H. David Reines

Predictors of Nonalcoholic Steatohepatitis and Advanced Fibrosis in Morbidly Obese Patients

Background: Nonalcoholic fatty liver disease (NAFLD) is a common form of chronic liver disease in the United States. It is commonly associated with the components of the metabolic syndrome including obesity. From the spectrum of NAFLD, only patients with nonalcoholic steatohepatitis (NASH) have been convincingly shown to have a potential for progression to cirrhosis. We report the prevalence of NAFLD and NASH as well as predictors of NASH and advanced fibrosis in morbidly obese patients. Methods: 212 consecutive patients who underwent bariatric surgery were enrolled in the study. A liver biopsy was performed at the time of the surgery. Causes of chronic liver disease other than NAFLD were excluded by clinical and laboratory evaluation. Results: The prevalence of NAFLD was 93%. Of those with NAFLD, 26% had NASH. 17 patients (9%) had advanced fibrosis (i.e., bridging fibrosis or cirrhosis). Male gender, AST, and type 2 diabetes mellitus were independently associated with NASH. Waistto-hip ratio, AST, and focal hepatocyte necrosis on liver biopsy were independently associated with advanced fibrosis. Interestingly, while AST was associated with NASH and advanced fibrosis, the majority of the patients with either NASH or advanced fibrosis had normal AST. Conclusions: NAFLD and NASH are very common in morbidly obese patients undergoing bariatric surgery. Features associated with the metabolic syndrome and liver cell injury are independently associated with either NASH or advanced fibrosis.

General surgery and otolaryngology resident perspectives on obtaining competency in thyroid surgery.

OBJECTIVE General surgery (GS) and otolaryngology (OTO) do not require a minimum number of thyroidectomies to qualify for board certification. No standardized criteria exist for declaring competence in this procedure. A survey was created to assess GS and OTO resident perspectives on becoming competent in thyroid surgery. DESIGN A survey was electronically mailed to all GS and OTO residents assessing their competence in thyroid surgery. SETTING National survey of general surgery and otolaryngology residents. PARTICIPANTS National general surgery and otolaryngology residents. RESULTS A convenience sample of 526 residents responded (246/280 = GS/OTO). The mean clinical year of training was 3.3 (3.1/3.5). Most residents (50%/41%) performed between 1 and 10 thyroid operations. Residents believed 13 and 25 (GS/OTO) thyroidectomies were required by their respective Boards. Both groups felt that 30 (27/33) thyroid operations were necessary to obtain competence (p < 0.01). The most important feature was operative volume with graduated responsibility, followed by guidance under an expert mentor. Analysis of residents PGY4 and greater showed no significant differences. CONCLUSIONS While residents of both specialties generally agree on learning methods, the perception of readiness to perform thyroid surgery after training is variable. A disconnect is present between the number of cases required for Board certification, the number of cases residents believe are required, and the number of cases residents believe it takes to achieve competency.

Using NSQIP to Investigate SCIP Deficiencies in Surgical Patients With a High Risk of Developing Hospital-Associated Urinary Tract Infections

The study objectives were to identify risk factors for surgical patients who develop postoperative urinary tract infections (UTIs) and to characterize urethral catheter practices at the study hospital. Patients from the 2006-2010 institutional National Surgical Quality Improvement Program database were evaluated. Patients with UTIs within 30 postoperative days (n = 116) were compared to patients without UTIs (n = 8685) using multivariable logistic regression. A nested case-control study evaluated the effects of catheter practices on postoperative UTI using conditional logistic regression. Independent predictors of UTI were sex, age, inpatient stay, functional status, renal failure, preoperative transfusion, and preoperative hospital stay. Compared with controls, patients with UTI more often maintained catheters for >2 postoperative days (66% vs 43%, P < .001) and had longer mean catheter duration (11.6 vs 5.1 days, P < .001). Study findings led to institutional recommendations to reduce catheter-associated UTIs. Quality improvement initiatives can increase awareness of performance enhancement opportunities and encourage collaborative, interdisciplinary improvement through shared objectives.

Apples and Oranges Comparison of ACS-NSQIP Observed Outcomes With Premier’s Quality Manager–Predicted Outcomes

The National Surgical Quality Improvement Program (NSQIP) is used by the American College of Surgeons to measure and report surgical quality and outcomes. Premier’s Quality Manager (QM) generates expected outcomes from patient charts. The authors compared observed NSQIP morbidity and mortality outcomes with those predicted by QM. NSQIP data for 1919 patients were entered into QM. The discriminatory accuracy of the QM model was assessed using the C statistic (1.0 implies perfect discrimination, and 0.5 implies no discrimination). NSQIP and QM both identified 51 deaths (C statistic, 0.91). NSQIP identified 478 postoperative occurrences, whereas QM predicted 714 patients with at least 1 complication; 223 of these were subclassified as patients with at least 1 morbid complication (C statistic, 0.83). QM did not perform as well in predicting the observed NSQIP morbidities. Surgical leaders and hospital administrators must critically evaluate products before adopting programs designed to improve patient outcomes or making decisions regarding physician practice.

Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot.

BACKGROUND Patients managed non-operatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where non-operative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed non-operatively to evaluate variability in non-operative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered. METHODS Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in non-operative patients, rates of adverse outcomes were identified and hospitals were ranked by performance with and then without including non-operative cases. RESULTS 2,091 patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of non-operative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS Pilot, non-operative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of non-operative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with 4 hospitals changing by 3 or more positions. CONCLUSIONS This study identifies a gap in performance evaluation when non-operative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating non-operative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include non-operative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation. LEVEL OF EVIDENCE III, Prognostic and Epidemiological.BACKGROUND Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered. METHODS Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases. RESULTS Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions. CONCLUSION This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation. LEVEL OF EVIDENCE Care management, level IV; Epidemiologic, level III.

Interrater Reliability of Hospital Readmission Evaluations for Surgical Patients.

Value-based purchasing initiatives have helped shift attention to the accuracy of hospital readmission information at the most clinically detailed level. The purpose of this study was to determine the interrater reliability (IRR) of surgical experts in assessing surgical inpatient readmissions for categorical causes, relation to index procedure, and potential preventability. Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program local database. Of 1840 cases, 156 patients (8.5%) were readmitted within 30 days of the procedure. Surgical site infection was the most common readmission cause (32%), followed by obstruction or ileus (17%). IRR was moderate for readmission cause (60% agreement, κ = 0.51), substantial for readmission in relation to surgical procedure (92%, κ = 0.70), and lowest for potential preventability of readmissions (57%, κ = 0.18). Results suggest that readmission cause and relation to surgical procedure can be determined with moderate to high degree of IRR, while preventability of readmissions may require stricter definitions to improve IRR.

Morbidity and mortality conference is not sufficient for surgical quality control: Processes and outcomes of a successful attending Physician Peer Review committee

BACKGROUND Physician Peer Review (PPR) is required by The Joint Commission to assure examination of individual and group outcomes. Although surgeons may utilize Morbidity and Mortality (M&M) conference, applying these data to determine Focused Professional Practice Evaluations involves outcomes review. A PPR Committee of senior surgeons was created. This report describes one institutions surgical PPR process and results. METHOD A two-year (2014-2015) retrospective review of significant non-trauma complications and unanticipated deaths evaluated by PPR was performed. A faculty questionnaire evaluated perceptions of quality outcomes reporting. RESULTS Of 395 reviewed cases, almost half (48.9%) demonstrated no care improvement opportunities, 48.6% revealed possible improvements, 2% were deviations from standard of care, and 0.5% represented unacceptable care. Although most surgeons (94%) wanted to know their complication rates, only 41% reported maintaining an outcomes database. CONCLUSIONS As a complement to M&M, PPR is a valuable tool in the evaluation of individual surgical quality and can be the basis for further quality improvement opportunities. This process has been largely successful; only a small number of significant concerns were discovered.

Introducing the Testimonial-Commentator Format to the Musculoskeletal Curriculum of Medical Students

Principal Objective: We implemented a rheumatology curriculum redesign for second-year medical students. Goal: Our agenda was to emphasize patient contact in the support of learning. Methodology: A testimonial-commentator format of instruction, based on three seminars concerning rheumatoid arthritis, systemic lupus erythematosus and psoriatic arthritis, was implemented and studied using a multiple case study design. All second year medical students were included in the protocol and none were excluded. Each seminar had two distinct parts. The first half was comprised of a patient’s personal testimonial followed by a pathophysiological overview of the disease. The second half of the seminar was comprised of an expert panel answering the student’s questions as submitted to the moderator during the intervening break. The students completed a post-session structured feedback form and a Likert favorability score (on a scale of 1 to 5 where 5 reflects preference for the new method of teaching). Results: Favorability scores averaged over 3.7, and thereby consistently supported the new teaching method over traditional didactics, seminar by seminar, and year by year, for each of three years. To compare the effectiveness of the new method of instruction versus the traditional method, analysis of the multiple choice final test comparing a control group (previous class) with the intervention group (current class) demonstrated no statistical difference year by year suggesting that the new method was non-inferior to the traditional method. Conclusion: Specific challenges to the implementation of our revised curriculum centered upon creating administrative-level acceptance of the redesigned course. Nevertheless, our curriculum redesign was met with enthusiasm and suffered no loss of learning as compared to traditional didactic methods.

A simple method of predicting severe sepsis in burned patients

Twenty-six patients with major thermal injury were studied with sequential tests of immunocompetence. Five to 8 days after burn, 12 of 26 patients developed a marked depression in the phytohemagglutinin response (17 +/- 8 percent of baseline) and an increase in suppression of the normal mixed leukocyte response (70 +/- 13 percent suppression), which was followed by severe life-threatening sepsis 4 to 5 days later. Concomitant with this marked immunosuppression, the 12 patients developed red debris in the normally white mononuclear layer of the Ficoll-Hypaque density centrifugation gradients used to separate mononuclear cells. None of the 14 patients with minimal or no sepsis developed red debris in Ficoll-Hypaque gradients, nor did they show signs of immune depression by phytohemagglutinin or mixed leukocyte response assays. The only patients in the severe sepsis group who survived were those given aminoglycosides at the time red debris was observed on the Ficoll-Hypaque gradients. The presence of red debris on Ficoll-Hypaque separation appears to be a simple and reliable predictor of impending sepsis, which allows the use of antibiotics before the clinical onset of sepsis.