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BOSTON: Most complications of colorectal resection procedures steadily decreased and the number of early hospital discharges increased based on a review of 10 years of data in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) according to study results presented at the American College of Surgeons Clinical Congress 2018.
In the new study, researchers at New York-Presbyterian Hospital/Columbia University Medical Center in New York City evaluated 310,632 nonemergency colorectal resections—surgical removal of part or all of the colon (also called colectomy)—included in ACS NSQIP between 2007 and 2016. Over that decade, they found significant reductions in the following complications occurring in the first postoperative month: surgical site and urinary tract infections, sepsis (bloodstream infection), septic shock, venous thromboembolism (blood clot in a vein), respiratory complications, the need to reoperate, and deaths.
"This is one of the few studies to evaluate whether the introduction of ACS NSQIP has improved postoperative outcomes over time," said principal investigator P. Ravi Kiran, MD, FRCS, FACS, FASCRS, professor of surgery at Columbia University and chief of the medical center's Division of Colorectal Surgery.
ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in North American hospitals.
From 2007 to 2016, surgical site infections (SSIs) after colorectal resection decreased from 13.7 percent to 4.7 percent, the investigators reported. Additionally, nearly half of colorectal surgical patients—47 percent—went home in fewer than five days ("early discharge") in 2016 compared with only about 8 percent in 2007.
Dr. Kiran attributed the improved outcomes to several factors. First, NSQIP's national data allows participants to benchmark, or compare outcomes, with peer hospitals and identify areas for improvement. Second, this then encourages participating centers to follow evidence-based recommendations such as the ACS guidelines, including those for preventing SSIs,1 and the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR),2 an ACS-administered program that aims to safely speed surgical patients' recovery.
Third, Dr. Kiran commended NSQIP for development of procedure-targeted datasets, in which participating hospitals can report additional, optional data specific to an operation. For instance, the colectomy-targeted dataset includes data on occurrence of an anastomotic leak—a serious complication that may occur at the surgical connection between loops of intestine—and on the preoperative use of antibiotics plus bowel preparation, which many studies3 show can improve complication rates. Colorectal resection typically is performed for the treatment of cancers of the colon and rectum or inflammatory bowel diseases.
In an important part of their study, Dr. Kiran and his coworkers divided the NSQIP data into two groups, before and after introduction of the NSQIP colectomy-targeted dataset: 131,122 resection procedures performed from 2006 to 2012 versus 179,510 procedures performed between 2013 and 2016. He said they controlled for all potentially influential factors, including differences in surgical techniques such as the increasing use of minimally invasive laparoscopy.
Study authors reported that their multivariable statistical analysis found that use of NSQIP colectomy-targeted data was independently associated with an SSI odds ratio of 0.78. This measure means that patients undergoing colorectal resection after introduction of the procedure-targeted data had 0.78 times the odds of developing an SSI, or a risk reduction of 22 percent, compared with patients before procedure-targeted outcomes data became available. Additionally, the odds of a urinary tract infection were 30 percent less and the need for reoperation, 12 percent less. Furthermore, the odds of having an early discharge were 1.6 times greater than those of patients in the period before NSQIP's introduction of these targeted data.
The reduced odds of experiencing a complication likely translate to hundreds of complications saved each year, Dr. Kiran noted.
A prior study of 118 hospitals participating in ACS NSQIP between 2005 and 2007 found that each hospital prevented 250 to 500 complications annually.4 The researchers also found that all types of hospitals, not just large teaching hospitals, improved their surgical outcomes.
Dr. Kiran recommended that patients considering having colorectal resection ask their surgeon if the hospital participates in ACS NSQIP, so they know whether the surgical team is committed to having the best possible outcomes for patients.
"NSQIP represents tremendous work by ACS in terms of developing an outcomes database with procedure-specific data," he said.
The NSQIP data are very important to improving surgical outcomes, said Clifford Y. Ko, MD, MS, MSHS, FACS, Director of the ACS Division of Research and Optimal Patient Care, which administers ACS NSQIP. "However, improvement in outcomes is also a credit to the organizations leading the quality improvement efforts, which effectively use the data," said Dr. Ko, who was not involved in this study.
The 30-plus surgical procedures with targeted datasets in NSQIP resulted from the ACS listening to NSQIP users, who requested more clinically detailed information, said Dr. Ko, who also is a professor of surgery at the University of California-Los Angeles School of Medicine.
Dr. Kiran's research colleagues for the study, all research fellows from Columbia University Medical Center, were: Ahmed M. Al-Mazrou, MD, who presented the findings at the Congress and is now a general surgery resident at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City; Haiqing Zhang, MD; and Guanying Yu, MD.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
1 Source: Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 update. J Am Coll Surg. 2017;224(1):59-74.
2 AHRQ Safety Program for Improving Surgical Care and Recovery. https://www.facs.org/quality-programs/iscr. Accessed September 4, 2018.
3 For instance, Kaslow SR, Gani F, Alshaikh HN, Canner JK. Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery. BJS Open. 2018;2(4):238-245.
4 Source: Hall BL, Hamilton BH, Richards K, et al. Does surgical quality improve in the American College of Surgeons National Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250(3):363-376.
