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Analysis of risk factors associated with unplanned re-operations following paediatric plastic surgery
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MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2017) xx, 1e2
Invited Commentary
Analysis of risk factors associated with unplanned re-operations following paediatric plastic surgery Catherine de Blacam Royal College of Surgeons in Ireland, Ireland Received 2 July 2017; accepted 24 July 2017
Jubbal et al. have used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database to identify parameters associated with an increased likelihood of unplanned reoperation following plastic surgery in children under 18 years of age.1 To interpret this study, it is important to understand a little of the background to the database from which it was drawn. The ACS-NSQIP comprises a prospectively maintained database, established in 1994 for the purpose of improving outcomes in the then much-criticised Veterans Affairs health system. On a paid subscription basis, the ACS-NSQIP facilitates the collection of reliable clinical data and comparison of an individual institution’s 30-day surgical outcomes with those of other participants in the programme. Implementation of the ACS-NSQIP has been associated with a significant reduction in morbidity and mortality across the contributing institutions. In the current US healthcare climate, where many payors refuse to cover the treatment of complications, over 600 hospitals across the United States voluntarily subscribe to the database in an effort to reduce their adverse outcomes. Participation fulfils the American Board of Surgery Maintenance of Certification requirement for all surgeons working in the participating institutions.
DOI of original article: http://dx.doi.org/10.1016/j.bjps.2017. 05.008. E-mail address: [email protected].
The ACS-NSQIP Pediatric (NSQIP-P) is designed in the same way and began accruing data in 2008. The data points collected have been modified from the adult program and do not pertain to individual paediatric surgical procedures or diagnoses. For example, for a child with syndromic craniosynostosis, only the overarching terms “neurological condition” or “congenital malformation” can be recorded. Thus, whether or not a child has a syndrome is not included in multivariate analyses of the data e a point that should be borne in mind when considering the results of the current study. As with the adult program, patient outcomes are assessed for 30 days following paediatric surgical procedures. Jubbal et al.’s paper reports a reduced reoperation rate in comparison to previously published work, likely as a result of the premature cutoff point. Recent studies from the same group querying the database on craniosynostosis and cleft have highlighted similar shortcomings.2,3 The limitation imposed by this time cutoff has been extensively cited in plastic surgery NSQIP publications. For example, in the first study that queried the NSQIP database from a plastic surgery perspective, Ogunleye et al. demonstrated that amongst breast reconstruction cases, complication rates were considerably higher in autologous than in implant-based procedures, a finding that differs from the published literature and is likely attributable to the 30 day cutoff period.4 A further limitation is that the NSQIP does not capture procedure-specific complications such as fistula formation following cleft palate repair, development of obstructive
http://dx.doi.org/10.1016/j.bjps.2017.07.010 1748-6815/ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: de Blacam C, Analysis of risk factors associated with unplanned re-operations following paediatric plastic surgery, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/10.1016/j.bjps.2017.07.010
+
MODEL
2 sleep apnoea after surgery for velopharyngeal dysfunction or specific intracerebral pathologies post craniosynostosis surgery. As a result of these limitations, complications which contribute significantly to patient morbidity in paediatric plastic surgery are not being recorded by the NSQIP. The database in its current format cannot therefore be used to make accurate inferences about overall complication rates in paediatric plastic surgery. Based on the collected data, both the adult and paediatric ACS-NSQIP databases have facilitated the development of postoperative complication risk calculators. However, their validity in relation to plastic surgery procedures has not been proven. Recently, Johnson et al. retrospectively entered the preoperative risk factors of just under 5000 adult plastic surgery patients into the ACSNSQIP Surgical Risk Calculator, and compared predicted outcomes with actual morbidities. The calculator accurately predicted an above average risk for only 21% of patients who experienced serious complications.5 The group concluded that the ACS-NSQIP Surgical Risk Calculator is not a valid tool for the field of plastic surgery without further research to develop accurate risk stratification tools. Deidentified data files are available to participating centres for the purpose of research, with the current (2015) adult ACS-NSQIP file comprising 885,502 cases submitted from 603 participating sites. A brief search of PubMed would suggest that since the programme’s inception, over 2000 papers have been published on the basis of these data files. The flood of studies arising from the paediatric database has only just begun. With this volume of data available, one must be cautious of papers written for publication’s sake. While the numbers in the current study are large, the procedures that have emerged as being “high risk” for unscheduled return to theatre are somewhat obscure and as such, the applicability of the results to either general paediatric plastic surgery or subspeciality practice is limited. Perhaps the rush to produce papers
C. de Blacam should be tempered by refinement of the data points collected by the NSQIP-P? In contrast to the adult database, literature linking the NSQIP-P and improvement in quality is lacking to date. Furthermore, validity of the risk calculator associated with the paediatric database remains to be elucidated. Researchers should find ample publication opportunity by investigating these areas further. In the meantime, readers are encouraged to consider the significant limitations outlined here before applying results of the current wave of NSQIP studies in their clinical practice.
Conflict of interest None to declare.
References 1. Jubbal KT, Zavlin D, Buchanan EP, Hollier Jr LH. Analysis of risk factors associated with unplanned reoperations following pediatric plastic surgery. J Plast Reconstr Aesthet Surg 2017 May 18. Epub ahead of print. 2. Jubbal KT, Agrawal N, Hollier Jr LH. Analysis of morbidity, readmission, and reoperation after craniosynostosis repair in children. J Craniofac Surg 2017;28:401e5. 3. Paine KM, Paliga JT, Tahiri Y, et al. An assessment of 30-day complications in primary cleft palate repair: a review of the 2012 ACS NSQIP pediatric. Cleft Palate Craniofac J 2016;53: 357e62. 4. Ogunleye AA, de Blacam C, Curtis MS, et al. An analysis of delayed breast reconstruction outcomes as recorded in the American College of Surgeons National Surgical Quality Improvement Program. J Plast Reconstr Aesthet Surg 2012;65: 289e94. 5. Johnson C, Campwala I, Gupta S. Examining the validity of the ACS-NSQIP Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Investig Med 2017;65:722e5.
Please cite this article in press as: de Blacam C, Analysis of risk factors associated with unplanned re-operations following paediatric plastic surgery, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/10.1016/j.bjps.2017.07.010
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2017) xx, 1e2
Invited Commentary
Analysis of risk factors associated with unplanned re-operations following paediatric plastic surgery Catherine de Blacam Royal College of Surgeons in Ireland, Ireland Received 2 July 2017; accepted 24 July 2017
Jubbal et al. have used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database to identify parameters associated with an increased likelihood of unplanned reoperation following plastic surgery in children under 18 years of age.1 To interpret this study, it is important to understand a little of the background to the database from which it was drawn. The ACS-NSQIP comprises a prospectively maintained database, established in 1994 for the purpose of improving outcomes in the then much-criticised Veterans Affairs health system. On a paid subscription basis, the ACS-NSQIP facilitates the collection of reliable clinical data and comparison of an individual institution’s 30-day surgical outcomes with those of other participants in the programme. Implementation of the ACS-NSQIP has been associated with a significant reduction in morbidity and mortality across the contributing institutions. In the current US healthcare climate, where many payors refuse to cover the treatment of complications, over 600 hospitals across the United States voluntarily subscribe to the database in an effort to reduce their adverse outcomes. Participation fulfils the American Board of Surgery Maintenance of Certification requirement for all surgeons working in the participating institutions.
DOI of original article: http://dx.doi.org/10.1016/j.bjps.2017. 05.008. E-mail address: [email protected].
The ACS-NSQIP Pediatric (NSQIP-P) is designed in the same way and began accruing data in 2008. The data points collected have been modified from the adult program and do not pertain to individual paediatric surgical procedures or diagnoses. For example, for a child with syndromic craniosynostosis, only the overarching terms “neurological condition” or “congenital malformation” can be recorded. Thus, whether or not a child has a syndrome is not included in multivariate analyses of the data e a point that should be borne in mind when considering the results of the current study. As with the adult program, patient outcomes are assessed for 30 days following paediatric surgical procedures. Jubbal et al.’s paper reports a reduced reoperation rate in comparison to previously published work, likely as a result of the premature cutoff point. Recent studies from the same group querying the database on craniosynostosis and cleft have highlighted similar shortcomings.2,3 The limitation imposed by this time cutoff has been extensively cited in plastic surgery NSQIP publications. For example, in the first study that queried the NSQIP database from a plastic surgery perspective, Ogunleye et al. demonstrated that amongst breast reconstruction cases, complication rates were considerably higher in autologous than in implant-based procedures, a finding that differs from the published literature and is likely attributable to the 30 day cutoff period.4 A further limitation is that the NSQIP does not capture procedure-specific complications such as fistula formation following cleft palate repair, development of obstructive
http://dx.doi.org/10.1016/j.bjps.2017.07.010 1748-6815/ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: de Blacam C, Analysis of risk factors associated with unplanned re-operations following paediatric plastic surgery, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/10.1016/j.bjps.2017.07.010
+
MODEL
2 sleep apnoea after surgery for velopharyngeal dysfunction or specific intracerebral pathologies post craniosynostosis surgery. As a result of these limitations, complications which contribute significantly to patient morbidity in paediatric plastic surgery are not being recorded by the NSQIP. The database in its current format cannot therefore be used to make accurate inferences about overall complication rates in paediatric plastic surgery. Based on the collected data, both the adult and paediatric ACS-NSQIP databases have facilitated the development of postoperative complication risk calculators. However, their validity in relation to plastic surgery procedures has not been proven. Recently, Johnson et al. retrospectively entered the preoperative risk factors of just under 5000 adult plastic surgery patients into the ACSNSQIP Surgical Risk Calculator, and compared predicted outcomes with actual morbidities. The calculator accurately predicted an above average risk for only 21% of patients who experienced serious complications.5 The group concluded that the ACS-NSQIP Surgical Risk Calculator is not a valid tool for the field of plastic surgery without further research to develop accurate risk stratification tools. Deidentified data files are available to participating centres for the purpose of research, with the current (2015) adult ACS-NSQIP file comprising 885,502 cases submitted from 603 participating sites. A brief search of PubMed would suggest that since the programme’s inception, over 2000 papers have been published on the basis of these data files. The flood of studies arising from the paediatric database has only just begun. With this volume of data available, one must be cautious of papers written for publication’s sake. While the numbers in the current study are large, the procedures that have emerged as being “high risk” for unscheduled return to theatre are somewhat obscure and as such, the applicability of the results to either general paediatric plastic surgery or subspeciality practice is limited. Perhaps the rush to produce papers
C. de Blacam should be tempered by refinement of the data points collected by the NSQIP-P? In contrast to the adult database, literature linking the NSQIP-P and improvement in quality is lacking to date. Furthermore, validity of the risk calculator associated with the paediatric database remains to be elucidated. Researchers should find ample publication opportunity by investigating these areas further. In the meantime, readers are encouraged to consider the significant limitations outlined here before applying results of the current wave of NSQIP studies in their clinical practice.
Conflict of interest None to declare.
References 1. Jubbal KT, Zavlin D, Buchanan EP, Hollier Jr LH. Analysis of risk factors associated with unplanned reoperations following pediatric plastic surgery. J Plast Reconstr Aesthet Surg 2017 May 18. Epub ahead of print. 2. Jubbal KT, Agrawal N, Hollier Jr LH. Analysis of morbidity, readmission, and reoperation after craniosynostosis repair in children. J Craniofac Surg 2017;28:401e5. 3. Paine KM, Paliga JT, Tahiri Y, et al. An assessment of 30-day complications in primary cleft palate repair: a review of the 2012 ACS NSQIP pediatric. Cleft Palate Craniofac J 2016;53: 357e62. 4. Ogunleye AA, de Blacam C, Curtis MS, et al. An analysis of delayed breast reconstruction outcomes as recorded in the American College of Surgeons National Surgical Quality Improvement Program. J Plast Reconstr Aesthet Surg 2012;65: 289e94. 5. Johnson C, Campwala I, Gupta S. Examining the validity of the ACS-NSQIP Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Investig Med 2017;65:722e5.
Please cite this article in press as: de Blacam C, Analysis of risk factors associated with unplanned re-operations following paediatric plastic surgery, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/10.1016/j.bjps.2017.07.010