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HSR&D Publication Briefs
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  • Risk of Adverse Events Increases with Each Additional Day of Prophylactic Antimicrobial Exposure following Surgery
    National guidelines recommend surgical antimicrobial prophylaxis be initiated within 1 hour prior to incision and discontinued within 24 hours post-operatively for most procedures – and within 48 hours for cardiac surgery. This study sought to characterize the association of type and duration of prophylaxis with surgical site infection (SSI), acute kidney injury (AKI), and Clostridium difficile infection among all Veterans undergoing major cardiac, orthopedic total joint replacement, colorectal, and vascular procedures between October 2008 and September 2013. Findings showed that every day matters. Surgical prophylaxis durations lasting for greater than 24 hours increase the incidence of adverse events, such as acute kidney injury and C. difficile, but do not reduce surgical site infections. Risk of harm increases with each additional day of antimicrobial exposure. The choice of surgical prophylaxis affects the incidence of SSI and other adverse events. For example, the use of vancomycin was independently associated with increased odds of AKI following both cardiac procedures and non-cardiac procedures.
    Date: April 24, 2019
  • Preoperative Surgical Screening for Asymptomatic Bacteriuria is Not Beneficial
    Strong evidence that preoperative screening for bacteria in the urine, and treatment with antibiotics if found to be positive, improves clinical outcomes is lacking. This study sought to measure the association between asymptomatic bacteriuria (ASB) and key postoperative infectious outcomes, including surgical-site infection (SSI) and UTI, and determine if directed antimicrobial therapy was associated with reduced rates of infection after major surgical procedures. Findings showed that routine screening of preoperative urine cultures before major cardiac, orthopedic, and vascular surgical procedures was a low-yield clinical practice. ASB was identified in 4% of urine cultures, and after adjustments for other factors associated with postoperative infections (age, American Society of Anesthesiologists physical status class, smoking status, demographics, and diabetes status), Veterans with or without ASB had similar chances of surgical site infection (2.4% vs 1.6%). Antibiotic treatment of asymptomatic patients with ASB did not lead to improvement in any measurable postoperative clinical outcome. The incidence of SSI, UTI, and positive wound and urine culture results were the same in patients who were treated as in those who were untreated. This study – the largest and most robust to date – provides strong evidence that preoperative screening is of little value and should be discontinued as routine clinical practice.
    Date: December 12, 2018
  • VA Outpatient Surgery May Be More Risky than Previously Considered
    This study sought to characterize the nature and severity of adverse events (AEs) among outpatient surgical cases performed from FY2012 through FY2015 at 111 VA hospitals and 20 ambulatory surgery facilities. Investigators identified cases with both high and low likelihood of adverse events based on post-operative healthcare use. Findings showed that among VA outpatient surgeries selected based on the likelihood of an adverse event, nearly 40% of identified events carried more than minimal patient harm, suggesting that outpatient surgery is relatively less safe than previously thought. Adverse events were found in 51% of high-likelihood surgeries and 12% of low-likelihood surgeries. While 63% of all AEs involved minimal harm, 28% required hospitalization, and 9% were severely harmful, including 8 adverse events that required intervention to sustain life – and 2 deaths. Among 1,010 unique adverse events, the most common were wound issues (26%), urinary retention (23%), and urinary tract infections (12%).
    Date: July 1, 2018
  • Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare
    To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury.
    Date: March 1, 2018
  • Surgery Does Not Significantly Reduce Mortality among Patients with Prostate Cancer versus Observation after 20 Years of Follow-up
    This study reports on all-cause and prostate cancer mortality through nearly 20 years of follow-up and describes disease progression, treatments received, and patient-reported outcomes during follow-up. Findings showed that surgery (radical prostatectomy) did not significantly reduce all-cause mortality or prostate cancer mortality compared with observation in men with localized prostate cancer diagnosed in the early PSA era. “Any progression” of prostate cancer occurred in 41% of men randomized to surgery versus 68% randomized to observation. Most disease progression was local, and about half asymptomatic. Surgery may reduce mortality in men with intermediate-risk prostate cancer, depending on the pathological classification. However, surgery resulted in large long-term increases in urinary, erectile, and sexual dysfunction and smaller shorter-term adverse effects on physical function and activities of daily living. Authors suggest reducing overtreatment in men with localized prostate cancer, especially those with low-risk disease.
    Date: July 13, 2017
  • Frailty Screening Initiative Associated with Improved Post-Operative Survival among Veterans
    The Frailty Screening Initiative (FSI) is aimed at improving post-operative survival. This study assessed the impact of the FSI on mortality and complications by comparing surgical outcomes before and after implementation of the FSI. Findings showed that implementing frailty screening was associated with reduced mortality, suggesting both the feasibility of widespread screening of patients pre-operatively to identify frailty – and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Overall, 30-day mortality dropped from 1.6% to 0.7% after FSI implementation. Improvement was greatest among the frail (12% to 4%). Moreover, the magnitude of improvement among frail patients increased at 180 and 365 days. After controlling for age, frailty, and predicted mortality, models showed that the FSI resulted in a three-fold survival benefit in this study cohort. Frailty screening of preoperative patients is feasible, and may be an effective and scalable tool for improving surgical outcomes for aging and increasingly frail U.S. and Veteran populations.
    Date: November 30, 2016
  • VA Makes Significant Improvements in Surgical Care for Veterans
    This study used VA Surgical Quality Improvement Program data to examine post-operative outcomes for 704,901 Veterans who underwent inpatient general, vascular, thoracic, genitourinary, neurosurgical, orthopedic, or spine surgery from FY2000 through FY2014 at 143 VA hospitals. Findings showed that over the last 15 years, there have been decreases of 25%, 54%, and 41% in morbidity, mortality, and failure to rescue (respectively), with an ~40%-50% decrease in the odds of post-operative adverse events over that time among Veterans undergoing surgery in VA facilities. Notably, these improvements have occurred VA-wide and not only at the best-performing VA hospitals.
    Date: September 21, 2016
  • Similar Effectiveness and Costs of Elective Open vs. Endovascular Aortic Abdominal Aneurysm Repair in VA
    This study compared the total and abdominal aortic aneurysm (AAA)-related use of healthcare resources, costs, and cost-effectiveness of the randomized groups to the end of the Open vs. Endovascular Repair trial, with 9 years of follow-up. Findings showed that survival, quality of life, costs, and cost-effectiveness were not significantly different between elective open and endovascular AAA repair after a mean of 5.2 years of follow-up. Mortality was significantly lower with endovascular repair at 30 days after surgery – and 2 and 3 years after randomization, but not thereafter. Total mean healthcare costs did not differ significantly between the two groups: $142,745 for endovascular compared to $153,533 for open. Lower costs due to shorter hospitalization for initial endovascular repair were offset by increased costs from AAA-related secondary procedures and imaging studies. Thus, for patients with AAA who are candidates for both procedures, selection of either one remains reasonable and can be guided by patient and physician preference.
    Date: September 14, 2016
  • Sustained Weight Loss Advantage among Obese Veterans Receiving Specific Bariatric Surgery
    This study compared 10-year weight change between Veterans who underwent Roux-en-Y gastric bypass (RYGB) and Veterans who did not undergo surgery. It also compared 4-year weight change between RYGB patients and Veterans who underwent sleeve gastrectomy (SG) and Veterans who underwent adjustable gastric banding (AGB). Findings showed that among obese Veterans who received VA care, patients who underwent RYGB lost much more weight than matched non-surgical patients – and were able to sustain most of this weight loss in the long term. RYGB patients had lost 21% more of their baseline weight at 10 years than matched non-surgical patients. More than 70% of RYGB patients had at least 20% weight loss and approximately 40% had at least 30% weight loss at 10 years compared with 11% and 4%, respectively, for non-surgical matches. Among surgical patients, RYGB patients experienced the greatest weight loss (28%) after four years; SG patients experienced significantly less weight loss than RYGB (18%), while AGB patients lost the least weight (11%).
    Date: August 31, 2016
  • Disclosure of Clinical Adverse Events between VA Surgeons and their Patients
    This study assessed surgeons’ reports of disclosing adverse events and aspects of their experiences with the disclosure process. Findings showed that surgeons reporting they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences were more negatively affected by disclosure than others: 60% indicated that the event had moderately, quite a bit, or extremely affected them. Most surgeons did not report significant impacts of the event on job satisfaction, confidence, professional reputation, or sleep, but 27% reported anxiety about future outcomes or events.
    Date: July 20, 2016
  • Mental Health Conditions Common among Patients Seeking and Undergoing Bariatric Surgery
    This systematic review had three aims: 1) to estimate the prevalence of mental health conditions among bariatric surgery candidates and recipients; 2) to evaluate the association between preoperative mental health conditions and weight loss after surgery; and 3) to evaluate the association between surgery and the clinical course of mental health conditions. Findings showed that mental health conditions are common among patients seeking and undergoing bariatric surgery, particularly depression and binge-eating disorder (BED). Prevalence estimates for mood disorders (22%), depression (19%), and BED (17%) were higher than published rates for the general U.S. population, (10%, 8%, and 1-5%, respectively) suggesting that special attention should be paid to these conditions among bariatric patients. There was moderate-quality evidence to support an association between bariatric surgery and lower rates of depression post-operatively. Depression improved following surgery in 11 of the 12 studies, including two randomized controlled trials evaluating preoperative behavioral health interventions.
    Date: January 12, 2016
  • Bundled Intervention Associated with Lower Rates of Surgical Site Infections following Cardiac or Orthopedic Operations
    This study evaluated whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus surgical site infections (SSIs) in patients undergoing cardiac operations or hip or knee arthroplasties. Findings showed that implementation of an SSI prevention bundle was associated with reduced S. aureus SSI rates. During the pre-intervention period, there were 101 complex S. aureus SSIs compared with 29 during the intervention period. Also, the number of months without any complex S. aureus SSIs increased from 2 of 39 (5%) to 8 of 22 (36%). After a 3-month phase-in period, bundle adherence was 83%. The complex S. aureus SSI rates decreased significantly among patients in the fully adherent group compared with the pre-intervention period, but rates did not decrease significantly in the partially adherent or non-adherent group.
    Date: June 2, 2015
  • Bariatric Surgery Compared to Usual Care May Lower Mortality Rates among Obese Veterans
    This study examined long-term survival in a large multi-site cohort of obese Veterans who underwent bariatric surgery compared to matched controls. Findings showed that when compared to matched control patients who did not have the surgery, obese Veterans who underwent bariatric surgery in the VA healthcare system had lower all-cause mortality starting at 5 years and up to 14 years following the procedure. After a mean follow up of 6.9 years in the surgical group and 6.6 years in the matched control group, there were a total of 263 deaths and 1,277 deaths, respectively, at the end of the 14-year study period. Study analyses estimated 1-year, 5-year and 10-year mortality rates that were 2.4%, 6.4% and 13.8% for Veterans who underwent bariatric surgery, and 1.7%, 10.4% and 23.9% for Veterans who did not undergo bariatric surgery. There were no significant differences in the association of bariatric surgery on mortality found across groups defined by sex, diabetes diagnosis, period of surgery, or super-obesity. These study results provide further evidence for the beneficial association between surgery and survival that has been demonstrated in younger, predominantly female, non-VA populations.
    Date: January 6, 2015
  • Surgical Patients Less Likely to Receive Hospice or Palliative Care Compared to Medical Patients
    This study examined the use of end-of-life care in the VA healthcare system among surgical and medical patients at the end of life. Findings showed that VA surgical patients were less likely to receive either hospice or palliative care in the year prior to death compared with medical patients (38% vs. 41%, respectively). This difference also was present in a separate analysis of palliative care (37% surgical vs. 39% medical) and hospice care (21% surgical vs. 24% medical). Moreover, differences in the use of palliative or hospice care were intensified after adjusting for patient characteristics. However, among Veterans who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (median of 26 days versus 23 days). The use of palliative services increased over the study period – from 29% to 47% for medical patients and from 27% to 45% for surgical patients. Likewise, hospice use increased from 21% to 27% and from 19% to 24% for medical and surgical patients, respectively. The median time between palliative or hospice initiation and death increased over the study period – from 22 to 25 days for medical patients and from 22 to 30 days for surgical patients.
    Date: September 24, 2014
  • Systematic Frailty Screening may Lead to Reduced Post-Operative Mortality in Frail Veterans
    Investigators in this study implemented a quality improvement initiative to screen Veterans scheduled for elective surgery for frailty in order to identify those at high risk for post-operative mortality and morbidity. This systematic frailty-screening program effectively identified at-risk surgical patients and was associated with a significant reduction in mortality in Veterans undergoing palliative care consultation. Implementation of the screening program was associated with a 33% reduction in 180-day mortality even after controlling for age, frailty, and whether the patients had surgery. Further, given the high risk of dying in this frail cohort, study models suggest that for every four patients screened, one death was prevented or delayed at 180 days. After implementation of the frailty-screening program, palliative care consultations were more frequently ordered by surgeons, and they were more likely to take place before the index operation. Moreover, pre-operative palliative care consultations ordered by a surgeon were associated with the greatest reduction in mortality.
    Date: September 10, 2014
  • Costs Associated with Surgical Site Infections
    This study sought to determine the excess costs associated with both superficial and deep surgical site infections (SSIs) among all VA operations performed in FY10, including five high-volume surgical specialties – neurosurgery, orthopedic, general surgery, peripheral vascular, and urology. Findings showed that SSIs were associated with a significant increase in attributable post-surgical costs, even after adjusting for patient-level, surgical-level, and facility-level factors. Patients with deep SSIs had costs 1.93 times higher than patients without site infections. Moreover, if VA hospitals in the highest 10th percentile (e.g., worst) reduced their SSI rates to the rates found in the 50th percentile, the VA healthcare system could save about $6.7 million per year. The greatest mean cost attributable to SSI was among neurosurgery patients, followed by orthopedic surgery, general surgery, peripheral vascular surgery, and urology. Among 54,233 Veterans who underwent surgery in FY10, 3% experienced an SSI. Overall, 0.8% of the cohort had a deep SSI and 2.4% had a superficial SSI. Veterans who experienced an SSI were more likely to have pre-operative comorbid conditions (e.g., diabetes, chronic obstructive pulmonary disease) and were more likely to drink more than two drinks per day in the two weeks before the operation. They also were more likely to have a more severe wound classification – and to undergo emergent surgery.
    Date: May 21, 2014
  • Veterans Living Greater Distance from VA or Any Transplant Centers May have Less Chance of Receiving Liver Transplant
    This study evaluated the association between distance from a VA transplant center (VATC) and access to wait-listing and liver transplantation, as well as mortality. Findings showed that among VA patients meeting eligibility criteria for liver transplantation, greater distance from a VATC or any transplant center was associated with lower likelihood of wait-listing or transplantation, and greater likelihood of death. Of the 50,637 Veterans classified as potentially transplant-eligible during the study period, 6% were waitlisted (49% at a VATC and 51% at a non-VATC). Overall, 7% of Veterans at a VA medical center =100 miles from a VATC were waitlisted at a VATC, and 11% at any transplant center, compared with 3% and 5%, respectively, living >100 miles from a VATC. Three-year survival from first hepatic decompensation event for waitlisted Veterans differed by distance: 72% (=100 miles from VATC) vs. 66% (>100 miles). Increasing distance to a VATC was associated with significantly increased risk of mortality, with a 3% increased risk of mortality for every doubling of distance from local VAMC to VATC.
    Date: March 26, 2014
  • Rehabilitation Settings for Veterans Following Hospital Discharge for Hip Fracture
    This study explored the factors that impact choice of VA rehabilitation setting after acute hip fracture repair procedures. Findings showed that following hospitalization for hip fracture, nearly half (48%) of the Veterans in this study were discharged directly home – without VA-paid rehabilitation. Few Veterans (0.8%) were discharged with home health, with higher proportions discharged to a nursing home (15%), outpatient rehabilitation (19%), or inpatient rehabilitation (17%). Veterans with higher comorbidity scores were less likely to be discharged to inpatient rehabilitation. Veterans were more likely to be discharged to non-home settings if they had total functional dependence, had high American Society of Anesthesiology (ASA) class scores, had one or more surgical complications, or lived in counties with lower nursing home bed occupancy rates. Thus, it appeared that the most vulnerable patients were provided inpatient care. Surgical complications were the most significant predictor of discharge setting, but the availability of community resources also was an important predictor.
    Date: January 1, 2014
  • Risk Factors for Adverse Cardiac Events after non-Cardiac Surgery in Veterans with Coronary Stents
    This study examined the risk factors for major adverse cardiac events (MACE) in Veterans undergoing non-cardiac surgery following coronary stent implantation, including the relationship between stent type and time from stent to surgery. Findings showed that the three most significant risk factors associated with MACE following non-cardiac surgery in Veterans with recent coronary stent implantation were non-elective surgical admission, history of MI in the six months preceding surgery, and a revised cardiac risk index greater than 2. Stent type and timing of surgery beyond 6 months following stent implantation were not associated with MACE. Also, no association between APT cessation and MACE was observed. Investigators suggest that a more comprehensive approach to perioperative risk assessment and management among Veterans with coronary stents that emphasizes cardiac and surgical risk factors, rather than stent type, may be warranted.
    Date: October 9, 2013
  • Veterans with PTSD or Major Depression Less Likely to Undergo Four Major Invasive Procedures
    This study examined whether PTSD, after controlling for major depression, was associated with the likelihood of having four common types of major invasive procedures. Findings showed that Veterans with PTSD only and with depression only were less likely to undergo all types of procedures examined in this study. Having both PTSD and depression was associated with lower odds of hip/knee, CABG/PCI, and vascular procedures, but not digestive procedures. Vascular procedures had the strongest effect. The odds of undergoing CABG/PCI or vascular procedures for patients with depression only were 35% to 40% lower than for patients with neither PTSD nor depression, while patients with PTSD only were about 25% less likely to receive the procedures. African American and women at-risk patients (those with a pre-existing condition likely to be alleviated by a procedure) were less likely to undergo hip/knee, vascular, and CABG/PCI procedures. Given that African-Americans are more likely than non-Hispanic whites to die of heart disease, their reduced odds of receiving CABG/PCI or vascular procedures could be problematic.
    Date: October 1, 2013
  • Rates of Breast Conserving Surgery Performed in VA for Women Veterans with Breast Cancer Comparable to Private Sector
    Previous research suggested a lower rate of breast-conserving surgery (BCS) for the treatment of breast cancer in VA than in the private sector. Combining VA administrative data with VA Centralized Cancer Registry (VACCR) data, this study analyzed utilization rates of BCS among a cohort of women Veterans. Findings showed that, based on procedures performed solely in VA, rates of breast-conserving surgery for women Veterans decreased from 51% in 2000 to 42% in 2006. However, after accounting for procedures conducted in the private sector and paid for by VA, the BCS rate was 60%, which is more in line with private sector data. This suggests that previously reported differences in BCS rates between VA and the private sector may have been caused by the referral of BCS cases to the private sector, but the retention of mastectomies within VA. No statistically significant differences in the use of BCS were found based on age, race, income, marital status, or distance to a VAMC. None of the facility characteristics (including volume) was found to be significantly associated with the use of breast conserving surgery.
    Date: July 1, 2013
  • Literature Review Compares Bariatric Surgery to Non-Surgical Interventions among Non-Morbidly Obese Patients with Diabetes
    Given the lack of consistency, as well as uncertainties regarding the comparative effectiveness of different procedures for bariatric surgery, investigators conducted a systematic review of the relative risks and benefits associated with surgical and non-surgical therapies for treating diabetes or impaired glucose tolerance in patients with a BMI of less than 35. Findings showed that, for patients with diabetes and a BMI of 30 to 35, current evidence suggests that bariatric surgery is associated with greater short-term weight loss and improvements in HbA1c, fasting blood glucose levels, blood pressure, and hyperlipidemia than non-surgical interventions such as medication, diet, and behavioral changes. However, the evidence was insufficient to reach definitive conclusions about long-term outcomes.
    Date: June 5, 2013
  • No Significant Association between Timing of Surgical Antibiotic Prophylaxis and Risk of Surgical Site Infection
    This study sought to determine whether prophylactic antibiotic timing is associated with decreased surgical site infection (SSI). Findings showed that of the surgical procedures performed at VA hospitals included in this study, prophylactic antibiotics were administered at a median of 28 minutes prior to surgical incision; 92% of patients received antibiotics within the recommended time window. Of all patients, 5% of Veterans developed an SSI within 30 days of surgery. In adjusted models, no significant association between prophylactic antibiotic timing and SSI was observed. However, there was a significant association between choice of antibiotic and SSI for orthopedic and colorectal procedures: vancomycin hydrochloride was associated with higher SSI occurrence for orthopedic procedures, while cefazolin or quinolone in combination with an anaerobic agent were associated with fewer SSI events for colorectal procedures. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.
    Date: March 20, 2013
  • Effectiveness of Medical Pre-Operative Clinics
    This study evaluated the impact of the addition of a hospitalist-run pre-operative clinic to standard practice in one VAMC. Findings showed that the addition of an internal medicine-focused pre-operative clinic was associated with improved patient outcomes and reduced hospital length of stay for Veterans undergoing surgery. Inpatient mortality rates were reduced for Veterans seen in the hospitalist-run preoperative clinic in Period B (the first year of the new hospitalist-run system) compared to Veterans seen in Period A, when Anesthesia Department staff supervised the pre-operative clinic (0.36% vs. 1.27%). There also was a trend toward a reduction in same day, medically avoidable surgical cancellations (8.5% vs. 4.9%). There was a significant increase in the number of Veterans on perioperative beta blockers, with 26% in Period A compared to 33% in Period B.
    Date: September 7, 2012
  • Radical Prostatectomy Does Not Significantly Reduce All-Cause or Prostate-Cancer Mortality
    Among men with localized prostate cancer, which was detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate cancer mortality, as compared with observation, through at least 12 years. During the median follow-up of 10 years, 171 of 364 men (47%) assigned to radical prostatectomy died, compared with 183 of 367 men (50%) that were assigned to observation. Among men assigned to radical prostatectomy, 21 (6%) died from prostate cancer or treatment compared with 31 men (8%) assigned to observation. Sub-group analyses suggest that surgery might reduce mortality among men with higher PSA values and possibly among men with higher-risk tumors (absolute reductions in mortality between 7% and 13%), but not among men with PSA levels of 10 ng per milliliter or less, or among men with low-risk tumors. The effect of treatment on all-cause and prostate cancer mortality did not differ according to the patient’s age, race, co-existing conditions, or self-reported performance status. Peri-operative complications during the first 30 days after surgery occurred in 21% of men who underwent a radical prostatectomy, and included one death.
    Date: July 19, 2012
  • Gastric Bypass Surgery among Veterans Not Associated with Reduced Healthcare Expenditures Three Years Later
    Gastric bypass surgery does not appear to be associated with reduced healthcare expenditures three years after the procedure. Total expenditures trended higher for bariatric surgical cases in the year leading up to the procedure and then converged back to the lower expenditure levels of non-surgical controls one year after the procedure. Health expenditures were similar two and three years before the surgical procedure because surgical patients and non-surgical controls had similar weight and healthcare use trajectories several years before giving serious consideration to bariatric surgery. These results are notable because they contrast with results from several prior observational studies that found costs among post-surgical cases to be lower than those of non-surgical controls two to four years after the procedures. This may be explained by important differences in the populations examined (e.g., Veterans are generally older and sicker than the general population) and the methods of analysis.
    Date: July 1, 2012
  • Importance of Pre-Operative Alcohol Screening
    Among the Veterans in this study, 16% of men and 5% of women screened positive for alcohol misuse at levels associated with increased post-operative complications in the year before surgery. A majority of male and female surgical patients with alcohol misuse were relatively healthy and did not have diagnoses or chronic conditions commonly associated with alcohol misuse that might alert providers to their alcohol misuse. This finding highlights the value of routine pre-operative alcohol screening to proactively identify Veterans who misuse alcohol and to potentially implement interventions before surgery. Screening positive for alcohol misuse (AUDIT-C >5) was more common among men who were: younger than 60 years old, divorced or separated, current smokers, or ASA class 1-2 (pre-operative assessment by anesthesiologist as healthy patient or patient with mild systemic disease), and among men with cirrhosis, hepatitis, or substance use disorders.
    Date: April 11, 2012
  • Gastric Bypass Surgery Generates Significant Weight Loss, Especially for Caucasian and Female Veterans
    Gastric bypass surgery yields significant weight loss for most patients in VAMCs, but is particularly effective for female and Caucasian patients. Average estimated weight loss was 76 pounds at 6 months and 109 pounds at one year. Based upon estimated individual weight trajectories, 58% of the sample had lost a significant (30% or more) amount of weight one year after surgery, and <1% lost <10% of their baseline weight at 1 year. Veterans were more likely to lose 30% or more of their baseline weight if they were female or Caucasian.
    Date: March 12, 2012
  • Non-Cardiac Surgery Soon after Cardiac Revascularization with Stents Decreasing among Veterans
    In November 2007, American College of Cardiology/American Heart Association (ACC/AHA) guidelines were released that recommended delay of elective non-cardiac surgery for 12 months after cardiac revascularization with drug eluting stents (DES), compared with six weeks for bare metal stents (BMS). In this study, 12% of Veterans in the BMS cohort had early surgery (less than 6 weeks) compared with 47% of Veterans in the DES cohort who had early surgery (less than 12 months). Rates of non-cardiac surgery within the first year after a DES placement have steadily declined (15% to 8%), suggesting that the ACC/AHA guidelines are being adopted into practice across the VA healthcare system. The authors note that nearly half of operations after a DES, including major procedures, were performed within the first 12 months. Thus, many Veterans are still undergoing high-risk non-cardiac procedures during the high-risk time period after cardiac stent placement.
    Date: February 15, 2012
  • Depression and Race may Independently Affect Receipt of Some Surgeries
    This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
    Date: October 1, 2011
  • Adherence to National Prevention Measures for Surgical Site Infection Does Not Impact VA Surgical Outcomes
    This study evaluated whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates at the VA patient or hospital level. Findings showed that none of the 5 SCIP infection prevention measures were significantly associated with lower odds of SSI among Veterans after adjusting for variables known to predict SSI and procedure type. Individual hospital SCIP performance also was not associated with hospital SSI rates. While adherence to SCIP measures improved, risk-adjusted SSI rates remained stable. For Veterans with all measures assessed, the composite rate of adherence was 81%. Although SCIP measures are best practices and should continue, they may not discriminate hospital quality. Mandatory SCIP reporting without improvement in care may lead to health professional skepticism and fatigue with quality improvement measures.
    Date: September 1, 2011
  • Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
    This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
    Date: August 24, 2011
  • Adverse Post-Operative Events More Common among Current Veteran Smokers Compared with Prior or Non-Smokers
    This study assessed the attributable risk and potential benefits of smoking cessation on surgical outcomes for Veterans who underwent non-cardiac, elective surgery in a VA hospital between 2002 and 2008. Findings showed that compared with both never and prior smokers – and controlling for patient and procedure risk factors – Veterans who were current smokers had significantly more post-operative pneumonia and surgical-site infection, despite being younger and having fewer comorbidities. Moreover, current smokers had increased odds of dying up to one year after surgery compared with prior smokers or Veterans who had never smoked. There was a dose-dependent increase in pulmonary complications based on pack-year exposure (one pack-year equals smoking 20 cigarettes a day for one year), with greater than 20 pack-years leading to a significant increase in smoking-related surgical complications. Previous literature suggests that pre-operative quit smoking interventions may reduce the risk of post-operative complications. Authors suggest that smoking cessation intervention be considered for Veterans who are current smokers, with greater than 20 pack-years of exposure, who undergo major surgical procedures.
    Date: August 24, 2011
  • Excess Cost Associated with Post-Operative Complications among Veterans in VA Hospitals
    This study estimated excess costs associated with post-operative complications among inpatients treated in VA hospitals. Findings showed that among Veterans who survived to discharge, excess costs associated with post-operative complications were found to be considerable. Veterans experiencing complications had inpatient costs that ranged from 3% to 120% higher (for “cardiac arrest requiring CPR” and “failure to wean,” respectively) than those without complications. Among the 16 complications that were significantly related to cost, the estimated excess costs ranged from $8,234 for “progressive renal insufficiency” to $28,779 for “failure to wean from ventilator within 48 hours.” Results suggest that directing efforts toward reducing complications such as cerebral vascular accidents, sepsis, acute renal failure, and failure to wean, each of which incurred excess costs of greater than $20,000, might have high value.
    Date: August 1, 2011
  • Bariatric Surgery Does Not Decrease Mortality among Obese Veterans
    This study sought to determine whether bariatric surgery is associated with reduced mortality among Veterans, who are older and predominantly male compared to prior studies. Findings showed that in a matched cohort of obese, high-risk, predominantly male Veterans (847 who underwent surgery and 847 non-surgical controls), bariatric surgery was not significantly associated with a survival benefit during a median of 6.7 years of follow-up. In unmatched comparisons of 850 Veterans who underwent bariatric surgery and 41,244 Veterans who did not, those in the surgical group were significantly younger, had higher BMIs, and had greater comorbidity burden. Surgical patients also were more likely to be super-obese. However, analyses after matching reduced the significant differences in characteristics between surgical and control patients. These analyses also controlled more closely for time of follow-up and showed that the protection conferred by surgery was small and not statistically significant after 6.7 years.
    Date: June 15, 2011
  • Increased Wait Times for Surgical Cancer Treatment, Particularly at VA Medical Centers and NCI Cancer Centers
    This study sought to assess changes in wait times for initial cancer treatment over a decade (1995 - 2005) and to identify patient, tumor, and hospital factors associated with prolonged wait times, using data from National Cancer Institute (NCI)-designated cancer centers, VA medical centers, academic hospitals, and community hospitals. Findings show that wait times for cancer treatment progressively increased at all four hospital center types over the 10-year study period. The median time from diagnosis to treatment was significantly longer at VA medical centers and NCI-designated cancer centers compared to community hospitals for all eight cancers studied. For patients who were diagnosed and treated at the same hospital, the median time from diagnosis to treatment was longest at VA medical centers, and shortest at community hospitals. Patients were significantly more likely to undergo initial treatment more than 30 days following diagnosis if they were: older, African American, had more comorbidities, had Stage I disease, or were treated at NCI cancer centers or VA medical centers.
    Date: February 25, 2011
  • Complications Following Total Joint Arthroplasty Significantly Related to Pre-Operative Alcohol Misuse among Veterans
    This study evaluated the association between a standardized, pre-operative alcohol screening score (AUDIT-C [Alcohol Use Disorders Identification Test – Consumption]) and the risk of post-operative complications in Veterans who underwent total joint arthroplasty at one VA facility between 2004 and 2007. Findings show that complications following total joint arthroplasty were significantly related to alcohol misuse. Of the 185 Veterans in this study, 32 had alcohol screening scores suggestive of alcohol misuse, and 12 Veterans had at least one post-operative complication. Therefore, AUDIT-C scores signified a 29% increase in the expected mean number of complications with every additional AUDIT-C point above 1. The authors suggest that pre-operative alcohol misuse screening, and perhaps pre-operative counseling or referral to treatment for heavy drinkers, may be indicated for patients undergoing total joint arthroplasty.
    Date: February 1, 2011
  • VA Patient-Provider Communication Does Not Contribute to Racial Disparities in Use of Total Joint Replacement
    This study examined whether there were racial differences in patient-provider communication about treatment of chronic knee/hip osteoarthritis in African American and white Veterans referred to two VA orthopedic clinics over a 3-year period. Findings show that communication between VA orthopedic surgeons and patients regarding the management of chronic knee/hip osteoarthritis did not, for the most part, vary by patient race. No racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, Veteran activation/engagement statements, physician verbal dominance, display of positive affect by Veterans or providers, or discussion related to informed decision-making. However, visits with African American Veterans contained less discussion of biomedical topics and more rapport-building statements than visits with white Veterans. These findings diminish the potential role of communication in VA orthopedic settings as an explanation for racial disparities in the use of total joint replacement.
    Date: January 10, 2011
  • Alcohol Screening Results Up to One Year Prior to Surgery Associated with Increased Post-Operative Complications for Veterans
    This study evaluated whether results of alcohol screening with the AUDIT-C (Alcohol Use Disorders Identification Test – Consumption), administered up to one year before surgery, were associated with the risk of post-operative complications in Veterans undergoing major non-cardiac surgery in VA. Findings showed that AUDIT-C scores of 5 or higher up to one year before surgery were associated with increased post-operative complications. Overall, 16% of the total study population screened positive for alcohol misuse with AUDIT-C scores >5, and 8% had post-operative complications. There also was a dose-response relationship between AUDIT-C scores and post-operative complications, with complications increasing from 6% among low-risk drinkers to 14% among Veterans with the highest AUDIT-C scores. The authors suggest that AUDIT-C scores could be electronically loaded into surgery consults, surgery clinic notes, or pre-operative templates in VA’s computerized patient record system in order to alert clinicians to alcohol misuse at the time of referral to surgery.
    Date: September 28, 2010
  • Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement
    Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon. African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was not significant after controlling for Veterans’ willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure.
    Date: May 28, 2010
  • Better Outcomes for Veteran Amputees Receiving Specialized Rehabilitation Compared to Consultative Services
    Veterans who receive specialized rehabilitation can be expected to make comparatively higher gains than Veterans who receive consultative services, regardless of timing and clinical complexity. Advanced age, trans-femoral amputation, paralysis, serious nutritional compromise, and psychosis were associated with lower gains in physical function. Most Veterans (89.1%) received early rehabilitation occurring directly after surgery vs. late rehabilitation beginning during a separate hospitalization after discharge from the index surgical stay. Authors suggest that clinicians consider adjusting prognostic expectations to both clinical severity and the type of rehabilitation patients receive.
    Date: April 1, 2010
  • VA Care for Obese Veterans
    Of those Veterans identified as obese, only 27.7% had an obesity diagnosis in FY02; by 2006, 53.5% had an obesity diagnosis. Although suboptimal, these rates are comparable or better than those recently reported in the public sector. Results also show that an obesity diagnosis, and not BMI per se, was the strongest predictor of receiving obesity-related education. Only about 10-13% of obese Veterans received individual or group outpatient education in nutrition, exercise, or weight management on an annual basis, and only about one-third received any obesity-related education over the five-year study period. Obese Veterans who were older than 65 years, prescribed fewer types of medications, or lacking an EMR diagnosis of obesity or diabetes were less likely to have outpatient obesity-related education. Investigators also found limited utilization of weight loss medications and bariatric surgery, which may be partially due to system barriers such as access to surgery and medications.
    Date: February 24, 2010
  • “Super-obesity” Associated with Risk of Death Among Veterans Following Bariatric Surgery
    This retrospective study of 856 bariatric surgical cases conducted in 12 VAMCs between 2000 and 2006 sought to define the risk of death among Veterans with a body mass index (BMI) of 40 or greater – and to identify patient-level factors associated with mortality. Findings show that Veterans classified as “super-obese” (BMI of 50 or higher) and those with a higher chronic disease burden appear more likely to die within one year of having bariatric surgery. Authors recommend that the risks of bariatric surgery in patients with significant comorbidities should be carefully weighed against potential benefits in older male Veterans and those with super-obesity.
    Date: October 1, 2009
  • African Americans and Whites Equally Appropriate Candidates for Total Joint Arthroplasty
    This study sought to determine if racial differences in clinical appropriateness for surgery existed among a sample of primary care patients (425 whites and 260 African Americans) with moderate to severe symptomatic knee or hip osteoarthritis (OA) treated at one VA hospital and one county hospital between 3/03 and 9/06. Findings show that African Americans and whites were equally appropriate candidates for total joint arthroplasty (TJA). There were no significant ethnic differences found between the proportion of those deemed appropriate for TJA and those deemed inappropriate.
    Date: September 1, 2009
  • Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
    In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
    Date: September 1, 2009
  • Many Healthy Older Veterans Not Being Screened for Colorectal Cancer
    Many healthy older Veterans with substantial life expectancies are not being screened, while some with severe comorbidity are being screened. For example, only 47% of Veterans aged >70 without comorbidity were screened despite having a high probability of living >5 years. Number of outpatient visits was a strong predictor of screening, independent of comorbidity. Veterans without comorbidity who did not attend a VA primary care, gastroenterology, or general surgery clinic had a lower incidence of screening than patients with severe comorbidity who visited these clinics.
    Date: April 7, 2009
  • Spaced Education May Improve Teaching by Surgical Residents
    This randomized trial investigated whether feedback given by surgery residents to students could improve using a spaced-education program delivering succinct weekly e-mails. Findings show that succinct e-mails using spaced education methods are an effective tool to significantly improve both the frequency and quality of feedback given by surgical residents to medical students. Authors suggest that spaced-education techniques may help educate busy residents, for whom service and education responsibilities are often at odds with effective teaching strategies.
    Date: February 1, 2009
  • Intra-Operative Reading during Anesthesia Care
    What is considered acceptable or professional behavior and activities during periods of low clinical workload during anesthesia care are controversial. This study sought to ascertain the incidence of intra-operative reading and measure its effects on clinicians’ workload and vigilance. Findings show that anesthesia providers read during 60 of the 172 cases observed (35%). Reading was observed during the maintenance period, not during induction or emergence, thus it occurred when workload was low and did not appear to affect vigilance. However, when reading, anesthesia providers spent less time conversing with others, performing manual tasks, and record-keeping.
    Date: February 1, 2009
  • Study Suggests Changes Needed in Warfarin Dosing
    The lack of evidence regarding optimal management strategies for warfarin probably contributes to limited success in maintaining patients within the target International Normalized Ratio (INR) range (system used to report testing for coagulation). Findings from this study show that providers vary widely in their dose change thresholds in similar clinical situations and that the INR value was by far the most important predictor of dose change. Authors suggest that in addition to offering warfarin to as many optimal candidates as possible, we also need to optimize warfarin dose management to fully realize the benefits of anticoagulation.
    Date: January 1, 2009
  • Most Elderly Veterans Obtain High-Risk Surgeries in Non-VA Hospitals
    Regardless of where they live (rural vs. suburban vs. urban), most elderly veterans obtain high-risk procedures such as heart, vascular, and cancer surgeries in non-VA hospitals. Veterans generally traveled about as long to get to higher performance hospitals as to reach lower performance hospitals. Authors suggest that veterans might benefit from an effort to direct them to higher performance hospitals for these high-risk surgeries, and that this effort might best be initiated by focusing on veterans living beyond urban areas.
    Date: October 1, 2008
  • Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
    Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites.
    Date: September 1, 2008
  • Demographic and Clinical Factors Affect Ostomy Complications
    Demographic factors (age) and clinical factors (marking the stoma pre-operatively and provider explanation of the ostomy prior to surgery) are potential risk factors for the development of ostomy complications. In addition, the four quality of life domains measured in this study (physical, psychological, social, and spiritual) were strongly related to all three ostomy complications evaluated.
    Date: September 1, 2008