.5 °C, and Hypothermia III: <35 °C) and those who did not. RESULTS: A total of 313 patients were included, and 201 (64.2%) lobectomies, 50 (16.0%) segmentectomies, and 62 (19.8%) wedge resections were performed. Across all patients, 291 (93.0%) had a temperature less than 36 °C, 195 (62.3%) had a temperature less than 35.5 °C, and 100 (31.9%) had a temperature less than 35.0 °C. Patients experienced significant temperature change at all intervals (P < .001), with the greatest loss occurring during the preprocedure interval (between leaving preprocedure unit and anesthesia induction). On adjusted analysis, patients who experienced inadvertent perioperative hypothermia less than 35.5 °C were older (odds ratio, 1.03; 95% CI, 1.01-1.05), had lower body mass index (odds ratio, 0.95; 95% CI, 0.87-0.98), and had increasing operative time (odds ratio, 1.00; 95% CI, 1.00-1.01). Patients who experienced inadvertent perioperative hypothermia had higher risk-adjusted rates of overall morbidity and infectious postoperative complications. CONCLUSIONS: The majority of patients undergoing robotic-assisted thoracic surgery lung resections experience some degree of inadvertent perioperative hypothermia and have associated increased rates of 30-day morbidity. Structured and interval-specific interventions should be implemented to decrease rates of inadvertent perioperative hypothermia and subsequent complications.

Esophagram should be performed to diagnose esophageal perforation before inter-hospital transfer.

Background: Early recognition of esophageal perforation may prevent morbidity and mortality, and accurate diagnostic imaging facilitates triage. Stable patients with suspected perforation may be transferred to higher levels of care before appropriate work-up and diagnosis confirmation. We reviewed patients transferred for esophageal perforation to critically analyze the diagnostic workflow. Methods: We performed a retrospective review of patients transferred to our tertiary care institution from 2015-2021 for suspected esophageal perforation. Demographics, referring site characteristics, diagnostic studies, and management were analyzed. Bivariate comparisons were performed using Wilcoxon-Mann-Whitney tests for continuous variables and chi-squared or Fisher's exact tests for categorical variables. Results: Sixty-five patients were included. Etiology of suspected perforation was spontaneous in 53.8% and iatrogenic in 33.8%. Most patients were transferred within 24 hours from time of suspected perforation (66.2%). Transferring sites included seven states and were 101-300 miles (32.3%) or >300 miles (26.2%) away. CT imaging was obtained in 96.9% before transfer, most commonly demonstrating pneumomediastinum (46.2%). Only 21.5% of patients had an esophagram before transfer. Following transfer, 36.9% (n=24) were ultimately not found to have esophageal perforation, demonstrated by negative arrival esophagram in 79.1%. In patients with confirmed perforation (n=41), 58.5% had surgery, 26.8% endoscopic intervention, and 14.6% supportive care. Conclusions: After transfer a proportion of patients were ultimately found to not have esophageal perforation, typically demonstrated by negative esophagram upon arrival. We conclude that a recommendation of performing esophagram at the presenting site, when possible, may prevent unnecessary transfers, and will likely reduce costs, conserve resources, and decrease management delays.

Emergency thoracic surgery patients have worse risk-adjusted outcomes than non-emergency patients.

BACKGROUND: Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations. METHODS: We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005-2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with "emergency status" as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors. RESULTS: Of 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery. CONCLUSION: Patients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.

Formative evaluation of the development and implementation of the automated surveillance of postoperative infections tool.

BACKGROUND: The gold standard for detecting postoperative complications uses databases like the American College of Surgeons National Surgical Quality Improvement Program, a multi-centered database based on manual chart review. However, their limitations and costs have led many centers to discontinue participation. Novel techniques to detect postoperative complications must be developed and implemented with surgeon involvement, which is paramount to their adoption. We sought to assess surgeons' opinions of a newly developed postoperative complication detection tool, the Automated Surveillance of Postoperative Infections, within the contextual clinical environment. METHODS: This was a multi-site qualitative formative evaluation of surgeon perceptions of the Automated Surveillance of Postoperative Infections. We conducted semi-structured interviews and focus groups with surgeons and presented the Automated Surveillance of Postoperative Infections concept. Important domains and constructs, as categorized by Consolidated Framework for Implementation Research, were identified to support the successful adoption and implementation of the Automated Surveillance of Postoperative Infections. RESULTS: Twenty-four surgeons with 10 surgical subspecialties were interviewed. The following 4 main themes were found: (1) perception of the Automated Surveillance of Postoperative Infections tool-to provide important data that can improve and support clinical outcomes; (2) environment for implementation-description of factors to support or impede implementation; (3) adaptability of the Automated Surveillance of Postoperative Infections-to work with the complexity of surgical cases; and (4) the Automated Surveillance of Postoperative Infections report format and details. CONCLUSIONS: We successfully captured the perspectives and suggestions of surgeons to improve the Automated Surveillance of Postoperative Infections and potential barriers during the initial development phase. Barriers included fear of punitive action from reports and complex surgical cases. Facilitators identified were the need to improve clinical outcomes and organizational support. The results of this formative evaluation will be used to further develop Automated Surveillance of Postoperative Infections, starting with a prototype, the Automated Surveillance of Postoperative Infections 1.0.

Preoperative risk factors and postoperative complications associated with mortality after outpatient surgery in a broad surgical population: an analysis of 2.8 million ACS-NSQIP patients.

BACKGROUND: Thirty-day mortality after outpatient surgery is unexpected and undesired. We investigated preoperative risk factors, operative variables, and postoperative complications associated with 30-day death after outpatient surgery. METHODS: Using the 2005 to 2018 American College of Surgeons National Surgical Quality Improvement Program database, we evaluated 30-day mortality rate trends over time after outpatient operations. We analyzed associations between 37 preoperative variables, operation time, hospital length of stay, and 9 postoperative complications with mortality rate using χ2 analyses for categorical data and tests for continuous data. We used forward selection logistic regression models to determine the best predictors of mortality preoperatively and postoperatively. We also separately analyzed mortality by age group. RESULTS: A total of 2,822,789 patients were included. The 30-day mortality rate did not change significantly over time (P = .34, Cochran-Armitage trend test), remaining steady at around 0.06%. The most significant preoperative predictors of mortality included the patient having disseminated cancer, decreased functional health status, increased American Society of Anesthesiology Physical Status classification, increased age, and ascites, accounting for 95.8% (0.837/0.874) of the full model c-index. The most significant postoperative complications associated with increased risk of mortality included having cardiac (26.95% yes vs 0.04% no), pulmonary (10.25% vs 0.04%), stroke (9.22% vs 0.06%), and renal (9.33% vs 0.06%) complications. Postoperative complications conferred a greater risk for mortality than preoperative variables. Mortality risk increased incrementally with age, particularly past age 80. CONCLUSION: The operative mortality rate after outpatient surgery has not changed over time. Patients over 80 years with disseminated cancer, decreased functional health status, or increased ASA class should generally be considered for inpatient surgery. However, there might be some circumstances where outpatient surgery could be considered.

Development and validation of a multivariable preoperative prediction model for postoperative length of stay in a broad inpatient surgical population.

BACKGROUND: Postoperative length of stay is a meaningful patient-centered outcome and an important determinant of healthcare costs. The Surgical Risk Preoperative Assessment System preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict postoperative length of stay has not been assessed. We aimed to determine whether the Surgical Risk Preoperative Assessment System variables could accurately predict postoperative length of stay up to 30 days in a broad inpatient surgical population. METHODS: This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database from 2012 to 2018. A model using the Surgical Risk Preoperative Assessment System variables and a 28-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program preoperative nonlaboratory variables, were fit to the analytical cohort (2012-2018) using multiple linear regression and compared using model performance metrics. Internal chronological validation of the Surgical Risk Preoperative Assessment System model was conducted using training (2012-2017) and test (2018) datasets. RESULTS: We analyzed 3,295,028 procedures. The adjusted R2 for the Surgical Risk Preoperative Assessment System model fit to this cohort was 93.3% of that for the full model (0.347 vs 0.372). In the internal chronological validation of the Surgical Risk Preoperative Assessment System model, the adjusted R2 for the test dataset was 97.1% of that for the training dataset (0.3389 vs 0.3489). CONCLUSION: The parsimonious Surgical Risk Preoperative Assessment System model can preoperatively predict postoperative length of stay up to 30 days for inpatient surgical procedures almost as accurately as a model using all 28 American College of Surgeons' National Surgical Quality Improvement Program preoperative nonlaboratory variables and has shown acceptable internal chronological validation.

A comparison of the National Surgical Quality Improvement Program and the Society of Thoracic Surgery Cardiac Surgery preoperative risk models: a cohort study.

BACKGROUND: Cardiac surgery prediction models and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have not been reported. The authors sought to develop preoperative prediction models and estimates of postoperative outcomes for cardiac surgery using the ACS-NSQIP and compare these to the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD). METHODS: In a retrospective analysis of the ACS-NSQIP data (2007-2018), cardiac operations were identified using cardiac surgeon primary specialty and sorted into cohorts of coronary artery bypass grafting (CABG) only, valve surgery only, and valve+CABG operations using CPT codes. Prediction models were created using backward selection of the 28 non-laboratory preoperative variables in ACS-NSQIP. Rates of nine postoperative outcomes and performance statistics of these models were compared to published STS 2018 data. RESULTS: Of 28 912 cardiac surgery patients, 18 139 (62.8%) were CABG only, 7872 (27.2%) were valve only, and 2901 (10.0%) were valve+CABG. Most outcome rates were similar between the ACS-NSQIP and STS-ACSD, except for lower rates of prolonged ventilation and composite morbidity and higher reoperation rates in ACS-NSQIP (all P <0.0001). For all 27 comparisons (9 outcomes × 3 operation groups), the c-indices for the ACS-NSQIP models were lower by an average of ~0.05 than the reported STS models. CONCLUSIONS: The ACS-NSQIP preoperative risk models for cardiac surgery were almost as accurate as the STS-ACSD models. Slight differences in c-indexes could be due to more predictor variables in STS-ACSD models or the use of more disease- and operation-specific risk variables in the STS-ACSD models.

Social vulnerability is associated with increased postoperative morbidity following esophagectomy.

OBJECTIVES: The effect of a patient's Social Vulnerability Index (SVI) on complication rates after esophagectomy remains unstudied. The purpose of this study was to determine how social vulnerability influences morbidity following esophagectomy. METHODS: This was a retrospective review of a prospectively collected esophagectomy database at one academic institution, 2016 to 2022. Patients were grouped into low-SVI (<75%ile) and high-SVI (>75%ile) cohorts. The primary outcome was overall postoperative complication rate; secondary outcomes were rates of individual complications. Perioperative patient variables and postoperative complication rates were compared between the 2 groups. Multivariable logistic regression was used to control for covariates. RESULTS: Of 149 patients identified who underwent esophagectomy, 27 (18.1%) were in the high-SVI group. Patients with high SVI were more likely to be of Hispanic ethnicity (18.5% vs 4.9%, P = .029), but there were no other differences in perioperative characteristics between groups. Patients with high SVI were significantly more likely to develop a postoperative complication (66.7% vs 36.9%, P = .005) and had greater rates of postoperative pneumonia (25.9% vs 6.6%, P = .007), jejunal feeding-tube complications (14.8% vs 3.3%, P = .036), and unplanned intensive care unit readmission (29.6% vs 12.3%, P = .037). In addition, patients with high SVI had a longer postoperative hospital length of stay (13 vs 10 days, P = .017). There were no differences in mortality rates. These findings persisted on multivariable analysis. CONCLUSIONS: Patients with high SVI have greater rates of postoperative morbidity following esophagectomy. The effect of SVI on esophagectomy outcomes warrants further investigation and may prove useful in identifying populations that benefit from interventions to mitigate these complications.

The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis.

BACKGROUND: The number of obese surgical patients continues to grow, and yet obesity's association with surgical outcomes is not totally clear. This study examined the association between obesity and surgical outcomes across a broad surgical population using a very large sample size. METHODS: This was an analysis of the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement database, including all patients from 9 surgical specialties (general, gynecology, neurosurgery, orthopedics, otolaryngology, plastics, thoracic, urology, and vascular). Preoperative characteristics and postoperative outcomes were compared by body mass index class (normal weight 18.5-24.9 kg/m2, overweight 25.0-29.9, obese class I 30.0-34.9, obese II 35.0-39.9, obese III ≥40). Adjusted odds ratios were computed for adverse outcomes by body mass index class. RESULTS: A total of 5,572,019 patients were included; 44.6% were obese. Median operative times were marginally higher for obese patients (89 vs 83 minutes, P < .001). Compared to normal weight patients, overweight and obese patients in classes I, II, and III all had higher adjusted odds of developing infection, venous thromboembolism, and renal complications, but they did not exhibit elevated odds of other postoperative complications (mortality, overall morbidity, pulmonary, urinary tract infection, cardiac, bleeding, stroke, unplanned readmission, or discharge not home (except for class III patients). CONCLUSION: Obesity was associated with increased odds of postoperative infection, venous thromboembolism, and renal but not the other American College of Surgeons National Surgical Quality Improvement complications. Obese patients need to be carefully managed for these complications.