Search

To evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012-2019 in a collaborative quality improvement network.Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall, however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design.We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012-2019. Risk- and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last two years and the first two years of the study period.There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012-2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points).Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.

BACKGROUND There is increased focus on the value of surgical care. Postoperative complications decrease value, but it is unknown whether high-value hospitals spend less than low-value hospitals in cases without complications. Previous studies have not evaluated both expenditures and validated outcomes in the same patients, limiting the understanding of interactions between clinical performance, efficient utilization of services, and costliness of surgical episodes. OBJECTIVE This study aimed to identify payment differences between low- and high-value hospitals in colectomy cases without adverse outcomes using a linked data set of multipayer claims and validated clinical outcomes. DESIGN This is a retrospective observational cohort study. We assigned each hospital a value score (ratio of cases without adverse outcome to mean episode payment). We stratified hospitals into tertiles by value and used analysis of variance tests to compare payments between low- and high-value hospitals, first for all cases, and then cases without adverse outcome. SETTING January 2012 to December 2016, this investigation used clinical registry data from 56 hospitals participating in the Michigan Surgical Quality Collaborative, linked with 30-day episode payments from the Michigan Value Collaborative. PATIENTS A total of 2947 patients undergoing elective colectomy were selected. MAIN OUTCOME MEASURES The primary outcome measured was risk-adjusted, price-standardized 30-day episode payments. RESULTS The mean adjusted complication rate was 31% (±10.7%) at low-value hospitals and 14% (±4.6%) at high-value hospitals (p < 0.001). Low-value hospitals were paid $3807 (17%) more than high-value hospitals ($22,271 vs $18,464, p < 0.001). Among cases without adverse outcome, payments were still $2257 (11%) higher in low-value hospitals ($19,424 vs $17,167, p = 0.04). LIMITATIONS This study focused on outcomes and did not consider processes of care as drivers of value. CONCLUSIONS In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases without adverse outcome, indicating mechanisms for increasing value beyond reducing complications. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care. See Video Abstract at http://links.lww.com/DCR/B56. LOGRANDO LA COLECTOMIA DE ALTO VALOR: PREVINIENDO COMPLICACIONES O MEJORANDO LA EFICIENCIA: Hay un mayor enfoque en el valor de la atencion quirurgica. Las complicaciones postoperatorias disminuyen el valor, pero se desconoce si en los casos sin complicaciones, los hospitales de alto valor gastan menos que los hospitales de bajo valor. Estudios anteriores no han evaluado ambos gastos y validado resultados en los mismos pacientes, limitando la comprension de las interacciones entre el rendimiento clinico, utilizacion eficiente de los servicios y costos de los episodios quirurgicos.Identificar las diferencias de pago entre los hospitales de alto y bajo valor, en casos de colectomia sin resultados adversos, utilizando un conjunto de datos vinculados de reclamos de pago multiple y resultados clinicos validados.Estudio de cohorte observacional retrospectivo. Asignamos a cada hospital una puntuacion de valor (proporcion de casos sin resultado adverso al pago medio del episodio). Estratificamos los hospitales por valor en terciles y utilizamos el analisis de pruebas de varianza para comparar los pagos entre hospitales de bajo y alto valor, primero para todos los casos y luego casos sin resultados adversos.De enero del 2012 a diciembre del 2016, utilizando datos de registro clinico de 56 hospitales que participan en el Michigan Surgical Quality Collaborative, vinculado con pagos de episodios de 30 dias, del Michigan Value Collaborative.Un total de 2947 pacientes con colectomia electiva.Pagos por episodio de 30 dias, ajustados al riesgo y estandarizados por precio.La tasa media de complicacion ajustada fue de 31% (±10.7%) en hospitales de bajo valor y 14% (±4.6%) en hospitales de alto valor (p < 0.001). A los hospitales de bajo valor se les pago $3807 (17%) mas que a los hospitales de alto valor ($22,271 frente a $18,464, p < 0.001). Entre los casos sin resultados adversos, los pagos fueron de $2257 (11%) mas altos en hospitales de bajo valor ($19,424 vs $17,167, p = 0.04).Este estudio se centro en los resultados y no se consideraron a los procesos de atencion, como impulsores de valor.En la colectomia electiva, los hospitales de alto valor logran pagos de episodios mas bajos, que en los hospitales de bajo valor con casos sin resultados adversos, indicando mecanismos para aumentar el valor, mas alla que la reduccion de complicaciones. Objetivos valiosos para optimizar el valor de la colectomia electiva, pueden incluir mejoras en los protocolos de recuperacion, asi como otras intervenciones que aumenten la eficiencia en todas las fases de la atencion. Vea el resumen del video en http://links.lww.com/DCR/B56.

Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement.Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons.Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates.The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals.Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons.Main outcome measures included 30-day risk-adjusted postoperative complications.The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41).Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms.Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA= 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Few studies have evaluated whether outcome disparities between Medicaid and private insurance beneficiaries are driven by the hospital at which the patient receives care. The purpose of this study was to evaluate the effect of the hospital on surgical outcomes in Medicaid beneficiaries. We identified 139,566 non-elderly Medicaid and private insurance beneficiaries undergoing general, vascular, or gynecological surgery between 2012 and 2017 using a statewide clinical registry in Michigan. We calculated risk-adjusted rates of complications, readmissions, emergency department (ED) visits, and post-acute care utilization using multivariable logistic regression, accounting for patient and procedural factors. We then evaluated whether, and to what extent, the hospital influenced outcome disparities between Medicaid and privately insured beneficiaries. Risk-adjusted rates for all outcomes were higher in Medicaid beneficiaries. For example, overall post-discharge ED visit rates were 14.3% (95% CI 13.7% to 14.9%) for Medicaid compared to 7.5% (95% CI 7.1% to 7.9%, P

This article describes how to start, replicate, scale, and sustain a learning health system for quality improvement, based on the experience of the Michigan Surgical Quality Collaborative (MSQC). The key components to operationalize a successful collaborative improvement infrastructure and the features of a learning health system are explained. This information is designed to guide others who desire to implement quality improvement interventions across a regional network of hospitals using a collaborative approach. A toolkit is provided (under Supporting Information) with practical information for implementation.

Background Total mesorectal excision is associated with decreased local recurrence and improved disease-free survival following rectal cancer resection. The extent to which total mesorectal excision has been adopted in the United States is unknown. Objective We sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals. Design This is a retrospective cohort study from the Michigan Surgical Quality Collaborative. Trends in total mesorectal excision performance and grade assignment were analyzed by using χ tests and linear regression. Settings Participating hospitals (initially 14 hospitals, now 38) abstracted medical records data for rectal cancer cases from 2007 to 2016. Patients Patients who underwent rectal cancer resection were included. Main outcome measure The main outcome measures were surgeon-documented total mesorectal excision performance and pathologist-reported total mesorectal excision grade. Results Of 510 rectal cancer cases, 367 (72.0%) had surgeon-reported total mesorectal excision performance and 78 (15.3%) had pathologist-reported total mesorectal excision grade. Between-hospital variability in total mesorectal excision performance ranged from 0% to 97% and total mesorectal excision grading ranged from 0% to 90%. Total mesorectal excision grading was associated with a higher likelihood of also having adequate lymph node assessment (88.5% versus 71.9%, p = 0.002). There has been a statistically significant trend toward an increase in total mesorectal excision grading in the original 14 hospitals (p = 0.001), but not in the complete cohort of all hospitals (p = 0.057). Limitations This is a retrospective cohort design with sampled rectal cancer cases. In addition, there is insufficient granularity to capture all factors associated with total mesorectal excision performance or grade assignment. Conclusions The rates of total mesorectal excision performance and grade assignment are widely variable throughout the state of Michigan. Overall, grade assignment remains very low. This suggests an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation. See Video Abstract at http://links.lww.com/DCR/B53. IMPLEMENTACION DE LA ESCISION MESORRECTAL TOTAL Y LA CLASIFICACION POR ESCISION MESORRECTAL TOTAL PARA EL CANCER RECTAL: UN ESTUDIO A NIVEL ESTATAL.: La escision mesorrectal total se asocia con una menor recurrencia local y una mejor supervivencia libre de enfermedad despues de la reseccion del cancer rectal. Se desconoce hasta que punto se ha adoptado la escision mesorrectal total en los Estados Unidos.Se intento evaluar las tendencias en el rendimiento y la clasificacion de la escision mesorrectal total en los hospitales de Michigan.Este es un estudio de cohorte retrospectivo de la "Michigan Surgical Quality Collaborative". Las tendencias en el rendimiento de la escision mesorrectal total y la asignacion de grado se analizaron mediante pruebas de chi-cuadrada y regresion lineal.Los hospitales participantes (inicialmente 14 hospitales, ahora 38) extrajeron datos de registros medicos de los casos de cancer rectal desde 2007 hasta 2016.Pacientes que se sometieron a reseccion de cancer rectal.Las principales medidas de resultado fueron el rendimiento de la escision mesorrectal total documentado por el cirujano y el grado de escision mesorrectal total informada por el patologo.De 510 casos de cancer rectal, 367 (72.0%) tenian un rendimiento de escision mesorrectal total reportado por el cirujano y 78 (15.3%) tenian un grado de escision mesorrectal total reportado por el patologo. La variabilidad entre hospitales en el rendimiento de la escision mesorrectal total vario del 0 al 97% y la clasificacion de la escision mesorrectal total vario del 0 al 90%. La clasificacion de la escision mesorrectal total se asocio con una mayor probabilidad de tener tambien una evaluacion adecuada de los ganglios linfaticos (88.5% versus 71.9%, p = 0.002). Ha habido una tendencia estadisticamente significativa hacia un aumento en la clasificacion de la escision mesorrectal total en los 14 hospitales originales (p = 0.001), pero no en la cohorte completa de todos los hospitales (p = 0.057).Diseno de cohorte retrospectivo con casos de cancer rectal muestreados. Ademas, no hay suficiente granularidad para capturar todos los factores asociados con el rendimiento de la escision mesorrectal total o la asignacion de grados.Las tasas de rendimiento de escision mesorrectal total y asignacion de grado son muy variables en todo el estado de Michigan. En general, la asignacion de calificaciones sigue siendo muy baja. Esto sugiere una oportunidad para que los proyectos de mejora de la calidad aumenten el rendimiento y la clasificacion de la escision mesorrectal total, involucrando tanto a los cirujanos como a los patologos para una implementacion efectiva. Vea el resumen del video en http://links.lww.com/DCR/B53.

Background Perioperative hyperglycemia and its associated increase in morbidity and mortality have been well studied in the critical care and cardiac surgery literature. However, there is little data regarding the impact of intraoperative hyperglycemia on post-operative infectious complications in non-cardiac surgery. Methods All National Surgery Quality Improvement Program patients undergoing general, vascular, and urological surgery at our tertiary care center were reviewed. After integrating intraoperative glucose measurements from our intraoperative electronic health record, we categorized patients as experiencing mild (8.3–11.0 mmol/L), moderate (11.1–16.6 mmol/L), and severe (≥ 16.7 mmol/L) intraoperative hyperglycemia. Using multiple logistic regression to adjust for patient comorbidities and surgical factors, we evaluated the association of hyperglycemia with the primary outcome of postoperative surgical site infection, pneumonia, urinary tract infection, or sepsis within 30 days. Results Of 13,954 patients reviewed, 3150 patients met inclusion criteria and had an intraoperative glucose measurement. 49% (n = 1531) of patients experienced hyperglycemia and 15% (n = 482) patients experienced an infectious complication. Patients with mild (adjusted odds ratio 1.30, 95% confidence interval [1.01 to 1.68], p-value = 0.04) and moderate hyperglycemia (adjusted odds ratio 1.57, 95% confidence interval [1.08–2.28], p-value = 0.02) had a statistically significant risk-adjusted increase in infectious complications. The model c-statistic was 0.72 [95% confidence interval 0.69–0.74]. Conclusions This is one of the first studies to demonstrate an independent relationship between intraoperative hyperglycemia and postoperative infectious complications. Future studies are needed to evaluate a causal relationship and impact of treatment. Electronic supplementary material The online version of this article (10.1186/s12871-018-0546-0) contains supplementary material, which is available to authorized users.

Surgical site infections (SSI) after colectomy are associated with increased morbidity and health care use. Since 2012, the Michigan Surgical Quality Collaborative (MSQC) has promoted a "bundle" of care processes associated with lower SSI risk, using an audit-and-feedback system for adherence, face-to-face meetings, and support for quality improvement projects at participating hospitals. The purpose of this study was to determine whether practices changed over time.We previously found 6 processes of care independently associated with SSI in colectomy. From 2012 to 2016, we promoted a bundle of 3 care measures (cefazolin/metronidazole, oral antibiotics after mechanical bowel preparation, and normoglycemia) in 52 hospitals. Primary outcome was change in use of the 3-item SSI bundle. We also used a hierarchical logistic regression model to assess the association between 6-item compliance and SSI rate, morbidity, and health care use.The use of cefazolin/metronidazole increased from 18.6% to 32.3% (p0.001), oral antibiotic preparation increased from 42.9% to 62.0% (p0.001). The increase in normoglycemia was not significant. Concurrently, the SSI rate fell from 6.7% to 3.9% in the 52 hospitals (p = 0.012). Patients receiving more bundle measures had decreased rates of SSI, sepsis, and pneumonia. Morbidity and health care use significantly decreased with increased bundle compliance.These data show a significant increase in use of process measures promoted by a regional quality improvement collaborative, and an associated decrease in SSI after elective colectomy. These results highlight the promise of regional collaboratives to accelerate practice change and improve outcomes.

To delineate the use of opportunistic salpingectomy over the study period, to examine factors associated with its use, and to evaluate whether salpingectomy was associated with perioperative complications.A retrospective cross-sectional study (Canadian Task Force classification II-2).The Michigan Surgical Quality Collaborative.Women undergoing ovarian-conserving hysterectomy for benign indications from January 2013 through April 2015.The primary outcome was the performance of opportunistic salpingectomy with ovarian preservation during benign hysterectomy. The change in the rate of salpingectomy was examined at 4-month intervals to assess a period effect over the study period. Multivariate logistic regression was performed to evaluate independent effects of patient, operative, and period factors. Perioperative outcomes were compared using propensity score matching.There were 10 676 (55.9%) ovarian-conserving hysterectomies among 19 090 benign hysterectomies in the Michigan Surgical Quality Collaborative in the study period. The rate of opportunistic salpingectomy was 45.8% (n = 4890). Rates of opportunistic salpingectomy increased over the study period from 27.5% to 61.6% (p .001), demonstrating a strong period effect in the consecutive 4-month period analysis. Salpingectomy was more likely with the laparoscopic approach (odds ratio = 3.48; 95% confidence interval, 3.15-3.85) and among women younger than 60 years of age (odds ratio = 1.60; 95% CI, 1.34-1.92). There was substantial variation in salpingectomy across hospital sites, ranging from 3.6% to 79.9%. Salpingectomy was associated with a 12-minute increase in operative time (p .001), but there were no differences in the estimated blood loss or perioperative complications.The rates of salpingectomy increased significantly over the study period. The laparoscopic approach and younger age are associated with an increased probability of salpingectomy. Salpingectomy is not associated with increased blood loss or perioperative complications.

To compare preoperative chlorhexidine-alcohol topical antiseptic agent with povidone-iodine in patients undergoing abdominal hysterectomy for benign indications.A retrospective cohort study of patients undergoing abdominal hysterectomy from July 2012 to February 2015 in the Michigan Surgical Quality Collaborative was performed. The primary exposure was the use of chlorhexidine-alcohol or povidone-iodine. The primary outcome was surgical site infection within 30 days. Multivariable logistic regression and propensity score matching analysis were done to estimate the independent association of skin antiseptic choice on the rate of surgical site infection.Of the total 4,259 abdominal hysterectomies included, chlorhexidine-alcohol was used in 70.5% (n=3,005) and povidone-iodine in 29.5% (n=1,254) of surgeries. The overall unadjusted rate of any surgical site infection was 2.9% (95% CI 2.5-3.5; n=124). The unadjusted rate of surgical site infection 2.6% (95% CI 2.1-3.3; n=79) for chlorhexidine-alcohol and 3.6% (95% CI 2.7-4.8; n=45; P=.09) for the povidone-iodine group. Using multivariate logistic regression and adjusting for differences between populations in patient demographic factors (age and body mass index), medical comorbidities (American Society of Anesthesiologists class and diabetes status), perioperative variables (estimated blood loss, surgical time, intraoperative adhesions, and antibiotic categories), and hospital characteristics (bed size and teaching status), we estimate that patients receiving chlorhexidine-alcohol had 44% lower odds of developing a surgical site infection (adjusted odds ratio 0.56, 95% CI 0.37-0.85, P=.01). Propensity score matching (one to one) yielded 808 patients in the chlorhexidine-alcohol group and 845 patients in the povidone-iodine group. In the matched groups, the rate of surgical site infection was 1.5% (95% CI 0.8-2.6; n=12) for the chlorhexidine-alcohol group and 4.7% (95% CI 3.5-6.4; n=40) for the povidone-iodine group (P.001).In abdominal hysterectomy performed for benign indications, chlorhexidine-alcohol-based skin antisepsis is associated with overall lower odds of surgical site infection compared with povidone-iodine.

OBJECTIVE To assess the value of bundling perioperative care measures in colon surgery. BACKGROUND Surgical site infections (SSI) in colectomy are associated with increased morbidity and cost. Perioperative care bundling has been designed to improve processes of care surrounding colectomy operations. METHODS Retrospective cohort study performed by the Michigan Surgical Quality Collaborative (MSQC) of patients who underwent elective colon surgery from 2012 to 2015. We identified 3,387 patients in the MSQC database who underwent colon surgery. Of these cases, 332 had associated episodic cost data. RESULTS High compliance (3-6 bundle elements) and low compliance (0-2 bundle elements) had a risk-adjusted SSI rate of 8.2% (95% confidence interval, CI, 7.2-9.2%) and 16.0% (95% CI, 12.9-19.1%), respectively (P < 0.01). When compared with low compliance, the high compliance group had an absolute risk reduction of 3.6% (P < 0.01), 2.9% (P < 0.01) and 1.3% (P < 0.01) for SSI rates in superficial space, deep space, and organ space, respectively. Low compliance had an average episodic cost of $20,046 (95% CI, $17,281-$22,812) whereas high compliance had an episodic cost of $15,272 (95% CI, $14,354-$16,192). This showed a $4,774 (95% CI, $1,859-$7,688) and 23.8% cost reduction (P < 0.01). Facility base payments decreased 14.8% ($13,444; $11,458), professional payments decreased 43.9% ($5,180; $2,906), and other payments decreased 36.2% ($1,422; $908). CONCLUSIONS A colectomy perioperative care bundle in Michigan is associated with improved value of surgical care. We will expand efforts to implement perioperative care bundles in Michigan to improve outcomes and reduce costs.

OBJECTIVE To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery. BACKGROUND Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices. METHODS Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS). RESULTS There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings. CONCLUSIONS Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function.

Surgery remains the cornerstone therapy for colorectal cancer (CRC). This study assesses CRC quality measures for surgical cases in Michigan.In this retrospective cohort study, processes of care and outcomes for CRC resection cases were abstracted in 30 hospitals in the Michigan Surgical Quality Collaborative (2014-2015). Measures were case-mix and reliability adjusted, using logistic regression models.For 871 cases (640 colon cancer, 231 rectal cancer), adjusted morbidity (27.4%) and mortality rates (1.5%) were low. Adjusted process measures showed gaps in quality of care. Mesorectal excision was documented in 59.4% of rectal cancer (RC) cases, 65% of RC cases had sphincter preserving surgery, 18.7% of cases had 12 lymph nodes examined, 7.9% had a positive margin, 52.1% of stage II/III RC cases had neoadjuvant therapy, and 36% of ostomy cases had site marking.This study finds gaps in quality of care measures for CRC, suggesting opportunity for regional quality improvement.

OBJECTIVES The aim of this study was to investigate the relationship between primary insurance type and major complications after hysterectomy. METHODS A retrospective analysis was performed on women with Medicaid, Medicare, and private insurance who underwent hysterectomy from January 1, 2012, to July 1, 2014, and were included in the Michigan Surgical Quality Collaborative. Major complications within 30 days of surgery included the following: deep/organ space surgical site infection, deep venous and pulmonary thromboembolism, myocardial infarction or stroke, pneumonia or sepsis, blood transfusion, readmission, and death. Multivariable logistic regression was used to identify factors associated with major complications and characteristics associated with the Medicaid and Medicare groups. RESULTS A total of 1577 women had Medicaid, 2103 had Medicare, and 11,611 had private insurance. The Medicaid and Medicare groups had a similar rate of major complications, nearly double that of the private insurance group (6.85% vs 7.85% vs 3.79%; P < .001). Compared with private insurance, women with Medicaid and Medicare had increased odds of major complications (Medicaid: odds ratio [OR], 1.60; 95% confidence interval [CI], 1.26-2.04; P < .001; Medicare: OR, 1.34; 95% CI, 1.04-1.73; P = .03). Women with Medicaid were more likely to be nonwhite, have a higher body mass index (BMI), report tobacco use in the last year and undergo an abdominal hysterectomy. Those with Medicare were more likely to be white, to have gynecologic cancer, and to be functionally dependent. Both groups had increased odds of American Society of Anesthesiology class 3 or higher and decreased odds of undergoing hysterectomy at large hospitals (≥500 beds). CONCLUSIONS Women with Medicaid and Medicare insurance have increased odds of major complications after hysterectomy. Abdominal hysterectomy, BMI, and smoking are potentially modifiable risk factors for women with Medicaid.

OBJECTIVE The aim of the study was to characterize patient-reported outcomes of analgesia practices in a population-based surgical collaborative. BACKGROUND Pain control among hospitalized patients is a national priority and effective multimodal pain management is an essential component of postoperative recovery, but there is little understanding of the degree of variation in analgesia practice and patient-reported pain between hospitals. METHODS We evaluated patient-reported pain scores after colorectal operations in 52 hospitals in a state-wide collaborative. We stratified hospitals by quartiles of average pain scores, identified hospital characteristics, pain management practices, and clinical outcomes associated with highest and lowest case-mix-adjusted pain scores, and compared against Hospital Consumer Assessment of Healthcare Providers and Systems pain management metrics. RESULTS Hospitals with the lowest pain scores were larger (503 vs 452 beds; P < 0.001), higher volume (196 vs 112; P = 0.005), and performed more laparoscopy (37.7% vs 27.2%; P < 0.001) than those with highest scores. Their patients were more likely to receive local anesthesia (31.1% vs 12.9%; P < 0.001), nonsteroidal anti-inflammatory drugs (33.5% vs 14.4%; P < 0.001), and patient-controlled analgesia (56.5% vs 22.8%; P < 0.001). Adverse postoperative outcomes were less common in hospitals with lowest pain scores, including complications (20.3% vs 26.4%; P < 0.001), emergency department visits (8.2% vs 15.8%; P < 0.001), and readmissions (11.3% vs 16.2%; P = 0.01). CONCLUSIONS Pain management after colorectal surgery varies widely and predicts significant differences in patient-reported pain and clinical outcomes. Enhanced postoperative pain management requires dissemination of multimodal analgesia practices. Attention to patient-reported outcomes often omitted from surgical outcomes registries is essential to improving quality from the patient's perspective.

To identify hospital staffing models associated with failure to rescue (FTR) rates at low- and high-performing hospitals.FTR is an important quality measure in surgical safety and is a metric that hospitals are seeking to improve. Specific unit-level determinants of FTR, however, remain unknown.Retrospective, observational study using data from the Michigan Quality Surgical Collaborative, which is a prospectively collected and clinically audited database in the state of Michigan. We identified 44,567 patients undergoing major general or vascular surgery from 2008 to 2012. Our main outcome measures were mortality, complications, and FTR rates.Hospital rates of FTR across low, middle, and high tertiles were 8.9%, 16.5%, and 19.9%, respectively (P0.001). Low FTR hospitals tended to have a closed intensive care unit staffing model (56% vs 20%, P0.001) and a higher proportion of board-certified intensivists (88% vs 60%, P0.001) when compared to high FTR hospitals. There was also significantly more staffing of low FTR hospitals by hospitalists (85% vs 20%, P0.001) and residents (62% vs 40%, P0.01). Low FTR hospitals were noted to have more overnight coverage (75% vs 45%, P0.001) as well as a dedicated rapid response team (90% vs 60%, P0.001).Low FTR hospitals had significantly more staffing resources than high FTR hospitals. Although hiring additional staff may be beneficial, there remain significant financial limitations for many hospitals to implement robust staffing models. Thus, our ongoing work seeks to improve rescue and implement effective staffing strategies within these constraints.

Objective To determine if the use of intraoperative hemostatic agents was a risk factor for post-operative adverse events within 30 days of patients undergoing hysterectomy. Method A population-based retrospective cohort study included data from patients undergoing hysterectomy for any indication between January 1, 2013, and December 31, 2014, at 52 hospitals in Michigan, USA. Any individuals with missing covariate data were excluded, and multivariable logistic regression and propensity score-matching were used to estimate the rate of post-operative adverse events associated with intra-operative hemostatic agents independent of demographic and surgical factors. Results There were 17 960 surgical procedures included in the analysis, with 4659 (25.9%) that included the use of hemostatic agents. Hemostatic agent use was associated with an increase in predicted hospital re-admissions (P=0.007). Among all hysterectomy approaches, and after adjusting for demographic and surgical factors, hemostatic agent use during robotic-assisted laparoscopic hysterectomy was associated with an increased predicted rate of blood transfusions (P=0.019), an increased predicted rate of pelvic abscess diagnoses (P=0.001), an increased predicted rate of hospital re-admission (P=0.001), and an increased predicted rate of re-operation (P=0.021). Conclusion Hemostatic agents should be used carefully owing to associations with increased post-operative re-admissions and re-operations when used during hysterectomy.

Small bowel obstruction (SBO) is a common diagnosis; however, outcomes of and risk factors for SBO and malignant bowel obstruction (MBO) surgery are not well understood. We sought to characterize outcomes and risk factors for surgery for SBO and MBO. A retrospective cohort study was performed utilizing prospectively collected data from the Michigan Surgical Quality Collaborative (7/2012–3/2015). Cases included those with ICD9 diagnosis code of bowel obstruction and CPT codes for lysis of adhesions, intestinal bypass, and small bowel resection. Cases were stratified by disseminated malignancy (MBO). Factors associated with complications and 30-day mortality were evaluated. Two thousand two hundred thirty-three patients underwent surgery for bowel obstruction, including 86 patients (3.9 %) with MBO. MBO patients had an adjusted mortality rate of 14.5 % (benign 5.0 %); the adjusted complication rate was 32.2 % (benign 27.0 %). Factors independently associated with mortality included disseminated cancer, older age, American Society of Anesthesiologists IV/V, cirrhosis, ascites, urinary tract infection, sepsis, albumin

To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy.A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving β-lactam antibiotics and those receiving alternatives to β-lactam antibiotics. Patients receiving nonrecommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving nonstandard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results.The study included 21,358 hysterectomies. The overall rate of any surgical site infection was 2.06% (n=441). Unadjusted rates of "any surgical site infection" were 1.8%, 3.1%, and 3.7% for β-lactam, β-lactam alternatives, and nonstandard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared with the β-lactam antibiotics (reference group), the risk of "any surgical site infection" was higher for the group receiving β-lactam alternatives (odds ratio [OR] 1.7, confidence interval [CI] 1.27-2.07) or the nonstandard antibiotics (OR 2.0, CI 1.31-3.1).Compared with women receiving β-lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended β-lactam alternative or nonstandard regimen.

The Michigan Surgical Quality Collaborative (MSQC) was one of the first large-scale regional collaborative quality improvement (CQI) organizations, bringing together surgeons and nurses from 70 Michigan hospitals with a goal of improving surgical outcomes. In this article, we describe the evolution of the MSQC, the science of collaborative quality improvement, and the colorectal surgery-focused projects that MSQC has implemented. Colorectal surgery initiatives have focused on (1) surgical site infection reduction, (2) improving quality of care for colorectal cancer, (3) enhanced recovery pathways, (4) technical skills coaching using video review, and (5) opioid use reduction.

BACKGROUND: Black patients and older adults are less likely to receive minimally invasive hernia repair. These differences by race and age may be influenced by surgeon-specific utilization rate of minimally invasive repair. In this study, we explored the association between race, age, and surgeon utilization of minimally invasive surgery (MIS) with the likelihood of receiving MIS inguinal hernia repair. METHODS: A retrospective cohort study was performed in patients undergoing elective primary inguinal hernia repair from 2012-2016, using data from the Michigan Surgical Quality Collaborative, a 72-hospital clinical registry. Surgeons were stratified by proportion of MIS performed. Using hierarchical logistic regression models, we investigated the association between receiving MIS repair and race, age, and surgeon MIS utilization rate. RESULTS: Out of 4,667 patients, 1253 (27%) received MIS repair. Out of 190 surgeons, 81 (43%) performed only open repair. Controlling for surgeon MIS utilization, race was not associated with MIS receipt (OR 0.93, p=0.775), but older patients were less likely to receive MIS repair (OR 0.41, p

Annually, more than 2 million patients are admitted with emergency general surgery (EGS) conditions. Emergency general surgery cases comprise 11% of all general surgery operations, yet account for 47% of mortalities and 28% of complications. Using the statewide general surgery Michigan Surgical Quality Collaborative (MSQC) data, we previously confirmed that wide variations in EGS outcomes were unrelated to case volume/complexity. We assessed whether patient care model (PCM) affected EGS outcomes.There were 34 hospitals that provided data for PCM, resources, surgeon practice patterns, and comprehensive MSQC patient data from January 1, 2008 to December 31, 2016 (general surgery cases = 126,494; EGS cases = 39,023). Risk and reliability adjusted outcomes were determined using hierarchical multivariable logistic regression analysis with multiple clinical covariates and PCM.The general surgery service (GSS) model was more common (73%) than acute care surgery (ACS, 27%). Emergency general surgery 30-day mortality was 4.1% (intestinal resections 11.6%). The ACS model was associated with a reduction of 31% in mortality (odds ratio [OR] 0.69; 95% CI 0.52-0.92] for EGS cases, related to decreased mortality in the intestinal resection cohort (8.5% ACS vs 12% GSS, p0.0001). Morbidity in EGS was 17.4% (9.7% elective); highest (40%) in intestinal resection, and PCM did not affect morbidity. We identified specific variables for an optimal EGS risk adjustment model.This is the first multi-institutional study to identify that an ACS model is associated with a significant 31% mortality reduction in EGS using prospectively collected, clinically obtained, research-quality collaborative data. We identified that new risk adjustment models are necessary for EGS outcomes evaluations.

Background and objectives The traditional open approach is still a common option for colectomy and the most common option chosen for rectal resections for cancer. Randomized trials and large database studies have reported the merits of the minimally invasive approach, while studies comparing laparoscopic and robotic options have reported inconsistent results. Methods This study was designed to compare open, laparoscopic, and robotic colorectal surgery outcomes in protocol-driven regional and national databases. Logistic and multiple linear regression analyses were used to compare standard 30-day colorectal outcomes in the Michigan Surgical Quality Collaborative (MSQC) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases. The primary outcome was overall complications. Results A total of 10,054 MSQC patients (open 37.5%, laparoscopic 48.8%, and robotic 13.6%) and 80,535 ACS-NSQIP patients (open 25.0%, laparoscopic 67.1%, and robotic 7.9%) met inclusion criteria. Overall complications and surgical site infections were significantly favorable for the laparoscopic and robotic approaches compared with the open approach. Anastomotic leaks were significantly fewer for the laparoscopic and robotic approaches compared with the open approach in ACS-NSQIP, while there was no significant difference between robotic and open approaches in MSQC. Laparoscopic complications were significantly less than robotic complications in MSQC but significantly more in ACS-NSQIP. Laparoscopic 30-day mortality was significantly less than for the robotic approach in MSQC, but there was no difference in ACS-NSQIP. Conclusion Minimally invasive colorectal surgery is associated with fewer complications and has several other outcomes advantages compared with the traditional open approach. Individual complication comparisons vary between databases, and caution should be exercised when interpreting results in context.

Background It is well established that sarcopenic patients are at higher risk of postoperative complications and short-term health care utilization. Less well understood is how these patients fare over the long term after surviving the immediate postoperative period. We explored costs over the first postoperative year among sarcopenic patients. Methods We identified 1279 patients in the Michigan Surgical Quality Collaborative database who underwent inpatient elective surgery at a single institution from 2006–2011. Sarcopenia, defined by gender-stratified tertiles of lean psoas area, was determined from preoperative computed tomography scans using validated analytic morphomics. Data were analyzed to assess sarcopenia's relationship to costs, readmissions, discharge location, intensive care unit admissions, hospital length of stay, and mortality. Multivariate models were adjusted for patient demographics and surgical risk factors. Results Sarcopenia was independently associated with increased adjusted costs at 30, 90, and 180 but not 365 d. The difference in adjusted postsurgical costs between sarcopenic and nonsarcopenic patients was $16,455 at 30 d and $14,093 at 1 y. Sarcopenic patients were more likely to be discharged somewhere other than home (P

Study objective To determine whether preoperatively untreated obstructive sleep apnea (OSA) affects postoperative outcomes. Design Cohort study of patients undergoing surgery between July 2012 and September 2013, utilizing prospectively collected data from the Michigan Surgical Quality Collaborative. Multivariable regression models were used to compare complication rates between treated and untreated OSA, while adjusting for important patient covariates and clustering within hospitals. Setting Fifty-two community and academic hospitals in Michigan. Patients Adult patients undergoing various general or vascular operations were categorized as: (1) no diagnosis or low risk of OSA; (2) documented OSA without therapy or suspicion of OSA; and (3) diagnosis of OSA with treatment (e.g., positive airway pressure). Exposures OSA, preoperatively treated or untreated, was the exposure variable. Postoperative 30-day cardiopulmonary complications including arrhythmias, cardiac arrest, myocardial infarction, unplanned reintubation, pulmonary embolism, and pneumonia were the outcomes of interest. Measurements and results Of 26,842 patients, 2,646 (9.9%) had a diagnosis or suspicion of OSA. Of those, 1,465 (55.4%) were untreated. Patient and procedural risk factors were evenly balanced between treated and untreated groups. Compared with treated OSA, untreated OSA was independently associated with more cardiopulmonary complications (risk-adjusted rates 6.7% versus 4.0%; adjusted odds ratio [aOR] = 1.8, P = 0.001), particularly unplanned reintubations (aOR = 2.5, P = 0.003) and myocardial infarction (aOR = 2.6, P = 0.031). Conclusions Patients with obstructive sleep apnea (OSA) who are not treated with positive airway pressure preoperatively are at increased risks for cardiopulmonary complications after general and vascular surgery. Improving the recognition of OSA and ensuring adequate treatment may be a strategy to reduce risk for surgical patients with OSA.

Objectives: To identify the patient-level effects of blood transfusion on postoperative outcomes and to estimate the effects of different transfusion practices on hospital-level risk-adjusted outcomes. Background: Postoperative transfusion practices and their effects on short-term outcomes in patients undergoing noncardiac surgery are not well understood. Methods: Demographic, operative, and outcomes data for 48,720 patients undergoing general or vascular surgery at 52 hospitals between July 2012 and April 2014 were obtained. The main exposure variable was receipt of any blood transfusion within 72 hours after surgery. Thirty-day mortality, any morbidity, infectious complications, and postoperative myocardial infarction were the outcomes of interest. Propensity score matching was used to minimize confounding by indication. Hospitals were categorized as having a restrictive, average, or liberal transfusion practice based on average trigger hemoglobin values. Results: A total of 2243 (4.6%) patients received a postoperative blood transfusion. After propensity matching, a postoperative transfusion was associated with increased 30-day mortality (3.6% excess absolute risk), any morbidity (4.4% excess absolute risk), and infectious morbidity (1.0% excess absolute risk). However, a transfusion was associated with 3.5% absolute risk reduction in postoperative myocardial infarction. At the hospital level, there was a wide variation in transfusion practices. Hospitals with liberal practices were twice as likely to transfuse patients and had higher risk-adjusted mortality rates than restrictive hospitals (3.1% vs 2.2%; P = 0.002). Conclusions and Relevance: Postoperative transfusions after noncardiac surgery are associated with increased adverse postoperative outcomes, with the exception of postoperative myocardial infarction. Hospitals that are liberal in their transfusion practices have higher 30-day mortality rates, suggesting potential interventions for quality improvement.

To assess the prevalence of and risk factors for venous thromboembolism after hysterectomy.This is a retrospective analysis of data from a voluntary, statewide surgical quality improvement collaborative. Demographics and perioperative data were obtained for hysterectomies performed from January 1, 2008, to April 4, 2014. Postoperative venous thromboembolism was defined as a deep vein thrombosis, pulmonary embolism, or both diagnosed within 30 days of hysterectomy. Significant variables related to postoperative venous thromboembolism were identified using bivariate analyses, and then logistic mixed modeling was used to develop a final model for venous thromboembolism.The rate of postoperative venous thromboembolism was 0.5% (110/20,496). Women who had a postoperative venous thromboembolism more frequently had a body mass index 35 or greater (40.0% compared with 25.2%, odds ratio [OR] 1.96, 95% confidence interval [CI] 1.08-3.56, P=.03), abdominal hysterectomy (referent nonabdominal hysterectomy; 61.8% compared with 29.9%, OR 2.67, 95% CI 1.46-4.86, P=.001), and gynecologic cancer as the indication for surgery (16.4% compared with 9.6%, OR 2.49, 95% CI 1.22-5.07, P=.01). Increasing surgical time (hours; referent 1 hour; OR 1.55, 95% CI 1.31-1.84, P.001) was also an associated factor. In bivariate analyses, women with, compared with without, venous thromboembolism more frequently received both preoperative and postoperative heparin (31.9% compared with 15.2%, P.001 and 55.9% compared with 33.5%, P.001, respectively), but this did not remain significant in the final model.Body mass index 35 or greater, abdominal hysterectomy, increasing surgical time, and cancer as the indication for surgery are risk factors for venous thromboembolism after hysterectomy.III.

A strong relationship between hospital caseload and adverse outcomes has been demonstrated for pancreatic resections. Participation in regional surgical collaboratives may mitigate this phenomenon. This study sought to investigate changes over time in adverse outcomes after pancreatectomy across hospitals with different caseloads in a statewide surgical collaborative. The study investigated patients undergoing pancreatic resection from January 2008 to August 2013 at Michigan Surgical Quality Collaborative (MSQC) hospitals (1007 patients in 19 academic and community hospitals). Risk-adjusted rates of major complications, mortality, and failure to rescue were compared between hospitals based on caseloads (low, medium, and high) in early (2008–2010) and later (2011–2013) periods. Finally, the degree to which different complications explained changes in hospital outcome variation was assessed. Adjusted rates of major complications and mortality decreased over time, driven largely by improvements at low-caseload hospitals. In 2008–2010, risk-adjusted major complication rates were higher for low-caseload than for high-caseload hospitals (27.8 vs. 17.8 %; p = 0.02). However, these differences were attenuated in 2011–2013 (22.2 vs. 20.0 %; p = 0.74). Similarly, adjusted mortality rates were higher in low-caseload hospitals in 2008–2010 (6.2 vs. 0.8 %; p = 0.02), but these differences were attenuated in 2011–2013 (3.3 vs. 1.1 %; p = 0.18). Variation in major complications decreased, largely due to decreased variation in “medical” complication rates, with less change in surgical-site complications. Participation in regional quality collaboratives by lower-volume hospitals can attenuate the volume–outcome relationship for pancreatic surgery. Continued work in collaboratives with an emphasis on technical and intraoperative aspects of care may improve overall quality of care.

To define the incidence of unexpected gynecologic malignancies among women who underwent hysterectomy for benign indications.We conducted a data analysis of hysterectomy cases from a quality and safety database maintained by the Michigan Surgical Quality Collaborative, a statewide group of hospitals that voluntarily reports perioperative outcomes. Cases were abstracted from January 1, 2013, through December 8, 2013. Benign preoperative surgical indications included pelvic mass, family history of cancer, hyperplasia without atypia, prolapse, endometriosis, pelvic pain, abnormal uterine bleeding, or leiomyomas. Women with a surgical indication of cancer, cervical dysplasia, or hyperplasia with atypia were excluded.During the study period, 7,499 women underwent a hysterectomy and 85.24% (n = 6,360) were performed for benign indications. The incidence of unexpected gynecologic malignancy among hysterectomies performed for benign indications was 2.7% (n = 172) and included ovarian, peritoneal, and fallopian tube cancer (n = 69 [1.08%]), endometrial cancer (n = 65 [1.02%]), uterine sarcoma (n = 14 [0.22%]), metastatic cancer (n = 13 [0.20%]), and cervical cancer (n = 11 [0.17%]). The most common indications for hysterectomy were leiomyomas and abnormal uterine bleeding. There was no difference in the mean age (46.86 ± 10.57 compared with 47.0 ± 10.76 years, P = .96) of women with unexpected sarcoma compared with benign disease. Women with unexpected sarcoma were more likely to have a history of venous thromboembolism and preoperative blood transfusion, but this did not reach statistical significance.The 2.7% incidence of unexpected gynecologic malignancy includes a 0.22% incidence of uterine sarcoma and 1.02% incidence of endometrial cancer. No reliable predictors of uterine sarcoma exist and caution is warranted in preoperative planning for hysterectomy.

OBJECTIVE The purpose of this study was to evaluate complete episode expenditures for laparoscopic cholecystectomy, a common and lower-risk operation, to characterize novel targets for value-based quality improvement. SUMMARY BACKGROUND DATA Despite enthusiasm for improving the overall value of surgical care, most efforts have focused on high-risk inpatient surgery. METHODS We identified 19,213 patients undergoing elective laparoscopic cholecystectomy from 2012 to 2015 using data from Medicare and a large private payer. We calculated price-standardized payments for the entire surgical episode of care and stratified patients by surgeon. We used linear regression to risk- and reliability-adjusted expenditures for patient characteristics, diagnoses, and the use of additional procedures. RESULTS Fully adjusted total episode costs varied 2.4-fold across surgeons ($7922-$17,500). After grouping surgeons by adjusted total episode payments, each component of the total episode was more expensive for patients treated by the most expensive versus the least expensive quartile of surgeons. For example, payments for physician services were higher for the most expensive surgeons [$1932, 95% confidence interval (CI) $1844-$2021] compared to least expensive surgeons ($1592, 95% CI $1450-$1701, P < 0.01). Overall differences were driven by higher rates of complications (10% vs. 5%) and readmissions (14% vs. 8%), and lower rates of ambulatory procedures (77% vs. 56%) for surgeons with the highest versus lowest expenditures. Projections showed that a 10% increase ambulatory operations would yield $3.6 million in annual savings for beneficiaries. CONCLUSIONS Episode payments for laparoscopic cholecystectomy vary widely across surgeons. Although improvements in several domains would reduce expenditures, efforts to expand ambulatory surgical practices may result in the largest savings to beneficiaries in Michigan.

Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons.To assess rates of complications for MIC compared with OC among surgeons.We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches.Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC.Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC.Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

Quality improvement programs in Europe have had a markedly beneficial effect on the processes and outcomes of rectal cancer care. The quality of rectal cancer care in the United States is not as well understood, and scalable quality improvement programs have not been developed. The purpose of this article is to describe the implementation of a hospital-based quality assessment program for rectal cancer, targeting both community and academic hospitals.We recruited 10 hospitals from a surgical quality improvement organization. Nurse reviewers were trained to abstract rectal cancer data from hospital medical records, and abstracts were assessed for accuracy. We conducted two surveys to assess the training program and limitations of the data abstraction. We validated data completeness and accuracy by comparing hospital medical record and tumor registry data.Nine of 10 hospitals successfully performed abstractions with ≥ 90% accuracy. Experienced nurse reviewers were challenged by the technical details in operative and pathology reports. Although most variables had less than 10% missing data, outpatient testing information was lacking from some hospitals' inpatient records. This implementation project yielded a final quality assessment program consisting of 20 medical records variables and 11 tumor registry variables.An innovative program linking tumor registry data to quality-improvement data for rectal cancer quality assessment was successfully implemented in 10 hospitals. This data platform and training program can serve as a template for other organizations that are interested in assessing and improving the quality of rectal cancer care.

Background Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement. Objective The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement. Design This was a retrospective cohort study. Settings The study took place within the 34-hospital Michigan Surgical Quality Collaborative. Patients Patients included were those undergoing ostomy creation surgery between 2006 and 2011. Main outcome measures We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type). Results A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals. Limitations This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes. Conclusions Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

To assess the utility of full bowel preparation with oral nonabsorbable antibiotics in preventing infectious complications after elective colectomy.Bowel preparation before elective colectomy remains controversial. We hypothesize that mechanical bowel preparation with nonabsorbable oral antibiotics is associated with a decreased rate of postoperative infectious complications when compared with no bowel preparation.Patient and clinical data were obtained from the Michigan Surgical Quality Collaborative-Colectomy Best Practices Project. Propensity score analysis was used to match elective colectomy cases based on primary exposure variable-full bowel preparation (mechanical bowel preparation with nonabsorbable oral antibiotics) or no bowel preparation (neither mechanical bowel preparation given nor nonabsorbable oral antibiotic given). The primary outcomes for this study were occurrence of surgical site infection and Clostridium difficile colitis.In total, 2475 cases met the study criteria. Propensity analysis created 957 paired cases (n = 1914) differing only by the type of bowel preparation. Patients receiving full preparation were less likely to have any surgical site infection (5.0% vs 9.7%; P = 0.0001), organ space infection (1.6% vs 3.1%; P = 0.024), and superficial surgical site infection (3.0% vs 6.0%; P = 0.001). Patients receiving full preparation were also less likely to develop postoperative C difficile colitis (0.5% vs 1.8%, P = 0.01).In the state of Michigan, full bowel preparation is associated with decreased infectious complications after elective colectomy. Within this context, the Michigan Surgical Quality Collaborative recommends full bowel preparation before elective colectomy.

Objectives To determine whether failure to rescue, as a driver of mortality, can be used to identify which hospitals attenuate the specific risks inherent to elderly adults undergoing surgery. Design Retrospective cohort study. Setting State-wide surgical collaborative in Michigan. Participants Older adults undergoing major general or vascular surgery between 2006 and 2011 (N = 24,216). Measurements: Thirty-four hospitals were ranked according to risk-adjusted 30-day mortality and grouped into tertiles. Within each tertile, rates of major complications and failure to rescue were calculated, stratifying outcomes according to age (

Background Surgical site infections (SSIs) represent a significant preventable source of morbidity, mortality, and cost. Prophylactic antibiotics have been shown to decrease SSI rates, and β-lactam antibiotics are recommended by national guidelines. It is currently unclear whether recommended β-lactam and recommended non-β-lactam antibiotic regimens are equivalent with respect to SSI risk reduction in colectomy patients. Study Design We conducted a retrospective cohort study of SSI rates between prophylactic intravenously administered recommended β-lactam and non-β-lactam in colectomy patients (25 CPT codes) collected by the Michigan Surgical Quality Collaborative from January 2013 to February 2018. Surgical site infection rates were compared as a dichotomous variable (no SSI vs SSI). Mixed-effects regression was used to compare the association between receiving a β-lactam or non-β-lactam antibiotic and likelihood of having an SSI. Results Of 9,949 patients, 9,411 (94.6%) received β-lactam antibiotics and 538 (5.4%) received non-β-lactam antibiotics. Overall, there were 622 (6.3%) patients with SSIs. Of the patients receiving β-lactam antibiotics, SSIs developed in 571 (6.1%) compared with 51 (9.5%) patients in the non-β-lactam group. After applying mixed-effects logistic regression, prophylactic treatment with a non-β-lactam regimen was associated with significantly higher odds of surgical site infection (odds ratio 1.65; 95% CI 1.20 to 2.26; p Conclusions Colectomy patients receiving β-lactam antibiotics had a lower likelihood of SSI compared with those receiving non-β-lactam antibiotics, even when antibiotics were compliant with national recommendations. Our findings suggest that surgeons should prescribe β-lactam antibiotics for prophylaxis whenever possible, reserving alternatives for those rare patients with true allergies or clinical indications for non-β-lactam antibiotic prophylaxis.

Importance There is growing evidence that opioids are overprescribed following surgery. Improving prescribing requires understanding factors associated with opioid consumption. Objective To describe opioid prescribing and consumption for a variety of surgical procedures and determine factors associated with opioid consumption after surgery. Design, Setting, and Participants A retrospective, population-based analysis of the quantity of opioids prescribed and patient-reported opioid consumption across 33 health systems in Michigan, using a sample of adults 18 years and older undergoing surgery. Patients were included if they were prescribed an opioid after surgery. Surgical procedures took place between January 1, 2017, and September 30, 2017, and were included if they were performed in at least 25 patients. Exposures Opioid prescription size in the initial postoperative prescription. Main Outcomes and Measures Patient-reported opioid consumption in oral morphine equivalents. Linear regression analysis was used to calculate risk-adjusted opioid consumption with robust standard errors. Results In this study, 2392 patients (mean age, 55 years; 1353 women [57%]) underwent 1 of 12 surgical procedures. Overall, the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption (median, 30 pills; IQR, 27-45 pills of hydrocodone/acetaminophen, 5/325 mg, vs 9 pills; IQR, 1-25 pills;P Conclusions and Relevance The quantity of opioid prescribed is associated with higher patient-reported opioid consumption. Using patient-reported opioid consumption to develop better prescribing practices is an important step in combating the opioid epidemic.

Laparoscopic cholecystectomy (LC) is the procedure of choice for treatment of cholelithiasis/cholecystitis. Conversion rates (CR) to open cholecystectomy (OC) have been reported previously as 5-15% in elective cases, and up to 25% in patients with acute cholecystitis. We examined the CR in a tertiary-care academic hospital and a statewide surgery quality collaborative, and to compare complications and outcomes in elective and emergency cholecystectomy.Prospective data were obtained from: 1) Non-Trauma Emergency Surgery (NTE) database of all emergent cholecystectomies 1/1/2008-12/31/2009; and 2) Michigan Surgical Quality Collaborative (MSQC) database with a random sample of 20-30% of all operations performed 1/1/2005-12/31/2010, including both University of Michigan (UM) data and statewide data from 34 participating hospitals. Patient characteristics, CR, and outcomes were compared for emergent vs. elective cases.Non-trauma ES patients had a mean hospital length of stay (HLOS) of 4.9 d. Open cholecystectomy-HLOS was greater (4.0, LC; 7.9 laparoscopic converted to open cholecystectomy; 8.7, OC, p0.0001); mortality was 0.35% and CR was 17.5%. In the UM-MSQC dataset, OC-HLOS was greater (6.8 OC vs. 4.6 LC, p0.001); mortality was 0.65%; CR was 9.1% in elective cases and 14.9% in emergent cases. CR was almost two-fold higher [17.5% of all NTE cholecystectomies vs. 9.1% of UM-MSQC elective cholecystectomies (p=0.00078)]. The statewide MSQC cholecystectomy data showed significantly increased HLOS in emergent cholecystectomy patients (4.34 vs. 2.65 d; p0.0001). Morbidity (8.8 vs. 3.7%) and mortality (2.6 vs. 0.5%) rates were also significantly higher in emergent vs. elective cholecystectomies (p0.0001).In NTE patients requiring cholecystectomy, CR is almost two-fold higher but is lower than in reports published previously (25%). However, there is a wide variability in mortality and morbidity for emergency cholecystectomy in both unadjusted and risk-adjusted analyses. Further studies are required to determine modifiable risk factors to improve outcomes in emergency cholecystectomy.

The National Quality Forum (2011) recommends the use of alcohol-based skin preparation agents before surgery to help prevent infections. This multihospital study (n = 3,794) evaluates its use in a general surgery patient population before the National Quality Forum recommendation. Forty-seven percent of cases received an alcohol-based skin preparation agent.

Sarcopenia is associated with poor outcomes after major surgery. There are currently no data regarding the financial implications of providing care for these high-risk patients.We identified 1,593 patients within the Michigan Surgical Quality Collaborative (MSQC) who underwent elective major general or vascular surgery at a single institution between 2006 and 2011. Patient sarcopenia, determined by lean psoas area (LPA), was derived from preoperative CT scans using validated analytic morphomic methods. Financial data including hospital revenue and direct costs were acquired for each patient through the hospital's finance department. Financial data were adjusted for patient and procedural factors using multiple linear regression methods, and Mann-Whitney U test was used for significance testing.After controlling for patient and procedural factors, decreasing LPA was independently associated with increasing payer costs ($6,989.17 per 1,000 mm(2) LPA, p0.001). The influence of LPA on payer costs increased to $26,988.41 per 1,000 mm(2) decrease in LPA (p0.001) in patients who experienced a postoperative complication. Further, the covariate-adjusted hospital margin decreased by $2,620 per 1,000 mm(2) decrease in LPA (p0.001) such that average negative margins were observed in the third of patients with the smallest LPA.Sarcopenia is associated with high payer costs and negative margins after major surgery. Although postoperative complications are universally expensive to payers and providers, sarcopenic patients represent a uniquely costly patient demographic. Given that sarcopenia may be remediable, efforts to attenuate costs associated with major surgery should focus on targeted preoperative interventions to optimize these high risk patients for surgery.

Surgical mortality increases exponentially with age.[1] Conservative estimates show nearly one third of elderly Americans undergo major inpatient surgery within the last year of their life.[2] With the United States Census Bureau projecting that the percentage of the nation’s population over 65 will increase from 12% in 2010 to over 20% by 2030, this may pose a significant public health crisis.[3] The consequences for hospitals remain unknown, as they prepare for patients who tend to experience higher rates of perioperative morbidity and mortality.[4–6] Potentially the most vulnerable subset of this patient population is those undergoing emergent surgery. Recent evidence demonstrates nearly ten-fold higher mortality rates in the elderly undergoing major emergency surgery when compared to younger patients.[7] Given these concerns, the American College of Surgeons and American Geriatric Society have jointly attempted to mitigate perioperative risk by forming “best practices” for the preoperative assessment and optimization of elderly patients.[8] However, despite these efforts, it remains unclear how best to reduce surgical mortality in elderly patients. The relative importance of complication prevention versus complication management is not well defined for elderly patients and may be particularly relevant in the emergent setting. Some posit that the elderly’s decreased physiologic reserve underlies patient-level differences in morbidity and mortality.[9, 10] However, others have shown that there is significant hospital variation in outcomes following emergency general surgery in the elderly, thus pointing to differences in the structure and systems of care.[11] Recent efforts to explain hospital-level differences in mortality have focused on the hospital’s ability to respond to major complications (i.e. failure to rescue). [12–14] The importance of this observation is unknown in the emergent surgical setting where geriatric postoperative management represents an important target for quality improvement. In this context, we used data from the Michigan Surgical Quality Collaborative to examine hospital variation in morbidity, mortality, and failure to rescue after emergency surgery. We then focused on the magnitude of variation in outcomes between the elderly and younger patients. We hypothesize that failure to rescue is a fundamental driver of the inferior outcomes appreciated in the elderly undergoing emergency surgery.

Introduction Within a large, statewide collaborative, significant improvement in surgical quality has been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative, variations in outcomes among hospitals, and variations in adherence to evidence-based process measures. Overall, these data will form a basis for a broad-based quality improvement initiative within Michigan. Methods We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (N = 190,826) within 34 hospitals participating in the Michigan Surgical Quality Collaborative from 2005 to 2010. Adjusted hospital-specific outcomes were calculated using a stepwise multivariable logistic regression model. Adjustment covariates included patient specific comorbidities and case complexity. Hospitals were also compared on the basis of their adherence to evidence-based process measures [measures at the patient level for each case-Surgical Care Improvement Project (SCIP)-1 and SCIP-2 compliance]. Results Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was $126 million for emergency cases and $329 million for elective cases. Adjusted patient outcomes varied widely within Michigan Surgical Quality Collaborative hospitals; morbidity and mortality rates ranged from 16.3% to 33.9% and 4.0% to 12.4%, respectively. The variation among hospitals was not correlated with volume of emergency cases and case complexity. Hospital performance in emergency surgery was found to not depend on its share of emergent cases but rather was found to directly correlate with its performance in elective surgery. For emergency colectomies, there was a wide variation in compliance with SCIP-1 and SCIP-2 measures and overall compliance (42.0%) was markedly lower than that for elective colon surgery (81.7%). Conclusions Emergency surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.

In the setting of cardiovascular (CV) risk evaluation before major elective surgery, current risk assessment tools are relatively poor for discriminating among patients. For example, patients with clinical CV risk factors can be clearly identified; but among those without appreciated clinical CV risk, there may be a subset with stigmata of CV disease noted during the preoperative radiographic evaluation. Our study evaluated the relationship between abdominal aortic (AA) calcification measured on preoperative computed tomography (CT) imaging and surgical complications in patients undergoing general elective and vascular surgery. We hypothesized that patients with no known CV risk factors but significant aortic calcification on preoperative imaging will have inferior surgical outcomes.The study group included 1180 patients from the Michigan Surgical Quality Collaborative (MSQC) database who underwent major general or vascular elective surgery between 2006 and 2009 and who had a CT scan of the abdomen specifically for preoperative planning. AA calcification was measured using novel analytic morphomic techniques and reported as a percentage of the total wall area containing calcification. Patients were divided into cohorts by clinical CV risk and extent of AA calcification. Univariate analysis was used to compare postoperative morbidity between patient cohorts. Multivariate logistic regression analysis was used to compare continuous AA calcification with overall morbidity in patients with no clinical CV risk factors.AA calcification was strongly skewed to the right (53.5% had no AA calcification) and was significantly correlated with age (ρ = 0.43, P0.001). Unadjusted univariate analysis of morbidity showed no significant differences in complication rates between patients in the clinical CV risk and significant AA calcification (no known CV risk factor) categories. The clinical CV risk (P0.001) and significant AA calcification without CV risk factors (P = 0.009) populations both had significantly more infectious and overall complications than patients with no AA calcification and no clinical CV risk. Multivariate logistic regression confirmed that AA calcification was a significant predictor of morbidity in patients with no clinical CV risk factors (odds ratio = 1.35, P = 0.017).This study suggests that AA calcification may be related to progression of CV disease and surgical outcomes. A better understanding of the complex interaction of patient physiology with overall ability to recover from major surgery, using novel approaches such as analytic morphomics, has great potential to improve risk stratification and patient selection.