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Objective: To morphometrically measure to muscle mass which may reflect physical components of frailty. Hence, we evaluated the association between L4 total psoas area (TPA) and operative outcome after radical cystectomy (RC) for bladder cancer., Methods: In a retrospective single-center study, bladder cancer patients who underwent RC and urinary diversion between 2007 and 2012 were enrolled. TPA was evaluated in the cross-sectional imaging. The psoas muscles were normalized with the height. Male patients with a psoas mass index ≤7.4 cm 2 /m 2 and female patients with a psoas mass index ≤5.2 cm 2 /m 2 were classified as sarcopenic. Outcome measures were 30- and 90-day readmission and complications, and survival. Multivariable logistic and Cox proportional-hazards regression models were used to determine relevant predictors., Results: The median age of the 441 participants and follow up time was 68 years (IQR 59-75) and 1.2 years (IQR 0.5-1.9), respectively. One hundred forty-three patients (32.4%) were sarcopenic. The 30-day readmission and the complication rates were 13.8% and 44.7%, respectively. The 90-day readmission and complication rates were 23.9% and 53.1%, respectively. The 1-year mortality rate was 11.6% (95%CI 8.7-15.4). Multivariable logistic regression analysis revealed an association between increased TPA and lower odds of 30-day complications after RC (OR 0.95, 95%CI 0.92-0.99, P = .02); similarly, an increase in TPA was of prognostic value, although not statistically significant in the multivariable model (P = .05) once adjusting for other patient factors., Conclusion: Sarcopenia predicted early complications and showed an informative trend for overall survival after RC, and thus may inform models predicting postsurgical outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: While pre and postoperative hyperglycemia is associated with increased risk of surgical site infection, myocardial infarction, stroke and risk of death, there are no multicenter data regarding the association of intraoperative blood glucose levels and outcomes for the non-cardiac surgical population., Methods: We conducted a retrospective cohort study from the Michigan Surgical Quality Collaborative, a network of 64 hospitals that prospectively collects validated data on surgical patients for the purpose of quality improvement. We included data for adult general, vascular, endocrine, hepatobiliary, and gastrointestinal operations between 2013 and 2015. We assessed the risk-adjusted, independent relationship between intraoperative hyperglycemia (glucose > 180) and the primary outcome of 30-day morbidity/mortality and secondary outcome of infectious complications using multivariable logistic regression modelling. Post hoc sensitivity analysis to assess the association between blood glucose values ≥250 mg/dL and outcomes was also performed., Results: Ninety-two thousand seven hundred fifty-one patients underwent surgery between 2013 and 2015 and 5014 (5.4%) had glucose testing intra-operatively. Of these patients, 1647 patients (32.9%) experienced the primary outcome, and 909 (18.1%) the secondary outcome. After controlling for patient comorbidities and surgical factors, peak intraoperative glucose > 180 mg/dL was not an independent predictor of 30-day mortality/morbidity (adjusted OR 1.05, 95%CI:0.86 to 1.28; p-value 0.623; model c-statistic of 0.720) or 30-day infectious complications (adjusted OR 0.93, 95%CI:0.74,1.16; p 0.502; model c-statistic of 0.709). Subgroup analysis for patients with or without diabetes yielded similar results. Sensitivity analysis demonstrated blood glucose of 250 mg/dL was a predictor of 30-day mortality/morbidity (adjusted OR: 1.59, 95% CI: 1.24, 2.05; p < 0.001)., Conclusions: Among more than 5000 patients across 64 hospitals who had glucose measurements during surgery, there was no difference in postoperative outcomes between patients who had intraoperative glucose > 180 mg/ dL compared to patients with glucose values ≤180 mg/ dL.

Background: Intraoperative fluid management during laparoscopic donor nephrectomy (LDN) may have a significant effect on donor and recipient outcomes. We sought to quantify variability in fluid management and investigate its impact on donor and recipient outcomes., Methods: A retrospective review of patients who underwent LDN from July 2011 to January 2016 with paired kidney recipients at a single center was performed. Patients were divided into tertiles of intraoperative fluid management (standard, high, and aggressive). Donor and recipient demographics, intraoperative data, and postoperative outcomes were analyzed., Results: Overall, 413 paired kidney donors and recipients were identified. Intraoperative fluid management (mL/h) was highly variable with no correlation to donor weight (kg) (R = 0.017). The aggressive fluid management group had significantly lower recipient creatinine levels on postoperative day 1. However, no significant differences were noted in creatinine levels out to 6 months between groups. No significant differences were noted in recipient postoperative complications, graft loss, and death. There was a significant increase (P < 0.01) in the number of total donor complications in the aggressive fluid management group., Conclusions: Aggressive fluid management during LDN does not improve recipient outcomes and may worsen donor outcomes compared to standard fluid management., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: As patients with chronic kidney disease become older, there is greater need to identify who will most benefit from kidney transplantation. Analytic morphomics has emerged as an objective risk assessment tool distinct from chronologic age. We hypothesize that morphometric age is a significant predictor of survival following transplantation., Methods: A retrospective cohort of 158 kidney transplant patients from 2005 to 2014 with 1-year preoperative imaging was identified. Based on a control population comprising of trauma patients and kidney donors, morphometric age was calculated using the validated characteristics of psoas area, psoas density, and abdominal aortic calcification. The primary outcome was post-transplant survival., Results: Cox regression showed morphometric age was a significant predictor of survival (hazard ratio, 1.06 per morphometric year [95% confidence interval, 1.03-1.08]; P < .001). Chronological age was not significant (hazard ratio, 1.03 per year [0.98-1.07]; P = .22). Among the chronologically oldest patients, those with younger morphometric age had greater survival rates compared to those with older morphometric age., Conclusions: Morphometric age predicts survival following kidney transplantation. Particularly for older patients, it offers improved risk stratification compared to chronologic age. Morphomics may improve the transplant selection process and provide a greater assessment of prospective survival benefits., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Better risk assessment tools are needed to predict post-transplantation diabetes mellitus (PTDM). Using analytic morphomic measurements from computed tomography (CT) scans, we aimed to identify specific measures of body composition associated with PTDM., Methods: We retrospectively reviewed 99 non-diabetic kidney transplant recipients who received pre-transplant CT scans at a single institution between 1/2005 and 5/2014. Analytic morphomic techniques were used to measure abdominal adiposity, abdominal size, and psoas muscle area and density, standardized by gender. We measured the associations of these morphomic factors with PTDM., Results: One-year incidence of PTDM was 18%. The morphomic factors significantly associated with PTDM included visceral fat area (OR=1.84 per standard deviation increase, P=.020), body depth (OR=1.79, P=.035), and total body area (OR=1.67, P=.049). Clinical factors significantly associated with PTDM included African American race (OR=3.01, P=.044), hypertension (OR=2.97, P=.041), and dialysis vintage (OR=1.24 per year on dialysis, P=.048). Body mass index was not associated with PTDM (OR=1.05, P=.188). On multivariate modeling, visceral fat area was an independent predictor of PTDM (OR=1.91, P=.035)., Conclusions: Analytic morphomics can identify pre-transplant measurements of body composition that are predictive of PTDM in kidney transplant recipients. Pre-transplant imaging contains a wealth of underutilized data that may inform PTDM prevention strategies., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: To explore the clinical and financial implications of preoperative opioid use in major abdominal surgery., Background: Opioids are increasingly used to manage chronic pain, and chronic opioid users are challenging to care for perioperatively. Given the epidemic of opioid-related morbidity and mortality, it is critical to understand how preoperative opioid use impacts surgical outcomes., Methods: This was an analysis of nonemergent, abdominopelvic surgeries from 2008 to 2014 from a single center within the Michigan Surgical Quality Collaborative clinical registry database. Preoperative opioid use (binary exposure variable) was retrospectively queried from the home medication list of the preoperative evaluation. Our primary outcome was 90-day total hospital costs. Secondary outcomes included hospital length of stay, 30-day major complication rates, discharge destination, and 30-day hospital readmission rates. Analyses were risk-adjusted for case complexity and patient-specific risk factors such as demographics, insurance, smoking, comorbidities, and concurrent medication use., Results: In all, 2413 patients met the inclusion criteria. Among them, 502 patients (21%) used opioids preoperatively. After covariate adjustment, opioid users (compared with those who were opioid-naïve) had 9.2% higher costs [95% confidence interval (CI) 2.8%-15.6%; adjusted means $26,604 vs $24,263; P = 0.005), 12.4% longer length of stay (95% CI 2.3%-23.5%; adjusted means 5.9 vs 5.2 days; P = 0.015), more complications (odds ratio 1.36; 95% CI 1.04-1.78; adjusted rates 20% vs 16%; P = 0.023), more readmissions (odds ratio 1.57; 95% CI 1.08-2.29; adjusted rates 10% vs 6%; P = 0.018), and no difference in discharge destination (P = 0.11)., Conclusions: Opioid use is common before abdominopelvic surgery, and is independently associated with increased postoperative healthcare utilization and morbidity. Preoperative opioids represent a potentially modifiable risk factor and a novel target to improve quality and value of surgical care.

Background: Significant intercenter variation exists in mortality and death-censored graft loss (DCGL) after transplantation. Failure to rescue (FTR, death after a major complication) is an emerging tool in quality improvement and may underlie this variation. This study is the first effort to investigate the relationship between FTR and outcomes in transplantation to assess its utility in care improvement., Methods: Using the Studies of Pediatric Liver Transplantation database, we identified 2330 children undergoing primary liver transplants at 21 centers. Centers were ranked by risk-adjusted mortality and sorted into tertiles. We then compared mortality, complications, and FTR across tertiles., Results: Overall mortality was 4.9%, ranging from 1.4% to 8.1% in the low and high mortality tertiles (P < 0.01). The low mortality tertile had significantly lower rates of complications (30.9% vs 38.5% and 40.4%, P < 0.01) as well as FTR (4.6% vs 9.9% and 14.3%, P < 0.01). A similar trend was seen in the DCGL analysis., Conclusions: Our results demonstrate that although centers with higher mortality and DCGL have more frequent major complications, they exhibit 3-fold the rate of FTR. Efforts to standardize perioperative care, and thus minimize FTR, will have value to pediatric liver transplantation recipients. This preliminary study indicates that FTR may provide a useful quality improvement tool for the field of transplantation and warrants further investigation.

Introduction: Sarcopenic liver transplant recipients have higher rates of mortality, but mechanisms underlying these rates remain unclear. Failure to rescue (FTR) has been shown to be a primary driver of mortality following major general and vascular surgery. We hypothesized that FTR is common in sarcopenic liver transplant recipients., Methods: We retrospectively reviewed 348 liver transplant recipients with perioperative CT scans. Analytic morphomic techniques were used to assess trunk muscle size via total psoas area (TPA). One-yr major complication and FTR rates were calculated across TPA tertiles., Results: The one-yr complication rate was 77% and the FTR rate was 19%. Multivariate regression showed TPA as a significant predictor of FTR (OR = 0.27 per 1000 mm(2) increase in TPA, p < 0.001). Compared to patients in the largest muscle tertile, patients in the smallest tertile had 1.4-fold higher adjusted complication rates (91% vs. 66%) and 2.8-fold higher adjusted FTR rates (22% vs. 8%)., Discussion: These results suggest that mortality in sarcopenic liver transplant recipients may be strongly related to FTR. Efforts aimed at early recognition and management of complications may decrease postoperative mortality. Additionally, this work highlights the need for expanded multicenter collaborations aimed at collection and analysis of postoperative complications in liver transplant recipients., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: We sought to determine the reliability of surgeon-specific postoperative complication rates after colectomy., Background: Conventional measures of surgeon-specific performance fail to acknowledge variation attributed to statistical noise, risking unreliable assessment of quality., Methods: We examined all patients who underwent segmental colectomy with anastomosis from 2008 through 2010 participating in the Michigan Surgical Quality Collaborative Colectomy Project. Surgeon-specific complication rates were risk-adjusted according to patient characteristics with multiple logistic regression. Hierarchical modeling techniques were used to determine the reliability of surgeon-specific risk-adjusted complication rates. We then adjusted these rates for reliability. To evaluate the extent to which surgeon-level variation was reduced, surgeons were placed into quartiles based on performance and complication rates were compared before and after reliability adjustment., Results: A total of 5033 patients (n = 345 surgeons) undergoing partial colectomy reported a risk-adjusted complication rate of 24.5%. Approximately 86% of the variability of complication rates across surgeons was explained by measurement noise, whereas the remaining 14% represented true signal. Risk-adjusted complication rates varied from 0% to 55.1% across quartiles before adjusting for reliability. Reliability adjustment greatly diminished this variation, generating a 1.2-fold difference (21.4%-25.6%). A caseload of 168 colectomies across 3 years was required to achieve a reliability of more than 0.7, which is considered a proficient level. Only 1 surgeon surpassed this volume threshold., Conclusions: The vast majority of surgeons do not perform enough colectomies to generate a reliable surgeon-specific complication rate. Risk-adjusted complication rates should be viewed with caution when evaluating surgeons with low operative volume, as statistical noise is a large determinant in estimating their surgeon-specific complication rates.

Objective: Postoperative myocardial infarction (poMI) is a serious and costly complication. Multiple risk factors for poMI are known, but the effect of anemia and cardioprotective medications have not been defined in real-world surgical practice., Methods: Patients undergoing inpatient elective surgery were assessed at 17 hospitals from 2008 to 2011 for the occurrence of poMI (American Heart Association definition). Non-MI control patients were chosen randomly on the basis of case type. Descriptive, univariable, and multivariable statistical analysis were performed for primary outcomes of poMI and death at 30 days., Results: Compared with controls (N = 304), patients with poMI (N = 222) were older (72 ± 11 vs 60 ± 17 years, P < .0001), had a lesser preoperative hematocrit (37 ± 6 vs 39 ± 5, P < .0001), more often were smokers, had a preoperative T-wave abnormality (21% vs 9%, P < .0001), and had a preoperative stress test with a fixed deficit (26% vs 3%; P < .001). Preoperative factors associated with poMI included peripheral vascular disease (odds ratio 2.6; 95% confidence interval 1.3-5.3), tobacco use (1.7; 1.01-2.9), history of percutaneous coronary angioplasty (2.8; 1.6-5.0), and age (1.05; 1.03-1.07), whereas hematocrit >35 (0.51; 0.32-0.82) and preoperative acetylsalicylic acid, ie, aspirin (0.59; 0.4-0.97) were protective. Preoperative β-blockade, statin, and use of angiotensin-converting enzyme inhibitors were not associated with lesser rates of poMI. Non-MI complication rates were 23-fold greater in the poMI group compared with the control group (P < .0001). Mortality with poMI within 30 days was 11% compared with 0.3% in non-MI control patients (P < .0001). In patients with poMI, factors independently associated with death included use of epidurals (3.5; 1.07-11.4) and bleeding (4.2; 1.1-16), whereas preoperative use of aspirin (0.29; 0.1-0.88), and postoperative β-blockade (0.18; 0.05-0.63) were protective. Cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass grafting after poMI was performed in 34% of those alive and 20% of those who died (P = .16)., Conclusion: In the current era, poMI patients have a markedly increased risk of death. This risk is decreased with preoperative use of acetylsalicylic acid and post MI β-blockade. Further study is warranted to explore the role of anemia and cardiac interventions after poMI., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Surgeons often face difficult decisions in selecting which patients can tolerate major surgical procedures. Although recent studies suggest the potential for trunk muscle size, as measured on preoperative imaging, to inform surgical risk, these measures are static and do not account for the effect of the surgery itself. We hypothesize that trunk muscle size will show dynamic changes over the perioperative period, and this change correlates with postoperative mortality risk., Methods: A total of 425 patients who underwent inpatient general surgery were identified to have both a 90-d preoperative and a 90-d postoperative abdominal computed tomography scan. The change in trunk muscle size was calculated using analytic morphomic techniques. The primary outcome was 1-y survival. Covariate-adjusted outcomes were assessed using multivariable logistic regression., Results: A total of 82.6% patients (n = 351) experienced a decrease in trunk muscle size in the time between their scans (average 62.1 d). When stratifying patients into tertiles of rate of change in trunk muscle size and adjusting for other covariates, patients in the tertile of the greatest rate loss had significantly increased risk of 1-y mortality than those in the tertile of the least rate loss (P = 0.002; odds ratio = 3.40 95% confidence interval, 1.55-7.47). The adjusted mortality rate for the tertile of the greatest rate loss was 24.0% compared with 13.3% for the tertile of the least decrease., Conclusions: Trunk muscle size changes rapidly in the perioperative period and correlates with mortality. Trunk muscle size may be a critical target for interventional programs focusing on perioperative optimization of the surgical patient., (Copyright © 2014. Published by Elsevier Inc.)

Background: Perioperative mortality in the elderly is high after emergency surgery and varies considerably among hospitals-an observation partially explained by differences in failure to rescue. We hypothesize that failure to rescue after certain types of complications underlies the disproportionately poor outcomes observed in elderly patients., Study Design: We identified 23,217 patients undergoing emergent general or vascular surgery procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2007 and 2012. Patients' first complications were identified and categorized by type. We compared failure to rescue rates at the patient-level between patients younger than 75 and 75 years of age and older. We then compared failure to rescue rates after specific complications across hospitals grouped in tertiles by risk-adjusted 30-day mortality., Results: Risk-adjusted failure to rescue rates were significantly higher in the elderly after a first infectious (21.7% vs 10.3%; p < 0.01) or pulmonary (38.2% vs 20.4%; p < 0.01) complication when compared with younger patients. At the hospital level, high-mortality centers failed to rescue elderly patients more frequently than low-mortality centers after a first infectious (35.6% vs 22.2%; p < 0.01) and pulmonary (24.3 vs 14.3; p < 0.01) complication. Failure to rescue rates after cardiovascular complications did not differ significantly across patient ages or tertiles of hospital mortality., Conclusions: Hospitals fail to rescue elderly patients at higher rates than younger patients after infectious and pulmonary complications. Efforts to recognize and manage these specific complications have the potential to improve emergency surgical care of the elderly in Michigan., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the relationship between postoperative morbidity and mortality and patients' perspectives of care., Background: Priorities in health care quality research are shifting to place greater emphasis on patient-centered outcomes. Whether patients' perspectives of care correlate with surgical outcomes remains unclear., Design: Retrospective cohort study., Methods: Using data from the Michigan Surgical Quality Collaborative clinical registry (2008-2012), we identified 41,833 patients undergoing major elective general or vascular surgery. Our exposure variables were the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Total and Base Scores derived from the Hospital Value-Based Purchasing Patient Experience of Care Domain. Using multilevel, mixed-effects logistic regression models, we adjusted hospitals' rates of morbidity and mortality for patient comorbidities and case mix. We stratified reporting of outcomes by quintiles of hospitals' Total and Base Scores., Results: Risk-adjusted morbidity (13.6%-28.6%) varied widely across hospitals. There were no significant differences in risk-adjusted morbidity rates between hospitals with the lowest and highest HCAHPS Total Scores (24.5% vs 20.2%, P = 0.312). The HCAHPS Base Score, which quantifies sustained achievement or improvement in patients' perspectives of care, was not associated with a reduction in postoperative morbidity over the study period despite an overall decrease of 2.5% for all centers. We observed a similar relationship between HCAHPS Total and Base Scores and postoperative mortality., Conclusions and Relevance: Patients' perspectives of care do not correlate with the incidence of morbidity and mortality after major surgery. Improving patients' perspectives and objective outcomes may require separate initiatives for surgeons in Michigan.

Background: Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement., Objective: The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement., Design: This was a retrospective cohort study., Settings: The study took place within the 34-hospital Michigan Surgical Quality Collaborative., Patients: Patients included were those undergoing ostomy creation surgery between 2006 and 2011., Main Outcome Measures: We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type)., Results: A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals., Limitations: This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes., Conclusions: Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

Objective: Recently, failure to rescue (FTR; death following major complication) has been shown to be a primary driver of mortality in highly morbid operations. Establishing this relationship for open and endovascular repair of abdominal aortic aneurysms may be a critical first step in improving mortality following these procedures. We sought to examine the relative contribution of severe complications and FTR to variations in mortality rate., Methods: We examined endovascular aortic repair (EVAR) and open aortic repair (OAR; n = 3215) performed in 40 hospitals participating in the Michigan Surgical Quality Collaborative from 2007 to 2012. Hospitals were first divided into risk-adjusted mortality tertiles. We then determined rates of severe complications and FTR within each tertile., Results: For EVAR, risk-adjusted hospital mortality rates varied significantly between the lowest and highest tertiles (0.07% vs 6.14%; P < .01). However, while major complication rates were almost identical (9.0 vs 9.8; P = NS), FTR rates were about 35 times greater in high-mortality hospitals (4.0% vs 33.3%). Similar associations with mortality, severe complications, and FTR were seen for OAR as well. The most common complications that led to FTR events were postoperative transfusion (OAR 29.8% vs EVAR 5.8%) and prolonged ventilation (OAR 18.2% vs EVAR 1.0%). The average number of severe complications per FTR event was 2.85 and 2.66 for OAR and EVAR, respectively., Conclusions: FTR appears to drive a large proportion of the variation in mortality associated with abdominal aortic aneurysm repair. The exact mechanisms underlying this variation remain unknown. Nonetheless, FTR is influenced by the structural characteristics and safety culture related to the timely recognition and management of severe complications. Hospitals that are unable to effectively handle severe complications following EVAR or OAR require close scrutiny., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Living kidney donor pools are expanding with the use of "medically complex" donors. Whether or not to include cigarette smokers as living kidney donors remains unclear. The aim of this study was to determine the relationship between donor smoking and recipient outcomes. We hypothesized that donor smoking would increase donor complications and decrease allograft and recipient survival over time., Methods: The charts of 602 living kidney donors and their recipients were retrospectively reviewed. Kaplan-Meier survival analysis and Cox modeling were used to assess the relationships between smoking and recipient and allograft survival., Results: No difference in postoperative complications was seen in smoking versus non-smoking donors. Donor smoking at time of evaluation did not significantly decrease allograft survival (HR = 1.19, p = 0.52), but recipient smoking at evaluation did reduce allograft survival (HR = 1.74, p = 0.05). Both donor and recipient smoking decreased recipient survival (HR = 1.93, p < 0.01 vs HR = 1.74, p = 0.048)., Discussion: When controlled for donor and recipient factors, cigarette smoking by living kidney donors significantly reduced recipient survival. This datum suggests that careful attention to smoking history is an important clinical measure in which to counsel potential donors and recipients. Policy efforts to limit donors with a recent smoking history should be balanced with the overall shortage of appropriate kidney donors., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: To determine whether failure to rescue, as a driver of mortality, can be used to identify which hospitals attenuate the specific risks inherent to elderly adults undergoing surgery., Design: Retrospective cohort study., Setting: State-wide surgical collaborative in Michigan., Participants: Older adults undergoing major general or vascular surgery between 2006 and 2011 (N = 24,216)., Measurements: Thirty-four hospitals were ranked according to risk-adjusted 30-day mortality and grouped into tertiles. Within each tertile, rates of major complications and failure to rescue were calculated, stratifying outcomes according to age (<75 vs ≥ 75). Next, differences in failure-to-rescue rates between age groups within each hospital were calculated., Results: Failure-to-rescue rates were more than two times as high in elderly adults as in younger individuals in each tertile of hospital mortality (26.0% vs 10.3% at high-mortality hospitals, P < .001). Within hospitals, the average difference in failure-to-rescue rates was 12.5%. Nine centers performed better than expected, and three performed worse than expected, with the largest differences exceeding 25%., Conclusion: Although elderly adults experience higher failure-to-rescue rates, this does not account for hospitals' overall capacity to rescue individuals from complications. Comparing rates of younger and elderly adults within hospitals may identify centers where efforts toward complication rescue favor, or are customized for, elderly adults. These centers should be studied as part of the collaborative's effort to address the disparate outcomes that elderly adults in Michigan experience., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objective: To determine whether a hospital's ability to rescue patients from major complications underlies variation in outcomes for elderly patients undergoing emergent surgery., Background: Perioperative mortality rates in elderly patients undergoing emergent general/vascular operations are high and vary widely across Michigan hospitals., Methods: We identified 23,224 patients undergoing emergent general/vascular surgical procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2006 and 2011. Hospitals were ranked by risk- and reliability-adjusted 30-day mortality rates and grouped into tertiles. We stratified patients by age (<75 and ≥75 years). Risk-adjusted major complication and failure-to-rescue (ie, mortality after major complication) rates were determined for each tertile of hospital mortality., Results: Risk-adjusted mortality rates in elderly patients varied 2-fold across all hospitals. Complication rates correlated poorly with mortality. Failure-to-rescue rates, however, were markedly higher in high-mortality hospitals (29% lowest tertile vs 41% highest tertile; P < 0.01). When compared with younger patients, overall failure-to-rescue rates were almost 2-fold greater in the elderly (36.1% ≥75 vs 18.7% <75; P < 0.01)., Conclusions: A hospital's failure to rescue patients from major complications seems to underlie the variation in mortality rates across Michigan hospitals after emergent surgery. Although higher failure-to-rescue rates in the elderly may signify their diminished physiological reserve for surviving critical illness, the wide variation across hospitals also highlights the importance of systems aimed at the early recognition and effective management of major complications in this vulnerable population.

Background: In the setting of a statewide quality collaborative approach to the review of cardiac surgical mortalities in intensive care units (ICUs), variations in complication-related outcomes became apparent. Utilizing "failure to rescue" methodology (FTR; the probability of death after a complication), we compared FTR rates after adult cardiac surgery in low, medium, and high mortality centers from a voluntary, 33-center quality collaborative., Methods: We identified 45,904 patients with a Society of Thoracic Surgeons predicted risk of mortality who underwent cardiac surgery between 2006 and 2010. The 33 centers were ranked according to observed-to-expected ratios for mortality and were categorized into 3 equal groups. We then compared rates of complications and FTR., Results: Overall unadjusted mortality was 2.6%, ranging from 1.5% in the low-mortality group to 3.6% in the high group. The rate of 17 complications ranged from 19.1% in the low group to 22.9% in the high group while FTR rates were 6.6% in the low group, 10.4% in the medium group, and 13.5% in the high group (p < 0.001). The FTR rate was significantly better in the low mortality group for the majority of complications (11 of 17) with the most significant findings for cardiac arrest, dialysis, prolonged ventilation, and pneumonia., Conclusions: Low mortality hospitals have superior ability to rescue patients from complications after cardiac surgery procedures. Outcomes review incorporating a collaborative multi-hospital approach can provide an ideal opportunity to review processes that anticipate and manage complications in the ICU and help recognize and share "differentiators" in care., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Though robust clinical data are available within transplantation, these data are not used for broad-based, multicentered quality improvement initiates. This article describes a targeted quality improvement initiative within the Studies of Pediatric Liver Transplantation (SPLIT) Registry. Using standard statistical techniques and clinical expertise to adjust for data and statistical reliability, we identified the pediatric liver transplant centers in North America with the lowest hepatic artery thrombosis rate and biliary complication rates. A survey was completed to establish current practices within the entire SPLIT group. Surgeons from the highest performing centers presented a detailed, technically oriented overview of their current practices. The presentations and discussion that followed were recorded and form the basis of the best practices described herein. We frame this work as a unique six-step approach roadmap that may serve as an efficient and cost effective model for novel broad-based quality improvement initiatives within transplantation., (© Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.)

We sought to estimate the effect of smoking on the biliary complication rate following orthotopic liver transplantation. We retrospectively evaluated the records of liver transplant recipients at our center from July 1, 1999 to October 26, 2007. Using Cox proportional hazards models, we estimated the time to the earliest biliary complication (leak or stricture) based on smoking exposure, as active, former, or lifetime nonsmoker, adjusting for other clinical factors. Overall, 409 liver transplant recipients were evaluated. The overall biliary complication rate was 37.7% (n = 154). Biliary complications included 66 anastomotic leaks, 60 anastomotic strictures, and 28 nonanastomotic lesions. ERCP was the primary diagnostic modality (n = 112). 18.1% of liver transplant recipients were active smokers (n = 74) and 42.8% were former smokers (n = 175). Active smokers were at greatest risk for biliary complications on unadjusted analysis (P = 0.022). After multivariable adjustment, active smokers had a 92% higher rate of biliary complication rates compared with lifetime nonsmokers (HR 1.92, 95% CI 1.07-3.43), but no difference was noted in the rate of complication resolution. Smoking clearly portends a significant risk of biliary complications following liver transplantation. Smoking status should be clearly defined when evaluating transplant candidacy and in counseling patients with cirrhosis., (© 2010 The Authors. Journal compilation © 2010 European Society for Organ Transplantation.)

Background: The effect of obesity on perioperative outcomes following hepatic resection is not clearly defined. We sought to understand the implications of obesity on post-hepatectomy outcomes in a nationally represented cohort of patients., Methods: Using a retrospective cohort design, we studied the effect of obesity on complications and 30-day mortality using multivariable logistic regression using comprehensive clinical data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2008)., Results: During our study period, 3,960 patients underwent hepatic resection; 32.4% had a normal body mass index (BMI; 18.5-24.9 kg/m(2)), 2.5% were underweight (<18.5 kg/m(2)), 33.4% were overweight (25.0-29.9 kg/m(2)), and 31.7% were obese (>30.0 kg/m(2)). 23.3% had at least one post-operative complication and the overall mortality rate was 2.5%. Compared to normal patients, obese patients had significantly higher unadjusted odds of having a complication (26.5% vs. 21.3%, OR 1.34, 95% CI 1.12-1.61) and dying (3.0% vs. 1.7%, OR 1.79, 95% CI 1.05-3.05). The obese were also more likely to have multiple complications compared to normal BMI patients (6.1% vs. 3.7%, OR 1.70, 95% CI 1.17-2.46). After risk adjustment, obesity was associated with attenuated but significantly higher odds of having any perioperative complication (OR 1.24, 95% CI 1.01-1.55), but was not a significant predictor of mortality., Conclusions: After adjusting for other clinical factors, the degree of obesity is independently associated with an increasing complication rate but not mortality. Risk adjustment may not capture the total clinical risk of patients at the extremes of BMI.

Background: Surgical site infection (SSI) after kidney transplantation has been associated with worse graft and patient survival. Although there are clinical incentives to reduce the incidence of SSI, it is unknown whether these are aligned with financial incentives for payers and providers. We use post-kidney transplant surgical site infection (SSI) to quantify the financial implications of surgical complications. The goal of this study was to quantify the financial costs of SSI after kidney transplantation and to determine the party bearing the brunt of these costs., Study Design: This was a retrospective cohort study of all adult, first-time kidney-only transplant recipients at the University of Michigan Health System from September 2003 to April 2008 (n = 869). The primary exposure variable was SSI. SSI was defined as skin dehiscence, fascial dehiscence, or bowel evisceration. Primary outcomes measures were hospital revenue (payer costs), hospital inpatient costs, and hospital margin. We used simple univariate (t-test) analysis and multivariate (generalized linear regression) models to control for donor, recipient, and insurer characteristics., Results: Eighteen percent of patients had documented SSIs. In cases with an SSI hospital revenue increased by $20,176, hospital margin decreased by $4,278, and hospital costs increased by $24,454. When adjusted for donor and recipient characteristics, SSI was independently associated with an $11,132 increase in hospital revenue., Conclusions: Although SSIs have negative financial effects on both hospitals and payers, the impact is greater on payers. Payers have the primary financial incentive to reduce SSI, and broad-based, quality improvement initiatives can be prudent investments for payers. Quantification of the costs associated with SSI can be used to define financial parameters for such initiatives that might prove beneficial to multiple stakeholders., (Copyright (c) 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) provides reliable, risk-adjusted outcomes data using standardized definitions and end points. Collection of the data is time consuming, and the surgical clinical nurse reviewers (SCNRs) can sample only a subset of all surgical cases. We sought to test the feasibility of using an informatics tool to automatically identify postoperative complications stored as free-text documents in our electronic medical record., Study Design: We used a locally developed electronic medical record search engine (EMERSE) to build sets of terminology that could accurately identify postoperative complications of both myocardial infarction (MI) and pulmonary embolism (PE) as defined by the ACS-NSQIP. All complications had been previously identified by our SCNRs and these were considered the gold standard. We used 5,894 cases from 2001 to 2004 from our institution's ACS-NSQIP dataset for building the terminology and 4,898 cases from 2005 to 2006 for validation. False-positive cases were then further reviewed manually., Results: We achieved sensitivities of 100.0% and 92.8% for identifying postoperative myocardial infarction and pulmonary embolism, respectively, with somewhat lower specificities of 93.0% and 95.9%, respectively. These results compared favorably with results from the SCNRs, especially because our manual review uncovered cases previously missed., Conclusions: Informatics has the potential to improve the efficiency and accuracy of chart abstraction by SCNRs for the ACS-NSQIP. Using such tools may eventually allow all cases at an institution to be reviewed rather than a small subset.

Background: Complications after liver transplantation are common and expensive. The incremental costs of adult posttransplantation liver transplantation complications and who pays for these complications (center or payor) is unknown., Study Design: We reviewed the medical and financial records (first 90 postoperative days) of all adult liver transplant recipients at our center between July 1, 2002, and October 30, 2005 (N = 214). The association of donor, recipient, and financial data points (total costs, reimbursements, and profits) was assessed using standard univariable analyses. The incremental costs of complications were determined with multiple linear regression models to control for the costs inherent to donor and recipient characteristics., Results: Univariate analyses demonstrated that both total hospital costs and reimbursements were substantially increased in patients with several different complications. Multiple linear regression analysis, controlling for recipient (age, gender, race, and laboratory Model for End-Stage Liver Disease [MELD]) and donor factors (donor risk index), noted that increased hospital costs and hospital reimbursements were independently associated with laboratory MELD (incremental costs of $3,368 and $2,787, respectively, per MELD point) and pneumonia ($83,718 and $68,214, respectively). A negative profit margin for the medical center was independently associated with peritonitis ($21,760). Commercial insurance was associated with no changes in total costs when compared with public insurer, but it was associated with decreased reimbursement and profit., Conclusions: The incremental costs of complications in liver transplantation are high for both the medical center and payor, but medical center profits are not affected substantially. The payor bears the financial burden for post-liver transplantation complications.

Background: The authors investigated the incidence and risk factors for postoperative acute renal failure after major noncardiac surgery among patients with previously normal renal function., Methods: Adult patients undergoing major noncardiac surgery with a preoperative calculated creatinine clearance of 80 ml/min or greater were included in a prospective, observational study at a single tertiary care university hospital. Patients were followed for the development of acute renal failure (defined as a calculated creatinine clearance of 50 ml/min or less) within the first 7 postoperative days. Patient preoperative characteristics and intraoperative anesthetic management were evaluated for associations with acute renal failure. Thirty-day, 60-day, and 1-yr all-cause mortality was also evaluated., Results: A total of 65,043 cases between 2003 and 2006 were reviewed. Of these, 15,102 patients met the inclusion criteria; 121 patients developed acute renal failure (0.8%), and 14 required renal replacement therapy (0.1%). Seven independent preoperative predictors were identified (P < 0.05): age, emergent surgery, liver disease, body mass index, high-risk surgery, peripheral vascular occlusive disease, and chronic obstructive pulmonary disease necessitating chronic bronchodilator therapy. Several intraoperative management variables were independent predictors of acute renal failure: total vasopressor dose administered, use of a vasopressor infusion, and diuretic administration. Acute renal failure was associated with increased 30-day, 60-day, and 1-yr all-cause mortality., Conclusions: Several preoperative predictors previously reported to be associated with acute renal failure after cardiac surgery were also found to be associated with acute renal failure after noncardiac surgery. The use of vasopressor and diuretics is also associated with acute renal failure.

Objective: We hypothesize that the systems of care within academic medical centers are sufficiently disrupted with the beginning of a new academic year to affect patient outcomes., Methods: This observational multiinstitutional cohort study was conducted by analysis of the National Surgical Quality Improvement Program-Patient Safety in Surgery Study database. The 30-day morbidity and mortality rates were compared between 2 periods of care: (early group: July 1 to August 30) and late group (April 15 to June 15). Patient baseline characteristics were first compared between the early and late periods. A prediction model was then constructed, via stepwise logistic regression model with a significance level for entry and a significance level for selection of 0.05., Results: There was 18% higher risk of postoperative morbidity in the early (n = 9941) versus the late group (n = 10313) (OR 1.18, 95%, CI 1.07-1.29, P = 0.0005, c-index 0.794). There was a 41% higher risk for mortality in the early group compared with the late group (OR 1.41, CI 1.11-1.80, P = 0.005, c-index 0.938). No significant trends in patient risk over time were noted., Conclusion: Our data suggests higher rates of postsurgical morbidity and mortality related to the time of the year. Further study is needed to fully describe the etiologies of the seasonal variation in outcomes.

We use biliary complication following liver transplantation to quantify the financial implications of surgical complications and make a case for surgical improvement initiatives as a sound financial investment. We reviewed the medical and financial records of all liver transplant patients at the UMHS between July 1, 2002 and June 30, 2005 (N = 256). The association of donor, transplant, recipient and financial data points was assessed using both univariable (Student's t-test, a chi-square and logistic regression) and multivariable (logistic regression) methods. UMHS made a profit of $6822 +/- 39087 on patients without a biliary complication while taking a loss of $5742 +/- 58242 on patients with a biliary complication (p = 0.04). Reimbursement by the payer was $5562 higher in patients with a biliary complication compared to patients without a biliary complication (p = 0.001). Using multivariable logistic regression analysis, the two independent risk factors for a negative margin included private insurance (compared to public) (OR 1.88, CI 1.10-3.24, p = 0.022) and biliary leak (OR = 2.09, CI 1.06-4.13, p = 0.034). These findings underscore the important impact of surgical complications on transplant finances. Medical centers have a financial interest in transplant surgical quality improvement, but payers have the most to gain with improved surgical outcomes.