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OBJECTIVE: To explore hospital-level variation in postoperative delirium using a multi-institutional data source. BACKGROUND: Postoperative delirium is closely related to serious morbidity, disability, and death in older adults. Yet, surgeons and hospitals rarely measure delirium rates, which limits quality improvement efforts. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Pilot (2014 to 2015) collects geriatric-specific variables, including postoperative delirium using a standardized definition. Hierarchical logistic regression models, adjusted for case mix [Current Procedural Terminology (CPT) code] and patient risk factors, yielded risk-adjusted and smoothed odds ratios (ORs) for hospital performance. Model performance was assessed with Hosmer-Lemeshow (HL) statistic and c-statistics, and compared across surgical specialties. RESULTS: Twenty thousand two hundred twelve older adults (≥65 years) underwent inpatient operations at 30 hospitals. Postoperative delirium occurred in 2427 patients (12.0%) with variation across specialties, from 4.7% in gynecology to 13.7% in cardiothoracic surgery. Hierarchical modeling with 20 risk factors (HL = 9.423, P = 0.31; c-statistic 0.86) identified 13 hospitals as statistical outliers (5 good, 8 poor performers). Per hospital, the median risk-adjusted delirium rate was 10.4% (range 3.2% to 27.5%). Operation-specific risk and preoperative cognitive impairment (OR 2.9, 95% confidence interval 2.5-3.5) were the strongest predictors. The model performed well across surgical specialties (orthopedic, general surgery, and vascular surgery). CONCLUSION: Rates of postoperative delirium varied 8.5-fold across hospitals, and can feasibly be measured in surgical quality datasets. The model performed well with 10 to 12 variables and demonstrated applicability across surgical specialties. Such efforts are critical to better tailor quality improvement to older surgical patients.
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Delírio/etiologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Complicações Pós-Operatórias , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Delírio/epidemiologia , Delírio/prevenção & controle , Estudos de Viabilidade , Feminino , Hospitais/normas , Hospitais/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Risco Ajustado , Fatores de Risco , Especialidades Cirúrgicas , Estados UnidosAssuntos
Confidencialidade , Garantia da Qualidade dos Cuidados de Saúde , Melhoria de Qualidade , Sistema de Registros , Reembolso de Incentivo , Humanos , Garantia da Qualidade dos Cuidados de Saúde/ética , Garantia da Qualidade dos Cuidados de Saúde/métodos , Garantia da Qualidade dos Cuidados de Saúde/normas , Melhoria de Qualidade/ética , Melhoria de Qualidade/normas , Sistema de Registros/ética , Sistema de Registros/normas , Reembolso de Incentivo/ética , Reembolso de Incentivo/normas , Estados UnidosRESUMO
BACKGROUND: Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS: We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS: In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION: There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.
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Traumatismos Abdominais , Laparotomia , Humanos , Estudos Retrospectivos , Pennsylvania/epidemiologia , Centros de Traumatologia , Avaliação de Resultados em Cuidados de Saúde , Escala de Gravidade do Ferimento , Traumatismos Abdominais/cirurgiaRESUMO
INTRODUCTION: Injured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality. METHODS: We queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology. RESULTS: Of 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59-0.97, p = 0.030). CONCLUSION: After adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened.
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Traumatismos Craniocerebrais , Choque , Ferimentos e Lesões , Humanos , Centros de Traumatologia , Serviço Hospitalar de Emergência , Pennsylvania/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Mortalidade Hospitalar , Escala de Gravidade do Ferimento , Estudos Retrospectivos , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions. METHODS: We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models. RESULTS: We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups. CONCLUSION: In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.
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Centros de Traumatologia , Humanos , Escala de Gravidade do Ferimento , Pennsylvania/epidemiologia , Sistema de Registros , Estudos Retrospectivos , Mortalidade HospitalarRESUMO
BACKGROUND: Although volume-outcome literature supports regionalization for complex procedures, travel may be burdensome. We assessed the relationship between overall survival and travel distance for patients undergoing pancreatic resection for adenocarcinoma. METHODS: We analyzed the Fall 2018 National Cancer Database Public Use File. We defined distance traveled as a categorical variable (<12.5 miles, 12.5-50mi, and >50mi). We analyzed overall survival (OS) as a function of distance traveled using the log rank test and Cox proportional hazards models; we estimated stratified models to assess for interaction between distance and other relevant covariates. RESULTS: In adjusted analysis of 39,089 patients, greater distance was associated with decreased OS (p = 0.0029). We found interactions between distance and center type, comorbidities, and age. Distance traveled was a negative factor for patients treated at low-volume academic centers (but not high-volume academic or non-academic centers). Additionally, distance traveled was a negative factor for OS in young, healthy patients but not geriatric, ill patients. CONCLUSION: Traveling more than 12.5 miles for pancreatic resection was associated with worse OS. Prior to regionalization, evaluation of local resources may be necessary.
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Adenocarcinoma/cirurgia , Acessibilidade aos Serviços de Saúde , Neoplasias Pancreáticas/cirurgia , Viagem , Adenocarcinoma/mortalidade , Idoso , Feminino , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Masculino , Neoplasias Pancreáticas/mortalidade , Estudos Retrospectivos , Determinantes Sociais da Saúde , Taxa de SobrevidaRESUMO
BACKGROUND: The American College of Surgeons (ACS) NSQIP Surgical Risk Calculator (SRC) plays an important role in risk prediction and decision-making. We sought to enhance the existing ACS NSQIP SRC with functionality to predict geriatric-specific outcomes and assess the predictive value of geriatric-specific risk factors by comparing performance in outcomes prediction using the traditional ACS NSQIP SRC with models that also included geriatric risk factors. STUDY DESIGN: Data were collected from 21 ACS NSQIP Geriatric Surgery Pilot Project hospitals between 2014 and 2017. Hierarchical regression models predicted 4 postoperative geriatric outcomes (ie pressure ulcer, delirium, new mobility aid use, and functional decline) using the traditional 21-variable ACS NSQIP SRC models and 27-variable models that included 6 geriatric risk factors (ie living situation, fall history, mobility aid use, cognitive impairment, surrogate-signed consent, and palliative care on admission). RESULTS: Data from 38,048 patients 65 years or older undergoing 197 unique operations across 10 surgical subspecialties were used. Stable model discrimination and calibration between developmental and validation datasets confirmed predictive validity. Models with and without geriatric risk factors demonstrated excellent performance (C statistic >0.8) with inclusion of geriatric risk factors improving performance. Of the 21 ACS NSQIP variables, CPT code, COPD, age, functional dependence, sex, disseminated cancer, diabetes, and sepsis were the strongest risk predictors, and impaired cognition, fall history, and mobility aid use were the strongest geriatric predictors. CONCLUSIONS: The ACS NSQIP SRC can predict 4 unique outcomes germane to geriatric surgical patients, with improvement of predictive capability after accounting for geriatric risk factors. Augmentation of ACS NSQIP SRC can enhance shared decision-making to improve the quality of surgical care in older adults.
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Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Medição de Risco , Procedimentos Cirúrgicos Operatórios , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Previsões , Humanos , Masculino , Fatores de Risco , Estados UnidosRESUMO
Importance: Functional outcomes have value for older adults who undergo surgical procedures. Preventing postoperative functional decline in this patient population necessitates the identification of the factors associated with this outcome and minimizing their implications. Objectives: To assess the prevalence of functional decline 30 days after a surgical procedure among older adults 80 years or older, examine the risk factors of this decline, and identify ways to minimize this decline by addressing its mutable factors. Design, Setting, and Participants: This retrospective cohort study used patient data from the Geriatric Surgery Pilot Project, a multi-institutional data registry of the American College of Surgeons National Surgical Quality Improvement Program. Inclusion criteria were patients 80 years or older who underwent a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the Geriatric Surgery Pilot Project from January 1, 2015, to December 31, 2018, and had preoperative and postoperative functional health status data. Data analysis was performed from January 7, 2019, to December 2, 2019. Exposures: Adults 80 years or older who underwent an inpatient surgical procedure. Main Outcomes and Measures: The primary outcome was 30-day postoperative functional decline defined by a change in functional health status from admission or before the surgical procedure (ie, from independent to partially or totally dependent, or from partially dependent to totally dependent). Functional health status was measured by a patient's ability to perform activities of daily living. Secondary outcomes were hospital readmission and 30-day postoperative living location. Results: Of the 2013 patients analyzed in this study, 1128 were women (56.0%) and the mean (SD) age was 84.9 (3.9) years. Functional decline at 30 days after the surgical procedure was present in 406 patients (20.2%). Prevalence of this outcome increased with age, with 337 of 1751 patients aged 80 to 89 years (19.2%) experiencing decline compared with 69 of 262 patients 90 years or older (26.3%). In a risk-adjusted model, the geriatric-specific risk factors statistically significantly associated with this outcome included preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22; P < .001) and malnutrition (OR, 1.88; 95% CI, 1.04-3.43; P = .04) as well as postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02; P < .001), pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30; P = .04), and mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59; P < .001). Among patients with a 30-day functional decline, 106 (26.1%) required hospital readmission and only 219 (53.9%) were living at home compared with 388 patients (95.6%) living at home before the procedure. Conclusions and Relevance: In this study, 1 in 5 older adults experienced a functional decline that persisted 30 days after a surgical procedure, an outcome that appeared to be associated with several geriatric-specific risk factors. Future trials are needed to evaluate whether the prevention or mitigation of these factors can decrease the rates of postoperative functional decline in this patient population.
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Atividades Cotidianas , Avaliação Geriátrica , Nível de Saúde , Recuperação de Função Fisiológica , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Fatores Etários , Idoso de 80 Anos ou mais , Feminino , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Masculino , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Projetos Piloto , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Prevalência , Melhoria de Qualidade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The American College of Surgeons Coalition for Quality in Geriatric Surgery is a multidisciplinary stakeholder group that aims to systematically improve the surgical care of older adults by establishing a verifiable quality improvement program with standards based on best evidence. Prior work confirmed the validity of a preliminary set of 308 standards to improve the quality of geriatric surgery, but concerns exist as to whether the standards are feasible for hospitals to implement. OBJECTIVE: Our aim was to utilize data gained from a multi-institutional survey and interview to improve the scalability and generalizability of a geriatric quality improvement program. METHODS: Using a survey followed by a targeted debrief interview, 15 hospitals gathered an interdisciplinary panel to answer whether each standard was already in place at their institution, and if not, the perceived difficulty of implementation according to a five-point Likert scale (from 1 [very easy] to 5 [very difficult]). The standards were then placed into categories according to the hospital responses. Standards were designated "duplicative" if 11 or more hospitals reported baseline implementation, "prohibitively difficult" if 6 or more hospitals rated the standard as such, and "high potential" if they were neither duplicative nor difficult. A targeted debrief interview was then conducted with each participating hospital. RESULTS: Fifteen participating hospitals evaluated the feasibility of 108 standards and found 28 (26%) duplicative, 35 (32%) too difficult, and 45 (42%) high potential. Of the 108 standards, 49 (45%) were selected for the next iteration of standards, and 59 were removed. Among the standards that were removed, the majority (64%) were rated duplicative and/or difficult. CONCLUSION: A multi-institutional survey and interview successfully identified care standards that were redundant or too difficult to implement on the hospital level. These data will help improve the generalizability and scalability of the program while maintaining the overall goal of improving care. J Am Geriatr Soc 67:1074-1078, 2019.
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Avaliação Geriátrica/métodos , Pesquisas sobre Atenção à Saúde/métodos , Hospitais/normas , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Procedimentos Cirúrgicos Operatórios/normas , Idoso , Estudos de Viabilidade , Feminino , Humanos , Masculino , Estados UnidosRESUMO
BACKGROUND: Racial disparities in medical treatment for seriously injured patients across the spectrum of care are well established, but racial disparities in end of life decision making practices have not been well described. When time from admission to time to withdrawal of life-sustaining treatment (WLST) increases, so does the potential for ineffective care, health care resource loss, and patient and family suffering. We sought to determine the existence and extent of racial disparities in late WLST after severe injury. METHODS: We queried the American College of Surgeons' Trauma Quality Improvement Program (2013-2016) for all severely injured patients (Injury Severity Score, > 15; age, > 16 years) with a WLST order longer than 24 hours after admission. We defined late WLST as care withdrawn at a time interval beyond the 75th percentile for the entire cohort. Univariate and multivariate analyses were performed using descriptive statistics, and t tests and χ tests where appropriate. Multivariable regression analysis was performed with random effects to account for institutional-level clustering using late WLST as the primary outcome and race as the primary predictor of interest. RESULTS: A total of 13,054 patients from 393 centers were included in the analysis. Median time to WLST was 5.4 days (interquartile range, 2.6-10.3). In our unadjusted analysis, African-American patients (10.1% vs. 7.1%, p < 0.001) and Hispanic patients (7.8% vs. 6.8%, p < 0.001) were more likely to have late WLST as compared to early WLST. After adjustment for patient, injury, and institutional characteristics, African-American (odds ratio, 1.42; 95% confidence interval, 1.21-1.67) and Hispanic (odds ratio, 1.23; 95% confidence interval, 1.04-1.46) race were significant predictors of late WLST. CONCLUSION: African-American and Hispanic race are both significant predictors of late WLST. These findings might be due to patient preference or medical decision making, but speak to the value in assuring a high standard related to identifying goals of care in a culturally sensitive manner. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.
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Tomada de Decisão Clínica/métodos , Disparidades em Assistência à Saúde/etnologia , Grupos Raciais , Suspensão de Tratamento/tendências , Ferimentos e Lesões/etnologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico , Estudos Retrospectivos , Estados Unidos/epidemiologia , Ferimentos e Lesões/psicologia , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Surgical quality datasets can be better tailored toward older adults. The American College of Surgeons (ACS) NSQIP Geriatric Surgery Pilot collected risk factors and outcomes in 4 geriatric-specific domains: cognition, decision-making, function, and mobility. This study evaluated the contributions of geriatric-specific factors to risk adjustment in modeling 30-day outcomes and geriatric-specific outcomes (postoperative delirium, new mobility aid use, functional decline, and pressure ulcers). STUDY DESIGN: Using ACS NSQIP Geriatric Surgery Pilot data (January 2014 to December 2016), 7 geriatric-specific risk factors were evaluated for selection in 14 logistic models (morbidities/mortality) in general-vascular and orthopaedic surgery subgroups. Hierarchical models evaluated 4 geriatric-specific outcomes, adjusting for hospitals-level effects and including Bayesian-type shrinkage, to estimate hospital performance. RESULTS: There were 36,399 older adults who underwent operations at 31 hospitals in the ACS NSQIP Geriatric Surgery Pilot. Geriatric-specific risk factors were selected in 10 of 14 models in both general-vascular and orthopaedic surgery subgroups. After risk adjustment, surrogate consent (odds ratio [OR] 1.5; 95% CI 1.3 to 1.8) and use of a mobility aid (OR 1.3; 95% CI 1.1 to 1.4) increased the risk for serious morbidity or mortality in the general-vascular cohort. Geriatric-specific factors were selected in all 4 geriatric-specific outcomes models. Rates of geriatric-specific outcomes were: postoperative delirium in 12.1% (n = 3,650), functional decline in 42.9% (n = 13,000), new mobility aid in 29.7% (n = 9,257), and new or worsened pressure ulcers in 1.7% (n = 527). CONCLUSIONS: Geriatric-specific risk factors are important for patient-centered care and contribute to risk adjustment in modeling traditional and geriatric-specific outcomes. To provide optimal patient care for older adults, surgical datasets should collect measures that address cognition, decision-making, mobility, and function.