Melanie S. Morris

Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections.

BACKGROUND: Surgical site infection is a major cause of morbidity after colorectal resections. Despite evidence that preoperative oral antibiotics with mechanical bowel preparation reduce surgical site infection rates, the use of oral antibiotics is decreasing. Currently, the administration of oral antibiotics is controversial and considered ineffective without mechanical bowel preparation. OBJECTIVE: The aim of this study is to examine the use of mechanical bowel preparation and oral antibiotics and their relationship to surgical site infection rates in a colorectal Surgical Care Improvement Project cohort. DESIGN: This retrospective study used Veterans Affairs Surgical Quality Improvement Program preoperative risk and surgical site infection outcome data linked to Veterans Affairs Surgical Care Improvement Project and Pharmacy Benefits Management data. Univariate and multivariable models were performed to identify factors associated with surgical site infection within 30 days of surgery. SETTINGS: This study was conducted in 112 Veterans Affairs hospitals. PATIENTS: Included were 9940 patients who underwent elective colorectal resections from 2005 to 2009. MAIN OUTCOME MEASURE: The primary outcome measured was the incidence of surgical site infection. RESULTS: Patients receiving oral antibiotics had significantly lower surgical site infection rates. Those receiving no bowel preparation had similar surgical site infection rates to those who had mechanical bowel preparation only (18.1% vs 20%). Those receiving oral antibiotics alone had an surgical site infection rate of 8.3%, and those receiving oral antibiotics plus mechanical bowel preparation had a rate of 9.2%. In adjusted analysis, the use of oral antibiotics alone was associated with a 67% decrease in surgical site infection occurrence (OR=0.33, 95% CI 0.21–0.50). Oral antibiotics plus mechanical bowel preparation was associated with a 57% decrease in surgical site infection occurrence (OR=0.43, 95% CI 0.34–0.55). Timely administration of parenteral antibiotics (Surgical Care Improvement Project-1) had a modest protective effect, with no effect observed for other Surgical Care Improvement Project measures. Hospitals with higher rates of oral antibiotics use had lower surgical site infection rates (R2 = 0.274, p < 0.0001). LIMITATIONS: Determination of the use of oral antibiotics and mechanical bowel preparation is based on retrospective prescription data, and timing of actual administration cannot be determined. CONCLUSIONS: Use and type of preoperative bowel preparation varied widely. These results strongly suggest that preoperative oral antibiotics should be administered for elective colorectal resections. The role of oral antibiotics independent of mechanical bowel preparation should be examined in a prospective randomized trial.

The Relationship Between Timing of Surgical Complications and Hospital Readmission

IMPORTANCE Readmissions after surgery are costly and may reflect quality of care in the index hospitalization. OBJECTIVES To determine the timing of postoperative complications with respect to hospital discharge and the frequency of readmission stratified by predischarge and postdischarge occurrence of complications. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study of national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcome data on the Surgical Care Improvement Project cohort for operations performed from January 2005 to August 2009, including colorectal, arthroplasty, vascular, and gynecologic procedures. The association between timing of complication with respect to index hospitalization and 30-day readmission was modeled using generalized estimating equations. MAIN OUTCOME AND MEASURE All-cause readmission within 30 days of the index surgical hospitalization discharge. RESULTS Our study of 59 273 surgical procedures performed at 112 Department of Veterans Affairs (VA) hospitals found an overall complication rate of 22.6% (predischarge complications, 71.9%; postdischarge complications, 28.1%). The proportion of postdischarge complications varied significantly, from 8.7% for respiratory complications to 55.7% for surgical site infection (P < .001). The overall 30-day readmission rate was 11.9%, of which only 56.0% of readmissions were associated with a currently assessed complication. Readmission was predicted by patient comorbid conditions, procedure factors, and the occurrence of postoperative complications. Multivariable generalized estimating equation models of readmission adjusting for patient and procedure characteristics, hospital, and index length of stay found that the occurrence of postdischarge complications had the highest odds of readmission (odds ratio, 7.4-20.8) compared with predischarge complications (odds ratio, 0.9-1.48). CONCLUSIONS AND RELEVANCE More than one-quarter of assessed complications are diagnosed after hospital discharge and strongly predict readmission. Hospital discharge is an insufficient end point for quality assessment. Although readmission is associated with complications, almost half of readmissions are not associated with a complication currently assessed by the Veterans Affairs Surgical Quality Improvement Program.

Oral Antibiotic Bowel Preparation Significantly Reduces Surgical Site Infection Rates and Readmission Rates in Elective Colorectal Surgery.

OBJECTIVE To determine the relationship between oral antibiotic bowel preparation (OABP) and surgical site infection (SSI) rates in a national colectomy cohort. BACKGROUND OABP for elective colorectal surgery has fallen out of favor. Large cohort studies show that OABP is associated with a 50% reduction in SSI after colectomy. METHODS A retrospective analysis of the National Surgical Quality Improvement Program colectomy cohort from 2011 to 2012 was performed to examine the association between use of OABP and outcomes of SSI, length of stay (LOS), and readmission after elective colectomy. Univariate and multivariable analyses for SSI were performed. RESULTS The cohort included 8415 colorectal operations of which 5291 (62.9%) had a minimally invasive surgical (MIS) approach. Overall, 25.6% had no bowel preparation, 44.9% had mechanical bowel preparation (MBP) only, and 29.5% received OABP. The SSI rate was 11.1%, and it varied by preparation type: 14.9% no preparation, 12.0% MBP, and 6.5% OABP (P < 0.001). OABP group had significantly shorter hospital LOS: (median = 4, interquartile range: 3-6) versus other preparations (median LOS = 5) (P < 0.001). Readmission rates were lowest in OABP (8.1%) and highest in the no preparation group (11.8%). Multivariable logistic regressions found OABP associated with lower SSI [adjusted odds ratio (ORadj) = 0.46, 95% confidence interval (CI): 0.36-0.59]. Stratified models found OABP protective for SSI for both open procedures (ORadj = 0.40, 95% CI: 0.30-0.53) and MIS procedures (ORadj = 0.48, 95% CI: 0.36-0.65). CONCLUSIONS OABP is associated with reduced SSI rates, shorter LOS, and fewer readmissions. Adoption of OABP before elective colectomy would reduce SSI without effecting LOS. The practice of MBP alone should be abandoned.

Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery.

BACKGROUND Oral antibiotic bowel preparation (OABP) before colorectal resection has been shown to reduce surgical site infections. We examined whether OABP decreases length of stay (LOS) and readmissions for colorectal surgery. STUDY DESIGN This retrospective study used national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcomes data linked to Veterans Affairs Administrative and Pharmacy Benefits Management data on patients undergoing elective colorectal resections from 2005 to 2009. Exclusion criteria were preoperative LOS >2 days, American Society of Anesthesiologists class 5, or death before discharge. Patient and surgery characteristics, bowel preparation use, presence of an ostomy, indication for surgery, and indication for readmission using ICD-9 codes were determined. Negative binomial regression was used to model LOS. Logistic regression analyses modeled 30-day readmission. RESULTS Of the 8,180 patients, 1,161 (14.2%) were readmitted within 30 days. Length of stay and readmissions varied significantly by bowel preparation, procedure, presence of an ostomy, and American Society of Anesthesiologists class. Oral antibiotic bowel preparation was associated with a below-median postoperative LOS (negative binomial regression estimate = -0.1159; p < 0.0001) and fewer 30-day readmissions (adjusted odds ratio = 0.81; 95% CI, 0.68-0.97). Overall, 4.9% were readmitted for infections (ICD-9 codes) and this varied by bowel preparation (no preparation 6.1%, mechanical 5.4%, OABP 3.9%; p = 0.001). The readmission rate for noninfectious reasons was 9.3% and did not differ significantly by bowel preparation (no preparation 9.9%, mechanical 9.6%, OABP 8.8%; p = 0.38). CONCLUSIONS Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative LOS and lower 30-day readmission rates, primarily due to fewer readmissions for infections. Prospective studies are needed to verify these results.

Postoperative 30-day Readmission: Time to Focus on What Happens Outside the Hospital.

Objective: The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions. Background: Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk. Methods: National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data. Variables were categorized as preoperative, operative, postoperative/predischarge, and postdischarge. Logistic models predicting 30-day readmission were compared using adjusted R2 and c-statistics with cross-validation to estimate predictive discrimination. Results: Our study sample included 237,441 surgeries: 43% orthopedic, 39% general, and 18% vascular. Overall 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9%, and orthopedic 7.6%, P < 0.001). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%), and fluid/electrolyte (7.5%) complications. Models using information available at the time of discharge explained 10.4% of the variability in readmissions. Of these, preoperative patient-level factors contributed the most to predictive models (R2 7.0% [c-statistic 0.67]); prediction was improved by inclusion of intraoperative (R2 9.0%, c-statistic 0.69) and postoperative variables (R2 10.4%, c-statistic 0.71). Including postdischarge complications improved predictive ability, explaining 19.6% of the variation (R2 19.6%, c-statistic 0.76). Conclusions: Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.

Association of the Modified Frailty Index With 30-Day Surgical Readmission

Importance Frail patients are known to have poor perioperative outcomes. There is a paucity of literature investigating how the Modified Frailty Index (mFI), a validated measure of frailty, is associated with unplanned readmission among military veterans following surgery. Objective To understand the association between frailty and 30-day postoperative unplanned readmission. Design, Setting, and Participants A retrospective cohort study was conducted among adult patients who underwent surgery and were discharged alive from Veterans Affairs hospitals for orthopedic, general, and vascular conditions between October 1, 2007, and September 30, 2014, with a postoperative length of stay between 2 and 30 days. Exposure Frailty, as calculated by the 11 variables on the mFI. Main Outcomes and Measures The primary outcome of interest is 30-day unplanned readmission. Secondary outcomes included any 30-day predischarge or postdischarge complication, 30-day postdischarge mortality, and 30-day emergency department visit. Results The study sample included 236 957 surgical procedures (among 223 877 men and 13 080 women; mean [SD] age, 64.0 [11.3] years) from high-volume surgical specialties: 101 348 procedures (42.8%) in orthopedic surgery, 92 808 procedures (39.2%) in general surgery, and 42 801 procedures (18.1%) in vascular surgery. The mFI was associated with readmission (odds ratio [OR], 1.11; 95% CI, 1.10-1.12; R2 = 10.3%; C statistic, 0.71). Unadjusted rates of overall 30-day readmission (26 262 [11.1%]), postdischarge emergency department visit (34 204 [14.4%]), any predischarge (13 855 [5.9%]) or postdischarge (14 836 [6.3%]) complication, and postdischarge mortality (1985 [0.8%]) varied by frailty in a dose-dependent fashion. In analysis by individual mFI components using Harrell ranking, impaired functional status, identified as nonindependent functional status (OR, 1.16; 95% CI, 1.11-1.21; P < .01) or having a residual deficit from a prior cerebrovascular accident (OR, 1.17; 95% CI, 1.11-1.22; P < .01), contributed most to the ability of the mFI to anticipate readmission compared with the other components. Acutely impaired sensorium (OR, 1.12; 95% CI, 0.99-1.27; P = .08) and history of a myocardial infarction within 6 months (OR, 0.93; 95% CI, 0.81-1.06; P = .28) were not significantly associated with readmission. Conclusions and Relevance The mFI is associated with poor surgical outcomes, including readmission, primarily due to impaired functional status. Targeting potentially modifiable aspects of frailty preoperatively, such as improving functional status, may improve perioperative outcomes and decrease readmissions.

A 100% Departmental Mortality Review Improves Observed-to-Expected Mortality Ratios and University HealthSystem Consortium Rankings

BACKGROUND Public reporting of mortality, Patient Safety Indicators (PSI) and hospital-acquired conditions (HACs) is the reality of quality measurement. A review of our departments data identified opportunities for improvement. We began a surgeon-led 100% review of mortality, PSIs, and HACs to improve patient care and surgeon awareness of these metrics. STUDY DESIGN From December 2012 through August 2013, there were 11,899 patients cared for on 12 surgical services. A surgeon from each service led monthly reviews of all mortality, PSIs, or HACs with central reporting of preventability and coding accuracy. We compared the University HealthSystem Consortium observed-to-expected (OE) mortality ratios (mean <1 fewer observed than expected deaths) and University HealthSystem Consortium relative rankings (lower number is better) before and after implementation. Statistical significance was p < 0.05 by Poisson regression. RESULTS Of the 11,899 patients in the study period, there were 235 deaths, 290 PSIs, and 26 HACs identified and reviewed. The most common PSIs were postoperative deep vein thrombosis/pulmonary thromboembolism (n = 75), respiratory failure (n = 61), hemorrhage/hematoma (n = 33), and accidental puncture/laceration (n = 33). Before December 20, 2012, the OE ratio for mortality was consistently >1, then fell and remained <1 during the study period (p < 0.05). The OE mortality ratio in the fourth quarter of 2012 was 1.14 and fell to 0.88, 0.91, and 0.75 in the first, second, and third quarters of calendar year 2013 (p < 0.05). The overall Inpatient Quality Indicators #90 (composite postoperative mortality rank) rankings increased from 109 of 118 in the third quarter of 2012 to 47 of 119 in the third quarter of 2013. CONCLUSIONS A surgeon-led systematic review of mortality, PSIs, and HACs improved our OE ratio and University HealthSystem Consortium postsurgical relative rankings. Surgeon engagement and ownership is critical for success.

Association Between Preoperative Hemoglobin A1c Levels, Postoperative Hyperglycemia, and Readmissions Following Gastrointestinal Surgery

Importance Preoperative hyperglycemia is associated with adverse postoperative outcomes among patients who undergo surgery. Whether preoperative hemoglobin A1c (HbA1c) or postoperative glucose levels are more useful in predicting adverse events following surgery is uncertain in the current literature. Objective To examine the use of preoperative HbA1c and early postoperative glucose levels for predicting postoperative complications and readmission. Design, Setting, and Participants In this observational cohort study, inpatient gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to 2014 were identified, and cases of known infection within 3 days before surgery were excluded. Preoperative HbA1c levels were examined as a continuous and categorical variable (<5.7%, 5.7%-6.5%, and >6.5%). A logistic regression modeled postoperative complications and readmissions with the closest preoperative HbA1c within 90 days and the highest postoperative glucose levels within 48 hours of undergoing surgery. Main Outcomes and Measures Postoperative complications and 30-day unplanned readmission following discharge. Results Of 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7 (10.6) years. The cohort included 23 094 operations with measurements of preoperative HbA1c levels and postoperative glucose levels. The complication and 30-day readmission rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA1c, postoperative glucose levels, postoperative insulin use, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), and other patient and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). By contrast, a preoperative HbA1c of more than 6.5% was associated with decreased 30-day readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA1c increased, the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an HbA1c <5.7%, 5.7%-6.4%, and >6.5%, respectively; P < .001). Patients with a preoperative HbA1c of more than 6.5% had lower thresholds for postoperative insulin use. Conclusions and Relevance Early postoperative hyperglycemia was associated with increased readmission, but elevated preoperative HbA1c was not. A higher preoperative HbA1c was associated with increased postoperative glucose level checks and insulin use, suggesting that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may explain this finding.

Primary Care Physician Perspectives on Barriers to Statin Treatment.

PurposeDiscontinuation of statin therapy represents a major challenge for effective cardiovascular disease prevention. It is unclear how often primary care physicians (PCPs) re-initiate statins and what barriers they encounter. We aimed to identify PCP perspectives on factors influencing statin re-initiation.MethodsWe conducted six nominal group discussions with 23 PCPs from the Deep South Continuing Medical Education network. PCPs answered questions about statin side effects, reasons their patients reported for discontinuing statins, how they respond when discontinuation is reported, and barriers they encounter in getting their patients to re-initiate statin therapy. Each group generated a list of responses in round-robin fashion. Then, each PCP independently ranked their top three responses to each question. For each PCP, the most important reason was given a weight of 3 votes, and the second and third most important reasons were given weights of 2 and 1, respectively. We categorized the individual responses into themes and determined the relative importance of each theme using a “percent of available votes” metric.ResultsPCPs reported that side effects, especially muscle/joint-related symptoms, were the most common reason patients reported for statin discontinuation (47% of available votes). PCPs reported statin re-challenge as their most common response when a patient discontinues statin use (31% of available votes). Patients’ fear of side effects was ranked as the biggest challenge PCPs encounter in getting their patients to re-initiate statin therapy (70% of available votes).ConclusionPCPs face challenges getting their patients to re-initiate statins, particularly after a patient reports side effects.

The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits.

Objective: We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits. Background: Surgical readmissions have few known modifiable predictors. Pain experienced by patients may reflect surgical complications and/or inadequate or difficult symptom management. Methods: National Veterans Affairs Surgical Quality Improvement data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital sign, health care utilization, and postoperative complications data. Six distinct postoperative inpatient patient-reported pain trajectories were identified: (1) persistently low, (2) mild, (3) moderate or (4) high trajectories, and (5) mild-to-low or (6) moderate-to-low trajectories based on postoperative pain scores. Regression models estimated the association between pain trajectories and postdischarge utilization while controlling for important patient and clinical variables. Results: Our sample included 211,231 surgeries—45.4% orthopedics, 37.0% general, and 17.6% vascular. Overall, the 30-day unplanned readmission rate was 10.8%, and 30-day ED utilization rate was 14.2%. Patients in the high pain trajectories had the highest rates of postdischarge readmissions and ED visits (14.4% and 16.3%, respectively, P < 0.001). In multivariable models, compared with the persistently low pain trajectory, there was a dose-dependent increase in postdischarge ED visits and readmission for pain-related diagnoses, but not postdischarge complications (&khgr;2 trend P < 0.001). Conclusions: Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits, and do not seem to be mediated by postdischarge complications. Addressing pain control expectations before discharge may help reduce surgical readmissions in high pain categories.