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Expansion of a laparoscopic colon and rectal surgery practice does not adversely affect patient and practice outcomes
Vol. 201, No. 3S, September 2005
Quality, Outcomes, and Cost II
S71
by clinical and socio-demographic considerations to optimize efficacy and equity in bariatric surgery.
operative hyperbilirubinemia, associated with increased in-hospital morbidity and mortality. Long-term consequences of this complication are unknown.
Healthcare provider estimates of height, weight, and body mass index: implications for research and patient safety
METHODS: Medical records of CABG with CPB patients were reviewed; long-term outcomes were ascertained through National Death Index. ANOVA, contingency, Kaplan-Meier, and logistic regression analyses were utilized.
Kimberly Hendershot MD, Linda Robinson RN, MA, MS, Samir Fakhry MD, FACS, Jason Roland MD, Khashayar Vaziri MD, Kevin Dwyer MD, Hani Seoudi MD Inova Regional Trauma Center, Inova Fairfax Hospital, Falls Church, VA INTRODUCTION: Research suggests that weight impacts patient care and outcomes. Health care professionals (HCP) frequently rely on patient self-reports or HCP estimates of height and weight (H/W). The purpose of this study was to determine the accuracy of self-reported H/W and HCP estimations of H/W and corresponding BMI classification. METHODS: Attendings, residents and nurses provided H/W and BMI estimates for 93 trauma patients. Self-reported and measured H/W were obtained with appropriate calibrated devices. Patient BMIs based on estimated H/W and measured H/W were calculated. Data were analyzed using descriptive statistics. RESULTS: Weight estimates by HCPs were 49% accurate (⫹ 10%) and ranged from 74 lbs under to 100 lbs over measured weight. BMI classification by HCPs was 54% accurate. Estimates were most likely to be correct when BMI was in normal range. Selfreports were 68% accurate, however 28% were unavailable due to language or injury. Patient reports had the lowest margin of error, but resulted in BMI misclassification of 32%. Table 1: Percent correctly calculated BMI’s from estimated height and weight Total n ⴝ 93
Underweight nⴝ5
Normal n ⴝ 35
Overweight n ⴝ 28
Obese n ⴝ 21
Severely Obese nⴝ3
Attendings
48
20
77
32
24
66
Residents
54
40
74
39
33
100
Nurses
60
0
83
50
29
100
Patients
68
40
73
65
68
100
CONCLUSIONS: This study demonstrates that HCPs estimates of H/W and BMI are highly inaccurate. Patient self-reports of H/W are only marginally better. Objective measurements with calibrated instruments are necessary for accuracy for research studies and patient safety in clinical practice.
Post-operative hyperbilirubinemia is an independent predictor of long term outcome after coronary artery bypass surgery Alexander Kraev BA, Thomas Fabian MD, Mikhail Torosoff MD, PhD, R Anthony Perez-Tamayo MD, PhD Albany Medical College, Rush University/Cook County Hospital, Chicago, IL INTRODUCTION: Previous, decades-old, studies of cardiopulmonary bypass (CPB) patients documented 25-35% incidence of post-
RESULTS: Of 830 patients, Group I patients bilirubin did not exceed 1.4 mg/dl, 18% had bilirubin of less than 2.8 mg/dl (Group II), 8.1% had bilirubin exceeding 2.8 mg/dl (Group III). Elevated bilirubin was associated with older age, reduced ejection fraction, history of CHF or hemodynamic instability, prolonged bypass time, need for blood products, post-operative stroke, infection, renal or respiratory failure. In-hospital mortality in Group II was 5.2% and 25.4% in Group III, compared to 0.8% in Group I (p⬍0.0001). Long-term survival was 80% in Group I, 70% in Group II, and 40% in Group III patients (p⬍0.001). Multivariate predictors of longterm mortality were age, diabetes, need for transfusion, postoperative stroke, renal failure, and elevated bilirubin: 3-fold decrease in Group II 2-year survival (95% CI 1.511-5.906; p⬍0.005) and 5.2-fold decrease in Group IIl (95% CI 2.248-12.006; p⬍0.001). CONCLUSIONS: Post-operative bilirubin elevation, observed in CABG with CPB patients, is common and deadly. The predictive power of hyperbilirubinemia is similar to such of post-operative CVA or renal failure. Etiology of post-bypass hyperbilirubinemia is unknown and is probably multi-factorial. Further prospective studies of post-operative hyperbilirubinemia are warranted.
Expansion of a laparoscopic colon and rectal surgery practice does not adversely affect patient and practice outcomes Imran Hassan MD, Heidi Nelson MD, FACS, David Larson MD, Robert Cima MD, Eric Dozois MD, Tonia Young-Fadok MD, FACS Mayo Clinic, Rochester, MN INTRODUCTION: The surgical community has expressed concerns regarding the safety and feasibility of integrating minimally invasive techniques into colorectal surgical practices. A single institution’s prospective database was analyzed to investigate whether increasing the number of surgeons performing laparoscopically-assisted colorectal procedures (LCP) would adversely affect patient and practice outcomes. METHODS: One-thousand and seven LCP were performed between 1992-2004. The number of staff colorectal surgeons performing LCP (⬎20 cases/year) increased from 1 in 1992 to 2 in 1998 to 6 in 2004 (3 senior/3 junior). The clinical characteristics of the laparoscopic practice during these 3 times-periods (1992, 1998, and 2004) were analyzed. RESULTS: Gender distribution, median age (64, 56, 53 yrs) and median BMI (24,27,26 kg/m2) of patients were comparable. Indications for LCP expanded from being limited to cancer/ polyps (48%/29%) in 1992, to include IBD (40%), cancer/polyps (17%/ 11%) and diverticular disease (18%) in 2004. Table.1 shows overall
S72
Quality, Outcomes, and Cost II
J Am Coll Surg
conversion rates and percentage of laparoscopic right colon resections (L-RC) and ileal pouch anal anastomosis (L-IPAA) performed of the total (open and laparoscopic) RC and IPAA practice in the 3 time-periods. Mortality was 0.002%. Surgical re-intervention rate for postoperative complications (grade IIIB) were similar (2%, 0.15%, 0.2%). Incidence of grade I and II postoperative complications was (0%, 8%, 11%).
Year
Number Total number of Overall Right colon’s IPAA’s surgeons (% laparoscopic conversion done lap done lap all surgeons) Cases rate, % (%) (%)
1992
1 (16)
28
28
6
0
1998
2 (28)
100
19
22
1
2004
6 (75)
270
8
34
55
CONCLUSIONS: Our experience shows that expansion of a laparoscopic colorectal practice to include 75% of the surgeons is feasible and has resulted in an increase in the number and complexity of LCP being performed without compromising patient and practice outcomes.
Should rural residents with colon cancer travel to urban hospitals for colectomy? Melissa Meyers MD, Samuel RG Finlayson MD, MPH, FACS Dartmouth Medical School, Lebanon, NH INTRODUCTION: Many rural patients travel to urban hospitals expecting better care. Whether rural patients requiring elective colectomy lower their risk of operative mortality by traveling to urban hospitals is unknown. METHODS: We used Medicare claims data to compare mortality rates with colectomy for cancer in rural vs. urban hospitals in the US from 1994 to 1999. Urban and rural designations were based on Rural-Urban Commuting Area codes. Multiple logistic regression was used to describe the relationship between mortality (combined in-hospital and 30 day) and rural/urban hospital location, controlling for patient and hospital characteristics. RESULTS: Adjusted operative mortality in small rural hospitals (6.7%, 95% CI 6.4-7.0) was slightly higher than in urban hospitals (6.4%, 95% CI 6.3-6.5), but this difference was not statistically significant. Nearly 90% of rural hospitals were in the lowest two quintiles of hospital procedure volume (⬍57 colectomies/year), compared to 28% of urban hospitals. Adjusted operative mortality in these low volume rural hospitals (6.6%, 95% CI 6.3-6.9%) was significantly lower than mortality in urban hospitals with similar procedure volume (7.2%, 95% CI 7.0-7.4%). CONCLUSIONS: Rural patients who choose to travel to an urban hospital for colectomy may not experience lower mortality risk. Our finding that low volume urban hospitals have higher mortality rates than low volume rural hospitals suggests that patients who elect to travel to the city for care must choose their providers carefully.
Complementary therapy use in female long-term colorectal cancer survivors Chris M Schu¨ssler-Fiorenza MD, Amy Trentham-Dietz PhD, Tara M Breslin MD, MS, John M Hampton MS, Patrick L Remington MD, MPH University of Wisconsin, Madison, WI INTRODUCTION: The aim of this study was to characterize the use of prayer, complementary and alternative medicine (CAM) in longterm female colorectal cancer survivors. METHODS: Data from a 9 year follow-up questionnaire completed by long term survivors of a population-based sample of female colorectal cancer cases in Wisconsin were analyzed. Analysis with chisquared statistics was conducted on the women (n⫽257) who completed the CAM portion of the questionnaire. RESULTS: We found that 74% of respondents reported using CAM and/or prayer, 68% used prayer, 41% used CAM and 46% of CAM users utilized more than one therapy. The three most common therapies were chiropractic (14.1%), spiritual healing (11.7%) and megavitamin therapy (10.6%). Younger age, higher income, working outside the home, and education were strongly associated with CAM use (p⬍0.05). Depression/anxiety was strongly associated with both mind-body (p⫽0.021) and energy/manual healing therapies. Thinking about being diagnosed with cancer again was the only factor significantly associated with increased use of prayer (p⫽0.0012) and it also influenced rates of mind- body CAM use. (p⫽0.004) Cancer characteristics were less strongly associated with CAM usage, although there was an association between site (colonrectum) and whole-body/biologically based CAM use. (p⫽0.02) CONCLUSIONS: CAM and prayer in colorectal cancer survivors is common and use is influenced by demographic factors, depression/ anxiety and fear of cancer recurrence. Inquiring about CAM use and addressing any associated psychologic factors is an important part of the care of long-term colorectal cancer survivors.
Risk indices predict adverse outcomes after surgery for small bowel obstruction (SBO) Julie A Margenthaler MD, Walter E Longo MD, Katherine S Virgo PhD, Frank E Johnson MD, Erik M Grossman MD, Tracy L Schifftner MS, William G Henderson PhD, Shukri F Khuri MD, FASC Washington University School of Medicine, St. Louis, MO INTRODUCTION: The objective was to construct risk indices predicting adverse outcomes after surgery for SBO. METHODS: The VA NSQIP contains prospectively collected data on ⬎1,000,000 patients. Patients undergoing adhesiolysis only or small bowel resection for SBO between 1991-2002 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.
Quality, Outcomes, and Cost II
S71
by clinical and socio-demographic considerations to optimize efficacy and equity in bariatric surgery.
operative hyperbilirubinemia, associated with increased in-hospital morbidity and mortality. Long-term consequences of this complication are unknown.
Healthcare provider estimates of height, weight, and body mass index: implications for research and patient safety
METHODS: Medical records of CABG with CPB patients were reviewed; long-term outcomes were ascertained through National Death Index. ANOVA, contingency, Kaplan-Meier, and logistic regression analyses were utilized.
Kimberly Hendershot MD, Linda Robinson RN, MA, MS, Samir Fakhry MD, FACS, Jason Roland MD, Khashayar Vaziri MD, Kevin Dwyer MD, Hani Seoudi MD Inova Regional Trauma Center, Inova Fairfax Hospital, Falls Church, VA INTRODUCTION: Research suggests that weight impacts patient care and outcomes. Health care professionals (HCP) frequently rely on patient self-reports or HCP estimates of height and weight (H/W). The purpose of this study was to determine the accuracy of self-reported H/W and HCP estimations of H/W and corresponding BMI classification. METHODS: Attendings, residents and nurses provided H/W and BMI estimates for 93 trauma patients. Self-reported and measured H/W were obtained with appropriate calibrated devices. Patient BMIs based on estimated H/W and measured H/W were calculated. Data were analyzed using descriptive statistics. RESULTS: Weight estimates by HCPs were 49% accurate (⫹ 10%) and ranged from 74 lbs under to 100 lbs over measured weight. BMI classification by HCPs was 54% accurate. Estimates were most likely to be correct when BMI was in normal range. Selfreports were 68% accurate, however 28% were unavailable due to language or injury. Patient reports had the lowest margin of error, but resulted in BMI misclassification of 32%. Table 1: Percent correctly calculated BMI’s from estimated height and weight Total n ⴝ 93
Underweight nⴝ5
Normal n ⴝ 35
Overweight n ⴝ 28
Obese n ⴝ 21
Severely Obese nⴝ3
Attendings
48
20
77
32
24
66
Residents
54
40
74
39
33
100
Nurses
60
0
83
50
29
100
Patients
68
40
73
65
68
100
CONCLUSIONS: This study demonstrates that HCPs estimates of H/W and BMI are highly inaccurate. Patient self-reports of H/W are only marginally better. Objective measurements with calibrated instruments are necessary for accuracy for research studies and patient safety in clinical practice.
Post-operative hyperbilirubinemia is an independent predictor of long term outcome after coronary artery bypass surgery Alexander Kraev BA, Thomas Fabian MD, Mikhail Torosoff MD, PhD, R Anthony Perez-Tamayo MD, PhD Albany Medical College, Rush University/Cook County Hospital, Chicago, IL INTRODUCTION: Previous, decades-old, studies of cardiopulmonary bypass (CPB) patients documented 25-35% incidence of post-
RESULTS: Of 830 patients, Group I patients bilirubin did not exceed 1.4 mg/dl, 18% had bilirubin of less than 2.8 mg/dl (Group II), 8.1% had bilirubin exceeding 2.8 mg/dl (Group III). Elevated bilirubin was associated with older age, reduced ejection fraction, history of CHF or hemodynamic instability, prolonged bypass time, need for blood products, post-operative stroke, infection, renal or respiratory failure. In-hospital mortality in Group II was 5.2% and 25.4% in Group III, compared to 0.8% in Group I (p⬍0.0001). Long-term survival was 80% in Group I, 70% in Group II, and 40% in Group III patients (p⬍0.001). Multivariate predictors of longterm mortality were age, diabetes, need for transfusion, postoperative stroke, renal failure, and elevated bilirubin: 3-fold decrease in Group II 2-year survival (95% CI 1.511-5.906; p⬍0.005) and 5.2-fold decrease in Group IIl (95% CI 2.248-12.006; p⬍0.001). CONCLUSIONS: Post-operative bilirubin elevation, observed in CABG with CPB patients, is common and deadly. The predictive power of hyperbilirubinemia is similar to such of post-operative CVA or renal failure. Etiology of post-bypass hyperbilirubinemia is unknown and is probably multi-factorial. Further prospective studies of post-operative hyperbilirubinemia are warranted.
Expansion of a laparoscopic colon and rectal surgery practice does not adversely affect patient and practice outcomes Imran Hassan MD, Heidi Nelson MD, FACS, David Larson MD, Robert Cima MD, Eric Dozois MD, Tonia Young-Fadok MD, FACS Mayo Clinic, Rochester, MN INTRODUCTION: The surgical community has expressed concerns regarding the safety and feasibility of integrating minimally invasive techniques into colorectal surgical practices. A single institution’s prospective database was analyzed to investigate whether increasing the number of surgeons performing laparoscopically-assisted colorectal procedures (LCP) would adversely affect patient and practice outcomes. METHODS: One-thousand and seven LCP were performed between 1992-2004. The number of staff colorectal surgeons performing LCP (⬎20 cases/year) increased from 1 in 1992 to 2 in 1998 to 6 in 2004 (3 senior/3 junior). The clinical characteristics of the laparoscopic practice during these 3 times-periods (1992, 1998, and 2004) were analyzed. RESULTS: Gender distribution, median age (64, 56, 53 yrs) and median BMI (24,27,26 kg/m2) of patients were comparable. Indications for LCP expanded from being limited to cancer/ polyps (48%/29%) in 1992, to include IBD (40%), cancer/polyps (17%/ 11%) and diverticular disease (18%) in 2004. Table.1 shows overall
S72
Quality, Outcomes, and Cost II
J Am Coll Surg
conversion rates and percentage of laparoscopic right colon resections (L-RC) and ileal pouch anal anastomosis (L-IPAA) performed of the total (open and laparoscopic) RC and IPAA practice in the 3 time-periods. Mortality was 0.002%. Surgical re-intervention rate for postoperative complications (grade IIIB) were similar (2%, 0.15%, 0.2%). Incidence of grade I and II postoperative complications was (0%, 8%, 11%).
Year
Number Total number of Overall Right colon’s IPAA’s surgeons (% laparoscopic conversion done lap done lap all surgeons) Cases rate, % (%) (%)
1992
1 (16)
28
28
6
0
1998
2 (28)
100
19
22
1
2004
6 (75)
270
8
34
55
CONCLUSIONS: Our experience shows that expansion of a laparoscopic colorectal practice to include 75% of the surgeons is feasible and has resulted in an increase in the number and complexity of LCP being performed without compromising patient and practice outcomes.
Should rural residents with colon cancer travel to urban hospitals for colectomy? Melissa Meyers MD, Samuel RG Finlayson MD, MPH, FACS Dartmouth Medical School, Lebanon, NH INTRODUCTION: Many rural patients travel to urban hospitals expecting better care. Whether rural patients requiring elective colectomy lower their risk of operative mortality by traveling to urban hospitals is unknown. METHODS: We used Medicare claims data to compare mortality rates with colectomy for cancer in rural vs. urban hospitals in the US from 1994 to 1999. Urban and rural designations were based on Rural-Urban Commuting Area codes. Multiple logistic regression was used to describe the relationship between mortality (combined in-hospital and 30 day) and rural/urban hospital location, controlling for patient and hospital characteristics. RESULTS: Adjusted operative mortality in small rural hospitals (6.7%, 95% CI 6.4-7.0) was slightly higher than in urban hospitals (6.4%, 95% CI 6.3-6.5), but this difference was not statistically significant. Nearly 90% of rural hospitals were in the lowest two quintiles of hospital procedure volume (⬍57 colectomies/year), compared to 28% of urban hospitals. Adjusted operative mortality in these low volume rural hospitals (6.6%, 95% CI 6.3-6.9%) was significantly lower than mortality in urban hospitals with similar procedure volume (7.2%, 95% CI 7.0-7.4%). CONCLUSIONS: Rural patients who choose to travel to an urban hospital for colectomy may not experience lower mortality risk. Our finding that low volume urban hospitals have higher mortality rates than low volume rural hospitals suggests that patients who elect to travel to the city for care must choose their providers carefully.
Complementary therapy use in female long-term colorectal cancer survivors Chris M Schu¨ssler-Fiorenza MD, Amy Trentham-Dietz PhD, Tara M Breslin MD, MS, John M Hampton MS, Patrick L Remington MD, MPH University of Wisconsin, Madison, WI INTRODUCTION: The aim of this study was to characterize the use of prayer, complementary and alternative medicine (CAM) in longterm female colorectal cancer survivors. METHODS: Data from a 9 year follow-up questionnaire completed by long term survivors of a population-based sample of female colorectal cancer cases in Wisconsin were analyzed. Analysis with chisquared statistics was conducted on the women (n⫽257) who completed the CAM portion of the questionnaire. RESULTS: We found that 74% of respondents reported using CAM and/or prayer, 68% used prayer, 41% used CAM and 46% of CAM users utilized more than one therapy. The three most common therapies were chiropractic (14.1%), spiritual healing (11.7%) and megavitamin therapy (10.6%). Younger age, higher income, working outside the home, and education were strongly associated with CAM use (p⬍0.05). Depression/anxiety was strongly associated with both mind-body (p⫽0.021) and energy/manual healing therapies. Thinking about being diagnosed with cancer again was the only factor significantly associated with increased use of prayer (p⫽0.0012) and it also influenced rates of mind- body CAM use. (p⫽0.004) Cancer characteristics were less strongly associated with CAM usage, although there was an association between site (colonrectum) and whole-body/biologically based CAM use. (p⫽0.02) CONCLUSIONS: CAM and prayer in colorectal cancer survivors is common and use is influenced by demographic factors, depression/ anxiety and fear of cancer recurrence. Inquiring about CAM use and addressing any associated psychologic factors is an important part of the care of long-term colorectal cancer survivors.
Risk indices predict adverse outcomes after surgery for small bowel obstruction (SBO) Julie A Margenthaler MD, Walter E Longo MD, Katherine S Virgo PhD, Frank E Johnson MD, Erik M Grossman MD, Tracy L Schifftner MS, William G Henderson PhD, Shukri F Khuri MD, FASC Washington University School of Medicine, St. Louis, MO INTRODUCTION: The objective was to construct risk indices predicting adverse outcomes after surgery for SBO. METHODS: The VA NSQIP contains prospectively collected data on ⬎1,000,000 patients. Patients undergoing adhesiolysis only or small bowel resection for SBO between 1991-2002 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.