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January 1, 2021, the Centers for Medicare and Medicaid Services (CMS) implemented a Hospital Price Transparency Rule. Consumerism as a means of reducing healthcare expenditures is predicated on informed consumers making discrete choices.For 10 months, immediately following an academic medical center preoperative clinic visit, patients and their surgeons were surveyed regarding their estimation of hospital cost and hospital reimbursement for the upcoming surgery. Responses were compared to average FY 2019 institutional Cost for Medicare patients undergoing a laparoscopic approach for each operation. We calculated the difference between actual reimbursements and costs with patients' estimates and actual reimbursements and costs with surgeons' estimates.66 questionnaires were collected from patients who underwent laparoscopic: cholecystectomy (n=20), inguinal hernia (n=17), umbilical hernia repair (n=6), ventral hernia repair (n=6), incisional hernia (n=6), hiatal hernia repair (n=1), and lipoma or cyst excision (n=10). Patients' estimates for hospital costs exceeded actual hospital costs by a median of $4502 and were less than hospital reimbursements by a median of $1834. Surgeon estimates for direct costs were $825 less than hospital direct costs and $1659 less than hospital reimbursement.Patients as well as their surgeons do not estimate healthcare costs or remuneration accurately and therefore will be ineffective change agents in reducing surgical spending based on price transparency without further education of both parties. Patients consistently overestimated surgical costs while surgeons consistently underestimated surgical costs and reimbursements. Better-informed surgeons and patients are likely necessary prerequisites for CMS Price Transparency Rules to be effective in reducing Medicare expenditures in surgery.

Liver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis.This retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality.A total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis.The VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.

Medical errors were largely concealed prior to the landmark report "To Err Is Human". The purpose of this systematic scoping review was to determine the extent pediatric surgery defines and studies errors, and to explore themes among papers focused on errors in pediatric surgery.The methodological framework used to conduct this scoping study has been outlined by Arksey and O'Malley. In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Oxford Level of Evidence was assigned to each study; only studies rated Level 3 or higher were included.Of 3,064 initial studies, 12 were included in the final analysis: 4 cohort studies, and 8 outcome/audit studies. This data represented 5,442,000 aggregate patients and 8,893 errors. There were 6 different error definitions and 5 study methods. Common themes amongst the studies included a systems-focused approach, an increase in errors seen with increased complexity, and studies exploring the relationship between error and adverse events.This study revealed multiple error definitions, multiple error study methods, and common themes described in the pediatric surgical literature. Opportunities exist to improve the safety of surgical care of children by reducing errors. Original Scientific Research Type of Study: Systematic Scoping Review Level of Evidence Rating: 1.

Our objective was to determine the extent surgical disciplines categorize, define, and study errors, then use this information to provide recommendations for both current practice and future study.The report "To Err is Human" brought the ubiquity of medical errors to public attention. Variability in subsequent literature suggests the true prevalence of error remains unknown.In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Only studies with Oxford Level of Evidence Level 3 or higher were included.Of 3064 studies, 92 met inclusion criteria: 6 randomized controlled trials, 4 systematic reviews, 24 cohort, 10 before-after, 35 outcome/audit, 5 cross sectional and 8 case-control studies. Over 15,933,430 patients and 162,113 errors were represented. There were 6 broad error categories, 13 different definitions of error, and 14 study methods.Reported prevalence of error varied widely due to a lack of standardized categorization, definitions, and study methods. Future research should focus on immediately recognizing errors to minimize harm.

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

BACKGROUND AND PURPOSE The Medicare Value-Based Purchasing (VBP) program established performance-based financial incentives for hospitals. We hypothesized that total performance scores (TPS) would vary by hospital type. METHODS Value-Based Purchasing reports were collected from 2015 to 2017 and merged with the Centers for Medicare and Medicaid Services (CMS) Impact File data. A total of 3,005 hospitals were grouped into physician-owned surgical hospitals (POSH), accountable care organizations (ACO), Kaiser, Vizient, and General hospitals. Longitudinal linear mixed-effects models compared temporal differences of TPS and secondary composite outcome, process, patient satisfaction, safety, and cost efficiency measures between hospital types. RESULTS Total performance scores decreased across all hospital types (p < .001). Physician-owned surgical hospitals had the highest TPS (59.9), followed by Kaiser (49.2), ACO (36.7), General (34.8), and Vizient (30.7) (p < .001). Hospital types differed significantly in size, geography, mean case-mix index, Medicare patient discharges, percent Medicare days to inpatient days, Disproportionate Share Hospital payments, and uncompensated care per claim. Scores improved in 84% of POSH and 14.6% of Kaiser hospitals using score reallocations. CONCLUSION In comparison with General hospitals, the TPS was higher for POSH and Kaiser and lower for Vizient in part due to weighting reallocation and individual domain scores. IMPLICATIONS Centers for Medicare and Medicaid Services scoring system changes have not addressed the methodological biases favoring certain hospital types.

While errors can harm patients they remain poorly studied. This study characterized errors in the care of surgical patients and examined the association of errors with morbidity and mortality.Errors have been reported to cause10% or60% of adverse events. Such discordant results underscore the need for further exploration of the relationship between error and adverse events.Patients with operations performed at a single institution and abstracted into the American College of Surgeons National Surgical Quality Improvement Program from January 1, 2018, to December 31, 2018 were examined. This matched case control study comprised cases who experienced a postoperative morbidity or mortality. Controls included patients without morbidity or mortality, matched 2:1 using age (±10 years), sex, and Current Procedural Terminology (CPT) group. Two faculty surgeons independently reviewed records for each case and control patient to identify diagnostic, technical, judgment, medication, system, or omission errors. A conditional multivariable logistic regression model examined the association between error and morbidity.Of 1899 patients, 170 were defined as cases who experienced a morbidity or mortality. The majority of cases (n=93; 55%) had at least 1 error; of the 329 matched control patients, 112 had at least 1 error (34%). Technical errors occurred most often among both cases (40%) and controls (23%). Logistic regression demonstrated a strong independent relationship between error and morbidity (odds ratio=2.67, 95% confidence interval: 1.64-4.35, P0.001).Errors in surgical care were associated with postoperative morbidity. Reducing errors requires measurement of errors.

BACKGROUND Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population. METHODS Pancreatectomy and hepatectomy operation-specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC). RESULTS A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58). CONCLUSION HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies.

Our objective was to examine the associations between early discharge and readmission after major abdominal operations.Advances in patient care resulted in earlier patient discharge after complex abdominal operations. Whether early discharge is associated with patient readmissions remains controversial.Patients who had colorectal, liver, and pancreas operations abstracted in 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were included. Patient readmission was stratified by 6 operative groups. Patients who were discharged before median discharge date within each operative group were categorized as an early discharge. Analyses tested associations between early discharge and likelihood of 30-day postoperative unplanned readmission.A total of 364,609 patients with major abdominal operations were included. Individual patient groups and corresponding median day of discharge were: laparoscopic colectomy (n = 152,575; median = 4), open colectomy (n =137,462; median = 7), laparoscopic proctectomy (n = 12,238; median = 5), open proctectomy (n = 24,925; median = 6), major hepatectomy (n = 9,805; median = 6), pancreatoduodenectomy (n = 27,604; median = 8). Early discharge was not associated with an increase in proportion of readmissions in any operative group. Early discharge was associated with a decrease in average proportion of patient readmissions compared to patients discharged on median date in each of the operative groups: laparoscopic colectomy 6% versus 8%, open colectomy 11% versus 14%, laparoscopic proctectomy 13% versus 16%, open proctectomy 13% vs 17%, major hepatectomy 8% versus 12%, pancreatoduodenectomy 16% versus 20% (all P ≤ 0.02). Serious morbidity composite was significantly lower in patients who were discharged early than those who were not in each operative group (all P0.001).Early discharge in selected patients after major abdominal operations is associated with lower, and not higher, rate of 30-day unplanned readmission.

As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications. Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naive patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications. 707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p

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

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

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

Efficacy of single-shot opioid spinal analgesia after pancreatoduodenectomy remains understudied and lacks comparison to standard continuous thoracic epidural analgesia (TEA).Pancreatoduodenectomy patients who underwent TEA or opioid spinal for postoperative pain management from 2015 to 2020 were included in this observational cohort study. Primary outcome was patient-reported mean daily pain scores. Secondary outcomes included postoperative morphine milligram equivalents (MMEs) and length of stay (LOS). Multivariable linear regression models were constructed to compare risk-adjusted outcomes.180 patients were included: 56 TEA and 124 opioid spinal. Compared to epidural patients, opioid spinal patients were more likely to be older (67.0 vs. 64.6, p=0.045), have greater BMI (26.5 vs. 24.4, p=0.02), and less likely to be smokers (19.4% vs. 41.1%, p=0.002). Opioid spinal, compared to TEA, was associated with lower intraoperative MMEs (0.25 vs. 22.7, p0.001) and postoperative daily MMEs (7.9 vs. 10.3, p=0.03) on univariate analysis. However, after multivariable adjustment, there was no difference in average pain scores across the postoperative period (spinal vs. epidural: 4.18 vs. 4.14, p=0.93), daily MMEs (p=0.50), or LOS (p=0.23).There was no significant difference in postoperative pain scores, opioid use, or LOS between patients managed with TEA or opioid spinal after pancreatoduodenectomy.

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

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

Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population.Pancreatectomy and hepatectomy operation-specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC).A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58).HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies.

Unplanned reoperations and unplanned readmissions can increase morbidity and mortality. Few studies however, have explored the association of reoperation and readmission among general surgery patients. Our aim was to examine this relationship in selected abdominal operations.Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files from 2014 to 2018 were utilized. Six groups of operations, defined by ACS NSQIP procedure codes for ventral hernia repair, colectomy, appendectomy, proctectomy, small bowel resection, and gastrectomy, were assessed. Patients discharged ≤ 14 days after operation were included in the study. This time period was selected to reduce ACS NSQIP 30 day post-surgery follow-up bias. Unplanned reoperations were defined as those occurring during the index hospitalization. The primary outcome was unplanned readmission that occurred ≤ 14 days from the date of discharge. Logistic regression models were used to examine variables associated with unplanned readmission for each procedure group.A total of 787,118 patients were included: ventral hernia repair 35.2%, colectomy 30.6%, appendectomy 26.5%, proctectomy 3.7%, small bowel resection 3.2%, and gastrectomy 0.8%. Unplanned reoperation was independently associated with unplanned readmission for ventral hernia repair (OR 2.84, 95% CI 2.28-3.54, P0.001), colectomy (OR 1.58, CI 1.42- 1.76, P0.001), appendectomy (OR 2.91, CI 2.21-3.84, P0.001), and proctectomy (OR 1.41, CI 1.10-1.81, P = 0.006). Other clinically relevant covariates associated with readmission were partially dependent functional status before colectomy (OR 1.34, CI 1.23-1.46, P0.001), ventral hernia repair (OR 1.79, CI 1.54-2.09, P0.001), and small bowel resection (OR 1.44, CI 1.18-1.77, P0.001; and ASA 4/5 classification for colectomy (OR 2.71, CI 2.36-3.11, P0.001), proctectomy (OR 2.10, CI 1.48-2.97, P0.001), ventral hernia repair (OR 8.19, CI 6.78-9.88, P0.001), appendectomy (OR 2.80, CI 2.35-3.34, P0.001), and small bowel resection (OR 3.42, CI 2.20-5.32, P0.001). ASA 2, ASA 3 classification, age, and sex were also associated with unplanned readmission for most procedures.Unplanned reoperations are associated with an increase in unplanned readmission after selected abdominal operations included in this study. This factor should be considered in discharge and follow-up planning to help reduce unplanned readmissions.

Background In North America, the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risk posed by preoperative esophageal disease for patients undergoing abdominal operations. Method American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP; 2005-2015) data were merged with institutional clinical data repository records to identify esophageal disease in surgical patients undergoing intra-abdominal procedures. Patients with esophageal disease were classified as gastroesophageal reflux disorder (GERD) or other, which included patients with esophageal stricture, spasm, ulcer, or diverticuli, achalasia, esophagitis, reflux esophagitis, Barrett's esophagus, and multiple esophageal diagnoses, excluding GERD. ACS NSQIP–targeted procedure groups included were colectomy, proctectomy, ventral hernia repair, bariatric surgery, hepatectomy, appendectomy, abdominal aortic aneurysm repair, open aortoiliac repair, hysterectomy, myomectomy, and oophorectomy. Multivariable logistic regression was used to model postoperative complication rates, adjusting for ACS NSQIP risk of morbidity, demographic factors, ACS NSQIP–targeted procedure groups, and open versus laparoscopic surgery. Results Of 9172 intra-abdominal cases, 21.3% had preoperative esophageal disease (19.6% GERD and 1.7% other). After adjustment, patients with GERD were at higher risk for experiencing a number of complications, including all-cause 30-d complication (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.05-1.41, P = 0.044), renal complication (OR = 1.43, 95% CI 1.09-1.87, P = 0.036), wound complication (OR = 1.40, 95% CI 1.10-1.79, P = 0.028), and readmission within 30 d (OR = 1.66, 95% CI 1.35-2.04, P Conclusions Preoperative GERD is associated with increased postoperative complication rate. Surgeons should consider assessing GERD in patients undergoing abdominal operations.

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

Medicare's Value-Based Purchasing Program (VBPP) compensates hospitals based on value of care provided. VBPP's total performance score (TPS) components data were evaluated by hospital groups: physician-owned surgical hospitals (POSH), Kaiser Hospitals, University HealthSystem Consortium Hospitals, Pioneer Accountable Care Organization Hospitals, US News and World Report Honor Roll Hospitals, and other hospitals. Multilevel random coefficient models estimated mean and significance of TPS differences from fiscal year (FY) 2015 and FY 2016, by hospital type. Overall mean TPS for 2985 hospitals decreased from 41.65 to 40.25. POSH and Kaiser Hospitals had significantly higher TPS in FY 2015 and FY 2016. POSH Patient Experience Domain scores exceeded all other Patient Experience Domain scores. The Efficiency Domain scores of Kaiser greatly exceeded the scores of all groups. Results suggest that POSH and Kaiser Hospitals provide significantly greater value of care with consistency from year to year when compared with other groups studied.

Estimating surgeon-level value in health care remains relatively unexplored. American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2013) were linked with total costs at a single institution. Random intercepts in 3-level random effects logistic regression models predicted 30-day postoperative mortality or morbidity for each surgeon each year. Value was defined as quality (morbidity or mortality) divided by costs for surgeons performing general surgery and vascular procedures. Forty-four surgeons performed 11 965 surgeries. Risk-adjusted costs trended down over time. For all surgeries, mortality value increased by 3.27 per year (95% confidence interval = 2.54-4.01; P < .001) on a 100-point scale, while morbidity value did not change. Of 21 surgeons with data for 5 years or longer, mortality value increased for all surgeons except one. Continuous increase in complication rates from 2008 contributed to decreased morbidity value. Value may assist surgeons in exploring performance opportunities better than morbidity or mortality alone.

Adequate lymphadenectomy is associated with improved survival in patients who undergo oncologic resection of colorectal cancer and has been identified as a quality metric. Neoadjuvant chemotherapy has been found to be associated with collection of 12 lymph nodes. Of 9077 patients with a diagnosis of colon cancer who underwent colectomy, a minimum of 12 lymph nodes was harvested in 7897 (87%). Significant factors independently associated with inadequate lymphadenectomy included preoperative chemotherapy, emergent surgery, and T1 tumors (all P < 0.05). A large majority of patients who undergo colectomy for colon cancer have at least 12 lymph nodes collected. Preoperative chemotherapy is a major risk factor for inadequate lymph node retrieval. Recognition of factors associated with inadequate lymphadenectomy may improve colectomy lymph node yield and survival in patients with colon cancer.

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

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

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

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

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

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

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

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

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

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

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

The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models.The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index.Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US NewsWorld Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p0.0001), US NewsWorld Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index.The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals.

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

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

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

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

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

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

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

This study evaluates the risk of complications associated with elective laparoscopic adrenalectomy (LA) as reported in a national dataset. We hypothesize that the risk for major complication is associated with identifiable perioperative variables. This information may aid in understanding who safely could be discharged early after surgery, including same-day discharge. Elective LA from 2009 to 2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File were reviewed. A priori selection of likely risk factors for complications was assessed for their association with morbidity. Sequential bivariable logistic regression was used to measure the statistical significance of each risk factor's observed association with the occurrence of major morbidity after surgery. The potential for multiple comparisons bias was accounted for by using a high threshold ( P < 0.01) for identifying statistically significant associations. One thousand ninety-nine patients were identified. The 30-day mortality rate was 0.18 per cent, and 4.8 per cent of patients experienced a major morbidity within 30 days of surgery. Return to the operating room occurred in 1.46 per cent of cases. Statistically significant associations occurred for 15 patient characteristics at P < 0.05. Diabetes, nonindependent functional status before surgery, American Society of Anesthesiologists classification >2, and operative time were statistically significant at P < 0.01. Complications are rare events among elective LA patients. However, several readily identifiable patient characteristics are associated with the occurrence of complications among these patients. These patient characteristics should be taken into account when considering future trials of early discharge after LA, including same-day discharge.

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