Jason B. Liu

Patient characteristics associated with undergoing cancer operations at low-volume hospitals

BACKGROUND Although strong volume‐outcome relationships exist for many cancer operations, patients continue to undergo these operations at low‐volume hospitals. METHODS Patients were identified from the National Cancer Data Base from 2010–2013 who underwent resection for bladder, breast, esophagus, lung, pancreas, rectum, and stomach cancers. Low‐volume hospitals were defined as those in the bottom quartile by surgical volume for each cancer type separately. Logistic regression models were constructed to assess patient‐level factors associated with undergoing cancer surgery at low‐volume hospitals across cancer types while controlling for tumor characteristics. Survival outcomes (30‐ and 90‐day mortality; overall survival) were also assessed. RESULTS Low volume thresholds were 4, 84, 4, 18, 8, 7, and 4 resections per year for bladder, breast, esophagus, lung, pancreas, rectum, and stomach cancers, respectively, resulting in 772 (74.1%), 828 (57.5%), 664 (77.5%), 830 (64.7%), 716 (79.2%), 898 (65.1%), and 888 (68.5%) hospitals classified as low‐volume hospitals, respectively. For all the cancers examined, patients were more likely to undergo operation at low‐volume hospitals if they traveled shorter distances (home to surgical facility), resided in rural locations, or had not received neoadjuvant therapy. Other patient and tumor factors were not associated consistently with undergoing operation at low‐volume hospitals. Patients who went to low‐volume hospitals had poorer outcomes among the studied cancers. CONCLUSION Patients continue to undergo operation at low‐volume hospitals due to where they live and how far they have to travel. Regionalization policy initiatives will remain challenging in this population. Efforts should therefore continue to emphasize quality improvement locally at each facility caring for patients with cancer.

Weighing the value of completion nodal dissection for melanoma.

In the United States, approximately half of patients with a positive sentinel lymph node biopsy undergo a completion lymphadenectomy. Because of the equivocal survival benefits in pursuing a completion lymphadenectomy in these patients, surgeons must weigh the postoperative morbidity of the operation with concerns facing a patients quality of life and risk of tumor recurrence. We discuss the value of a completion lymphadenectomy in light of the uncertainties facing this management strategy for melanoma. J. Surg. Oncol. 2016;114:281–287.

Surgical Management of Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine tumors (PNETs) are a rare, heterogeneous group of neoplasms infamous for their endocrinopathies. Up to 90% of PNETs, however, are nonfunctional and are frequently detected incidentally on axial imaging during the evaluation of vague abdominal symptoms. Surgery remains the mainstay of therapy for patients diagnosed with both functional and nonfunctional PNETs. However, the multifaceted nature of PNETs challenges treatment decision making. In general, resection is recommended for patients with acceptable perioperative risk and amenable lesions.

Outcomes of Concurrent Operations: Results From the American College of Surgeons’ National Surgical Quality Improvement Program

Objective: To determine whether concurrently performed operations are associated with an increased risk for adverse events. Background: Concurrent operations occur when a surgeon is simultaneously responsible for critical portions of 2 or more operations. How this practice affects patient outcomes is unknown. Methods: Using American College of Surgeons’ National Surgical Quality Improvement Program data from 2014 to 2015, operations were considered concurrent if they overlapped by ≥60 minutes or in their entirety. Propensity-score-matched cohorts were constructed to compare death or serious morbidity (DSM), unplanned reoperation, and unplanned readmission in concurrent versus non-concurrent operations. Multilevel hierarchical regression was used to account for the clustered nature of the data while controlling for procedure and case mix. Results: There were 1430 (32.3%) surgeons from 390 (77.7%) hospitals who performed 12,010 (2.3%) concurrent operations. Plastic surgery (n = 393 [13.7%]), otolaryngology (n = 470 [11.2%]), and neurosurgery (n = 2067 [8.4%]) were specialties with the highest proportion of concurrent operations. Spine procedures were the most frequent concurrent procedures overall (n = 2059/12,010 [17.1%]). Unadjusted rates of DSM (9.0% vs 7.1%; P < 0.001), reoperation (3.6% vs 2.7%; P < 0.001), and readmission (6.9% vs 5.1%; P < 0.001) were greater in the concurrent operation cohort versus the non-concurrent. After propensity score matching and risk-adjustment, there was no significant association of concurrence with DSM (odds ratio [OR] 1.08; 95% confidence interval [CI] 0.96–1.21), reoperation (OR 1.16; 95% CI 0.96–1.40), or readmission (OR 1.14; 95% CI 0.99–1.29). Conclusions: In these analyses, concurrent operations were not detected to increase the risk for adverse outcomes. These results do not lessen the need for further studies, continuous self-regulation and proactive disclosure to patients.

Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments

Background: Current preoperative cardiac risk stratification practices group operations into broad categories, which might inadequately consider the intrinsic cardiac risks of individual operations. We sought to define the intrinsic cardiac risks of individual operations and to demonstrate how grouping operations might lead to imprecise estimates of perioperative cardiac risk. Methods: Elective operations (based on Common Procedural Terminology codes) performed from January 1, 2010 to December 31, 2015 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program were studied. A composite measure of perioperative adverse cardiac events was defined as either cardiac arrest requiring cardiopulmonary resuscitation or acute myocardial infarction. Operations’ intrinsic cardiac risks were derived from mixed-effects models while controlling for patient mix. Resultant risks were sorted into low-, intermediate-, and high-risk categories, and the most commonly performed operations within each category were identified. Intrinsic operative risks were also examined using a representative grouping of operations to portray within-group variation. Results: Sixty-six low, 30 intermediate, and 106 high intrinsic cardiac risk operations were identified. Excisional breast biopsy had the lowest intrinsic cardiac risk (overall rate, 0.01%; odds ratio, 0.11; 95% CI, 0.02 to 0.25) relative to the average, whereas aorto-bifemoral bypass grafting had the highest (overall rate, 4.1%; odds ratio, 6.61; 95% CI, 5.54 to 7.90). There was wide variation in the intrinsic cardiac risks of operations within the representative grouping (median odds ratio, 1.40; interquartile range, 0.88 to 2.17). Conclusions: A continuum of intrinsic cardiac risk exists among operations. Grouping operations into broad categories inadequately accounts for the intrinsic cardiac risk of individual operations.

Reliability of the American College of Surgeons Commission on Cancer's Quality of Care Measures for Hospital and Surgeon Profiling.

BACKGROUND Efforts to improve healthcare quality involve profiling hospitals and providers. Whether cancer-specific measures can be used reliably for profiling purposes has not been reported. STUDY DESIGN Hospitals and surgeons were profiled with 3 measures assessing the adequacy of lymphadenectomy for colon (ie at least 12 regional lymph nodes [12RLN] are removed and pathologically examined for resected colon cancer), gastric (ie at least 15 regional lymph nodes [G15RLN] are removed and pathologically examined for resected gastric cancer), and non-small cell lung (ie at least 10 regional lymph nodes [10RLN] are removed and pathologically examined for American Joint Committee on Cancer stage IA, IB, IIA, and IIB resected non-small cell lung cancer) cancers using hierarchical models. National Cancer Data Base cases spanning 2010 to 2013 were included if they met measure eligibility. Reliability estimates for hospital and surgeon performance across cumulative years of data (2013, 2012 to 2013, 2011 to 2013, and 2010 to 2013) were calculated with and without risk adjustment. Surgeon caseload minimums were projected to achieve reliabilities of 0.40 and 0.70. RESULTS Reliability estimates tended to increase with longer periods of data collection but at different rates, depending on measure, level of aggregation, and performance outlier status. Profiling hospitals using 12RLN with 2 years of data yielded a median reliability of 0.72 (interquartile range [IQR] 0.55 to 0.83); however, 4 years of data yielded a median reliability of only 0.31 (IQR 0.14 to 0.54) for surgeons. The G15RLN performance was poor overall; 10RLN had high reliability at both hospital (0.74; IQR 0.50 to 0.86) and surgeon (0.61; IQR 0.34 to 0.80) levels using 1 year of data, but the literature questions this measures validity. Few surgeons could achieve appropriate levels of reliability regardless of increased data collection duration. CONCLUSIONS Profiling hospitals based on measures such as these can achieve acceptable reliability in reasonable timeframes, but does not always. Either lower levels of reliability should be accepted to profile surgeons with these measures or longer timeframes should be used.

Procedure-Specific Trends in Surgical Outcomes

BACKGROUND Quality improvement efforts have generally focused on hospital benchmarking, and processes and outcomes shared among all operations. However, quality improvement could be inconsistent across different types of operations. The objective of this study was to identify operations needing additional concerted quality improvement efforts by examining their outcomes trends. STUDY DESIGN Ten procedures (colectomy, esophagectomy, hepatectomy, hysterectomy, pancreatectomy, proctectomy, total hip arthroplasty, total knee arthroplasty, thyroidectomy, and ventral hernia repair) commonly accrued into the American College of Surgeons NSQIP between 2008 and 2015 were included. Trends in risk-adjusted, standardized, smoothed rates were constructed for each procedure across 6 outcomes (mortality, pneumonia, renal failure, surgical site infection, unplanned intubation, and urinary tract infection [UTI]). RESULTS Of 1,255,575 operations analyzed, the overall unadjusted rate for mortality across all 10 procedures was 1.08%, for pneumonia 1.44%, for renal failure 0.67%, for surgical site infection 5.28%, for unplanned intubation 1.11%, and for UTI 1.86%. Hepatectomy demonstrated the greatest improvement across outcomes (4 of 6 outcomes; 362 adverse events avoided out of 10,000 procedures), and UTI demonstrated the greatest improvement across procedures (8 of 10 procedures; 989 adverse events avoided out of 10,000). For pancreatectomy, rates of mortality, unplanned intubation, and UTI improved, but surgical site infection rates were detected to have significantly increased (p < 0.05). CONCLUSIONS Hepatectomy was detected to have improved across the greatest number of outcomes, and UTI rates improved significantly across the greatest number of procedures. Surgical site infection rates after pancreatectomy, however, were detected to have increased, identifying an urgent need for additional concerted quality improvement efforts.

Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program

Importance Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation. Objective To evaluate the association of the ERIN pilot with LOS after colectomy. Design, Setting, and Participants Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals. Interventions Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration. Main Outcomes and Measures The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite. Results There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P < .001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P < .001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P < .001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P < .001). Conclusions and Relevance Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot may inform efforts to scale this effective and evidence-based intervention.

Variation of Thyroidectomy-Specific Outcomes Among Hospitals and Their Association With Risk Adjustment and Hospital Performance

Importance Current surgical quality metrics might be insufficient to fully judge the quality of certain operations because they are not procedure specific. Hypocalcemia, recurrent laryngeal nerve (RLN) injury, and hematoma are considered to be the most relevant outcomes to measure after thyroidectomy. Whether these outcomes can be used as hospital quality metrics is unknown. Objectives To evaluate whether thyroidectomy-specific outcomes vary among hospitals, whether the addition of thyroidectomy-specific variables affects risk adjustment, and whether differences in hospital performance are associated with thyroidectomy-specific care processes. Design, Setting, and Participants In this retrospective cohort study, patients undergoing thyroidectomies from January 1, 2013, through December 31, 2015, at hospitals participating in the American College of Surgeons’ National Surgical Quality Improvement Program were studied. Exposure Thyroidectomy-related care. Main Outcomes and Measures Clinically severe hypocalcemia, RLN injury, and clinically significant hematoma within 30 days of thyroid surgery and hospital-level performance variation, change in risk adjustment, and association with processes. Results Overall, 14 540 patients (mean [SD] age, 52.1 [15.0] years; 11 499 [79.1%] female) underwent operations at 98 hospitals. Because operations missing thyroidectomy-specific outcomes were excluded, the numbers of operations and hospitals analyzed differed by outcome. Of 14 540 operations included, clinically severe hypocalcemia occurred in 450 patients (3.3% overall, 0.6% after partial, and 4.7% after subtotal or total thyroidectomy), RLN injury in 755 patients (5.7% overall, 4.2% after partial, and 6.6% after subtotal or total thyroidectomy), and hematoma in 175 patients (1.3%). Hospital performance varied for hypocalcemia and RLN injury but not for hematoma. Hospital performance rankings were largely unaffected by the inclusion of thyroidectomy-specific data in risk adjustment. With regard to processes, patients undergoing thyroidectomies at the best-performing vs worst-performing hospitals less frequently had their postoperative parathyroid hormone level measured (593 [19.9%] vs 457 [31.7%], P < .001) and more often were prescribed oral calcium, vitamin D, or both (2281 [76.6%] vs 962 [66.8%], P < .001). When profiled by RLN injury, use of energy devices (1517 [69.1%] vs 507 [55.2%], P < .001) and intraoperative nerve monitoring (1223 [55.7%] vs 346 [37.7%], P < .001) were more prevalent at the best- compared with the worst-performing hospitals. Conclusions and Relevance Postoperative hypocalcemia and RLN injury, but not hematoma, potentially could be used as thyroidectomy-specific national hospital quality improvement metrics. Strategies aimed at reducing these complications after thyroidectomy may improve the care of these patients.

Concurrent bariatric operations and association with perioperative outcomes: registry based cohort study

Objective To determine whether perioperative outcomes differ between patients undergoing concurrent compared with non-concurrent bariatric operations in the USA. Design Retrospective, propensity score matched cohort study. Setting Hospitals in the US accredited by the American College of Surgeons’ metabolic and bariatric surgery accreditation and quality improvement program. Participants 513 167 patients undergoing bariatric operations between 1 January 2014 and 31 December 2016. Main outcome measures The primary outcome measure was a composite of 30 day death, morbidity, readmission, reoperation, anastomotic or staple line leak, and bleeding events. Operative duration and lengths of stay were also assessed. Operations were defined as concurrent if they overlapped by 60 or more minutes or in their entirety. Results In this study of 513 167 operations, 739 (29.5%) surgeons at 483 (57.8%) hospitals performed 6087 (1.2%) concurrent operations. The most frequently performed concurrent bariatric operations were sleeve gastrectomy (n=3250, 53.4%) and Roux-en-Y gastric bypass (n=1601, 26.3%). Concurrent operations were more often performed at large academic medical centers with higher operative volumes and numbers of trainees and by higher volume surgeons. Compared with non-concurrent operations, concurrent operations lasted a median of 34 minutes longer (P<0.001) and resulted in 0.3 days longer average length of stay (P<0.001). Perioperative adverse events were not observed to more likely occur in concurrent compared with non-concurrent operations (7.5% v 7.4%; relative risk 1.02, 95% confidence interval 0.90 to 1.15; P=0.84). Conclusions Concurrent bariatric operations occurred infrequently, but when they did, there was no observable increased risk for adverse perioperative outcomes compared with non-concurrent operations. These results, however, do not argue against improved and more meaningful disclosure of concurrent surgery practices.