Dataset Information

"A National Study Demonstrating the Need for Improved Frailty Indices for Preoperative Risk Assessment of Common Urologic Procedures".

ABSTRACT: OBJECTIVE:To compare the associations between frailty indices and postoperative complications among older adults undergoing common urologic procedures. Frailty is known to be strongly associated with poor postoperative complications; however, the optimal way to measure frailty remains unknown. METHODS:We identified the 20 most common urologic procedures from 2013-2016 in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Frailty was measured using the NSQIP frailty index, simplified frailty index, and Risk Analysis Index. Multivariable logistic regression models were performed with each index and the American Society of Anesthesiologists (ASA) classification system with postoperative complications (any, major, or minor) as the outcomes. Statistical models were compared using the following fit parameters: area under the curve, Akaike information criterion, and Bayesian information criterion. RESULTS:A total of 158,855 procedures were identified. All frailty indices (NSQIP frailty index, simplified frailty index, and Risk Analysis Index) and ASA were associated with increased odds for any, major, and minor complications (all P values <.001). ASA demonstrated stronger model fit parameters for any, major and minor complications compared to all other indices, with an area under the curve of 0.63, 0.64, and 0.64, respectively (all P values <.001). Adding ASA to each frailty index resulted in slight improvement of model fit parameters (P value <.001). CONCLUSION:ASA slightly outperforms current frailty indices in predicting postoperative complications among individuals undergoing commonly performed urologic procedures. Our findings highlight the need for improved frailty measures for preoperative risk assessment.

SUBMITTER: Amin KA

PROVIDER: S-EPMC6778010 | biostudies-other | 2019 Oct

REPOSITORIES: biostudies-other

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"A National Study Demonstrating the Need for Improved Frailty Indices for Preoperative Risk Assessment of Common Urologic Procedures".

Amin Katherine A KA Lee Una J UJ Jin Chengshi C Boscardin John J Medendorp Andrew R AR Anger Jennifer T JT Suskind Anne M AM

Urology 20190711

<h4>Objective</h4>To compare the associations between frailty indices and postoperative complications among older adults undergoing common urologic procedures. Frailty is known to be strongly associated with poor postoperative complications; however, the optimal way to measure frailty remains unknown.<h4>Methods</h4>We identified the 20 most common urologic procedures from 2013-2016 in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Frailty was me ...[more]

PMID: 31302138

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Project description:ImportanceThe American Urological Association guidelines recommend 24 or fewer hours of antimicrobial prophylaxis for most urologic procedures. Continuing antimicrobial therapy beyond 24 hours may carry more risks than advantages.ObjectivesTo assess guideline discordance of antimicrobial prophylaxis for common urologic endoscopic procedures, and to identify opportunities for improving antimicrobial prescribing through future stewardship interventions.Design, setting, and participantsThis multicenter cohort study conducted manual audits of medical records of 375 patients who underwent 1 of 3 urologic procedures (transurethral resection of bladder tumor [TURBT], transurethral resection of the prostate [TURP], and ureteroscopy [URS]) at 5 Veterans Health Administration facilities from January 1, 2016, to June 30, 2017. Antimicrobial prescribing practices across the national Veterans Health Administration system were assessed using the administrative data for 29?530 records.Main outcomes and measuresGuideline discordance was assessed in the medical record review. Excessive postprocedural antimicrobial use was measured in the national administrative data analysis.ResultsThe medical records of a total of 375 patients were manually reviewed. Among the 375 patients, 366 (97.6%) were male and 9 (2.4%) were female, with a mean (SD) age of 64.2 (10.9) years and a predominantly white race/ethnicity (289 [77.1%]). In addition, 29?530 patient records in the national administrative database were assessed. Among the patient records, 28?938 (98.0%) were male and 592 (2.0%) were female with a mean (SD) age of 69.1 (10.2) years and a predominantly white race/ethnicity (23?297 [78.9%]). Among the manually reviewed medical records, periprocedural or postprocedural antimicrobial prescribing was guideline discordant in 217 patients (57.9%). Postprocedural antimicrobial agents were continued beyond 24 hours in 211 patients (56.3%) and were guideline discordant in 177 patients (83.9%), with a median (interquartile range) duration of 3 (3-5) days of unnecessary antimicrobial therapy. In the analysis of national administrative data, excessive postprocedural antimicrobial agents were prescribed in 10?988 of 29?350 patient records (37.2%), with a median (interquartile range) of 3 (2-6) excess days. For any given facility, a statistically significant correlation was observed in the frequency of postprocedural antimicrobial prescribing between any 2 procedures, indicating that facilities with higher rates of excessive use for 1 procedure also had higher rates for another procedure: TURP and TURBT (??=?0.719; 95% CI, 0.603-0.803; P?<?.001), TURP and URS (??=?0.629; 95% CI, 0.476-0.741; P?<?.001), and TURBT and URS (??=?0.813; 95% CI, 0.724-0.873; P?<?.001).Conclusions and relevanceIn this study of patients who underwent common urologic procedures, the rate of guideline-discordant antimicrobial use was high mostly because of overprescribing of postprocedural antimicrobial agents; future antimicrobial stewardship interventions should target the postprocedural period.

Project description:ImportanceSurgeons must balance management of acute postoperative pain with opioid stewardship. Patient-centered methods that immediately evaluate pain and opioid consumption can be used to guide prescribing and shared decision-making.ObjectiveTo assess the difference between the number of opioid tablets prescribed and the self-reported number of tablets taken as well as self-reported pain intensity and ability to manage pain after orthopedic and urologic procedures with use of an automated text messaging system.Design, setting, and participantsThis quality improvement study was conducted at a large, urban academic health care system in Pennsylvania. Adult patients (aged ≥18 years) who underwent orthopedic and urologic procedures and received postoperative prescriptions for opioids were included. Data were collected prospectively using automated text messaging until postoperative day 28, from May 1 to December 31, 2019.Main outcomes and measuresThe primary outcome was the difference between the number of opioid tablets prescribed and the patient-reported number of tablets taken (in oxycodone 5-mg tablet equivalents). Secondary outcomes were self-reported pain intensity (on a scale of 0-10, with 10 being the highest level of pain) and ability to manage pain (on a scale of 0-10, with 10 representing very able to control pain) after orthopedic and urologic procedures.ResultsOf the 919 study participants, 742 (80.7%) underwent orthopedic procedures and 177 (19.2%) underwent urologic procedures. Among those who underwent orthopedic procedures, 384 (51.8%) were women, 491 (66.7%) were White, and the median age was 48 years (interquartile range [IQR], 32-61 years); 514 (69.8%) had an outpatient procedure. Among those who underwent urologic procedures, 145 (84.8%) were men, 138 (80.7%) were White, and the median age was 56 years (IQR, 40-67 years); 106 (62%) had an outpatient procedure. The mean (SD) pain score on day 4 after orthopedic procedures was 4.72 (2.54), with a mean (SD) change by day 21 of -0.40 (1.91). The mean (SD) ability to manage pain score on day 4 was 7.32 (2.59), with a mean (SD) change of -0.80 (2.72) by day 21. The mean (SD) pain score on day 4 after urologic procedures was 3.48 (2.43), with a mean (SD) change by day 21 of -1.50 (2.12). The mean (SD) ability to manage pain score on day 4 was 7.34 (2.81), with a mean (SD) change of 0.80 (1.75) by day 14. The median quantity of opioids prescribed for patients who underwent orthopedic procedures was high compared with self-reported consumption (20 tablets [IQR, 15-30 tablets] vs 6 tablets used [IQR, 0-14 tablets]), similar to findings for patients who underwent urologic procedures (7 tablets [IQR, 5-10 tablets] vs 1 tablet used [IQR, 0-4 tablets]). Over the study period, 9452 of 15 581 total tablets prescribed (60.7%) were unused. A total of 589 patients (64.1%) used less than half of the amount prescribed, and 256 patients (27.8%) did not use any opioids (179 [24.1%] who underwent orthopedic procedures and 77 [43.5%] who underwent urologic procedures).Conclusions and relevanceIn this quality improvement study of adult patients reporting use of opioids after common orthopedic and urologic surgical procedures through a text messaging system, the quantities of opioids prescribed and the quantity consumed differed. Patient-reported data collected through text messaging may support clinicians in tailoring prescriptions and guide shared decision-making to limit excess quantities of prescribed opioids.

Project description:Frailty assessment may inform surgical risk and prognosis not captured by conventional surgical risk scores.To evaluate the evidence for various frailty instruments used to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCEs) in older adults undergoing cardiac surgical procedures.MEDLINE and EMBASE (without language restrictions), from their inception to 2 May 2016.Cohort studies evaluating the association between frailty and mortality or functional status at 6 months or later in patients aged 60 years or older undergoing major or minimally invasive cardiac surgical procedures.2 reviewers independently extracted study data and assessed study quality.Mobility, disability, and nutrition were frequently assessed domains of frailty in both types of procedures. In patients undergoing major procedures (n = 18 388; 8 studies), 9 frailty instruments were evaluated. There was moderate-quality evidence to assess mobility or disability and very-low- to low-quality evidence for using a multicomponent instrument to predict mortality or MACCEs. No studies examined functional status. In patients undergoing minimally invasive procedures (n = 5177; 17 studies), 13 frailty instruments were evaluated. There was moderate- to high-quality evidence for assessing mobility to predict mortality or functional status. Several multicomponent instruments predicted mortality, functional status, or MACCEs, but the quality of evidence was low to moderate. Multicomponent instruments that measure different frailty domains seemed to outperform single-component ones.Heterogeneity of frailty assessment, limited generalizability of multicomponent frailty instruments, few validated frailty instruments, and potential publication bias.Frailty status, assessed by mobility, disability, and nutritional status, may predict mortality at 6 months or later after major cardiac surgical procedures and functional decline after minimally invasive cardiac surgery.National Institute on Aging and National Heart, Lung, and Blood Institute.

Project description:To quantify national complication rates, perioperative outcomes, and predictors for a broad range of urologic procedures to demonstrate background rates and discuss benchmarking.Urologic procedures from the National Surgical Quality Improvement Program (2006-2011) were analyzed to identify 30-day rates of 21 complications; outcomes (length of stay, reoperation, and death); and predictors including resident involvement for 18 specific procedures. Multivariate logistic regression models assessed predictors for any complication and for Clavien grade IV or V complication.A total of 39,700 procedures were included with abdominopelvic operations more morbid than endoscopic, scrotal, incontinence, or prolapse procedures. Cystectomy had the highest morbidity (10.8 days length of stay and 3.2% mortality), with 56% experiencing any complication followed by nephrectomy (21%), retroperitoneal lymph node dissection (20%), and radical retropubic prostatectomy (19%). Transurethral resection of bladder tumor (11%) and transurethral resection of the prostate (10%) had the highest rates for endoscopic procedures. Older age, American Society of Anesthesiologists class, dependent functional status, acute kidney injury (odds ratio [OR], 2.70 [1.89-3.87]), and ?5 units preoperative transfusion (OR, 4.44 [3.40-5.80]) were the strongest predictors of any complication. Higher ORs of similar predictors along with chronic obstructive pulmonary disorder (OR, 1.52 [1.21-1.92]) and steroid use (OR, 1.51 [1.07-2.14]) were associated with Clavien grade IV or V complication. Resident involvement increased odds of any complication (OR, 1.18 [1.09-1.29]), mostly for abdominopelvic and urogynecologic procedures, but not Clavien grade IV or V complication (P = .55).Complication rates of urologic procedures based on the retrospective experience of few surgeons do not allow for appropriate benchmarking. Baseline rates and benchmarks derived from the National Surgical Quality Improvement Program may help hospitals better track deficient areas and improvements in quality of care. Many predictors were similar across procedures, although magnitudes differed, and resident trainees did not impact rates of serious complications (Clavien-Dindo grade IV or V).

Dataset Information

"A National Study Demonstrating the Need for Improved Frailty Indices for Preoperative Risk Assessment of Common Urologic Procedures".

Publications

"A National Study Demonstrating the Need for Improved Frailty Indices for Preoperative Risk Assessment of Common Urologic Procedures".

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