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The impact of obesity on postoperative outcomes after pancreatoduodenectomy remains insufficiently studied.All pancreatoduodenectomy patients were abstracted from the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program data sets and were stratified into the following 3 body mass index categories: non-obese (body mass index 18.5-29.9), class 1/2 obesity (body mass index 30-39.9), and class 3 severe obesity (body mass index ≥ 40). Analyses tested associations between patient factors and four 30-day postoperative outcomes: mortality, composite morbidity, delayed gastric emptying, and postoperative pancreatic fistula. Multivariable logistic regression models tested independent associations between patient factors and these 4 outcome measures.A total of 16,823 patients were included in the study: 12,234 (72.7%) non-obese, 4,030 (24%) obese, and 559 (3.3%) with severe obesity. Bivariable analyses demonstrated significant associations between obesity, severe obesity, and greater proportions of numerous preoperative comorbidities as well as a greater likelihood of postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, composite morbidity, and mortality (all P ≤ .001). After adjusting for significant covariates, obesity was independently associated with postoperative pancreatic fistula (odds ratio 1.49, 95% confidence interval: 1.33-1.67, P.001), delayed gastric emptying (odds ratio 1.16, 95% confidence interval: 1.05-1.28, P = .004), composite morbidity (odds ratio 1.28, 95% confidence interval: 1.18-1.38, P .001), and mortality (odds ratio 1.79, 95% confidence interval: 1.36-2.36, P .001).Obesity and severe obesity are significantly associated with worse short-term outcomes after pancreatoduodenectomy. Preoperative considerations, such as weight management strategies during individualized treatment planning, could improve outcomes in this population.

Background Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations. Methods Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination. Results A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p 0.055). Patients 75–84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p

OBJECTIVE We hypothesize the Distressed Communities Index (DCI), a composite socioeconomic ranking by ZIP code, will predict risk-adjusted outcomes after surgery. SUMMARY OF BACKGROUND DATA Socioeconomic status affects surgical outcomes; however, the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) database does not account for these factors. METHODS All ACS NSQIP patients (17,228) undergoing surgery (2005 to 2015) at a large academic institution were paired with the DCI, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies. Developed by the Economic Innovation Group, DCI scores range from 0 (no distress) to 100 (severe distress). Multivariable regressions were used to evaluate ACS NSQIP predicted risk-adjusted effect of DCI on outcomes and inflation-adjusted hospital cost. RESULTS A total of 4522 (26.2%) patients came from severely distressed communities (top quartile). These patients had higher rates of medical comorbidities, transfer from outside hospital, emergency status, and higher ACS NSQIP predicted risk scores (all P < 0.05). In addition, these patients had greater resource utilization, increased postoperative complications, and higher short- and long-term mortality (all P < 0.05). Risk-adjustment with multivariate regression demonstrated that DCI independently predicts postoperative complications (odds ratio 1.1, P = 0.01) even after accounting for ACS NSQIP predicted risk score. Furthermore, DCI independently predicted inflation-adjusted cost (+$978/quartile, P < 0.0001) after risk adjustment. CONCLUSIONS The DCI, an established metric for socioeconomic distress, improves ACS NSQIP risk-adjustment to predict outcomes and hospital cost. These findings highlight the impact of socioeconomic status on surgical outcomes and should be integrated into ACS NSQIP risk models.

Background Perioperative efficiency has been studied, although little is known about patient and personnel factors associated with a timely operating room start. We hypothesize that patient, personnel factors, and induction-order decisions are associated with anesthesia induction time. Methods An institutional database was used to identify the anesthesia induction time of adults undergoing first-start, elective operations from January 2014 to May 2017 at an academic quaternary care center. Data included patient demographics; surgeon and anesthesiologist, as well as their seniority (years since initial board certification); certified registered nurse anesthetist versus anesthesia resident staffing; and use of neuraxial anesthesia. Times were measured as minutes from scheduled start to induction. Univariate and multivariate analyses were performed to identify factors associated with induction time. Results We identified 15,823 cases. Predictors of later induction included add-on cases (1,224 cases were add-ons, 7.73%), American Society of Anesthesiologists classification ≥ 3, neuraxial anesthesia, and certified registered nurse anesthetist staffing. Surgeon seniority—but not gender—affected induction time. In 11,093 cases (70.1%), the anesthesiologist was scheduled for multiple first starts with a choice of which patient to induce first. Surgeon gender was predictive of induction order, with cases of male surgeons induced first more frequently than female surgeons’ (47.0% vs 44.1%, P = .02). Cases staffed by anesthesiology residents were more likely to be induced first compared with those staffed by certified registered nurse anesthetists (52.1% vs 41.5%, P Conclusion Patient and personnel factors affect the order of case induction, but induction time is most dependent on patient factors. Hospitals should focus on improving preparedness and limiting bias to create a more equitable and efficient perioperative process.

BACKGROUND Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. OBJECTIVE This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. DESIGN This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. SETTINGS The study was conducted at a large academic medical center. PATIENTS All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. MAIN OUTCOME MEASURES Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. RESULTS A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). LIMITATIONS The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACION DE UN PROTOCOLO DE RECUPERACION ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CANCER COLORRECTAL:: El inicio tardio de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cancer colorrectal. Los protocolos de recuperacion acelerada colorrectales dan lugar a una disminucion de las complicaciones y la duracion de estancia hospitalaria; sin embargo, el impacto de la recuperacion acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administracion a tiempo de la quimioterapia adyuvante despues de la cirugia de cancer colorrectal, con la hipotesis de que la implementacion de un protocolo de recuperacion acelerada daria lugar a que mas pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administracion de quimioterapia adyuvante a tiempo despues de la reseccion del cancer colorrectal antes y despues de la implementacion de un protocolo de recuperacion acelerada.Centro medico academico grande.Todos los pacientes que se sometieron a resecciones de cancer colorrectal no emergentes con intencion curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenian indicacion de quimioterapia adyuvante, que recibieron quimioterapia sistemica preoperatoria o no tenian registros medicos de oncologia disponibles.Los pacientes se compararon antes y despues de la implementacion de la recuperacion acelerada, con la tasa de administracion de quimioterapia adyuvante a tiempo como el resultado primario. La administracion de quimioterapia adyuvante se considero a tiempo si se inicio ≤8 semanas despues de la operacion, y el tratamiento se considero retrasado / omitido si se inicio> 8 semanas despues de la operacion (retrasado) o nunca fue recibido (omitido). La regresion logistica multivariable identifico predictores de administracion de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusion, con 189 (52.1%) pacientes sometidos a cirugia despues de la implementacion de recuperacion acelerada. Los grupos difirieron en el abordaje laparoscopico y la duracion media del procedimiento; ambos factores fueron mayores despues de la recuperacion acelerada. Significativamente mas pacientes recibieron quimioterapia a tiempo despues de la implementacion de recuperacion acelerada (p = 0.007). La recuperacion acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseno retrospectivo, tipo ¨antes y despues¨ no aleatorizado.La recuperacion acelerada se asocio con la recepcion de quimioterapia adyuvante a tiempo. Debido a que el inicio rapido de la quimioterapia adyuvante mejora la supervivencia en el cancer colorrectal, en el futuro sera necesario investigar los resultados oncologicos a largo plazo para evaluar el impacto potencial de la recuperacion acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

Early discharge after laparoscopic sleeve gastrectomy (SG) is common and safe, but two-thirds of patients are still hospitalized longer than 1 day. The purpose of this study was to evaluate factors associated with early discharge at a single institution with intention to discharge on postoperative day 1. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing SG at an academic hospital between 2010 and 2016. The primary outcome measure was length of stay (LOS). Multivariate logistic regression was used to identify independent predictors of prolonged LOS. A total of 367 patients undergoing SG were included. Two hundred eighty-seven (78%) were women and 294 (80%) were Caucasian. Mean age was 45.5 years and mean body mass index (BMI) was 48.7 kg/m2. One hundred twenty-three patients (33.5%) had a LOS ≤ 1 day. Compared to patients staying ≥ 2 days, early discharge patients had significantly lower BMI, creatinine, and American Society of Anesthesiologists class, were more likely to be White, married, have private insurance, and were more likely to have a morning start and no postoperative upper gastrointestinal (UGI) swallow study. Regression analysis demonstrated several independent predictors of prolonged LOS including institutional experience (OR 0.5, p

This study aims to test associations between perioperative blood transfusion and postoperative morbidity and mortality after major abdominal operations.The 2014 ACS NSQIP dataset was queried for all patients who underwent one of the ten major abdominal operations. Separate multivariable regression models, were developed to evaluate the independent effects of perioperative blood transfusion on morbidity and mortality.Of 48,854 patients in the study cohort, 4887 (10%) received a blood transfusion. Rates of transfusion ranged from 4% for laparoscopic gastrointestinal resection to 58% for open AAA. After adjusting for significant effects of NSQIP-estimated probabilities, transfusion was independently associated with morbidity and mortality after open AAA repair (OR = 1.99/14.4 respectively, p ≤ 0.010), esophagectomy (OR = 2.80/3.0, p 0.001), pancreatectomy (OR = 1.88/3.01, p 0.001), hepatectomy (OR = 2.82/5.78, p 0.001), colectomy (OR = 2.15/3.17, p 0.001), small bowel resection (OR = 2.81/3.83, p ≤ 0.004), and laparoscopic gastrointestinal operations (OR = 2.73/4.05, p 0.001).Perioperative blood transfusion is independently associated with an increased risk of morbidity and mortality after most major abdominal operations.

BACKGROUND: Surgical site infection is a frequent cause of morbidity after colorectal resection, and is a quality measure for hospitals and surgeons. In an effort to reduce the risk of postoperative infections, many wounds are left open at the time of surgery for secondary or delayed primary wound closure. OBJECTIVE: Evaluate the impact of delayed wound closure on the rate of surgical infections and resource utilization. DESIGN: This retrospective propensity matched study compared colorectal surgery patients with wounds left open with a cohort of patients with primary skin closure. SETTINGS: The American College of Surgeons National Quality Improvement Program Participant Use file for 2014 was queried. PATIENTS: 50,212 patients who underwent elective or emergent colectomy, proctectomy, and stoma creation were included. MAIN OUTCOME MEASURES: Rates of postoperative infections and discharge to medical facilities. RESULTS: Surgical wounds were left open in 2.9% of colorectal cases (n=1,466). Patients with skin left open were broadly higher-risk, as evident by a significantly higher median estimated probability of 30-day mortality (3.4% vs 0.45%, p0.05). Resource utilization was higher for patients with incisions left open including longer length of stay (11 vs 10 days, p=0.006) and higher rates of discharge to a facility (34% vs 27%, p

BACKGROUND: Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy and to better understand the impact of bile leak on morbidity and mortality. METHODS: Adult patients in the 2014–2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak. RESULTS: Of 6,859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly higher in patients after major compared to minor hepatectomy (12.6% vs 5.1%, p

Prior studies have demonstrated a reoperation rate ranging from 5.8 to 7.6% following colorectal surgery. However, the indications for reoperation have not been extensively evaluated. We aimed to describe the indications for reoperation and associated procedures following colorectal resection. This is a retrospective cohort study of all patients undergoing colorectal resection at a single institution from 2003 to 2013. For patients who returned to the operating room, the primary indication was categorized into mutually exclusive categories and all procedures performed within 30 days of the initial operation were indexed. Univariate and multivariate analyses were performed. We identified 2793 patients who underwent colorectal operations, of which 407 (14.6%) were emergent. A total of 178 (6.7%) patients returned to the operating room. On multivariate analysis, emergent operation, malnutrition, corticosteroid use, and operative duration were independently associated with reoperation; independent functional status was protective. The most common indications for reoperation were anastomotic leak and bowel obstruction. The most common procedures performed were ostomy creation, bowel resection, and adhesiolysis. Reoperation after colorectal surgery is a relatively common occurrence for which we have identified the risk factors, most common indications, and specific procedures performed. This knowledge will help identify areas for improvement.

Background Relationships between surgical errors and adverse events have not been fully explored and were examined in this study. Materials and methods This retrospective cohort study reviewed records of deceased surgical patients over 12 months. Bivariate associations between predictors and errors were examined. Results 84 deaths occurred following 5,209 operations. Errors in care (63%) compared to those without had significantly more adverse events, (98% vs 80% respectively, p = 0.004). Significant association occurred between error and emergency status, p = 0.016); length of stay >10 days, p = 0.011; adverse events, p = 0.005). Regression results indicated number of adverse events (OR = 1.27, 95% CI (1.08–1.49), p = 0.003) and length of stay (OR = 1.05, 95% CI (1.01–1.09), p = 0.008) were associated with surgical errors. Conclusions Examining postoperative adverse events in error cases identified opportunities for improvement. Reducing medical errors requires measuring medical errors.

Elderly patients (65 years of age and older) undergo an increasing number of operations performed annually in the US and they present with unique healthcare needs. Preventing postoperative readmission remains an important challenge to improving surgical care. This study examined whether geriatric-specific variables were independently associated with postoperative readmissions of elderly patients.The American College of Surgeons (ACS) Geriatric Surgery Research File (GSRF) was joined with the ACS NSQIP Participant Use Data Files for 2014 to 2016. This data set included 13 GSRF variables and 26 ACS NSQIP variables. Associations between clinically relevant variables and readmission were tested with multivariable logistic regression.The data represented 6,039 general surgery patients age 65 years and older. Fifty-eight percent of patients had colorectal operations, 19% pancreatic or hepatobiliary, 15% hernia, 4% thyroid or esophageal, and 3% had appendix operations. Twenty-four percent of patients experienced an NSQIP-defined 30-day postoperative complication and 3% died within 30 days after operation. Eleven percent of patients had unplanned 30-day readmission. Standard NSQIP variables, including 30-day composite morbidity (odds ratio [OR] 5.11; 95% CI, 4.24 to 6.16; p0.001), reoperation (OR 2.8; 95% CI, 2.07 to 3.79; p0.001), and steroid use (1.42; 95% CI, 1.03 to 1.96; p = 0.03) were associated with readmission. In addition, GSRF variables, including incompetent on admission (OR 1.63; 95% CI, 1.11 to 2.38; p = 0.01), fall risk at discharge (OR 1.42; 95% CI, 1.11 to 1.82; p = 0.005), use of mobility aid (OR 1.26; 95% CI, 1.02 to 1.56; p = 0.03), and discharged home with skilled care (OR, 1.22; 95% CI, 1.0 to 1.49; p = 0.04) were associated with readmission.Four GSRF and 3 current standard ACS NSQIP variables were important in the evaluation of postoperative readmission of elderly patients. Geriatric-specific variables contributed to the explanation of the relationship between clinical variables and readmissions in elderly surgical patients.

BACKGROUND: Independent associations between chronic liver disease, MELD, and postoperative outcomes among patients selected for liver resection have not been completely established. We hypothesized independent associations between MELD, cirrhosis, and postoperative mortality. METHODS: Patient-level data from the targeted hepatectomy module and ACS NSQIP PUF during 2014–2015 were merged. Multivariable regression models with interaction effect between MELD and liver texture (normal vs congested/fatty vs cirrhotic) tested the independent effects of covariates on mortality and morbidity. RESULTS: 3,530 patients were included, of whom 668 patients (19%) had cirrhosis. ACS NSQIP defined mortality (3.9%vs1.1%) and morbidity (23.5%vs15.8%) were higher in patients with cirrhosis (both p

As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications.Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naïve patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications.707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p 0.01) and more likely to smoke (27.6 vs 17.1%; p 0.01). Laparoscopic procedures were less common among opioid-exposed patients (44.8 vs 58.1%; p 0.01). Median morphine equivalents received were higher in opioid-exposed patients (65.0 vs 20.1 mg; p 0.01), but compliance to ERP elements was otherwise equivalent. Postoperative complications were higher among opioid-exposed patients (28.5 vs 15.0%; p 0.01), as was median length of stay (4.0 vs 3.0 days; p 0.01). Logistic regression identified multiple patient- and procedure-related factors independently associated with postoperative complications, including preoperative opioid use (p = 0.001).Preoperative opioid use is associated with increased risk of postoperative complications in elective colorectal surgery patients within an ERP. These results highlight the negative impact of opioid use, suggesting an opportunity to further reduce the risk of surgical complications through ERP expansion to include preoperative mitigation strategies for opioid-exposed patients.

Background Reintubations following extubation from mechanical ventilation are costly, resulting in increased morbidity and mortality. The preparation for and timing of extubation from mechanical ventilation can reduce unplanned reintubations. Few studies have investigated reintubation in the surgical intensive care unit (SICU) population. Objective To identify risk factors that predict extubation failure in nontrauma surgical postoperative intensive care patients. Methods Retrospective analysis utilizing American College of Surgeons National Surgical Quality Improvement Program data and institutional clinical variables from July 1, 2013, to December 31, 2015, in a sample (N = 93) of surgical patients admitted postoperatively to a SICU with an endotracheal tube in place, requiring invasive mechanical ventilation. Logistic regression analysis was used to model extubation failure as a function of clinical variables in the 24 hours preceding extubation. Results Of 93 patients, 70 were successfully extubated, and 23 experienced failure. Increasing respiratory rate in the 24 hours preceding extubation significantly predicted failure (odds ratio, 1.086; 95% confidence interval, 1.006-1.172; P = .034). Discussion Elevated respiratory rates during the 24 hours preceding extubation are an underappreciated risk factor for extubation failure. This has direct implications for nurses who are assessing intensive care unit patients' readiness for extubation. Opportunity exists for nurses to better integrate respiratory rate data into extubation planning to improve unplanned reintubation rates in SICU patients.

BackgroundSocioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation.MethodsAll patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0–100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation.ResultsA total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, pConclusionIncreasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.

Following weight-loss surgery, patients who failed to achieve or sustain weight loss have nevertheless reported high satisfaction with their long-term bariatric experience. Understanding this phenomenon better will likely improve patients' experiences.The purpose of this study was to explore patients' long-term experiences following bariatric surgery.A 604-bed academic health system in the USA.Participants rated satisfaction and shared spontaneous comments regarding their gastric bypass experience. A phenomenological mode of inquiry explored participants' experiences. Transcribed phrases were categorized and themes identified.In a 2004 surgical cohort, with 55% (155/281) participation, 99% of participants rated bariatric experience satisfaction (mean score 8.4) and 74% (115/155) shared comments regarding experiences. Responses were categorized as positive (63% 72/115), neutral (25% 29/115), or negative (12% 14/115). Satisfaction, Appreciation, and Gratefulness emerged as themes from positive comments, with 8% (6/72) explicitly acknowledging amount of weight loss achieved. Twenty-five percent (18/72) spontaneously mentioned undergoing surgery again or recommending the procedure to others. Neutral comments contained the themes of Reflection, Acknowledgment, and Wistfulness. Themes of Dissatisfaction, Disappointment, and Regret emerged from negative comments. Forty-three percent (6/14) of negative comments remarked on regaining weight or not reaching goal weight. Twenty-one percent (3/14) of negative comments explicitly stated regret at having undergone surgery.Participants readily shared comments regarding their gastric bypass experience. Exploring themes provided insight into patients' satisfaction with bariatric surgery even when weight-loss goals were not met and conversely substantial dissatisfaction even when weight loss occurred. This study underscores the importance of understanding the patients' long-term experience following bariatric surgery.

Monitoring and prevention of long-term nutrient deficiency after laparoscopic Roux-en-Y gastric bypass (LRYGB) remains ill defined due to limited surgical follow-up after bariatric surgery. This study compared nutrient supplementation as well as surgeon and primary care physician (PCP) follow-up between patients with short-term versus long-term follow-up. All patients undergoing LRYGB at a single institution in 2004 (long-term group, n = 281) and 2012–2013 (short-term group, n = 149) were evaluated. Prospectively collected database, electronic medical record (EMR) review and telephone survey were used to obtained follow-up for both cohorts. Multivariate logistic regression was used to assess factors independently predicting multivitamin use. Complete follow-up was achieved in 172 (61 %) long-term and 107 (72 %) short-term patients. We demonstrate a significant difference (p

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p 0.001).Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

Congestive heart failure (CHF) predicts surgical morbidity and mortality. However, few studies evaluate CHF's impact on noncardiac operations. Because of CHFs serious threat to health and survival, surgeons must understand risks CHF poses to patients undergoing a diverse array of operations.We used 2009 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Files to estimate the risk of serious morbidity, reoperation, readmission, mortality, and other postoperative complications associated with preoperative diagnosis of CHF. Multivariable logistic regression analysis provided odds ratios (OR) and 95% confidence intervals (CI) for outcomes in 34 ACS NSQIP procedure groups, controlling for age, sex, race, emergency surgery status, American Society of Anesthesiologists Classification, body mass index, and selected laboratory values.Unadjusted ORs indicate adverse effects of CHF on surgical outcomes for most procedures considered. When adjusted for age and other confounders, CHF persists with adverse effects on most outcomes, including serious morbidity (OR 1.52, 95% CI, 1.44 to 1.61; p 0.001); reoperation (OR 1.29, 95% CI, 1.17 to 1.42; p0.001); readmission (OR 1.39, 95% CI, 1.29 to 1.50; p0.001); and 30-day mortality (OR 1.96, 95% CI 1.80 to 2.13; p0.001). The impact of CHF on morbidity and mortality substantially affected those undergoing carotid endarterectomy and lower extremity endovascular repair. Cardiac arrest, mortality, unplanned intubation, and ventilator48 hours were complications most affected by CHF.Congestive heart failure strongly predicts serious morbidity, unplanned reoperation, readmission, and surgical mortality for noncardiac operations. Surgeons must pay particular attention to recognizing CHF and optimizing perioperative management when considering surgery.

Roux-en-Y Gastric Bypass (RYGB) is well known to ameliorate type 2 diabetes mellitus (T2DM), and recent work suggests that the preoperative DiaREM model predicts successful remission up to 1 year post-RYGB. However, no data exist for long-term validity. Therefore, we sought to determine the utility of this score on long-term RYGB effectiveness for T2DM resolution at 2 and 10 years, respectively. T2DM patients (Age: 48, BMI: 49, HbA1C: 8.1) undergoing RYGB at the University of Virginia between 2004–2006 (n = 42) and 2012–2014 (n = 59) were evaluated prospectively to assess preoperative DiaREM score, defined from insulin use, age, HbA1C, and type of antidiabetic medication. T2DM partial remission status was based on the American Diabetes Association guidelines (HbA1C

Background Implicit bias has been documented in candidate selection within academic medicine. Gender bias is exposed when writers systematically use different language to describe attributes of male and female applicants. This study examined the presence of gender bias in recommendation letters for surgical residency candidates. Study Design Recommendation letters for 2016 to 2017 surgery resident applicants selected for interview at an academic institution were analyzed using qualitative text analysis, quantitative text mining, and topic modeling. Dedoose, QDA Miner, and RStudio analytic software were used for analysis. Results There were 332 letters of recommendation for 89 applicants (51% male) analyzed. Of 265 letter writers, 86% were male, 21% chairs, and 50% professors. Average word count was 404. Letter writers for male compared with female applicants had a significantly higher average word count (male = 421, SD 144; female = 388, SD 140, p = 0.035). Standout adjectives (eg exceptional), reference to awards, achievement, ability, hardship, leadership, scholarship, and use of applicant's name were most often applied to male applicants. Comments on positive general terms (eg delightful), grindstone words (eg hard-working), physical description, doubt raisers, and work ethic were most often applied to female applicants. Topic modeling and term frequencies revealed achievement words (performance, career, leadership, and knowledge) used more often with male applicants, while caring words (care, time, patients, and support) were used more often with female applicants. Conclusions Gendered differences examined through language and text exist in surgical residents' recommendation letters. Implementing tools to help faculty write recommendation letters with meaningful content and editing letters for reflections of stereotypes may improve the resident selection process by reducing bias.

Adequate lymphadenectomy is associated with improved survival in patients who undergo oncologic resection of colorectal cancer and has been identified as a quality metric. Neoadjuvant chemotherapy has been found to be associated with collection of12 lymph nodes in patients with rectal cancer. The purpose of this study was to evaluate patient and operative risk factors for inadequate lymph node retrieval during oncologic colectomy. The 2014 American College of Surgeons National Surgical Quality Improvement Program Participant Use File data set for oncologic colectomy (n = 9077) was analyzed. Patient- and operation-related factors were assessed by univariate and multivariate regression analyses to determine factors associated with the number of lymph nodes collected. Adequate lymphadenectomy was defined by collection of12 lymph nodes. Of 9077 patients with a diagnosis of colon cancer who underwent colectomy, a minimum of 12 lymph nodes was harvested in 7897 (87%). Significant factors independently associated with inadequate lymphadenectomy included preoperative chemotherapy, emergent surgery, and T1 tumors (all P0.05). A large majority of patients who undergo colectomy for colon cancer have at least 12 lymph nodes collected. Preoperative chemotherapy is a major risk factor for inadequate lymph node retrieval. Recognition of factors associated with inadequate lymphadenectomy may improve colectomy lymph node yield and survival in patients with colon cancer.

Background Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored. Methods All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods. Results A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76). Conclusions Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies.

Objective The purpose of this study is to determine if patient selection varies based on years of surgical practice. Background The impact of hospital and surgeon volume as a marker of experience has demonstrated an inverse association with surgical outcomes. However, temporal measures of experience often demonstrate no effect. Additionally, a self-reporting survey demonstrated decreasing case complexity over time, suggesting that changes in patient selection may account for some of these observed discrepancies. Methods General surgery cases at a single tertiary care center reported to the American College of Surgeons National Surgical Quality Improvement Program over a 10-year period were identified. Additionally general surgery cases from the ACS NSQIP 2008 PUF data were used to create risk models for any complications, 30-day mortality, or a composite complication or mortality outcome. These models then estimated risk for our local data. Years of experience after American Board of Surgery certification were calculated for each surgeon for each case. Multivariate linear regression, controlling for surgeon clustering, was used to determine the association between years of surgical experience and preoperative risk of complications and mortality. Results Eighteen thousand six hundred and eighty eight cases were identified from our institution. Surgeons selected patients of increasing operative risk until 15 years of practice before selecting lower risk patients throughout the rest of their career. After adjusting for risk, no association was observed between years from board certification and mortality. However, there was a trend toward decreasing complication rates with increasing experience. Conclusions Surgical experience significantly impacts patient selection. Surgeons with over 25 years of experience had lower complication rates. Experience had no impact on mortality.

Health policy experts have proposed a framework defining value as outcomes achieved per dollar spent on health care. However, few institutions quantify their delivery of care along these dimensions. Our objective was to measure the value of our surgical services over time.We reviewed the data of patients undergoing general and vascular surgery from 2002 through 2012 at a tertiary care university hospital as abstracted by the American College of Surgeons NSQIP. Morbidity and mortality data from the American College of Surgeons NSQIP database were risk adjusted to calculate observed-to-expected ratios, which were then inverted into a numerator as a surrogate for quality. Costs, the denominator of the value equation, were determined for each patient's hospitalization. The ratio was then transformed by a constant and analyzed with linear regression to analyze and compare values from 2002 through 2012.A total of 25,453 patients met criteria for inclusion. Overall, the value of surgical services increased from 2002 through 2012. The observed increase in value was greater in general surgery than in vascular surgery, and value actually decreased in vascular procedures. Although there was a similar increase in outcomes in vascular surgery compared with general surgery, costs rose significantly higher ($474/year vs -$302/year; p0.001). These increased costs were mostly observed from 2006 through 2010 with the adoption of endovascular technology.Despite the challenges posed by current information systems, calculating risk-adjusted value in surgical services represents a critical first step for providers seeking to improve outcomes, avoid ill-advised cost containment, and determine the costs of innovation.

Background Deep venous thrombosis and pulmonary embolus are leading preventable causes of death after surgery. Venous thromboembolism (VTE) prophylaxis management guidelines, with evidenced-based recommendations, are available in the literature. However, over 40% of “at-risk” surgical patients fail to receive appropriate VTE prophylaxis. Decision support–based interventions to reduce venous thromboembolic events were explored. Methods A venous thromboembolic risk stratification tool embedded in the electronic medical record, Epic, linking risk category to venous thromboembolic prophylaxis order sets was created, implemented, and analyzed for general surgery patients. Logistic regression analysis was used to compare rates of venous thromboembolic events before and after the intervention, controlling for age, gender, race, body mass index, inpatient status, transfer status, elective/emergent case status, American Society of Anesthesiologists classification, and wound classification. Results Venous thromboembolic events in the preintervention and postintervention periods were 55 (1.25%) and 12 (0.64%), respectively (P = 0.033). All-cause mortality events decreased after intervention from 49 (1.12%) to 14 (0.75%; P = 0.187). Multivariable analyses show that the risk of a venous thromboembolic event after intervention was half (odds ratio = 0.532; 95% confidence interval, 0.284-0.997; P = 0.049) as likely compared to that in the preintervention period. From 2012 to 2015, our institution moved from the ninth decile (poor) to the first decile (best) for the incidence of venous thromboembolic events among 760 National Surgical Quality Improvement Program hospitals across the nation. Conclusions Postoperative thromboembolic events decreased after implementation of a VTE risk stratification tool, linking risk category to venous thromboembolic prophylaxis order sets, embedded in the electronic medical record, Epic.

The University of Virginia (UVA) has recently become an Accountable Care Organization (ACO), intensifying efforts to provide better care for individuals. UVA's ACO population resides across the entire Commonwealth, with a large percentage of patients living in rural areas. To provide better health for this population, the central tenet of the ACO mission, we identified geographic risk factors influencing hospital readmission. We analyzed the relationship between the distance of patients’ residence to the nearest hospital and 30-day readmission in general surgery patients. A retrospective chart review using January 1, 2011 through October 31, 2013 American College of Surgeons National Surgical Quality Improvement Program data for general surgery procedures was conducted. ArcGIS mapped street addresses provided graphical representation of distance between surgical population and the nearest hospital. We analyzed the impact on readmission, of time traveled, insurance status, and median household income. Each increase of 10 minutes in travel time from the patient's residence to the nearest hospital, not just UVA, was associated with a 9 per cent increase in the probability of readmission after adjusting for patient characteristics, preoperative comorbidities, laboratory values, and postoperative complications before or after discharge (odds ratio = 1.09; 95% confidence interval = 1.01–1.17; P = 0.019). Unlike urban hospitals, those serving rural populations may be at particular risk of postsurgical readmissions. Patients living furthest from a hospital facility are most at risk for readmission after a general surgery procedure. This vulnerable population may benefit most from comprehensive discharge planning.

The 30-day readmission rate is a quality metric under the Affordable Care Act. Readmission rates after thyroidectomy and parathyroidectomy and associated factors remain ill-defined. We evaluated patient and perioperative factors for association with readmission after thyroidectomy and parathyroidectomy.The American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) data for thyroid (n = 3,711) and parathyroid (n = 3,358) resections were analyzed. Patient- and operation-related factors were assessed by univariate and multivariate analyses.Among 7,069 patients, 30-day readmission rate was 4.0%: 4.1% after thyroidectomy and 3.8% after parathyroidectomy. Significant associations for 30-day readmission included declining functional status (odds ratio [OR], 6.4-10.1), preoperative hemodialysis (OR, 2.6; 95% CI, 1.5-4.7), malnutrition (OR, 3.4; 95% CI, 1.2-10.1), increasing American Society of Anesthesiologists class (OR 1.3-4.7), unplanned reoperation (OR, 61.6), and length of stay (LOS)24 hours (OR, 0.61; 95% CI, 0.45-0.85; all P.05). Readmission was associated with greater total and postoperative LOS and major postoperative complications, including renal insufficiency (all P.01).Thirty-day readmission after cervical endocrine resection occurs in 4% of patients. Discharge within 24 hours of operation does not affect the likelihood of readmission. Risk factors for readmission are multifactorial and driven by preoperative conditions. Decreasing the index hospital stay and preventing major postoperative complications may decrease readmissions and improve quality metrics.

Treemaps are space-constrained visualizations for displaying hierarchical data structures using nested rectangles. The visualization allows large amounts of data to be examined in one display. The objective of this research was to examine the effects of using treemap visualizations to help surgeons assess surgical quality data from the American College of Surgeons created the National Surgical Quality Improvement Program database in a quick and timely manner.A controlled human subjects experiment was conducted to assess the ability of individuals to make quick and accurate judgments on surgery data by visualizing a treemap, with data hierarchically displayed by surgeon group, surgeon, and patient. Participants were given 20 task questions to complete involving examining the treemap and comparing surgeons' patients based on outcomes (dead or alive) and length of stay days. The outcomes measured were error (incorrect or correct) and task completion time.120 participants completed 20 task questions for a total of 2400 responses. The main effects of layout and node size were found to be significant for absolute error, P 0.0505 and P 0.0185, respectively. The average judgment time to complete a task was 24 s with an accuracy rate of approximately 68%.This study served as a proof of concept to determine if treemaps could be beneficial in assessing surgical data retrospectively by allowing surgeons and healthcare administrators to make quick visual judgments. The study found that factors about the layout design affect judgment performance. Future research is needed to examine whether implementing the treemap within a dashboard system will improve on judgment accuracy for surgical quality questions.

The American College of Surgeons (ACS) NSQIP Virginia Surgical Quality Collaborative (VSQC) exists to improve surgical outcomes through multi-institutional collaboration. Enhanced recovery (ER) protocols improve morbidity and reduce length of stay (LOS) after elective surgery. We hypothesized implementation of ER through VSQC would reduce postoperative complications and LOS in patients undergoing elective colectomy. Our objective was to evaluate whether standardization of care based on evidenced-based practices in healthcare settings across multiple institutions improved outcomes.In 2013, VSQC incrementally implemented ER for patients undergoing elective colectomy at participating institutions. Institutions shared protocols, order sets, educational materials, and met semi-annually to discuss progress. Risk-adjusted ACS NSQIP data (January 1, 2012 through December 31, 2016) was queried in 4 participating hospitals. The association of ER with surgical outcomes was evaluated with a before and after ER implementation analysis and multivariable logistic regression modeling with a priori selection of clinically relevant variables.There were 2,438 consecutive colectomies included in analysis (1,035 pre-ER/1,403 post-ER). In the post-ER implementation patient cohort, relatively more patients were treated laparoscopically (68%) compared with the pre-ER cohort (52%) (p0.001). Median LOS decreased from 5 to 4 days after ER implementation in patients undergoing open colectomy (p 0.001), although total complications were similar in frequency (23% vs 22%). Laparoscopic patients had a reduced LOS (4 vs 3 days; p0.001), 30-day readmissions (12% vs 8%; p = 0.01), and total complications (16% vs 9%; p0.001) after ER implementation. In multivariable models, American Society of Anesthesiologists Physical Status Classification, hypertension, smoking, ER, and laparoscopy were independently associated with complication risk.Implementation of ER across VSQC was associated with reduction in LOS and complications in patients undergoing elective laparoscopic colectomy.

Background Postoperative pulmonary complications (PPCs; unplanned reintubation, postoperative pneumonia, and failure to liberate from mechanical ventilation within 48 hours), contribute significantly to increased rates of morbidity and mortality. Procedure type is an important factor that contributes risk in generalized PPC prediction models. The objective of this study was to develop and validate procedure-specific risk scores for the 6 procedures with the highest rates of PPCs. Study Design American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File data (2005 to 2015) for patients undergoing pancreatectomy, hepatectomy, esophagectomy, abdominal aortic aneurysm repair, open aortoiliac repair, and lung resection were used for analysis. Multivariable logistic regression was used to develop pulmonary complications risk scores (PCRS) for each procedure. Youden indices were used to identify cutoff points within each PCRS and were further validated using a random selection of the original NSQIP dataset collected. Results Twenty-one variables were included in the initial analysis, which yielded unique relative risk score models for each procedure. Within all the risk score models, long operative time (within the last quartile) was a strong predictor of PPCs. An increased rate of PPCs was associated with increasing PCRS values in both the training and validation samples for all procedures. Conclusions Important variables were identified for 6 common procedures that yield an increased risk of PPCs. These variables differed by procedure type, outlining the importance of procedure-specific risk scores. Each procedure-specific PCRS developed in this study can be used by health care professionals to better predict the risk of PPCs and to optimize patient outcomes.

BACKGROUND:Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. METHODS:All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. RESULTS:A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p

Background: Ever-increasing numbers of in-house acute care surgeons and competition for operating room time during normal daytime business hours have led to an increased frequency of nonemergent general and vascular surgery procedures occurring at night when there are fewer residents, consultants, nurses, and support staff available for assistance. This investigation tests the hypothesis that patients undergoing such procedures after hours are at increased risk for postoperative morbidity and mortality. Methods: Clinical data for 10,426 operative procedures performed over a 5-year period at a single academic tertiary care hospital were obtained from the American College of Surgeons National Surgical Quality Improvement Program Database. The prevalence of preoperative comorbid conditions, postoperative length of stay, morbidity, and mortality was compared between two cohorts of patients: one who underwent nonemergent operative procedures at night and other who underwent similar procedures during the day. Subsequent statistical comparisons utilized X 2 tests for comparisons of categorical variables and F-tests for continuous variables. Results: Patients undergoing procedures at night had a greater prevalence of serious preoperative comorbid conditions. Procedure complexity as measured by relative value unit did not differ between groups, but length of stay was longer after night procedures (7.8 days vs. 4.3 days, p < 0.0001). Conclusions: Patients undergoing nonemergent general and vascular surgery procedures at night in an academic medical center do not seem to be at increased risk for postoperative morbidity or mortality. Performing nonemergent procedures at night seems to be a safe solution for daytime overcrowding of operating rooms.

Numerous series demonstrate the benefits of laparoscopic versus open adrenalectomy, but fail to adjust for confounding factors. This study uses the Veterans Affairs National Surgical Quality Improvement Program database to compare these two approaches, adjusting for baseline differences.Laparoscopic (n=358) and open (n=311) adrenalectomy data were collected at 123 Department of Veterans Affairs and 14 university hospitals from October 1, 2001 to September 30, 2004. Preoperative characteristics, operative data, and 30-day outcomes were compared using the chi-square or Fisher's exact test for categorical variables and the t-test for continuous variables. Unadjusted odds ratio (OR) and 95% confidence interval (CI) were computed for the effect of operative approach on postoperative morbidity. Adjusted odds ratios and 95% CI were computed for this same effect, adjusting for variables that were predictive of outcomes or imbalanced at baseline. Data are reported as means +/-SD, unless otherwise indicated.Patients undergoing open adrenalectomy were more likely to be older (57.8+/-11.9 years versus 53.5+/-13.2 years, p0.0001), harbor malignancy (44.5% versus 13.5%, p0.0001), have higher American Society of Anesthesiologists classifications (p=0.0037), smoke (35.4% versus 22.6%, p=0.0003), and have lower serum albumin levels (3.9+/-0.5 g/dL versus 4.0+/-0.5 g/dL, p=0.0241). Open procedures had increased operative times (3.9+/-1.8 hours versus 2.9+/-1.3 hours, p0.0001), transfusion requirements (0.7+/-1.8 U versus 0.1+/-0.5 U, p0.0001), reoperations (4.8% versus 1.4%, p=0.0094), length of stay (9.4+/-11.0 days versus 4.1+/-4.7 days, p0.0001) and 30-day morbidity rates (17.4% versus 3.6%, p0.0001) with unadjusted and adjusted odds ratio (95% CI) of 5.52 (2.94, 10.33), and 3.97 (1.92, 8.22), respectively. Open procedures resulted in more pneumonia, unplanned intubation, unsuccessful ventilator wean, systemic sepsis, cardiac arrest, renal insufficiency, and wound infections.Even after adjustment for confounding factors, 30-day morbidity was much higher for patients having open adrenalectomy.

Background Sarcopenia, a loss of skeletal muscle mass associated with aging, is a practical measure of frailty and has been previously identified as a predictor of outcomes in surgical cohorts including cancer resection and elderly patients. We hypothesized that sarcopenia, as measured by preoperative computerized tomography (CT) scan, predicts mortality and morbidity in emergent laparotomy. Methods Institutional American College of Surgeons National Surgical Quality Improvement Program data were queried for adult patients who underwent open emergency abdominal surgery between 2008 and 2013. Patients with abdominal CT scans within 30 d before surgery were included, and cross-sectional areas of the psoas muscles at vertebral level L4 were summed, normalized by patient height, and stratified by sex. The influence of this total psoas area (TPA) on postoperative morbidity and mortality was evaluated using univariate and multivariate analysis. Results Of 781 surgeries, 593 (75.9%) had appropriate preoperative CT scans. Median patient age was 61 years old, median TPA was 1719 mm2, and median body mass index was 26.7. Univariate analysis demonstrated a significant association between TPA and total postoperative morbidity (P = 0.0133), increased length of stay ( Conclusions Sarcopenia, as measured by TPA, significantly predicted mortality in univariate analysis but lost significance in multivariate analysis when factors such as American Society of Anesthesiologists score were included. Because TPA is readily available at no additional risk or cost, it is a convenient additional tool for preoperative risk assessment and counseling.

Background Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy. Materials and methods Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality. Results Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm ( n = 229, 44%), primary hepatic neoplasm ( n = 108, 21%), primary extra-hepatic biliary neoplasm ( n = 23, 4%), and nonmalignant indications ( n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870). Conclusions Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.

The aim of the study was to evaluate the clinical effectiveness and long-term durability of Roux-en-Y Gastric Bypass (RYGB) at an accredited center.Short-term data have established the effectiveness of RYGB for weight loss and comorbidity amelioration. The long-term durability of this operation remains infrequently described in the American population.All patients (N = 1087) undergoing RYGB at a single institution over a 20-year study period (1985-2004) were evaluated. Univariate differences in preoperative comorbidities, operative characteristics (laparoscopic vs. open), postoperative complications, annual weight loss, and current comorbidities were analyzed to establish trends and outcomes 10 years after surgery.Among 1087 RYGB patients, 651 (60%) had complete 10-year follow-up, including 335 open RYGB and 316 laparoscopic RYGB. Patients undergoing open RYGB had a higher preoperative body mass index. Otherwise, preoperative characteristics were similar. Postoperative incisional hernia rates were expectedly higher in open (vs laparoscopic) RYGB (16.9% vs 4.7%; P = 0.02). Annual % reduction in excess body mass index significantly improved over time, peaking at 74% by 24 months, with a slow trend down to 52% at 10 years (all P0.001). Importantly, a highly significant decrease in obesity-related comorbid disease persisted at 10 years of follow-up after RYGB.Roux-en-Y Gastric Bypass remains an excellent and durable operation for long-term weight loss and treatment of obesity-related comorbid disease. Laparoscopic RYGB results in highly favorable outcomes with reduced incisional hernia rates. These 10-year data help to more clearly define long-term outcomes and demonstrate outstanding reduction in comorbid disease following RYGB.

Background The long-term durability of Roux-en-Y gastric bypass (RYGB) remains ill-defined in the American population secondary to poor follow-up after bariatric surgery. Objectives This study evaluated the population lost to follow-up to better define the long-term durability of RYGB for weight loss and co-morbidity amelioration. Methods All patients (n = 1087) undergoing RYGB at a single institution between 1985 and 2004 were evaluated. Univariate differences in preoperative co-morbidities, postoperative complications, annual weight loss, and 10-year co-morbidities were analyzed to compare outcomes between patients with routine follow-up and those without. Using electronic medical record review for all encounters at our academic medical center and telephone survey, we obtained data for patients lost to follow-up. Results Among 1087 RYGB patients, 151 (14%) had consistent 10-year follow-up in our prospectively collected database, with yearly clinic visits beyond 2 years postoperatively. Electronic medical record review and telephone survey data were collected on an additional 500 (46%) patients, resulting in 60% of patients having 10-year follow-up after RYGB. There was no statistical difference in any preoperative or postoperative variables between the 2 groups. We found no difference in co-morbidity prevalence preoperatively or at 10 years between groups. Examination of percent excess body mass index lost at yearly intervals revealed no difference between the groups at each interval up to 10 years ( P = .36). Conclusion We found no difference in 10-year outcomes, including weight loss and co-morbidity reduction, between patients with routine clinic visits and those lost to follow-up. These 10-year data address the gap in knowledge resulting from poor long-term follow-up after bariatric surgery.

Background Surgical site infection is common following colorectal surgery, yet the incidence varies widely. CDC criteria include "diagnosis by attending physician," which can be subjective. Alternatively, the ASEPSIS score is an objective scoring system based on the presence of clinical findings. Objective The aim of this study is to compare the interrater reliability of the ASEPSIS score vs CDC definitions in identifying surgical site infection. Design This 24-month prospective study used serial photography of the wound. Three attending surgeons independently reviewed blinded photographic/clinical data. Settings This study was conducted at an academic institution. Patients Patients undergoing elective colorectal surgery were selected. Interventions Surgeons assigned an ASEPSIS score and identified surgical site infection by using CDC definitions. The interrater reliability of ASEPSIS and the CDC criteria were compared by using the κ statistic. These data were also compared with the institutional National Surgical Quality Improvement Program database. Results One hundred seventy-one patients were included. Four surgical site infections (2.4%) were identified by the National Surgical Quality Improvement Program. Data from the surgeons demonstrated significantly higher yet discrepant rates of infection by the CDC criteria, at 6.2%, 7.4%, and 14.1% with a κ of 0.55 indicating modest interrater agreement. Alternatively, the ASEPSIS assessments demonstrated excellent interrater agreement between surgeons with 96% agreement (2.4%, 2.4%, and 3.6%) and a κ of 0.83. Limitations This was a single-institution study. Conclusions This study demonstrates the relatively poor reliability of CDC definitions for surgical site infections in comparison with an objective scoring system. These findings could explain the wide variability in the literature and raise concern for the comparison of institutional surgical site infection rates as a quality indicator. Alternatively, an objective scoring system, like the ASEPSIS score, may yield more reliable measures for comparison.

This study evaluates the risk of complications associated with elective laparoscopic adrenalectomy (LA) as reported in a national dataset. We hypothesize that the risk for major complication is associated with identifiable perioperative variables. This information may aid in understanding who safely could be discharged early after surgery, including same-day discharge. Elective LA from 2009 to 2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File were reviewed. A priori selection of likely risk factors for complications was assessed for their association with morbidity. Sequential bivariable logistic regression was used to measure the statistical significance of each risk factor's observed association with the occurrence of major morbidity after surgery. The potential for multiple comparisons bias was accounted for by using a high threshold (P0.01) for identifying statistically significant associations. One thousand ninety-nine patients were identified. The 30-day mortality rate was 0.18 per cent, and 4.8 per cent of patients experienced a major morbidity within 30 days of surgery. Return to the operating room occurred in 1.46 per cent of cases. Statistically significant associations occurred for 15 patient characteristics at P0.05. Diabetes, nonindependent functional status before surgery, American Society of Anesthesiologists classification2, and operative time were statistically significant at P0.01. Complications are rare events among elective LA patients. However, several readily identifiable patient characteristics are associated with the occurrence of complications among these patients. These patient characteristics should be taken into account when considering future trials of early discharge after LA, including same-day discharge.

Background The aging population of the United States results in increasing numbers of surgical operations on elderly patients. This study observed aging related to morbidity, mortality, and their risk factors in patients undergoing major operations. Study design We reviewed our institution's American College of Surgeons National Surgical Quality Improvement Program database from February 24, 2002, through June 30, 2005, including standardized preoperative, intraoperative, and 30-day postoperative data points. This required review and analysis of the prospectively collected data. We examined patient demographics, preoperative risk factors, intraoperative risk factors, and 30-day outcomes with a focus on those aged 80 years and older. Results A total of 7,696 surgical procedures incurred a 28% morbidity rate and 2.3% mortality rate, although those older than 80 years of age had a morbidity of 51% and mortality of 7%. Hypertension and dyspnea were the most frequent risk factors in those aged 80 years and older. Preoperative transfusion, emergency operation, and weight loss best predicted morbidity for those 80 years of age and older. Operative duration predicted "other" postoperative occurrences and emergent case status predicted respiratory occurrences across all age groups. Preoperative impairment of activities of daily living, emergency operation, and increased American Society of Anesthesiology classification predicted mortality across all age groups. A 30-minute increment of operative duration increased the odds of mortality by 17% in patients older than 80 years. Postoperative morbidity and mortality increased progressively with increasing age. Age was statistically significantly associated with morbidity (wound, p=0.021; renal, p=0.001; cardiovascular, p=0.0004; respiratory, p Conclusions Although several risk factors for postoperative morbidity and mortality increase with age, increasing age itself remains an important risk factor for postoperative morbidity and mortality.

Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement. Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.

Intraoperative wound classification is a predictor of postoperative infection. Therefore, accurately assigning the correct classification to a surgical wound is of particular importance. Our institution participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a national outcomes database that collects wound classification for all qualifying operative procedures, and we noted discrepancies when comparing ACS NSQIP wound classification coding with perioperative coding in our electronic medical record. We tested the effectiveness of an intervention that included staff educational sessions, informational posters, and postoperative debriefings on improving the accuracy of documented intraoperative wound classification. The χ(2) test was used to compare proportions of wound classification miscodings before and after educational sessions and debriefings commenced. Baseline data revealed misclassification of wounds occurred 21 per cent (30 of 141) of the time in predominately colorectal procedures performed by two surgeons from April through August 2012. Errors decreased to 9 per cent (13 of 147) from August to December 2012, after our intervention of education sessions with operating room staff and the surgeons incorporating a statement confirming the wound classification at the end of the case debriefing. The χ(2) statistic was 8.7589. The P value was significant at 0.003. Ensuring concordance of classification between the surgeon and nurse during a postprocedure debriefing as well as education of perioperative nursing staff through posters and seminars significantly improved the accuracy of intraoperative wound classification coding.

Given the current climate of outcomes-driven quality reporting, it is critical to appropriately risk stratify patients using standardized metrics.To elucidate the risk associated with urgent surgery on complications and mortality after general surgical procedures.This retrospective review used the American College of Surgeons National Surgery Quality Improvement Program database to capture all general surgery cases performed at 435 hospitals nationwide between January 1, 2013, and December 31, 2013. Data analysis was performed from November 11, 2015, to February 16, 2017.Any operations coded as both nonelective and nonemergency were designated into a novel category titled urgent.The primary outcome was 30-day mortality; secondary outcomes included 30-day rates of complications, reoperation, and readmission in urgent cases compared with both elective and emergency cases.Of 173 643 patients undergoing general surgery (101 632 females and 72 011 males), 130 235 (75.0%) were categorized as elective, 22 592 (13.0%) as emergency, and 20 816 (12.0%) as nonelective and nonemergency. When controlling for standard American College of Surgeons National Surgery Quality Improvement Program preoperative risk factors, with elective surgery as the reference value, the 3 groups had significantly distinct odds ratios (ORs) of experiencing any complication (urgent surgery: OR, 1.38; 95% CI, 1.30-1.45; P .001; and emergency surgery: OR, 1.65; 95% CI, 1.55-1.76; P .001) and of mortality (urgent surgery: OR, 2.32; 95% CI, 2.00-2.68; P .001; and emergency surgery: OR, 2.91; 95% CI, 2.48-3.41; P .001). Surgical procedures performed urgently had a 12.3% rate of morbidity (n = 2560) and a 2.3% rate of mortality (n = 471).This study highlights the need for improved risk stratification on the basis of urgency because operations performed urgently have distinct rates of morbidity and mortality compared with procedures performed either electively or emergently. Because we tie quality outcomes to reimbursement, such a category should improve predictive models and more accurately reflect the quality and value of care provided by surgeons who do not have traditional elective practices.

Background Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. Study Design A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. Results One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. Conclusions Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.

Background There is limited outcome data for super-super-obese (SSO) patients, those with Body Mass Index (BMI) ≥ 60 kg/m 2 , who seek surgical treatment with Laparoscopic Roux-en-Y Gastric Bypass (LRYGB). A large single center LRYGB experience was reviewed to compare the safety and efficacy of LRYGB in SSO patients to the standard obese population undergoing this procedure. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database and an Institutional Review Board approved prospective database was used to identify all patients undergoing LRYGB by multiple surgeons at a single institution between 1/1/1994 and 11/15/2013. Preoperative co-morbidities, postoperative complications, 30-day outcomes, and weight loss at yearly intervals were analyzed to determine difference between SSO patients and NonSSO patients (BMI 2 ). Results Of the 2009 patients undergoing LRYGB over the past 20 years; 328 had BMI≥60 kg/m 2 . Preoperative co-morbidities, conversion to open, and length of stay were significantly increased among SSO patients; however there was no significant difference in postoperative outcomes or complications. Percent reduction of excess BMI beyond 12 months was significantly improved among NonSSO patients with less than 30% follow-up beyond 2 years. Conclusions LRYGB appears well tolerated for super-super-obese patients with BMI≥60 kg/m 2 in experienced centers. These patients still have significant reduction in excess BMI despite being less than NonSSO patients undergoing RYGB. The ACS NSQIP database provides excellent tracking of institutional progress with bariatric surgical outcomes to facilitate the improvement of best practice techniques.

Anastomotic leak, a potentially deadly postoperative occurrence, particularly interests surgeons performing gastrointestinal procedures. We investigated incidence, cost, and impact on survival of anastomotic leak in gastrointestinal surgical procedures at an academic center.We conducted a chart review of American College of Surgeons NSQIP operative procedures with gastrointestinal anastomosis from January 1, 2003 through April 30, 2006. Each case with an American College of Surgeons NSQIP 30-day postoperative complication was systematically reviewed for evidence of anastomotic leak for 12 months after the operative date. We tracked patients for up to 10 years to determine survival. Morbidity, mortality, and cost for patients with gastrointestinal anastomotic leaks were compared with patients with anastomoses that remained intact.Unadjusted analyses revealed significant differences between patients who had anastomotic leaks develop and those who did not: morbidity (98.0% vs. 28.4%; p0.0001), length of stay (13 vs. 5 days; p ≤ 0.0001), 30-day mortality (8.4% vs. 2.5%; p0.0001), long-term mortality (36.4% vs. 20.0%; p ≤ 0.0001), and hospital costs (chi-square [2] = 359.8; p0.0001). Multivariable regression demonstrated that anastomotic leak was associated with congestive heart failure (odds ratio [OR] = 31.5; 95% CI, 2.6-381.4; p = 0.007), peripheral vascular disease (OR = 4.6; 95% CI, 1.0-20.5; p = 0.048), alcohol abuse (OR = 3.7; 95% CI, 1.6-8.3; p = 0.002), steroid use (OR = 2.3; 95% CI: 1.1-5.0; p = 0.027), abnormal sodium (OR = 0.4; 95% CI, 0.2-0.7; p = 0.002), weight loss (OR = 0.2; 95% CI, 0.06-0.7; p = 0.011), and location of anastomosis: rectum (OR = 14.0; 95% CI, 2.6-75.5; p = 0.002), esophagus (OR = 13.0; 95% CI, 3.6-46.2; p0.0001), pancreas (OR = 12.4; 95% CI, 3.3-46.2; p0.0001), small intestine (OR = 6.9; 95% CI, 1.8-26.4; p = 0.005), and colon (OR = 5.2; 95% CI, 1.5-17.7; p = 0.009).Significant morbidity, mortality, and cost accompany gastrointestinal anastomotic leaks. Patients who experience an anastomotic leak have lower rates of survival at 30 days and long term.

Increasingly, surgical site infection (SSI) is being tied to quality of care. The incidence of SSI after colorectal surgery differs widely. We hypothesize that it is difficult to define SSI reliably and reproducibly when adhering to the U.S. Centers for Disease Control and Prevention (CDC) definitions.Elective intra-abdominal colorectal procedures via a clean-contaminated incision performed at a single institution between January 1 and May 1, 2011 were queried. Three attending surgeons examined all patients' records retrospectively for documentation of SSI. These data were compared with the institutional National Surgeon Quality Improvement Program (NSQIP) data with regard to deep and superficial incisional SSI.Seventy-one cases met the inclusion criteria. There were six SSIs identified by NSQIP, representing 8.4% of cases. Review of the three attending surgeons demonstrated a significantly higher incidence of SSI, at 27%, 38%, and 23% (p=0.002). The percent of overall agreement between all reviewers was 82.16 with a kappa of 0.64, indicating only modest inter-rater agreement. Lack of attending surgeon documentation and subjective differences in chart interpretation accounted for most discrepancies between the surgeon and NSQIP SSI capture rates.This study highlights the difficulty in defining SSI in colon and rectal surgery, which oftentimes is subjective and difficult to discern from the medical record. According to these preliminary data from our institution, there is poor reliability between clinical reviewers in defining SSI on the basis of the CDC criteria, which has serious implications. The interpretation of clinical trials may be jeopardized if we cannot define SSI accurately. Furthermore, according to current CDC definitions and infection tracking strategies, these data suggest that the institutional incidence of SSI may not be a reliable measure by which to compare institutions. Better methods for defining SSI should be implemented if these data are made publicly available and tied to performance measures.

To examine the relationship between body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and 30-day mortality risk among patients in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program. Obesity is a prevalent chronic disease in the United States, and general and vascular surgeons are caring for an increasing population of obese patients.Multivariable logistic regression analysis was used to assess the statistical significance of the relationship between BMI and mortality, with adjustments for patient-level differences in overall mortality risk and principal operating procedures. Odds ratios with 95% CIs were calculated to measure the relative difference in mortality by BMI quintile, with reference to the middle quintile of the BMI. The overall significance of the BMI and of the other covariates was measured using the Wald χ(2) test statistic. A separate multivariable logistic regression model was developed to assess the significance of the interaction between BMI and primary procedure.A total of 183 sites.Patients with major surgical procedures reported in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program.The data included 189 533 cases of general and vascular surgical procedures reported in 2005 and 2006 for patients with known overall probabilities of death. Among these, 3245 patients died within 30 days of their surgery (1.7%). Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death, with 40% higher odds compared with patients in the middle range for BMI (26.3 to29.7). Important differences in the association between BMI and mortality risk occur by type of primary procedure.Body mass index is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death.