Southern Surgical Association (SSA): Annual Meeting

HOT SPRINGS, VA – Using risk adjustment alone to compare surgical site infection rates among hospitals may not be valid, judging by a retrospective analysis of data on colorectal procedures.

An examination of data submitted on 336,190 cases by 237 hospitals participating in the National Surgical Quality Improvement Project (NSQIP) in 2009 revealed that a patient’s underlying disease state is an important contributor to the risk of surgical site infection, said Dr. Robert Cima.

Dr. Cima and his colleagues at the Mayo Clinic Rochester, Minn., identified 24,673 colorectal procedures, using CPT codes. Of those procedures, 6,324 patients had colon cancer, 2,061 had benign neoplasm, 2,859 had rectal cancer, 4,821 had diverticular disease, 764 had ulcerative colitis, 862 had regional enteritis (Crohn’s disease), and 6,982 had other conditions, which included perforation, volvulus, intestinal obstruction, rectal prolapse, fistula, vascular insufficiency and unspecified neoplasms.

"Comparisons between hospitals could be misleading if they don’t include case mix," Dr. Cima said.

They specifically analyzed colorectal procedures because they are associated with the largest rate of surgical site infections (SSI; 5%-30%) and those infections led to a longer length of stay, higher costs, and higher mortality.

To get a baseline rate of SSIs for comparison purposes, the authors queried the data set to determine which procedure had the lowest rate. Benign neoplasms had the lowest overall rate, and because they were not caused by underlying disorders or malignancies, that rate was chosen as the reference, Dr. Cima said at the annual meeting of the Southern Surgical Association.

The authors conducted a regression analysis using the same factors used in the NSQIP risk adjustment: age, body mass index, American Society of Anesthesiology classification, wound classification, and relative value units (RVU) used, which are a surrogate for CPT codes. Odds ratios for SSIs were then calculated for each procedure.

Overall, 13.5% of patients developed an SSI. Rectal cancer patients had the highest overall odds ratio at 1.9, followed by Crohn’s disease, at 1.7. Rectal cancer patients also had the highest risk of superficial incisional SSI at 1.6; diverticular disease patients had a 1.6-fold higher risk than did those with benign neoplasms.

The patients at highest risk for deep incisional infections were those with ulcerative colitis (OR, 2.4), followed by rectal cancer (2.1). Both of those conditions also put patients at higher risk for organ/space infections (OR, 2.2 and 2.1).

The difference in infection rates by underlying disease led the researchers to question whether case mix might have an effect on the infection rates at individual institutions. Looking at the Mayo Clinic’s profile, compared with all NSQIP facilities’ case mix, they found that there was a higher percentage of patients with the higher-risk conditions: rectal cancer, regional enteritis, and ulcerative colitis.

The NSQIP data include a disease diagnosis, but it does not factor that into risk-adjusted figures, which will soon be publicly reported, noted Dr. Cima. Comparisons between hospitals could be misleading if they don’t include case mix, he said. And, there are implications for quality improvement, said Dr. Cima.

"If we had just looked at the overall surgical site infection rate and tried to design studies or processes to just reduce it without consideration of case mix, we would not be able to really determine whether or not we can drive it down," he said.

"This is a provocative and important study," said Dr. Danny Jacobs, chairman of the department of surgery at Duke University, Durham, N.C., in commenting on the paper. And, he said, it raises questions about whether the risk-adjustment system being used by NSQIP is adequate.

Dr. Susan Galandiuk, a professor of surgery at the University of Louisville (Ky.), questioned whether infection rates weren’t also influenced by the duration of surgery and whether patients were given appropriate antibiotic prophylaxis.

Dr. Cima said that while many studies have shown that infections rise as the length of surgery increases, it was not clear whether that was a factor in his study.

He agreed with Dr. Jacobs that the paper raised questions. The data do "go to the very heart of using data sets to drive quality improvement," he said.

HOT SPRINGS, VA – Using risk adjustment alone to compare surgical site infection rates among hospitals may not be valid, judging by a retrospective analysis of data on colorectal procedures.

An examination of data submitted on 336,190 cases by 237 hospitals participating in the National Surgical Quality Improvement Project (NSQIP) in 2009 revealed that a patient’s underlying disease state is an important contributor to the risk of surgical site infection, said Dr. Robert Cima.

Dr. Cima and his colleagues at the Mayo Clinic Rochester, Minn., identified 24,673 colorectal procedures, using CPT codes. Of those procedures, 6,324 patients had colon cancer, 2,061 had benign neoplasm, 2,859 had rectal cancer, 4,821 had diverticular disease, 764 had ulcerative colitis, 862 had regional enteritis (Crohn’s disease), and 6,982 had other conditions, which included perforation, volvulus, intestinal obstruction, rectal prolapse, fistula, vascular insufficiency and unspecified neoplasms.

"Comparisons between hospitals could be misleading if they don’t include case mix," Dr. Cima said.

They specifically analyzed colorectal procedures because they are associated with the largest rate of surgical site infections (SSI; 5%-30%) and those infections led to a longer length of stay, higher costs, and higher mortality.

To get a baseline rate of SSIs for comparison purposes, the authors queried the data set to determine which procedure had the lowest rate. Benign neoplasms had the lowest overall rate, and because they were not caused by underlying disorders or malignancies, that rate was chosen as the reference, Dr. Cima said at the annual meeting of the Southern Surgical Association.

The authors conducted a regression analysis using the same factors used in the NSQIP risk adjustment: age, body mass index, American Society of Anesthesiology classification, wound classification, and relative value units (RVU) used, which are a surrogate for CPT codes. Odds ratios for SSIs were then calculated for each procedure.

Overall, 13.5% of patients developed an SSI. Rectal cancer patients had the highest overall odds ratio at 1.9, followed by Crohn’s disease, at 1.7. Rectal cancer patients also had the highest risk of superficial incisional SSI at 1.6; diverticular disease patients had a 1.6-fold higher risk than did those with benign neoplasms.

The patients at highest risk for deep incisional infections were those with ulcerative colitis (OR, 2.4), followed by rectal cancer (2.1). Both of those conditions also put patients at higher risk for organ/space infections (OR, 2.2 and 2.1).

The difference in infection rates by underlying disease led the researchers to question whether case mix might have an effect on the infection rates at individual institutions. Looking at the Mayo Clinic’s profile, compared with all NSQIP facilities’ case mix, they found that there was a higher percentage of patients with the higher-risk conditions: rectal cancer, regional enteritis, and ulcerative colitis.

The NSQIP data include a disease diagnosis, but it does not factor that into risk-adjusted figures, which will soon be publicly reported, noted Dr. Cima. Comparisons between hospitals could be misleading if they don’t include case mix, he said. And, there are implications for quality improvement, said Dr. Cima.

"If we had just looked at the overall surgical site infection rate and tried to design studies or processes to just reduce it without consideration of case mix, we would not be able to really determine whether or not we can drive it down," he said.

"This is a provocative and important study," said Dr. Danny Jacobs, chairman of the department of surgery at Duke University, Durham, N.C., in commenting on the paper. And, he said, it raises questions about whether the risk-adjustment system being used by NSQIP is adequate.

Dr. Susan Galandiuk, a professor of surgery at the University of Louisville (Ky.), questioned whether infection rates weren’t also influenced by the duration of surgery and whether patients were given appropriate antibiotic prophylaxis.

Dr. Cima said that while many studies have shown that infections rise as the length of surgery increases, it was not clear whether that was a factor in his study.

He agreed with Dr. Jacobs that the paper raised questions. The data do "go to the very heart of using data sets to drive quality improvement," he said.

HOT SPRINGS, VA – Using risk adjustment alone to compare surgical site infection rates among hospitals may not be valid, judging by a retrospective analysis of data on colorectal procedures.

An examination of data submitted on 336,190 cases by 237 hospitals participating in the National Surgical Quality Improvement Project (NSQIP) in 2009 revealed that a patient’s underlying disease state is an important contributor to the risk of surgical site infection, said Dr. Robert Cima.

Dr. Cima and his colleagues at the Mayo Clinic Rochester, Minn., identified 24,673 colorectal procedures, using CPT codes. Of those procedures, 6,324 patients had colon cancer, 2,061 had benign neoplasm, 2,859 had rectal cancer, 4,821 had diverticular disease, 764 had ulcerative colitis, 862 had regional enteritis (Crohn’s disease), and 6,982 had other conditions, which included perforation, volvulus, intestinal obstruction, rectal prolapse, fistula, vascular insufficiency and unspecified neoplasms.

"Comparisons between hospitals could be misleading if they don’t include case mix," Dr. Cima said.

They specifically analyzed colorectal procedures because they are associated with the largest rate of surgical site infections (SSI; 5%-30%) and those infections led to a longer length of stay, higher costs, and higher mortality.

To get a baseline rate of SSIs for comparison purposes, the authors queried the data set to determine which procedure had the lowest rate. Benign neoplasms had the lowest overall rate, and because they were not caused by underlying disorders or malignancies, that rate was chosen as the reference, Dr. Cima said at the annual meeting of the Southern Surgical Association.

The authors conducted a regression analysis using the same factors used in the NSQIP risk adjustment: age, body mass index, American Society of Anesthesiology classification, wound classification, and relative value units (RVU) used, which are a surrogate for CPT codes. Odds ratios for SSIs were then calculated for each procedure.

Overall, 13.5% of patients developed an SSI. Rectal cancer patients had the highest overall odds ratio at 1.9, followed by Crohn’s disease, at 1.7. Rectal cancer patients also had the highest risk of superficial incisional SSI at 1.6; diverticular disease patients had a 1.6-fold higher risk than did those with benign neoplasms.

The patients at highest risk for deep incisional infections were those with ulcerative colitis (OR, 2.4), followed by rectal cancer (2.1). Both of those conditions also put patients at higher risk for organ/space infections (OR, 2.2 and 2.1).

The difference in infection rates by underlying disease led the researchers to question whether case mix might have an effect on the infection rates at individual institutions. Looking at the Mayo Clinic’s profile, compared with all NSQIP facilities’ case mix, they found that there was a higher percentage of patients with the higher-risk conditions: rectal cancer, regional enteritis, and ulcerative colitis.

The NSQIP data include a disease diagnosis, but it does not factor that into risk-adjusted figures, which will soon be publicly reported, noted Dr. Cima. Comparisons between hospitals could be misleading if they don’t include case mix, he said. And, there are implications for quality improvement, said Dr. Cima.

"If we had just looked at the overall surgical site infection rate and tried to design studies or processes to just reduce it without consideration of case mix, we would not be able to really determine whether or not we can drive it down," he said.

"This is a provocative and important study," said Dr. Danny Jacobs, chairman of the department of surgery at Duke University, Durham, N.C., in commenting on the paper. And, he said, it raises questions about whether the risk-adjustment system being used by NSQIP is adequate.

Dr. Susan Galandiuk, a professor of surgery at the University of Louisville (Ky.), questioned whether infection rates weren’t also influenced by the duration of surgery and whether patients were given appropriate antibiotic prophylaxis.

Dr. Cima said that while many studies have shown that infections rise as the length of surgery increases, it was not clear whether that was a factor in his study.

He agreed with Dr. Jacobs that the paper raised questions. The data do "go to the very heart of using data sets to drive quality improvement," he said.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.

Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don’t have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.

He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. "A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients," said Dr. Inabnet at the annual meeting of the Southern Surgical Association.

The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.

BOLD is maintained by the American Society for Metabolic and Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.

A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)

Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m².

Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers "were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches."

At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.

Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.

Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.

Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors’ regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.

Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.

Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.

The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the "study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity," said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.

The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. "This paper is important because it’s another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice," said Dr. Richards.

He questioned whether the low mortality rate was a reflection of surgeons’ opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.

Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it doesn’t seem that older patients are being operated on less often than are younger patients.

"What is the best operation? That really is the million dollar question," he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.

Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.

HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.

Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don’t have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.

He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. "A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients," said Dr. Inabnet at the annual meeting of the Southern Surgical Association.

The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.

BOLD is maintained by the American Society for Metabolic and Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.

A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)

Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m².

Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers "were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches."

At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.

Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.

Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.

Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors’ regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.

Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.

Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.

The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the "study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity," said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.

The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. "This paper is important because it’s another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice," said Dr. Richards.

He questioned whether the low mortality rate was a reflection of surgeons’ opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.

Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it doesn’t seem that older patients are being operated on less often than are younger patients.

"What is the best operation? That really is the million dollar question," he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.

Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.

HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.

Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don’t have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.

He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. "A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients," said Dr. Inabnet at the annual meeting of the Southern Surgical Association.

The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.

BOLD is maintained by the American Society for Metabolic and Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.

A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)

Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m².

Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers "were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches."

At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.

Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.

Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.

Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors’ regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.

Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.

Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.

The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the "study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity," said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.

The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. "This paper is important because it’s another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice," said Dr. Richards.

He questioned whether the low mortality rate was a reflection of surgeons’ opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.

Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it doesn’t seem that older patients are being operated on less often than are younger patients.

"What is the best operation? That really is the million dollar question," he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.

Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.

HOT SPRINGS, VA. – Since tort reform in Texas, the number of lawsuits and associated costs have decreased, but patient complaints to the state medical board and board investigations of physicians have risen, according to an analysis presented at the meeting.

Dr. Ronald M. Stewart and his colleagues from the University of Texas Health Science Center at San Antonio obtained publicly available data from the Texas Medical Board and compared the 7-year period before tort reform (1996-2002) and the 6 years after the law was enacted (2004-2010).

Photo (c) -Oxford-/iStock.com

The data were adjusted for the increase in the physician population; before reform there were about 170 physicians per 100,000 residents. After the law went into effect, the number rose to 195 physicians per 100,000, said Dr. Stewart, chairman of the department of surgery.

Before reform, about 125 complaints per 1,000 physicians were made to the medical board. That number increased by 13% after reform, to around 140 complaints per 1,000 physicians, said Dr. Stewart.

The rate of investigations increased from 38 per 1,000 to 52 per 1,000, with 5% of physicians the subject of a medical board inquiry. Postreform, there were more disciplinary actions when compared to open investigations, at about 8 per 1,000 in the latter period. Before reform, 0.5 per 1,000 physicians were ordered to revoke or to voluntarily surrender their licenses; after reform, that value rose to 0.8 per 1,000, a significant increase, noted Dr. Stewart.

The most striking change before and after reform was the decline in financial penalties. The state collected a total of $4.7 million in the postreform period. To put that figure into context, the San Antonio department of surgery alone spent $4.8 million on liability settlements in the prereform period, said Dr. Stewart.

It’s not clear why complaints and disciplinary actions went up, Dr. Stewart said. Having access to electronic information and greater awareness of the ability to complain to the medical board probably spurred more patient reporting.

The increases in investigations and disciplinary actions were mainly driven by the legislature, according to Dr. Stewart. The lawmakers mandated greater oversight by the medical board, so that undoubtedly led to an increase in enforcement.

"It appears that tort reform in Texas has done what it was intended to do," increased the activity of the Texas Medical Board, and decreased the activity of the medical liability tort system, said Dr. Russell Postier, chairman of the surgery department at the University of Oklahoma, Oklahoma City, in discussing the paper.

Further, it appears to have increased the number of physicians practicing in the state, which could "make other states take notice and potentially enact tort reform," Dr. Postier said.

Dr. Stewart said that putting malpractice in the hands of the medical board had decreased costs and been generally positive. For instance, he said, the medical board process is transparent and allows more input from stakeholders like physicians.

"There’s no question that the benefits of tort reform in my opinion outweigh the potential negative consequences to physicians," he said.

Dr. Stewart and Dr. Postier reported no financial conflicts.

HOT SPRINGS, VA. – Since tort reform in Texas, the number of lawsuits and associated costs have decreased, but patient complaints to the state medical board and board investigations of physicians have risen, according to an analysis presented at the meeting.

Dr. Ronald M. Stewart and his colleagues from the University of Texas Health Science Center at San Antonio obtained publicly available data from the Texas Medical Board and compared the 7-year period before tort reform (1996-2002) and the 6 years after the law was enacted (2004-2010).

Photo (c) -Oxford-/iStock.com

The data were adjusted for the increase in the physician population; before reform there were about 170 physicians per 100,000 residents. After the law went into effect, the number rose to 195 physicians per 100,000, said Dr. Stewart, chairman of the department of surgery.

Before reform, about 125 complaints per 1,000 physicians were made to the medical board. That number increased by 13% after reform, to around 140 complaints per 1,000 physicians, said Dr. Stewart.

The rate of investigations increased from 38 per 1,000 to 52 per 1,000, with 5% of physicians the subject of a medical board inquiry. Postreform, there were more disciplinary actions when compared to open investigations, at about 8 per 1,000 in the latter period. Before reform, 0.5 per 1,000 physicians were ordered to revoke or to voluntarily surrender their licenses; after reform, that value rose to 0.8 per 1,000, a significant increase, noted Dr. Stewart.

The most striking change before and after reform was the decline in financial penalties. The state collected a total of $4.7 million in the postreform period. To put that figure into context, the San Antonio department of surgery alone spent $4.8 million on liability settlements in the prereform period, said Dr. Stewart.

It’s not clear why complaints and disciplinary actions went up, Dr. Stewart said. Having access to electronic information and greater awareness of the ability to complain to the medical board probably spurred more patient reporting.

The increases in investigations and disciplinary actions were mainly driven by the legislature, according to Dr. Stewart. The lawmakers mandated greater oversight by the medical board, so that undoubtedly led to an increase in enforcement.

"It appears that tort reform in Texas has done what it was intended to do," increased the activity of the Texas Medical Board, and decreased the activity of the medical liability tort system, said Dr. Russell Postier, chairman of the surgery department at the University of Oklahoma, Oklahoma City, in discussing the paper.

Further, it appears to have increased the number of physicians practicing in the state, which could "make other states take notice and potentially enact tort reform," Dr. Postier said.

Dr. Stewart said that putting malpractice in the hands of the medical board had decreased costs and been generally positive. For instance, he said, the medical board process is transparent and allows more input from stakeholders like physicians.

"There’s no question that the benefits of tort reform in my opinion outweigh the potential negative consequences to physicians," he said.

Dr. Stewart and Dr. Postier reported no financial conflicts.

HOT SPRINGS, VA. – Since tort reform in Texas, the number of lawsuits and associated costs have decreased, but patient complaints to the state medical board and board investigations of physicians have risen, according to an analysis presented at the meeting.

Dr. Ronald M. Stewart and his colleagues from the University of Texas Health Science Center at San Antonio obtained publicly available data from the Texas Medical Board and compared the 7-year period before tort reform (1996-2002) and the 6 years after the law was enacted (2004-2010).

Photo (c) -Oxford-/iStock.com

The data were adjusted for the increase in the physician population; before reform there were about 170 physicians per 100,000 residents. After the law went into effect, the number rose to 195 physicians per 100,000, said Dr. Stewart, chairman of the department of surgery.

Before reform, about 125 complaints per 1,000 physicians were made to the medical board. That number increased by 13% after reform, to around 140 complaints per 1,000 physicians, said Dr. Stewart.

The rate of investigations increased from 38 per 1,000 to 52 per 1,000, with 5% of physicians the subject of a medical board inquiry. Postreform, there were more disciplinary actions when compared to open investigations, at about 8 per 1,000 in the latter period. Before reform, 0.5 per 1,000 physicians were ordered to revoke or to voluntarily surrender their licenses; after reform, that value rose to 0.8 per 1,000, a significant increase, noted Dr. Stewart.

The most striking change before and after reform was the decline in financial penalties. The state collected a total of $4.7 million in the postreform period. To put that figure into context, the San Antonio department of surgery alone spent $4.8 million on liability settlements in the prereform period, said Dr. Stewart.

It’s not clear why complaints and disciplinary actions went up, Dr. Stewart said. Having access to electronic information and greater awareness of the ability to complain to the medical board probably spurred more patient reporting.

The increases in investigations and disciplinary actions were mainly driven by the legislature, according to Dr. Stewart. The lawmakers mandated greater oversight by the medical board, so that undoubtedly led to an increase in enforcement.

"It appears that tort reform in Texas has done what it was intended to do," increased the activity of the Texas Medical Board, and decreased the activity of the medical liability tort system, said Dr. Russell Postier, chairman of the surgery department at the University of Oklahoma, Oklahoma City, in discussing the paper.

Further, it appears to have increased the number of physicians practicing in the state, which could "make other states take notice and potentially enact tort reform," Dr. Postier said.

Dr. Stewart said that putting malpractice in the hands of the medical board had decreased costs and been generally positive. For instance, he said, the medical board process is transparent and allows more input from stakeholders like physicians.

"There’s no question that the benefits of tort reform in my opinion outweigh the potential negative consequences to physicians," he said.

Dr. Stewart and Dr. Postier reported no financial conflicts.

HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.

The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.

A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.

With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).

However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.

At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.

Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.

"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.

The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.

The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.

Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.

Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.

"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."

He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.

Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?

Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.

Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.

Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."

Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.

HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.

The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.

A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.

With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).

However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.

At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.

Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.

"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.

The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.

The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.

Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.

Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.

"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."

He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.

Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?

Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.

Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.

Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."

Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.

HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.

The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.

A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.

With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).

However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.

At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.

Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.

"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.

The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.

The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.

Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.

Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.

"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."

He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.

Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?

Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.

Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.

Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."

Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.

HOT SPRINGS, VA. – An analysis of a prospectively collected database indicates that breast cancer patients with multiple nodal disease need a metastatic work-up only if they have tumor grade 3 or 4.

Current NCCN (National Comprehensive Cancer Network) guidelines recommend that patients with stage III and node-positive disease receive a work-up if they are N1. But the NCCN guidelines are less clear about what to do about N2 and N3 patients, said Dr. Quyen Chu at the annual meeting of the Southern Surgical Association.

About 20% of patients with stage III disease will have distant metastases, said Dr. Chu, chief of the surgical oncology division at Louisiana State University Health Sciences Center, Shreveport.

He and his colleagues at LSU extracted data from an ongoing, prospective breast cancer database, which was created in 1998 and comprises patient experience primarily from the LSU center but also from E.A. Conway Hospital in Monroe, La. They analyzed 256 patients with N2 or N3 disease who began treatment in 2010.

There was little difference between the two groups. The mean age of the 158 N2 patients was 58 years; it was 57 for the 68 N3 patients. The mean tumor grade was 2.5, and the mean tumor size was 4.6 cm. The tumor stage was similar between the two groups, with about 40% overall staged at T2.

"Are we risking an observation based on the play of chance?"

About half of the tumors were estrogen receptor positive overall. There was no difference in estrogen receptor status between the two groups. But more of the N3 patients had HER2-positive tumors, at 43% (31 of 72 patients), compared with 26% (27 of 103 patients) for the N2 group.

The primary end point for the study was the incidence of stage IV disease, either at the time of diagnosis or within 30 days of surgery. Patients underwent bone scans, CT, and/or PET to detect metastases.

Unexpectedly, the researchers found two T0 patients and 35 T1 patients who had stage III metastatic disease. The overall risk of stage IV disease was 16%. In all, 6% of T2 patients had stage IV disease, compared with 22% of T3 patients and 36% of T3 patients.

By N stage, about 83% of N2 and N3 patients had stage III disease, whereas 15% of each group had stage IV disease.

There was no difference in overall survival between the N2 and N3 groups, but those with stage IV disease had a predictably and statistically significant lower overall survival. Using a Cox proportional hazard model, the researchers determined that the only significant predictors of survival were T stage and grade.

Commenting on the paper, Dr. William C. Wood said that Dr. Chu’s observations were "unique," and that the data might help clinicians to more accurately judge tumor progression. "The rate of progression is very important to prognosis," said Dr. Wood, professor of surgery at Emory University in Atlanta. He cautioned, however, that the data set was small. Given that there was no difference in prognosis among the N2 and N3 groups, he asked, "Are we risking an observation based on the play of chance?"

Dr. Wood also suggested that there might not be any utility to identifying patients who had asymptomatic stage IV disease. Staging studies could be avoided, along with potential false positives, and the decision to not identify such patients "could avoid a longer period [of] awareness of stage IV disease in a person who could otherwise be blissfully unaware," he said.

Dr. Chu agreed that this was a valid question. But he suggested that newer agents and aggressive surgical intervention have been shown recently to potentially extend survival in stage IV disease.

Several other commentators wondered if the findings had prompted any change at LSU. "This paper by no means suggests we should change our standard of care," said Dr. Chu. It might prompt some review of the role of different imaging modalities used, he noted. And he added that the study should cause clinicians to question the biology of breast cancer.

"A lot of us have the preconceived notion that if you have N2 or N3 disease, [the] outcome is very bad. But in actuality, it may not be the case," he said. "You may have a subset [of patients] who do quite well, who are true stage III rather than stage IV."

Dr. Chu reported no conflicts.

HOT SPRINGS, VA. – An analysis of a prospectively collected database indicates that breast cancer patients with multiple nodal disease need a metastatic work-up only if they have tumor grade 3 or 4.

Current NCCN (National Comprehensive Cancer Network) guidelines recommend that patients with stage III and node-positive disease receive a work-up if they are N1. But the NCCN guidelines are less clear about what to do about N2 and N3 patients, said Dr. Quyen Chu at the annual meeting of the Southern Surgical Association.

About 20% of patients with stage III disease will have distant metastases, said Dr. Chu, chief of the surgical oncology division at Louisiana State University Health Sciences Center, Shreveport.

He and his colleagues at LSU extracted data from an ongoing, prospective breast cancer database, which was created in 1998 and comprises patient experience primarily from the LSU center but also from E.A. Conway Hospital in Monroe, La. They analyzed 256 patients with N2 or N3 disease who began treatment in 2010.

There was little difference between the two groups. The mean age of the 158 N2 patients was 58 years; it was 57 for the 68 N3 patients. The mean tumor grade was 2.5, and the mean tumor size was 4.6 cm. The tumor stage was similar between the two groups, with about 40% overall staged at T2.

"Are we risking an observation based on the play of chance?"

About half of the tumors were estrogen receptor positive overall. There was no difference in estrogen receptor status between the two groups. But more of the N3 patients had HER2-positive tumors, at 43% (31 of 72 patients), compared with 26% (27 of 103 patients) for the N2 group.

The primary end point for the study was the incidence of stage IV disease, either at the time of diagnosis or within 30 days of surgery. Patients underwent bone scans, CT, and/or PET to detect metastases.

Unexpectedly, the researchers found two T0 patients and 35 T1 patients who had stage III metastatic disease. The overall risk of stage IV disease was 16%. In all, 6% of T2 patients had stage IV disease, compared with 22% of T3 patients and 36% of T3 patients.

By N stage, about 83% of N2 and N3 patients had stage III disease, whereas 15% of each group had stage IV disease.

There was no difference in overall survival between the N2 and N3 groups, but those with stage IV disease had a predictably and statistically significant lower overall survival. Using a Cox proportional hazard model, the researchers determined that the only significant predictors of survival were T stage and grade.

Commenting on the paper, Dr. William C. Wood said that Dr. Chu’s observations were "unique," and that the data might help clinicians to more accurately judge tumor progression. "The rate of progression is very important to prognosis," said Dr. Wood, professor of surgery at Emory University in Atlanta. He cautioned, however, that the data set was small. Given that there was no difference in prognosis among the N2 and N3 groups, he asked, "Are we risking an observation based on the play of chance?"

Dr. Wood also suggested that there might not be any utility to identifying patients who had asymptomatic stage IV disease. Staging studies could be avoided, along with potential false positives, and the decision to not identify such patients "could avoid a longer period [of] awareness of stage IV disease in a person who could otherwise be blissfully unaware," he said.

Dr. Chu agreed that this was a valid question. But he suggested that newer agents and aggressive surgical intervention have been shown recently to potentially extend survival in stage IV disease.

Several other commentators wondered if the findings had prompted any change at LSU. "This paper by no means suggests we should change our standard of care," said Dr. Chu. It might prompt some review of the role of different imaging modalities used, he noted. And he added that the study should cause clinicians to question the biology of breast cancer.

"A lot of us have the preconceived notion that if you have N2 or N3 disease, [the] outcome is very bad. But in actuality, it may not be the case," he said. "You may have a subset [of patients] who do quite well, who are true stage III rather than stage IV."

Dr. Chu reported no conflicts.

HOT SPRINGS, VA. – An analysis of a prospectively collected database indicates that breast cancer patients with multiple nodal disease need a metastatic work-up only if they have tumor grade 3 or 4.

Current NCCN (National Comprehensive Cancer Network) guidelines recommend that patients with stage III and node-positive disease receive a work-up if they are N1. But the NCCN guidelines are less clear about what to do about N2 and N3 patients, said Dr. Quyen Chu at the annual meeting of the Southern Surgical Association.

About 20% of patients with stage III disease will have distant metastases, said Dr. Chu, chief of the surgical oncology division at Louisiana State University Health Sciences Center, Shreveport.

He and his colleagues at LSU extracted data from an ongoing, prospective breast cancer database, which was created in 1998 and comprises patient experience primarily from the LSU center but also from E.A. Conway Hospital in Monroe, La. They analyzed 256 patients with N2 or N3 disease who began treatment in 2010.

There was little difference between the two groups. The mean age of the 158 N2 patients was 58 years; it was 57 for the 68 N3 patients. The mean tumor grade was 2.5, and the mean tumor size was 4.6 cm. The tumor stage was similar between the two groups, with about 40% overall staged at T2.

"Are we risking an observation based on the play of chance?"

About half of the tumors were estrogen receptor positive overall. There was no difference in estrogen receptor status between the two groups. But more of the N3 patients had HER2-positive tumors, at 43% (31 of 72 patients), compared with 26% (27 of 103 patients) for the N2 group.

The primary end point for the study was the incidence of stage IV disease, either at the time of diagnosis or within 30 days of surgery. Patients underwent bone scans, CT, and/or PET to detect metastases.

Unexpectedly, the researchers found two T0 patients and 35 T1 patients who had stage III metastatic disease. The overall risk of stage IV disease was 16%. In all, 6% of T2 patients had stage IV disease, compared with 22% of T3 patients and 36% of T3 patients.

By N stage, about 83% of N2 and N3 patients had stage III disease, whereas 15% of each group had stage IV disease.

There was no difference in overall survival between the N2 and N3 groups, but those with stage IV disease had a predictably and statistically significant lower overall survival. Using a Cox proportional hazard model, the researchers determined that the only significant predictors of survival were T stage and grade.

Commenting on the paper, Dr. William C. Wood said that Dr. Chu’s observations were "unique," and that the data might help clinicians to more accurately judge tumor progression. "The rate of progression is very important to prognosis," said Dr. Wood, professor of surgery at Emory University in Atlanta. He cautioned, however, that the data set was small. Given that there was no difference in prognosis among the N2 and N3 groups, he asked, "Are we risking an observation based on the play of chance?"

Dr. Wood also suggested that there might not be any utility to identifying patients who had asymptomatic stage IV disease. Staging studies could be avoided, along with potential false positives, and the decision to not identify such patients "could avoid a longer period [of] awareness of stage IV disease in a person who could otherwise be blissfully unaware," he said.

Dr. Chu agreed that this was a valid question. But he suggested that newer agents and aggressive surgical intervention have been shown recently to potentially extend survival in stage IV disease.

Several other commentators wondered if the findings had prompted any change at LSU. "This paper by no means suggests we should change our standard of care," said Dr. Chu. It might prompt some review of the role of different imaging modalities used, he noted. And he added that the study should cause clinicians to question the biology of breast cancer.

"A lot of us have the preconceived notion that if you have N2 or N3 disease, [the] outcome is very bad. But in actuality, it may not be the case," he said. "You may have a subset [of patients] who do quite well, who are true stage III rather than stage IV."

Dr. Chu reported no conflicts.

HOT SPRINGS, VA. – Despite the predominant view that islet cell transplantation is a radical procedure, it is effective for chronic pancreatitis when endoscopic duct drainage does not relieve the pain, according to researchers at the University of Minnesota, where the standard is to perform islet autotransplants in almost all cases of chronic pancreatitis.

The university began islet transplantation in 1977, but 60% of the procedures have been performed in the past 5 years. The total is now 374 adult cases and 57 pediatric cases. Dr. David Sutherland, professor of surgery at the university, presented data on the adult cases at the annual meeting of the Southern Surgical Association.

Islet autografts are still both a science and an art, said Dr. Sutherland. The pancreas is removed; importantly, the blood supply has to be preserved to the point of removal to avoid warm ischemia, he said. The islets are then isolated in a processing center. Each isolation must be adjusted to each individual’s diseased pancreas. The cells are then infused into the liver.

Minnesota’s case mix is very different from what is typical for pancreatitis. Seventy-three percent of the patients in the analysis were female, and only 7% of cases were due to alcoholism. In an interview after the presentation, Dr. Timothy Pruett, chief of the division of transplantation at the University of Minnesota, said that patients seem to be learning about the Minnesota procedure online and self-selecting to come to the university.

Some 41% of the cases were idiopathic in origin. Ninety-two percent did not have diabetes before transplantation.

Pain was a predominant factor for most patients. The average duration of pain was 9 years, and the duration of narcotic use was almost 4 years on average. This has many implications, including the central sensitization of pain and opioid-induced hyperalgesia.

The mortality rate for autotransplants has been low, with 97% of the most recent cohort (2006-2011) alive at 1 year. At 5 years, 86%-88% of the earlier transplant patients were still alive. Twenty-year survival is 66%, said Dr. Sutherland. Overall, 16% of patients have required reoperation; of those, about 10% needed surgery because of bleeding.

To assess the effectiveness of the islet autografts, the researchers looked at the 201 patients who had more than 1 year of follow-up. Regardless of the islet yield, 91% of the patients are C-peptide positive and 83% have a hemoglobin A_1c level in the desired range of 7% or less. Higher islet yields produce better results, with fewer patients becoming diabetic.

At 3 years, 70% of patients who had a high yield of islet cells were insulin independent. Only 10%-20% of the patients who had lower yields of cells did not need insulin, however.

Pancreatitis pain resolved in 80%-90% of patients overall. In 60% of patients, narcotics were withdrawn by 2 years. It is a slow process, noted Dr. Sutherland.

The pain rating went down for most patients – from a 66 to a 44 on a 100-point scale. There was also improvement in all eight categories on the Short Form-36 quality of life survey, said Dr. Sutherland. Although pain scores improved more in the insulin-independent patients, significant pain improvement was also seen in the insulin-dependent group.

"There’s no doubt in my mind that this procedure is safe and effective in the management of intractable chronic pain associated with pancreatitis in selected patients," said Dr. David B. Adams, who commented on the presentation. However, it is not clear how to best identify patients who would benefit from the procedure, said Dr. Adams, a professor of surgery at the Medical University of South Carolina in Charleston. Calling the Minnesota report a "landmark paper," he added that while the procedure does not cure patients, it does improve quality of life, which is crucial in this group.

Dr. Kenneth L. Brayman, division chief of transplant surgery at the University of Virginia, Charlottesville, said that "islet autotransplantation has emerged as successful therapy." At his institution, 40%-50% of autograft patients are insulin free and 80% are pain free.

Noting the success at Virginia and in other programs, Dr. Brayman said that "it remains curious to me and others, why the management of chronic pancreatitis remains so controversial."

"The question of whether this is a radical procedure or not is in the eyes of the beholder," said Dr. Pruett. "It’s not radical in our hands. It is what we do."

Dr. Sutherland and Dr. Pruett reported no conflicts.

HOT SPRINGS, VA. – Despite the predominant view that islet cell transplantation is a radical procedure, it is effective for chronic pancreatitis when endoscopic duct drainage does not relieve the pain, according to researchers at the University of Minnesota, where the standard is to perform islet autotransplants in almost all cases of chronic pancreatitis.

The university began islet transplantation in 1977, but 60% of the procedures have been performed in the past 5 years. The total is now 374 adult cases and 57 pediatric cases. Dr. David Sutherland, professor of surgery at the university, presented data on the adult cases at the annual meeting of the Southern Surgical Association.

Islet autografts are still both a science and an art, said Dr. Sutherland. The pancreas is removed; importantly, the blood supply has to be preserved to the point of removal to avoid warm ischemia, he said. The islets are then isolated in a processing center. Each isolation must be adjusted to each individual’s diseased pancreas. The cells are then infused into the liver.

Minnesota’s case mix is very different from what is typical for pancreatitis. Seventy-three percent of the patients in the analysis were female, and only 7% of cases were due to alcoholism. In an interview after the presentation, Dr. Timothy Pruett, chief of the division of transplantation at the University of Minnesota, said that patients seem to be learning about the Minnesota procedure online and self-selecting to come to the university.

Some 41% of the cases were idiopathic in origin. Ninety-two percent did not have diabetes before transplantation.

Pain was a predominant factor for most patients. The average duration of pain was 9 years, and the duration of narcotic use was almost 4 years on average. This has many implications, including the central sensitization of pain and opioid-induced hyperalgesia.

The mortality rate for autotransplants has been low, with 97% of the most recent cohort (2006-2011) alive at 1 year. At 5 years, 86%-88% of the earlier transplant patients were still alive. Twenty-year survival is 66%, said Dr. Sutherland. Overall, 16% of patients have required reoperation; of those, about 10% needed surgery because of bleeding.

To assess the effectiveness of the islet autografts, the researchers looked at the 201 patients who had more than 1 year of follow-up. Regardless of the islet yield, 91% of the patients are C-peptide positive and 83% have a hemoglobin A_1c level in the desired range of 7% or less. Higher islet yields produce better results, with fewer patients becoming diabetic.

At 3 years, 70% of patients who had a high yield of islet cells were insulin independent. Only 10%-20% of the patients who had lower yields of cells did not need insulin, however.

Pancreatitis pain resolved in 80%-90% of patients overall. In 60% of patients, narcotics were withdrawn by 2 years. It is a slow process, noted Dr. Sutherland.

The pain rating went down for most patients – from a 66 to a 44 on a 100-point scale. There was also improvement in all eight categories on the Short Form-36 quality of life survey, said Dr. Sutherland. Although pain scores improved more in the insulin-independent patients, significant pain improvement was also seen in the insulin-dependent group.

"There’s no doubt in my mind that this procedure is safe and effective in the management of intractable chronic pain associated with pancreatitis in selected patients," said Dr. David B. Adams, who commented on the presentation. However, it is not clear how to best identify patients who would benefit from the procedure, said Dr. Adams, a professor of surgery at the Medical University of South Carolina in Charleston. Calling the Minnesota report a "landmark paper," he added that while the procedure does not cure patients, it does improve quality of life, which is crucial in this group.

Dr. Kenneth L. Brayman, division chief of transplant surgery at the University of Virginia, Charlottesville, said that "islet autotransplantation has emerged as successful therapy." At his institution, 40%-50% of autograft patients are insulin free and 80% are pain free.

Noting the success at Virginia and in other programs, Dr. Brayman said that "it remains curious to me and others, why the management of chronic pancreatitis remains so controversial."

"The question of whether this is a radical procedure or not is in the eyes of the beholder," said Dr. Pruett. "It’s not radical in our hands. It is what we do."

Dr. Sutherland and Dr. Pruett reported no conflicts.

HOT SPRINGS, VA. – Despite the predominant view that islet cell transplantation is a radical procedure, it is effective for chronic pancreatitis when endoscopic duct drainage does not relieve the pain, according to researchers at the University of Minnesota, where the standard is to perform islet autotransplants in almost all cases of chronic pancreatitis.

The university began islet transplantation in 1977, but 60% of the procedures have been performed in the past 5 years. The total is now 374 adult cases and 57 pediatric cases. Dr. David Sutherland, professor of surgery at the university, presented data on the adult cases at the annual meeting of the Southern Surgical Association.

Islet autografts are still both a science and an art, said Dr. Sutherland. The pancreas is removed; importantly, the blood supply has to be preserved to the point of removal to avoid warm ischemia, he said. The islets are then isolated in a processing center. Each isolation must be adjusted to each individual’s diseased pancreas. The cells are then infused into the liver.

Minnesota’s case mix is very different from what is typical for pancreatitis. Seventy-three percent of the patients in the analysis were female, and only 7% of cases were due to alcoholism. In an interview after the presentation, Dr. Timothy Pruett, chief of the division of transplantation at the University of Minnesota, said that patients seem to be learning about the Minnesota procedure online and self-selecting to come to the university.

Some 41% of the cases were idiopathic in origin. Ninety-two percent did not have diabetes before transplantation.

Pain was a predominant factor for most patients. The average duration of pain was 9 years, and the duration of narcotic use was almost 4 years on average. This has many implications, including the central sensitization of pain and opioid-induced hyperalgesia.

The mortality rate for autotransplants has been low, with 97% of the most recent cohort (2006-2011) alive at 1 year. At 5 years, 86%-88% of the earlier transplant patients were still alive. Twenty-year survival is 66%, said Dr. Sutherland. Overall, 16% of patients have required reoperation; of those, about 10% needed surgery because of bleeding.

To assess the effectiveness of the islet autografts, the researchers looked at the 201 patients who had more than 1 year of follow-up. Regardless of the islet yield, 91% of the patients are C-peptide positive and 83% have a hemoglobin A_1c level in the desired range of 7% or less. Higher islet yields produce better results, with fewer patients becoming diabetic.

At 3 years, 70% of patients who had a high yield of islet cells were insulin independent. Only 10%-20% of the patients who had lower yields of cells did not need insulin, however.

Pancreatitis pain resolved in 80%-90% of patients overall. In 60% of patients, narcotics were withdrawn by 2 years. It is a slow process, noted Dr. Sutherland.

The pain rating went down for most patients – from a 66 to a 44 on a 100-point scale. There was also improvement in all eight categories on the Short Form-36 quality of life survey, said Dr. Sutherland. Although pain scores improved more in the insulin-independent patients, significant pain improvement was also seen in the insulin-dependent group.

"There’s no doubt in my mind that this procedure is safe and effective in the management of intractable chronic pain associated with pancreatitis in selected patients," said Dr. David B. Adams, who commented on the presentation. However, it is not clear how to best identify patients who would benefit from the procedure, said Dr. Adams, a professor of surgery at the Medical University of South Carolina in Charleston. Calling the Minnesota report a "landmark paper," he added that while the procedure does not cure patients, it does improve quality of life, which is crucial in this group.

Dr. Kenneth L. Brayman, division chief of transplant surgery at the University of Virginia, Charlottesville, said that "islet autotransplantation has emerged as successful therapy." At his institution, 40%-50% of autograft patients are insulin free and 80% are pain free.

Noting the success at Virginia and in other programs, Dr. Brayman said that "it remains curious to me and others, why the management of chronic pancreatitis remains so controversial."

"The question of whether this is a radical procedure or not is in the eyes of the beholder," said Dr. Pruett. "It’s not radical in our hands. It is what we do."

Dr. Sutherland and Dr. Pruett reported no conflicts.

HOT SPRINGS, VA. – A shorter length of stay appears to be associated with a higher risk of readmission after colectomy, but only in patients who are older and have more preoperative comorbidities and perioperative complications, results of a large database review demonstrate.

Dr. Timothy Pawlik and his colleagues from Johns Hopkins Hospital, Baltimore, conducted a retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database of 149,622 Medicare patients with a primary diagnosis of colorectal cancer who underwent colectomy from 1986 to 2005. The goal was to determine trends in readmission rates during the first 30 days.

"How do we begin to remedy the demonization of legitimate readmissions either politically, medically, or both?"

Increasingly, payers – especially Medicare – are penalizing hospitals for failing to prevent readmissions, which cost about $40 billion annually. Moreover, up to three-quarters of readmissions may be avoidable. In the meantime, many hospitals are fast-tracking patients for discharge after colorectal surgery.

In the SEER data, the mean age was 75 years in the 1986-1990 period and 77 years in the later period of 2001-2005. Patients were sicker in the later time period, with 63% having a Charlson comorbidity score of 3 or greater, compared with only 53% in the earlier time frame.

Most patients (38%) had a right colectomy; 23% had a sigmoid procedure, 13% had a rectal procedure, and 11% had a left colectomy. Forty-six percent of patients had lymph node metastasis, and 17% had an emergent procedure.

Morbidity for the entire study period was 37%; most complications were gastrointestinal or related to bleeding or postoperative infection. Again, there was a significant difference between the earlier and the later time frames. Perioperative morbidity was 27% in the 1986-1990 time frame, vs. 40% in 2001-2005. Mortality, at 4%, remained stable over time.

The mean length of stay decreased from 14 to 10 days from the early time to the later time period. And, over time, the percentage of patients discharged to home decreased, while discharges to skilled nursing facilities increased.

Overall, there were 17,000 readmissions, for a rate of 11%. Readmissions also increased, from 10% early on to 14% in 2001-2005. During that later time frame, patients had a 46% increased risk of readmission. Almost half of the readmissions occurred within the first 7 days after surgery, primarily for complications, dehydration, or infection. The mortality rate associated with readmission was 8%.

Multivariate analysis showed that the factors most likely to impact readmission were multiple comorbidities or a history of any perioperative complication, said Dr. Pawlik. Early discharge alone was not associated with a higher risk of readmission.

The study shows that "ongoing initiatives to reduce risk of readmissions and the associated costs, morbidity, and mortality are needed," said Dr. Pawlik.

It also "provides data that we all know to be true: namely, that the patients we are operating on have more comorbidities and that length of stay increases the rate of readmissions," said Dr. Susan Galandiuk, the discussant at the meeting. However, payers have been using length of stay and readmissions as quality surrogates, said Dr. Galandiuk, professor of surgery at the University of Louisville, Ky.

Not readmitting an elderly patient with many comorbidities and complications "would be a quality of care issue, and not the other way around," she added. The problem now is, "How do we begin to remedy the demonization of legitimate readmissions either politically, medically, or both?" asked Dr. Galandiuk.

Dr. Pawlik agreed that readmissions should not necessarily be held to be all bad. "Blaming readmissions on length of stay is a gross oversimplification of what’s going on," he added. Surgeons are clearly operating on older and sicker patients, and are doing more complicated operations that may result in a higher rate of morbidity – all this "in a culture of being asked to send people home earlier," he said.

"Our data clearly show that early discharge is feasible in some patients, but it needs to be used judiciously, especially in an older population," said Dr. Pawlik.

Dr. Pawlik and Dr. Galandiuk reported no conflicts.

HOT SPRINGS, VA. – A shorter length of stay appears to be associated with a higher risk of readmission after colectomy, but only in patients who are older and have more preoperative comorbidities and perioperative complications, results of a large database review demonstrate.

Dr. Timothy Pawlik and his colleagues from Johns Hopkins Hospital, Baltimore, conducted a retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database of 149,622 Medicare patients with a primary diagnosis of colorectal cancer who underwent colectomy from 1986 to 2005. The goal was to determine trends in readmission rates during the first 30 days.

"How do we begin to remedy the demonization of legitimate readmissions either politically, medically, or both?"

Increasingly, payers – especially Medicare – are penalizing hospitals for failing to prevent readmissions, which cost about $40 billion annually. Moreover, up to three-quarters of readmissions may be avoidable. In the meantime, many hospitals are fast-tracking patients for discharge after colorectal surgery.

In the SEER data, the mean age was 75 years in the 1986-1990 period and 77 years in the later period of 2001-2005. Patients were sicker in the later time period, with 63% having a Charlson comorbidity score of 3 or greater, compared with only 53% in the earlier time frame.

Most patients (38%) had a right colectomy; 23% had a sigmoid procedure, 13% had a rectal procedure, and 11% had a left colectomy. Forty-six percent of patients had lymph node metastasis, and 17% had an emergent procedure.

Morbidity for the entire study period was 37%; most complications were gastrointestinal or related to bleeding or postoperative infection. Again, there was a significant difference between the earlier and the later time frames. Perioperative morbidity was 27% in the 1986-1990 time frame, vs. 40% in 2001-2005. Mortality, at 4%, remained stable over time.

The mean length of stay decreased from 14 to 10 days from the early time to the later time period. And, over time, the percentage of patients discharged to home decreased, while discharges to skilled nursing facilities increased.

Overall, there were 17,000 readmissions, for a rate of 11%. Readmissions also increased, from 10% early on to 14% in 2001-2005. During that later time frame, patients had a 46% increased risk of readmission. Almost half of the readmissions occurred within the first 7 days after surgery, primarily for complications, dehydration, or infection. The mortality rate associated with readmission was 8%.

Multivariate analysis showed that the factors most likely to impact readmission were multiple comorbidities or a history of any perioperative complication, said Dr. Pawlik. Early discharge alone was not associated with a higher risk of readmission.

The study shows that "ongoing initiatives to reduce risk of readmissions and the associated costs, morbidity, and mortality are needed," said Dr. Pawlik.

It also "provides data that we all know to be true: namely, that the patients we are operating on have more comorbidities and that length of stay increases the rate of readmissions," said Dr. Susan Galandiuk, the discussant at the meeting. However, payers have been using length of stay and readmissions as quality surrogates, said Dr. Galandiuk, professor of surgery at the University of Louisville, Ky.

Not readmitting an elderly patient with many comorbidities and complications "would be a quality of care issue, and not the other way around," she added. The problem now is, "How do we begin to remedy the demonization of legitimate readmissions either politically, medically, or both?" asked Dr. Galandiuk.

Dr. Pawlik agreed that readmissions should not necessarily be held to be all bad. "Blaming readmissions on length of stay is a gross oversimplification of what’s going on," he added. Surgeons are clearly operating on older and sicker patients, and are doing more complicated operations that may result in a higher rate of morbidity – all this "in a culture of being asked to send people home earlier," he said.

"Our data clearly show that early discharge is feasible in some patients, but it needs to be used judiciously, especially in an older population," said Dr. Pawlik.

Dr. Pawlik and Dr. Galandiuk reported no conflicts.

HOT SPRINGS, VA. – A shorter length of stay appears to be associated with a higher risk of readmission after colectomy, but only in patients who are older and have more preoperative comorbidities and perioperative complications, results of a large database review demonstrate.

Dr. Timothy Pawlik and his colleagues from Johns Hopkins Hospital, Baltimore, conducted a retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database of 149,622 Medicare patients with a primary diagnosis of colorectal cancer who underwent colectomy from 1986 to 2005. The goal was to determine trends in readmission rates during the first 30 days.

"How do we begin to remedy the demonization of legitimate readmissions either politically, medically, or both?"

Increasingly, payers – especially Medicare – are penalizing hospitals for failing to prevent readmissions, which cost about $40 billion annually. Moreover, up to three-quarters of readmissions may be avoidable. In the meantime, many hospitals are fast-tracking patients for discharge after colorectal surgery.

In the SEER data, the mean age was 75 years in the 1986-1990 period and 77 years in the later period of 2001-2005. Patients were sicker in the later time period, with 63% having a Charlson comorbidity score of 3 or greater, compared with only 53% in the earlier time frame.

Most patients (38%) had a right colectomy; 23% had a sigmoid procedure, 13% had a rectal procedure, and 11% had a left colectomy. Forty-six percent of patients had lymph node metastasis, and 17% had an emergent procedure.

Morbidity for the entire study period was 37%; most complications were gastrointestinal or related to bleeding or postoperative infection. Again, there was a significant difference between the earlier and the later time frames. Perioperative morbidity was 27% in the 1986-1990 time frame, vs. 40% in 2001-2005. Mortality, at 4%, remained stable over time.

The mean length of stay decreased from 14 to 10 days from the early time to the later time period. And, over time, the percentage of patients discharged to home decreased, while discharges to skilled nursing facilities increased.

Overall, there were 17,000 readmissions, for a rate of 11%. Readmissions also increased, from 10% early on to 14% in 2001-2005. During that later time frame, patients had a 46% increased risk of readmission. Almost half of the readmissions occurred within the first 7 days after surgery, primarily for complications, dehydration, or infection. The mortality rate associated with readmission was 8%.

Multivariate analysis showed that the factors most likely to impact readmission were multiple comorbidities or a history of any perioperative complication, said Dr. Pawlik. Early discharge alone was not associated with a higher risk of readmission.

The study shows that "ongoing initiatives to reduce risk of readmissions and the associated costs, morbidity, and mortality are needed," said Dr. Pawlik.

It also "provides data that we all know to be true: namely, that the patients we are operating on have more comorbidities and that length of stay increases the rate of readmissions," said Dr. Susan Galandiuk, the discussant at the meeting. However, payers have been using length of stay and readmissions as quality surrogates, said Dr. Galandiuk, professor of surgery at the University of Louisville, Ky.

Not readmitting an elderly patient with many comorbidities and complications "would be a quality of care issue, and not the other way around," she added. The problem now is, "How do we begin to remedy the demonization of legitimate readmissions either politically, medically, or both?" asked Dr. Galandiuk.

Dr. Pawlik agreed that readmissions should not necessarily be held to be all bad. "Blaming readmissions on length of stay is a gross oversimplification of what’s going on," he added. Surgeons are clearly operating on older and sicker patients, and are doing more complicated operations that may result in a higher rate of morbidity – all this "in a culture of being asked to send people home earlier," he said.

"Our data clearly show that early discharge is feasible in some patients, but it needs to be used judiciously, especially in an older population," said Dr. Pawlik.

Dr. Pawlik and Dr. Galandiuk reported no conflicts.