Procedure-specific venous thromboembolism prophylaxis: a paradigm from colectomy surgery.

BACKGROUND: Colectomy patients are at high-risk for venous thromboembolism (VTE), but associated risk factors and best prophylaxis in this defined population are only generalized. METHODS: Fifteen hospitals prospectively collected pre-, peri-, and postoperative variables related to VTE and prophylaxis, in addition to the variables defined by the National Surgical Quality Improvement Program between 2008 and 2009 concerning open and laparoscopic colectomy patients with 30-day outcomes. Symptomatic VTE was the primary outcome, and risk factors were tested for association with VTE using multiple logistic regression. RESULTS: The cohort included 3,464 patients with a mean age of 65; 53% were female. Overall, the 30d incidence of VTE was 2.2%. VTE prophylaxis included sequential compression devices (SCDs, 11%) alone; pharmacologic prophylaxis alone (15%); and both SCDs and pharmacologic prophylaxis (combined prophylaxis, 74%). VTE was associated with each additional year of age (OR, 1.05; 95% CI 1.02-1.06, P < .001); increased body mass index (OR 1.03; CI 1.01-1.05; P = .02); preoperative anemia (OR 2.4; CI 1.2-4.8; P = .011); contaminated wound (OR 3.4; CI 1.6-7.3; P < .01); postoperative surgical site infection (OR 2.5; CI 1.2-5.2; P < .011); and postoperative sepsis/pneumonia (OR 3.6;CI 1.9-6.7; P < .01). Postoperative factors alone accounted for 32% of VTE risk. When controlling for all other factors, only combination prophylaxis was protective against VTE (OR 0.48; CI 0.27-0.9; P = .02). Operative time, presence of disseminated malignancy, anastomotic leak, transfusion, urinary tract infection, and laparoscopic procedure were not significantly associated with VTE. Propensity matching showed that unfractionated heparin was equivalent to low molecular weight heparin, and the transfusion rate was not increased with pharmacologic prophylaxis compared to SCDs alone. CONCLUSION: Regardless of preoperative factors, VTE prophylaxis using a combination of SCDs and chemoprophylaxis was associated with significant reduction in VTE and should be standard care for patients after colectomy.

A statewide consortium of surgical care: a longitudinal investigation of vascular operative procedures at 16 hospitals.

BACKGROUND: Regional surgical quality improvement consortiums are becoming more common. Herein we have reported the effectiveness of a statewide consortium focusing on open vascular operative procedures. METHODS: The statewide Michigan Surgical Quality Consortium was established in 2005 with 16 hospitals that report cases of vascular open operative intervention, in a sampling manner consistent with the private sector National Surgical Quality Improvement Program. Data are abstracted by onsite trained nurses using defined and validated pre-, peri-, and postoperative variables with 30-day follow-up. Outpatient and emergent cases were excluded. We compared outcomes over the course of the consortium (era I, April 2005-March 2007; era II, April 2007-March 2008) via univariate and multivariate techniques. RESULTS: Era I (n = 2,453) and era II (n = 3,409) cases were similar in age (mean, 68 years), gender (61% male), relative value units (mean, 21), and distribution of Current Procedural Terminology codes. Duration of stay and operative time decreased by 15% and 11%, respectively, when comparing era I with era II (P < .001). Mortality at 30 days was not different between eras I and II (2.7% vs 2.5%; P = NS), but morbidity was decreased (15.8% vs 13.8%; P = .02). Specific decreases were noted in sepsis and pulmonary, but not cardiac or renal, complications. When evaluating both eras, modifiable variables (able to be altered by the surgeon) for morbidity included increased length of operation (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.003-1.005; P < .0001), hypertension (OR, 1.46; 95% CI, 1.03-2.1; P = .03), and blood transfusion (OR, 2.8; 95% CI, 2.04-3.88; P < .0001). However, anemic patients (11%; hematocrit <30) who were transfused were less likely to suffer morbidity (OR, 56; 95% CI, 0.47-0.67; P < .0001) than those transfused who were not anemic. The absolute 2% reduction in complications led to a $172 cost savings for the payers per patient in era II compared with era I. CONCLUSION: A statewide quality-of-care consortium with timely feedback of data was associated with decreased morbidity over a relatively short follow-up period in vascular patients. Focusing on best processes in real-world practice, such as appropriate transfusion and length of operation, may further improve vascular surgical outcomes.

Financial impact of surgical site infection after kidney transplantation: implications for quality improvement initiative design.

BACKGROUND: Surgical site infection (SSI) after kidney transplantation has been associated with worse graft and patient survival. Although there are clinical incentives to reduce the incidence of SSI, it is unknown whether these are aligned with financial incentives for payers and providers. We use post-kidney transplant surgical site infection (SSI) to quantify the financial implications of surgical complications. The goal of this study was to quantify the financial costs of SSI after kidney transplantation and to determine the party bearing the brunt of these costs. STUDY DESIGN: This was a retrospective cohort study of all adult, first-time kidney-only transplant recipients at the University of Michigan Health System from September 2003 to April 2008 (n = 869). The primary exposure variable was SSI. SSI was defined as skin dehiscence, fascial dehiscence, or bowel evisceration. Primary outcomes measures were hospital revenue (payer costs), hospital inpatient costs, and hospital margin. We used simple univariate (t-test) analysis and multivariate (generalized linear regression) models to control for donor, recipient, and insurer characteristics. RESULTS: Eighteen percent of patients had documented SSIs. In cases with an SSI hospital revenue increased by $20,176, hospital margin decreased by $4,278, and hospital costs increased by $24,454. When adjusted for donor and recipient characteristics, SSI was independently associated with an $11,132 increase in hospital revenue. CONCLUSIONS: Although SSIs have negative financial effects on both hospitals and payers, the impact is greater on payers. Payers have the primary financial incentive to reduce SSI, and broad-based, quality improvement initiatives can be prudent investments for payers. Quantification of the costs associated with SSI can be used to define financial parameters for such initiatives that might prove beneficial to multiple stakeholders.