The Comprehensive Complication Index (CCI®) is a Novel Cost Assessment Tool for Surgical Procedures

OBJECTIVE The aim of this study was to identify a readily available, reproducible, and internationally applicable cost assessment tool for surgical procedures. SUMMARY OF BACKGROUND DATA Strong economic pressure exists worldwide to slow down the rising of health care costs. Postoperative morbidity significantly impacts on cost in surgical patients. The comprehensive complication index (CCI), reflecting overall postoperative morbidity, may therefore serve as a new marker for cost. METHODS Postoperative complications and total costs from a single tertiary center were prospectively collected (2014 to 2016) up to 3 months after surgery for a variety of abdominal procedures (n = 1388). CCI was used to quantify overall postoperative morbidity. Pearson correlation coefficient (rpears) was calculated for cost and CCI. For cost prediction, a linear regression model based on CCI, age, and type of surgery was developed and validated in an international cohort of patients. RESULTS We found a high correlation between CCI and overall cost (rpears = 0.75) with the strongest correlation for more complex procedures. The prediction model performed very well (R = 0.82); each 10-point increase in CCI corresponded to a 14% increase to the baseline cost. Additional 12% of baseline cost must be added for patients older than 50 years, or 24% for those over 70 years. The validation cohorts showed a good match of predicted and observed cost. CONCLUSION Overall postoperative morbidity correlates highly with cost. The CCI together with the type of surgery and patient age is a novel and reliable predictor of expenses in surgical patients. This finding may enable objective cost comparisons among centers, procedures, or over time obviating the need to look at complex country-specific cost calculations (www.assessurgery.com)

Post-Operative Functional Outcomes in Early Age Onset Rectal Cancer

Background: Impairment of bowel, urogenital and fertility-related function in patients treated for rectal cancer is common. While the rate of rectal cancer in the young (<50 years) is rising, there is little data on functional outcomes in this group. Methods: The REACCT international collaborative database was reviewed and data on eligible patients analysed. Inclusion criteria comprised patients with a histologically confirmed rectal cancer, <50 years of age at time of diagnosis and with documented follow-up including functional outcomes. Results: A total of 1428 (n=1428) patients met the eligibility criteria and were included in the final analysis. Metastatic disease was present at diagnosis in 13%. Of these, 40% received neoadjuvant therapy and 50% adjuvant chemotherapy. The incidence of post-operative major morbidity was 10%. A defunctioning stoma was placed for 621 patients (43%); 534 of these proceeded to elective restoration of bowel continuity. The median follow-up time was 42 months. Of this cohort, a total of 415 (29%) reported persistent impairment of functional outcomes, the most frequent of which was bowel dysfunction (16%), followed by bladder dysfunction (7%), sexual dysfunction (4.5%) and infertility (1%). Conclusion: A substantial proportion of patients with early-onset rectal cancer who undergo surgery report persistent impairment of functional status. Patients should be involved in the discussion regarding their treatment options and potential impact on quality of life. Functional outcomes should be routinely recorded as part of follow up alongside oncological parameters

Benchmark analyses in minimally invasive esophagectomy—impact on surgical quality improvement

Over the last decades, benchmarking has become an established management tool to improve quality in commercial economics. It is a rather new concept in the healthcare industry, and a confusingly wide range of approaches referring to "benchmarking" have been employed in the field of minimally invasive esophageal cancer surgery. It is our conviction that benchmarking will be an essential element of surgical research in the future. Therefore, defining and implementing standards is not only a desirable, but a vital step. Recently, we have introduced a standardized method of establishing valid benchmarks for surgical quality improvement including ideal outcome thresholds for total minimally invasive transthoracic esophagectomy (ttMIE). The present article aims at discussing the actual literature on benchmarking in minimally invasive esophagectomy (MIE) and at fueling the debate on how to further improve the current practice of surgical outcome research

Can early postoperative complications predict high morbidity and decrease failure to rescue following major abdominal surgery?

OBJECTIVE: To assess whether specific patterns of early postoperative complications may predict overall severe morbidity after major surgery, warranting early escalation of care and prevention of failure to rescue. SUMMARY OF BACKGROUND DATA: It is unclear whether early postoperative complications predict a poor outcome. Detailed knowledge of the chronology and type of early complications after major surgery may alert clinicians when to expect higher risk for subsequent major negative events. METHODS: All 90-day postoperative events following complex pancreas, liver, and rectal surgeries, and liver transplantation were analyzed over a 3-year period in a single tertiary center. Each complication was recorded regarding severity, type (cardiac, infectious, etc), etiology (surgical/medical), and timing of occurrence. The Comprehensive Complication Index (CCI), covering the first 7 postoperative days, was calculated as a measure for early cumulative postoperative morbidity. The statistical analysis (descriptive, sequence pattern analyses, and logistic regression analyses) aimed to detect any combinations of events predicting poor outcome as defined by a cumulative CCI ≥37.1 at 90-days. RESULTS: The occurrence of ≥2 complications, irrespective of severity, type or etiology, was strongly associated with a severe postoperative course (P < 0.001). Even 2 mild complications (≤ grade II) greatly increased the chance for high morbidity compared to patients with 0 or 1 complication within the first postoperative week (odds ratio 10.2, 95% confidence interval 5.82-17.98). The CCI at postoperative day 7 strongly predicted high 90-day morbidity (odds ratio 3.96 per 10 CCI points, P < 0.001). CONCLUSION: Multiple complications of any cause or severity within the first postoperative days represents a "warning-signal" for overall high morbidity by 90 days, which should be used to trigger an escalation of care to prevent failure to rescue and eventually poor outcome

How to establish benchmarks for surgical outcomes?: A checklist based on an international expert Delphi consensus

OBJECTIVE: To define a standardized methodology for establishing benchmarks for relevant outcomes in surgery. SUMMARY BACKGROUND DATA: Benchmarking is an established tool to improve quality in industry and economics, and is emerging in assessing outcome values in surgery. Despite a recent 10-step approach to identify such benchmark values, a standardized and more widely agreed-on approach is still lacking. METHODS: A multinational web-based Delphi survey with a focus on methodological requirements for establishing benchmarks for surgical outcomes was performed. Participants were selected among internationally renowned specialists in abdominal, vascular, and thoracic surgery. Consensus was defined as ≥70% agreement and results were used to develop a checklist to establish benchmarks in surgery. RESULTS: Forty-one surgical opinion leaders from 19 countries and 5 continents were involved. Experts' response rates were 98% and 80% in rounds 1 and 2, respectively. Upon completion of the final Delphi round, consensus was successfully achieved for 26 of 36 items covering the following areas: center eligibility, validation of databases, patient cohort selection, procedure selection, duration of follow-up, statistical analysis, and publication requirements regarding center-specific outcomes. CONCLUSIONS: This multinational Delphi survey represents the first expert-led process for developing a standardized approach for establishing benchmarks for relevant outcome measures in surgery. The provided consensual checklist customizes the methodology of outcome reporting in surgery and thus improves reproducibility and comparability of data and should ultimately serve to improve quality of care

Surgical outcome improvement by shared decision-making: value of a preoperative multidisciplinary target clinic for the elderly in colorectal surgery

Purpose Frailty and comorbidities increase the risk of postoperative complications and raise treatment costs. Perioperative optimisation is shown to improve surgical outcomes for the elderly. The aim of this study was to assess the impact of introducing a multidisciplinary preoperative clinic for older patients (Colchester Older Persons’ Evaluation for Surgery (COPES) clinic) undergoing major colorectal surgery. Methods This 5-year single centre study included patients >65 years with ≥3 comorbidities undergoing major colorectal surgery. From October 2018, patients with these characteristics were evaluated and optimised in the COPES clinic by a geriatrician and an anaesthetist. Outcomes were compared to high-risk patients operated on prior to COPES (pre-COPES group). The primary outcomes were postoperative morbidity at discharge and 6 months measured by the Comprehensive Complication Index. Patients were matched on age and number of comorbidities. Results A total of 54 patients were enrolled in the pre-COPES and 18 in the COPES group. After matching, the results were comparable for both groups. The length of stay was shorter in the COPES group and the recurrence rate was higher; however, it did not reach statistical signifcance in both fndings. Conclusion This clinic intends to improve treatment quality, placing emphasis on shared decision-making. More focus should be put on patient-reported outcomes and experiences. Especially for elderly patients, quality of life and maintaining independence are often their priority. To determine the true value of a preoperative multidisciplinary clinic targeting elderly comorbid patients, a prospective study with larger cohort is needed, focusing not only on objective outcomes but also on patient-reported outcomes. </p