To skeletonize the internal thoracic artery or not? Is that the question?
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Blood Flow Velocity↗
Biomedical subjects
Shukri F Khuri
Publications and source records attributed to Shukri F Khuri.
Risk factors for adverse outcomes after transurethral resection of bladder tumors.
BACKGROUND: Risk factors for adverse outcomes after transurethral resection of bladder tumors (TURBT) have not been identified to date. Such information would facilitate preoperative risk stratification and case-mix-adjusted outcome comparison, and lead to the development of processes of care directed at improving outcomes and ultimately the quality of care for bladder carcinoma patients. METHODS: The National Surgical Quality Improvement Program (NSQIP) is a prospective quality management initiative of 123 Veterans Affairs Medical Centers nationwide. Since 1991, a total of 21,515 TURBTs have been prospectively registered by the NSQIP; these cases compose the current study population. Using multivariable logistic regression, the authors determined the independent association between preoperative patient risk factors and perioperative elements of structure/process and morbidity, mortality, and prolonged length of stay (LOS) outcomes. RESULTS: The postoperative complication, 30-day, and 90-day mortality rates were 4.3%, 1.3%, and 3.3%, respectively. The median, 75th percentile, and 90th percentile for LOS among patients undergoing TURBT was 2 days, 3 days, and 8 days, respectively. Robust preoperative patient risk factors that were found to be uniformly associated with all adverse outcomes included the presence of disseminated disease (odds ratio [OR], 1.9-5.2) weight loss (OR, 1.8-3.8), low serum albumin (OR, 2.3-7.1), elevated serum creatinine (OR, 1.3-2.9), a dependent functional status (OR, 1.5-2.7), and emergent case status (OR, 1.8-3.1). Compared with models using preoperative patient factors alone, models including perioperative structure and process measures explained further variation in surgical outcomes (each likelihood ratio test, P < .0001). CONCLUSIONS: The findings of the current study highlight the fact that there are a wide array of patient risk factors that are associated with adverse outcomes after TURBT. Validation of those processes implemented to modify such elements can provide a basis for quality metrics in the context of TURBT.
Aged↗
Intracoronary shunt-induced endothelial cell damage in porcine heart.
BACKGROUND: Injury to and dysfunction of the endothelium can compromise the patency of coronary arteries and lead to impaired perfusion of the heart. Such injury can occur after the application of an intravascular shunt and/or a snare to a coronary artery during bypass surgery. In this study, multiphoton microscopy was used to assess the integrity of endothelium in porcine coronary arteries subjected to shunting and snaring during off-pump coronary artery bypass grafting (OPCAB). MATERIALS AND METHODS: In open chest porcine, the left anterior descending artery was manipulated in different regions using snare and shunt to simulate OPCAB. Sections of left anterior descending artery were labeled with fluorescent dyes to evaluate the viability of the endothelium. The structural integrity of the endothelium was evaluated by calcein- and ethidium homodimer-mediated fluorescence. Endothelial functional viability was assessed by measuring cellular esterase activity, calcium mobilization, and endothelial nitric oxide synthase-mediated generation of nitric oxide using fluorescence dyes and multiphoton microscopy. RESULTS: Substantial endothelial damage was observed in shunted region of the coronary arteries. In contrast, endothelium remained structurally viable in regions that were snared, similar to control regions of the coronary arteries that were not manipulated. Esterase activity, calcium mobilization, and nitric oxide generation was greater in the control and snared regions of the coronary arteries in comparison to the shunted region. CONCLUSIONS: The use of intracoronary shunts led to structural damage and attenuation of endothelial function in porcine coronary arteries, whereas snared vessels maintained their viability and integrity, similar to the control sections. The routine use of shunts in OPCABG may lead to endothelial damage and possibly to long-term graft failure.
Anastomosis, Surgical↗
Risk factors for serious complication after uvulopalatopharyngoplasty.
OBJECTIVE: To test the hypothesis that comorbidity, performance of concurrent sleep apnea procedures in addition to uvulopalatopharyngoplasty, body mass index, apnea-hypopnea index, and lowest oxygen saturation are risk factors for serious perioperative complications after uvulopalatopharyngoplasty. DESIGN: Prospective cohort and nested case-control studies. SETTING: United States Veterans Affairs medical centers. PATIENTS: A prospective cohort of 3130 consecutive adult inpatients who underwent uvulopalatopharyngoplasty from 1991 to 2001 was retrospectively analyzed from the Veterans Affairs National Surgical Quality Improvement Program database to determine the relationship between perioperative complications and both concurrent procedures and medical comorbidity. A nested case-control analysis was conducted on 43 cases with complications and 212 controls without complications from the cohort. Controls were matched on age, sex, year of operation, and concurrent surgery; this case-control analysis enabled the study of body mass index, apnea-hypopnea index, and lowest oxygen saturation, which were not available in the cohort database. Multivariate logistic regression measured associations between risk factors and complications, adjusting or controlling for age, sex, race, smoking status, year of uvulopalatopharyngoplasty, and presence of any concurrent procedure. MAIN OUTCOME MEASURE: Sixteen specific serious perioperative complications, including 30-day mortality. RESULTS: The cohort included 3130 veterans (97% were men aged 50+/-11 [mean+/-SD] years). In the cohort study, comorbidity was associated with serious complication: the adjusted risk ratio was 1.96 (95% confidence interval, 1.16-3.18) for each increase in American Society of Anesthesiologists class. Concurrent nonnasal procedures increased the risk of complication compared with no concurrent procedures (adjusted risk ratio, 4.94; 95% confidence interval, 2.34-10.4). In the case-control analyses, the apnea-hypopnea index, body mass index, and medical comorbidity were each associated with serious complication after adjustment for confounding variables, but this study had insufficient power to determine if these risk factors were independent of each other. Concurrent retrolingual procedures demonstrated an independent association with complication after adjustment for confounders. The lowest oxygen saturation was not associated with serious complication. CONCLUSIONS: Apnea-hypopnea index, body mass index, and medical comorbidity were each associated with serious complication; however, the low complication rate precluded demonstration of associations independent of each other. Concurrent retrolingual procedures were also associated with serious complication, but the cumulative risk of separate retrolingual procedures is unknown.
Adult↗
Propensity score analysis in observational studies: outcomes after abdominal aortic aneurysm repair.
OBJECTIVE: Large databases composed of well-designed prospectively collected cohort data provide an opportunity to examine and compare healthcare treatments in actual clinical practice settings. Because the analysis of these data often leads to a retrospective cohort design, it is essential to adequately adjust for lack of balance in patient characteristics when making treatment comparisons. We used matched propensity scoring in a cohort of patients undergoing elective aneurysm repair as an illustrative example of this important statistical method that adjusts for baseline characteristics and selection bias by matching covariables. METHODS: By using prospectively collected clinical data from the National Surgical Quality Improvement Program of the Department of Veterans Affairs, we studied 30-day mortality, 1-year survival, and postoperative complications in 1904 patients who underwent elective AAA repair (endovascular aneurysm repair [EVAR], n=717 (37.7%); open aneurysm repair, n=1187 [62.3%]) at 123 Veterans Health Administration's hospitals between May 1, 2001, and September 30, 2003. In bivariate analysis, patient characteristics and operative and hospital variables were associated with both type of surgery and outcomes of surgery. Therefore, the predicted probability of receiving EVAR was tabulated for all patients by using multiple logistic regression to control for 32 independent demographic and clinical characteristics and then stratified into 5 groups. Patients were matched within strata based on similar levels of the independent measures (a propensity score technique), creating a pseudo-randomized control design. The proportion of patients with the morbidity and mortality outcomes was then compared between the EVAR and open procedures within strata to control for selection. RESULTS: Patients undergoing EVAR had significantly lower unadjusted 30-day (3.1% versus 5.6%, P=.01) and 1-year mortality (8.7% versus 12.1%, P=.018) than patients undergoing open repair. By using propensity scoring, the proportions of EVAR patients experiencing 30-day mortality were equal or less than patients undergoing open procedures for all levels of probability and decreased as the probability of EVAR increased. Furthermore, propensity scoring also showed that patients having EVAR had lower 1-year mortality and experienced fewer perioperative complications. CONCLUSIONS: We used a propensity score approach to examine outcomes after elective AAA repair to statistically control for many factors affecting both treatment selection and outcome. Patients who underwent elective EVAR had substantially lower perioperative mortality and morbidity rates compared with patients having open repair, which was not explained solely by patient selection in an observational dataset.
Aged↗
Past accomplishments and future directions: risk prevention in anesthesia and surgery.
Anesthesiology has served as a model for patient safety in health care and was the first medical profession to treat patient safety as an independent problem. Anesthesiology has implemented widely accepted guidelines on basic monitoring, conducted long-term analyses of closed malpractice claims, developed patient simulators as meaningful training tools, and addressed problems of human error. The National Surgical Quality Improvement Program is the first national, validated, and peer-controlled program that uses risk-adjusted outcomes for the comparative assessment and improvement of the quality of surgical care. The program has reduced postoperative complications in the Veterans Administration, at both national and local levels. It is becoming more evident that processes and events during surgery can be important determinants of long-term outcomes after anesthesia and surgery.
Anesthesia↗
Open versus endovascular abdominal aortic aneurysm repair in VA hospitals.
BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR), when compared with conventional open surgical repair, has been shown to reduce perioperative morbidity and mortality. We performed a retrospective cohort study with prospectively collected data from the Department of Veterans Affairs to examine outcomes after elective aneurysm repair. STUDY DESIGN: We studied 30-day mortality, 1-year survival, and postoperative complications in 1,904 patients who underwent elective abdominal aortic aneurysm repair (EVAR n=717 [37.7%]; open n=1,187 [62.3%]) at 123 Department of Veterans Affairs hospitals between May 1, 2001 and September 30, 2003. We investigated the influence of patient, operative, and hospital variables on outcomes. RESULTS: Patients undergoing EVAR had significantly lower 30-day (3.1% versus 5.6%, p=0.01) and 1- year mortality rates (8.7% versus 12.1%, p=0.018) than patients having open repair. EVAR was associated with a decrease in 30-day postoperative mortality (adjusted odds ratio[OR]=0.59; 95% CI=0.36, 0.99; p=0.04). The risk of perioperative complications was much less after EVAR (15.5% versus 27.7%; p<0.001; unadjusted OR 0.48; 95% CI=0.38, 0.61; p<0.001). Patients operated on at low volume hospitals (25% of entire cohort) were more likely to have had open repair (31.3% compared with 15.9% EVAR; p<0.001) and a nearly two-fold increase in adjusted 30-day mortality risk (OR=1.9; 95% CI=1.19, 2.98; p=0.006). CONCLUSIONS: In routine daily practice, veterans who undergo elective EVAR have substantially lower perioperative mortality and morbidity rates compared with patients having open repair. The benefits of a minimally invasive approach were readily apparent in this cohort, but we recommend using caution in choosing EVAR for all elective abdominal aortic aneurysm repairs until longer-term data on device durability are available.
Aged↗
The effects of adjusting for case mix on mortality and length of stay following radical cystectomy.
PURPOSE: Prior studies evaluating quality of care following radical cystectomy have been constrained by the use of retrospective reviews of single institutional series and limited ability to examine risk factors in a comprehensive manner. Characterization of these factors could enhance preoperative patient counseling and facilitate perioperative management, thereby improving the quality of patient care. MATERIALS AND METHODS: The National Surgical Quality Improvement Project is a prospective quality management initiative at 123 Veterans Affairs Medical Centers nationwide. The project collects preoperative clinical and intraoperative data, and outcomes on a wide variety of surgical procedures from multiple surgical disciplines. Since 1991, 2,538 radical cystectomies have been captured by the National Surgical Quality Improvement Project. Modeling using logistic regression was performed to identify preoperative risk factors associated with mortality and prolonged length of stay (greater than 90th percentile) after radical cystectomy. RESULTS: The 30 and 90-day mortality rates following cystectomy were 2.9% and 6.8%, respectively, and median hospital stay was 11 days (90th percentile 30). Robust preoperative factors associated with mortality and prolonged length of stay that uniformly increased risk were older patient age (OR 1.2 to 1.4), American Society of Anesthesiologists class 3 or greater (OR 1.5 to 3.3), dependent functional status (OR 1.7 to 2.0) and low serum albumin (OR 2.1 to 12.0). CONCLUSIONS: A defined set of preoperative risk factors is independently associated with greater mortality and hospital stay following radical cystectomy. The breadth of these factors suggests that complex case mix adjustment is mandatory when comparing outcomes. Implementation of novel processes directed toward minimizing patient risk has the potential to improve outcomes following cystectomy.
Age Factors↗
Risk factors for adverse outcomes following surgery for small bowel obstruction.
OBJECTIVE: To construct risk indices predicting adverse outcomes following surgery for small bowel obstruction (SBO). METHODS: The VA National Surgical Quality Improvement Program contains prospectively collected data on more than 1 million patients. Patients undergoing adhesiolysis only or small bowel resection for SBO from 1991 to 2002 were selected. Independent variables included 68 presurgical and 12 intraoperative risk factors; dependent variables were 21 adverse outcomes including death. Stepwise logistic regression was used to construct models predicting 30-day morbidity and mortality and to derive risk index values. Patients were then divided into risk classes. RESULTS: Of the 2002 patients, 1650 underwent adhesiolysis only and 352 underwent small bowel resection. Thirty-seven percent undergoing adhesiolysis only and 47% undergoing small bowel resection had more than 1 complication (P < 0.001). The overall 30-day mortality was 7.7% and did not differ significantly between the groups. Odds of death were highest for dirty or infected wounds, ASA class 4 or 5, age >80 years, and dyspnea at rest. Morbidity ranged from 22%, among patients with 0 to 7 risk points, to 62% for those with >19 risk points. Mortality ranged from 2% among patients with 0 to 12 risk points to 28% for those with >31 risk points. CONCLUSIONS: Morbidity and mortality after surgery for SBO in VA hospitals are comparable with those in other large series. The morbidity rate, but not the mortality rate, is significantly higher in patients requiring small bowel resection compared with those requiring adhesiolysis only (P < 0.001). The risk indices presented provide an easy-to-use tool for clinicians to predict outcomes for patients undergoing surgery for SBO.
Comorbidity↗
National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels.
OBJECTIVE: The purpose of this study was to determine the relationship between the American Society of Anesthesiologists' Physical Status (ASA PS) classifications and the other National Surgical Quality Improvement Program (NSQIP) preoperative risk factors. BACKGROUND: The ASA PS has been shown to predict morbidity and mortality in surgical patients but is inconsistently applied and clinically imprecise. It is desirable to have a method for validating ASA PS classification levels. METHODS: The NSQIP preoperative risk factors, including ASA PS, were recorded from a random sample of 5878 surgical patients on 6 services between October 1, 2001 and September 30, 2003 at the University of Kentucky Medical Center. Mortality, morbidity, costs, and length of stay were obtained and compared across ASA PS levels. The ability of 1) ASA PS alone, 2) the other NSQIP risk factors, and, 3) all factors combined to predict outcomes was analyzed. A model using the other NSQIP risk factors was developed to predict ASA PS. RESULTS: ASA PS alone was a strong predictor of outcomes (P < 0.01). However, the other NSQIP risk factors were better predictors as a group. There was significant interdependence between the ASA PS and the other NSQIP risk factors. Predictions of ASA PS using the other factors showed strong agreement with the anesthesiologists' assignments. CONCLUSIONS: The NSQIP risk factors other than ASA PS can and should be used to validate ASA PS classifications.
Anesthesiology↗
Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program.
OBJECTIVE: To compare laparoscopic versus open gastric bypass procedures with respect to 30-day morbidity and mortality rates, using multi-institutional, prospective, risk-adjusted data. SUMMARY BACKGROUND DATA: Laparoscopic Roux-en-Y gastric bypass for weight loss is being performed with increasing frequency, partly driven by consumer demand. However, there are no multi-institutional, risk-adjusted, prospective studies comparing laparoscopic and open gastric bypass outcomes. METHODS: A multi-institutional, prospective, risk-adjusted cohort study of patients undergoing laparoscopic and open gastric bypass procedures was performed from hospitals (n = 15) involved in the Private Sector Study of the National Surgical Quality Improvement Program (NSQIP). Data points have been extensively validated, are based on standardized definitions, and were collected by nurse reviewers who are audited for accuracy. RESULTS: From 2000 to 2003, data from 1356 gastric bypass procedures was collected. The 30-day mortality rate was zero in the laparoscopic group (n = 401), and 0.6% in the open group (n = 955) (P = not significant). The 30-day complication rate was significantly lower in the laparoscopic group as compared with the open group: 7% versus 14.5% (P < 0.0001). Multivariate logistic regression analysis was performed to control for potential confounding variables and showed that patients undergoing an open procedure were more likely to develop a complication, as compared with patients undergoing an laparoscopic procedure (odds ratio = 2.08; 95% confidence interval, 1.33-3.25). Propensity score modeling revealed similar results. A prediction model was derived, and variables that significantly predict higher complication rates after gastric bypass included an open procedure, a high ASA class (III, IV, V), functionally dependent patient, and hypertension as a comorbid illness. CONCLUSIONS: Multicenter, prospective, risk-adjusted data show that laparoscopic gastric bypass is safer than open gastric bypass, with respect to 30-day complication rate.
Adult↗
Limitations of the hematocrit level to assess the need for red blood cell transfusion in hypovolemic anemic patients.
BACKGROUND: The transfusion trigger that physicians use to determine whether a patient requires a red blood cell (RBC) transfusion is the peripheral venous hematocrit (Hct) value. Although this measurement is an indicator of the concentration of RBCs in the blood, it does not reveal the RBC volume, plasma volume, or total blood volume, nor does it give any indication of whether the patient is hypovolemic, normovolemic, or hypervolemic. STUDY DESIGN AND METHODS: Two patient populations were studied: 41 consecutive patients subjected to elective vascular surgery and 20 consecutive patients subjected to cardiopulmonary bypass surgery. The RBC volume was measured with (51)Cr- or (99m)Tc-labeled autologous fresh RBCs, and the plasma volume and total blood volume were estimated from the measured RBC volume and the total body Hct level. Measurements made 1 to 2 and 24 hours after surgery were compared to the preoperative values for these two groups of patients. RESULTS: During the 24-hour postoperative period, the RBC, plasma, and total blood volumes were reduced compared to the preoperative volumes. These patients were hypovolemic and anemic, and their Hct values during the 24-hour postoperative period were increased by a mean of 4 to 5 volume-percent compared to values that would be expected if they were normvolemic and anemic. CONCLUSIONS: The Hct values in hypovolemic anemic patients are elevated because the plasma volume does not increase to achieve the normovolemic anemic state.
Aged↗
Safety, quality, and the National Surgical Quality Improvement Program.
The Institute of Medicine 1999 publication, To Err is Human, focused attention on preventable provider errors in surgery, and prompted numerous new national initiatives to improve patient safety. It is uncertain whether these initiatives have actually improved patient safety, mainly because of the lack of a quantitative metric for the assessment of patient safety in surgery. A 15-year experience with the National Surgical Quality Improvement Program, which originated in the Veteran's Administration in 1991 and was recently made available to the private sector, prompts the surgical community to place patient safety in surgery within a much larger conceptual framework than that of the Institute of Medicine report, and provides a quantitative metric for the assessment of patient safety initiatives. This conceptual framework defines patient safety in surgery as safety from all adverse outcomes (not only preventable errors and sentinel events); regards safety as an integral part of quality of surgical care; recognizes that adverse outcomes, and hence patient safety, are primarily determined by quality of systems of care; and uses comparative risk-adjusted outcome data as a metric for the identification of system problems and for the assessment and improvement of patient safety from adverse outcomes.
General Surgery↗
Comparative analysis of vagotomy and drainage versus vagotomy and resection procedures for bleeding peptic ulcer disease: results of 907 patients from the Department of Veterans Affairs National Surgical Quality Improvement Program database.
BACKGROUND: The purpose of this study was to determine postoperative outcomes and risk factors for morbidity and mortality in patients requiring surgery for bleeding peptic ulcer disease (PUD). Vagotomy and drainage procedures are technically simpler but are usually associated with higher ulcer recurrence rates. In contrast, vagotomy and resection approaches offer lower ulcer recurrences but represent much more challenging operations and are associated with considerable morbidity and mortality. STUDY DESIGN: Data collected through the Department of Veterans Affairs National Surgical Quality Improvement Program database from 1991 to 2001 were submitted for stepwise logistic regression analysis for prediction of 30-day postoperative morbidity and mortality, rebleeding, and postoperative length of stay. The study population included all patients operated on for bleeding PUD within an 11-year period. RESULTS: The 30-day morbidity, mortality, and rebleeding rates were comparable between surgical groups. Age, American Society of Anesthesiologists class, presence of ascites, coma, diabetes, functional status, hemiplegia, and history of steroid use were predictors of postoperative death. Risk factors for rebleeding included dependent functional status, history of congestive heart failure, smoking, steroid use, and preoperative transfusions. Having a resective procedure, American Society of Anesthesiologists class, hemiplegia, history of COPD, and requiring ventilator-assisted respirations before surgery were positively associated with increased length of hospital stay. CONCLUSIONS: No differences were observed in 30-day mortality, morbidity, or rebleeding rates between surgical groups. Having a resective procedure was a predictor of prolonged postoperative stay. Dependent status and chronic use of steroids were predictors of both rebleeding and postoperative mortality.
Academic Medical Centers↗
Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty.
OBJECTIVE: The utilization of joint arthroplasty for knee or hip osteoarthritis varies markedly by patient race/ethnicity. Because of concerns about surgical risk, black patients are less willing to consider this treatment. There are few published race/ethnicity-specific data on joint arthroplasty outcomes. The present study was undertaken to examine racial/ethnic differences in mortality and morbidity following elective knee or hip arthroplasty. METHODS: Using information from the Veterans Administration National Surgical Quality Improvement Program database, data on 12,108 patients who underwent knee arthroplasty and 6,703 patients who underwent hip arthroplasty over a 5-year period were analyzed. Racial/ethnic differences were determined using prospectively collected data on patient characteristics, procedures, and short-term outcomes. The main outcome measures were risk-adjusted 30-day mortality and complication rates. RESULTS: Adjusted rates of both non-infection-related and infection-related complications after knee arthroplasty were higher among black patients compared with white patients (relative risk [RR] 1.50, 95% confidence interval [95% CI] 1.08-2.10 and RR 1.42, 95% CI 1.06-1.90, respectively). Hispanic patients had a significantly higher risk of infection-related complications after knee arthroplasty (RR 1.64, 95% CI 1.08-2.49) relative to otherwise similar white patients. Race/ethnicity was not significantly associated with the risk of non-infection-related complications (RR 0.97, 95% CI 0.68-1.38 in blacks; RR 1.18, 95% CI 0.60-2.30 in Hispanics) or infection-related complications (RR 1.27, 95% CI 0.91-1.78 in blacks; RR 1.22, 95% CI 0.63-2.36 in Hispanics) after hip arthroplasty. The overall 30-day mortality was 0.6% following knee arthroplasty and 0.7% following hip arthroplasty, with no significant differences by race/ethnicity observed for either procedure. CONCLUSION: Although absolute risks of complication are low, our findings indicate that, after adjustment, black patients have significantly higher rates of infection-related and non-infection-related complications following knee arthroplasty, compared with white patients. In addition, adjusted rates of infection-related complications after knee arthroplasty are higher in Hispanic patients than in white patients. Such differences between ethnic groups are not seen following hip arthroplasty. These groups do not appear to differ significantly in terms of post-arthroplasty mortality rates.
Aged↗
The case against volume as a measure of quality of surgical care.
Healthcare purchasers, represented by the Leapfrog Group, have attempted to set standards for "quality" of surgical care that include a minimum volume for each of five major surgical procedures, with the assumption that higher volumes in surgery bring better outcomes. The VA National Surgical Quality Improvement Program (NSQIP) is a validated, outcome-based program that prospectively collects clinical data on all major surgical operations in the VA, and builds validated risk-adjustment models that generate, for each hospital and each surgical specialty within a hospital, risk-adjusted outcomes expressed as O/E (observed to expected) ratios for 30-day mortality and morbidity. The O/E ratio has been validated as a reliable comparative measure of the quality of surgical care. Unlike retrospective studies that are based on administrative databases, NSQIP studies have failed to demonstrate a direct relationship between volume and risk-adjusted outcomes of surgery across various specialties. These studies have emphasized that the quality of systems of care was more important than volume in determining the overall quality of surgical care at an institution. High-volume hospitals could still deliver poor care in as much as low-volume hospitals could deliver good care. NSQIP studies have also underscored the major limitations of claims data and administrative databases in the provision of adequate risk-adjustment models that are crucial for volume-outcome studies. Therefore, volume should not be substituted for prospectively monitored and properly risk-adjusted outcomes as a comparative measure of the quality of surgical care.
General Surgery↗
Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals.
BACKGROUND: There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system. METHODS: Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood. RESULTS: A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant. CONCLUSIONS: Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.
Female↗
Adverse 30-day outcomes after cardiac surgery: predictive role of intraoperative myocardial acidosis.
BACKGROUND: Regional myocardial acidosis in patients undergoing cardiac surgery has been shown to be reflective of regional myocardial ischemia. This study elucidates the relationship between intraoperative regional myocardial acidosis and 30-day postoperative outcomes after cardiac surgery. METHODS: Intramyocardial tissue pH in the anterior and posterior left ventricular walls was measured in 397 adult patients undergoing valve replacement or coronary revascularization surgery between 1987 and 2001. Dedicated nurses and research assistants prospectively collected preoperative, intraoperative, and outcomes data. Regional myocardial acidosis was defined in terms of pH thresholds identified by recursive partitioning. Adverse 30-day outcome, defined as death or any one of six complications, was the dependent variable in a multivariate logistic regression analysis. A morbidity score was developed on the basis of the sensitivity of each of the six complications in predicting death, and was the dependent variable in a multivariate linear regression analysis. RESULTS: During the period of aortic clamping, a mean intramyocardial tissue pH less than 6.85 was identified to be significant by recursive partitioning, and was encountered in either the anterior or posterior left ventricular wall in 85.4% of patients. After adjusting for preoperative and intraoperative variables, this pH threshold was found to be significantly associated with increased adverse outcomes within 30 days after surgery (p = 0.045). It was also significantly associated with increase in the morbidity score (p = 0.05). CONCLUSIONS: Regional myocardial acidosis of a magnitude frequently encountered during aortic clamping is an independent determinant of adverse 30-day outcomes after cardiac surgery. Its reversal by pH-guided myocardial management has the potential of improving postoperative patient outcomes.
Acidosis↗