Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs.

OBJECTIVE: To determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings. SUMMARY BACKGROUND DATA: The Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows. METHODS: The database of the VA National Surgical Quality Improvement Program was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independently verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity. RESULTS: Teaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals. CONCLUSION: Compared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable risk-adjusted 30-day mortality rates. Risk-adjusted 30-day morbidity rates in teaching hospitals are higher in some specialties and operations than in nonteaching hospitals. Although this may reflect the weak predictive validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to teaching hospitals. Despite good quality of care in teaching hospitals, as evidenced by the 30-day mortality data, efforts should be made to examine further the structures and processes of surgical care prevailing in these hospitals.

Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program.

OBJECTIVE: To examine, in the Veterans Health Administration (VHA), the relation between surgical volume and outcome in eight commonly performed operations of intermediate complexity. SUMMARY BACKGROUND DATA: In multihospital health care systems such as VHA, consideration is often given to closing low-volume surgical services, with the assumption that better surgical outcomes are achieved in hospitals with larger surgical volumes. Literature data to support this assumption in intermediate-complexity operations are either limited or controversial. METHODS: The VHA National Surgical Quality Improvement Program data on nonruptured abdominal aortic aneurysmectomy, vascular infrainguinal reconstruction, carotid endarterectomy (CEA), lung lobectomy/pneumonectomy, open and laparoscopic cholecystectomy, partial colectomy, and total hip arthroplasty were used. Pearson correlation, analysis of variance, mixed effects hierarchical logistic regression, and automatic interaction detection analysis were used to assess the association of annual procedure/specialty volume with risk-adjusted 30-day death (and stroke in CEA). RESULTS: Eight major surgical procedures (68,631 operations) were analyzed. No statistically significant associations between procedure or specialty volume and 30-day mortality rate (or 30-day stroke rate in CEA) were found. CONCLUSIONS: In VHA hospitals, the procedure and surgical specialty volume in eight prevalent operations of intermediate complexity are not associated with risk-adjusted 30-day mortality rate from these operations, or with the risk-adjusted 30-day stroke rate from CEA. Volume of surgery in these operations should not be used as a surrogate for quality of surgical care.

The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program.

OBJECTIVE: To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the monitoring and improvement of the quality of surgical care to all veterans. SUMMARY BACKGROUND DATA: Outcome-based comparative measures of the quality of surgical care among surgical services and surgical subspecialties have been elusive. METHODS: This study included prospective assessment of presurgical risk factors, process of care during surgery, and outcomes 30 days after surgery on veterans undergoing major surgery in 123 medical centers; development of multivariable risk-adjustment models; identification of high and low outlier facilities by observed-to-expected outcome ratios; and generation of annual reports of comparative outcomes to all surgical services in the Veterans Health Administration (VHA). RESULTS: The National VA Surgical Quality Improvement Program (NSQIP) data base includes 417,944 major surgical procedures performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mortality ratios; 13 VAMCs were high outliers for risk-adjusted observed-to-expected mortality ratios. Identification of high and low outliers by unadjusted mortality rates would have ascribed an outlier status incorrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. CONCLUSIONS: Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.

Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality rates for surgical services in Veterans Health Administration. STUDY DESIGN: This cohort study was conducted in 44 Veterans Affairs Medical Centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measure was all-cause mortality within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. Risk-adjusted surgical mortality rates were expressed as observed-to-expected ratios and were compared with unadjusted 30-day postoperative mortality rates. RESULTS: Patient risk factors predictive of postoperative mortality included serum albumin level, American Society of Anesthesia class, emergency operation, and 31 additional preoperative variables. Considerable variability in unadjusted mortality rates for all operations was observed across the 44 hospitals (1.2-5.4%). After risk adjustment, observed-to-expected ratios ranged from 0.49 to 1.53. Rank order correlation of the hospitals by unadjusted and risk-adjusted mortality rates for all operations was 0.64. Ninety-three percent of the hospitals changed rank after risk adjustment, 50% by more than 5 and 25% by more than 10. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of risk-adjusted postoperative mortality rates after major noncardiac operations. Risk adjustment had an appreciable impact on the rank ordering of the hospitals and provided a means for monitoring and potentially improving the quality of surgical care.

Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality and morbidity rates for surgical services in the Veterans Health Administration. STUDY DESIGN: This was a cohort study conducted at 44 Veterans Affairs Medical Centers closely affiliated with university medical centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measures in this report are 21 postoperative adverse events (morbidities) occurring within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. RESULTS: Patient risk factors predictive of postoperative morbidity included serum albumin level, American Society of Anesthesia class, the complexity of the operation, and 17 other preoperative risk variables. Wide variation in the unadjusted rates of one or more postoperative morbidities for all operations was observed across the 44 hospitals (7.4-28.4%). Risk-adjusted observed-to-expected ratios ranged from 0.49 to 1.46. The Spearman rank order correlation between the ranking of the hospitals based on unadjusted morbidity rates and risk-adjusted observed-to-expected ratios for all operations was 0.87. There was little or no correlation between the rank order of the hospitals by risk-adjusted morbidity and risk-adjusted mortality. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of postoperative mortality and morbidity rates after major noncardiac operations. Risk adjustment had only a modest effect on the rank order of the hospitals.

Complications of needle catheter jejunostomy in 2,022 consecutive applications.

BACKGROUND: We commonly use needle catheter jejunostomy (NCJ) for early enteral feeding in selected patients. Review of our approach was prompted by the suggestion that enteral feeding represents a "stress test" for the bowel and may be associated with a high complication rate. MATERIALS AND METHODS: We reviewed patients with NCJ inserted over the past 16 years by prospective database, chart review, and conference minutes, with emphasis on complications. RESULTS: During the conduct of 28,121 laparotomies, 2,022 NCJs inserted in 1,938 patients (7.2%) resulted in 34 NCJ-related complications in 29 patients (1.5%) The most common complication was premature loss of the catheter from occlusion or dislodgment (n = 15; 0.74%), and the most serious was bowel necrosis (n = 3; 0.15%). CONCLUSIONS: Needle catheter jejunostomy may be inserted and used with a low complication rate. Most complications were preventable through greater attention to detail and better monitoring of physical examination of patients with marginal gut function.

Biliary pancreatitis. Operative outcome with a selective approach.

To evaluate the efficacy of a selective approach to biliary pancreatitis, we reviewed the outcomes in 276 consecutive patients undergoing operations for this diagnosis during a 7-year period. Initial conservative therapy resulted in elective operations in 63% and urgent operations in 37%. Only 10 patients (3.6%) required primary pancreatic operations, 50% of them as emergencies. The proportion of common duct surgical explorations fell from 70% of those operated immediately after hospital admission to 20% by the third hospital day. Overall mortality was 1.8% but was increased to 30% in patients having an initial pancreatic operation. We conclude that a selective approach to biliary pancreatitis allows the operation to be performed electively in most patients and is associated with a low mortality and an acceptable length of stay. Most common duct stones pass spontaneously permitting cholecystectomy alone.

Antivenin and fasciotomy/debridement in the treatment of the severe rattlesnake bite.

This experimental study of severe rattlesnake envenomation compares antivenin alone, fasciotomy and debridement alone, and a combination of the two methods as definitive treatment. Superior survival and preservation of muscle function were observed in the animals treated with antivenin alone.

DNA-mediated transfection as a model for oncogenesis.

DNA transfer technology has greatly contributed to progress in understanding molecular biology and genetics. In recent years, great efforts have been expended to determine the oncogenic potential of single, defined genes or complex gene mixtures as a prelude to defining the role those genes may play in neoplastic transformation in vitro and tumor induction in vivo. This paper reviews the currently available DNA transfection techniques and their application toward understanding cancer initiation and progression, and how the in vitro and animal models may apply to human cancer.

Orchiectomy during herniorrhaphy: what should we tell the patient?

Although orchiectomy is rarely required during inguinal herniorrhaphy, it is frequently a topic of preoperative concern. Our study disclosed a concomitant orchiectomy rate of 2 percent during 1,817 groin herniorrhaphies. The risk of orchiectomy was greatest in patients with incarceration (relative risk 22 times) but was also increased by herniorrhaphy for recurrence (relative risk 8 times) (Table II). On the other hand, patients undergoing repair of a primary reducible hernia were at low risk. Of the 29 patients undergoing orchiectomy, only 12 of the procedures were performed for specifically recorded testicular or spermatic cord abnormalities. The precise reason for orchiectomy was often not stated or was vague. We conclude that orchiectomy is more likely to be associated with repair of complicated hernias and that permission for possible orchiectomy should be obtained from these patients preoperatively. On the other hand, consent for orchiectomy and detailed discussion is unwarranted for patients with primary reducible hernias. In addition, orchiectomy during herniorrhaphy should be limited to cases of specific testicular and cord abnormalities, and the reason for orchiectomy should be clearly documented in the operative record.

Gastric devascularization.

Gastric devascularization has been reported to effectively control massive hemorrhage from stress related gastric mucosal injury with acceptable mortality and morbidity rates. Since this type of injury formation is partially based upon decreased gastric mucosal blood flow, the success of devascularization seems paradoxical. Thus, gastric devascularization was performed upon miniature swine and the gastric mucosal blood flow was serially measured in order to attempt to explain its efficacy. Total gastric mucosal blood flow decreased immediately, a maximum 36 per cent at 60 minutes. At three hours, gastric mucosal blood flow, although still significantly lowered (11 per cent), had begun a recovery that was total at one week. These results suggest that the efficacy of devascularization lies in its ability to modulate decreased gastric mucosal blood flow and, thereby, stop hemorrhage from established lesions. The rapid rebound of gastric mucosal blood flow to near normal levels prevents extension of the erosive process. These factors form the physiologic basis for the efficacy of gastric devascularization.

Phenotypic changes and gene expression in human colon mucosal epithelial cells upon transfection of a SV40 DNA-gpt recombinant.

Phenotypic changes (increased longevity, decreased growth factor requirements, altered cell surface features, growth in semisolid agarose, and SV40 T antigen expression) suggesting in vitro transformation were displayed by human normal colon mucosal epithelial cells transfected with pSV3gpt, a pBR322 recombinant containing the SV40 "early" T antigen coding region and the dominant selectable marker bacterial gene, xanthine-guanine phosphoribosyltransferase. In contrast, control cultures which received neither DNA nor the recombinant pSV2gpt (which is identical to pSV3gpt but lacks the SV40 T antigen region) were not phenotypically altered.

Pancreatic cancer: continuing diagnostic and therapeutic dilemma.

Improved survival for patients with cancer of the pancreas awaits future therapeutic advances. A more immediate objective for these patients is to provide accurate diagnosis and effective palliation. Adherence to a diagnostic strategy should provide an accurate diagnosis with the least number of tests, minimizing cost to the patient in terms of both money and discomfort. Effective palliation using a variety of available techniques can and should be accomplished expeditiously in order to extend useful survival.

Evaluation of nonpalpable breast lesions. Experience in a training institution.

Biopsy directed by needle localization is a safe and relatively simple method of obtaining abnormal tissue for histologic examination without sacrificing surrounding normal breast tissue. In the setting of a training institution, accurate results can be expected as technical skills are obtained by a variety of housestaff. In this series of 70 biopsies, the lesion targeted on mammography was removed on the initial attempt in all but 1 instance, for an overall accuracy of 99 percent.

The value and cost effectiveness of abdominal roentgenograms in the evaluation of stab wounds to the abdomen.

The value of roentgenograms of the abdomen in the evaluation and management of stab wounds to the abdomen has not been well documented. This retrospective study demonstrates that the overwhelming majority of patients with injury requiring repair have normal roentgenograms. We also found that, even when abnormal, abdominal roentgenograms make a negligible contribution to the evaluation in these patients. These findings indicate that abdominal roentgenograms are not cost effective in patients with stab wounds to the abdomen and should not be obtained on a routine basis.

Effects of gastrin, glutamine, and somatostatin on the in vitro growth of normal and malignant human gastric mucosal cells.

This study evaluated the dose-related trophic effects of glutamine, gastrin, and somatostatin on the in vitro growth of human gastric cancer cells and normal human gastric mucosal cells. Quadruplicate cell cultures were seeded into growth medium with or without glutamine, gastrin, or somatostatin. After 72 hours' incubation, cells were counted and their numbers compared with those of controls. Glutamine and gastrin stimulated the growth of both normal and malignant gastric mucosal cells. Compared with normal cells, the malignant cells responded to these growth factors at lower concentrations. Somatostatin enhanced growth of gastric cancer cells at all concentrations and inhibited growth of normal cells at high concentrations. Further studies on the responsiveness of gastric adenocarcinoma to gastrointestinal tract hormones may elucidate mechanisms of oncogenesis and suggest new therapeutic avenues for patients with gastric cancer.