Journal of the American College of Surgeons
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Multicenter Study
Variation in quality of care after emergency general surgery procedures in the elderly.
The elderly (age ≥65 years) comprise an increasing proportion of patients undergoing emergency general surgery (EGS) procedures and have distinct needs compared with the young. We postulated that the needs of the elderly require different processes of care than those required for the young to assure optimal outcomes. To explore this hypothesis, we evaluated 30-day outcomes following EGS procedures in the young and the elderly and determined whether hospital performance was consistent across these 2 age strata. ⋯ Elderly patients are at substantially greater risk for adverse events following EGS procedures. Hospitals had only slight agreement in mortality outcomes in the elderly compared with those in young patients. Processes of care that may account for this disparity should be further investigated.
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The Agency for Healthcare Research and Quality (AHRQ) recently designed the Patient Safety Indicators (PSIs) to detect potential safety-related adverse events. The National Quality Forum has endorsed several of these ICD-9-CM-based indicators as quality-of-care measures. We examined the positive predictive value (PPV) of 3 surgical PSIs: postoperative pulmonary embolus and deep vein thrombosis (pPE/DVT), iatrogenic pneumothorax (iPTX), and accidental puncture and laceration (APL). ⋯ Until coding revisions are implemented, these PSIs, especially pPE/DVT, should be used primarily for screening and case-finding. Their utility for public reporting and pay-for-performance needs to be reassessed.
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Multicenter Study
How valid is the AHRQ Patient Safety Indicator "postoperative respiratory failure"?
The Agency for Healthcare Research and Quality Patient Safety Indicator postoperative respiratory failure (PRF) uses administrative data to screen for potentially preventable respiratory failure after elective surgery based on a respiratory failure diagnosis or an intubation or ventilation procedure code. Data on PRF accuracy in identifying true events is scant; a recent study using University HealthSystem Consortium data found a positive predictive value (PPV) of 83%. We examined the indicator's PPV in the Veterans Health Administration. ⋯ Based on our and University HealthSystem Consortium's findings, PRF should continue to be used as a screen for potential patient-safety events. Its PPV could be substantially improved in the Veterans Health Administration through introduction of an admission status code. Many PRF-identified cases appeared to be at high risk, based on patient and procedure-related factors. The degree to which such cases are truly preventable events requires additional assessment.
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Multicenter Study
Positive predictive value of the AHRQ Patient Safety Indicator "postoperative wound dehiscence".
The Agency for Healthcare Research and Quality patient safety indicator (PSI) 14, or "postoperative wound dehiscence," is 1 of 4 PSIs recently adopted by the Centers for Medicare & Medicaid Services to compare quality and safety across hospitals. We determined how well it identifies true cases of postoperative wound dehiscence by examining its positive predictive value (PPV). ⋯ PSI 14 has relatively good predictive ability to identify true cases of postoperative wound dehiscence. It has the highest PPV among all PSIs evaluated within the Veterans Health Administration system. Inaccurate coding was the reason for false positives. Providing additional training to medical coders could potentially improve the PPV of this indicator. At present, this PSI is a promising measure for both quality improvement and performance measurement; however, its use in pay-for-performance efforts seems premature.
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Comparative Study
Molecular diagnosis of response to neoadjuvant chemoradiation therapy in patients with locally advanced rectal cancer.
Pathologic complete response (pCR) to neoadjuvant chemoradiation (CRT) is an important prognostic factor in locally advanced rectal cancer. However, it is uncertain if histopathological techniques accurately detect pCR. We tested a novel molecular approach for detecting pCR and compared it with current histopathological approaches. ⋯ Sensitive molecular techniques detect K-ras and p53 mutations in post-CRT surgical specimens in some patients with a pCR. This suggests histopathological techniques might not be completely accurate, and some patients diagnosed with a pCR to CRT might have occult cancers cells in their surgical specimens.