Current Literature

Statewide, Simultaneous Surgical QI Initiatives Reduce Morbidity and Mortality

Silver CM, Yang AD, Shan Y, et al. Changes in Surgical Outcomes in a Statewide Quality Improvement Collaborative with Introduction of Simultaneous, Comprehensive Interventions. J Am Coll Surg. 2023, in press.

Casey M. Silver, MD, and coauthors reported postoperative patient outcomes (mortality and morbidity) in a cohort of 180,582 patients after implementation of a quality improvement collaborative in 48 hospitals. The collaborative was launched in all hospitals simultaneously and provided benchmarked reports of patient data, training in quality improvement, funding for local quality improvement initiatives, and mentorship. The collaborative also coordinated statewide training in process improvement and statewide quality improvement projects.

The authors noted that while quality improvement collaboratives have been shown to improve outcomes, this type of simultaneous, comprehensive approach to quality improvement has not been studied previously. Mortality and various morbidities (SSI, pneumonia, wound complications, renal failure, and venous thromboembolism) were recorded. Outcomes recorded in the 48 participating hospitals were compared to hospital data from the ACS NSQIP program participant file. The analysis showed that outcomes for hospitals participating in the statewide program were significantly better for mortality and for all reported morbidities except venous thromboembolism.

The authors concluded that statewide, simultaneous implementation of a comprehensive quality improvement program in multiple hospitals was feasible and resulted in reduced postoperative mortality and morbidity.

New Definitions of Multimorbidity in Older Surgical Patients Identified Higher Risk Patients Accurately

Ramadan OI, Rosenbaum PR, Reiter JG, et al. Redefining Multimorbidity in Older Patients. J Am Coll Surg. 2023, in press.

The conventional definition of multimorbidity is the presence of two or more comorbid factors. Use of this definition results in most older patients being classified as “multimorbidity” and prevents accurate identification of high-risk surgical patients.

This study described in this article used Medicare claims data to identify combinations of comorbid factors in patients undergoing general surgical, orthopaedic, or vascular procedures. Comorbid condition combinations that resulted in a 1.5–2-fold increase in 30-day mortality were identified, and these identifiers were used to obtain 30-day mortality estimates for patients in the Medicare database over the interval 2018–2019.

Applying the new morbidity combinations reduced the percentage of patients identified as “multimorbidity” by 24%–48%, depending on the selected surgical specialty (general, orthopaedic, or vascular). Patients defined by the new criteria had statistically significant increased mortality at 30 days in all specialty groups. The authors then examined data from “better-resourced” hospitals (defined by nursing skill-mix, surgical volume, and teaching status) and compared outcomes in these institutions to the entire dataset. Mortality rates were lower in these institutions for general and orthopedic surgery procedures but not for vascular procedures.

The authors concluded that the new definitions of multimorbidity identified higher risk patients accurately, and use of these definitions could potentially improve clinical decision-making.

Editorial

Puzio TJ, Adams SD, Kao LS. Targeting Many or a Few? A Commentary on Redefining Multimorbidity in Older Surgical Patients. J Am Coll Surg 2023, in press

In the accompanying editorial comment, Thaddeus J. Puzio, MD, and coauthors noted that realizing benefits of these definitions would depend on institutional objectives (targeting all older patients or only high-risk patients), as well as availability of institutional resources and staff motivation.

Small Study Finds High Recurrence-Free Survival in Lobectomy and Total Thyroidectomy for Papillary Thyroid Cancer

Xu S, Huang H, Huang Y, et al. Comparison of Lobectomy vs Total Thyroidectomy for Intermediate-Risk Papillary Thyroid Carcinoma with Lymph Node Metastasis. JAMA Surg. Jan 1 2023;158(1):73-79.

Clinical practice guidelines have supported use of thyroid lobectomy for patients with papillary thyroid cancer at low risk for metastatic disease, with low risk being defined as primary tumor localized in one lobe of the thyroid gland and no nodal metastases beyond central cervical nodes. For patients with higher-risk tumors, total thyroidectomy with radioactive iodine ablation is recommended, but the value of total thyroidectomy versus thyroid lobectomy has been the subject of debate among surgeons and endocrinologists.

The objective of this study was to compare rates of recurrence-free survival in patients with papillary thyroid cancer and ipsilateral lateral cervical lymph node metastases who underwent thyroid lobectomy without radioactive iodine ablation or total thyroidectomy with radioactive iodine ablation. Propensity score matching was used to derive a risk-matched comparison group of patients. Lobectomy was performed in 624 patients, and total thyroidectomy in 322 matched patients. Recurrence-free survival at 5 years of follow up was greater than 92% and was similar for both comparison groups.

Editorial

Mulder MB, Duh Q. Is Lobectomy as Effective as Total Thyroidectomy in Treating Patients with Intermediate-Risk Papillary Thyroid Carcinoma with Lateral Lymph Node Metastasis? JAMA Surg. 2023;158(1):80.

In the editorial that accompanied the article, Michelle B. Mulder, MD, and Quan-Yang Duh, MD, FACS, noted that the results need to be interpreted in light of the facts that this is a single-institution study and patients did not undergo preoperative or postoperative genetic testing. It is also necessary to recognize that adoption of this approach for higher risk patients with papillary thyroid cancer will require a carefully designed postoperative follow-up plan to monitor patients for recurrence.