American College of Surgeons (ACS): Annual Clinical Congress

CHICAGO – Surgical patients receiving care at the least complex hospitals had a 50% increased risk of death compared with those treated at more complex hospitals, based on data from more than 400,000 patients.

Data from previous research suggest that the characteristics of individual hospitals predict surgical outcomes, but the relationship between hospital complexity and surgical mortality has not been well studied, Dr. Marta McCrum said at the annual clinical congress of the American College of Surgeons.

She and her colleagues reviewed Medicare administrative claims data from 2008-2009 and information on hospital characteristics from the American Hospital Association Survey 2009 on 2,695 hospitals. The hospitals were divided into quintiles based on complexity, which for purposes of this study was defined as the number of unique diagnoses and procedures performed at each facility.

"Our research suggests that outcomes for certain surgical procedures are better at more complex hospitals."

"Hospitals that see a wide variety of conditions (common problems but also very rare or complicated diagnoses) would be equipped with the wide range of services and resources needed to support them – that is, they would be complex. Similarly, hospitals that perform the widest range of unique procedures would also have the greatest diversity of services and technology," Dr. McCrum of Harvard University, Boston, explained in an interview.

"We therefore ranked the hospitals separately based on the number of unique diagnoses and procedures they saw, and then summed the ranks to assign a numeric value to the complexity of that hospital in comparison to the others. For the analysis, we separated the hospitals into quintiles based on this value."

Not surprisingly, low-complexity hospitals tended to be smaller, more rural, and located in lower-income areas, and the more complex hospitals tended to be larger, urban, and in higher-income areas, she said.

"Of note, the surgical mortality rate of the highest-complexity hospitals was 7.3%, versus 12.6% at the lowest-complexity hospitals," for an absolute risk reduction of 5.3%, she said.

The researchers controlled for hospital and population characteristics, including total number of hospital discharges, public/private ownership, percentage of Medicare patients, urban location, and county income. Hospital complexity remained a significant predictor of mortality between each quintile compared with the highest-complexity quintile.

"The average aggregate mortality rate at the lowest-complexity hospitals is 46% higher than that of the highest-complexity hospitals," said Dr. McCrum.

Overall, the research model explained 28% of the variability in mortality rates, and within the model, hospital complexity explained the greatest proportion of variability in mortality rates. Although hospital volume was a statistically significant predictor of mortality, the effect was small, she noted.

The study was limited by the fact that approximately two-thirds of the variability remained unexplained, likely due to a combination of patient factors and hospital factors, she said. Additional limitations included the lack of an existing metric to measure hospital complexity, and the limitations of using administrative claims data.

"Our research suggests that outcomes for certain surgical procedures are better at more complex hospitals," Dr. McCrum said in an interview. "This might be due in part to the expanded capabilities and systems of care present at these centers. By identifying these lifesaving elements that are cultivated in complex centers, and making them available in lower-complexity hospitals, we can ensure that all surgical procedures take place in facilities with the appropriate systems to support them," she said.

Dr. McCrum had no financial conflicts to disclose.

CHICAGO – Surgical patients receiving care at the least complex hospitals had a 50% increased risk of death compared with those treated at more complex hospitals, based on data from more than 400,000 patients.

Data from previous research suggest that the characteristics of individual hospitals predict surgical outcomes, but the relationship between hospital complexity and surgical mortality has not been well studied, Dr. Marta McCrum said at the annual clinical congress of the American College of Surgeons.

She and her colleagues reviewed Medicare administrative claims data from 2008-2009 and information on hospital characteristics from the American Hospital Association Survey 2009 on 2,695 hospitals. The hospitals were divided into quintiles based on complexity, which for purposes of this study was defined as the number of unique diagnoses and procedures performed at each facility.

"Our research suggests that outcomes for certain surgical procedures are better at more complex hospitals."

"Hospitals that see a wide variety of conditions (common problems but also very rare or complicated diagnoses) would be equipped with the wide range of services and resources needed to support them – that is, they would be complex. Similarly, hospitals that perform the widest range of unique procedures would also have the greatest diversity of services and technology," Dr. McCrum of Harvard University, Boston, explained in an interview.

"We therefore ranked the hospitals separately based on the number of unique diagnoses and procedures they saw, and then summed the ranks to assign a numeric value to the complexity of that hospital in comparison to the others. For the analysis, we separated the hospitals into quintiles based on this value."

Not surprisingly, low-complexity hospitals tended to be smaller, more rural, and located in lower-income areas, and the more complex hospitals tended to be larger, urban, and in higher-income areas, she said.

"Of note, the surgical mortality rate of the highest-complexity hospitals was 7.3%, versus 12.6% at the lowest-complexity hospitals," for an absolute risk reduction of 5.3%, she said.

The researchers controlled for hospital and population characteristics, including total number of hospital discharges, public/private ownership, percentage of Medicare patients, urban location, and county income. Hospital complexity remained a significant predictor of mortality between each quintile compared with the highest-complexity quintile.

"The average aggregate mortality rate at the lowest-complexity hospitals is 46% higher than that of the highest-complexity hospitals," said Dr. McCrum.

Overall, the research model explained 28% of the variability in mortality rates, and within the model, hospital complexity explained the greatest proportion of variability in mortality rates. Although hospital volume was a statistically significant predictor of mortality, the effect was small, she noted.

The study was limited by the fact that approximately two-thirds of the variability remained unexplained, likely due to a combination of patient factors and hospital factors, she said. Additional limitations included the lack of an existing metric to measure hospital complexity, and the limitations of using administrative claims data.

"Our research suggests that outcomes for certain surgical procedures are better at more complex hospitals," Dr. McCrum said in an interview. "This might be due in part to the expanded capabilities and systems of care present at these centers. By identifying these lifesaving elements that are cultivated in complex centers, and making them available in lower-complexity hospitals, we can ensure that all surgical procedures take place in facilities with the appropriate systems to support them," she said.

Dr. McCrum had no financial conflicts to disclose.

CHICAGO – Surgical patients receiving care at the least complex hospitals had a 50% increased risk of death compared with those treated at more complex hospitals, based on data from more than 400,000 patients.

Data from previous research suggest that the characteristics of individual hospitals predict surgical outcomes, but the relationship between hospital complexity and surgical mortality has not been well studied, Dr. Marta McCrum said at the annual clinical congress of the American College of Surgeons.

She and her colleagues reviewed Medicare administrative claims data from 2008-2009 and information on hospital characteristics from the American Hospital Association Survey 2009 on 2,695 hospitals. The hospitals were divided into quintiles based on complexity, which for purposes of this study was defined as the number of unique diagnoses and procedures performed at each facility.

"Our research suggests that outcomes for certain surgical procedures are better at more complex hospitals."

"Hospitals that see a wide variety of conditions (common problems but also very rare or complicated diagnoses) would be equipped with the wide range of services and resources needed to support them – that is, they would be complex. Similarly, hospitals that perform the widest range of unique procedures would also have the greatest diversity of services and technology," Dr. McCrum of Harvard University, Boston, explained in an interview.

"We therefore ranked the hospitals separately based on the number of unique diagnoses and procedures they saw, and then summed the ranks to assign a numeric value to the complexity of that hospital in comparison to the others. For the analysis, we separated the hospitals into quintiles based on this value."

Not surprisingly, low-complexity hospitals tended to be smaller, more rural, and located in lower-income areas, and the more complex hospitals tended to be larger, urban, and in higher-income areas, she said.

"Of note, the surgical mortality rate of the highest-complexity hospitals was 7.3%, versus 12.6% at the lowest-complexity hospitals," for an absolute risk reduction of 5.3%, she said.

The researchers controlled for hospital and population characteristics, including total number of hospital discharges, public/private ownership, percentage of Medicare patients, urban location, and county income. Hospital complexity remained a significant predictor of mortality between each quintile compared with the highest-complexity quintile.

"The average aggregate mortality rate at the lowest-complexity hospitals is 46% higher than that of the highest-complexity hospitals," said Dr. McCrum.

Overall, the research model explained 28% of the variability in mortality rates, and within the model, hospital complexity explained the greatest proportion of variability in mortality rates. Although hospital volume was a statistically significant predictor of mortality, the effect was small, she noted.

The study was limited by the fact that approximately two-thirds of the variability remained unexplained, likely due to a combination of patient factors and hospital factors, she said. Additional limitations included the lack of an existing metric to measure hospital complexity, and the limitations of using administrative claims data.

"Our research suggests that outcomes for certain surgical procedures are better at more complex hospitals," Dr. McCrum said in an interview. "This might be due in part to the expanded capabilities and systems of care present at these centers. By identifying these lifesaving elements that are cultivated in complex centers, and making them available in lower-complexity hospitals, we can ensure that all surgical procedures take place in facilities with the appropriate systems to support them," she said.

Dr. McCrum had no financial conflicts to disclose.

CHICAGO – Laparoscopic ultrasound was as effective as transabdominal ultrasound for detecting cholelithiasis, and superior at finding gallbladder polyps, based on data from 253 adults undergoing laparoscopic gastric bypass procedures.

Morbidly obese patients are at increased risk for cholelithiasis, with approximately 22%-52% developing the condition, said Dr. Kosisochi M. Obinwanne at the annual clinical congress of the American College of Surgeons.

For surgeons who perform gallbladder surgery separate from the gastric bypass, "it becomes necessary to obtain images of the gallbladder to determine the presence of gallstones," said Dr. Obinwanne of Gundersen Lutheran Health System in La Crosse, Wisc.

"Transabdominal ultrasound is the gold standard for detecting cholelithiasis," he said. However, the increased visceral and subcutaneous fat in patients with morbid obesity can make detection of gallbladder pathology difficult using transabdominal ultrasound (TAU), but laparoscopic ultrasound (LU) has the potential to be as effective as TAU, he noted.

To evaluate the sensitivity and specificity of LU vs. TAU for detecting gallbladder pathology in morbidly obese patients, Dr. Obinwanne and his colleagues conducted a prospective study of 253 patients who underwent laparoscopic gastric bypass over a 6-year period. Their average age was 43 years, average body mass index was 48 kg/m², and 76% were women.

The patients underwent both TAU and LU during laparoscopic gastric bypass surgery. Certified ultrasonographers performed TAU, and surgeons blinded to the TAU results performed LU, Dr. Obinwanne said.

Overall, LU and TAU identified cholelithiasis in 60 and 61 patients, respectively, said Dr. Obinwanne. The average common bile duct diameter measurement was 3.7 mm with LU and 4.0 mm with TAU.

However, LU found significantly more gallbladder polyps than did TAU (41 vs. 6). The sensitivity and specificity of LU were 90% and 98%, respectively, for gallbladder pathology and 83% and 85%, respectively, for polyps.

"The mean time to complete an LU procedure was 4 minutes," Dr. Obinwanne said.

The study was limited by its small size, but the results suggest that LU is safe, quick, and easy to perform – and thus it’s an alternative to TAU for detecting gallbladder pathology in bariatric surgery patients.

Dr. Obinwanne had no financial conflicts to disclose.

CHICAGO – Laparoscopic ultrasound was as effective as transabdominal ultrasound for detecting cholelithiasis, and superior at finding gallbladder polyps, based on data from 253 adults undergoing laparoscopic gastric bypass procedures.

Morbidly obese patients are at increased risk for cholelithiasis, with approximately 22%-52% developing the condition, said Dr. Kosisochi M. Obinwanne at the annual clinical congress of the American College of Surgeons.

For surgeons who perform gallbladder surgery separate from the gastric bypass, "it becomes necessary to obtain images of the gallbladder to determine the presence of gallstones," said Dr. Obinwanne of Gundersen Lutheran Health System in La Crosse, Wisc.

"Transabdominal ultrasound is the gold standard for detecting cholelithiasis," he said. However, the increased visceral and subcutaneous fat in patients with morbid obesity can make detection of gallbladder pathology difficult using transabdominal ultrasound (TAU), but laparoscopic ultrasound (LU) has the potential to be as effective as TAU, he noted.

To evaluate the sensitivity and specificity of LU vs. TAU for detecting gallbladder pathology in morbidly obese patients, Dr. Obinwanne and his colleagues conducted a prospective study of 253 patients who underwent laparoscopic gastric bypass over a 6-year period. Their average age was 43 years, average body mass index was 48 kg/m², and 76% were women.

The patients underwent both TAU and LU during laparoscopic gastric bypass surgery. Certified ultrasonographers performed TAU, and surgeons blinded to the TAU results performed LU, Dr. Obinwanne said.

Overall, LU and TAU identified cholelithiasis in 60 and 61 patients, respectively, said Dr. Obinwanne. The average common bile duct diameter measurement was 3.7 mm with LU and 4.0 mm with TAU.

However, LU found significantly more gallbladder polyps than did TAU (41 vs. 6). The sensitivity and specificity of LU were 90% and 98%, respectively, for gallbladder pathology and 83% and 85%, respectively, for polyps.

"The mean time to complete an LU procedure was 4 minutes," Dr. Obinwanne said.

The study was limited by its small size, but the results suggest that LU is safe, quick, and easy to perform – and thus it’s an alternative to TAU for detecting gallbladder pathology in bariatric surgery patients.

Dr. Obinwanne had no financial conflicts to disclose.

CHICAGO – Laparoscopic ultrasound was as effective as transabdominal ultrasound for detecting cholelithiasis, and superior at finding gallbladder polyps, based on data from 253 adults undergoing laparoscopic gastric bypass procedures.

Morbidly obese patients are at increased risk for cholelithiasis, with approximately 22%-52% developing the condition, said Dr. Kosisochi M. Obinwanne at the annual clinical congress of the American College of Surgeons.

For surgeons who perform gallbladder surgery separate from the gastric bypass, "it becomes necessary to obtain images of the gallbladder to determine the presence of gallstones," said Dr. Obinwanne of Gundersen Lutheran Health System in La Crosse, Wisc.

"Transabdominal ultrasound is the gold standard for detecting cholelithiasis," he said. However, the increased visceral and subcutaneous fat in patients with morbid obesity can make detection of gallbladder pathology difficult using transabdominal ultrasound (TAU), but laparoscopic ultrasound (LU) has the potential to be as effective as TAU, he noted.

To evaluate the sensitivity and specificity of LU vs. TAU for detecting gallbladder pathology in morbidly obese patients, Dr. Obinwanne and his colleagues conducted a prospective study of 253 patients who underwent laparoscopic gastric bypass over a 6-year period. Their average age was 43 years, average body mass index was 48 kg/m², and 76% were women.

The patients underwent both TAU and LU during laparoscopic gastric bypass surgery. Certified ultrasonographers performed TAU, and surgeons blinded to the TAU results performed LU, Dr. Obinwanne said.

Overall, LU and TAU identified cholelithiasis in 60 and 61 patients, respectively, said Dr. Obinwanne. The average common bile duct diameter measurement was 3.7 mm with LU and 4.0 mm with TAU.

However, LU found significantly more gallbladder polyps than did TAU (41 vs. 6). The sensitivity and specificity of LU were 90% and 98%, respectively, for gallbladder pathology and 83% and 85%, respectively, for polyps.

"The mean time to complete an LU procedure was 4 minutes," Dr. Obinwanne said.

The study was limited by its small size, but the results suggest that LU is safe, quick, and easy to perform – and thus it’s an alternative to TAU for detecting gallbladder pathology in bariatric surgery patients.

Dr. Obinwanne had no financial conflicts to disclose.

CHICAGO – A majority of unplanned 30-day readmissions of general surgery patients to a pediatric hospital resulted from the initial surgery or procedure for which the child was hospitalized, according to data on more than 300 patients. The findings were presented at the annual clinical congress of the American College of Surgeons.

Hospital readmission within 30 days has become an important quality measure, but data on the frequency and epidemiology of pediatric surgery readmissions are limited, said Dr. Andre Marshall of Vanderbilt University, Nashville, Tenn.

"In order to decrease readmissions, pediatric surgeons must know where to focus efforts," he said.

To determine the proportion of readmissions associated with each surgical service, Dr. Marshall and colleagues reviewed data from 12,438 surgical admissions at a single center between January 2007 and December 2010. Data were taken from the Pediatric Health Information System database and electronic medical records.

A 30-day readmission was defined as any readmission within 30 days of an index hospitalization. Surgical services included general surgery, thoracic surgery, neurosurgery, cardiac surgery, orthopedics, otolaryngology, urologic surgery, ophthalmology, plastic surgery, and kidney and liver transplants.

In all, 1,178 patients were readmitted during the study period, for a readmission rate of 10%. Of these, 318 (27%) were general surgery readmissions. The next highest readmission rates by specialty were neurosurgery (26%), cardiac surgery (18%), and orthopedics (10%). The average age of the readmitted patients was 3 years, and 58% were male.

Of the 318 general surgery readmissions, 295 were unplanned, Dr. Marshall said. Of these, 174 (59%) were related to the index surgery or procedure, and 121 (41%) were related to a new illness, new trauma, or other reason not related to the initial procedure.

Among general surgery patients, infection complications were the most common reason for 30-day readmission (38%), followed by gastrointestinal issues (28%), respiratory complications (9%), planned readmissions (7%), postoperative pain (5%), and other (13%).

The most common preoperative diagnoses associated with 30-day readmission were acute appendicitis (18%), congenital malformations (17%), and gastroesophageal reflux disease (14%).

"Improving processes to anticipate which patients and diagnoses are at the greatest risk of 30-day readmission will potentially allow for early interventions by providers," Dr. Marshall said. Early intervention will allow clinicians to implement strategies to help reduce overall readmission rates and improve the quality of patient care, he added.

Dr. Marshall had no financial conflicts to disclose.

CHICAGO – A majority of unplanned 30-day readmissions of general surgery patients to a pediatric hospital resulted from the initial surgery or procedure for which the child was hospitalized, according to data on more than 300 patients. The findings were presented at the annual clinical congress of the American College of Surgeons.

Hospital readmission within 30 days has become an important quality measure, but data on the frequency and epidemiology of pediatric surgery readmissions are limited, said Dr. Andre Marshall of Vanderbilt University, Nashville, Tenn.

"In order to decrease readmissions, pediatric surgeons must know where to focus efforts," he said.

To determine the proportion of readmissions associated with each surgical service, Dr. Marshall and colleagues reviewed data from 12,438 surgical admissions at a single center between January 2007 and December 2010. Data were taken from the Pediatric Health Information System database and electronic medical records.

A 30-day readmission was defined as any readmission within 30 days of an index hospitalization. Surgical services included general surgery, thoracic surgery, neurosurgery, cardiac surgery, orthopedics, otolaryngology, urologic surgery, ophthalmology, plastic surgery, and kidney and liver transplants.

In all, 1,178 patients were readmitted during the study period, for a readmission rate of 10%. Of these, 318 (27%) were general surgery readmissions. The next highest readmission rates by specialty were neurosurgery (26%), cardiac surgery (18%), and orthopedics (10%). The average age of the readmitted patients was 3 years, and 58% were male.

Of the 318 general surgery readmissions, 295 were unplanned, Dr. Marshall said. Of these, 174 (59%) were related to the index surgery or procedure, and 121 (41%) were related to a new illness, new trauma, or other reason not related to the initial procedure.

Among general surgery patients, infection complications were the most common reason for 30-day readmission (38%), followed by gastrointestinal issues (28%), respiratory complications (9%), planned readmissions (7%), postoperative pain (5%), and other (13%).

The most common preoperative diagnoses associated with 30-day readmission were acute appendicitis (18%), congenital malformations (17%), and gastroesophageal reflux disease (14%).

"Improving processes to anticipate which patients and diagnoses are at the greatest risk of 30-day readmission will potentially allow for early interventions by providers," Dr. Marshall said. Early intervention will allow clinicians to implement strategies to help reduce overall readmission rates and improve the quality of patient care, he added.

Dr. Marshall had no financial conflicts to disclose.

CHICAGO – A majority of unplanned 30-day readmissions of general surgery patients to a pediatric hospital resulted from the initial surgery or procedure for which the child was hospitalized, according to data on more than 300 patients. The findings were presented at the annual clinical congress of the American College of Surgeons.

Hospital readmission within 30 days has become an important quality measure, but data on the frequency and epidemiology of pediatric surgery readmissions are limited, said Dr. Andre Marshall of Vanderbilt University, Nashville, Tenn.

"In order to decrease readmissions, pediatric surgeons must know where to focus efforts," he said.

To determine the proportion of readmissions associated with each surgical service, Dr. Marshall and colleagues reviewed data from 12,438 surgical admissions at a single center between January 2007 and December 2010. Data were taken from the Pediatric Health Information System database and electronic medical records.

A 30-day readmission was defined as any readmission within 30 days of an index hospitalization. Surgical services included general surgery, thoracic surgery, neurosurgery, cardiac surgery, orthopedics, otolaryngology, urologic surgery, ophthalmology, plastic surgery, and kidney and liver transplants.

In all, 1,178 patients were readmitted during the study period, for a readmission rate of 10%. Of these, 318 (27%) were general surgery readmissions. The next highest readmission rates by specialty were neurosurgery (26%), cardiac surgery (18%), and orthopedics (10%). The average age of the readmitted patients was 3 years, and 58% were male.

Of the 318 general surgery readmissions, 295 were unplanned, Dr. Marshall said. Of these, 174 (59%) were related to the index surgery or procedure, and 121 (41%) were related to a new illness, new trauma, or other reason not related to the initial procedure.

Among general surgery patients, infection complications were the most common reason for 30-day readmission (38%), followed by gastrointestinal issues (28%), respiratory complications (9%), planned readmissions (7%), postoperative pain (5%), and other (13%).

The most common preoperative diagnoses associated with 30-day readmission were acute appendicitis (18%), congenital malformations (17%), and gastroesophageal reflux disease (14%).

"Improving processes to anticipate which patients and diagnoses are at the greatest risk of 30-day readmission will potentially allow for early interventions by providers," Dr. Marshall said. Early intervention will allow clinicians to implement strategies to help reduce overall readmission rates and improve the quality of patient care, he added.

Dr. Marshall had no financial conflicts to disclose.

CHICAGO – A total of 80% of bowel resection patients tolerated early fluids one day after surgery, based on data from 100 patients.

"Early oral feeding is an important part of fast-track surgery, which enhances recovery after surgery," but feeding in patients undergoing emergency bowel resection is often delayed until the resolution of ileus, Dr. Mohamed E. Shams of Suez Canal University in Ismailia, Egypt, said at the annual clinical congress of the American College of Surgeons.

Dr. Shams and colleagues randomized 100 adults who underwent small or large bowel resection into two groups. The early group comprised 50 patients who received fluid oral feedings on the first day after surgery. The late group comprised 50 patients who received oral feedings after the resolution of ileus.

Overall, 80% of patients in the early group tolerated the early oral feeding. In addition, patients in the early group averaged a significantly shorter time than did the late group to the passage of flatus (3.2 days vs. 0.8 days, respectively), and stool (4.4 days vs. 1.2 days, respectively).

Postoperative monitoring showed that the chest infections occurred in four patients in the early feeding group compared with 10 patients in the late feeding group, while wound infections occurred in 12 patients in the early group and 15 patients in the late group, Dr. Shams said. No incidents of a burst abdomen occurred in the early group, and three incidents occurred in the late group.

"Early oral feeding after emergency intestinal surgery is safe and well tolerated by the majority of patients, without an increase in mortality and morbidity risk," said Dr. Shams. "It also has a positive impact on reduction in hospital stay," he said.

The findings were limited by the small number of patients, but the results suggest that a majority of patients undergoing emergency intestinal surgery can benefit from early feeding, Dr. Shams noted.

Dr. Shams had no financial conflicts to disclose.

CHICAGO – A total of 80% of bowel resection patients tolerated early fluids one day after surgery, based on data from 100 patients.

"Early oral feeding is an important part of fast-track surgery, which enhances recovery after surgery," but feeding in patients undergoing emergency bowel resection is often delayed until the resolution of ileus, Dr. Mohamed E. Shams of Suez Canal University in Ismailia, Egypt, said at the annual clinical congress of the American College of Surgeons.

Dr. Shams and colleagues randomized 100 adults who underwent small or large bowel resection into two groups. The early group comprised 50 patients who received fluid oral feedings on the first day after surgery. The late group comprised 50 patients who received oral feedings after the resolution of ileus.

Overall, 80% of patients in the early group tolerated the early oral feeding. In addition, patients in the early group averaged a significantly shorter time than did the late group to the passage of flatus (3.2 days vs. 0.8 days, respectively), and stool (4.4 days vs. 1.2 days, respectively).

Postoperative monitoring showed that the chest infections occurred in four patients in the early feeding group compared with 10 patients in the late feeding group, while wound infections occurred in 12 patients in the early group and 15 patients in the late group, Dr. Shams said. No incidents of a burst abdomen occurred in the early group, and three incidents occurred in the late group.

"Early oral feeding after emergency intestinal surgery is safe and well tolerated by the majority of patients, without an increase in mortality and morbidity risk," said Dr. Shams. "It also has a positive impact on reduction in hospital stay," he said.

The findings were limited by the small number of patients, but the results suggest that a majority of patients undergoing emergency intestinal surgery can benefit from early feeding, Dr. Shams noted.

Dr. Shams had no financial conflicts to disclose.

CHICAGO – A total of 80% of bowel resection patients tolerated early fluids one day after surgery, based on data from 100 patients.

"Early oral feeding is an important part of fast-track surgery, which enhances recovery after surgery," but feeding in patients undergoing emergency bowel resection is often delayed until the resolution of ileus, Dr. Mohamed E. Shams of Suez Canal University in Ismailia, Egypt, said at the annual clinical congress of the American College of Surgeons.

Dr. Shams and colleagues randomized 100 adults who underwent small or large bowel resection into two groups. The early group comprised 50 patients who received fluid oral feedings on the first day after surgery. The late group comprised 50 patients who received oral feedings after the resolution of ileus.

Overall, 80% of patients in the early group tolerated the early oral feeding. In addition, patients in the early group averaged a significantly shorter time than did the late group to the passage of flatus (3.2 days vs. 0.8 days, respectively), and stool (4.4 days vs. 1.2 days, respectively).

Postoperative monitoring showed that the chest infections occurred in four patients in the early feeding group compared with 10 patients in the late feeding group, while wound infections occurred in 12 patients in the early group and 15 patients in the late group, Dr. Shams said. No incidents of a burst abdomen occurred in the early group, and three incidents occurred in the late group.

"Early oral feeding after emergency intestinal surgery is safe and well tolerated by the majority of patients, without an increase in mortality and morbidity risk," said Dr. Shams. "It also has a positive impact on reduction in hospital stay," he said.

The findings were limited by the small number of patients, but the results suggest that a majority of patients undergoing emergency intestinal surgery can benefit from early feeding, Dr. Shams noted.

Dr. Shams had no financial conflicts to disclose.

CHICAGO – Complication rates for bariatric surgery patients on Medicare declined after Medicare began to cover the procedure in 2006, an analysis of state inpatient data from 12 states has found.

Data from previous studies suggest that bariatric surgery outcomes for Medicare patients improved after the implementation of Medicare’s National Coverage Determination in 2006, said Dr. Justin B. Dimick of the University of Michigan, Ann Arbor. But specific safety data on Medicare patients who have undergone bariatric surgery since the time of the decision are limited, Dr. Dimick said. The decision allowed for Medicare coverage of patients who sought care at facilities certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery.

To assess the impact of the National Coverage Determination on the safety of bariatric surgery, Dr. Dimick and his colleagues reviewed state inpatient data from 12 large, geographically dispersed states. Patients were identified on the basis of ICD-9 codes and diagnosis-related groups for weight loss surgery.

The outcomes were categorized according to any complication, a serious complication, or a reoperation.

The percentage of Medicare patients with any complications dropped from 12% before the determination to 8% afterward. Similarly, the percentage of non-Medicare patients with any complications dropped from 7% before to 5% after the determination.

In a multivariate analysis, the factors contributing to improved outcomes for bariatric surgery in Medicare patients were an increase in the use of laparoscopic gastric banding (lap band surgery), the transfer of patients to better hospitals, and quality improvement within individual hospitals, Dr. Dimick said.

Improvements in the safety of bariatric surgery did not, however, result from patients being redirected to safer hospitals, said Dr. Dimick. In fact, complication rates for procedures performed at Centers of Excellence versus non–Centers of Excellence were not significantly different (odds ratio for any complications, 0.97), he noted.

"CMS should consider dropping the COE [Centers of Excellence] aspect of the coverage decision [that] limits patient access without a beneficial improvement in outcomes," Dr. Dimick said. "Alternatively, CMS could revise the national coverage decision to further encourage participation in a quality improvement registry." Such a registry would need to include measures of long-term effectiveness to identify any unintended consequences of the increase in lap band surgery, he added.

Dr. Dimick is an equity owner and cofounder of ArborMetrix, a health care analytics and software firm.

CHICAGO – Complication rates for bariatric surgery patients on Medicare declined after Medicare began to cover the procedure in 2006, an analysis of state inpatient data from 12 states has found.

Data from previous studies suggest that bariatric surgery outcomes for Medicare patients improved after the implementation of Medicare’s National Coverage Determination in 2006, said Dr. Justin B. Dimick of the University of Michigan, Ann Arbor. But specific safety data on Medicare patients who have undergone bariatric surgery since the time of the decision are limited, Dr. Dimick said. The decision allowed for Medicare coverage of patients who sought care at facilities certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery.

To assess the impact of the National Coverage Determination on the safety of bariatric surgery, Dr. Dimick and his colleagues reviewed state inpatient data from 12 large, geographically dispersed states. Patients were identified on the basis of ICD-9 codes and diagnosis-related groups for weight loss surgery.

The outcomes were categorized according to any complication, a serious complication, or a reoperation.

The percentage of Medicare patients with any complications dropped from 12% before the determination to 8% afterward. Similarly, the percentage of non-Medicare patients with any complications dropped from 7% before to 5% after the determination.

In a multivariate analysis, the factors contributing to improved outcomes for bariatric surgery in Medicare patients were an increase in the use of laparoscopic gastric banding (lap band surgery), the transfer of patients to better hospitals, and quality improvement within individual hospitals, Dr. Dimick said.

Improvements in the safety of bariatric surgery did not, however, result from patients being redirected to safer hospitals, said Dr. Dimick. In fact, complication rates for procedures performed at Centers of Excellence versus non–Centers of Excellence were not significantly different (odds ratio for any complications, 0.97), he noted.

"CMS should consider dropping the COE [Centers of Excellence] aspect of the coverage decision [that] limits patient access without a beneficial improvement in outcomes," Dr. Dimick said. "Alternatively, CMS could revise the national coverage decision to further encourage participation in a quality improvement registry." Such a registry would need to include measures of long-term effectiveness to identify any unintended consequences of the increase in lap band surgery, he added.

Dr. Dimick is an equity owner and cofounder of ArborMetrix, a health care analytics and software firm.

CHICAGO – Complication rates for bariatric surgery patients on Medicare declined after Medicare began to cover the procedure in 2006, an analysis of state inpatient data from 12 states has found.

Data from previous studies suggest that bariatric surgery outcomes for Medicare patients improved after the implementation of Medicare’s National Coverage Determination in 2006, said Dr. Justin B. Dimick of the University of Michigan, Ann Arbor. But specific safety data on Medicare patients who have undergone bariatric surgery since the time of the decision are limited, Dr. Dimick said. The decision allowed for Medicare coverage of patients who sought care at facilities certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery.

To assess the impact of the National Coverage Determination on the safety of bariatric surgery, Dr. Dimick and his colleagues reviewed state inpatient data from 12 large, geographically dispersed states. Patients were identified on the basis of ICD-9 codes and diagnosis-related groups for weight loss surgery.

The outcomes were categorized according to any complication, a serious complication, or a reoperation.

The percentage of Medicare patients with any complications dropped from 12% before the determination to 8% afterward. Similarly, the percentage of non-Medicare patients with any complications dropped from 7% before to 5% after the determination.

In a multivariate analysis, the factors contributing to improved outcomes for bariatric surgery in Medicare patients were an increase in the use of laparoscopic gastric banding (lap band surgery), the transfer of patients to better hospitals, and quality improvement within individual hospitals, Dr. Dimick said.

Improvements in the safety of bariatric surgery did not, however, result from patients being redirected to safer hospitals, said Dr. Dimick. In fact, complication rates for procedures performed at Centers of Excellence versus non–Centers of Excellence were not significantly different (odds ratio for any complications, 0.97), he noted.

"CMS should consider dropping the COE [Centers of Excellence] aspect of the coverage decision [that] limits patient access without a beneficial improvement in outcomes," Dr. Dimick said. "Alternatively, CMS could revise the national coverage decision to further encourage participation in a quality improvement registry." Such a registry would need to include measures of long-term effectiveness to identify any unintended consequences of the increase in lap band surgery, he added.

Dr. Dimick is an equity owner and cofounder of ArborMetrix, a health care analytics and software firm.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

CHICAGO – High-volume intra-abdominal irrigation significantly increased the risk of postoperative abscess in a study of 327 appendectomy patients and led investigators to conclude that use of irrigation should be limited in these patients.

The classical thinking that irrigation during appendectomies washes away bacteria is changing, as additional data suggest that irrigation might create pockets of fluid that can lead to the formation of abscesses, Dr. Esteban Gnass said at the annual clinical congress of the American College of Surgeons.

Previous studies have shown that postoperative abscess (POA) formation significantly increases the length of a patient’s hospital stay and hospital costs, said Dr. Gnass of Riverside County Regional Medical Center in Moreno Valley, Calif.

To determine the association between irrigation during surgery and POA formation, he and his colleagues reviewed data from 265 laparoscopic and 62 open procedures conducted between January 2009 and June 2011. There were no significant demographic differences between patients in the two procedure groups. Patients also were subdivided according to perforated vs. nonperforated and irrigated vs. nonirrigated.

A total of 17 postoperative abscesses were observed, all of which occurred in irrigated patients. In addition, 88% of the postoperative abscess cases involved at least 500 mL of irrigation. "Large irrigation volumes carried a higher risk of POA," Dr. Gnass said.

After controlling for multiple variables, the investigators found that both irrigation volume and perforation were significantly associated with abscess formation.

In both the laparoscopic and open groups, 100% of perforated patients received at least 500 mL of irrigation, compared with 75% of the nonperforated patients in the laparoscopy group and 0% of nonperforated patients in the open group.

POA rates and perforation rates were not significantly different between laparoscopic and open groups (5% vs. 4%, and 25% vs. 37%, respectively).

On further analysis of the POA cases only, perforation rates were not significantly different between laparoscopic and open groups (72% vs. 67%).

"Surgical technique was not associated with abscess formation," Dr. Gnass noted.

Among the perforated cases only, postoperative abscesses developed in 18% of those who received at least 500 mL of irrigation and in none of those who received less than 500 mL of irrigation.

More research in the form of a prospective, randomized trial is needed to confirm the results, but based on the current findings, "we can suggest limiting the use of irrigation to 500 cc or less" in appendectomy procedures, Dr. Gnass said.

He reported having no relevant financial disclosures.

CHICAGO – High-volume intra-abdominal irrigation significantly increased the risk of postoperative abscess in a study of 327 appendectomy patients and led investigators to conclude that use of irrigation should be limited in these patients.

The classical thinking that irrigation during appendectomies washes away bacteria is changing, as additional data suggest that irrigation might create pockets of fluid that can lead to the formation of abscesses, Dr. Esteban Gnass said at the annual clinical congress of the American College of Surgeons.

Previous studies have shown that postoperative abscess (POA) formation significantly increases the length of a patient’s hospital stay and hospital costs, said Dr. Gnass of Riverside County Regional Medical Center in Moreno Valley, Calif.

To determine the association between irrigation during surgery and POA formation, he and his colleagues reviewed data from 265 laparoscopic and 62 open procedures conducted between January 2009 and June 2011. There were no significant demographic differences between patients in the two procedure groups. Patients also were subdivided according to perforated vs. nonperforated and irrigated vs. nonirrigated.

A total of 17 postoperative abscesses were observed, all of which occurred in irrigated patients. In addition, 88% of the postoperative abscess cases involved at least 500 mL of irrigation. "Large irrigation volumes carried a higher risk of POA," Dr. Gnass said.

After controlling for multiple variables, the investigators found that both irrigation volume and perforation were significantly associated with abscess formation.

In both the laparoscopic and open groups, 100% of perforated patients received at least 500 mL of irrigation, compared with 75% of the nonperforated patients in the laparoscopy group and 0% of nonperforated patients in the open group.

POA rates and perforation rates were not significantly different between laparoscopic and open groups (5% vs. 4%, and 25% vs. 37%, respectively).

On further analysis of the POA cases only, perforation rates were not significantly different between laparoscopic and open groups (72% vs. 67%).

"Surgical technique was not associated with abscess formation," Dr. Gnass noted.

Among the perforated cases only, postoperative abscesses developed in 18% of those who received at least 500 mL of irrigation and in none of those who received less than 500 mL of irrigation.

More research in the form of a prospective, randomized trial is needed to confirm the results, but based on the current findings, "we can suggest limiting the use of irrigation to 500 cc or less" in appendectomy procedures, Dr. Gnass said.

He reported having no relevant financial disclosures.

CHICAGO – High-volume intra-abdominal irrigation significantly increased the risk of postoperative abscess in a study of 327 appendectomy patients and led investigators to conclude that use of irrigation should be limited in these patients.

The classical thinking that irrigation during appendectomies washes away bacteria is changing, as additional data suggest that irrigation might create pockets of fluid that can lead to the formation of abscesses, Dr. Esteban Gnass said at the annual clinical congress of the American College of Surgeons.

Previous studies have shown that postoperative abscess (POA) formation significantly increases the length of a patient’s hospital stay and hospital costs, said Dr. Gnass of Riverside County Regional Medical Center in Moreno Valley, Calif.

To determine the association between irrigation during surgery and POA formation, he and his colleagues reviewed data from 265 laparoscopic and 62 open procedures conducted between January 2009 and June 2011. There were no significant demographic differences between patients in the two procedure groups. Patients also were subdivided according to perforated vs. nonperforated and irrigated vs. nonirrigated.

A total of 17 postoperative abscesses were observed, all of which occurred in irrigated patients. In addition, 88% of the postoperative abscess cases involved at least 500 mL of irrigation. "Large irrigation volumes carried a higher risk of POA," Dr. Gnass said.

After controlling for multiple variables, the investigators found that both irrigation volume and perforation were significantly associated with abscess formation.

In both the laparoscopic and open groups, 100% of perforated patients received at least 500 mL of irrigation, compared with 75% of the nonperforated patients in the laparoscopy group and 0% of nonperforated patients in the open group.

POA rates and perforation rates were not significantly different between laparoscopic and open groups (5% vs. 4%, and 25% vs. 37%, respectively).

On further analysis of the POA cases only, perforation rates were not significantly different between laparoscopic and open groups (72% vs. 67%).

"Surgical technique was not associated with abscess formation," Dr. Gnass noted.

Among the perforated cases only, postoperative abscesses developed in 18% of those who received at least 500 mL of irrigation and in none of those who received less than 500 mL of irrigation.

More research in the form of a prospective, randomized trial is needed to confirm the results, but based on the current findings, "we can suggest limiting the use of irrigation to 500 cc or less" in appendectomy procedures, Dr. Gnass said.

He reported having no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately one-third of surgical complications were diagnosed after patients left the hospital, based on data from nearly 60,000 procedures performed at 112 hospitals.

Reporting postoperative complications, including surgical site infections, has become a mandatory quality reporting initiative for hospitals, and the Affordable Care Act requires reporting of readmissions, said Dr. Melanie Morris of the University of Alabama at Birmingham.

"Some postoperative complications may lead to readmissions, but this may not tell the whole story," she noted at the annual clinical congress of the American College of Surgeons.

To determine the timing of postoperative complications and the nature of readmissions, Dr. Morris and her colleagues reviewed Veterans Affairs data from the noncardiac Surgical Care Improvement Project (SCIP) cohort from 2005 to 2009 for 59,464 surgical procedures in which there was at least one complication.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge."

Surgical cases were classified by specialty into gastrointestinal, gynecologic, orthopedic, and vascular. Complications were grouped into organ-based systems. For example, urinary complications included renal failure, renal insufficiency, and urinary tract infections; respiratory complications included failure to wean, pneumonia, and reintubation; and surgical site infections (SSIs) included both deep and superficial wounds.

The overall complication rate was approximately 15%, and 32% of complications were diagnosed after hospital discharge, Dr. Morris said. More than half (56%) of all SSIs were diagnosed after discharge, she added.

A statistically significant difference appeared in postdischarge complications by surgical specialty. The SSI rate was 5.4%, followed by respiratory complications (5.0%), urinary tract infection (4.9%), cardiac complications (3.2%), and venous thromboembolism (1.2%).

"Our GI surgical patients had the highest overall complication rate," Dr. Morris noted. Among GI patients, colectomy patients had the highest SSI rate (11%), and 23% of the GI complications were diagnosed after hospital discharge.

In addition, 78% of SSIs in orthopedic patients were diagnosed after discharge, as were 39% of SSIs in GI patients, 77% of SSIs in vascular surgery patients, and 95% of SSIs in gynecologic patients, said Dr. Morris.

There were no significant differences in length of hospital stay based on complications, Dr. Morris said.

The overall readmission rate was 11.9%, and 70% of these patients had no identifiable postoperative complication. Of those who did have an identifiable postop complication, 72% were diagnosed before discharge from the hospital.

The probability of being readmitted to the hospital over time was highest in patients with a postdischarge diagnosis of a complication. The overall length of stay was 5 days, and the average length of stay for patients with any complication was 9 days.

Patient-specific factors associated with an increased risk of readmission included a history of heart failure, renal failure, diabetes, weight loss, and smoking. Procedure-specific factors associated with an increased risk of readmission included a longer operating time, a more contaminated wound, and a higher ASA (American Society of Anesthesiologists) class.

Length of stay was slightly protective for readmission, and the presence of any complication was associated with a high risk of readmission.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge," said Dr. Morris. "Postoperative complications must be measured beyond hospital discharge to capture the whole story.

"Systematic collection of postoperative complications must include postdischarge data as well as readmissions to accurately measure quality," she said.

Dr. Morris said she had no relevant financial disclosures.

CHICAGO – Approximately one-third of surgical complications were diagnosed after patients left the hospital, based on data from nearly 60,000 procedures performed at 112 hospitals.

Reporting postoperative complications, including surgical site infections, has become a mandatory quality reporting initiative for hospitals, and the Affordable Care Act requires reporting of readmissions, said Dr. Melanie Morris of the University of Alabama at Birmingham.

"Some postoperative complications may lead to readmissions, but this may not tell the whole story," she noted at the annual clinical congress of the American College of Surgeons.

To determine the timing of postoperative complications and the nature of readmissions, Dr. Morris and her colleagues reviewed Veterans Affairs data from the noncardiac Surgical Care Improvement Project (SCIP) cohort from 2005 to 2009 for 59,464 surgical procedures in which there was at least one complication.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge."

Surgical cases were classified by specialty into gastrointestinal, gynecologic, orthopedic, and vascular. Complications were grouped into organ-based systems. For example, urinary complications included renal failure, renal insufficiency, and urinary tract infections; respiratory complications included failure to wean, pneumonia, and reintubation; and surgical site infections (SSIs) included both deep and superficial wounds.

The overall complication rate was approximately 15%, and 32% of complications were diagnosed after hospital discharge, Dr. Morris said. More than half (56%) of all SSIs were diagnosed after discharge, she added.

A statistically significant difference appeared in postdischarge complications by surgical specialty. The SSI rate was 5.4%, followed by respiratory complications (5.0%), urinary tract infection (4.9%), cardiac complications (3.2%), and venous thromboembolism (1.2%).

"Our GI surgical patients had the highest overall complication rate," Dr. Morris noted. Among GI patients, colectomy patients had the highest SSI rate (11%), and 23% of the GI complications were diagnosed after hospital discharge.

In addition, 78% of SSIs in orthopedic patients were diagnosed after discharge, as were 39% of SSIs in GI patients, 77% of SSIs in vascular surgery patients, and 95% of SSIs in gynecologic patients, said Dr. Morris.

There were no significant differences in length of hospital stay based on complications, Dr. Morris said.

The overall readmission rate was 11.9%, and 70% of these patients had no identifiable postoperative complication. Of those who did have an identifiable postop complication, 72% were diagnosed before discharge from the hospital.

The probability of being readmitted to the hospital over time was highest in patients with a postdischarge diagnosis of a complication. The overall length of stay was 5 days, and the average length of stay for patients with any complication was 9 days.

Patient-specific factors associated with an increased risk of readmission included a history of heart failure, renal failure, diabetes, weight loss, and smoking. Procedure-specific factors associated with an increased risk of readmission included a longer operating time, a more contaminated wound, and a higher ASA (American Society of Anesthesiologists) class.

Length of stay was slightly protective for readmission, and the presence of any complication was associated with a high risk of readmission.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge," said Dr. Morris. "Postoperative complications must be measured beyond hospital discharge to capture the whole story.

"Systematic collection of postoperative complications must include postdischarge data as well as readmissions to accurately measure quality," she said.

Dr. Morris said she had no relevant financial disclosures.

CHICAGO – Approximately one-third of surgical complications were diagnosed after patients left the hospital, based on data from nearly 60,000 procedures performed at 112 hospitals.

Reporting postoperative complications, including surgical site infections, has become a mandatory quality reporting initiative for hospitals, and the Affordable Care Act requires reporting of readmissions, said Dr. Melanie Morris of the University of Alabama at Birmingham.

"Some postoperative complications may lead to readmissions, but this may not tell the whole story," she noted at the annual clinical congress of the American College of Surgeons.

To determine the timing of postoperative complications and the nature of readmissions, Dr. Morris and her colleagues reviewed Veterans Affairs data from the noncardiac Surgical Care Improvement Project (SCIP) cohort from 2005 to 2009 for 59,464 surgical procedures in which there was at least one complication.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge."

Surgical cases were classified by specialty into gastrointestinal, gynecologic, orthopedic, and vascular. Complications were grouped into organ-based systems. For example, urinary complications included renal failure, renal insufficiency, and urinary tract infections; respiratory complications included failure to wean, pneumonia, and reintubation; and surgical site infections (SSIs) included both deep and superficial wounds.

The overall complication rate was approximately 15%, and 32% of complications were diagnosed after hospital discharge, Dr. Morris said. More than half (56%) of all SSIs were diagnosed after discharge, she added.

A statistically significant difference appeared in postdischarge complications by surgical specialty. The SSI rate was 5.4%, followed by respiratory complications (5.0%), urinary tract infection (4.9%), cardiac complications (3.2%), and venous thromboembolism (1.2%).

"Our GI surgical patients had the highest overall complication rate," Dr. Morris noted. Among GI patients, colectomy patients had the highest SSI rate (11%), and 23% of the GI complications were diagnosed after hospital discharge.

In addition, 78% of SSIs in orthopedic patients were diagnosed after discharge, as were 39% of SSIs in GI patients, 77% of SSIs in vascular surgery patients, and 95% of SSIs in gynecologic patients, said Dr. Morris.

There were no significant differences in length of hospital stay based on complications, Dr. Morris said.

The overall readmission rate was 11.9%, and 70% of these patients had no identifiable postoperative complication. Of those who did have an identifiable postop complication, 72% were diagnosed before discharge from the hospital.

The probability of being readmitted to the hospital over time was highest in patients with a postdischarge diagnosis of a complication. The overall length of stay was 5 days, and the average length of stay for patients with any complication was 9 days.

Patient-specific factors associated with an increased risk of readmission included a history of heart failure, renal failure, diabetes, weight loss, and smoking. Procedure-specific factors associated with an increased risk of readmission included a longer operating time, a more contaminated wound, and a higher ASA (American Society of Anesthesiologists) class.

Length of stay was slightly protective for readmission, and the presence of any complication was associated with a high risk of readmission.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge," said Dr. Morris. "Postoperative complications must be measured beyond hospital discharge to capture the whole story.

"Systematic collection of postoperative complications must include postdischarge data as well as readmissions to accurately measure quality," she said.

Dr. Morris said she had no relevant financial disclosures.