- Email: [email protected]
Health Care Reform and Equity in Bariatric Surgery: Does Increased Access to Care Mitigate Disparities?
S126
J Am Coll Surg
Scientific Forum Abstracts
Harnessing the Electronic Medical Record to Identify Patients at Risk for In-Hospital Complications Robert H Hollis, MD, Laura Graham, MPH, John P Lazenby, MD, Daran M Brown, RN, MBA, Benjamin B Taylor, MD, Martin J Heslin, MD, MSHA, FACS, Loring W Rue III, MD, FACS, Mary T Hawn, MD, MPH, FACS University of Alabama at Birmingham, Birmingham, AL INTRODUCTION: Abnormal vitals often precede inpatient complications, providing an opportunity for early identification and intervention. We examined whether a validated early warning score (EWS) calculated from vital signs could predict complications in surgical patients. METHODS: Inpatient general surgery procedures with NSQIP data from 2013 and 2014 were matched with enterprise data on vital signs and neurologic status to calculate the EWS for each postoperative vital set measured on the ward. Outcomes of complications, ICU transfer, and medical emergency team (MET) activation were classified using the Clavien system as grade I to IV. Relationship between EWS and timing of first complication was assessed using Kruskal-Wallis test and linear regression accounting for clustering with generalized estimating equation. RESULTS: Among 552 patients admitted to the ward postoperatively, 70 (12.7%) developed at least 1 grade I to III complication and 60 (10.9%) developed a grade IV (life-threatening) complication. The mean maximum EWS was significantly higher in the 48 hours preceding grade IV complications (6.65) or grade I to III complications (4.46) compared to patients without complications (3.34; p<0.001). The EWS significantly increased in the 3 days preceding grade IV complications (p<0.001) and declined in patients without complications in the 3 days prior to discharge (p<0.001) (Table). A threshold EWS of 6 predicted occurrences of grade IV complications with a 62% sensitivity, 94% specificity, and 55% positive predictive value. Table. Maximum EWS by Day Preceding Complication/ Discharge, MeanSE Complication status
Day 3
Day 2
Day 1
Complication/ discharge
No complication 3.7 0.1 3.3 0.1
3.0 0.1
2.4 0.1
Grade I-III complication
3.9 0.7 3.8 0.7
4.6 0.6*
3.8 0.5*
Grade IV complication
4.1 0.5 5.3 0.5* 5.8 0.3*
6.8 0.5*
*Significant difference as compared to no complication, p<0.001).
CONCLUSIONS: Life-threatening postoperative complications are preceded by rising EWS. The EWS has promise for early identification and intervention to reduce severity of postoperative complications for surgical patients.
Health Care Providers’ Perceptions of Team Identity and Teamwork in the Operating Room Lane L Frasier, MD, Sudha R Pavuluri Quamme, MD, Aimee M Becker, MD, Sara Booth, RN, Adam Gutt, RN, Douglas Wiegmann, PhD, Caprice C Greenberg, MD, FACS University of Wisconsin-Madison, Madison, WI INTRODUCTION: Teamwork and communication play critical roles in patient safety. Operating room team (OR) composition changes frequently, introducing system variability and potential vulnerability. We sought to describe the perceptions of health care providers about team identity, hand-offs, and team unfamiliarity in the OR. METHODS: We conducted separate focus groups for anesthesia providers, nurses/scrub technicians, and surgeons. Using openended questions and inductive analysis, we explored the themes listed above. RESULTS: Perceptions of team identity varied by provider type. Nurses and surgical technicians identified their team as other nurses and technicians who primarily cover similar types of cases (general surgery or gynecology). Anesthesia providers identified their team as anyone assisting in the provision of anesthetic care during the pre-, peri-, and postoperative periods. Surgeons had the broadest conceptualization, identifying providers in the emergency department, ICU, and PACU, in addition to everyone present in the OR as team members. Several common themes also emerged. Providers within and across disciplines could not agree as to whether the ideal hand-off was unobtrusive and discipline-specific or included an announcement, representing an opportunity for reanchoring the entire operative team. The electronic medical record was identified across disciplines as a potential barrier to effective communication. All disciplines agreed on the the key role of surgeon behaviors in “setting the tone” during preoperative set-up and time-out. CONCLUSIONS: We identified differences and commonalities between health care disciplines’ perceptions of operative teams and teamwork. These themes provide a framework for future studies and interventions to improve team and system performance in the OR. Health Care Reform and Equity in Bariatric Surgery: Does Increased Access to Care Mitigate Disparities? Andrew P Loehrer, MD*, Zirui Song, MD, PhD, David C Chang, PhD, MPH, MBA, Matthew M Hutter, MD, MPH, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Morbid obesity is increasingly common and disproportionately affects non-white and underinsured populations. The 2006 Massachusetts health care reform, a model for the Affordable Care Act, serves as a natural experiment to study the impact of near-universal insurance coverage on racial disparities in bariatric surgery. METHODS: We conducted a cohort study comparing Massachusetts with 4 control states from 2002 through 2010 using
Vol. 221, No. 4S1, October 2015
Healthcare Cost and Utilization Project State Inpatient Databases. Non-elderly white, black, and Hispanic adult patients, with government-subsidized or no insurance coverage, undergoing bariatric procedure were included (n¼27,797). Primary outcomes were rates of bariatric procedures. Difference-in-difference models evaluated for changes in rates of surgery associated with expanded insurance coverage, controlling for confounding factors and secular trends. RESULTS: After expansion of health insurance, rates of bariatric surgery for all Massachusetts residents increased relative to concurrent trends in control states (+9.5 cases per 100,000, p<0.001). Non-white patients in Massachusetts had increased rates of bariatric surgery controlling for trends in white patients in Massachusetts as well as concurrent changes in control states (+2.4 cases per 100,000, p<0.001). Hispanic patients in Massachusetts saw a particularly striking increased rate of bariatric procedures (+3.7 cases per 100,000, p<0.001). After reform, non-white patients in Massachusetts had a higher rate of bariatric surgery compared with white patients (+1.8 cases per 100,000, p<0.001), while racial disparities persisted in control states (-4.3 cases per 100,000, p<0.001). CONCLUSIONS: Expanded insurance coverage after the 2006 Massachusetts health care reform was associated with increased use of bariatric surgery for all government-subsidized/self-pay residents, especially Hispanic patients, and better equity compared with that in control states. Hospital-Level Variation in Anastomotic Leak after Colectomy Julia Berian, MD, Mark E Cohen, PhD, Karl Y Bilimoria, MD, FACS American College of Surgeons, Chicago, IL; Northwestern University, Chicago, IL; University of Chicago, Chicago, IL INTRODUCTION: Anastomotic leak remains a significant source of morbidity and mortality after colonic resections. Before now, hospital-to-hospital variation in leak rates was unknown because a multi-institutional data source with accurate leak data was not available. Our objective was to examine hospital variation in leak rates after colectomy. METHODS: Based on American College of Surgeons NSQIP colectomy data (2012 to 2013), risk-adjusted leak rates were estimated while adjusting for patient risk factors (eg, age, American Society of Anesthsologists [ASA] class, diabetes, smoking history) and operative factors (eg, operative approach, emergent). Leaks were defined as those requiring treatment (eg, IR drainage, reoperation, NPO status, antibiotics). Characteristics of high-performing and poor-performing hospitals were compared using American Hospital Association data. RESULTS: The overall rate of clinically significant anastomotic leak after colectomy was 3.2%. Anastomotic leak was managed operatively in 62% of cases, with 30% undergoing percutaneous intervention and the remaining 8% of cases treated with
Scientific Forum Abstracts
S127
noninvasive means (NPO status, antibiotics). Among 153 hospitals, risk-adjusted anastomotic leak rates ranged from 2.2% to 5.2%. Four hospitals (2.6%) and 2 hospitals (1.3%) were identified as poor- and high-performing outliers, respectively. There were no differences in high- vs poor-performing hospitals with respect to bed size, operative volume, accreditations, and availability of intensive care. CONCLUSIONS: Leak rates vary 2.5-fold between the best and worst performing hospitals. Because the available hospital characteristics do not explain variation in performance, poor-performing hospitals will need to develop targeted improvement initiatives.
How Should Surgical Residents Be Educated about Patient Safety in the Operating Room: A Pilot Randomized Trial Luke R Putnam, MD, Dean H Pham, MPH, Jason M Etchegaray, PhD, Tiffany G Ostovar-Kermani, MD, MPH, Madelene Ottosen, RN, MSN, Eric J Thomas, MD MPH, Lillian S Kao, MD, FACS, Kevin P Lally, MD, FACS, KuoJen Tsao, MD, FACS The University of Texas Health Science Center at Houston, Houston, TX INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) mandates patient safety education for all graduate medical education without specific curricular guidelines. We hypothesized that a dedicated, adjunctive, resident safety workshop (SW) compared with an online curriculum (OC) alone would improve residents’ patient safety perceptions and behaviors. METHODS: A randomized, controlled trial was performed from 2014 to 2015 within a university-based general surgery residency. Control and intervention groups, stratified by post-graduate year, participated in a hospital-based OC; the intervention group participated in an additional SW. Primary outcomes were perceptions of safety culture, teamwork, and speaking up per the validated Safety Attitudes Questionnaire (SAQ) at 6- and 12-months post-intervention. Secondary outcomes included behavioral performance scored by blinded surgical faculty using the Oxford Non-Technical Skills (NOTECHS) scale. RESULTS: Fifty-one residents were enrolled (control¼25, intervention¼26). The SAQ response rates were 100%, 100%, and 76% at baseline, 6 months, and 12 months, respectively. The SAQ scores were similar at baseline without significant changes at 6 or 12 months (Table), independent of PGY level. Overall NOTECHS scores were similar; however, senior residents in the intervention group scored significantly higher in teamwork, decision-making, and situational awareness (all p<0.05), while junior residents in the intervention group trended toward lower scores in all categories.
J Am Coll Surg
Scientific Forum Abstracts
Harnessing the Electronic Medical Record to Identify Patients at Risk for In-Hospital Complications Robert H Hollis, MD, Laura Graham, MPH, John P Lazenby, MD, Daran M Brown, RN, MBA, Benjamin B Taylor, MD, Martin J Heslin, MD, MSHA, FACS, Loring W Rue III, MD, FACS, Mary T Hawn, MD, MPH, FACS University of Alabama at Birmingham, Birmingham, AL INTRODUCTION: Abnormal vitals often precede inpatient complications, providing an opportunity for early identification and intervention. We examined whether a validated early warning score (EWS) calculated from vital signs could predict complications in surgical patients. METHODS: Inpatient general surgery procedures with NSQIP data from 2013 and 2014 were matched with enterprise data on vital signs and neurologic status to calculate the EWS for each postoperative vital set measured on the ward. Outcomes of complications, ICU transfer, and medical emergency team (MET) activation were classified using the Clavien system as grade I to IV. Relationship between EWS and timing of first complication was assessed using Kruskal-Wallis test and linear regression accounting for clustering with generalized estimating equation. RESULTS: Among 552 patients admitted to the ward postoperatively, 70 (12.7%) developed at least 1 grade I to III complication and 60 (10.9%) developed a grade IV (life-threatening) complication. The mean maximum EWS was significantly higher in the 48 hours preceding grade IV complications (6.65) or grade I to III complications (4.46) compared to patients without complications (3.34; p<0.001). The EWS significantly increased in the 3 days preceding grade IV complications (p<0.001) and declined in patients without complications in the 3 days prior to discharge (p<0.001) (Table). A threshold EWS of 6 predicted occurrences of grade IV complications with a 62% sensitivity, 94% specificity, and 55% positive predictive value. Table. Maximum EWS by Day Preceding Complication/ Discharge, MeanSE Complication status
Day 3
Day 2
Day 1
Complication/ discharge
No complication 3.7 0.1 3.3 0.1
3.0 0.1
2.4 0.1
Grade I-III complication
3.9 0.7 3.8 0.7
4.6 0.6*
3.8 0.5*
Grade IV complication
4.1 0.5 5.3 0.5* 5.8 0.3*
6.8 0.5*
*Significant difference as compared to no complication, p<0.001).
CONCLUSIONS: Life-threatening postoperative complications are preceded by rising EWS. The EWS has promise for early identification and intervention to reduce severity of postoperative complications for surgical patients.
Health Care Providers’ Perceptions of Team Identity and Teamwork in the Operating Room Lane L Frasier, MD, Sudha R Pavuluri Quamme, MD, Aimee M Becker, MD, Sara Booth, RN, Adam Gutt, RN, Douglas Wiegmann, PhD, Caprice C Greenberg, MD, FACS University of Wisconsin-Madison, Madison, WI INTRODUCTION: Teamwork and communication play critical roles in patient safety. Operating room team (OR) composition changes frequently, introducing system variability and potential vulnerability. We sought to describe the perceptions of health care providers about team identity, hand-offs, and team unfamiliarity in the OR. METHODS: We conducted separate focus groups for anesthesia providers, nurses/scrub technicians, and surgeons. Using openended questions and inductive analysis, we explored the themes listed above. RESULTS: Perceptions of team identity varied by provider type. Nurses and surgical technicians identified their team as other nurses and technicians who primarily cover similar types of cases (general surgery or gynecology). Anesthesia providers identified their team as anyone assisting in the provision of anesthetic care during the pre-, peri-, and postoperative periods. Surgeons had the broadest conceptualization, identifying providers in the emergency department, ICU, and PACU, in addition to everyone present in the OR as team members. Several common themes also emerged. Providers within and across disciplines could not agree as to whether the ideal hand-off was unobtrusive and discipline-specific or included an announcement, representing an opportunity for reanchoring the entire operative team. The electronic medical record was identified across disciplines as a potential barrier to effective communication. All disciplines agreed on the the key role of surgeon behaviors in “setting the tone” during preoperative set-up and time-out. CONCLUSIONS: We identified differences and commonalities between health care disciplines’ perceptions of operative teams and teamwork. These themes provide a framework for future studies and interventions to improve team and system performance in the OR. Health Care Reform and Equity in Bariatric Surgery: Does Increased Access to Care Mitigate Disparities? Andrew P Loehrer, MD*, Zirui Song, MD, PhD, David C Chang, PhD, MPH, MBA, Matthew M Hutter, MD, MPH, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Morbid obesity is increasingly common and disproportionately affects non-white and underinsured populations. The 2006 Massachusetts health care reform, a model for the Affordable Care Act, serves as a natural experiment to study the impact of near-universal insurance coverage on racial disparities in bariatric surgery. METHODS: We conducted a cohort study comparing Massachusetts with 4 control states from 2002 through 2010 using
Vol. 221, No. 4S1, October 2015
Healthcare Cost and Utilization Project State Inpatient Databases. Non-elderly white, black, and Hispanic adult patients, with government-subsidized or no insurance coverage, undergoing bariatric procedure were included (n¼27,797). Primary outcomes were rates of bariatric procedures. Difference-in-difference models evaluated for changes in rates of surgery associated with expanded insurance coverage, controlling for confounding factors and secular trends. RESULTS: After expansion of health insurance, rates of bariatric surgery for all Massachusetts residents increased relative to concurrent trends in control states (+9.5 cases per 100,000, p<0.001). Non-white patients in Massachusetts had increased rates of bariatric surgery controlling for trends in white patients in Massachusetts as well as concurrent changes in control states (+2.4 cases per 100,000, p<0.001). Hispanic patients in Massachusetts saw a particularly striking increased rate of bariatric procedures (+3.7 cases per 100,000, p<0.001). After reform, non-white patients in Massachusetts had a higher rate of bariatric surgery compared with white patients (+1.8 cases per 100,000, p<0.001), while racial disparities persisted in control states (-4.3 cases per 100,000, p<0.001). CONCLUSIONS: Expanded insurance coverage after the 2006 Massachusetts health care reform was associated with increased use of bariatric surgery for all government-subsidized/self-pay residents, especially Hispanic patients, and better equity compared with that in control states. Hospital-Level Variation in Anastomotic Leak after Colectomy Julia Berian, MD, Mark E Cohen, PhD, Karl Y Bilimoria, MD, FACS American College of Surgeons, Chicago, IL; Northwestern University, Chicago, IL; University of Chicago, Chicago, IL INTRODUCTION: Anastomotic leak remains a significant source of morbidity and mortality after colonic resections. Before now, hospital-to-hospital variation in leak rates was unknown because a multi-institutional data source with accurate leak data was not available. Our objective was to examine hospital variation in leak rates after colectomy. METHODS: Based on American College of Surgeons NSQIP colectomy data (2012 to 2013), risk-adjusted leak rates were estimated while adjusting for patient risk factors (eg, age, American Society of Anesthsologists [ASA] class, diabetes, smoking history) and operative factors (eg, operative approach, emergent). Leaks were defined as those requiring treatment (eg, IR drainage, reoperation, NPO status, antibiotics). Characteristics of high-performing and poor-performing hospitals were compared using American Hospital Association data. RESULTS: The overall rate of clinically significant anastomotic leak after colectomy was 3.2%. Anastomotic leak was managed operatively in 62% of cases, with 30% undergoing percutaneous intervention and the remaining 8% of cases treated with
Scientific Forum Abstracts
S127
noninvasive means (NPO status, antibiotics). Among 153 hospitals, risk-adjusted anastomotic leak rates ranged from 2.2% to 5.2%. Four hospitals (2.6%) and 2 hospitals (1.3%) were identified as poor- and high-performing outliers, respectively. There were no differences in high- vs poor-performing hospitals with respect to bed size, operative volume, accreditations, and availability of intensive care. CONCLUSIONS: Leak rates vary 2.5-fold between the best and worst performing hospitals. Because the available hospital characteristics do not explain variation in performance, poor-performing hospitals will need to develop targeted improvement initiatives.
How Should Surgical Residents Be Educated about Patient Safety in the Operating Room: A Pilot Randomized Trial Luke R Putnam, MD, Dean H Pham, MPH, Jason M Etchegaray, PhD, Tiffany G Ostovar-Kermani, MD, MPH, Madelene Ottosen, RN, MSN, Eric J Thomas, MD MPH, Lillian S Kao, MD, FACS, Kevin P Lally, MD, FACS, KuoJen Tsao, MD, FACS The University of Texas Health Science Center at Houston, Houston, TX INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) mandates patient safety education for all graduate medical education without specific curricular guidelines. We hypothesized that a dedicated, adjunctive, resident safety workshop (SW) compared with an online curriculum (OC) alone would improve residents’ patient safety perceptions and behaviors. METHODS: A randomized, controlled trial was performed from 2014 to 2015 within a university-based general surgery residency. Control and intervention groups, stratified by post-graduate year, participated in a hospital-based OC; the intervention group participated in an additional SW. Primary outcomes were perceptions of safety culture, teamwork, and speaking up per the validated Safety Attitudes Questionnaire (SAQ) at 6- and 12-months post-intervention. Secondary outcomes included behavioral performance scored by blinded surgical faculty using the Oxford Non-Technical Skills (NOTECHS) scale. RESULTS: Fifty-one residents were enrolled (control¼25, intervention¼26). The SAQ response rates were 100%, 100%, and 76% at baseline, 6 months, and 12 months, respectively. The SAQ scores were similar at baseline without significant changes at 6 or 12 months (Table), independent of PGY level. Overall NOTECHS scores were similar; however, senior residents in the intervention group scored significantly higher in teamwork, decision-making, and situational awareness (all p<0.05), while junior residents in the intervention group trended toward lower scores in all categories.