Rethinking performance benchmarks in kidney transplantation

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145501/1/ajt14947_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145501/2/ajt14947.pd

Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135970/1/hesr12482_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135970/2/hesr12482.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135970/3/hesr12482-sup-0001-AuthorMatrix.pd

Utilization of Intensive Care Unit Nutrition Consultation Is Associated With Reduced Mortality

BackgroundThe aim of this project was to investigate the prevalence of nutrition consultation (NC) in U.S. intensive care units (ICUs) and to examine its association with patient outcomes.MethodsData from the Healthcare Cost and Utilization Project’s state inpatient databases was utilized from 2010 â 2014. A multilevel logistic regression model was used to evaluate the relationship between NC and clinical outcomes.ResultsInstitutional ICU NC rates varied significantly (mean: 14%, range: 0.1%â 73%). Significant variation among underlying disease processes was identified, with burn patients having the highest consult rate (P < 0.001, mean: 6%, range: 2%â 25%). ICU patients who received NC had significantly lower inâ hospital mortality (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.48â 0.74, P < 0.001), as did the subset with malnutrition (OR 0.72, 95% CI 0.53â 0.99, P = 0.047) and the subset with concomitant physical therapy consultation (OR 0.53, 95% CI 0.38â 0.74, P < 0.001). NC was associated with significantly lower rates of intubation, pulmonary failure, pneumonia, and gastrointestinal bleeding (P < 0.05). Furthermore, patients who received NC were more likely to receive enteral or parenteral nutrition (ENPN) (OR 1.8, 95% CI 1.4â 2.3, P < 0.001). Patients who received followâ up NC were even more likely to receive ENPN (OR 3.0, 95% CI 2.1â 4.2, P < 0.001).ConclusionsRates of NC were low in critically ill patients. This study suggests that increased utilization of NC in critically ill patients may be associated with improved clinical outcomes.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154413/1/jpen1534_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154413/2/jpen1534.pd

Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study

OBJECTIVE: To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG). BACKGROUND: Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood. METHODS: We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10. RESULTS: Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate CONCLUSION: Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience

Technique or technology? Evaluating leaks after gastric bypass

OBJECTIVE: To assess the relationship between technique and surgical devices on anastomotic and staple-line leaks after laparoscopic Roux-en-Y gastric bypass. BACKGROUND: Leaks after bariatric surgery remain a major source of morbidity and mortality. The association of surgical technique and devices with leaks after gastric bypass is poorly understood. SETTING: Multi-centered study that included teaching and non-teaching hospitals that participate in a statewide consortium for quality improvement using a payer-funded outcome registry. METHODS: We analyzed data from the Michigan Bariatric Surgery Collaborative and performed a case-control study comparing patients who sustained a leak with those who did not after primary laparoscopic Roux-en-Y gastric bypass. A total of 71 (.44%) patients with leaks were identified between January 2007 and December 2011. The leak group was matched 1:2 to a control group (nonleak) based on procedure type, age, body mass index, sex, and the year in which the procedure was performed. Technique-specific case characteristics and device-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. RESULTS: The rate of leak decreased during the study period, and there was a significant downward trend (slope estimate: -.19961%, P = .0372). After performing multivariate analysis, the type of anastomosis (circular stapler, hand-sewn, or linear stapler) and stapler manufacturer were not associated with leaks. The use of buttressing material was associated with a higher rate of leaks (odds ratio: 8.79 [95% confidence interval: 2.49-31.01], P = .0007), whereas the use of fibrin sealant was associated with a lower rate of leaks (odds ratio .11 [95% confidence interval: .03-.41], P = .0013). These findings could not be explained by differences in measures of surgeon performance. CONCLUSION: Leak rates after laparoscopic gastric bypass have fallen in Michigan despite variations in technique and device utilization. Although the type of anastomosis and stapler manufacturer do not appear to be significantly associated with leaks, it appears that the use of buttressing material was more common in cases in which leaks occurred, whereas the use of fibrin sealant was not. Given the complex interplay of multiple variables that affect surgical outcomes, future studies justifying the benefits of operative devices should be evaluated prospectively in the context of surgeon technique and skill