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October 2015 Featured Articles, Volume 221
CONTINUING MEDICAL EDUCATION PROGRAM
October 2015 Featured Articles, Volume 221
Get credit right away by taking all CME tests online http://jacscme.facs.org Article 1: General Surgery
Using human factors and systems engineering to evaluate readmission after complex surgery. Acher AW, LeCaire TJ, Hundt AS, et al. J Am Coll Surg 2015;221:810e820 Article 2: Pediatric Surgery
Does the American College of Surgeons NSQIP-Pediatric accurately represent overall patient outcomes? Gross ER, Christensen M, Schultz JA, et al. J Am Coll Surg 2015;221:828e836 Article 3: Colon/Rectal
Is a colectomy always just a colectomy? Additional procedures as a proxy for operative complexity. Simmons KD, Hoffman RL, Kuo LE, et al. J Am Coll Surg 2015;221:862e870 Article 4: General Surgery
Preoperative glycosylated hemoglobin and postoperative glucose together predict major complications after abdominal surgery. Goodenough CJ, Liang MK, Nguyen MT, et al. J Am Coll Surg 2015;221:854e861
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME and Self-Assessment credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two articles are available each month in the print version, and up to 4 are available online for each monthly issue, going back 24 months.
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Using human factors and systems engineering to evaluate readmission after complex surgery Acher AW, LeCaire TJ, Hundt AS, et al J Am Coll Surg 2015;221:810e820 Learning Objectives: After study of this article, surgeons should be able to discuss research methods that are necessary to understanding patient readmission rates and recognizing health care work system processes that affect patients’ transitional care outcomes.
Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Question 1 Patient- and clinician provider-identified issues that were perceived as contributing to hospital readmission: a) Revealed problems primarily in the post-discharge experience. b) Addressed unnecessary involvement of caregivers in the discharge process. c) Highlighted a need for enhanced transitional care support programs for complex abdominal surgical patients and their caregivers. d) Singled out postoperative cognitive dysfunction and delirium as the failure point in education processes. e) Identified rapid change of patients feeling confident at hospital discharge to confusion within 48 hours.
Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
895
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.002 ISSN 1072-7515/15
896
Continuing Medical Education Program
Critique: A mixed-method approach was used to analyze patient and clinician provider perspectives on the etiology of hospital readmission. Readmitted patients were interviewed to understand patient perspectives and to reveal patient-identified issues and themes that they believed led to their readmission. Providers and clinicians were also engaged via focus group in order to gain a perspective as professional care providers about possible reasons for patient caretaking deficits and events that led to, for example, hurried discharges. Ten themes were revealed as contributing to risks for patient readmission. Three components that are the most actionable to bolster the transition of care involve increasing patient and caregiver understanding and education, care team communication, and the discharge process. Question 2 Care team communication with patients: a) Affected events leading to hospital readmissions solely via electronic health record inaccuracies. b) Could be improved with more communication with more care team members, according to patients. c) Regularly consists of detailed, patient-specific care plans well in advance of discharge to allow for patients to formulate questions. d) Increased misunderstanding when some care team members had premature discussions about test results that had not yet been finalized. e) Was identified as a theme that did not affect readmissions. Critique: Care team communication has been identified as 1 of the 3 actionable components for aiding in surgical patients’ transition of care. Given that many patients experience postoperative cognitive dysfunction and postoperative delirium, communication with the care team needs to be as clear and as frequent as possible. If patients and caregivers receive contradictory information from different members of the care team, this leads to further confusion. The overarching theme patients voiced was that the discharge process was too rushed, they were provided too much information that did not address their specific needs, and they were too overwhelmed and ill to adequately process the information. Question 3 Patient-identified problems with patient educationinvolved issue(s) include: a) Inability of patients/caregivers to understand and have realistic expectations of their needs or consequences of surgery.
J Am Coll Surg
b) Incomplete patient training on details that are specific to patient needs and overgeneralized discharge education materials. c) Lack of clinical and/or procedural expertise to manage patients outside of the academic surgical center. d) Inadequate after-business-hours access to physicians and other providers. e) Poor postoperative cognitive status. Critique: The Systems Engineering Initiative for Patient Safety (SEIPS) Framework was used to analyze patient perspectives on the etiology of hospital readmission. Resulting from qualitative research methods with patients and clinician-providers, 10 themes were revealed as contributing to risks for patient readmission. Each of these themes was categorized into one of the SEIPS work system elements: People, Tasks, Technology & Tools, Organization, or Environment. People (in this case, the patients) are at the center of the SEIPS model. An identified theme contributing to hospital readmission by the clinician-provider focus group was misunderstanding the patient’s needs associated with complex abdominal surgery and having unrealistic expectations of the patient’s abilities at home. This theme in the People element is related to themes in other elements. For example, the discharge preparation process (categorized into the element of Tasks) must account for the expectations and understanding of the patient (People). Two particular themes regarding education were identified and categorized into the elements of Tasks (processes) and Technology & Tools (materials and technology). Question 4 A mixed method approach was used in evaluating hospital readmissions post-discharge for patients undergoing complex abdominal surgery. Qualitative data gathered during this project: a) Provided patient perspectives on events that led to their hospital readmission. b) Described only post-discharge events that led to hospital readmissions. c) Identified specific preventable readmissions. d) Could not focus on discharge and education processes. e) Are less reliable than quantitative data available in large administrative databases. Critique: Mixed method approaches to research involve the use of quantitative methods and qualitative methods. Quantitative methods are methods that record variation in terms of quantities (numbers or
Vol. 221, No. 4, October 2015
attributes that can be ordered in terms of magnitude). Qualitative methods try to capture data as participants experience the phenomena (eg, hospital readmission) and do not often have direct numerical interpretation. In this research project, qualitative data were gathered with patients as well as clinician-providers through semi-structured interviews and a focus group, respectively. The topics of these discussions involved hospital and post-discharge experiences and events.
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Does the American College of Surgeons NSQIPPediatric accurately represent overall patient outcomes? Gross ER, Christensen M, Schultz JA, et al J Am Coll Surg 2015;221:828e836
Continuing Medical Education Program
897
Critique: Children are generally healthy compared with adults. The data from NSQIP-Pediatric show that, unlike in adults, mortality is so low that this variable cannot be used to differentiate hospital outcomes. Both adult and pediatric NSQIP programs record occurrences within 30 days of an operative procedure. When the earlier results from NSQIP-Pediatric were analyzed, it was apparent that several high-risk operations were performed infrequently. To create a system that would give more useful data for quality improvement, NSQIP-Pediatric was modified to collect outcomes from select CPT codes that are associated with more complex or high-risk procedures. The CPT codes for inguinal hernia repairs have been excluded from the most recent analysis because of the low postoperative event rate for this procedure. Question 2 The Pediatric and Infant and Case Log and Outcomes (PICaLO):
Learning Objectives: After reading this article, the surgeon should understand the fundamental differences between adult and pediatric NSQIP with respect to data collection and analysis, in order to collect meaningful data for quality improvement efforts; have a basic understanding of Pediatric and Infant and Case Log and Outcomes (PICaLO) and how it differs from NSQIPPediatric; understand that procedures currently being abstracted by NSQIP-Pediatric represent a high risk group of patients with a high frequency of postoperative occurrences; and understand that a more comprehensive log, such as PICaLO, may offer complementary use in quality improvement, at the level of an individual surgeon or at a population level.
a) Is an administrative database collected through the Children’s Hospital Association. b) Is an institutional database using a Research Electronic Data Capture platform that serves both as a case log for the surgeons as well as a repository for complications discussed during regular morbidity and mortality conferences. c) Is an American College of Surgeons-based duplicate system of collecting complications to ensure validity of NSQIP data. d) Tracks only occurrences that NSQIP-Pediatric collects. e) Is a proprietary database that records charges for operative procedures.
Question 1 Data from the American College of Surgeons NSQIPPediatric show:
Critique: The PICaLO is a web-based instrument using Research Electronic Data Capture to record all surgical procedures as well as adverse outcomes at our institution. The primary source of complications is the weekly morbidity and mortality conference. Returns to system, such as unplanned clinic visit, emergency room visit, and readmissions are noted by the resident team and the clinic staff and entered into the database. Adverse outcomes that may not be collected in NSQIP-Pediatric are collected by PICaLO. These include anastomotic leaks, abdominal compartment syndrome, chylothoraces, and pneumothoraces, to name a few. It is noted, though, that NSQIPPediatric is better at collecting other types of occurrencesdmost notably, blood transfusions and unplanned reintubations. Because PICaLO is a case log for all surgical procedures at 1 hospital, it collects data on all procedures performed at the General and Thoracic
a) Thirty-day mortality is an effective differentiation of hospital performance in pediatric surgical patients. b) Preoperative morbid conditions are just as prevalent in the pediatric population as in adult patients. c) NSQIP-Pediatric records 90-day outcomes for all general pediatric surgery operations in an enrolled institution. d) Many high-risk procedures are performed infrequently, even in high-volume centers, prompting a different methodology to extract institutional level risk-adjusted data for outcomes. e) Procedures that are performed more frequently, such as hernia repairs, are preferentially selected for data collection.
898
Continuing Medical Education Program
Pediatric Surgery Service. In addition, complications are recorded beyond postoperative day 30. Question 3 When the sampled NSQIP-Pediatric patients were compared with the entire complement of patients with any type of complications or occurrences (group A), it was found that: a) NSQIP-Pediatric patients had a lower complication rate than all patients with all complications. b) NSQIP-Pediatric patients had a statistically equivalent complication rate than all patients with all complications. c) NSQIP-Pediatric patients had a higher complication rate than all patients with all complications. d) This comparison cannot be performed because of low inter-rater reliability rate among data collectors for each database. e) This comparison cannot be performed because the event rates for both groups are too low to make meaningful statistical conclusions. Critique: The postoperative event rate for the NSQIPPediatric sample was 12.5%, or 135 of the 1,077 cases submitted for analysis for 2 years. For the same time period, there were 6,884 cases in PICaLO, with 407 cases that had occurrences (5.9%). This represents a significantly smaller percentage of complications compared with NSQIP-Pediatric (p < 0.0001). Group A also had a significantly lower complication rate in cases with 1 or more occurrences. These findings support the need to focus analysis on the highest risk group to effect the greatest change for quality improvement. Question 4 When the sampled NSQIP-Pediatric patients were compared with total patients with diagnosis codes collected by NSQIP who had occurrences tracked by NSQIP (group D), it was found that:
J Am Coll Surg
a) NSQIP-Pediatric patients had a higher complication rate than all patients with all complications. b) NSQIP-Pediatric patients had a statistically equivalent complication rate to all patients with all complications. c) NSQIP-Pediatric patients had a lower complication rate than all patients with all complications. d) This comparison cannot be performed because of low inter-rater reliability rate among data collectors for each database. e) This comparison cannot be performed because the event rate for both groups is too low to make meaningful statistical conclusions. Critique: When single outcomes are compared between these 2 groups, there is no statistical difference between the outcomes except for organ/space surgical site infection, unplanned reintubations, and perioperative (within 72 hours) blood transfusions. Perioperative transfusions are not routinely reported in the surgical or anesthesia morbidity and mortality conferences. Regarding unplanned intubations, we noted that PICaLO did not capture events that occurred beyond the immediate postoperative period, around 21 to 30 days. Single chart reviews showed these events to be unrelated to the operation. Airway stabilization was typically required due to altered mental status, sepsis, or progression of disease. Group D was the subset that was most similar to the NSQIPPediatric dataset in that it included cases with the same CPT codes and the same postoperative occurrences. However, it also included occurrences beyond 30 days after surgery. NSQIP-Pediatric had a significantly higher rate of postoperative occurrences compared with group D (12.5% vs 9.4%, respectively; p ¼ 0.004). The proportion of cases with 2 or more occurrences was also significantly higher in the NSQIP-Pediatric dataset when compared with PICaLO group D (p ¼ 0.0183).
Vol. 221, No. 4, October 2015
Continuing Medical Education Program
899
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue). Issues are available for the past 24 months. You can print your certificate immediately.
For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
October 2015 Featured Articles, Volume 221 Using human factors and systems engineering to evaluate readmission after complex surgery Acher AW, LeCaire TJ, Hundt AS, et al. J Am Coll Surg 2015;221:810e820 Does the American College of Surgeons NSQIP-Pediatric accurately represent overall patient outcomes? Gross ER, Christensen M, Schultz JA, et al. J Am Coll Surg 2015;221:828e836
October 2015 Featured Articles, Volume 221
Get credit right away by taking all CME tests online http://jacscme.facs.org Article 1: General Surgery
Using human factors and systems engineering to evaluate readmission after complex surgery. Acher AW, LeCaire TJ, Hundt AS, et al. J Am Coll Surg 2015;221:810e820 Article 2: Pediatric Surgery
Does the American College of Surgeons NSQIP-Pediatric accurately represent overall patient outcomes? Gross ER, Christensen M, Schultz JA, et al. J Am Coll Surg 2015;221:828e836 Article 3: Colon/Rectal
Is a colectomy always just a colectomy? Additional procedures as a proxy for operative complexity. Simmons KD, Hoffman RL, Kuo LE, et al. J Am Coll Surg 2015;221:862e870 Article 4: General Surgery
Preoperative glycosylated hemoglobin and postoperative glucose together predict major complications after abdominal surgery. Goodenough CJ, Liang MK, Nguyen MT, et al. J Am Coll Surg 2015;221:854e861
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME and Self-Assessment credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two articles are available each month in the print version, and up to 4 are available online for each monthly issue, going back 24 months.
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Using human factors and systems engineering to evaluate readmission after complex surgery Acher AW, LeCaire TJ, Hundt AS, et al J Am Coll Surg 2015;221:810e820 Learning Objectives: After study of this article, surgeons should be able to discuss research methods that are necessary to understanding patient readmission rates and recognizing health care work system processes that affect patients’ transitional care outcomes.
Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Question 1 Patient- and clinician provider-identified issues that were perceived as contributing to hospital readmission: a) Revealed problems primarily in the post-discharge experience. b) Addressed unnecessary involvement of caregivers in the discharge process. c) Highlighted a need for enhanced transitional care support programs for complex abdominal surgical patients and their caregivers. d) Singled out postoperative cognitive dysfunction and delirium as the failure point in education processes. e) Identified rapid change of patients feeling confident at hospital discharge to confusion within 48 hours.
Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
895
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.002 ISSN 1072-7515/15
896
Continuing Medical Education Program
Critique: A mixed-method approach was used to analyze patient and clinician provider perspectives on the etiology of hospital readmission. Readmitted patients were interviewed to understand patient perspectives and to reveal patient-identified issues and themes that they believed led to their readmission. Providers and clinicians were also engaged via focus group in order to gain a perspective as professional care providers about possible reasons for patient caretaking deficits and events that led to, for example, hurried discharges. Ten themes were revealed as contributing to risks for patient readmission. Three components that are the most actionable to bolster the transition of care involve increasing patient and caregiver understanding and education, care team communication, and the discharge process. Question 2 Care team communication with patients: a) Affected events leading to hospital readmissions solely via electronic health record inaccuracies. b) Could be improved with more communication with more care team members, according to patients. c) Regularly consists of detailed, patient-specific care plans well in advance of discharge to allow for patients to formulate questions. d) Increased misunderstanding when some care team members had premature discussions about test results that had not yet been finalized. e) Was identified as a theme that did not affect readmissions. Critique: Care team communication has been identified as 1 of the 3 actionable components for aiding in surgical patients’ transition of care. Given that many patients experience postoperative cognitive dysfunction and postoperative delirium, communication with the care team needs to be as clear and as frequent as possible. If patients and caregivers receive contradictory information from different members of the care team, this leads to further confusion. The overarching theme patients voiced was that the discharge process was too rushed, they were provided too much information that did not address their specific needs, and they were too overwhelmed and ill to adequately process the information. Question 3 Patient-identified problems with patient educationinvolved issue(s) include: a) Inability of patients/caregivers to understand and have realistic expectations of their needs or consequences of surgery.
J Am Coll Surg
b) Incomplete patient training on details that are specific to patient needs and overgeneralized discharge education materials. c) Lack of clinical and/or procedural expertise to manage patients outside of the academic surgical center. d) Inadequate after-business-hours access to physicians and other providers. e) Poor postoperative cognitive status. Critique: The Systems Engineering Initiative for Patient Safety (SEIPS) Framework was used to analyze patient perspectives on the etiology of hospital readmission. Resulting from qualitative research methods with patients and clinician-providers, 10 themes were revealed as contributing to risks for patient readmission. Each of these themes was categorized into one of the SEIPS work system elements: People, Tasks, Technology & Tools, Organization, or Environment. People (in this case, the patients) are at the center of the SEIPS model. An identified theme contributing to hospital readmission by the clinician-provider focus group was misunderstanding the patient’s needs associated with complex abdominal surgery and having unrealistic expectations of the patient’s abilities at home. This theme in the People element is related to themes in other elements. For example, the discharge preparation process (categorized into the element of Tasks) must account for the expectations and understanding of the patient (People). Two particular themes regarding education were identified and categorized into the elements of Tasks (processes) and Technology & Tools (materials and technology). Question 4 A mixed method approach was used in evaluating hospital readmissions post-discharge for patients undergoing complex abdominal surgery. Qualitative data gathered during this project: a) Provided patient perspectives on events that led to their hospital readmission. b) Described only post-discharge events that led to hospital readmissions. c) Identified specific preventable readmissions. d) Could not focus on discharge and education processes. e) Are less reliable than quantitative data available in large administrative databases. Critique: Mixed method approaches to research involve the use of quantitative methods and qualitative methods. Quantitative methods are methods that record variation in terms of quantities (numbers or
Vol. 221, No. 4, October 2015
attributes that can be ordered in terms of magnitude). Qualitative methods try to capture data as participants experience the phenomena (eg, hospital readmission) and do not often have direct numerical interpretation. In this research project, qualitative data were gathered with patients as well as clinician-providers through semi-structured interviews and a focus group, respectively. The topics of these discussions involved hospital and post-discharge experiences and events.
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Does the American College of Surgeons NSQIPPediatric accurately represent overall patient outcomes? Gross ER, Christensen M, Schultz JA, et al J Am Coll Surg 2015;221:828e836
Continuing Medical Education Program
897
Critique: Children are generally healthy compared with adults. The data from NSQIP-Pediatric show that, unlike in adults, mortality is so low that this variable cannot be used to differentiate hospital outcomes. Both adult and pediatric NSQIP programs record occurrences within 30 days of an operative procedure. When the earlier results from NSQIP-Pediatric were analyzed, it was apparent that several high-risk operations were performed infrequently. To create a system that would give more useful data for quality improvement, NSQIP-Pediatric was modified to collect outcomes from select CPT codes that are associated with more complex or high-risk procedures. The CPT codes for inguinal hernia repairs have been excluded from the most recent analysis because of the low postoperative event rate for this procedure. Question 2 The Pediatric and Infant and Case Log and Outcomes (PICaLO):
Learning Objectives: After reading this article, the surgeon should understand the fundamental differences between adult and pediatric NSQIP with respect to data collection and analysis, in order to collect meaningful data for quality improvement efforts; have a basic understanding of Pediatric and Infant and Case Log and Outcomes (PICaLO) and how it differs from NSQIPPediatric; understand that procedures currently being abstracted by NSQIP-Pediatric represent a high risk group of patients with a high frequency of postoperative occurrences; and understand that a more comprehensive log, such as PICaLO, may offer complementary use in quality improvement, at the level of an individual surgeon or at a population level.
a) Is an administrative database collected through the Children’s Hospital Association. b) Is an institutional database using a Research Electronic Data Capture platform that serves both as a case log for the surgeons as well as a repository for complications discussed during regular morbidity and mortality conferences. c) Is an American College of Surgeons-based duplicate system of collecting complications to ensure validity of NSQIP data. d) Tracks only occurrences that NSQIP-Pediatric collects. e) Is a proprietary database that records charges for operative procedures.
Question 1 Data from the American College of Surgeons NSQIPPediatric show:
Critique: The PICaLO is a web-based instrument using Research Electronic Data Capture to record all surgical procedures as well as adverse outcomes at our institution. The primary source of complications is the weekly morbidity and mortality conference. Returns to system, such as unplanned clinic visit, emergency room visit, and readmissions are noted by the resident team and the clinic staff and entered into the database. Adverse outcomes that may not be collected in NSQIP-Pediatric are collected by PICaLO. These include anastomotic leaks, abdominal compartment syndrome, chylothoraces, and pneumothoraces, to name a few. It is noted, though, that NSQIPPediatric is better at collecting other types of occurrencesdmost notably, blood transfusions and unplanned reintubations. Because PICaLO is a case log for all surgical procedures at 1 hospital, it collects data on all procedures performed at the General and Thoracic
a) Thirty-day mortality is an effective differentiation of hospital performance in pediatric surgical patients. b) Preoperative morbid conditions are just as prevalent in the pediatric population as in adult patients. c) NSQIP-Pediatric records 90-day outcomes for all general pediatric surgery operations in an enrolled institution. d) Many high-risk procedures are performed infrequently, even in high-volume centers, prompting a different methodology to extract institutional level risk-adjusted data for outcomes. e) Procedures that are performed more frequently, such as hernia repairs, are preferentially selected for data collection.
898
Continuing Medical Education Program
Pediatric Surgery Service. In addition, complications are recorded beyond postoperative day 30. Question 3 When the sampled NSQIP-Pediatric patients were compared with the entire complement of patients with any type of complications or occurrences (group A), it was found that: a) NSQIP-Pediatric patients had a lower complication rate than all patients with all complications. b) NSQIP-Pediatric patients had a statistically equivalent complication rate than all patients with all complications. c) NSQIP-Pediatric patients had a higher complication rate than all patients with all complications. d) This comparison cannot be performed because of low inter-rater reliability rate among data collectors for each database. e) This comparison cannot be performed because the event rates for both groups are too low to make meaningful statistical conclusions. Critique: The postoperative event rate for the NSQIPPediatric sample was 12.5%, or 135 of the 1,077 cases submitted for analysis for 2 years. For the same time period, there were 6,884 cases in PICaLO, with 407 cases that had occurrences (5.9%). This represents a significantly smaller percentage of complications compared with NSQIP-Pediatric (p < 0.0001). Group A also had a significantly lower complication rate in cases with 1 or more occurrences. These findings support the need to focus analysis on the highest risk group to effect the greatest change for quality improvement. Question 4 When the sampled NSQIP-Pediatric patients were compared with total patients with diagnosis codes collected by NSQIP who had occurrences tracked by NSQIP (group D), it was found that:
J Am Coll Surg
a) NSQIP-Pediatric patients had a higher complication rate than all patients with all complications. b) NSQIP-Pediatric patients had a statistically equivalent complication rate to all patients with all complications. c) NSQIP-Pediatric patients had a lower complication rate than all patients with all complications. d) This comparison cannot be performed because of low inter-rater reliability rate among data collectors for each database. e) This comparison cannot be performed because the event rate for both groups is too low to make meaningful statistical conclusions. Critique: When single outcomes are compared between these 2 groups, there is no statistical difference between the outcomes except for organ/space surgical site infection, unplanned reintubations, and perioperative (within 72 hours) blood transfusions. Perioperative transfusions are not routinely reported in the surgical or anesthesia morbidity and mortality conferences. Regarding unplanned intubations, we noted that PICaLO did not capture events that occurred beyond the immediate postoperative period, around 21 to 30 days. Single chart reviews showed these events to be unrelated to the operation. Airway stabilization was typically required due to altered mental status, sepsis, or progression of disease. Group D was the subset that was most similar to the NSQIPPediatric dataset in that it included cases with the same CPT codes and the same postoperative occurrences. However, it also included occurrences beyond 30 days after surgery. NSQIP-Pediatric had a significantly higher rate of postoperative occurrences compared with group D (12.5% vs 9.4%, respectively; p ¼ 0.004). The proportion of cases with 2 or more occurrences was also significantly higher in the NSQIP-Pediatric dataset when compared with PICaLO group D (p ¼ 0.0183).
Vol. 221, No. 4, October 2015
Continuing Medical Education Program
899
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue). Issues are available for the past 24 months. You can print your certificate immediately.
For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
October 2015 Featured Articles, Volume 221 Using human factors and systems engineering to evaluate readmission after complex surgery Acher AW, LeCaire TJ, Hundt AS, et al. J Am Coll Surg 2015;221:810e820 Does the American College of Surgeons NSQIP-Pediatric accurately represent overall patient outcomes? Gross ER, Christensen M, Schultz JA, et al. J Am Coll Surg 2015;221:828e836