American College of Surgeons (ACS): Annual Clinical Congress

SAN FRANCISCO – Awareness of four factors that predict increased risk for hospital readmission after coronary artery bypass grafting may improve physicians’ ability to reduce early readmission rates among patients undergoing the procedure.

The four factors that independently predicted increased risk for hospital readmission after CABG in a study of 818 patients were preoperative congestive heart failure, chronic lung disease, a body mass index of 40 kg/m² or greater, and longer time spent on cardiopulmonary bypass, Dr. Kelly B. Currie said at the annual clinical congress of the American College of Surgeons.

Medicare payments to hospitals with high readmission rates will be reduced starting in October 2012 under provisions of the Patient Protection and Affordable Care Act. Payments will change from a fee-for-service model to a value-based model.

Readmission rates within 30 days of CABG range from 6% to 21% in the medical literature. In the third quarter of 2010, 10% of patients in the Society of Thoracic Surgeons (STS) database who underwent CABG were readmitted within 30 days, said Dr. Currie, a surgery resident at Bassett Medical Center, Cooperstown, N.Y.

She and her associates analyzed data from 460 patients undergoing CABG at their center from 2003 to 2010 and from 358 patients in the STS Heartsource database. Once they identified independent predictors of readmission, they conducted a second logistic regression analysis on the 358 patients in the STS database and created a "probability calculator" of readmission risk.

Congestive heart failure was associated with a 77% increase in risk for early readmission after CABG, and chronic lung disease was associated with an 82% increase in risk. The risk of readmission increased significantly by 0.6% with longer perfusion time, and increased nearly fourfold in obese patients with a body mass index of 40 or greater compared with normal-weight patients.

The risk for readmission decreased significantly by 40% in patients who underwent endoscopic vein harvest, she added.

Physicians may want to focus resources on the high-risk patients to decrease readmissions, Dr. Curry said. Readmissions might be lessened by instituting follow-up calls within a day of discharge, and/or having patients see their primary care physicians within 7 days of discharge. Efforts to improve verbal handoffs of patient care between inpatient nurses and visiting nurses, as well as the use of telemedicine, might be other effective ways to help avoid readmissions, she suggested.

"These are things we are going to be implementing in the near future, hopefully," she said.

The readmission risk calculator developed in this study probably cannot be applied to a broad population of patients because some of the variables are specific to the cardiac surgery population, she noted. The study’s techniques could be applied, however, to develop risk calculators for other populations.

Dr. Currie is collaborating with researchers at Columbia University in New York to develop an improved calculator by studying data on an expected 1,400 adult cardiac surgery cases at nine hospitals in five states.

Dr. Currie said she has no relevant conflicts of interest.

SAN FRANCISCO – Awareness of four factors that predict increased risk for hospital readmission after coronary artery bypass grafting may improve physicians’ ability to reduce early readmission rates among patients undergoing the procedure.

The four factors that independently predicted increased risk for hospital readmission after CABG in a study of 818 patients were preoperative congestive heart failure, chronic lung disease, a body mass index of 40 kg/m² or greater, and longer time spent on cardiopulmonary bypass, Dr. Kelly B. Currie said at the annual clinical congress of the American College of Surgeons.

Medicare payments to hospitals with high readmission rates will be reduced starting in October 2012 under provisions of the Patient Protection and Affordable Care Act. Payments will change from a fee-for-service model to a value-based model.

Readmission rates within 30 days of CABG range from 6% to 21% in the medical literature. In the third quarter of 2010, 10% of patients in the Society of Thoracic Surgeons (STS) database who underwent CABG were readmitted within 30 days, said Dr. Currie, a surgery resident at Bassett Medical Center, Cooperstown, N.Y.

She and her associates analyzed data from 460 patients undergoing CABG at their center from 2003 to 2010 and from 358 patients in the STS Heartsource database. Once they identified independent predictors of readmission, they conducted a second logistic regression analysis on the 358 patients in the STS database and created a "probability calculator" of readmission risk.

Congestive heart failure was associated with a 77% increase in risk for early readmission after CABG, and chronic lung disease was associated with an 82% increase in risk. The risk of readmission increased significantly by 0.6% with longer perfusion time, and increased nearly fourfold in obese patients with a body mass index of 40 or greater compared with normal-weight patients.

The risk for readmission decreased significantly by 40% in patients who underwent endoscopic vein harvest, she added.

Physicians may want to focus resources on the high-risk patients to decrease readmissions, Dr. Curry said. Readmissions might be lessened by instituting follow-up calls within a day of discharge, and/or having patients see their primary care physicians within 7 days of discharge. Efforts to improve verbal handoffs of patient care between inpatient nurses and visiting nurses, as well as the use of telemedicine, might be other effective ways to help avoid readmissions, she suggested.

"These are things we are going to be implementing in the near future, hopefully," she said.

The readmission risk calculator developed in this study probably cannot be applied to a broad population of patients because some of the variables are specific to the cardiac surgery population, she noted. The study’s techniques could be applied, however, to develop risk calculators for other populations.

Dr. Currie is collaborating with researchers at Columbia University in New York to develop an improved calculator by studying data on an expected 1,400 adult cardiac surgery cases at nine hospitals in five states.

Dr. Currie said she has no relevant conflicts of interest.

SAN FRANCISCO – Awareness of four factors that predict increased risk for hospital readmission after coronary artery bypass grafting may improve physicians’ ability to reduce early readmission rates among patients undergoing the procedure.

The four factors that independently predicted increased risk for hospital readmission after CABG in a study of 818 patients were preoperative congestive heart failure, chronic lung disease, a body mass index of 40 kg/m² or greater, and longer time spent on cardiopulmonary bypass, Dr. Kelly B. Currie said at the annual clinical congress of the American College of Surgeons.

Medicare payments to hospitals with high readmission rates will be reduced starting in October 2012 under provisions of the Patient Protection and Affordable Care Act. Payments will change from a fee-for-service model to a value-based model.

Readmission rates within 30 days of CABG range from 6% to 21% in the medical literature. In the third quarter of 2010, 10% of patients in the Society of Thoracic Surgeons (STS) database who underwent CABG were readmitted within 30 days, said Dr. Currie, a surgery resident at Bassett Medical Center, Cooperstown, N.Y.

She and her associates analyzed data from 460 patients undergoing CABG at their center from 2003 to 2010 and from 358 patients in the STS Heartsource database. Once they identified independent predictors of readmission, they conducted a second logistic regression analysis on the 358 patients in the STS database and created a "probability calculator" of readmission risk.

Congestive heart failure was associated with a 77% increase in risk for early readmission after CABG, and chronic lung disease was associated with an 82% increase in risk. The risk of readmission increased significantly by 0.6% with longer perfusion time, and increased nearly fourfold in obese patients with a body mass index of 40 or greater compared with normal-weight patients.

The risk for readmission decreased significantly by 40% in patients who underwent endoscopic vein harvest, she added.

Physicians may want to focus resources on the high-risk patients to decrease readmissions, Dr. Curry said. Readmissions might be lessened by instituting follow-up calls within a day of discharge, and/or having patients see their primary care physicians within 7 days of discharge. Efforts to improve verbal handoffs of patient care between inpatient nurses and visiting nurses, as well as the use of telemedicine, might be other effective ways to help avoid readmissions, she suggested.

"These are things we are going to be implementing in the near future, hopefully," she said.

The readmission risk calculator developed in this study probably cannot be applied to a broad population of patients because some of the variables are specific to the cardiac surgery population, she noted. The study’s techniques could be applied, however, to develop risk calculators for other populations.

Dr. Currie is collaborating with researchers at Columbia University in New York to develop an improved calculator by studying data on an expected 1,400 adult cardiac surgery cases at nine hospitals in five states.

Dr. Currie said she has no relevant conflicts of interest.

SAN FRANCISCO – Surgical consultation is appropriate for all patients aged 80 years or older with primary hyperparathyroidism, the majority of whom will have a single adenoma, according to researchers from the University of Pennsylvania, Philadelphia, who evaluated safety and outcomes in the very elderly.

"General anesthesia for bilateral exploration can be performed safely in these older patients, and morbidity from parathyroidectomy is very low," said Dr. Parth Kishore Shah, a surgery resident who presented the study at the annual clinical congress of the American College of Surgeons.

Primary hyperparathyroidism is increasingly found to have a significant impact on quality of life in patients aged 80 years and older. The advantages of parathyroidectomy for primary hyperparathyroidism (pHPT) are well established, and include decreased risk of renal stones as well as improvements in constitutional symptoms, bone mineral density, and overall health-related quality of life.

The current indications for surgery include presence of symptoms, or, in asymptomatic patients, one of the following: age younger than 50 years; serum calcium 1 mg/dL above the upper limit of normal; 24-hour urinary calcium excretion less than 400 mg/24 hr; 30% reduction in creatinine clearance; diagnosis of osteoporosis; or difficulty in accomplishing medical surveillance.

"Patients aged 80 years and older, though, are often excluded from surgical management of pHPT because of their age, unappreciated symptoms, presence of comorbidities, and/or suspected high anesthesia and surgical risk," said Dr. Shah.

Large Database Analyzed

From a prospective database of 2,050 patients undergoing parathyroidectomy in 1997-2010, the investigators identified 61 patients aged 80 years or older and collected data on their preoperative clinical presentation, biochemical studies, intraoperative findings, and final pathology results.

Most patients (90%) were women, and the median age was 83 years. Presenting symptoms – including fatigue, mental impairment, depression, and bone pain – were observed in 48 patients (79%). All patients had evidence of osteoporosis, and comorbidities were also common, especially hypertension (69%).

The median preoperative calcium level was 11 mg/dL, and the median serum intact PTH level was 126 pg/mL. Two-thirds of patients had a positive preoperative localization.

In all, 13 patients (21%) were asymptomatic, and they met guidelines for parathyroidectomy in the following proportions: serum calcium level at least 1 mg/dL greater than normal (46%), 30% reduction in creatinine clearance (69%), and T score greater than –2.5 on DXA (dual-energy x-ray absorptiometry) scan to assess bone health (62%). More than half of the patients met more than one of the criteria, and 91% of the asymptomatic group had successful preoperative localization, Dr. Shah reported.

Operative Details and Pathology Results

General anesthesia was administered to 78%, whereas 19% had local anesthesia. Local was converted to general anesthesia in the remaining 3%. The method of parathyroidectomy was bilateral exploration in 49%, minimally invasive parathyroidectomy (MIP) in 41%, and MIP converted to bilateral in 10%. The median operative time was 86 minutes.

Intraoperative PTH (IOPTH) monitoring was done in 95% of patients, who had a mean IOPTH drop of 80%. A drop greater than 50% was observed in 95% of patients. "IOPTH monitoring can be used effectively in this group," Dr. Shah noted.

On final pathology review, 75% had a single adenoma, 17% had double adenomas, and 8% had four-gland hyperplasia. Presence of ectopic glands was noted in 7% of patients.

Procedure Found Safe

There were no postoperative deaths, and only four patients (6.6%) had complications, which were pneumothorax, stroke, aspiration, and reintubation for respiratory insufficiency. Complications were not related to any baseline or operative characteristics. Most patients (86%) were discharged in less than 24 hours.

"The morbidity from parathyroidectomy in this age group is very low and is comparable to that seen in patients younger than 80, although there appears to be a predilection for respiratory complications," Dr. Shah said.

Compared with a cohort of 122 patients younger than 80 years, the older patients were more likely to present with more than one symptom (62% vs. 37%; P = .001) and were more likely to have more than one comorbidity (46% vs. 30%; P = .05). The rates of general anesthesia and bilateral neck exploration were almost the same for the two age groups, as was the incidence of complications, except that there were more respiratory problems in the elderly.

"Our findings corroborate prior studies that report parathyroidectomy in patients aged 80 and older for pHPT can be safely performed, with little disruption to daily life," Dr. Shah concluded. "We believe that symptomatic patients with hypercalcemia in this age group should be strongly considered for surgery."

Dr. Shah reported no conflicts of interest.

SAN FRANCISCO – Surgical consultation is appropriate for all patients aged 80 years or older with primary hyperparathyroidism, the majority of whom will have a single adenoma, according to researchers from the University of Pennsylvania, Philadelphia, who evaluated safety and outcomes in the very elderly.

"General anesthesia for bilateral exploration can be performed safely in these older patients, and morbidity from parathyroidectomy is very low," said Dr. Parth Kishore Shah, a surgery resident who presented the study at the annual clinical congress of the American College of Surgeons.

Primary hyperparathyroidism is increasingly found to have a significant impact on quality of life in patients aged 80 years and older. The advantages of parathyroidectomy for primary hyperparathyroidism (pHPT) are well established, and include decreased risk of renal stones as well as improvements in constitutional symptoms, bone mineral density, and overall health-related quality of life.

The current indications for surgery include presence of symptoms, or, in asymptomatic patients, one of the following: age younger than 50 years; serum calcium 1 mg/dL above the upper limit of normal; 24-hour urinary calcium excretion less than 400 mg/24 hr; 30% reduction in creatinine clearance; diagnosis of osteoporosis; or difficulty in accomplishing medical surveillance.

"Patients aged 80 years and older, though, are often excluded from surgical management of pHPT because of their age, unappreciated symptoms, presence of comorbidities, and/or suspected high anesthesia and surgical risk," said Dr. Shah.

Large Database Analyzed

From a prospective database of 2,050 patients undergoing parathyroidectomy in 1997-2010, the investigators identified 61 patients aged 80 years or older and collected data on their preoperative clinical presentation, biochemical studies, intraoperative findings, and final pathology results.

Most patients (90%) were women, and the median age was 83 years. Presenting symptoms – including fatigue, mental impairment, depression, and bone pain – were observed in 48 patients (79%). All patients had evidence of osteoporosis, and comorbidities were also common, especially hypertension (69%).

The median preoperative calcium level was 11 mg/dL, and the median serum intact PTH level was 126 pg/mL. Two-thirds of patients had a positive preoperative localization.

In all, 13 patients (21%) were asymptomatic, and they met guidelines for parathyroidectomy in the following proportions: serum calcium level at least 1 mg/dL greater than normal (46%), 30% reduction in creatinine clearance (69%), and T score greater than –2.5 on DXA (dual-energy x-ray absorptiometry) scan to assess bone health (62%). More than half of the patients met more than one of the criteria, and 91% of the asymptomatic group had successful preoperative localization, Dr. Shah reported.

Operative Details and Pathology Results

General anesthesia was administered to 78%, whereas 19% had local anesthesia. Local was converted to general anesthesia in the remaining 3%. The method of parathyroidectomy was bilateral exploration in 49%, minimally invasive parathyroidectomy (MIP) in 41%, and MIP converted to bilateral in 10%. The median operative time was 86 minutes.

Intraoperative PTH (IOPTH) monitoring was done in 95% of patients, who had a mean IOPTH drop of 80%. A drop greater than 50% was observed in 95% of patients. "IOPTH monitoring can be used effectively in this group," Dr. Shah noted.

On final pathology review, 75% had a single adenoma, 17% had double adenomas, and 8% had four-gland hyperplasia. Presence of ectopic glands was noted in 7% of patients.

Procedure Found Safe

There were no postoperative deaths, and only four patients (6.6%) had complications, which were pneumothorax, stroke, aspiration, and reintubation for respiratory insufficiency. Complications were not related to any baseline or operative characteristics. Most patients (86%) were discharged in less than 24 hours.

"The morbidity from parathyroidectomy in this age group is very low and is comparable to that seen in patients younger than 80, although there appears to be a predilection for respiratory complications," Dr. Shah said.

Compared with a cohort of 122 patients younger than 80 years, the older patients were more likely to present with more than one symptom (62% vs. 37%; P = .001) and were more likely to have more than one comorbidity (46% vs. 30%; P = .05). The rates of general anesthesia and bilateral neck exploration were almost the same for the two age groups, as was the incidence of complications, except that there were more respiratory problems in the elderly.

"Our findings corroborate prior studies that report parathyroidectomy in patients aged 80 and older for pHPT can be safely performed, with little disruption to daily life," Dr. Shah concluded. "We believe that symptomatic patients with hypercalcemia in this age group should be strongly considered for surgery."

Dr. Shah reported no conflicts of interest.

SAN FRANCISCO – Surgical consultation is appropriate for all patients aged 80 years or older with primary hyperparathyroidism, the majority of whom will have a single adenoma, according to researchers from the University of Pennsylvania, Philadelphia, who evaluated safety and outcomes in the very elderly.

"General anesthesia for bilateral exploration can be performed safely in these older patients, and morbidity from parathyroidectomy is very low," said Dr. Parth Kishore Shah, a surgery resident who presented the study at the annual clinical congress of the American College of Surgeons.

Primary hyperparathyroidism is increasingly found to have a significant impact on quality of life in patients aged 80 years and older. The advantages of parathyroidectomy for primary hyperparathyroidism (pHPT) are well established, and include decreased risk of renal stones as well as improvements in constitutional symptoms, bone mineral density, and overall health-related quality of life.

The current indications for surgery include presence of symptoms, or, in asymptomatic patients, one of the following: age younger than 50 years; serum calcium 1 mg/dL above the upper limit of normal; 24-hour urinary calcium excretion less than 400 mg/24 hr; 30% reduction in creatinine clearance; diagnosis of osteoporosis; or difficulty in accomplishing medical surveillance.

"Patients aged 80 years and older, though, are often excluded from surgical management of pHPT because of their age, unappreciated symptoms, presence of comorbidities, and/or suspected high anesthesia and surgical risk," said Dr. Shah.

Large Database Analyzed

From a prospective database of 2,050 patients undergoing parathyroidectomy in 1997-2010, the investigators identified 61 patients aged 80 years or older and collected data on their preoperative clinical presentation, biochemical studies, intraoperative findings, and final pathology results.

Most patients (90%) were women, and the median age was 83 years. Presenting symptoms – including fatigue, mental impairment, depression, and bone pain – were observed in 48 patients (79%). All patients had evidence of osteoporosis, and comorbidities were also common, especially hypertension (69%).

The median preoperative calcium level was 11 mg/dL, and the median serum intact PTH level was 126 pg/mL. Two-thirds of patients had a positive preoperative localization.

In all, 13 patients (21%) were asymptomatic, and they met guidelines for parathyroidectomy in the following proportions: serum calcium level at least 1 mg/dL greater than normal (46%), 30% reduction in creatinine clearance (69%), and T score greater than –2.5 on DXA (dual-energy x-ray absorptiometry) scan to assess bone health (62%). More than half of the patients met more than one of the criteria, and 91% of the asymptomatic group had successful preoperative localization, Dr. Shah reported.

Operative Details and Pathology Results

General anesthesia was administered to 78%, whereas 19% had local anesthesia. Local was converted to general anesthesia in the remaining 3%. The method of parathyroidectomy was bilateral exploration in 49%, minimally invasive parathyroidectomy (MIP) in 41%, and MIP converted to bilateral in 10%. The median operative time was 86 minutes.

Intraoperative PTH (IOPTH) monitoring was done in 95% of patients, who had a mean IOPTH drop of 80%. A drop greater than 50% was observed in 95% of patients. "IOPTH monitoring can be used effectively in this group," Dr. Shah noted.

On final pathology review, 75% had a single adenoma, 17% had double adenomas, and 8% had four-gland hyperplasia. Presence of ectopic glands was noted in 7% of patients.

Procedure Found Safe

There were no postoperative deaths, and only four patients (6.6%) had complications, which were pneumothorax, stroke, aspiration, and reintubation for respiratory insufficiency. Complications were not related to any baseline or operative characteristics. Most patients (86%) were discharged in less than 24 hours.

"The morbidity from parathyroidectomy in this age group is very low and is comparable to that seen in patients younger than 80, although there appears to be a predilection for respiratory complications," Dr. Shah said.

Compared with a cohort of 122 patients younger than 80 years, the older patients were more likely to present with more than one symptom (62% vs. 37%; P = .001) and were more likely to have more than one comorbidity (46% vs. 30%; P = .05). The rates of general anesthesia and bilateral neck exploration were almost the same for the two age groups, as was the incidence of complications, except that there were more respiratory problems in the elderly.

"Our findings corroborate prior studies that report parathyroidectomy in patients aged 80 and older for pHPT can be safely performed, with little disruption to daily life," Dr. Shah concluded. "We believe that symptomatic patients with hypercalcemia in this age group should be strongly considered for surgery."

Dr. Shah reported no conflicts of interest.

SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.

The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.

In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.

Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program and associate professor of surgery at the University of Wisconsin, Madison.

Hand-offs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns (J. Am. Coll. Surg. 2007;204:533-40).

Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.

"Developing skills in communication are as important as the development and maintenance of technical skills."

Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.

The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.

"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.

A study of practices before instituting these policies found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time (Ann. Surg. 2009;250:861-5).

"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.

After adoption of the new guidelines, only 1 of 47 critical events (2%) was not communicated to an attending surgeon, the current study found (Ann. Surg. 2011;253:849-54).

"Developing skills in communication are as important as the development and maintenance of technical skills" to reduce the risk of errors, Dr. Greenberg said.

Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).

Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times.

It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.

Dr. Greenberg said she has no relevant conflicts of interest.

SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.

The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.

In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.

Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program and associate professor of surgery at the University of Wisconsin, Madison.

Hand-offs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns (J. Am. Coll. Surg. 2007;204:533-40).

Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.

"Developing skills in communication are as important as the development and maintenance of technical skills."

Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.

The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.

"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.

A study of practices before instituting these policies found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time (Ann. Surg. 2009;250:861-5).

"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.

After adoption of the new guidelines, only 1 of 47 critical events (2%) was not communicated to an attending surgeon, the current study found (Ann. Surg. 2011;253:849-54).

"Developing skills in communication are as important as the development and maintenance of technical skills" to reduce the risk of errors, Dr. Greenberg said.

Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).

Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times.

It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.

Dr. Greenberg said she has no relevant conflicts of interest.

SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.

The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.

In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.

Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program and associate professor of surgery at the University of Wisconsin, Madison.

Hand-offs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns (J. Am. Coll. Surg. 2007;204:533-40).

Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.

"Developing skills in communication are as important as the development and maintenance of technical skills."

Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.

The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.

"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.

A study of practices before instituting these policies found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time (Ann. Surg. 2009;250:861-5).

"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.

After adoption of the new guidelines, only 1 of 47 critical events (2%) was not communicated to an attending surgeon, the current study found (Ann. Surg. 2011;253:849-54).

"Developing skills in communication are as important as the development and maintenance of technical skills" to reduce the risk of errors, Dr. Greenberg said.

Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).

Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times.

It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.

Dr. Greenberg said she has no relevant conflicts of interest.

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

The policy was inspired by a 1994 study showing that there are four main reasons patients sue medical caregivers: they need an explanation; they want to ensure the safety of others; they want a sense of accountability; and they seek compensation (Lancet 1994;343:1609-13).

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system is able to compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, Dr. Campbell said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, Dr. Campbell said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

"It used to be a ‘defend and deny’ culture. Now it’s ‘disclose and discuss.’ "

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adoption of the disclosure policy. The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

The money saved under the new policy has been redirected to patient safety programs, he said.

Dr. Campbell, a surgeon specializing in liver transplantation, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during a patient handoff when the anesthesia team changed. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

The full-disclosure policy is "pretty dramatically different than what we’ve done before," he said.

Dr. Campbell said he has no relevant conflicts of interest.

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

The policy was inspired by a 1994 study showing that there are four main reasons patients sue medical caregivers: they need an explanation; they want to ensure the safety of others; they want a sense of accountability; and they seek compensation (Lancet 1994;343:1609-13).

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system is able to compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, Dr. Campbell said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, Dr. Campbell said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

"It used to be a ‘defend and deny’ culture. Now it’s ‘disclose and discuss.’ "

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adoption of the disclosure policy. The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

The money saved under the new policy has been redirected to patient safety programs, he said.

Dr. Campbell, a surgeon specializing in liver transplantation, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during a patient handoff when the anesthesia team changed. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

The full-disclosure policy is "pretty dramatically different than what we’ve done before," he said.

Dr. Campbell said he has no relevant conflicts of interest.

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

The policy was inspired by a 1994 study showing that there are four main reasons patients sue medical caregivers: they need an explanation; they want to ensure the safety of others; they want a sense of accountability; and they seek compensation (Lancet 1994;343:1609-13).

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system is able to compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, Dr. Campbell said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, Dr. Campbell said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

"It used to be a ‘defend and deny’ culture. Now it’s ‘disclose and discuss.’ "

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adoption of the disclosure policy. The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

The money saved under the new policy has been redirected to patient safety programs, he said.

Dr. Campbell, a surgeon specializing in liver transplantation, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during a patient handoff when the anesthesia team changed. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

The full-disclosure policy is "pretty dramatically different than what we’ve done before," he said.

Dr. Campbell said he has no relevant conflicts of interest.

SAN FRANCISCO – Thyroid cancer recurs in almost 40% of elderly patients, and while recurrence is accompanied by an increased mortality risk, this seems to be confined to the subset of patients with papillary thyroid cancer, according to researchers from Penn State Milton S. Hershey Medical Center in Hershey, Pa.

"Elderly patients with follicular disease and recurrence did not have a significantly different risk of death compared to patients without recurrences," said lead author Melissa M. Boltz, D.O., who presented the findings at the annual clinical congress of the American College of Surgeons.

About half of patients who develop recurrent disease will die from this, but little is known about the risk of recurrence. "We questioned whether the implications could be different for the elderly population," she said.

The researchers focused on recurrent well-differentiated thyroid cancer (WDTC) in patients aged 65 years or older and assessed its impact on 1-year and 5-year survival, controlling for patient-, disease-, and treatment-related variables.

From the SEER (Surveillance Epidemiology and End Results), Medicare-linked database, they identified 2,883 patients with primary WDTC treated between 1995 and 2007. They documented recurrence through billing codes, evidence of I-131 treatment, thyroid imaging, or the performance of additional thyroid procedures beyond 6 months of diagnosis.

Of these, 1,126 patients (39%) developed recurrent disease, and the recurrent group was not demographically different from the group of patients without recurrence. The majority recurred within the first 2 years of initial treatment, after which the probability of developing recurrence was never more than 45% over 10 years, Dr. Boltz said.

Risk factors associated with recurrence included older age, advanced stage, lack of surgical treatment, and regional disease, she reported.

Regional disease was present in 44% of the recurrent group, vs. only 24% of the nonrecurrent group, and thyroidectomy was performed on 33% vs. 60%, respectively.

At 10 years, of the total thyroid cancer population, 662 (23%) died of some form of cancer with thyroid cancer as the cause of death in 273 (41%).

"In the 1-year landmark analysis, patients with recurrence had a higher risk for cancer-specific mortality within 10 years, versus those without recurrence, and the trend was similar at the 5-year landmark," Dr. Boltz noted.

By histology, patients who recurred with papillary thyroid cancer were significantly more likely to die of thyroid cancer as compared to papillary thyroid cancer patients not experiencing recurrence. Papillary patients who were older, had regional or distant disease, and who did not undergo surgery were also at increased risk for cancer-specific death.

The hazard ratios for thyroid cancer death for papillary thyroid cancer patients were as follows:

• Recurrence: HR, 1.96 (P less than .001).

• Age, 5-year increases: HR, 1.46 (P less than .001).

• Regional disease: HR, 4.90 (P less than .001).

• Distant disease: HR, 16.97 (P less than .001).

• No surgery: HR, 7.98 (P less than .001).

• Treatment other than surgery: HR, 3.47 (P less than 0.001).

In contrast, patients with follicular thyroid cancer had an increase in cancer-specific mortality only in relation to the presence of distant disease (HR, 17.78; P less than 0.001). Older age was also associated with an increase in cancer-specific mortality (HR, 1.24; P = 0.04), but disease recurrence was not (HR 0.58; P = 0.16).

"Unlike papillary cancer, follicular cancer recurrence did not contribute to cancer-specific mortality. The only risks were related to older age and advanced stage," Dr. Boltz reported.

Dr. Boltz cautioned that this study pertained to elderly Medicare patients, and the results should not be generalized to a younger population, in which thyroid cancer is more prevalent.

Dr. Boltz reported no relevant conflicts of interest.

SAN FRANCISCO – Thyroid cancer recurs in almost 40% of elderly patients, and while recurrence is accompanied by an increased mortality risk, this seems to be confined to the subset of patients with papillary thyroid cancer, according to researchers from Penn State Milton S. Hershey Medical Center in Hershey, Pa.

"Elderly patients with follicular disease and recurrence did not have a significantly different risk of death compared to patients without recurrences," said lead author Melissa M. Boltz, D.O., who presented the findings at the annual clinical congress of the American College of Surgeons.

About half of patients who develop recurrent disease will die from this, but little is known about the risk of recurrence. "We questioned whether the implications could be different for the elderly population," she said.

The researchers focused on recurrent well-differentiated thyroid cancer (WDTC) in patients aged 65 years or older and assessed its impact on 1-year and 5-year survival, controlling for patient-, disease-, and treatment-related variables.

From the SEER (Surveillance Epidemiology and End Results), Medicare-linked database, they identified 2,883 patients with primary WDTC treated between 1995 and 2007. They documented recurrence through billing codes, evidence of I-131 treatment, thyroid imaging, or the performance of additional thyroid procedures beyond 6 months of diagnosis.

Of these, 1,126 patients (39%) developed recurrent disease, and the recurrent group was not demographically different from the group of patients without recurrence. The majority recurred within the first 2 years of initial treatment, after which the probability of developing recurrence was never more than 45% over 10 years, Dr. Boltz said.

Risk factors associated with recurrence included older age, advanced stage, lack of surgical treatment, and regional disease, she reported.

Regional disease was present in 44% of the recurrent group, vs. only 24% of the nonrecurrent group, and thyroidectomy was performed on 33% vs. 60%, respectively.

At 10 years, of the total thyroid cancer population, 662 (23%) died of some form of cancer with thyroid cancer as the cause of death in 273 (41%).

"In the 1-year landmark analysis, patients with recurrence had a higher risk for cancer-specific mortality within 10 years, versus those without recurrence, and the trend was similar at the 5-year landmark," Dr. Boltz noted.

By histology, patients who recurred with papillary thyroid cancer were significantly more likely to die of thyroid cancer as compared to papillary thyroid cancer patients not experiencing recurrence. Papillary patients who were older, had regional or distant disease, and who did not undergo surgery were also at increased risk for cancer-specific death.

The hazard ratios for thyroid cancer death for papillary thyroid cancer patients were as follows:

• Recurrence: HR, 1.96 (P less than .001).

• Age, 5-year increases: HR, 1.46 (P less than .001).

• Regional disease: HR, 4.90 (P less than .001).

• Distant disease: HR, 16.97 (P less than .001).

• No surgery: HR, 7.98 (P less than .001).

• Treatment other than surgery: HR, 3.47 (P less than 0.001).

In contrast, patients with follicular thyroid cancer had an increase in cancer-specific mortality only in relation to the presence of distant disease (HR, 17.78; P less than 0.001). Older age was also associated with an increase in cancer-specific mortality (HR, 1.24; P = 0.04), but disease recurrence was not (HR 0.58; P = 0.16).

"Unlike papillary cancer, follicular cancer recurrence did not contribute to cancer-specific mortality. The only risks were related to older age and advanced stage," Dr. Boltz reported.

Dr. Boltz cautioned that this study pertained to elderly Medicare patients, and the results should not be generalized to a younger population, in which thyroid cancer is more prevalent.

Dr. Boltz reported no relevant conflicts of interest.

SAN FRANCISCO – Thyroid cancer recurs in almost 40% of elderly patients, and while recurrence is accompanied by an increased mortality risk, this seems to be confined to the subset of patients with papillary thyroid cancer, according to researchers from Penn State Milton S. Hershey Medical Center in Hershey, Pa.

"Elderly patients with follicular disease and recurrence did not have a significantly different risk of death compared to patients without recurrences," said lead author Melissa M. Boltz, D.O., who presented the findings at the annual clinical congress of the American College of Surgeons.

About half of patients who develop recurrent disease will die from this, but little is known about the risk of recurrence. "We questioned whether the implications could be different for the elderly population," she said.

The researchers focused on recurrent well-differentiated thyroid cancer (WDTC) in patients aged 65 years or older and assessed its impact on 1-year and 5-year survival, controlling for patient-, disease-, and treatment-related variables.

From the SEER (Surveillance Epidemiology and End Results), Medicare-linked database, they identified 2,883 patients with primary WDTC treated between 1995 and 2007. They documented recurrence through billing codes, evidence of I-131 treatment, thyroid imaging, or the performance of additional thyroid procedures beyond 6 months of diagnosis.

Of these, 1,126 patients (39%) developed recurrent disease, and the recurrent group was not demographically different from the group of patients without recurrence. The majority recurred within the first 2 years of initial treatment, after which the probability of developing recurrence was never more than 45% over 10 years, Dr. Boltz said.

Risk factors associated with recurrence included older age, advanced stage, lack of surgical treatment, and regional disease, she reported.

Regional disease was present in 44% of the recurrent group, vs. only 24% of the nonrecurrent group, and thyroidectomy was performed on 33% vs. 60%, respectively.

At 10 years, of the total thyroid cancer population, 662 (23%) died of some form of cancer with thyroid cancer as the cause of death in 273 (41%).

"In the 1-year landmark analysis, patients with recurrence had a higher risk for cancer-specific mortality within 10 years, versus those without recurrence, and the trend was similar at the 5-year landmark," Dr. Boltz noted.

By histology, patients who recurred with papillary thyroid cancer were significantly more likely to die of thyroid cancer as compared to papillary thyroid cancer patients not experiencing recurrence. Papillary patients who were older, had regional or distant disease, and who did not undergo surgery were also at increased risk for cancer-specific death.

The hazard ratios for thyroid cancer death for papillary thyroid cancer patients were as follows:

• Recurrence: HR, 1.96 (P less than .001).

• Age, 5-year increases: HR, 1.46 (P less than .001).

• Regional disease: HR, 4.90 (P less than .001).

• Distant disease: HR, 16.97 (P less than .001).

• No surgery: HR, 7.98 (P less than .001).

• Treatment other than surgery: HR, 3.47 (P less than 0.001).

In contrast, patients with follicular thyroid cancer had an increase in cancer-specific mortality only in relation to the presence of distant disease (HR, 17.78; P less than 0.001). Older age was also associated with an increase in cancer-specific mortality (HR, 1.24; P = 0.04), but disease recurrence was not (HR 0.58; P = 0.16).

"Unlike papillary cancer, follicular cancer recurrence did not contribute to cancer-specific mortality. The only risks were related to older age and advanced stage," Dr. Boltz reported.

Dr. Boltz cautioned that this study pertained to elderly Medicare patients, and the results should not be generalized to a younger population, in which thyroid cancer is more prevalent.

Dr. Boltz reported no relevant conflicts of interest.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.