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Hospital-Level Variation in Anastomotic Leak after Colectomy
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.
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.