Julia R. Berian

The Constipation Severity Instrument: A Validated Measure

PurposeThis study was designed to develop and test the validity and reliability of the Constipation Severity Instrument.MethodsScale development was conducted in two stages: 1) 74 items were generated through a literature review and focus groups of constipated patients and medical providers; and 2) a preliminary instrument was administered to 191 constipated patients and 103 healthy volunteers. Test-retest reliability of the constipated group was assessed (N = 90). Content, convergent, divergent, and discriminant validity were evaluated by using other validated measures by performing one-way analysis of variance and Pearson correlations.ResultsExploratory and confirmatory factor analysis revealed three subscales: obstructive defecation, colonic inertia, and pain. Internal consistency (α = 0.88–0.91) and test-retest reliability (intraclass correlation coefficients = 0.84–0.91) were high for all subscales. Constipated patients were grouped by Rome II criteria: functional constipation (22 percent), pelvic floor dyssynergia (15 percent), constipation predominant irritable bowel syndrome (23 percent), and no specific criteria (40 percent). Those with constipation predominant irritable bowel syndrome or pelvic floor dyssynergia scored higher on the Obstructive Defecation and Colonic Inertia subscales than those with functional constipation or no specific criteria (P = 0.001–0.058). Subjects with functional constipation had much lower scores on the pain subscale than constipation predominant irritable bowel syndrome, functional constipation, or no specific criteria (P < 0.009).The Constipation Severity Instrument subscale and total score correlated very highly with the subscales and total score of the Patient Assessment of Constipation Symptom measure. The Constipation Severity Instrument subscales discriminated well between constipated patients and healthy volunteers (P < 0.001) and demonstrated excellent divergent validity. Higher Constipation Severity Instrument scores inversely correlated with general quality of life.ConclusionsThe Constipation Severity Instrument is a reliable and valid instrument for assessing constipated patients. Administration of the Constipation Severity Instrument to other constipated patients will further validate its use.

A valid and reliable measure of constipation-related quality of life.

PURPOSE: Few existing measures assess constipation-specific quality of life. This study sought to develop a valid and reliable quality-of-life measure for constipation. METHODS: First, we created a preliminary instrument that assessed quality-of-life domains affected by constipation: body image, eating, mood, and relationships with others. We conducted focus groups both with patients with constipation seeking treatment and the health care providers who treat them. Next, a 59-item questionnaire was given to 240 subjects with constipation (83% female) and 103 healthy volunteers (63% female). Test-retest reliability and discriminant, convergent, and divergent validity were assessed. RESULTS: Exploratory factor analysis revealed four domains: Social Impairment (five items), Distress (six items), Eating Habits (three items), and Bathroom Attitudes (four items). Internal consistency and test-retest reliability for all subscales was high (Cronbach’s alpha = 0.89; intraclass correlation coefficient = 0.87). All domains discriminated well between subjects with constipation and healthy volunteers (P < 0.001). Convergent validity was excellent: all subscales correlated highly with the Irritable Bowel Syndrome Quality of Life Scale total score (P < 0.001) and the Medical Outcomes Study Short Form-36 physical component and mental component summary scores (P < 0.001). Scores from our Constipation-Related Quality of Life measure were not significantly correlated with the Social Desirability Scale, demonstrating divergent validity. CONCLUSIONS: Our findings support the reliability and validity of the Constipation-Related Quality of Life measure. Future validation of the Constipation-Related Quality of Life measure for assessing changes in quality of life in response to treatments for constipation is needed.

Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures

IMPORTANCE Older adults are at increased risk for adverse events after surgical procedures. Loss of independence (LOI), defined as a decline in function or mobility, increased care needs at home, or discharge to a nonhome destination, is an important patient-centered outcome measure. OBJECTIVE To evaluate LOI among older adult patients after surgical procedures and examine the association of LOI with readmission and death after discharge in this population. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined 9972 patients 65 years and older with known baseline function, mobility, and living situation undergoing inpatient operations from January 2014 to December 2014 at 26 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project. A total of 4895 patients were excluded because they were totally dependent, classified as class 5 by the American Society of Anesthesiologists, undergoing orthopedic or spinal procedures, or died prior to discharge. EXPOSURES Loss of independence at time of discharge. MAIN OUTCOMES AND MEASURES Readmission and death after discharge. RESULTS Of the 5077 patients included in this study, 2736 (53.9%) were female and 3876 (76.3%) were white, with a mean (SD) age of 75 (7) years. For this cohort, LOI increased with age; LOI occurred in 1386 of 2780 patients (49.9%) aged 65 to 74 years, 1162 of 1726 (67.3%) aged 75 to 84 years, and 479 of 571 (83.9%) 85 years and older (P < .001). Readmission occurred in 517 patients (10.2%). In a risk-adjusted model, LOI was strongly associated with readmission (odds ratio, 1.7; 95% CI, 1.4-2.2) and postoperative complication (odds ratio, 6.7; 95% CI, 4.9-9.0). Death after discharge occurred in 69 patients (1.4%). After risk adjustment, LOI was the strongest factor associated with death after discharge (odds ratio, 6.7; 95% CI, 2.4-19.3). Postoperative complication was not significantly associated with death after discharge. CONCLUSIONS AND RELEVANCE Loss of independence, a patient-centered outcome, was associated with postoperative readmissions and death after discharge. Loss of independence can feasibly be collected across multiple hospitals in a national registry. Clinical initiatives to minimize LOI will be important for improving surgical care for older adults.

Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report From the Coalition for Quality in Geriatric Surgery.

Objective: The aim of this study was to establish high-quality, valid standards to improve surgical care of the older adult. Background: The aging population increases demand for high-quality surgical care. Building upon prior guidelines, quality indicators, and pilot projects, the Coalition for Quality in Geriatric Surgery (CQGS) includes 58 diverse stakeholder organizations committed to improving geriatric surgery. Methods: Using a modified RAND-UCLA Appropriateness Methodology, 44 of 58 CQGS Stakeholders twice rated validity (primary outcome) and feasibility for 308 standards, ranging from goals and decision-making, pre-operative assessment and optimization, perioperative and postoperative care, to transitions of care beyond the acute care hospital. Results: Three hundred six of 308 (99%) standards were rated as valid to improve quality of geriatric surgery. There were 4 sections. Section 1 included 157 (57%) standards and focused on goals and decision-making, preoperative optimization, and transitions into and out of the hospital. Section 2 included 84 (27.3%) standards focused on in-hospital care, across the immediate preoperative, intraoperative, and postoperative phases. Section 3 included 59 (19.1%) standards about program management, including personnel and committee structure, credentialing, and education. Section 4 included 8 (2.6%) standards establishing overarching concepts for data collection and patient follow-up. Two hundred ninety of 308 standards (94.2%) were rated as feasible; 18 (5.8%) were rated as uncertain in feasibility. Conclusions: CQGS Stakeholders rated the vast majority of standards of care as highly valid (99%) and feasible (94%) for improving the quality of surgical care provided to older adults. Future work will focus on a pilot phase to better understand and address challenges to implementation of the standards.

Process improvement in surgery

Process improvement in surgery Christina A. Minami, MD, Catherine R. Sheils, BA, Karl Y. Bilimoria, MD, MS, Julie K. Johnson, PhD, Elizabeth R. Berger, MD, Julia R. Berian, MD, Michael J. Englesbe, MD, Oscar D. Guillamondegui, MD, FACS, Leonard H. Hines, MD, FACS, Joseph B. Cofer, MD, FACS, David R. Flum, MD, MPH, Richard C. Thirlby, MD, Hadiza S. Kazaure, MD, Sherry M. Wren, MD, Kevin J. O’Leary, MD, Jessica L. Thurk, BA, Gregory D. Kennedy, MD, PhD, Sarah E. Tevis, MD, Anthony D. Yang, MD

Impact of depression and anxiety on the quality of life of constipated patients.

Constipation negatively affects quality of life (QOL), however, the specific mechanisms through which this relationship occurs are unclear. The present study examined anxiety and depression as potential mediators of the relationship between constipation severity and QOL in a sample of 142 constipated patients. Results indicated that depression symptom severity mediated the relationship between constipation severity and mental health-related QOL. For patients meeting diagnostic criteria for Major Depressive Disorder, indirect effects were observed in the relationship between constipation severity and both physical and mental health-related QOL. Anxiety did not contribute to this model. Treating depression may be useful in improving QOL in severely constipated patients, which highlights the importance of psychological screening and treatment referrals in primary care settings.

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.

Young Age and Aggressive Treatment in Colon Cancer.

Thedownwardtrend in colorectal cancer (CRC) incidenceandmortality over the past several decades1 has not held true for youngpatients. Currently, CRC incidence in patients younger than 50 years continues to increase,mostmarkedlyamong thoseyounger than35 years by approximately 2% per year. This trend was identified in a recent analysis that estimated patients younger than screening age (ie, age 50 years) will comprise 10.9% of colon and 22.9% of rectal cancers by 2030, compared with 4.8% and 9.5% in 2010, respectively.2 Young-onsetCRC is characterizedbymore advanced stages, poor tumor differentiation,mucinous carcinoma,more distal location, and even a particular profile of biomarkers.3 Although more aggressive disease usually results in worse outcomes, disease-specific and overall survival for patients with young-onset CRC consistently matches or surpasses that of older patients, stage-for-stage.3 Given this seemingly conflicting information, optimal treatment for these young patients remains unclear. In JAMA Surgery, Kneuertz et al4 provided insight into treatment patterns and prognosis in young adults with colon cancer. The authors confirmed that younger age at onset was associated with advanced presentation and worse histologic features. Younger patients—regardless of stage—were significantly more likely to be treated with chemotherapy, often multiagent regimens, than older patients. Not routinely recommended for earlystage disease, adjuvant chemotherapy resulted in little survival gain for these patients compared with the older group. This assessment of care suggests that, despite best intentions, treatment did little to improve the health of this population but rather was associated with increased risk for adverse outcomes and increased cost of care. Improving care for young patients with colon cancer requires that patterns of overtreatment be remedied. In light of these findings, it is important to address (1) overtreatment in young JAMASURGERY

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.

A systematic review of patient perspectives on surveillance after colorectal cancer treatment

PurposeSurveillance after colorectal cancer (CRC) treatment is routine, but intensive follow-up may offer little-to-no overall survival benefit. Given the growing population of CRC survivors, we aimed to systematically evaluate the literature for the patient perspective on two questions: (1) How do CRC patients perceive routine surveillance following curative treatment and what do they expect to gain from their surveillance testing or visits? (2) Which providers (specialists, nursing, primary care) are preferred by CRC survivors to guide post-treatment surveillance?MethodsSystematic searches of PubMed MEDLINE, Embase, the CENTRAL Register of Controlled Trials, CINAHL, and PsycINFO were conducted. Studies were screened for inclusion by two reviewers, with discrepancies adjudicated by a third reviewer. Data were abstracted and evaluated utilizing validated reporting tools (CONSORT, STROBE, CASP) appropriate to study design.ResultsCitations (3691) were screened, 91 full-text articles reviewed, and 23 studies included in the final review: 15 quantitative and 8 qualitative. Overall, 12 studies indicated CRC patients perceive routine surveillance positively, expecting to gain reassurance of continued disease suppression. Negative perceptions described in six studies included anxiety and dissatisfaction related to quality of life or psychosocial issues during follow-up. Although 5 studies supported specialist-led care, 9 studies indicated patient willingness to have follow-up with non-specialist providers (primary care or nursing).ConclusionsPatients’ perceptions of follow-up after CRC are predominantly positive, although unmet needs included psychosocial support and quality of life.Implications for Cancer Survivors:Survivors perceived follow-up as reassuring, however, surveillance care should be more informative and focused on survivor-specific needs.