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Hospital Operative Volume as a Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients

ABSTRACT: BACKGROUND:Within the growing geriatric population, there is an increasing need for emergency operations. Optimizing outcomes can require a structured system of surgical care based on key quality indicators. To investigate this, the current study sought to answer 2 questions. First, to what degree does hospital emergency operative volume impact mortality for geriatric patients undergoing emergency general surgery (EGS) operations? Second, at what procedure-specific hospital volume will geriatric patients undergoing an emergency operation achieve at or better than average mortality risk? STUDY DESIGN:Retrospective cohort study of geriatric patients (aged 65 years and older) who underwent 1 of 10 EGS operations identified from the California State Inpatient Database (2010 to 2011). ?-Logistic generalized linear regression was used, with the hospital as the unit of analysis, to investigate the relationship between hospital operative volume and in-hospital riskv-adjusted mortality. Hospital operative volume thresholds to optimize probability of survival were defined. RESULTS:There were 41,860 operations evaluated at 299 hospitals. For each operation, mortality decreased as hospital emergency operative volume increased (p < 0.001 for each operation); for every standardized increase in volume (meaning +1 natural logarithm of volume), the reduction in mortality ranged from 14% for colectomy to 61% for appendectomy. Hospital volume thresholds, which optimize to 95% probability of survival, varied by procedure, with a mean of 14 operations over 2 years. More than 50% of hospitals did not meet the threshold benchmarks, representing 22% of patients. CONCLUSIONS:Survival rates for geriatric patients were improved substantially when emergency operations were performed at hospitals with higher operative volumes. Consistent with all active Quality Programs of the American College of Surgeons, hospital operative volume appears to be an important metric of surgical quality for older patients undergoing emergency operations.

SUBMITTER: Becher RD

PROVIDER: S-EPMC6582986 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Hospital Operative Volume as a Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients

Becher Robert D RD DeWane Michael P MP Sukumar Nitin N Stolar Marilyn J MJ Gill Thomas M TM Becher Robert M RM Maung Adrian A AA Schuster Kevin M KM Davis Kimberly A KA

Journal of the American College of Surgeons 20190418 6

<h4>Background</h4>Within the growing geriatric population, there is an increasing need for emergency operations. Optimizing outcomes can require a structured system of surgical care based on key quality indicators. To investigate this, the current study sought to answer 2 questions. First, to what degree does hospital emergency operative volume impact mortality for geriatric patients undergoing emergency general surgery (EGS) operations? Second, at what procedure-specific hospital volume will g ...[more]

PMID: 31005629

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Project description:There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected.We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix.Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures.Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded by the National Institute on Aging.).

Project description:BACKGROUND:As the geriatric population grows, the need for hospitals performing high quality emergency general surgery (EGS) on older patients will increase. Identifying clusters of high-performing geriatric emergency general surgery hospitals would substantiate the need for in-depth analyses of hospital-specific structures and practices that benefit older EGS patients. The objectives of this study were therefore to identify clusters of hospitals based on mortality performance for geriatric patients undergoing common EGS operations and to determine if hospital performance was similar for all operation types. METHODS:Hospitals in the California State Inpatient Database were included if they performed a range of eight common EGS operations in patients 65 years or older, with a minimum requirement of three of each operation performed over 2 years. Multivariable beta regression models were created to define hospital-level risk-adjusted mortality. Centroid cluster analysis was used to identify groups of hospitals based on mortality and to determine if mortality-performance differed by operation. RESULTS:One hundred seven hospitals were included, performing a total of 24,279 operations in older patients. Hospitals separated into three distinct clusters: high, average, and low performers. The high-performing hospitals had survival rates 1 to 2 standard deviations better than the low-performers (p < 0.001). For each cluster, high performance in any one EGS operation consistently translated into high performance across all EGS operations. CONCLUSION:Hospitals conducting EGS operations in the geriatric patient population cluster into three distinct groups based on their survival performance. High-performing hospitals significantly outperform the average and low performers across every operation. The high-performers achieve reliable, high-quality results regardless of operation type. Further qualitative research is needed to investigate the perioperative drivers of hospital performance in the geriatric EGS population. LEVEL OF EVIDENCE:Study Type Prognostic, level III.

Project description:ImportanceFrailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.ObjectiveTo determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.Design, setting, and participantsA retrospective cohort study was conducted of 140?828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.Main outcomes and measuresThe association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.ResultsA total of 140?828 patients (80?147 women and 60?681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n?=?71?455), breast (n?=?51?267), thyroid, or parathyroid surgery (n?=?18?106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P?<?.001) for any complication and 2.00 (95% CI, 1.72-2.34; P?<?.001) for serious complications. A high modified frailty index score (?0.36, corresponding to ?4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P?<?.001) for any complication and 3.95 (95% CI, 2.65-5.87; P?<?.001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P?<?.001).Conclusions and relevanceFrailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.

Project description:IntroductionBariatric surgery performed at high volume centers decreases length of stay, cost, and morbidity and mortality. The effect of a high volume of bariatric surgery procedures on outcomes may extend not just to bariatric surgery but to any general surgical procedure in morbidly obese patients. We hypothesized that patients with morbid obesity (body mass index >40 kg/m2) undergoing common, nonbariatric general surgery would have decreased morbidity and mortality at centers performing high volumes of bariatric surgery.MethodsThe 2016 National Inpatient Sample (NIS) was used to identify the number of laparoscopic gastric bypass and sleeve gastrectomy performed at each hospital. Hospitals were classified as high volume bariatric hospitals (HVBH) ≥10 reported cases (50 actual)/year or low volume bariatric hospitals (LVBH) <10 reported cases (50 actual)/year, as NIS reports a 20% sample of actual cases. Patients with morbid obesity undergoing laparoscopic or open appendectomy, cholecystectomy, or ventral hernia repair were included for analysis. Propensity scores were developed based on available demographics, comorbidities, and hospital procedure volume. Postoperative complications during the index hospital admission, determined by ICD-10 code, were compared using inverse propensity weights. Differences were considered significant with a p value of <0.05.ResultsThe total number of general surgery patient cases analyzed was 14,028 from 2,482 hospitals, representing 70,140 admissions. The cohort of patients undergoing operations treated at HVBH were younger (p=0.03) with higher rates of COPD (p=0.04). Patients at LVBH had higher rates of nicotine dependence (p=0.0001) and obstructive sleep apnea (p < 0.001). On propensity-weighted analysis adjusting for preoperative comorbidities and hospital procedure volume, there were significantly higher rates of multiple postprocedure complications at LVBH, specifically, postprocedure respiratory failure for patients undergoing elective laparoscopic cholecystectomy, elective ventral hernia repair with mesh and appendectomy.ConclusionPatients with morbid obesity may have an advantage in having general surgery procedures at HVBH. HVBH may have a volume-outcomes relationship where the hospital and staff familiarity with the management principles required to minimize the postoperative risk associated with morbid obesity and improve patient outcomes.

Project description:ObjectiveThere is widespread evidence that cancer confers an increased risk of deep venous thrombosis (DVT). This risk is thought to vary among different cancer types. The purpose of this study is to better define the incidence of thrombotic complications among patients undergoing surgical treatment for a spectrum of prevalent cancer diagnoses in contemporary practice.MethodsAll patients undergoing one of 11 cancer surgical operations (breast resection, hysterectomy, prostatectomy, colectomy, gastrectomy, lung resection, hepatectomy, pancreatectomy, cystectomy, esophagectomy, and nephrectomy) were identified by Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes using the American College of Surgeons National Surgical Quality Improvement Program database (2007-2009). The study endpoints were DVT, pulmonary embolism (PE), and overall postoperative venous thromboembolic events (VTE) within 1 month of the index procedure. Multivariate logistic regression was utilized to calculate adjusted odds ratios for each endpoint.ResultsOver the study interval, 43,808 of the selected cancer operations were performed. The incidence of DVT, PE, and total VTE within 1 month following surgery varied widely across a spectrum of cancer diagnoses, ranging from 0.19%, 0.12%, and 0.28% for breast resection to 6.1%, 2.4%, and 7.3%, respectively, for esophagectomy. Compared with breast cancer, the incidence of VTE ranged from a 1.31-fold increase in VTE associated with gastrectomy (95% confidence interval, 0.73-2.37; P = .4) to a 2.68-fold increase associated with hysterectomy (95% confidence interval, 1.43-5.01; P = .002). Multivariate logistic regression revealed that inpatient status, steroid use, advanced age (≥60 years), morbid obesity (body mass index ≥35), blood transfusion, reintubation, cardiac arrest, postoperative infectious complications, and prolonged hospitalization were independently associated with increased risk of VTE.ConclusionsThe incidence of VTE and thromboembolic complications associated with cancer surgery varies substantially. These findings suggest that both tumor type and resection magnitude may impact VTE risk. Accordingly, such data support diagnosis and procedural-specific guidelines for perioperative VTE prophylaxis and can be used to anticipate the risk of potentially preventable morbidity.

Dataset Information

Hospital Operative Volume as a Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients

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Hospital Operative Volume as a Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients

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