Sarah E. Tevis

Postoperative complications in patients with rectal cancer are associated with delays in chemotherapy that lead to worse disease-free and overall survival.

OBJECTIVE: The objective of this study was to identify the risk factors for delays in chemotherapy after rectal cancer surgery and evaluate the effects of delayed therapy on long-term outcomes. We also sought to clarify what time frame should be used to define delayed adjuvant chemotherapy. BACKGROUND: Postoperative complications have been found to influence the timing of chemotherapy in patients with colon cancer. Delays in chemotherapy have been shown to be associated with worse overall and disease-free survival in patients with colorectal cancer, although the timing of delay has not been agreed upon in the literature. STUDY DESIGN: We performed a retrospective review of a prospectively maintained rectal cancer database. Univariate analysis was used to identify risk factors for delayed chemotherapy. Kaplan-Meier curves were generated to compare overall and disease-free survival in patients based on complications and timing of chemotherapy. SETTINGS: This study was performed at the University of Wisconsin Hospital, Madison, Wisconsin, between 1995 and 2012. PATIENTS: Patients with rectal cancer who underwent proctectomy with curative intent were included in this study. OUTCOME MEASURES: Timing of chemotherapy, 30-day complications, and 30-day readmissions were the main outcome measures. RESULTS: Postoperative complications and 30-day readmissions were associated with delays in chemotherapy ≥8 weeks after surgery. Patients who received chemotherapy ≥8 weeks postoperatively were found to have worse local and distant recurrence rates and worse overall survival in comparison with patients who received chemotherapy within 8 weeks of surgery. LIMITATIONS: The limitations of this study include its retrospective nature and that it was performed at a single institution. CONCLUSIONS: We found complications and readmissions to be risk factors for delayed chemotherapy. Patients who received therapy ≥8 weeks postoperatively had worse disease-free and overall survival.

Multiple complications and short length of stay are associated with postoperative readmissions

BACKGROUND The aim of this study was to characterize patients readmitted following inpatient general surgery procedures. We hypothesized that a decreased length of stay would increase risk for readmission. METHODS We utilized our institutional National Surgical Quality Improvement Project database from 2006 to 2011. The main outcome of interest was 30-day readmission. Univariate and logistic regression analyses identified risk factors for readmission. RESULTS We identified 3,556 patients, with 322 (9%) readmitted within 30 days after discharge. Multivariable analysis demonstrated age, dyspnea, and American Society of Anesthesiologists class to be independent risk factors for readmission. In addition, patients who suffered multiple complications had a decreased risk for readmission as length of stay increased. Patients with <2 postoperative complications had an increased risk for readmission as length of stay increased. CONCLUSIONS Contributors to postoperative readmissions are multifactorial. Perioperative factors predict risk for readmission and may help determine a target length of stay. Prevention of postoperative complications may reduce readmission rates.

Postdischarge complications are an important predictor of postoperative readmissions

BACKGROUND Thirty-day readmissions are common in general surgery patients and affect long-term outcomes including mortality. We sought to determine the effect of complication timing on postoperative readmissions. METHODS Patients from our institutional American College of Surgeons National Surgical Quality Improvement Project database who underwent general surgery procedures from 2006 to 2011 were included. The primary outcome of interest was 30-day hospital readmission. RESULTS Patients diagnosed with postdischarge complications were significantly more likely to be readmitted (56%) compared with patients diagnosed with complications before discharge (7%, P < .001). Independent predictors of postdischarge complications included laparoscopic case, short hospital stay, preoperative dyspnea, and independent functional status. Gastrointestinal complications and surgical site infection were the most common reasons for readmission. CONCLUSIONS The development of complications after hospital discharge places patients at significant risk for readmission. Early identification and treatment of gastrointestinal complications and surgical site infections in the outpatient setting may decrease postoperative readmission rates.

Nomogram to Predict Postoperative Readmission in Patients Who Undergo General Surgery

IMPORTANCE The Centers for Medicare and Medicaid Services have implemented penalties for hospitals with above-average readmission rates under the Hospital Readmissions Reductions Program. These changes will likely be extended to affect postoperative readmissions in the future. OBJECTIVES To identify variables that place patients at risk for readmission, develop a predictive nomogram, and validate this nomogram. DESIGN, SETTING, AND PARTICIPANTS Retrospective review and prospective validation of a predictive nomogram. A predictive nomogram was developed with the linear predictor method using the American College of Surgeons National Surgical Quality Improvement Program database paired with institutional billing data for patients who underwent nonemergent inpatient general surgery procedures. The nomogram was developed from August 1, 2006, through December 31, 2011, in 2799 patients and prospectively validated from November 1, 2013, through December 19, 2013, in 255 patients at a single academic institution. Area under the curve and positive and negative predictive values were calculated. MAIN OUTCOMES AND MEASURES The outcome of interest was readmission within 30 days of discharge following an index hospitalization for a surgical procedure. RESULTS Bleeding disorder (odds ratio, 2.549; 95% CI, 1.464-4.440), long operative time (odds ratio, 1.601; 95% CI, 1.186-2.160), in-hospital complications (odds ratio, 16.273; 95% CI, 12.028-22.016), dependent functional status, and the need for a higher level of care at discharge (odds ratio, 1.937; 95% CI, 1.176-3.190) were independently associated with readmission. The nomogram accurately predicted readmission (C statistic = 0.756) in a prospective evaluation. The negative predictive value was 97.9% in the prospective validation, while the positive predictive value was 11.1%. CONCLUSIONS AND RELEVANCE Development of an online calculator using this predictive model will allow us to identify patients who are at high risk for readmission at the time of discharge. Patients with increased risk may benefit from more intensive postoperative follow-up in the outpatient setting.

Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND Surgical site infection (SSI) is a costly complication leading to increased resource use and patient morbidity. We hypothesized that postdischarge SSI results in a high rate of preventable readmissions. METHODS We used our institutional American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing general surgery procedures from 2006 to 2011. RESULTS SSIs developed in 10% of the 3,663 patients who underwent an inpatient general surgical procedure. SSI was diagnosed after discharge in 48% of patients. Patients with a diagnosis of SSI after discharge were less likely to have a history of smoking (15% vs 28%, P = .001), chronic obstructive pulmonary disease (3% vs 9%, P = .015), congestive heart failure (0% vs 3%, P = .03), or sepsis within 48 hours preoperatively (17% vs 32%, P = .001) compared with patients diagnosed before discharge. Over 50% of the patients diagnosed with SSI after discharge required readmission. CONCLUSIONS A diagnosis of SSI after discharge is associated with a high readmission rate despite occurring in healthier patients. We propose discharge teaching improvements and a wound surveillance clinic within the first week may result in a decreased readmission rate.

Postoperative complications and implications on patient-centered outcomes

BACKGROUND Postoperative complications increase patient morbidity and mortality and are a target for quality improvement programs. The goal of this study was to review the worlds literature on postoperative complications in general surgery patients and try to examine the effect of these complications on patient-centered outcomes. METHODS A comprehensive search of the current literature identified 18 studies on the topic of postoperative complications in general surgery patients. RESULTS Postoperative complications are common in general surgery patients and contribute to increased mortality, length of stay, and need for an increased level of care at discharge (decline in disposition). CONCLUSIONS Although the concept of patient-centered outcomes is not new, it has not been applied to postoperative complications. It is likely that the effect of complications on length of hospital stay and postoperative discharge reflects an impact of complications on these patient-centered outcomes. Future studies should consider the effect of complications on those outcomes that are most important to the individual patient.

A composite index for predicting readmission following emergency general surgery

BACKGROUND Preventable readmission has become a national focus. It is clear that surgical patients present specific challenges to those interested in preventing readmission. Little is known about this outcome in the emergent population. We are interested in determining if there are readily available data variables to predict risk of readmission. The surgical Apgar score (SAS) is calculated from objective intraoperative variables and has been shown to be predictive of postoperative mortality in the nonemergent setting. The objectives of this study were to characterize 30-day readmissions in emergent general surgery and to determine whether certain variables were associated with readmissions. We hypothesized that the SAS correlates with the risk for readmission in emergency general surgery patients. PATIENTS AND METHODS Variables of interest were obtained from a retrospective analysis of the American College of Surgeons’ National Surgical Quality Improvement Program database at an academic institution, paired with the electronic medical record. We identified adult general surgery patients who underwent an emergency procedure from 2006 to 2012. Univariate analysis identified factors associated with 30-day readmission. Factors with p < 0.1 were included in the multivariate analysis to reveal potential risk factors. SPSS version 20 was used for the statistical analysis, with p < 0.05 considered to be significant on multivariate analysis. RESULTS As compared with nonemergency surgery patients, emergency surgery patients had a higher readmission rate (11.1% vs. 15.2%, p = 0.004). The SAS (odds ratio, 3.297; 95% confidence interval, 1.074–10.121; p = 0.037) and the combined variable of the American Society of Anesthesiologists Physical Status Classification and length of stay (odds ratio, 4.370; 95% confidence interval, 2.251–8.486; p < 0.001) were associated with elevated risk for readmission in emergency general surgery patients. CONCLUSION We have identified readily available measures that allow for the stratification of patients into low- and high-risk groups for 30-day readmission. The stratification of patients will enable the study of prospective interventions designed to decrease unplanned readmissions in emergency surgery patients. LEVEL OF EVIDENCE Prognostic study, level II.

Implications of Multiple Complications on the Postoperative Recovery of General Surgery Patients.

Objectives:To evaluate the association between multiple complications and postoperative outcomes and to assess which complications occur together in patients with multiple complications. Background:Patients who suffer multiple complications have increased risk of prolonged hospital stay and mortality. However, little is known about what places patients at risk for multiple complications or which complications tend to occur in these patients. Methods:Surgical patients were identified from the American College of Surgeons National Quality Improvement Program (ACS NSQIP) database from 2005 to 2011. The frequency of postoperative complications was assessed. Patients with less than two complications were compared with patients who had multiple complications using &khgr;2 and logistic regression analysis. Relationships among postoperative complications were explored by learning a Bayesian network model. Results:The study population consisted of 470,108 general surgery patients. The overall complication rate was 15% with multiple complications in 27,032 (6%) patients. Patients with multiple complications had worse postoperative outcomes (P < 0.001). The strongest predictors for developing multiple complications were admission from chronic care facility or nursing home, dependent functional status, and higher American Society of Anesthesiologist Physical Status classification. In patients with multiple complications, the most common complication was sepsis (42%), followed by failure to wean ventilator (31%), and organ space surgical site infection (27%). We found that severe complications were most strongly associated with development of multiple complications. Using a Bayesian network, we were able to identify how strongly associated specific complications were in patients who developed multiple complications. Conclusions:Almost half (40%) of patients with complications suffer multiple complications. Patient factors such as frailty and comorbidity strongly predict the development of multiple complications. The results of our Bayesian analysis identify targets for interventions aimed at disrupting the cascade of multiple complications in high-risk patients.

Does Anastomotic Leak Contribute to High Failure-to-rescue Rates?

Objective:Our aim was to evaluate failure-to-rescue (FTR) after anastomotic leak (AL) in colectomy patients. Background:In the era of pay for performance, it is imperative that we understand the quality measures under which we are scrutinized. FTR has been proposed as a marker of surgical quality. We investigated the role of complications in FTR rates in colectomy patients. Methods:Patients who underwent nonemergent colectomy from 2012 to 2013 were identified from the The American College of Surgeons National Quality Improvement Program (ACS NSQIP database). Mortality after AL was assessed and stratified in relation to mortality after other postoperative complications. &khgr;2 and logistic regression analysis were used to assess the effect of AL on mortality. Results:We identified 30,101 patients who met inclusion criteria, 1127 suffered an AL (3.7%). FTR was increased in patients with AL compared with those without AL (6% vs 1%, P < 0.001). The mortality rate after leak was similar to mortality after other major complications. Independent risk factors for death after AL included older age (odds ratio [OR] 3.140; 95% confidence interval [CI], 1.744–5.651), cancer diagnosis (OR 2.032; 95% CI, 1.177–3.507), and open approach (OR 2.124; 95% CI, 1.194–3.776) while preoperative bowel preparation was protective (OR 0.563; 95% CI, 0.328–0.969). Conclusions:AL is a common complication after colectomy with a relatively high FTR rate. As hospitals are penalized for not reaching specific rates of FTR, we must better understand these complex relationships to improve quality and safety of patient care.

Patient satisfaction: does surgical volume matter?

BACKGROUND Patient satisfaction is an increasing area of interest due to implications of pay for performance and public reporting of results. Although scores are adjusted for patient factors, little is known about the relationship between hospital structure, postoperative outcomes, and patient satisfaction with the hospital experience. METHODS Hospitals participating in the University HealthSystem Consortium database from 2011-2012 were included. Patients were restricted to those discharged by general surgeons to isolate surgical patients. Hospital data were paired with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results from the Hospital Compare website. Postoperative outcomes were dichotomized based on the median for all hospitals and stratified based on surgical volume. The primary outcome of interest was high on overall patient satisfaction, whereas other HCAHPS domains were assessed as secondary outcomes. Chi square and binary logistic regression analyses were performed to evaluate whether postoperative outcomes or surgical volume more significantly influenced high patient satisfaction. RESULTS The study population consisted of 171 hospitals from the University HealthSystem Consortium database. High surgical volume was a more important predictor of overall patient satisfaction regardless of hospital complication (P < 0.001), readmission (P < 0.001), or mortality rates (P = 0.009). Volume was found to play less of a role in predicting high satisfaction on the other HCAHPS domains. Postoperative outcomes were more predictive of high satisfaction with providers, the hospital experience, and environment. CONCLUSIONS High surgical volume more strongly predicted overall patient satisfaction on the HCAHPS survey than postoperative outcomes, whereas volume was less predictive in other HCAHPS domains. Patients may require more specific questioning to identify high quality, safe hospitals.