Jonah J. Stulberg

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

CONTEXT The Surgical Care Improvement Project (SCIP) aims to reduce surgical infectious complication rates through measurement and reporting of 6 infection-prevention process-of-care measures. However, an association between SCIP performance and clinical outcomes has not been demonstrated. OBJECTIVE To examine the relationship between SCIP infection-prevention process-of-care measures and postoperative infection rates. DESIGN, SETTING, PARTICIPANTS A retrospective cohort study, using Premier Incs Perspective Database for discharges between July 1, 2006 and March 31, 2008, of 405 720 patients (69% white and 11% black; 46% Medicare patients; and 68% elective surgical cases) from 398 hospitals in the United States for whom SCIP performance was recorded and submitted for public report on the Hospital Compare Web site. Three original infection-prevention measures (S-INF-Core) and all 6 infection-prevention measures (S-INF) were aggregated into 2 separate all-or-none composite scores. Hierarchical logistical models were used to assess process-of-care relationships at the patient level while accounting for hospital characteristics. MAIN OUTCOME MEASURE The ability of reported adherence to SCIP infection-prevention process-of-care measures (using the 2 composite scores of S-INF and S-INF-Core) to predict postoperative infections. RESULTS There were 3996 documented postoperative infections. The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95). The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection. None of the individual SCIP measures were significantly associated with a lower probability of infection. CONCLUSIONS Among hospitals in the Premier Inc Perspective Database reporting SCIP performance, adherence measured through a global all-or-none composite infection-prevention score was associated with a lower probability of developing a postoperative infection. However, adherence reported on individual SCIP measures, which is the only form in which performance is publicly reported, was not associated with a significantly lower probability of infection.

Uncemented total hip arthroplasty in osteonecrosis: A 2- to 10-year evaluation

All patients undergoing uncemented total hip arthroplasty for end stage hip disease related to osteonecrosis of the femoral head were assessed prospectively between November 1983 and October 1992. The results of clinical evaluation using the Harris Hip score and radiographic assessment of fixation were analyzed to identify features of success or failure that may be unique to this population. Four different stem types and 4 different acetabular components were used. Sixty-four patients had 98 hips implanted during the time of the study. The 42 male and 22 female patients averaged 41 years of age (range, 21-69 years). Average followup was 87.3 months (7.3 years; range, 31-134 months). The cause of osteonecrosis was corticosteroids (42 hips), alcohol (27 hips), trauma (5 hips), and other (24 hips). Three patients (5 hips) have died and 4 patients (6 hips) are lost to followup. At last followup 65 of 87 hips (75%) remained radiographically stable and clinically functional, 18 of 87 (21%) have been revised, and 4 were failing (osteolysis). Of the 22 hips with revision or impending failure, 4 were for technical reasons on the femoral side and 18 were for acetabular wear. Patient factors such as weight or underlying disease state did not seem to influence the ability to achieve stable fixation or contribute to accelerated failure. Failures related primarily to problems of first generation devices including accelerated wear of acetabular components, technical issues of femoral component placement (undersizing of components or femoral fracture), and the use of noncircumferentially coated femoral components. Age may be a factor in early failure. This 10-year experience with total hip arthroplasty for the patient with end stage hip disease due to osteonecrosis suggests that uncemented total hip arthroplasty can be applied predictably to this younger, potentially more active patient population.

Tract length predicts successful closure with anal fistula plug in cryptoglandular fistulas

PURPOSE: Collagen anal fistula plug treatment of transsphincteric fistulas produces variable results. The purpose of our study was to determine whether long-tract fistulas (>4 cm) correlated with successful closure. METHODS: All patients undergoing transsphincteric cryptoglandular fistula repair with anal fistula plugs were enrolled in a prospective database. Patients with Crohns disease were excluded. Fistula tract length was measured intraoperatively by subtracting the remaining plug length from the original plug size. All procedures used standardized techniques and postoperative care pathways. The primary outcome was complete fistula closure assessed through both postoperative outpatient visits and a follow-up telephone questionnaire. RESULTS: Forty-one patients with 42 fistula tracks were enrolled over a 39-month period. Complete closure was achieved in 18 of 42 (43%) fistulas at a mean follow-up of 25 months. Closure was not associated with gender, age, tract location, duration of seton, or length of follow-up. Successful closure was significantly associated with increased tract length, because fistulas longer than 4 cm were nearly 3 times more likely to heal compared with shorter fistulas ((14/23, 61%) vs (4/19, 21%), P = .004; relative risk = 2.8; 95% CI 1.14-7.03). CONCLUSIONS: Anal fistula plug repair of cryptoglandular anorectal fistulas is more successful for long-tract fistulas. Although the overall success is modest, limiting surgical indications to fistulas exceeding 4 cm may maximize benefits of the plug technique.

Chronic abdominal wall pain—A diagnostic challenge for the surgeon

BACKGROUND Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain. METHODS The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain. RESULTS CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnetts test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology. CONCLUSION The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.

A national comparison of laparoscopic vs. open colectomy using the National Surgical Quality Improvement Project data.

INTRODUCTION: We used a publicly available limited data set from the National Surgical Quality Improvement Project to assess the preoperative risk factors and postoperative complication rates reported for laparoscopic colectomy and open colectomy. METHODS: Patients were evaluated from this nationally reported database who underwent either laparoscopic colectomy (n = 2728) or open colectomy (n = 4719) from December 1, 2005 through September 1, 2007. RESULTS: Body mass index was similar for laparoscopic (27.9, SD 5.8) and open colectomy patients (28.0, SD 7.2). The open colectomy group had significantly higher rates of diabetes (16.0 percent vs. 12.0 percent), smoking (18.0 percent vs. 15.0 percent), dyspnea (14.0 percent vs. 9.0 percent), chronic obstructive pulmonary disease (7.0 percent vs. 4.0 percent), congestive heart failure (2.0 percent vs. 0.6 percent), myocardial infarction within previous 6 months (0.9 percent vs. 0.4 percent), and hypertension (54 percent vs. 50 percent). All perioperative complications were more frequent in the open colectomy group; mortality (4.9 percent vs. 0.8 percent), surgical site infections (12 percent vs. 8.0 percent), wound disruption (2.0 percent vs. 0.8 percent), pneumonia (5.0 percent vs. 2.0 percent), and acute renal failure (1.0 percent vs. 0.3 percent). CONCLUSION: The data, derived from the publicly available limited data set from the National Surgical Quality Improvement Project audit process, suggest a higher rate for all commonly identified complications for open compared to laparoscopic colectomy; however, open colectomy patients have an apparent higher preoperative risk.

Cyberknife stereotactic body radiation therapy for nonresectable tumors of the liver: preliminary results.

Purpose. Stereotactic body radiation therapy (SBRT) has emerged as a treatment option for local tumor control of primary and secondary malignancies of the liver. We report on our updated experience with SBRT in patients with non-resectable tumors of the liver. Methods. Our first 17 consecutive patients (mean age 58.1 years) receiving SBRT for HCC (n = 6), IHC (n = 3), and LM (n = 8) are presented. Mean radiation dose was 34Gy delivered over 1–3 fractions. Results. Treated patients had a mean decrease in maximum pretreatment tumor diameter from 6.9 ± 4.6 cm to 5.0 ± 2.1 cm at three months after treatment (P < .05). The mean total tumor volume reduction was 44% at six months (P < .05). 82% of all patients (14/17) achieved local control with a median follow-up of 8 months. 100% of patients with HCC (n = 6) achieved local control. Patients with surgically placed fiducial markers had no complications related to marker placement. Conclusion. Our preliminary results showed that SBRT is a safe and effective local treatment modality in selected patients with liver malignancies with minimal adverse events. Further studies are needed to define its role in the management of these malignancies.

The physician quality reporting initiative--a gateway to pay for performance: what every health care professional should know.

The Physician Quality Reporting Initiative (PQRI) is a pay-for-reporting (P4R) program sponsored by the Centers for Medicare & Medicaid Services open to all health care providers that treat Medicare patients. This P4R initiative provides financial incentives for participation and unlike most pay-for-performance (P4P) programs, there are no penalties for poor performance. PQRI therefore offers Medicare providers nationwide a low-risk opportunity to gain experience with reporting procedures likely to be incorporated into P4P reimbursement schemes. The 74 measures used during the first reporting period are applicable to both generalist and specialist providers and open participation in PQRI to a much broader audience compared with previous federal initiatives. Also in contrast to programs that measure hospital or group quality and reimburse for services at the health system level, measurement and reimbursement in PQRI directly affects individual Medicare providers. The combination of provider-level measurement and reimbursement and efforts to assess care delivered by both generalist and specialist Medicare providers highlights how this P4R initiative is truly a gateway to a P4P reimbursement system. Participation in the PQRI program provides useful experience to Medicare providers and their staff in preparing for future initiatives that try to tie quality to reimbursement.

Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway.

BACKGROUND: After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use. OBJECTIVE: The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes. DESIGN: This was a case-matched study. METHODS: After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex. SETTINGS: This study was performed at a tertiary referral center. PATIENTS: Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included. MAIN OUTCOME MEASURES: The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway. RESULTS: Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a

Pricing of Surgeries for Colon Cancer: Patient Severity and Market Factors

500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen. LIMITATIONS: The single-surgeon, single-institution design was a limitation of this study. CONCLUSIONS: The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.

Emergency laparoscopic colectomy: does it measure up to open?

This study examined effects of health maintenance organization (HMO) penetration, hospital competition, and patient severity on the uptake of laparoscopic colectomy and its price relative to open surgery for colon cancer.