55.10 A Nationwide Analysis of Outcomes in Patients with Myasthenia Gravis Undergoing Non-Thymic Surgery

Posted on January 26, 2017

R. H. Hollis1, L. N. Wood1, J. S. Richman1, M. S. Morris1, D. I. Chu1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction:
Patients with myasthenia gravis (MG) are at risk of myasthenia crisis when subjected to stress.  We examined the frequency of major, non-thymic surgery in patients with MG and hypothesized that MG would be associated with higher rates of postoperative complications, specifically respiratory failure.

Methods:
Patients undergoing colectomy, coronary artery bypass grafting (CABG), hysterectomy, and total hip replacement during 2012-2013 were identified in the Nationwide Inpatient Sample.  The primary outcome was inpatient respiratory failure; secondary outcomes included a composite of other inpatient complications and mortality.  Logistic regression was used to examine the association between MG and complications adjusting for patient, procedure, and hospital factors.  

Results:
Among 2,227,310 patients undergoing one of the four surgical procedures, 1780 (0.08%) had a history of MG.  The proportion of patients with MG was highest for colectomy (0.14%; n=670) followed by total hip replacement (0.08%; n=740), CABG (0.06%; n=210), and hysterectomy (0.03%; n=160).   The respiratory failure rate was 3.2%.  Additional inpatient complications occurred in 13.7% and mortality occurred in 1.5%.  In adjusted analyses, MG was associated with higher odds of respiratory failure compared to non-MG patients (OR 1.68; 95%CI 1.11-2.54).  However, patients with MG had similar adjusted odds of other complications (OR 1.03; 95%CI 0.75-1.40) and mortality (OR 0.69; 95%CI 0.32-1.50) compared to patients without MG.  Plasma exchange or intravenous immunoglobulin administration was utilized in only 3.6% of patients with MG.

Conclusion:

Patients with MG undergo major, non-thymic surgical procedures and are associated with significantly higher risk of inpatient respiratory failure, but not mortality or other complications. 

 

55.09 Perioperative antibiotics should be used for operative placement of implanted central venous ports

Posted on January 26, 2017

C. L. Scaife1, M. C. Mone1, M. E. Bowen1, D. S. Swords1, C. Zhang2, A. P. Presson2, E. W. Nelson1  1University Of Utah,General Surgery/Department Of Surgery,Salt Lake City, UTAH, USA 2University Of Utah,Epidemiology/Department Of Internal Medicine,Salt Lake City, UTAH, USA

Introduction: Central venous access ports (CVAP) are subcutaneously implanted devices used for delivery of long-term chemotherapy. There is a temporal risk for catheter related infection (CRI) to time of insertion (≤ 30 days). Perioperative prophylactic antibiotics (PABX) are often used in high risk populations and to meet Surgical Care Improvement Project standards. We previously reported a study (n=459), with a 2% CRI rate, all occurring in those without PABX. We also surveyed 5,000 members of American College of Surgeons and found that of those respondents placing CVAP (882 of 1,091), 88% gave PABX. Given these data, and growing concerns of antibiotic resistance; we expanded our dataset and employed propensity analysis to better understand the need for PABX use.

Methods: We conducted a retrospective, cohort analysis of CVAP placed (2007-2012) by two surgeons, in the operating room, at a university cancer center. We excluded patients currently receiving antibiotics and cases with concurrent surgical procedures. We evaluated whether PABX protected against CRI using propensity scores with matched weights. We used a total of 15 covariates, demographic and clinical, (see Table) with balance checked using standardized differences. Odds ratios (OR), 95% confidence intervals (CI), and p-values were reported for CRI at 14-day and 30-day totals.

Results:There were 1,091 CVAP placed, where 651 (59.7 %) received PABX and 440 (40.3%) did not. The majority, 95.7%, were placed in the internal jugular (n=1,044). The CRI rates for 14-day and 30-day totals were 0.82% (n=9) and 1.47% (n=16), respectively. Removal of CVAP occurred in 10 cases (63%). While results did not achieve statistical significance, use of PABX was associated with a clinically significant, 58%, reduction in the odds of 14-day CRI (OR=0.42, 95% CI: 0.05-2.28, p=0.34) and a 26% reduction of 30-day CRI (OR=0.74, 95% CI: 0.20-2.60, p=0.64).

Conclusion:This cohort analysis controlling for multiple covariates, examined PABX use in CVAP placement and found an overall lower rate of CRI. Although the results did not achieve statistical significance, the 58% reduction in odds of CRI within 14-days and 26% reduction within 30-days, point to clinically meaningful reductions in CRI when PABX are used. With so few CRI events, an extensive study, including thousands of patients would be required to achieve definitive results. The current findings are consistent with our previous research, suggesting a reduction in CRI with the use of PABX. Since treatment for a CRI can range from a course of oral antibiotics, or port removal and replacement, to admission for profound sepsis in an already immunocompromised patient, we suggest a conservative strategy of using PABX as the standard of care.

 

55.08 Positive Communication during Awake Surgical Procedures

Posted on January 26, 2017

C. S. Smith3, K. Guyton1, N. Schindler1,4, A. Langerman2  1University Of Chicago,Department Of Surgery,Chicago, IL, USA 2Vanderbilt University Medical Center,Department Of Otolaryngology,Nashville, TN, USA 3University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA 4Northshore University Health System,Department Of Surgery,Evanston, IL, USA

Introduction:
With improved local and regional anesthetic techniques, increasing numbers of procedures are performed on awake patients. However, patients report mixed perspectives on undergoing such procedures. The patient experience, increasingly used as a metric for quality and reimbursement, offers a critical impetus for optimizing surgeon communication during awake surgery. Patient input in this context is crucial, particularly in academic hospitals where attending surgeons must balance coaching and instruction of trainees and reassuring dialogue with patients.

Methods:
We contacted patients who underwent awake procedures at an academic institution in Urology, Ophthalmology, and Orthopedic Surgery over a two-month period. Patients were called within 21 days post-procedure and consented to participate in audio-recorded semi-structured interviews regarding their experience with communication during the procedure. Interviews were transcribed, coded and reviewed using the constant comparative method until thematic saturation was reached.

Results:
Forty (67%) of the 60 patients contacted during the study period agreed to participate.  Of these 40 patients, 32 (80%) cited some communication that made them feel good or better during their procedure. The positive communication cited by these patients fit into the themes of Perioperative Communication, Managing Expectations, Distraction, Emotional Comfort, Physical Comfort, Physician Qualities, Staff Interactions, and Prognosis. The most frequently expressed themes were Distraction (13/32 patients; 17 total comments), Managing Expectations (11/32; 11), Staff Interactions (9/32; 9), and Emotional Comfort (8/32; 9).

Conclusion: 

Eighty percent of patients reported positive experiences related to communication during awake procedures. This highlights that surgeons’ communication practices in the procedure room impact the patient’s awake surgery experience. Additionally, this research points to the importance of patients’ interactions with non-surgeon personnel. The most commonly referenced themes offer a framework for further development of best practices for communication in this context. Surgeons should consider the importance of managing patients’ expectations regarding the procedure, distracting them from the procedure at hand, and ensuring comfort. In prior research (1) we found that surgeons are aware of many of aspects of communication that contribute to both positive and negative (2) patient experiences. Surgeons’ success in utilizing the communication techniques that contribute to patients’ positive experiences will be imperative in developing a curriculum for communication during awake surgical procedures.

1. Smith, Claire S et al. Surgeon-Patient Communication during Awake Procedures. The American Journal of Surgery (in press).

2. Smith, Claire S et al. Negative Patient Experiences during Awake Procedures. The AAMC Medical Education Meeting; Seattle, WA (accepted 2016). 

55.07 The Center Volume-Outcome Effect in Pancreas Transplantation: A National Analysis from 2009-2012

Posted on January 26, 2017

V. K. Dhar1, Y. Kim1, K. Wima1, B. T. Xia1, R. Hoehn1, T. Diwan1, S. A. Shah1  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA

Introduction:  While increased hospital volume has been correlated with improved outcomes in certain surgical procedures, the effect of center volume on pancreas transplantation (PT) is less understood. Our study aims to establish whether a volume-outcome effect exists for pancreas transplantation. 

Methods:  Through an established linkage between the University HealthSystem Consortium and the Scientific Registry of Transplant Recipients databases, we performed a retrospective cohort analysis of adult PT recipients between 2009 and 2012. Surgical volume was trichotomized equally into low volume (LV), middle volume (MV), and high volume (HV) tertiles for each year that was studied. Median follow-up period was two years. Statistical analysis was performed using regression analyses and the Kaplan-Meier method.

Results: Among the 2,309 PT recipients included, 815 (35.3%) were performed at LV centers, 755 (32.7%) at MV centers, and 739 (32.0%) at HV centers. Compared with PT recipients at MV and LV centers, HV patients were more likely to have private insurance (51.7% vs 46.1% vs 39.9%, P < 0.0001), be of older age (31.5% >50 years old vs. 20.9% vs. 19.8%, P < 0.0001) and have worse functional status (38.3% dependent vs. 9.4% vs. 9.5%, P < 0.0001). Patient and graft survival were similar across hospital volume tertiles. Center volume was not predictive of readmission rates, total length of stay, intensive care unit length of stay, or total direct cost on multivariate analysis.

Conclusion: Whereas low surgical volume portends worse outcomes in selected procedures, short and long term PT outcomes are not affected by hospital volume. However, HV centers treat patients who are older and have worse functional status, without adversely impacting their short term performance.

55.06 Management of Periapical Abscess in the Emergency Department

Posted on January 26, 2017

A. Gupta1,2,3, W. A. Davis1,2,3, E. B. Schneider1,2,4  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3Harvard School Of Public Health,Boston, MA, USA 4Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:
Drainage of periapical abscess is one of the 44 surgeries identified as essential by the World Bank in 2015; the procedure meets the specific World Bank criteria of addressing a substantial need, being cost effective and feasible to implement. Periapical abscess is easily preventable through timely dental intervention; however, if untreated, periapical abscesses can lead to Emergency Department (ED) presentation for treatment.  We sought to describe the outcomes of patients who present to ED with periapical abscess, in terms of the procedures they receive in the ED and their subsequent disposition from ED. We also examined these outcomes with respect to patient insurance status and income level.

Methods:
Using the Nationwide Emergency Department Sample (NEDS) from 2006-2009 provided by Healthcare Cost and Utilization Survey (HCUP), we identified patients who presented with the primary ICD 9 Diagnosis Code 522.5 and 522.7. Analyses were performed using data weighted to represent national level estimates.

Results:

A total of 1,348,810 patients presented to the ED with a primary diagnosis of periapical abscess during the study period. Overall 10.5% presented at Level 1 trauma center. Most common procedure (37.65%) documented was ‘Brief Interview and Evaluation’. Next most common procedure was gum and alveolar incision (24.03%). Of those who received only Brief Interview and Evaluation, 80.41% did not undergo any other procedure during the ED visit and 35.32% of those were recorded as having symptoms representing moderately complex decision making along with symptoms classified as highly severe requiring urgent/immediate care. 99.2% of patients who received only Brief Interview and Evaluation, and underwent moderately complex decision making associated with symptoms requiring urgent or immediate care, were discharged routinely.

Of these who only received interview and evaluation and were routinely discharged, 85.6% were classified as having incomes below the 50th percentile. Nearly half (49.2%) of the patients whose only recorded treatment was interview and evaluation were classified as “self-pay” and 23.4% were classified as having private insurance.

Conclusion:
Most patients presenting with periapical abscess receive only symptomatic treatment or no procedure-based treatment at the ED. The majority of these patients were classified as low income and “self pay” leading to concerns that these patients may not seek timely definitive treatment for their condition at a dental clinic. This study highlights the possible importance of access to primary dental care to prevent ED visits for periapical abscess and reduce the need for oral-surgical intervention.

55.05 Inference From Observational Research Methods (INFORM) Project: Facilitating Evidence Interpretation

Posted on January 26, 2017

C. C. Chrystoja1,2, N. Baxter1,4, C. Bell1,5, G. Tomlinson1,2, D. Urbach1,2,3  1University of Toronto,Institute Of Health Policy, Management And Evaluation,Toronto, Ontario, Canada 2University Health Network,Toronto, Ontario, Canada 3Women’s College Hospital,Toronto, Ontario, Canada 4St. Micheal’s Hospital,Toronto, Ontario, Canada 5Mount Sinai Hospital,Toronto, ON, Canada

Introduction:  Poor-quality studies have frequently led to the adoption by mainstream medicine of surgical techniques and devices that were, at a later date, found to be faulty and devastating in their adverse outcomes for patients. There are many examples where clinicians, healthcare decision-makers, and regulators were unaware of the true risks of emergent medical technologies because no high-quality randomised studies evaluated the risks of the procedure and existing non-randomised studies were systematically biased. Our objective was to determine the extent to which study attributes associated with bias influence effect estimates in non-randomised studies.

Methods: We selected three case examples in different clinical areas, with representation of surgical procedures, medical devices, and drug therapy, including: (1) off-pump versus on-pump coronary artery bypass grafting, (2) mesh-augmented versus native tissue pelvic organ prolapse repair, and (3) hormone replacement therapy for postmenopausal women. MEDLINE was searched to identify non-randomised comparative studies and related systematic reviews, whose references were examined to identify additional studies. Study attributes were extracted using the INFORM tool, a quality assessment instrument we developed based on a conceptual framework of bias, review of existing instruments, consultation with experts, and an interactive process piloted with users of varying epidemiological backgrounds. Fixed-effects meta-analyses were separately performed for each outcome of interest: reintervention and stroke (for case #1), mesh erosion and incontinence (for case #2), and all-cause death and cardiovascular events (for case #3). Meta-regression was used to explore the effect of study attributes on outcomes.

Results: A total of 96 non-randomised studies were identified for case #1, 30 studies for case #2, and 39 studies for case #3. In case #1, 22 studies with 85,542 participants evaluated reintervention as an outcome and 82 studies with 698,776 participants assessed stroke. Sixteen studies with 2,154 participants evaluated mesh erosion in case #2 and 13 studies with 7,409 participants examined incontinence. In case #3, 12 studies with 514,872 participants looked at all-cause death and 17 studies with 262,329 participants assessed cardiovascular events. See Figure 1 for details.

Conclusion: Studies that did not match in the design phase showed a greater treatment benefit for off-pump coronary artery bypass grafting and hormone replacement therapy compared to studies that used a systematic approach. However, the other study attributes were associated with different direction and magnitude of treatment effects.

55.04 Utility of the AM-PAC Tool to Assess Post-Operative Functional Status and Predict Readmissions

Posted on January 26, 2017

J. K. Johnson1, R. L. Marcus1, G. J. Stoddard3, J. M. Fritz1, C. S. Noren4, B. S. Brooke2  1University Of Utah,Physical Therapy,Salt Lake City, UT, USA 2University Of Utah,Surgery,Salt Lake City, UT, USA 3University Of Utah,Internal Medicine,Salt Lake City, UT, USA 4University Of Utah,Rehabilitation Services,Salt Lake City, UT, USA

Introduction:  While an association between patients’ functional status and 30-day hospital readmission has been demonstrated in recent studies, the optimal tool to measure functional status during the post-operative period remains unclear. One potential tool is the Activity Measure for Post-Acute Care “6-Clicks” Basic Mobility Short Form (AM-PAC), which can be integrated into an electronic medical record and completed by providers in less than one minute. This study was designed to evaluate the utility of the AM-PAC for assessing post-operative functional status and its ability to predict risk for 30-day hospital readmission following major surgery.

Methods:  We identified all patients at a single academic hospital who underwent a major cardiothoracic, vascular, or general surgery procedure between August 2014 and July 2016 and underwent assessment of post-operative functional status using the AM-PAC.  Patient mobility at the time of hospital discharge was categorized by tertile of AM-PAC scores into high, low and very low.  The association between mobility tertiles and readmission risk was assessed using mixed effects Poisson regression models that controlled for patient-level confounders.

Results: Among 2,105 patients who underwent major surgery during the time period [640 (30%) cardiothoracic, 383 (18%) vascular, and 1,082 (52%) general surgery procedures], a total of 1,001 (48%) patients were assessed with AM-PAC at discharge. The overall 30-day readmission rate was 14.9%, and was significantly higher among patients in the lowest tertile of AM-PAC scores (22.6% low vs. 12.5% high; P=0.003).  Among all surgical patients, individuals with very low mobility at the time of hospital discharge had a significantly higher risk for readmission (aRR:1.57; 95%CI, 1.05-2.35) compared to patients with high mobility. This effect was found across different surgical specialties, including patients undergoing cardiothoracic (aRR:2.00; 95%CI, 1.02-3.93) and vascular (aRR:2.99; 95%CI, 0.98-9.12) surgery procedures, but was not significant for patients undergoing general (aRR:1.04; 95%CI, 0.58-1.87) surgeries (Figure).

Conclusion: Post-operative mobility can be easily assessed using the AM-PAC tool and used to predict 30-day readmission for diverse cohorts of surgical patients. Recognition of poor functional status in surgical patients prior to discharge can help identify the need for additional targeted physical therapist interventions and enhanced discharge planning as a strategy to reduce hospital readmissions.

55.03 The Infundibular Approach is Often Mistaken as the Critical View of Safety during Cholecystectomy.

Posted on January 26, 2017

L. Traub1, C. Chen1, F. Palazzo1, E. Rosato1, H. Lavu1, J. Winter1, C. J. Yeo1, M. J. Pucci1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA

Introduction: Over 700,000 laparoscopic cholecystectomies (LC) are performed annually in the United States; and, while widely considered a safe operation, over 2000 bile duct injuries (BDI) occur.  The critical view of safety (CVS) is a method of secure ductal identification to prevent BDI.  Although, widely publicized, it remains unclear if surgeons understand its criteria, or may instead mistake the CVS for the “infundibular” approach, where BDI is possible.

Methods: Fifty-one LC were recorded via video and scored on a 6-point scale consisting of scores from 0 to 2 for each of the three criteria of the CVS.  The operative notes were reviewed. A survey was sent to surgical faculty who routinely performed LC during the study period, asking them to label various commonly performed maneuvers as: potentially harmful, not necessary, preferred but not necessary, or safe and mandatory.

Results: Thirty-seven (73%) of the 51 operative notes reviewed documented CVS achievement. Only 8 (16%) cases scored > 4 (considered adequate) when reviewed on CVS assessment. Of the three criteria, “exposure of the cystic plate” scored lowest, with a mean of only 0.3.  Twelve surgeons responded to the survey with 83% indicating visualization of only 2 structures entering the gallbladder is mandatory, 42% indicating that clearance of the hepatocystic triangle is mandatory, and only 25% responding exposure of the cystic plate was mandatory. However, 92% of respondents believe the “infundibular” approach is safe.

Conclusion: While experienced surgeons routinely mention the CVS in operative notes, these data suggest a misunderstanding of the three criteria, with a tendency towards the infundibular approach. Greater education is necessary, as the infundibular approach may result in BDI.

 

55.01 Does the Stapler Size Matter?

Posted on January 26, 2017

C. Shwaartz1, B. Cohen1, J. Leanza1, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,General Surgery,New York, NY, USA

Introduction:
A stapled anastomosis is commonly used during colorectal surgery for different indications. Stapled anastomoses have many advantages such as ease and speed of performance, potentially less manipulations of the anal canal, and more uniformity. The purpose of this study was to determine whether stapler size used at colorectal anastomosis affects outcomes.

Methods: This is a retrospective review of 230 patients that underwent colorectal anastomosis with the use of circular stapler between October 2013 and April 2016 at The Mount Sinai Hospital. Patients were divided into two groups based on size of the circular stapler (stapler size 25-29 mm vs 31-33 mm). Preoperative and postoperative factors including outcomes such as stricture, anastomotic leak, and functional outcomes such as the number of bowel movements per day, and incontinence were recorded and compared between the two groups.  A multivariate statistical analysis was carried out to assess the associations between the stapler size and the outcomes. Patients were then called for follow up in order to assess for functional outcome using the Wexner score along with other measures.

Results:

 230 patients who underwent rectal surgery were identified. 72.2% had an anastomosis performed using a 25 – 29mm circular stapler while 27.8% used a 31 – 33mm stapler. Both groups were comparable in regard to age, sex, comorbidities, smoking history, recent use of immune modulating medications or chemoradiation, procedure, indication, and the presence of bowel diversion. Those in the large stapler group were more likely to have an ASA of 3-5 vs 1-2 (P=0.05), they had a longer mean hospital stay (P=0.04) and those in the small stapler group were more likely to have a lower preoperative albumin (P=0.02). Multivariate analysis revealed that the stapler size did not predict the rate of anastomotic leak or stricture. Patients undergoing a low anterior resection with a colorectal anastomosis, compared to an anterior resection/sigmoidectomy, was significantly associated with anastomotic leaks. Additionally, the presence of bowel diversion significantly predicted stricture formation.
Regarding functional outcomes and quality of life, there was no difference found between the small and large stapler groups concerning number of bowel movements per day, presence of urgency, incontinence, pad use, clustering, need for constipating agents, any change in lifestyle reported, and mean Wexner score. Additionally, functional outcomes did not significantly differ between those asked within 1 year of bowel continuity and those who were asked after 1 year. 

Conclusion:
Different stapler sizes used in rectal surgery are not associated with long term outcomes.

 

54.20 Barriers to Creating a Surgery Clinic-Based Opioid Retrieval Program

Posted on January 26, 2017

E. Blay1, J. Thomas1, J. Stulberg1  1Northwestern University,Surgical Outcomes & Quality Improvement Center,Chicago, IL, USA

Introduction: Opioid analgesic therapy remains a cornerstone of post-operative pain management, yet the majority of pills dispensed at discharge are not consumed by patients.  While there are myriad factors leading to the current opioid epidemic, there is mounting evidence to suggest that surgeons significantly contribute to the problem primarily through unused narcotics leading to diversion. While the Office of National Drug Control Policy’s 2011 Prescription Drug Abuse Prevention Plan has recommended the creation of opioid retrieval or take-back programs to help prevent diversion of opioids to the community, many barriers exist. We describe our experience and review of the legal and medical literature to help identify these barriers and discuss key elements to implementation of an Opioid Retrieval program.

Methods: A comprehensive literature review was performed using MEDLINE, Embase and Google Scholar for studies or articles describing clinic-based opioid retrieval program, and an extensive legal document search was performed with the help of our legal counsel to identify the federal and local legal barriers.
 

Results: In 2014, The Drug Enforcement Agency (DEA) released the “Final Rule” to provide guidance on the implementation of programs geared towards the disposal of controlled substances. The following components are necessary: 1) A hospital/clinic needs to first register through the DEA; 2) There must be an on-site pharmacy or retail pharmacy; 3) There must be a secured one-way collection receptacle, and 4) The rules governing collection are separate from those of destruction.  The destruction of controlled substances must take place in an on-site incinerator or use of a reverse distributor approved by the DEA.  We were unable to find medical articles which described the implementation of such programs into medical or surgical clinics, but did find a handful of studies that evaluated drug disposal programs within pharmacies and community events.  It was found that while the creation of these disposal programs can decrease the risk of diversion in the community, and get more unused drugs out of individual’s homes, it was still necessary that these programs are combined with integrated proper disposal education to further increase knowledge and expand efforts.

Conclusion: Creation of a clinic-based drug take-back program is possible but legal barriers exist. There are federal laws that detail how this can occur but guidance for the medical community is lacking. Take-back programs have been successful public health tools in pharmacies and community-based programs suggesting they could have similar success in clinic-based programs, and offer greater opportunity as a location to provide disposal education. More research is needed to answer questions about the role surgeons’ play in the opioid epidemic and how various reduction efforts can benefit our patients and our communities.

 

54.19 Outpatient Follow-up Does Not Prevent ED Utilization By Trauma Patients

Posted on January 26, 2017

M. K. Dalton1, N. M. Fox1, J. M. Porter1, J. P. Hazelton1  1Cooper University Hospital,Trauma Surgery,Camden, NJ, USA

Introduction:  Despite the fact that most trauma centers have a regularly scheduled trauma clinic, research demonstrates that trauma patients do not consistently attend follow-up appointments and often utilize the emergency department (ED) for costly outpatient care. We hypothesized that patients who utilized trauma clinic following discharge would have decreased ED utilization.

Methods:  A retrospective review of outpatient follow-up of patients admitted to the trauma service (Jan 2014-Dec2014) at an urban level 1 trauma center was conducted. Patients ≥18 at time of admission and discharged alive (n=2134) were included. Demographics, clinical characteristics and care utilization data were collected.

Results: 217 patients (10%) were evaluated in trauma clinic following discharge from the hospital. 21% of patients seen in trauma clinic visited the ED within 30d compared with 12% of those not seen in clinic (p<0.001) [Figure 1]. There were a total of 104 patients readmitted within 30d of discharge; no difference existed in the rate of hospital readmission between patients seen in clinic and those not seen in clinic (p>0.05).  Stepwise logistic regression showed that clinic follow-up was not a significant predictor of decreased ED utilization (adjusted OR 1.16 [95% CI 0.78-1.72], p=0.461) and also showed that while ED use was a significant predictor of readmission (adj OR 216 [93-500], p<0.001), clinic visits were not (adj OR 0.74 [0.33-1.69], p=0.48). The five most common reasons for ED visits within 30d of discharge were: neurological complaint (n=38, 14%), Musculoskeletal pain (35, 13%), Infection (24, 9%), Unrelated illness or injury (24, 9%), and Wound care (23, 8%).

Conclusion: Outpatient follow up in the trauma clinic does not decrease ED utilization or hospital readmissions indicating that interventions aimed at improving access to a conventional outpatient clinic will not impact ED utilization rates. Further study is necessary to determine the best system for providing clinically appropriate and cost-effective outpatient follow-up for trauma patients.

 

54.18 Safety of Bariatric Surgery vs Total Joint Replacement in The Severely Obese patients

Posted on January 26, 2017

K. Spaniolas2, M. Grzybowski1, M. Ball1, Z. Schafer1, W. Pories1  1East Carolina University Brody School Of Medicine,Greenville, NC, USA 2Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  With the national increase in obesity, total knee/hip arthroplasty (TKHA) rates in the severely obese are accelerating. Success rates in this patient population are less established. Bariatric surgery, however, leads to sustainable weight loss, decreased symptoms of osteoarthritis, and broader health benefits apart from osteoarthritis. This study investigated 30-day morbidity in severely obese patients undergoing TKHA and elective laparoscopic bariatric (BAR).   

Methods:  Using ACS-NSQUIP 2006-2013 data, a retrospective cohort of 105,108 severely obese patients were eligible following the application of exclusion criteria (TKHA n=31436, BAR n=73672). Propensity matching kept 6,282 in each treatment group (c=.94). Rates and odds ratios (ORs) and 95% confidence intervals (CIs) were computed for the ORs: unadjusted (ORu), age and sex-adjusted (ORa), and propensity-adjusted (ORp) associations for serious morbidity.

Results: Among 12,564 matched patients, the mean age (SD) and BMI (SD) were 56 (8.1) and 43.3 (5.7), respectively, with 70% being female.  For serious morbidity the unadjusted and propensity-adjusted rates for TKHA and BAR, respectively, were 54.7% vs 45.3% and 8.2% vs 2.8%. The ORu=.32 (.30-.33), p<.0001; OR(a)=.44 (.41-.46), p<.0001, and ORp=.25 (.21-.29), p<.0001.

Conclusion: Our findings suggest BAR is associated a 75% less likelihood of developing serious early postoperative morbidity after matching on many confounders than TKHA.  However, more evidence-based longitudinal studies are needed to assess the efficacy of both procedures. 

 

54.17 Can Increased Trauma Mortality At Weekends Be Explained by Failure to Rescue?

Posted on January 26, 2017

D. Metcalfe1, O. A. Olufajo6, A. J. Rios-Diaz5, C. K. Zogg4, R. Chowdhury2,3, A. Haider2,3, J. M. Havens2,3, A. Salim2,3  6Washington University School Of Medicine,Department Of Surgery,St Louis, MO, USA 1University Of Oxford,Kadoorie Centre for Critical Care Research,Oxford, OXFORDSHIRE, United Kingdom 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3Harvard Medical School,Boston, MA, USA 4Yale University School Of Medicine,New Haven, CT, USA 5Thomas Jefferson University Hospital,Department Of Surgery,Philadelphia, PA, USA

Introduction:

Previous studies found that trauma patients admitted to US hospitals at weekends have higher odds of mortality. We hypothesized that providers respond less effectively to serious adverse events (SAEs) at weekends. The aim of this study was to determine whether the trauma “weekend effect” could be explained by differences in FTR, i.e. death subsequent to an SAE.

Methods:

An observational study was undertaken using the Nationwide Inpatient Sample (NIS) 2001-2011. All inpatients with a primary injury diagnosis (ICD-9-CM 800-957) were included. The outcome measures were SAE (myocardial infarction, venous thromboembolism, acute renal failure, respiratory failure, pneumonia, bleeding), in-hospital mortality, and FTR. Logistic multivariable regression models were used to adjust for patient- (age, sex, race, payer status, Charlson score, ISS) and hospital-level (trauma designation) characteristics. Counterfactual modeling was used to explore the hypothetical effect of eliminating FTR.

Results:

There were 1,727,124 individual patient records (8.5 million weighted admissions). The overall rate of SAE was 11.1% (11.3% weekend, 11.1% weekday, p<0.001), in-hospital mortality 2.3% (2.4% weekend, 2.2% weekday, p<0.001), and FTR 9.8% (10.0% weekend, 9.8% weekday, p=0.181). Weekend admission was independently associated with higher adjusted odds of SAE (aOR 1.09, 95% CI 1.08-1.11) and death (OR 1.12, 1.09-1.15) but not FTR (1.04, 1.00-1.09). Within a counterfactual model, increased weekend mortality was not reduced by eliminating FTR (aOR 1.11, 1.07-1.16).

Conclusion:

Trauma patients have higher odds of death when admitted at weekends. This finding is more likely to be explained by increased SAEs at weekends than by FTR.

 

54.16 Improving Coordination of Care in Surgical Patients: A Systematic Review

Posted on January 26, 2017

E. F. Yates1, S. T. Hawley1, A. M. Morris1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: Coordination of care has been identified as a priority by the United States Institute of Medicine and is frequently cited as an area for improvement in surgical care. Despite the wide recognition of this deficiency, little is known about the effectiveness of interventions specifically targeting care coordination in the surgical setting.  

Methods: We performed a systematic review of published literature from 2000-2016 adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with key words indicating surgical care and [“coordination” OR “continuity” OR “surgical home”], in the Central, CINAHL, EMBASE, Ovid and Scopus online databases. Exclusion criteria were non-English language, non-U.S. health care system, patients <18 years, absence of primary or secondary data, absence of an intervention to improve coordination of care with evaluation of outcomes. Identified papers were screened by abstract for exclusion. Remaining articles were independently reviewed by two investigators using a data abstraction tool to assess eligibility, purpose, design, results, conclusion and study quality. Studies were discussed to consensus.

Results: The initial search identified 1870 potential articles, of which 26 were duplicates. Abstract screening yielded 165 articles for full review. Among these, 24 were appropriate for inclusion in the final evaluation. 

Coordination of care was referred to but never explicitly defined in any article. All interventions were tailored to institution or system specific challenges, and consisted of planning sessions (e.g. value stream mapping), e-tools linked to electronic medical records, interpersonal communication tools, assignation of personal responsibility, and interdisciplinary use of midlevel providers. Interventions were deployed in 5 setting types: outpatient clinics (n=2), operating rooms (n=2), in-hospital patient hand-offs (n=2), in-hospital perioperative care (n=16), and transitions to outpatient management (n=2). Measured outcomes included clinical outcomes (n=17), cost/resource savings and timeliness (n=9), and staff perceptions (n=7). Several studies measured outcomes in multiple categories. Clinical outcomes included symptom resolution, mortality and complication rates, and satisfaction with care. Staff perceptions addressed a wide variety of issues ranging from perceived safety climate to perceived patient education. Overall methodological rigor was low; 25% of quantitative studies failed to use any statistical tests and all mixed or qualitative studies had an absent or insufficient methodology.

Conclusion: In spite of the widely acknowledged critical importance of improving coordination of care in U.S. surgical settings, it remains inconsistently defined and studied. Agreement regarding fundamental concepts and standardization of relevant measures could potentially improve coordination, which is applicable to all facets of quality in surgical care.

54.15 Overlapping or Concurrent Surgery – Resident and Faculty Assessment of the "Critical Portion"

Posted on January 26, 2017

J. A. Marks1, P. M. Batista1, S. M. Devitt1, F. Palazzo1, G. A. Isenberg1, C. J. Yeo1, K. A. Chojnacki1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA

Introduction:
With recent increased public awareness of concurrent surgery as a putative quality or outcome metric, delineating the critical part(s) of an operation for which a surgeon must be present is essential. We aim to define the critical portions of operations as seen by residents and faculty and hypothesize the two lack concordance.

Methods:
Each of our section chiefs (n=12) was asked to outline the key portion(s) of their most commonly performed operations for which attending surgeon presence is imperative. Our senior surgical residents (PGY≥3; n=24) were asked to submit the steps for a list of operations that required direct attending involvement. Residents did not collaborate across years. We had five lists with outlined critical steps submitted by faculty leadership and each PGY class. Results were tabulated and compared.

Results:
Data were obtained for 35 operations. PGY3s tended to list more critical steps (not all correct and in greater detail) than more senior residents. Attending surgeons were most concise in their descriptions and number of key steps. Residents noted most bedside procedures did not require attending presence. For some complex or emergent procedures, residents indicated the attending should be present for the entirety. Faculty noted the critical portions could differ given the resident’s skill. Residents identified many of the same steps as faculty, yet intermittently left out some or listed all operative steps.

Conclusion:
We demonstrated a greater concordance between residents and faculty in identifying critical portion(s) of operations than expected. There was a clear trend towards fewer critical portion(s) and more agreement with attending perceptions as residents progressed through training. Further evaluation of critical portions for which faculty must be present could have profound impact on resident education, reimbursement practices, and the delivery of surgical care.
 

54.14 An Estimation of Population-Level Obesity Rates Using Electronic Health Record Data

Posted on January 26, 2017

L. M. Funk1,2, Y. Shan1, C. I. Voils3,4, J. Kloke5, L. Hanrahan6  1University Of Wisconsin,Surgery,Madison, WI, USA 2William S. Middleton (Madison) VA,Surgery,Madison, 53792, USA 3Duke University Medical Center,Medicine,Durham, NC, USA 4Durham VA,Medicine,Durham, NC, USA 5University Of Wisconsin,Biostatistics & Medical Informatics,Madison, WI, USA 6University Of Wisconsin,Family Medicine,Madison, WI, USA

Introduction: The measurement of population-level obesity rates is important for informing policy and targeting treatment. The gold standard method of estimating obesity rates in the U.S. is the National Health and Nutrition Examination Survey (NHANES). Given that NHANES requires household visits for height and weight measurement, NHANES samples < 0.1% of the adult population and does not target state- or and health system-level measurement. The objective of this study was to assess the feasibility of using body mass index (BMI) data from the electronic health record (HER) in a large health system to assess rates of overweight and obesity. To explore the possibility of selection bias in EHR data, we also compared overweight and obesity rates in the EHR to national NHANES estimates.

Methods: Using outpatient data from 42 clinics, we studied 388,762 patients who had at least one primary care visit in 2011-2012. We compared crude and adjusted overweight and obesity rates by age category and ethnicity between EHR patients and NHANES participants. Adjusted rates of overweight (BMI>25.0-29.9) and obesity (class I: BMI 30.0-34.4; class II: 35.0-39.9; and class III: >40) were calculated in a two-step process. The first step accounted for missing BMI data using inverse probability weighting via a multivariable logistic regression, while the second included a post-stratification correction to adjust the EHR population to a nationally representative sample.

Results: 59.6% (n=192,039) of patients in the EHR had at least one BMI value in the dataset. 70.0% (95% CI 69.8-70.2) of adults were overweight or obese, while 17.0% (95% CI 16.8.-17.1) had class II or III obesity. Adjusted rates of obesity for EHR patients were 37.3% (95% CI 37.1-37.5) compared to 35.1% (95% CI 32.3-38.1) for NHANES patients. Adjusted class III obesity rates were 7.4% (95% CI 7.3-7.5) and 6.4% (95% CI 5.2-7.7) for EHR and NHANES participants, respectively. Among the 16 obesity class and ethnicity (White, Black, Hispanic, Other) strata that were compared between EHR and NHANES patients, 14 (87.5%) contained similar obesity estimates (i.e. overlapping 95% CIs; Figure).

Conclusions: Obesity estimates from the analysis of electronic health records were largely similar to national estimates generated by NHANES. The electronic health record may be an ideal tool for identifying and targeting patients with obesity for implementation of public health and/or individual level interventions, such as behavioral, medical and/or surgical treatment.

54.13 Trends In Surgical Post-Operative Mortality: Are We Doing Better?

Posted on January 26, 2017

W. T. Mehtsun1,3, J. F. Figueroa2,3,4, K. D. Lillemoe1,2, A. K. Jha2,3  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3Harvard School Of Public Health,Department Of Health Policy And Management,Boston, MA, USA 4Brigham And Women’s Hospital,Department Of Medicine,Boston, MA, USA

Introduction: A recent series of national policy efforts, from public reporting to pay-for performance, has been implemented to improve surgical outcomes in U.S. hospitals. Whether these increased efforts have led to an observable decrease in surgical mortality rates remains unclear. Therefore, we sought to determine whether national 30-day mortality rates after complex and common surgeries are declining.

Methods:   Using 100% inpatient Medicare-fee-for-service beneficiary data from 2005 to 2014, we identified patients undergoing the following complex and common surgical procedures:  coronary artery by-pass graft (CABG), abdominal aortic aneurysm repair (AAA repair), esophagectomy, pancreatectomy, cystectomy, pulmonary lobectomy, colectomy, appendectomy, cholecystectomy, hip replacement, and knee replacement.  For each procedure we used linear regression models with hospital fixed effects to calculate yearly 30-day surgical mortality rates – risk adjusted by age, gender, urgency and Elixhauser comorbidity indicators.

Results:  Between 2005 and 2014, 30-day surgical mortality declined for all eleven selected procedures (N= 7,729,564). The greatest declines in 30-day surgical mortality were seen in patients who underwent esophagectomy (-0.23% per year, p<0.001), AAA repair (-0.18% per year, p<0.001), pancreatectomy (-0.19% per year, p<0.001), and pulmonary lobectomy (-0.14% per year, p<0.001). Notably, improvements were occurring mainly within hospitals, except for pancreactectomy, esophagectomy, and cystectomy where greater than 50% of the overall mortality trend was due to between hospital differences.

Conclusions: National 30-day surgical mortality rates for complex and common surgical procedures have declined over the past decade.   Whether this national decline in surgical mortality is due to shifting of patients to higher quality hospitals, or general improvements in surgical management is unclear and needs to be better delineated.

54.12 Expanding the Donor Pool: How Many Donation After Circulatory Death Organs are we Missing?

Posted on January 26, 2017

W. Z. Chancellor1, E. J. Charles1, J. H. Mehaffey1, R. Hawkins1, C. Foster1, A. K. Sharma1, V. Laubach1, C. Lau1, I. L. Kron1, C. Tribble1  1University Of Virginia,Division Of Thoracic And Cardiovascular Surgery,Charlottesville, VA, USA

Introduction:  The number of patients with end-stage pulmonary disease awaiting lung transplantation is at an all-time high while the supply of available organs remains stagnant. Utilizing donation after circulatory death (DCD) donors may help to address the supply-demand mismatch. The objective of this study is to determine the potential for donor pool expansion with increased procurement of DCD organs from patients that die at hospitals.

Methods:  A chart review of all patients who died at a single quaternary-care institution between August 2014 and June 2015 was performed. Data collected on each patient included cause of death, presence of lung pathology, arterial blood gas data, and chest radiograph findings within 7 days of death. Candidates for lung donation after circulatory death were those less than 65 years old, free of any cancer, without lung pathology, and did not die of respiratory causes or sepsis.

Results: 853 patients died over a one-year period and were stratified by age into three groups: <15 years old (6.0% n=51), 15 to 64 years old (38.0% n=324), and >65 years old (56.0% n=478). The number of patients less than 65 years old was 375 (44.0%), those without cancer totaled 778 (91.2%), and those without lung pathology at the time of death totaled 512 (59%). Based on the aforementioned criteria, 85 patients qualified as candidates for lung donation after circulatory death (Pediatric n=10, Young n=75, and Old n=0). Patients categorized as potential donors were significantly more likely to have clear chest X-ray findings (24.29% vs 9.96%, p=0.0006) and higher mean PaO2/FiO2 (342.1 vs 197.9, p<0.0001) compared to those screened as not eligible to be donors.

Conclusion: A significant number of DCD lungs are available every year from patients that die in hospitals. We estimate a potential 400% increase in lung donors with the use of DCD lungs per comparable-sized hospital per year based on average of 20 lung donors per hospital per year.

 

54.11 Is There A Difference In The Demographic Factors Between Laceration And Gunshot Violence?

Posted on January 26, 2017

N. Valsangkar1, C. B. Siedlecki1, T. M. Bell1, A. Fecher1  1Indiana University School Of Medicine,Surgery – Trauma Critical Care,Indianapolis, IN, USA

Introduction: Traumatic injuries are the leading cause of mortality for people ages 1-46. Within this population, patients ages 10-21 are a heterogeneous group with varying mechanisms and settings of injury. The objective of this study was to identify demographic trends in assault-related injuries and to define targeted primary prevention programs.

Methods: A retrospective analysis of 722 patients from 3 urban, Level I  trauma centers (2010-2014) was performed to examine trends in mechanisms of injury among patients ages 10-21 who were injured as a result of an assault.  The relationship between distance from the patient’s home to location of injury was examined. Gender and age group (ages 10-14, 15-18, 19-21) comparisons examined differences in the prevalence of penetrating and blunt injuries. Multivariate logistic regressions were used to predict the setting of stab/cut/pierce injuries and GSW injuries.

Results: The highest rates of injury were observed among males (87.7%) and older adolescents (50.1%). Penetrating injuries were most common (88.6%), of which the predominant form was GSW (79.4%). Females were more likely to sustain an injury at home compared to males who were more likely to sustain injuries more than 2 miles from home (p=0.03). There was also an increased risk of having a stab/cut/pierce injury compared to a GSW injury when the injury occurred in the home (OR=2.4;95%CI:1.4-4.1).

Conclusion: Our data demonstrates that females in the 19–21 age group represent a vulnerable population susceptible to stab wounds that occur at home. Index cases of a stab injuries at home currently prompted this institutions trauma registry to follow these patients in a separate database. However, a targeted outreach program based on our database likely represents the most efficient strategy to prevent young adolescent women in high-risk communities from experiencing violence-related injuries at home.

 

54.10 National Trends in Readmission Following Inpatient Surgery

Posted on January 26, 2017

W. T. Mehtsun1,2, I. Papanicolas2,4, K. D. Lillemoe1,3, A. K. Jha2,3  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Harvard School Of Public Health,Department Of Health Policy And Management,Boston, MA, USA 3Harvard School Of Medicine,Brookline, MA, USA 4The London School Of Economics And Political Science,LSE Health,London, , United Kingdom

Introduction: Hospital readmissions have recently become a focal point of national health policy efforts. The past decade has seen the implementation of public reporting and financial penalties targeted at improving readmission rates in U.S. hospitals. Consequently, the reduction of excess readmission following inpatient surgery has now become a national priority for clinicians, hospitals, and health policy leaders. Whether this increased attention and effort has led to an observable decrease in surgical readmission rates is unclear. Therefore, we sought to determine whether national 30-day readmission rates after common and complex surgeries are declining.

Methods: Using 100% inpatient Medicare-fee-for-service beneficiary data from 2005 to 2014, we identified patients undergoing the following complex and common surgical procedures:  coronary artery by-pass graft (CABG), abdominal aortic aneurysm repair (AAA repair), esophagectomy, pancreatectomy, cystectomy, pulmonary lobectomy, colectomy, appendectomy, cholecystectomy, hip replacement, and knee replacement.  For each procedure, we used linear regression models with hospital fixed effects to calculate yearly 30-day surgical readmission rates – risk adjusted by age, gender, urgency, and Elixhauser comorbidity indicators.

Results: Among Medicare fee-for-service patients, who underwent the selected procedures during the study period (N=7,411,230), 30-day surgical readmission rates declined for 8 out of 11 procedures.  The greatest declines in 30-day surgical readmission rates were in patients who underwent CABG (-0.52% per year, p<0.001), hip replacement (-0.41% per year, p<0.001), and pulmonary lobectomy (-0.36% per year, P<0.01).  There were non-significant declines in 30-day surgical readmission rates among patients who underwent esophagectomy (-0.15% per year, p=0.80), pancreatectomy (-0.02% per year, p=0.70), and cystectomy (-0.04% per year, p=0.70). We found that improvements in 30-day surgical readmission rates occurred mainly within hospitals.

Conclusions: Declines in 30-day surgical readmission rates were observed for most procedures, with the greatest readmission reductions seen among procedures that were targeted by pay-for-performance programs. 

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