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Mark E Cohen,
Clifford Y Ko,
Karl Y Bilimoria,
Lynn Zhou,
Kristopher Huffman,
Xue Wang,
Yaoming Liu,
Kari Kraemer,
Xiangju Meng,
Ryan Merkow,
Warren Chow,
Brian Matel,
Karen Richards,
Amy J Hart,
Justin B Dimick, Bruce L Hall
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ABSTRACT: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) collects detailed clinical data from participating hospitals using standardized data definitions, analyzes these data, and provides participating hospitals with reports that permit risk-adjusted comparisons with a surgical quality standard. Since its inception, the ACS NSQIP has worked to refine surgical outcomes measurements and enhance statistical methods to improve the reliability and validity of this hospital profiling. From an original focus on controlling for between-hospital differences in patient risk factors with logistic regression, ACS NSQIP has added a variable to better adjust for the complexity and risk profile of surgical procedures (procedure mix adjustment) and stabilized estimates derived from small samples by using a hierarchical model with shrinkage adjustment. New models have been developed focusing on specific surgical procedures (eg, "Procedure Targeted" models), which provide opportunities to incorporate indication and other procedure-specific variables and outcomes to improve risk adjustment. In addition, comparative benchmark reports given to participating hospitals have been expanded considerably to allow more detailed evaluations of performance. Finally, procedures have been developed to estimate surgical risk for individual patients. This article describes the development of, and justification for, these new statistical methods and reporting strategies in ACS NSQIP.
Journal of the American College of Surgeons 04/2013; · 4.55 Impact Factor
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ABSTRACT: OBJECTIVE:: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure. BACKGROUND:: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target. METHODS:: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds. RESULTS:: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%-26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008. CONCLUSIONS:: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.
Annals of surgery 01/2013; · 7.90 Impact Factor
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ABSTRACT: : Although risk-adjusted morbidity is widely used as a surgical quality indicator, it may not always be a reliable indicator of hospital quality. In this study, we assess the value of a novel composite measure for improving the reliability of hospital morbidity rankings.
: Using data from the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP), we studied all patients undergoing 4 surgical procedures (2008-2009): colectomy, ventral hernia repair, abdominal aortic aneurysm repair, and lower extremity bypass surgery. For these procedures, we created a composite measure by combining quality indicators from several distinct domains of quality: morbidity, reoperation, length of stay, and morbidity with other potentially related procedures. We empirically weighted each measure and adjusted for reliability using empirical Bayes techniques. To validate this approach, we assessed how well composite measures from 1 year (2008) predict morbidity in the next year (2009) compared with the standard ACS-NSQIP approach for assessing hospital rates of risk-adjusted morbidity.
: For all 4 operations, the composite measures explained a higher proportion of hospital-level variation in morbidity than the standard approach: ventral hernia repair (58% for the composite vs 8% for the standard approach), colon resection (33% vs 14%), abdominal aortic aneurysm repair (51% vs 38%), and lower extremity bypass surgery (32% vs 3%). When evaluating the ability to discriminate future performance, the composite approach performed best for ventral hernia repair. For this procedure, the bottom 20% of hospitals based on the composite approach had nearly threefold higher (odds ratio: 2.65; 95% confidence interval: 1.83-3.85) morbidity rates than the top 20% of hospitals. However, when using the standard approach, there was only a 1.3-fold difference (odds ratio: 1.30; 95% confidence interval: 0.87-1.96). Although the differences were smaller in magnitude, the composite measure also outperformed the standard approach for the other 3 procedures.
: Composite measures better reflect hospital quality than simple rates of risk-adjusted morbidity. In the context of ACS-NSQIP, composite measures would give hospitals a better sense of where they stand and help identify truly exemplary hospitals for benchmarking.
Annals of surgery 01/2013; 257(1):67-72. · 7.90 Impact Factor
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ABSTRACT: The measurement of hospital quality based on outcomes requires risk adjustment. The c-statistic is a popular tool used to judge model performance, but can be limited, particularly when evaluating specific operations in focused populations. Our objectives were to examine the interpretation and relevance of the c-statistic when used in models with increasingly similar case mix and to consider an alternative perspective on model calibration based on a graphical depiction of model fit.
From the American College of Surgeons National Surgical Quality Improvement Program (2008-2009), patients were identified who underwent a general surgery procedure, and procedure groups were increasingly restricted: colorectal-all, colorectal-elective cases only, and colorectal-elective cancer cases only. Mortality and serious morbidity outcomes were evaluated using logistic regression-based risk adjustment, and model c-statistics and calibration curves were used to compare model performance.
During the study period, 323,427 general, 47,605 colorectal-all, 39,860 colorectal-elective, and 21,680 colorectal cancer patients were studied. Mortality ranged from 1.0% in general surgery to 4.1% in the colorectal-all group, and serious morbidity ranged from 3.9% in general surgery to 12.4% in the colorectal-all procedural group. As case mix was restricted, c-statistics progressively declined from the general to the colorectal cancer surgery cohorts for both mortality and serious morbidity (mortality: 0.949 to 0.866; serious morbidity: 0.861 to 0.668). Calibration was evaluated graphically by examining predicted vs observed number of events over risk deciles. For both mortality and serious morbidity, there was no qualitative difference in calibration identified between the procedure groups.
In the present study, we demonstrate how the c-statistic can become less informative and, in certain circumstances, can lead to incorrect model-based conclusions, as case mix is restricted and patients become more homogenous. Although it remains an important tool, caution is advised when the c-statistic is advanced as the sole measure of a model performance.
Journal of the American College of Surgeons 03/2012; 214(5):822-30. · 4.55 Impact Factor
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ABSTRACT: Reliability adjustment, a novel technique for quantifying and removing statistical "noise" from quality rankings, is becoming more widely used outside surgery. We sought to evaluate its impact on hospital outcomes assessed with the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP).
We used prospective, clinical data from the ACS-NSQIP to identify all patients undergoing colon resection in 2007 (n = 181 hospitals, n = 18,455 patients). We first used standard NSQIP techniques to generate risk-adjusted mortality and morbidity rates for each hospital. Using hierarchical logistic regression models, we then adjusted these for reliability using empirical Bayes techniques. To evaluate the impact of reliability adjustment, we first estimated the extent to which hospital-level variation was reduced. We then compared hospital mortality and morbidity rankings and outlier status before and after reliability adjustment.
Reliability adjustment greatly diminished apparent variation in hospital outcomes. For risk-adjusted mortality, there was a 6-fold difference before (1.4%-7.8%) and less than a 2-fold difference (3.2% to 5.7%) after reliability adjustment. For risk-adjusted morbidity, there was a 2-fold difference (18.0%-38.2%) before and a 1.5-fold difference (20.8%-34.8%) after reliability adjustment. Reliability adjustment had a large impact on hospital mortality and morbidity rankings. For example, with rankings based on mortality, 44% (16 hospitals) of the "best" hospitals (top 20%) were reclassified after reliability adjustment. Similarly, 22% (8 hospitals) of the "worst" hospitals (bottom 20%) were reclassified after reliability adjustment.
Reliability adjustment reduces variation due to statistical noise and results in more accurate estimates of risk-adjusted hospital outcomes. Given the risk of misclassifying hospitals and surgeons using standard approaches, this technique should be considered when reporting surgical outcomes.
Annals of surgery 03/2012; 255(4):703-7. · 7.90 Impact Factor
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ABSTRACT: Postoperative complications are key outcomes of surgical procedures, but currently there is no uniform quantitative measure of complication severity. The purpose of this study was to evaluate and establish feasibility of quantitative morbidity scores for several common abdominal surgical procedures.
Using American College of Surgeons' National Surgical Quality Improvement Program data, complications were identified in 5 common abdominal procedures for one institution in 2005-2008, including inguinal hernia, appendectomy, laparoscopic colectomy, hepatectomy, and pancreaticoduodenectomy. Complications were graded by the 6-level "expanded" Accordion Severity Grading System. Quantification was performed using severity scores described previously.
Six hundred and seventy-six procedures were identified, including 88 patients (13.84%) who had complications and 5 patients (0.79%) who died. After severity weighting, the postoperative morbidity index (PMI) for each procedure was derived. An index of 0 would indicate no complication in any patient and an index of 1.000 would indicate that all operated patients died. PMIs were hernia repair 0.005; appendectomy 0.031; laparoscopic colectomy 0.082; hepatectomy 0.145; and pancreaticoduodenectomy 0.150. PMI of hepatectomy was greatly affected by the presence of a second procedure, ie, 0.070 without a second procedure and 0.427 with a second procedure. Weighted severity spectragrams were developed, portraying the impact of each grade of complication on overall morbidity.
Quantification of severity of postoperative complications is possible using American College of Surgeons' National Surgical Quality Improvement Program methods and the Accordion Severity Grading System. Procedural PMI can be useful in assessing surgical outcomes. Certain limitations, particularly the need for risk adjustment, still need to be addressed.
Journal of the American College of Surgeons 08/2011; 213(5):616-26. · 4.55 Impact Factor
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ABSTRACT: The aim of the study was to compare the cost-effectiveness of different imaging strategies for the diagnosis of pediatric intussusception using a decision analytic model.
A Markov decision model was constructed to model effects of radiation exposure at the time of intussusception in a hypothetical cohort of 2-year-old children. The 2 strategies compared were ultrasound followed conditionally by contrast enema (US/CE) vs contrast enema (CE) alone. The model simulated short-term and long-term outcomes of the patients, calculating the average quality-adjusted life years (QALYs) and health care costs associated with each arm.
The use of ultrasound as a first-line diagnostic modality would result in a decrease of 79.3 and 59.7 cases of radiation-induced malignancy per 100,000 male and female children evaluated, respectively. For male and female children with intussusception, US/CE was both the most costly initial imaging strategy and the most effective compared with CE. The incremental cost-effectiveness ratios of US/CE to CE was $70,100 (boy) and $92,227 (girl) per quality-adjusted life years gained.
In a Markov decision model of pediatric acute intussusception, initial US/CE was both the most costly and the most effective strategy.
Journal of Pediatric Surgery 06/2011; 46(6):1099-105. · 1.45 Impact Factor
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ABSTRACT: We aimed to determine whether hospital-level surgical performance was similar across outpatient and inpatient settings.
The majority of surgical procedures in the United States are performed in an outpatient setting but most quality improvement focuses on inpatient care.
Using data from the 2006 to 2008 American College of Surgeons- National Surgical Quality Improvement Program, risk-adjusted hospital observed to expected ratios for morbidity and mortality were compared for inpatient and outpatient cases. In addition, hospital outpatient performance in each year was compared with performances in subsequent years.
Hospitals demonstrated variation in outcomes for outpatient morbidity with both good and poor outliers in each year. Outpatient mortality was so rare as to not support robust modeling. There was a lack of congruence between hospital performance for outpatient morbidity and either inpatient morbidity or inpatient mortality in each year, indicating that inpatient performance is not interchangeable with outpatient performance. Outpatient morbidity performance correlation between years was only moderate (correlations 0.449-0.534, all P < 0.001) indicating that although outcomes from 1 year mildly predict subsequent years, substitution of data would likely lead to missed opportunities for improvement.
Assessments of risk-adjusted hospital-level outpatient morbidity performance demonstrate (1) variability across American College of Surgeons- National Surgical Quality Improvement Program sites; (2) a lack of congruence between outpatient morbidity performance and either inpatient morbidity or mortality performance; (3) year-to-year variation of outpatient morbidity performance at individual institutions. Continuing evaluation of both outpatient and inpatient outcomes is supported. Given the substantial volume of outpatient care delivered, outpatient assessments are likely to be an important component of ongoing quality improvement efforts.
Annals of surgery 03/2011; 253(3):611-8. · 7.90 Impact Factor
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ABSTRACT: Although the training of surgical residents is often considered in national policy addressing complications and safety, the influence of resident intraoperative involvement on surgical outcomes has not been well studied.
We identified 607,683 surgical cases from 234 hospitals from the 2006 to 2009 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Outcomes were compared by resident involvement for all general and vascular cases as well as for specific general surgical procedures.
After typical ACS NSQIP comorbidity risk adjustment and further adjustment for hospital teaching status and operative time in modeling, resident intraoperative involvement was associated with slightly increased morbidity when assessing overall general or vascular procedures (odds ratio [OR] 1.06; 95% CI 1.04 to 1.09), pancreatectomy or esophagectomy (OR 1.26; 95% CI 1.08 to 1.45), and colorectal resections (OR 1.15; 95% CI 1.09 to 1.22). In contrast, for mortality, resident intraoperative involvement was associated with reductions for overall general and vascular procedures (OR 0.91; 95% CI 0.84 to 0.99), colorectal resections (OR 0.88; 95% CI 0.78 to 0.99), and abdominal aortic aneurysm repair (OR 0.71; 95% CI 0.53 to 0.95). Results were moderated somewhat after hierarchical modeling was performed to account for hospital-level variation, with mortality results no longer reaching significance (overall morbidity OR 1.07; 95% CI 1.03 to 1.10, overall mortality OR 0.97; 95% CI 0.90 to 1.05). Based on risk-adjusted event rates, resident intraoperative involvement is associated with approximately 6.1 additional morbidity events but 1.4 fewer deaths per 1,000 general and vascular surgery procedures.
Resident intraoperative participation is associated with slightly higher morbidity rates but slightly decreased mortality rates across a variety of procedures and is minimized further after taking into account hospital-level variation. These clinically small effects may serve to reassure patients and others that resident involvement in surgical care is safe and possibly protective with regard to mortality.
Journal of the American College of Surgeons 03/2011; 212(5):889-98. · 4.55 Impact Factor
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ABSTRACT: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) empowers surgeons and medical centers to reliably collect, analyze, and act on clinically collected outcomes data. How individual ACS NSQIP leaders designated as Surgeon Champions (SC) utilize the ACS NSQIP at the hospital level and the obstacles they encounter are not well studied.
All SC representing the 236 hospitals participating in the ACS NSIQP were invited to complete a survey designed to assess the role of the SC, data use, continuous quality improvement (CQI) efforts, CQI culture, and financial implications.
We received responses from 109 (46.2%) SC. The majority (72.5%) of SC were not compensated for their CQI efforts. Factors associated with demonstrable CQI efforts included longer duration of participation in the program, frequent meetings with clinical reviewers, frequent presentation of data to administration, compensation for Surgical Champion efforts and providing individual surgeons with feedback (all P < 0.05). Almost all SC stated ACS NSQIP data improved the quality of care that patients received at the hospital level (92.4%) and that the ACS NSQIP provided data that could not be obtained by other sources (95.2%). All SCs considered future funding for participation in the ACS NSQIP secure.
Active use of ACS NSQIP data provide SC with demonstrable CQI by regularly reviewing data, having frequent interaction with clinical reviewers, and frequently sharing data with hospital administration and colleagues. SC thus play a key role in successful quality improvement at the hospital level.
Journal of Surgical Research 03/2011; 166(1):e15-25. · 2.25 Impact Factor
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ABSTRACT: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) provides validated assessment of surgical outcomes. This study reports initiation of an ACS NSQIP Pediatric at 4 children's hospitals.
From October 2008 to June 2009, 121 data variables were prospectively collected for 3315 patients, including 30-day outcomes and tailoring the ACS NSQIP methodology to children's surgical specialties.
Three hundred seven postoperative complications/occurrences were detected in 231 patients representing 7.0% of the study population. Of the patients with complications, 175 (75.7%) had 1, 39 (16.9%) had 2, and 17 (7.4%) had 3 or more complications. There were 13 deaths (0.39%) and 14 intraoperative occurrences (0.42%) detected. The most common complications were infection, 105 (34%) (SSI, 54; sepsis, 31; pneumonia, 13; urinary tract infection, 7); airway/respiratory events, 27 (9%); wound disruption, 18 (6%); neurologic events, 8 (3%) (nerve injury, 4; stroke/vascular event, 2; hemorrhage, 2); deep vein thrombosis, 3 (<1%); renal failure, 3 (<1%); and cardiac events, 3 (<1%). Current sampling captures 17.5% of cases across institutions with unadjusted complication rates ranging from 6.8% to 10.2%. Completeness of data collection for all variables exceeded 95% with 98% interrater reliability and 87% of patients having full 30-day follow-up.
These data represent the first multiinstitutional prospective assessment of specialty-specific surgical outcomes in children. The ACS NSQIP Pediatric is poised for institutional expansion and future development of risk-adjusted models.
Journal of Pediatric Surgery 01/2011; 46(1):115-21. · 1.45 Impact Factor
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ABSTRACT: Risk-adjusted evaluation is a key component of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). The purpose of this study was to improve standard ACS NSQIP risk adjustment using a novel procedure risk score.
Current Procedural Terminology codes (CPTs) represented in ACS NSQIP data were assigned to 136 procedure groups. Log odds predicted risk from preliminary logistic regression modeling generated a continuous risk score for each procedure group, used in subsequent modeling. Appropriate subsets of 271,368 patients in the 2008 ACS NSQIP were evaluated using logistic models for overall 30-day morbidity, 30-day mortality, and surgical site infection (SSI). Models were compared when including either work Relative Value Unit (RVU), RVU and the standard ACS NSQIP CPT range variable (CPT range), or RVU and the newly constructed CPT risk score (CPT risk), plus routine ACS NSQIP predictors.
When comparing the CPT risk models with the CPT range models for morbidity in the overall general and vascular surgery dataset, CPT risk models provided better discrimination through higher c statistics at earlier steps (0.81 by step 3 vs 0.81 by step 46), more information through lower Akaike's information criterion (127,139 vs 130,019), and improved calibration through a smaller Hosmer-Lemeshow chi-square statistic (48.76 vs 116.79). Improved model characteristics of CPT risk over CPT range were most apparent for broader patient populations and outcomes. The CPT risk and standard CPT range models were moderately consistent in identification of outliers as well as assignment of hospitals to quality deciles (weighted kappa ≥ 0.870).
Information from focused, clinically meaningful CPT procedure groups improves the risk estimation of ACS NSQIP models.
Journal of the American College of Surgeons 12/2010; 211(6):715-23. · 4.55 Impact Factor
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ABSTRACT: Facility-level process measure adherence is being publicly reported. However, the association between measure adherence and surgical outcomes is not well-established. Our objective was to determine the degree to which Surgical Care Improvement Project (SCIP) process measures are associated with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk-adjusted outcomes.
This cross-sectional study included hospitals participating in the ACS NSQIP and SCIP (n = 200). ACS NSQIP outcomes (30-day overall morbidity, serious morbidity, surgical site infections [SSI], and mortality) and adherence to SCIP SSI-related process measures (from the Hospital Compare database) were collected from January 1, 2008, through December 31, 2008. Hospital-level correlation coefficients between compliance with 4 process measures (ie, antibiotic administration within 1 hour before incision [SCIP-1]; appropriate antibiotic prophylaxis [SCIP-2]; antibiotic discontinuation within 24 hours after surgery [SCIP-3]; and appropriate hair removal [SCIP 6]) and 4 risk-adjusted outcomes were calculated. Regression analyses estimated the contribution of process measure adherence to risk-adjusted outcomes.
Of 211 ACS NSQIP hospitals, 95% had data reported by Hospital Compare. Depending on the measure, hospital-level compliance ranged from 60% to 100%. Of the 16 correlations, 15 demonstrated nonsignificant associations with risk-adjusted outcomes. The exception was the relationship between SCIP-2 and SSI (p = 0.004). SCIP-1 demonstrated an intriguing but nonsignificant relationship with SSI (p = 0.08) and overall morbidity (p = 0.08). Although adherence to SCIP-2 was a significant predictor of risk-adjusted SSI (p < 0.0001) and overall morbidity (p < 0.0001), inclusion of compliance for SCIP-1 and SCIP-2 caused only slight improvement in model quality.
Better adherence to infection-related process measures over the observed range was not significantly associated with better outcomes with one exception. Different measures of quality might be needed for surgical infection.
Journal of the American College of Surgeons 12/2010; 211(6):705-14. · 4.55 Impact Factor
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Annals of surgery 11/2010; 252(5):892. · 7.90 Impact Factor
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Annals of Surgical Oncology 11/2010; 18 Suppl 3:S295; author reply S296. · 4.17 Impact Factor
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ABSTRACT: Surgeons and hospitals are being increasingly assessed by third parties regarding surgical quality and outcomes, and much of this information is reported publicly. Our objective was to compare various methods used to classify hospitals as outliers in established surgical quality assessment programs by applying each approach to a single data set.
Using American College of Surgeons National Surgical Quality Improvement Program data (7/2008-6/2009), hospital risk-adjusted 30-day morbidity and mortality were assessed for general surgery at 231 hospitals (cases = 217,630) and for colorectal surgery at 109 hospitals (cases = 17,251). The number of outliers (poor performers) identified using different methods and criteria were compared.
The overall morbidity was 10.3% for general surgery and 25.3% for colorectal surgery. The mortality was 1.6% for general surgery and 4.0% for colorectal surgery. Programs used different methods (logistic regression, hierarchical modeling, partitioning) and criteria (P < 0.01, P < 0.05, P < 0.10) to identify outliers. Depending on outlier identification methods and criteria employed, when each approach was applied to this single dataset, the number of outliers ranged from 7 to 57 hospitals for general surgery morbidity, 1 to 57 hospitals for general surgery mortality, 4 to 27 hospitals for colorectal morbidity, and 0 to 27 hospitals for colorectal mortality.
There was considerable variation in the number of outliers identified using different detection approaches. Quality programs seem to be utilizing outlier identification methods contrary to what might be expected, thus they should justify their methodology based on the intent of the program (i.e., quality improvement vs. reimbursement). Surgeons and hospitals should be aware of variability in methods used to assess their performance as these outlier designations will likely have referral and reimbursement consequences.
Journal of Gastrointestinal Surgery 10/2010; 14(10):1600-7. · 2.83 Impact Factor
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ABSTRACT: There has been a long-standing desire to implement a multi-institutional, multispecialty program to address surgical quality improvement for children. This report documents results of the initial phase of the American College of Surgeons National Surgical Quality Improvement Program Pediatric.
From October 2008 to December 2009, patients from 4 pediatric referral centers were sampled using American College of Surgeons National Surgical Quality Improvement Program methodology tailored to children.
A total of 7,287 patients were sampled, representing general/thoracic surgery (n = 2,237; 30.7%), otolaryngology (n = 1,687; 23.2%), orthopaedic surgery (n = 1,367; 18.8%), urology (n = 893; 12.3%), neurosurgery (n = 697; 9.6%), and plastic surgery (n = 406; 5.6%). Overall mortality rate detected was 0.3% and 287 (3.9%) patients had postoperative occurrences. After accounting for demographic, preoperative, and operative factors, occurrences were 4 times more likely in those undergoing inpatient versus outpatient procedures (odds ratio [OR] = 4.71; 95% CI, 3.01-7.35). Other factors associated with higher likelihood of postoperative occurrences included nutritional/immune history, such as preoperative weight loss/chronic steroid use (OR = 1.49; 95% CI, 1.03-2.15), as well as physiologic compromise, such as sepsis/inotrope use before surgery (OR = 1.68; 95% CI, 1.10-1.95). Operative factors associated with occurrences included multiple procedures under the same anesthetic (OR = 1.58; 95% CI, 1.21-2.06) and American Society of Anesthesiologists classification category 4/5 versus 1 (OR = 5.74; 95% CI, 2.94-11.24). Specialty complication rates varied from 1.5% for otolaryngology to 9.0% for neurosurgery (p < 0.001), with specific procedural groupings within each specialty accounting for the majority of complications. Although infectious complications were the predominant outcomes identified across all specialties, distribution of complications varied by specialty.
Based on this initial phase of development, the highly anticipated American College of Surgeons National Surgical Quality Improvement Program Pediatric has the potential to identify outcomes of children's surgical care that can be targeted for quality improvement efforts.
Journal of the American College of Surgeons 10/2010; 212(1):1-11. · 4.55 Impact Factor
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Journal of the American College of Surgeons 09/2010; 211(3):435-6. · 4.55 Impact Factor
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ABSTRACT: To examine the effect of delay from surgical admission to induction of anesthesia on outcomes after appendectomy for acute appendicitis in adults.
Retrospective cohort study with the principal exposure being time to operation. Regression models yielded probabilities of outcomes adjusted for patient and operative risk factors.
Data were submitted to the American College of Surgeons National Surgical Quality Improvement Program database from January 1, 2005, through December 31, 2008.
Patients with acute appendicitis who underwent an appendectomy.
Thirty-day overall morbidity and serious morbidity/mortality.
Of 32,782 patients, 24,647 (75.2%) underwent operations within 6 hours of surgical admission, 4934 (15.1%) underwent operations more than 6 through 12 hours, and 3201 (9.8%) underwent operations more than 12 hours after surgical admission. Differences in operative duration (51, 50, and 55 minutes, respectively; P < .001) were statistically significant but not clinically meaningful. The length of postoperative stay (2.2 days for the >12-hour group vs 1.8 days for the remaining groups; P < .001) was statistically significant but not clinically meaningful. No significant differences were found in adjusted overall morbidity (5.5%, 5.4%, and 6.1%, respectively; P = .33) or serious morbidity/mortality (3.0%, 3.6%, and 3.0%, respectively; P = .17). Duration from surgical admission to induction of anesthesia was not predictive in regression models for overall morbidity or serious morbidity/mortality.
In this retrospective study, delay of appendectomy for acute appendicitis in adults does not appear to adversely affect 30-day outcomes. This information can guide the use of potentially limited operative and professional resources allocated for emergency care.
Archives of surgery (Chicago, Ill.: 1960) 09/2010; 145(9):886-92. · 4.32 Impact Factor
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ABSTRACT: The morbidity of pancreatoduodenectomy remains high and the mortality may be significantly increased in high-risk patients. However, a method to predict post-operative adverse outcomes based on readily available clinical data has not been available. Therefore, the objective was to create a 'Pancreatectomy Risk Calculator' using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database.
The 2005-2008 ACS-NSQIP data on 7571 patients undergoing proximal (n = 4621), distal (n = 2552) or total pancreatectomy (n = 177) as well as enucleation (n = 221) were analysed. Pre-operative variables (n = 31) were assessed for prediction of post-operative mortality, serious morbidity and overall morbidity using a logistic regression model. Statistically significant variables were ranked and weighted to create a common set of predictors for risk models for all three outcomes.
Twenty pre-operative variables were statistically significant predictors of post-operative mortality (2.5%), serious morbidity (21%) or overall morbidity (32%). Ten out of 20 significant pre-operative variables were employed to produce the three mortality and morbidity risk models. The risk factors included age, gender, obesity, sepsis, functional status, American Society of Anesthesiologists (ASA) class, coronary heart disease, dyspnoea, bleeding disorder and extent of surgery.
The ACS-NSQIP 'Pancreatectomy Risk Calculator' employs 10 easily assessable clinical parameters to assist patients and surgeons in making an informed decision regarding the risks and benefits of undergoing pancreatic resection. A risk calculator based on this prototype will become available in the future as on online ACS-NSQIP resource.
HPB 09/2010; 12(7):488-97. · 1.60 Impact Factor
