Jennifer Ritz

Preliminary NSQIP results: A tool for quality improvement

Objective: To utilize National Surgical Quality Improvement Program (NSQIP) data to evaluate patient outcomes in otolaryngology–head and neck surgery. Study Design: Retrospective medical chart abstraction of patients undergoing major surgical procedures in the inpatient and outpatient setting. Setting: Academic/teaching hospitals with more than 500 beds. Subjects and Methods: The American College of Surgeons NSQIP collects data on 135 variables including preoperative risk factors, intraoperative variables, and 30-day-postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in the inpatient and outpatient setting. As of August 2008, there are currently 47 hospitals submitting data for otolaryngology–head and neck surgery. Results: Opportunities for improvement were identified in respiratory, wound, and venothromboembolic (VTE) occurrences. Implementation of a standardized VTE and perioperative protocol resulted in a decreased length of stay and observed-to-expected (O/E) morbidity and mortality for all surgical services. Conclusion: NSQIP reports form the basis for quality improvement with targeted interventions in areas of concern that result in changes in patient care processes. The reports are composed of outcomes-based, risk-adjusted data that are submitted by participating hospitals and have recently included data for otolaryngology–head and neck surgery. Actions taken based on NSQIP data demonstrate improvements in patient morbidity and mortality, decreased length of stay, and decreased hospital costs. In a time of increased scrutiny of health care costs and outcomes, NSQIP is an important tool for surgeons to improve quality and decrease costs.

Implementation of the National Surgical Quality Improvement Program: critical steps to success for surgeons and hospitals.

The National Surgical Quality Improvement Program (NSQIP), as administered by the American College of Surgeons, became available to private sector hospitals across the United States in 2004. The program works to improve surgical outcomes by providing high-quality, risk-adjusted data to surgeons at a given hospital to stimulate discussion and define target areas for improvement. Although the NSQIP began in the early 1990s with Veterans Administration hospitals and expanded to private sector hospitals nearly 5 years ago, the “how to” process for NSQIP implementation has been left to individual institutions to manage on their own. The NSQIP was instituted at a large tertiary hospital in 2005, identifying through experience 12 critical steps to help surgeons and hospitals implement the NSQIP. (Am J Med Qual 2009;24:474-479)

Using Procedural Codes to Supplement Risk Adjustment: A Nonparametric Learning Approach

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program collects information related to procedures in the form of the work relative value unit (RVU) and current procedural terminology (CPT) code. We propose and evaluate a fully automated nonparametric learning approach that maps individual CPT codes to perioperative risk. STUDY DESIGN National Surgical Quality Improvement Program participant use file data for 2005-2006 were used to develop 2 separate support vector machines (SVMs) to learn the relationship between CPT codes and 30-day mortality or morbidity. SVM parameters were determined using cross-validation. SVMs were evaluated on participant use file data for 2007 and 2008. Areas under the receiver operating characteristic curve (AUROCs) were each compared with the respective AUROCs for work RVU and for standard CPT categories. We then compared the AUROCs for multivariable models, including preoperative variables, RVU, and CPT categories, with and without the SVM operation scores. RESULTS SVM operation scores had AUROCs between 0.798 and 0.822 for mortality and between 0.745 and 0.758 for morbidity on the participant use file used for both training (2005-2006) and testing (2007 and 2008). This was consistently higher than the AUROCs for both RVU and standard CPT categories (p < 0.001). AUROCs of multivariable models were higher for 30-day mortality and morbidity when SVM operation scores were included. This difference was not significant for mortality but statistically significant, although small, for morbidity. CONCLUSIONS Nonparametric methods from artificial intelligence can translate CPT codes to aid in the assessment of perioperative risk. This approach is fully automated and can complement the use of work RVU or traditional CPT categories in multivariable risk adjustment models like the National Surgical Quality Improvement Program.

The differential effects of surgical harm in elderly populations. Does the adage: “they tolerate the operation, but not the complications” hold true?

BACKGROUND Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old. METHODS Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY). RESULTS A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm (

NSQIP in Otolaryngology: Our 4-Year Experience

24,000) and decreased cost with age above 80 (-

A single, global patient-centered measure from the SF-36 instrument to assess surgical outcomes and quality of life: a pilot study.

7,000). CONCLUSIONS In the elderly surgical population, there is more harm and harm events are associated with higher mortality rates, but less additional cost and LOS. Differing goals or aggressiveness of care may explain cost avoidance in the elderly.

The differential effects of intermediate complications with postoperative mortality.

Objective: To present a 4-year experience with the American College of Surgeons (ACS) National Surgical Quality and Improvement Program (NSQIP) in Otolaryngology, Head and Neck Surgery, to highlight successes, and to demonstrate areas that provide opportunities for quality improvement. Method: The Henry Ford Health System (HFHS) database was utilized to analyze NSQIP outcomes and quality measures obtained for the Department of Otolaryngology–Head and Neck Surgery. This had been an ongoing project in our department over the last 4 years. Results: Overall mortality (0.34%) continues to be equal to the national average (0.34%). The overall wound infection rate (23.38%) has improved but is still slightly higher than the national average (17.4%). Initially, the wound infection rate was a significant high outlier (16.67%). The incidence of infection has improved to 0.00% (3rd Q, 2011). Individual categorical gains have been made in unplanned intubations, pneumonia rates, and off the ventilator rates within 48 hours. Sepsis and septic shock rates continue to be benchmarked compared to the national average. Patient length of stay with wound infection have improved and resulted in savings for the institution. Conclusion: Institutional participation in NSQIP has resulted in demonstrable improvements in patient care outcomes and key quality measures for patients treated at the Department of Otolaryngology–Head and Neck Surgery.