L. A. Gurien1, J. Ra1, H. Kendall1, L. Palmer1, A. J. Kerwin1, J. J. Tepas1 1University Of Florida College Of Medicine – Jacksonville,General Surgery,Jacksonville, FL, USA
Introduction:
The NSQIP dataset tracks specific patient comorbid conditions (CM) and post-operative adverse events (AE). While CM do not always cause AE, analysis of a matrix of concurrent CM and AE demonstrates interaction of CM and AE to define risk from a population perspective. Using our surgical performance dashboard which tracks population risk, categorizes effect of AE using the Clavien-Dindo (C-D) system, and ranks individual provider performance, we evaluated the effect of our surgical quality program over a four year period. We hypothesized that the dashboard would document dominant risk factors, guide analysis of “unexpected” AE occurring with no CM, track AE effect, and define specific procedures and providers for focused assistance in managing risk.
Methods:
Two 12-month cohorts of general-vascular cases from 2013-14 and 2016-17 were evaluated. We analyzed concomitant occurrence of CM and AE to define most common CM with highest AE rate, and most common AE and associated CM. “Unexpected” AE without CM were analyzed by CPT and type of AE. The impact of AE regarding additional resource consumption was compared across study periods using Wilcoxon matched pairs test accepting p<.05 as significant. Reflecting a “march to zero”, individual performance was measured as a surgeon’s proportion of AE divided by proportion of cases performed. Scores within the group mean ±1 SD were classified as “expected” and lower outliers as “exceptional”.
Results:
The 2013-14 cohort consisted of 651 cases with 21% (n=137) incidence of AE. The 2016-17 cohort consisted of 596 cases with 20% (n=120) incidence of AE. For both groups, hypertension was associated with highest incidence and severity of AE, and transfusion within 72 hr. was the most common AE. C-D effect analysis demonstrated a shift over time to less severe AE (Figure), although not statistically significant (p=.625). Of cases with unexpected AE based on no CM, 90% were elective oncologic procedures with infection and sepsis as the most common AE. Provider performance over time identified the same surgeons with the highest AE/volume; however scores improved over time for >50% of participants.
Conclusion:
This dashboard analysis demonstrates that hypertension, which is often clinically silent, is a population time bomb for adverse surgical outcome. Review of cases with unexpected AE illustrated the primacy of optimization and infection control as major adjuncts in these mostly elective complex cases. Individual provider and group performance identified quality improvement over time and a consistent provider cohort whose case mix mandates more aggressive preemptive strategies for avoidance of adverse events.
