Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot

Michael W. Wandling, Clifford Y. Ko, Paul E. Bankey, Chris Cribari, H. Gill Cryer, Jose J. Diaz, Therese M. Duane, S. Morad Hameed, Matthew M. Hutter, Michael H. Metzler, Justin L. Regner, Patrick M. Reilly, H. David Reines, Jason L. Sperry, Kristan L. Staudenmayer, Garth H Utter, Marie L. Crandall, Karl Y. Bilimoria, Avery B. Nathens

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

BACKGROUND: Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered. METHODS: Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases. RESULTS: Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions. CONCLUSION: This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.

Original languageEnglish (US)
Pages (from-to)837-844
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume83
Issue number5
DOIs
StatePublished - Nov 1 2017

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Quality Improvement
Emergencies
Appendicitis
Cholecystitis
Registries
Benchmarking
Patient Readmission
Acute Cholecystitis
Referral and Consultation
Morbidity

Keywords

  • Emergency general surgery
  • nonoperative management
  • surgical quality assessment

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Expanding the scope of quality measurement in surgery to include nonoperative care : Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot. / Wandling, Michael W.; Ko, Clifford Y.; Bankey, Paul E.; Cribari, Chris; Cryer, H. Gill; Diaz, Jose J.; Duane, Therese M.; Hameed, S. Morad; Hutter, Matthew M.; Metzler, Michael H.; Regner, Justin L.; Reilly, Patrick M.; Reines, H. David; Sperry, Jason L.; Staudenmayer, Kristan L.; Utter, Garth H; Crandall, Marie L.; Bilimoria, Karl Y.; Nathens, Avery B.

In: Journal of Trauma and Acute Care Surgery, Vol. 83, No. 5, 01.11.2017, p. 837-844.

Research output: Contribution to journalArticle

Wandling, MW, Ko, CY, Bankey, PE, Cribari, C, Cryer, HG, Diaz, JJ, Duane, TM, Hameed, SM, Hutter, MM, Metzler, MH, Regner, JL, Reilly, PM, Reines, HD, Sperry, JL, Staudenmayer, KL, Utter, GH, Crandall, ML, Bilimoria, KY & Nathens, AB 2017, 'Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot', Journal of Trauma and Acute Care Surgery, vol. 83, no. 5, pp. 837-844. https://doi.org/10.1097/TA.0000000000001670
Wandling, Michael W. ; Ko, Clifford Y. ; Bankey, Paul E. ; Cribari, Chris ; Cryer, H. Gill ; Diaz, Jose J. ; Duane, Therese M. ; Hameed, S. Morad ; Hutter, Matthew M. ; Metzler, Michael H. ; Regner, Justin L. ; Reilly, Patrick M. ; Reines, H. David ; Sperry, Jason L. ; Staudenmayer, Kristan L. ; Utter, Garth H ; Crandall, Marie L. ; Bilimoria, Karl Y. ; Nathens, Avery B. / Expanding the scope of quality measurement in surgery to include nonoperative care : Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot. In: Journal of Trauma and Acute Care Surgery. 2017 ; Vol. 83, No. 5. pp. 837-844.
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abstract = "BACKGROUND: Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered. METHODS: Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases. RESULTS: Two thousand ninety-one patients with EGS diagnoses were included, 46.6{\%} with appendicitis, 24.3{\%} with cholecystitis, and 29.1{\%} with SBO. The overall rate of nonoperative management was 27.4{\%}, 6.6{\%} for appendicitis, 16.5{\%} for cholecystitis, and 69.9{\%} for SBO. Despite comprising only 27.4{\%} of patients in the EGS pilot, nonoperative management accounted for 67.7{\%} of deaths, 34.3{\%} of serious morbidities, and 41.8{\%} of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions. CONCLUSION: This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.",
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T1 - Expanding the scope of quality measurement in surgery to include nonoperative care

T2 - Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot

AU - Wandling, Michael W.

AU - Ko, Clifford Y.

AU - Bankey, Paul E.

AU - Cribari, Chris

AU - Cryer, H. Gill

AU - Diaz, Jose J.

AU - Duane, Therese M.

AU - Hameed, S. Morad

AU - Hutter, Matthew M.

AU - Metzler, Michael H.

AU - Regner, Justin L.

AU - Reilly, Patrick M.

AU - Reines, H. David

AU - Sperry, Jason L.

AU - Staudenmayer, Kristan L.

AU - Utter, Garth H

AU - Crandall, Marie L.

AU - Bilimoria, Karl Y.

AU - Nathens, Avery B.

PY - 2017/11/1

Y1 - 2017/11/1

N2 - BACKGROUND: Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered. METHODS: Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases. RESULTS: Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions. CONCLUSION: This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.

AB - BACKGROUND: Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered. METHODS: Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases. RESULTS: Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions. CONCLUSION: This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.

KW - Emergency general surgery

KW - nonoperative management

KW - surgical quality assessment

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