Seth A. Waits

Cost of Major Surgery in the Sarcopenic Patient

BACKGROUND Sarcopenia is associated with poor outcomes after major surgery. There are currently no data regarding the financial implications of providing care for these high-risk patients. STUDY DESIGN We identified 1,593 patients within the Michigan Surgical Quality Collaborative (MSQC) who underwent elective major general or vascular surgery at a single institution between 2006 and 2011. Patient sarcopenia, determined by lean psoas area (LPA), was derived from preoperative CT scans using validated analytic morphomic methods. Financial data including hospital revenue and direct costs were acquired for each patient through the hospitals finance department. Financial data were adjusted for patient and procedural factors using multiple linear regression methods, and Mann-Whitney U test was used for significance testing. RESULTS After controlling for patient and procedural factors, decreasing LPA was independently associated with increasing payer costs (

Effects on Breast MRI of Artifacts Caused by Metallic Tissue Marker Clips

6,989.17 per 1,000 mm(2) LPA, p < 0.001). The influence of LPA on payer costs increased to

Improving mortality following emergent surgery in older patients requires focus on complication rescue.

26,988.41 per 1,000 mm(2) decrease in LPA (p < 0.001) in patients who experienced a postoperative complication. Further, the covariate-adjusted hospital margin decreased by

Morphometric Age and Mortality After Liver Transplant

2,620 per 1,000 mm(2) decrease in LPA (p < 0.001) such that average negative margins were observed in the third of patients with the smallest LPA. CONCLUSIONS Sarcopenia is associated with high payer costs and negative margins after major surgery. Although postoperative complications are universally expensive to payers and providers, sarcopenic patients represent a uniquely costly patient demographic. Given that sarcopenia may be remediable, efforts to attenuate costs associated with major surgery should focus on targeted preoperative interventions to optimize these high risk patients for surgery.

Failure to rescue and mortality following repair of abdominal aortic aneurysm

OBJECTIVE The purpose of our study was to investigate MR artifacts related to tissue marker clips used in breast imaging procedures. MATERIALS AND METHODS Breast phantoms were created using gelatin doped with gadolinium. Four commercially available tissue marker clips were evaluated. Clinical MR evaluation of all phantoms with 1.5-T gradient-recalled echo sequences was performed. Images were evaluated for size and character of the visible artifacts and graphically appreciable fat saturation inhomogeneities. Quantitative measurement of the local inhomogeneity in 3D parts per million maps was obtained as a function of distance from each tissue marker. RESULTS All tissue marker clips caused signal void artifacts on non-fat-suppressed images that measured 2-6 times the clip diameter. The degree of fat suppression inhomogeneity was minor but clinically appreciable. The local clip-induced field inhomogeneity varied from 0.25 to greater than 4.0 PPM for the four clips. At 0.25 PPM, the zonal diameter of frequency shift varied from 6 mm to 44 mm. CONCLUSION Artifacts caused by tissue marker clips could limit the sensitivity of MRI for detection and follow-up of breast cancer. The local effects on field inhomogeneity will affect local fat suppression and make spectroscopy data less reliable. These effects, though small, are measurable and vary among the different clips evaluated.

The importance of improving the quality of emergency surgery for a regional quality collaborative.

Objective: To determine whether a hospitals ability to rescue patients from major complications underlies variation in outcomes for elderly patients undergoing emergent surgery. Background: Perioperative mortality rates in elderly patients undergoing emergent general/vascular operations are high and vary widely across Michigan hospitals. Methods: We identified 23,224 patients undergoing emergent general/vascular surgical procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2006 and 2011. Hospitals were ranked by risk- and reliability-adjusted 30-day mortality rates and grouped into tertiles. We stratified patients by age (<75 and ≥75 years). Risk-adjusted major complication and failure-to-rescue (ie, mortality after major complication) rates were determined for each tertile of hospital mortality. Results: Risk-adjusted mortality rates in elderly patients varied 2-fold across all hospitals. Complication rates correlated poorly with mortality. Failure-to-rescue rates, however, were markedly higher in high-mortality hospitals (29% lowest tertile vs 41% highest tertile; P < 0.01). When compared with younger patients, overall failure-to-rescue rates were almost 2-fold greater in the elderly (36.1% ≥75 vs 18.7% <75; P < 0.01). Conclusions: A hospitals failure to rescue patients from major complications seems to underlie the variation in mortality rates across Michigan hospitals after emergent surgery. Although higher failure-to-rescue rates in the elderly may signify their diminished physiological reserve for surviving critical illness, the wide variation across hospitals also highlights the importance of systems aimed at the early recognition and effective management of major complications in this vulnerable population.

Geographic variation in use of laparoscopic colectomy for colon cancer

IMPORTANCE Morphometric assessment has emerged as a strong predictor of postoperative morbidity and mortality. However, a gap exists in translating this knowledge to bedside decision making. We introduced a novel measure of patient-centered surgical risk assessment: morphometric age. OBJECTIVE To investigate the relationship between morphometric age and posttransplant survival. DATA SOURCES Medical records of recipients of deceased-donor liver transplants (study population) and kidney donors/trauma patients (morphometric age control population). STUDY SELECTION A retrospective cohort study of 348 liver transplant patients and 3313 control patients. We assessed medical records for validated morphometric characteristics of aging (psoas area, psoas density, and abdominal aortic calcification). We created a model (stratified by sex) for a morphometric age equation, which we then calculated for the control population using multivariate linear regression modeling (covariates). These models were then applied to the study population to determine each patients morphometric age. DATA EXTRACTION AND SYNTHESIS All analytic steps related to measuring morphometric characteristics were obtained via custom algorithms programmed into commercially available software. An independent observer confirmed all algorithm outputs. Trained assistants performed medical record review to obtain patient characteristics. RESULTS Cox proportional hazards regression model showed that morphometric age was a significant independent predictor of overall mortality (hazard ratio, 1.03 per morphometric year [95% CI, 1.02-1.04; P < .001]) after liver transplant. Chronologic age was not a significant covariate for survival (hazard ratio, 1.02 per year [95% CI, 0.99-1.04; P = .21]). Morphometric age stratified patients at high and low risk for mortality. For example, patients in the middle chronologic age tertile who jumped to the oldest morphometric tertile have worse outcomes than those who jumped to the youngest morphometric tertile (74.4% vs 93.2% survival at 1 year [P = .03]; 45.2% vs 75.0% at 5 years [P = .03]). CONCLUSIONS AND RELEVANCE Morphometric age correlated with mortality after liver transplant with better discrimination than chronologic age. Assigning a morphometric age to potential liver transplant recipients could improve prediction of postoperative mortality risk.

Aneurysms in abdominal organ transplant recipients

OBJECTIVE Recently, failure to rescue (FTR; death following major complication) has been shown to be a primary driver of mortality in highly morbid operations. Establishing this relationship for open and endovascular repair of abdominal aortic aneurysms may be a critical first step in improving mortality following these procedures. We sought to examine the relative contribution of severe complications and FTR to variations in mortality rate. METHODS We examined endovascular aortic repair (EVAR) and open aortic repair (OAR; n = 3215) performed in 40 hospitals participating in the Michigan Surgical Quality Collaborative from 2007 to 2012. Hospitals were first divided into risk-adjusted mortality tertiles. We then determined rates of severe complications and FTR within each tertile. RESULTS For EVAR, risk-adjusted hospital mortality rates varied significantly between the lowest and highest tertiles (0.07% vs 6.14%; P < .01). However, while major complication rates were almost identical (9.0 vs 9.8; P = NS), FTR rates were about 35 times greater in high-mortality hospitals (4.0% vs 33.3%). Similar associations with mortality, severe complications, and FTR were seen for OAR as well. The most common complications that led to FTR events were postoperative transfusion (OAR 29.8% vs EVAR 5.8%) and prolonged ventilation (OAR 18.2% vs EVAR 1.0%). The average number of severe complications per FTR event was 2.85 and 2.66 for OAR and EVAR, respectively. CONCLUSIONS FTR appears to drive a large proportion of the variation in mortality associated with abdominal aortic aneurysm repair. The exact mechanisms underlying this variation remain unknown. Nonetheless, FTR is influenced by the structural characteristics and safety culture related to the timely recognition and management of severe complications. Hospitals that are unable to effectively handle severe complications following EVAR or OAR require close scrutiny.

Anticipating the Effects of Medicaid Expansion on Surgical Care

Introduction:Within a large, statewide collaborative, significant improvement in surgical quality has been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative, variations in outcomes among hospitals, and variations in adherence to evidence-based process measures. Overall, these data will form a basis for a broad-based quality improvement initiative within Michigan. Methods:We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (N = 190,826) within 34 hospitals participating in the Michigan Surgical Quality Collaborative from 2005 to 2010. Adjusted hospital-specific outcomes were calculated using a stepwise multivariable logistic regression model. Adjustment covariates included patient specific comorbidities and case complexity. Hospitals were also compared on the basis of their adherence to evidence-based process measures [measures at the patient level for each case—Surgical Care Improvement Project (SCIP)-1 and SCIP-2 compliance]. Results:Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was

Sarcopenia and failure to rescue following liver transplantation.

126 million for emergency cases and