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US experts are suggesting that more and more hospitals go for risk calculators. At the moment only 250 hospitals are equipped with such calculators derived by perusing thousands of hospital records across the country.
Research published in the June issue of the Journal of the American College of Surgeons shows that a risk calculator developed by the American College of Surgeons (ACS) could help surgeons provide patients with more detailed and accurate preoperative information about the risk of death and complications following colorectal surgery. The tool will also allow surgeons to adjust risk probabilities for patients based on their hospital's performance during prior years.
Advertisement"This novel predictive tool will help surgeons and patients more accurately weigh the risks and potential benefits of colorectal operations," said Mark E. Cohen, PhD, Division of Research and Optimal Patient Care, American College of Surgeons. "The calculator provides a comprehensive assessment of risk based on both patient and hospital factors and may serve as a template for the development of similar tools for other types of operations."
Risk calculators, used by heart surgeons for several years, are now being developed for other surgical specialties. The American College of Surgeons is designing similar tools for 18 other procedures, including gastric bypass, hernia repair and prostate surgery. The calculators use data from more than one million patient records gathered as part of the group's National Surgical Quality Improvement Program, which works with hospitals to reduce surgical errors and complications.
More than 30 million operations are performed in the U.S. annually to remove deadly cancers, repair diseased organs and replace worn-out joints. Yet going under the knife can be risky, leading to serious infections, blood clots, heart attacks and pneumonia. Those risks increase with age and for patients who are obese, smoke, abuse alcohol or have medical conditions such as diabetes and hypertension.
The elderly are more vulnerable to problems after a major surgical procedure than younger patients, but a team of investigators using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) suggested in November last that one way to improve surgical results in this age group is to have hospitals expand their quality control guidelines to include more types of surgery-related complications.
The investigators reviewed almost 55,000 gastrointestinal operations (GI) at 121 hospitals participating in ACS NSQIP. Specifically, these operations involved the upper GI tract, the gall bladder, pancreas, and colon and rectum. Elderly patients were up to twice as likely to have complications related to the operation than younger patients. The mortality rate in the elderly group was three to almost seven times higher than the younger group, depending on the procedure. The results of this study have been published last year in the November issue of Archives of Surgery.
"We know that when older patients undergo extensive operations there is higher risk. This study was undertaken to help raise institutional awareness of specific complications after these operations in order to prevent or treat complications as early as possible," explained study coauthor David J. Bentrem, MD, FACS, Harold L. and Margaret N. Method Research Professor in Surgery, Northwestern University Feinberg School of Medicine, Chicago.
The report authors concluded that quality improvement initiatives need to include pulmonary and urologic complications in older patients. "The next step would be to try to get this information back to more hospitals, have more hospitals involved in NSQIP and receive risk-adjusted data based on these specific complications in comparison to other hospitals, and to give them an idea of where to focus their quality improvement efforts," Dr. Bilimoria said.
In the coming months, according to Dr. Bilimoria, there will be a "risk estimator" through ACS NSQIP that will enable surgeons to evaluate risks before surgical procedures and to allow patients and physicians to make more informed decisions about the risks of surgery.
"Basically, surgeons can enter the risk factors of their patients preoperatively and identify the rates of these complications and discuss those with the patients," said Dr. Bilimoria. "It's one piece of decision making that can help guide the discussion about whether surgery should be done or whether the risk is too prohibitive." These data would be available through ACS NSQIP in 2010, according to Dr. Bilimoria.
Previously, research from the ACS NSQIP program published in the Annals of Surgery (September 2009) showed that hospitals participating in the program reported significant improvements in patient morbidity and mortality. The ACS NSQIP program provides a prospective, peer-controlled, validated database of surgical outcomes based on clinical data, not claims data. Originally launched in the 1990s by the Veterans Health Administration, the program was piloted in private sector hospitals in 2001 by the American College of Surgeons in partnership with the Agency for Healthcare Research and Quality (AHRQ). The program was made available to all private sector hospitals in 2004.
Such risk calculators enable hospital authorities to focus on preventive measures such as the use of antibiotics and monitoring patient wounds and that way reduce infection rates steadily, others have corroborated.
But why should only 250 hospitals avail of the services of such invaluable calculators? Well, the cost.
Clifford Ko, a colorectal surgeon at the University of California, Los Angeles, and director of research and optimal patient care for the American College of Surgeons, told Laura Landro of the Wall Street Journal that NSQUIP was initially designed for large community hospitals and academic medical centers and its $35,000 annual fee to participate was a barrier for some institutions. "The college is working on a pilot scheme to offer lower-cost participation to smaller and rural hospitals which perform fewer types of surgeries and don't need to collect as much data, "but still want to participate and evaluate their own quality."
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