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Quality indicators will likely be used in comprehensive surgical quality assessment and improvement programs. Quality indicators are the actions equated with good quality of care. As a case example, bariatric surgery quality indicators were developed using evidence in the literature combined with formal expert opinion validation. Qualitative analysis was performed to identify the critical thematic issues surrounding development of these surgical quality indicators. Researchers identified five major thematic categories during the development process. These included feasibility in medical records (availability, ease of abstraction, and cost), the number of indicators developed (optimal number), the lack of evidence in the literature (weight on expert opinion), structural versus process indicators, and linkage to outcomes (need to demonstrate that adherence to indicators is associated with better outcomes). This project, using bariatric surgery as an example, uncovered important issues that need to be addressed when developing quality assessment and quality improvement programs for evaluating surgical quality. As quality indicators will likely be developed and used increasingly, future projects in this regard will benefit from these lessons. [ABSTRACT FROM AUTHOR]

PURPOSE: A comprehensive analysis was performed for five histologic types of appendiceal tumors to compare incidence, clinicopathologic features, survival, and appropriateness of surgery. METHODS: All patients diagnosed with mucinous adenocarcinoma (n = 951), adenocarcinoma (n = 646), carcinoid (n = 435), goblet (n = 369), and signet-ring cell (n = 113) in the Surveillance, Epidemiology, and End Results database (1973–2001) were analyzed. Evaluation of incidence, stage, and five-year relative survival were determined for each histology. The appropriateness of the operative procedure (i.e., appendectomy vs. colectomy) was examined by tumor type and size. RESULTS: Tumor incidence, patient demographics, survival outcomes, and appropriateness of surgery varied significantly among the different appendiceal tumor histologies. The most common appendiceal tumors were mucinous. With regard to patient demographics, carcinoids presented at an earlier mean age of 41 years and 71 percent were female (P > 0.001 for both). Overall five-year survival was highest for carcinoid (83 percent) and lowest for signet ring (18 percent). Although current guidelines specify that a right hemicolectomy (rather than an appendectomy) be performed for all noncarcinoid tumors and carcinoid tumors <2 cm, we found that 30 percent of noncarcinoids underwent appendectomy. Similarly, 28 percent of carcinoids <2 cm underwent appendectomy, which is a lesser resection than is indicated. CONCLUSIONS: This study provides a population-based analysis of epidemiology, tumor characteristics, survival, and quality of care for appendiceal carcinomas. This characterization provides a novel description of the presentation and outcomes for malignancies of the appendix and highlights that a substantial number of patients with appendiceal tumors may not be receiving appropriate surgical resection. [ABSTRACT FROM AUTHOR]

Describes the conceptual and operational surgical quality improvement over the past decade. Use of risk-adjusted outcomes in surgery for measuring quality; Potential effects of contracting or regionalizing to high-volume providers on the healthcare system as a whole; Continuation of the discussion on improvement of quality by the healthcare community.

Background: The use of beta blockers in surgical patients has been suggested to decrease perioperative cardiac events. However, the overall risk reduction, on the basis of solely aggregate data from randomized studies, is unknown. The objective is to evaluate the effect of perioperative beta blockade in noncardiac surgery for protection against mortality or cardiac events. Methods: We performed a formal meta-analysis. The Medline database was searched for articles published from 1966-2004 by using the terms perioperative, beta blocker, surgery, and noncardiac. Inclusion criteria were randomized controlled trials evaluating perioperative beta blockade in noncardiac surgery. Studies were evaluated independently by 2 researchers. Cochrane Collaboration Software (Review Manager 4.2) was used to calculate relative risk (RR), risk difference (RD), and 95% confidence interval (CI). Six distinct postoperative adverse events were analyzed. Results: Eligible studies included 6 randomized controlled trials evaluating perioperative beta blockade in patients undergoing noncardiac surgery. These studies evaluated a total of 632 patients: 354 received perioperative beta blockade and 278 did not. Results for the 6 postoperative outcomes are shown.The 2 largest effects were a decrease in long-term cardiac mortality from 12% to 2% and a decrease in myocardial ischemia from 33% to 15%. All outcomes except perioperative overall mortality had improvements (P < .02), which favor the use of perioperative beta blockade. Conclusions: This report highlights for the first time the aggregated risk reduction from all published randomized controlled trials, and shows the protection of perioperative beta blockade against both short-term complications and mortality. [Copyright &y& Elsevier]

Background: Controversy exists regarding the effectiveness of surgery for weight loss and the resulting improvement in healthrelated outcomes. Purpose: To perform a meta-analysis of effectiveness and adverse events associated with surgical treatment of obesity. Data Sources: MEDLINE, EMBASE, Cochrane Controlled Trials Register, and systematic reviews. Study Selection: Randomized, controlled trials; observational studies; and case series reporting on surgical treatment of obesity. Data Extraction: Information about study design, procedure, population, comorbid conditions, and adverse events. Data Synthesis: The authors assessed 147 studies. Of these, 89 contributed to the weight loss analysis, 134 contributed to the mortality analysis, and 128 contributed to the complications analysis. The authors identified 1 large, matched cohort analysis that reported greater weight loss with surgery than with medical treatment in individuals with an average body mass index (BMI) of 40 kg/m2 or greater. Surgery resulted in a weight loss of 20 to 30 kg, which was maintained for up to 10 years and was accompanied by improvements in some comorbid conditions. For BMIs of 35 to 39 kg/m², data from case series strongly support superiority of surgery but cannot be considered conclusive. Gastric bypass procedures result in more weight loss than gastroplasty. Bariatric procedures in current use (gastric bypass, laparoscopic adjustable gastric band, vertical banded gastroplasty, and biliopancreatic diversion and switch) have been performed with an overall mortality rate of less than 1%. Adverse events occur in about 20% of cases. A laparoscopic approach results in fewer wound complications than an open approach. Limitations: Only a few controlled trials were available for analysis. Heterogeneity was seen among studies, and publication bias is possible. Conclusions: Surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with a BMI of 40 kg/m² or greater. More data are needed to determine the efficacy of surgery relative to nonsurgical therapy for less severely obese people. Procedures differ in efficacy and incidence of complications. [ABSTRACT FROM AUTHOR]

Longitudinal analyses of cancer registries provide an opportunity for population-based explanations of epidemiology and survival-related outcomes. This study used two population-based data sets to report on nine surgery-related cancers over the past three decades.Using the SEER cancer database (1973–1999), all patients (>18 years old) with adenocarcinoma of esophagus, gastric, biliary system, pancreas, small bowel, colon, rectum; esophageal squamous cell carcinoma (ESC), or hepatocellular (HCC) carcinoma (n = 379,640) were analyzed. Changes in incidence rates, stage at diagnosis, and 5-year cancer and stage-specific survivals were determined. A separate database, the California inpatient database (1990–2000), was concurrently used to evaluate inpatient mortality after surgical resection (n = 34,057).Incidence rates increased for three cancers (esophageal, HCC, small bowel); decreased for three (rectal, gastric, ESC); and stayed constant for three (biliary, pancreatic, colon). More patients presented with local/regional disease in the 1990s versus 1970s for eight tumors (except small bowel, P < 0.05). Five-year overall survival improved for all but small bowel (P < 0.05); and local stage survival was improved for all except small bowel and biliary (P < 0.05). Finally, inpatient mortality rates improved significantly for liver, esophageal, pancreatic, and gastric resections (P < 0.05) over the past decade.For these nine surgically treated cancers, we are detecting disease at earlier and therefore more treatable stages, and surgical care and outcomes also appear to have improved. Continued reexamination of longitudinal trends of surgically relevant outcomes is important for future improvement of surgical care. [Copyright &y& Elsevier]

Background With the aging of the baby boomers, individuals aged 65 years and older make up the fastest-growing segment of the US population. This aging of the population will lead to new challenges for the US health care system because older individuals are the largest consumers of health care. Hypothesis The general surgery workload will increase dramatically by 2020 as a result of the aging population. Data Sources The National Hospital Discharge Survey, National Survey of Ambulatory Surgery, US Census Bureau, and Centers for Medicare and Medicaid Services. Setting A nationally representative random sample of inpatient and outpatient general surgical operations performed in 1996 in the United States. Methods Age- and procedure-specific rates of general surgery were obtained from the National Hospital Discharge Survey and National Survey of Ambulatory Surgery. Population projections were derived from the census bureau. We used relative-value units as a proxy for surgical work. By linking these 3 data sources, we predicted the future general surgery workload by analyzing the rates of surgery and modeling both the aging and expansion of the population. Results General surgery operations (n = 63) were classified into 5 procedure categories. Whereas the population will grow by 18% between 2000 and 2020, the workload of general surgeons will increase by 31.5%. The amount of growth (19.9%-40.3%) varies among different categories of operations. Conclusions To our knowledge, this is one of the only studies to analyze the future workload of general surgery. We project a dramatic increase in workload in the next 20 years, largely as a result of the aging US population. Our baseline assumptions are relatively conservative, so this forecast may be an underestimation. Hence, the challenge for general surgeons is to develop strategies to address this problem while maintaining quality of care for our patients. [ABSTRACT FROM AUTHOR]

Background: The practice environment for surgery is changing. However, little is known regarding the trends or current status of inpatient surgery at a population level. Hypothesis: Inpatient surgical care has changed significantly over the last 10 years. Design: Longitudinal analysis of California inpatient discharge data (January 1, 1990, through December 31, 2000). Setting: All 503 nonfederal acute care hospitals in California. Patients: All inpatients undergoing general, vascular, and cardiothoracic surgery in California from January 1, 1990, through December 31, 2000, were obtained. Main Outcome Measures: Volume, mean age, comorbidity profile, length of hospital stay, and in-hospital mortality were obtained for inpatient general, vascular, and cardiothoracic surgical procedures performed during the period 1990 to 2000. Rates of change and trends were evaluated for the 10-year period. Results: Between January 1, 1990, and December 31, 2000, 1.64 million surgical procedures were performed. The number of surgical procedures increased 20.4%, from 135 795 in 1990 to 163 468 in 2000. Overall, patients were older and had more comorbid disease in 2000 compared with 1990. Both crude and adjusted (by type of operation) in-hospital mortality decreased from 3.9% in 1990 to 2.75% (P<.001) and 2.58% (P<.001), respectively, in 2000. Length of hospital stay decreased over the period for all operations analyzed. Conclusions: The total number of inpatient general, vascular, and cardiothoracic surgical procedures has increased over the past decade. Furthermore, our findings indicate that the outcomes of care (eg, in-hospital mortality and length of hospital stay) for patients who undergo general, vascular, and cardiothoracic surgical procedures have improved. However, continued evaluations at the population level are needed. [ABSTRACT FROM AUTHOR]

Current standard of care for complicated diverticulitis includes urgent resection with colostomy versus antibiotic treatment, followed by delayed resection with primary anastomosis at a second admission. In certain circumstances, it is possible to perform resection and anastomosis on the same admission for acute diverticulitis. A retrospective review was completed for patients undergoing surgery for diverticulitis from 1991 to 1998. Groups included: 1) sigmoid resection with primary anastomosis on same admission (n = 18); 2) resection with protective end colostomy (n = 16); and 3) in-patient antibiotic treatment alone, followed by a second admission for resection with primary anastomosis (n = 5). Four patients initially treated with antibiotics worsened symptomatically or developed radiographic evidence of perforation and required resection with colostomy. Five patients in Group 1 had abscesses or contained perforations based on radiographic studies. Findings on CT scans did not predict treatment. Group 1 patients had uneventful recoveries and few minor complications (wound infections and an incisional hernia). One anastomotic leak occurred in Group 2 after colostomy closure. Although there will continue to be a role for emergent operation for diverticulitis, same admission sigmoid resection with primary anastomosis after antibiotic treatment is safe, uses a shorter course of antibiotics, and has a low complication rate. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Determine if racial/ethnic disparities exist for access to high-volume surgeons (HVS) for patients with ovarian cancer. Methods: Retrospective study of ovarian cancer surgeries identified by the California Cancer Registry (CCR) linked to hospital discharge data (1991–2002). Surgeon volume was defined as HVS (>10 ovarian cancer surgeries/year), middle volume (MVS; 2–9/year), and low volume (LVS; ≤1/year). Multivariate ordered logistic regression predicting surgeon volume provided estimates of relative risk (RR) of surgeon volume by patient race/ethnicity. Results: 13,186 women had ovarian cancer (mean age 57.8 years; 72% non-Hispanic White (NHW), 4% Black, 8% Hispanic). 25% of cases were treated by HVS, 31% by MVS, and 44% by LVS. Compared to NHW, Black (RR: 0.70, p <0.05) and Hispanic women (RR: 0.75, p <0.05) were less likely to have care by a HVS. Hispanic women were significant more likely to have surgery by LVS (RR: 1.1; p <0.05). Conclusions: Disparities in access to HVS for cancer care exist for minority women. Selective referral to high-volume providers should be considered to improve outcomes among minority women. [Copyright &y& Elsevier]

Negative appendectomy rate varies significantly depending on patient age and sex. However, the impact of computed tomography (CT) scans on the diagnosis of appendicitis is unknown. The goal of this study was to examine the negative appendectomy rate using a statewide database and analyze the association of receipt of CT scan. Using the California Inpatient File, all patients undergoing appendectomy in 1999-2000 were identified (n = 75,452). Demographic and clinical data were analyzed, including procedure approach (open vs laparoscopic) and appendicitis type (negative, simple, abscess, peritonitis). Patients with CT scans performed were identified to compare the negative appendectomy rate. For the entire cohort, appendicitis type was 59 per cent simple, 10 per cent with abscess, 18.7 per cent with peritonitis, and 9.3 per cent negative. Males had a lower rate of negative appendicitis than females (6.0% vs 13.4%, P < 0.0001). The use of CT scans was associated with an overall lower negative appendectomy rate for females, especially in the < 5 years and > 45 years age categories. Use of CT scans in males does not appear to be efficacious, as the negative appendectomy rates were similar across all age categories. In conclusion, use of CT was associated with lower rate of negative appendectomy, depending on patient age and sex. [ABSTRACT FROM AUTHOR]

Elderly (80+ year old) individuals are the fastest-growing segment of the U.S. population. The objective of this study was to use population-based data to examine trends in the number of elderly undergoing major general, vascular, and cardiothoracic surgical procedures. California inpatient data from 1990-2000 was used to identify patients undergoing six procedures: abdominal aortic aneurysm repair (AAA), coronary artery bypass graft (CABG), carotid endarterectomy (CEA), colon resections, lung resections, and pancreatic resections. Despite comprising only 2.7 per cent of the California population, elderly patients were a significant percentage (6-22%) of the caseloads for the six procedures examined. For all six procedures, the percentage of patients that were elderly increased during the study period. The age-specific incidence rates for elderly individuals increased significantly for three of these procedures (CABG, CEA, lung resection), remained unchanged for two (AAA, pancreas resection), and decreased for one (colon resection). Elderly patients are a large and growing part of surgical caseloads. In the near future, the number of elderly individuals in the California state and the U.S. populations will increase dramatically (41% and 35% between 2000 and 2020). To provide the best quality of care, surgeons should embrace research, training, and educational opportunities regarding the treatment of elderly patients. [ABSTRACT FROM AUTHOR]

: BackgroundMany studies have demonstrated a significant relationship between high procedural volume and better outcomes. As the public becomes increasingly aware of this medical literature, consumer groups have collaborated with medical researchers to operationalize this body of evidence. One such organization, the Leapfrog Group, has proposed annual volume criteria for four operations: coronary bypass grafting (CABG), abdominal aortic aneurysm (AAA), carotid endarterectomy (CEA), and esophageal cancer resection (ECR). This study analyzes California hospitals within the context of these volume criteria.: Materials and methodsUsing the California inpatient database from 2000, we identified all CABG, AAA, CEA, and ECR operations performed at metropolitan hospitals. The volume of each of the four operations was tabulated by hospital and evaluated. Comparisons were made between academic and nonacademic hospitals.: ResultsMost hospitals in California did not meet Leapfrog''s volume criteria. Only 2 hospitals of 287 (0.7%) met the volume criteria for the operations that it performed. Of the 71 (25%) hospitals that performed all four procedures, none met the volume criteria of all four procedures. In fact, only 10% of California hospitals performing these operations were high-volume hospitals based on Leapfrog''s volume criteria. When comparing academic to nonacademic hospitals, academic hospitals performed more AAA operations than nonacademic hospitals (36 vs 12, P = 0.02). Although academic hospitals tended to have higher caseloads for CABG, CEA, and ECR, these did not reach statistical significance. Also, academic hospitals were more likely to be high volume for AAA (43.8% vs 7.0%, P < 0.01) and for ECR (23.1% vs 4.0%, P < 0.01).: ConclusionsCalifornia''s hospital system is far from being regionalized. Although academic hospitals appear better positioned than nonacademic hospitals, the vast majority of all hospitals do not meet Leapfrog''s volume criteria. As efforts to use volume as a proxy measure of quality gain momentum, hospitals and physicians will be forced to measure and report quality. As such, surgeons need to decide between accepting volume as an adequate measure of quality and developing other possibly more direct and reliable methods. [Copyright &y& Elsevier]