First Look: The American College of Surgeons Clinical Congress

All articles by ETHAN COVEY

Cutting Hospital Stay May Increase Complications

Focusing on shortening patients’ length of stay (LOS) following surgery may result in increased rates of postdischarge complications, according to a new study.

“LOS has been used as a meaningful outcomes measure and as a potential target for quality improvement,” said Roujia D. Li, MD, of Northwestern University Surgical Outcomes and Quality Improvement Center, in Evanston, Ill. “One way is by introducing accelerated pathways to decrease LOS, such as an enhanced recovery protocol.”

However, Dr. Roujia questioned whether a push toward shorter LOS has resulted in shifting complications to the post-discharge setting.

To answer this question, Dr. Roujia and her colleagues set out to characterize changes in LOS and post-discharge complications over time, and to evaluate risk factors associated with post-discharge complications.

Using data from the ACS National Surgical Quality Improvement Program (or NSQIP) Procedure-Targeted database, patients were identified who underwent colorectal, esophageal, hepato-pancreatico-biliary, gynecologic and urologic surgery from 2014 to 2019.

Among a total of 538,712 patients, median LOS decreased from three days in 2014 to two days in 2019. Additionally, overall postoperative complications, readmission rates, median LOS and mortality rates all decreased with time.

In contrast, while rates of postoperative complications often fell, those for post-discharge complications did not. The proportion of postdischarge complications—including surgical site infection/wound dehiscence, infections such as pneumonia, urinary tract infection, sepsis, cardiovascular complications and venous thromboembolism— increased from 44.6% in 2014 to 56.5% during 2019.

Patient characteristics associated with post-discharge complications included age, race/ethnicity, American Society of Anesthesiologists physical status class, functional status, body mass index and other comorbidities.

“It is crucial to develop a patient monitoring program to focus on the early identification and management of post-discharge complications,” Dr. Roujia said.

The way in which information about risks of treatments is communicated to patients can have a significant effect on their perceptions and decision making.

“Surgeons must frequently communicate the probability of various treatment outcomes, complications and chances of cure to their patients to help them make health care decisions,” said Joshua Eli Rosen, MD, of the Surgical Outcomes Research Center at the University of Washington, in Seattle. “Prior studies have shown that how probability information is communicated can impact its interpretation and ultimately decisions that are made with it.”

Yet, despite these concerns, no standard practice exists for how surgeons should communicate such information to their patients.

To further study the effect of different communication approaches, an online survey was conducted that queried respondents on a set of complications associated with surgical and antibiotic treatment of appendicitis.

Risk information was presented either verbally (i.e., “uncommon”), as quantitative point estimates (i.e., 3%), or via quantitative ranges (i.e., 1%-5%). Next, participants were asked to estimate the likelihood of a complication occurring for an average person with appendicitis. A total of 296 respondents completed the survey, with a mean age of 37 years.

Verbal risk communications were found to result in significantly higher ranges of risk estimates for each surveyed complication, and were found to consistently lead to overestimation of risk.

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Frederick L. Greene, MD Charlotte, NC

Gina Adrales, MD, MPH Baltimore, MD Maurice Arregui, MD Indianapolis, IN Philip S. Barie, MD, MBA New York, NY L.D. Britt, MD, MPH Norfolk, VA James Forrest Calland, MD Charlottesville, VA David Earle, MD Lowell, MA Sharmila Dissanaike, MD Lubbock, TX Edward Felix, MD Pismo Beach, CA Robert J. Fitzgibbons Jr., MD Omaha, NE Michael Goldfarb, MD Long Branch, NJ Leo A. Gordon, MD Los Angeles, CA Gary Hoffman, MD Los Angeles, CA Melissa Red Hoffman, MD Asheville, NC William Hope, MD Wilmington, NC Namir Katkhouda, MD Los Angeles, CA Jarrod Kaufman, MD Brick, NJ Peter K. Kim, MD Bronx, NY Lauren A. Kosinski, MD Chestertown, MD Marina Kurian, MD New York, NY Raymond J. Lanzafame, MD, MBA Rochester, NY Timothy Lepore, MD Nantucket, MA Robert Lim, MD Tulsa, OK John Maa, MD San Francisco, CA Gerald Marks, MD Wynnewood, PA Yosef Nasseri, MD Los Angeles, CA Eric Pauli, MD Hershey, PA Richard Peterson, MD San Antonio, TX Ajita Prabhu, MD Cleveland, OH Bruce Ramshaw, MD Knoxville, TN David M. Reed, MD New Canaan, CT Patricia Sylla, MD New York, NY Dana Telem, MD Ann Arbor, MI Paul Alan Wetter, MD Miami, FL Linda Wong, MD Honolulu, HI MISSION STATEMENT OF GSN It is the mission of General Surgery News to be an independent and reliable source of news and analysis about the current state of surgery. It strives to provide a venue for discussion and opinions, from all viewpoints, on the issues most important to surgeons. DISCLAIMER Opinions and statements published in General Surgery News are of the individual author or speaker and do not represent the views of the editorial advisory board, editorial staff or reporters. DISCLOSURE POLICY We endeavor to obtain relevant financial disclosures from all interviewees and rely on our sources to accurately provide this information, which we believe can be important in evaluating the research discussed in this publication.

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“There are many reasons why a surgeon may want to use a verbal descriptor of risk,” Dr. Rosen said. These may include convenience and fluidity of communication, lack of precise numerical estimates, or hesitation to communicate data with greater certainty than they feel is warranted by existing data.

“However,” Dr. Rosen added, “we must recognize that by addressing these concerns with verbal descriptors alone, we are simply passing that uncertainty and variability to the patient in an uncontrollable way that may result in suboptimal decision making.”

Although verbal descriptors of probability resulted in greatly variable and inaccurate interpretations of risk, participants were able to accurately interpret numerical point estimates and ranges.

“This is particularly notable given that many surgeons may be concerned that too much numerical risk information may overwhelm patients,” Dr. Rosen said. “These data may be used to inform how surgeons communicate probability of risks and benefits to their patients.”

Providing surgical staff with case cost receipts, which detail expenditures for procedures, can lead to sustainable cost-saving procedures.

“Health care costs in the U.S. continue to escalate at a rate outpacing general inflation, and operating room (OR) costs comprise nearly 25% of all inpatient health care costs,” said Bradley S. Kushner, MD, of the Department of Surgery at Washington University in St. Louis, citing data from a Peterson-KFF analysis of Organisation for Economic Co-operation and Development and National Health Expenditure data.

“By directly controlling OR supplies utilized, surgeons play a key role in reducing health care expenditure,” Dr. Kushner added.

Starting in the spring of 2020, Washington University in St. Louis began providing surgical faculty with case supply receipts, delivered immediately through the electronic health record following each surgical case. The receipts detailed total procedure costs, itemized breakdowns of supplies used during the surgery, and provided a comparison of overall costs with institutional peers.

Dr. Kushner and his colleagues conducted a survey to evaluate perceptions of the cost receipts and their effectiveness in enacting individual practice and/or cultural change.

A total of 119 individuals completed the survey. Response to the case receipts was very strong, with 62% very/extremely interested in the practice, and 74.5% commenting that they reviewed the receipts daily. In addition, 87% noted a feeling of responsibility for lowering costs. Over half reported that viewing the receipts resulted in altering their surgical technique due to cost feedback, 60% changed surgical supplies used, and 80% of the general surgery faculty reported now being aware of how to lower OR costs.

“Next steps include evaluating whether this perceived cultural change has led to actual decreases in OR costs,” Dr. Kushner said.

Patients who undergo procedures performed by surgeons who work at multiple sites (MSS) have higher 30-day readmission rates than patients receiving care from single-site surgeons (SSS).

“Integration of hospitals into systems raises concerns about the safety of surgeons operating at multiple sites,” said Ava Ferguson Bryan, MD, a general surgery resident at the University of Chicago, an MPH candidate at the Harvard T.H. Chan School of Public Health, in Boston, and an incoming ACS-MacLean Center Surgical Ethics Fellow at the University of Chicago.

Previous research has shown that surgeons who operate at single and multiple sites have equivalent mortality outcomes, but questions remain about the continuity of care provided by MSS.

“The literature currently lacks evaluation of SSS versus MSS surgeons on quality metrics other than mortality,” Dr. Bryan added.

Dr. Bryan and her colleagues analyzed Medicare data from patients who received surgery for hip/knee replacement, prostatectomy, colectomy, pulmonary lobectomy, abdominal aortic aneurysm repair and coronary artery bypass surgery via either SSS or MSS during 2011 to 2016.

Overall, MSS had significantly higher rates of 30-day readmission than SSS (8.78% vs. 8.66%; P<0.01), and the gap in performance of MSS versus SSS widened over time. When the data were stratified by system status, MSS performed more poorly in-system and not in-system (8.81% vs. 8.74%; P=0.09 and 9.26% vs. 9.06% P=0.05).

While the differences in rates were statistically significant, Dr. Bryan noted that it was unknown whether there were differences clinically, and there may not be major harm related to surgeons operating at multiple sites.

However, the trends may reflect fragmentation of care across sites.

“As health systems continue to expand and consolidate, we need to continue to monitor these trends in surgical quality to ensure consistency of care, whether the operation is performed by a SSS or MSS,” Dr. Bryan said.

Mass shootings occur most often in areas of the United States that have generally low access to trauma centers, resulting in a significant disparity in how communities can react to these events.

“Despite increasing gun violence and mass shooting incidence, advances in pre-hospital care and trauma systems have led to a decline in mortality,” said Kaylin Beiter, PhD, a third-year medical student at Louisiana State University School of Medicine, in Baton Rouge. “However, access to this lifesaving care may not be universal.”

To study this correlation, Dr. Beiter and her colleagues compared the locations of Level 1 and Level 2 trauma centers, extracted from the online registries maintained by the ACS and the Trauma Centers of America, with locations of mass shootings taken from the Gun Violence Archive. Mass shootings were defined as four or more people shot at a single event.

A total of 564 trauma centers and 1,672 mass shooting incidents were included in the analysis.

Overall, states with the greatest discordance between the number of mass shooting events and trauma care centers were generally clustered in the southeastern United States. Median household income was not significantly correlated with the number of trauma centers or the number of mass shootings. In contrast, it was significantly correlated with the ratio of mass shootings to trauma centers.

“These states where there was a high discrepancy in burden of mass shootings relative to need were also the states where there was a really high percentage of the population below the federal poverty limit,” Dr. Beiter said.

“Poverty remains a factor that must be considered when examining these systemic disparities, and overall there may be a need for improvement in hospital infrastructure in states and communities with high levels of poverty, rather than simply allocating resources to communities with obvious high levels of mass shootings,” Dr. Beiter noted. ■

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training also have sent a clear message to all residency training directors.

I am particularly delighted that the new 2020 Standards of the ACS Commission on Cancer introduced the concept of reporting essential elements of a cancer operation using a synoptic template. These standards will be highlighted outside of the traditional narrative or operative templates used. By means of this approach, important components of oncologic procedures will be mandated, and recognition of these standards will be made easier at future accreditation site visits. There are two important barriers to using information: 1) a significant amount of information is locked in text format, making it difficult to pull from the records; and 2) the textual information in the record is variable in content, accuracy and quality. These two barriers limit the usefulness of information, which becomes particularly evident when attempting to measure and track quality. An ideal future state involves surgeons having an efficient mechanism to document relevant information that allows for automatic extraction for use in front-line clinical care tools and for quality and research purposes.

My main concern, however, as one trained to report using a narrative approach, is that we may find it more Multiple articles in the peerreviewed literature have supported the notion that these templative approaches may actually capture the important elements of an operation better than the traditional narrative formats and, perhaps more importantly, allow for more complete billing!

difficult to personalize our operative descriptions in the future as we migrate to complete templative reporting. Will the templates allow for archiving all important elements of an operation? Will a template permit describing any unforeseen issues that arise? Will the template give opportunity to describe arcane anatomic variants? We must always realize that not only is the operative record the best source of cataloging and subsequently reviewing an operative event; it is also a formidable medicolegal document. Will a templative approach satisfy that role? Stay tuned! ■