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IAB 06-038 – HSR Study

IAB 06-038
Detailing Smoking Attributable Risks for Post-Morbidity: Planning for Policy and Clinical Interventions
Thomas K Houston, MD MPH
VA Bedford HealthCare System, Bedford, MA
Bedford, MA
Funding Period: July 2007 - June 2010
The VA has made great strides towards implementation of systematic outpatient tobacco control. Our proposal addresses another important service area in need of implementation of smoking cessation interventions - surgery. Over 375,000 surgical procedures are performed yearly in the VA. Based on VA National Surgical Quality Improvement Program (NSQIP), smoking prevalence among Veterans undergoing surgery (36%) is even higher than the overall smoking prevalence in Veterans using the VA (30%).

In this two-year project, we: 1. Refined knowledge about the impact of smoking on surgical complications. We further detailed the association of smoking and 30-day risk of surgical complications by analyzing variations by procedure and patient characteristics using a cohort of patients receiving surgery in the VA, using NSQIP data. 2. Described barriers, facilitators, and current pre-operative smoking cessation practices across VA.

The is a retrospective cohort study.

Project Findings I: Of the 393,769 procedures, there were 135,738 (34.5%) current, 71,421 (18.1%) prior and 186,610 (47.4%) never smokers. A total of 6,225 pneumonias, 11,430 surgical site infections (SSI), 2,040 DVT/PTE, 1,338 myocardial infarctions (MI), and 4,792 deaths occurred within 30 days of surgery. Current smokers were younger, lower ASA class and had slightly lower work RVU procedures. Compared with prior smokers and controlled for patient and procedure risk factors, current smokers had significantly more post-operative pneumonia, SSI and deaths. We found little variation in risk across patient characteristics, but did note that risk patterns were higher in elective orthopedic procedures (Hip and Knee replacement). This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger, healthier and undergoing slightly less complex operations, current smokers had more adverse perioperative events. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.

Smoking is a major risk factor for perioperative morbidity and mortality. Despite our goal of identifying synergistic risk between smoking status and procedure/patient factors, we found a relatively monotonic risk by strata. One exception was the elevated risk in orthopedic procedures.

A major advance of our analysis over prior research was the large dataset and the use of a three-category smoking exposure (current, prior, never smoker). Lumping prior smokers with never smoker creates differential misclassification of lifetime smoking exposure and reduces the potential of finding a significant effect. Our study reinforces prior literature demonstrating the risk of preoperative smoking. We overcome several methodologic limitations in prior studies. More research demonstrating that smoking is a risk, or exploring variations in risk, is not needed. Prior randomized trials have demonstrated an effect of preoperative smoking cessation interventions on surgical outcomes. However results vary based upon several factors including the duration and adherence to preoperative abstinence procedures. Implementation research is needed, understanding how to re-engineer care to best deliver smoking cessation interventions within the context of the primary care to surgery handoff. Experiments and simulations of surgical delay to maximize time for preoperative cessation are needed.

External Links for this Project

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Journal Articles

  1. Gajdos C, Hawn MT, Campagna EJ, Henderson WG, Singh JA, Houston T. Adverse effects of smoking on postoperative outcomes in cancer patients. Annals of Surgical Oncology. 2012 May 1; 19(5):1430-8. [view]
  2. Hawn MT, Itani KM, Gray SH, Vick CC, Henderson W, Houston TK. Association of timely administration of prophylactic antibiotics for major surgical procedures and surgical site infection. Journal of the American College of Surgeons. 2008 May 1; 206(5):814-9; discussion 819-21. [view]
  3. Hines RB, Shanmugam C, Waterbor JW, McGwin G, Funkhouser E, Coffey CS, Posey J, Manne U. Effect of comorbidity and body mass index on the survival of African-American and Caucasian patients with colon cancer. Cancer. 2009 Dec 15; 115(24):5798-806. [view]
  4. Hines RB, Chatla C, Bumpers HL, Waterbor JW, McGwin G, Funkhouser E, Coffey CS, Posey J, Manne U. Predictive capacity of three comorbidity indices in estimating mortality after surgery for colon cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2009 Sep 10; 27(26):4339-45. [view]
  5. Singh JA, Houston TK, Ponce BA, Maddox G, Bishop MJ, Richman J, Campagna EJ, Henderson WG, Hawn MT. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis care & research. 2011 Oct 1; 63(10):1365-74. [view]
  6. Hawn MT, Houston TK, Campagna EJ, Graham LA, Singh J, Bishop M, Henderson WG. The attributable risk of smoking on surgical complications. Annals of surgery. 2011 Dec 1; 254(6):914-20. [view]
  7. Hawn MT, Gray SH, Vick CC, Itani KM, Bishop MJ, Ordin DL, Houston TK. Timely administration of prophylactic antibiotics for major surgical procedures. Journal of the American College of Surgeons. 2006 Dec 1; 203(6):803-11. [view]
  8. Vick CC, Graham LA, Henderson WG, Houston TK, Hawn MT. Translating preoperative smoking cessation interventions into routine clinical care of veterans, provider beliefs. Translational behavioral medicine. 2011 Nov 24; 1(doi: 10.1007/s13142-001-0096-1):604-608. [view]
Conference Presentations

  1. Vick CC, Houston TK, Hawn MT. Association of Timely Administration of Prophylactic Antibiotics for Major Surgical Procedures and Surgical site Infection. Paper presented at: Southern Surgical Association Annual Meeting; 2007 Dec 3; Hot Springs, VA. [view]
  2. Hawn MT, Henderson W, Campagna E, Bishop M, Deierhoi RJ, Houston TK. Improving Surgical Outcomes: Is it Time to Engage the Patient in the Process? Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA. [view]
  3. Hawn MT, Gray SH. Patient Level Predictors of Timely Prophylactic Antibiotic Administration. Paper presented at: Society of Black Academic Surgeons Annual Meeting; 2006 Apr 6; Cincinnati, OH. [view]
  4. Hawn MT, Gray SH. Predictors of Timely Antibiotic Administration. Paper presented at: Frederick A. Collier Surgical Society Annual Meeting; 2006 Oct 5; Ann Arbor, MI. [view]
  5. Hawn MT, Gray SH. Predictors of Timely Antibiotic Administration for Surgical Site Invection Prevention. Paper presented at: VA Association of Surgeons Annual Meeting; 2006 May 9; Cincinnati, OH. [view]
  6. Vick CC, Graham LA, Coley H, Bishop MJ, Houston TK, Hawn MT. Pre-operative smoking cessation: Provider attitudes on delay or refusal of elective surgery based on smoking status. Presented at: VA Association of Surgeons Annual Meeting; 2010 May 11; Indianapolis, IN. [view]
  7. Vick CC, Graham LA, Coley H, Bishop M, Houston TK, Hawn MT. Preoperative Smoking Cessation: Provider Attitudes on Delay or Refusal of Elective Surgery Based on Smoking Status. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA. [view]
  8. Hawn MT. Prophylactic Antibiotic usage for Surgical Patients: Results of the Statewide Quality Improvement Collaborative. Paper presented at: American College of Surgeons Spring Meeting; 2006 May 20; Sandestin, FL. [view]
  9. Hawn MT. Prophylactic Antibiotics are Best Administered in the Operating Room. Paper presented at: American Society of Anesthesiologists Annual Meeting; 2006 Oct 19; Chicago, IL. [view]
  10. Graham LA, Vick CC, Coley H, Bishop M, Houston TK, Hawn MT. VA Provider Acceptance of the Current Practice Guidelines for the Treatment of Tobacco Use. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Substance Use Disorders
DRE: Treatment - Observational, Prevention
Keywords: Nicotine, Smoking, Surgery
MeSH Terms: none

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