Eva Chalas, MD, FACS, FACOGProfessor and Vice Chair

Department of Obstetrics and GynecologyDirector of Clinical Cancer Services

Winthrop University Hospital

Gynecology Module

American College of SurgeonsNational Surgical Quality Improvement Program

Introduction

• Overview of development of the gynecology module

• Initial outcomes from sites collecting multispecialty data

• Highlights from 2005-2009 database• Gynecology data from most recent SAR • Winthrop University Hospital experience• Future goals

NSQIP General SurgeryTop Ten Variables Predicting Morbidity

Men

Work RVUASA class

Serum AlbuminEmergency surgery

DyspneaBleeding disorder

BUN>40SepsisAge

HCT<38

Women

ASAWork RVU

Serum AlbuminEmergency surgeryWound infection

DyspneaVentilator dependence

HCT>45%WBC>11.1K

Age

Henderson WG et al. J Am Coll Surg 2007;204(6):1103-1126

Fink et al. J Am Coll Surg 2007;204(6):1127-1136

What About Gynecology?

• 2005 data– 927,709 inpatient gynecologic procedures

• 60% are hysterectomies

– $15.9 billion – Outcomes of procedures associated with varied

patient and surgeon factors– Current data collection does not adjust for

these factors

2006 Rank OrderPrincipal Procedure per Number of Discharges

Total number Standard error of

of discharges total number

RankCCS principal procedure category and name of discharges

1 137 Procedures to assist delivery 1,472,994 65,923

2 134 Cesarean section 1,268,420 48,217

3 115 Circumcision 1,102,667 46,115

4 70 Upper GI endoscopy, biopsy 731,239 22,554

5 45 PTCA 720,927 43,730

6 140 Repair of Ob laceration 680,536 39,430

7 216 Resp intubation & mech ventilat

676,430 19,964

8 47 Diagnostic cardiac catheterization

638,946 25,207

9 124 TAH and VH 574,564 19,074

10 222 Blood transfusion 568,245 20,126

0

5

10

15

20

25

Organ

Injury

Hem

orrhage

ALL

TAHVHLH

Makinen et al., 2001 Human Reproduction

TAH and VH

574,564

Organ: 1.5% = 8,618Infection: 10% = 57,456Any: 18% = 103,421

Complication Rates by Type of Hysterectomy

Predictors of MorbidityOvarian Cancer Surgery

• 450 cases in three major academic institutions

• 5-40% major morbidity• Factors determining outcome

– Performance status– Serum albumin level– Complexity of surgery performed for

cytoreduction

Aletti et al Gynecol Oncol 2007;107(1):99-106

Gynecology and ACSCollaboration

Gynecology Module DevelopmentGynecology Team American College of SurgeonsWilliam Cliby, MD Clifford Ko, MDJohn Brown, MD Bruce Hall, MDEva Chalas, MD William Henderson, PhDHal Lawrence, MD Shukri Khuri, MDDwight Chen, MD Karen RichardsDennis Chi, MD Kathy RowellRichard Drake, MD Marchelle DiordievicBrigid KrizekEvan Myers, MDFarr Nezhat, MDPeggy Norton, MDHoward Sharp, MDStewart Wetchler, MDJeff Cornella, MDRobert Bristow, MDMary EikenJennifer Bethke

SGO Collaborative Task Force

• SGO initiated collaborative approach with ACS, ACOG, AUGS and ASRM– Modify data collection tool used in the multi-specialty

module by National Surgical Quality Improvement Program (NSQIP)

– Determine feasibility of extraction of the data– Pilot data collection for 3-6 months in hospitals

participating in multi-specialty module of NSQIP– Modify collection tool based on pilot study– Implement final tool in multi-specialty module of NSQIP

Gynecology ModuleExpansion of Data Collection Tool

Add gynecologic surgery subspecialties

Expand to include:

Prior pelvic and abdominal operations

Add Surgical/Pathologic Factors

Benign:EndometriosisUterine weightPID

Malignancy:FIGO stageResidual Disease

Add:

Bowel obstruction/enteric leakUrinary tract obstruction/leak

NSQIP Initial Multispecialty Site Collection Results

Gynecologic operation Hysterectomy Oophorectomy(n=600) (n=135)

30-day mortality 0.23% 30-day morbidity 9.51% 8.08%Bleeding or DVT 0.46%Pneumonia/dehiscence 0.70% Sepsis/septic shock 1.00% 1.00%SSI 2.50% 2.00%UTI 5.10% 5.00%

Gynecology Data 2005-2011General Information

• 37,944 cases– Gender: 0.26% male, 0.16% unknown – Race: 74.7% white, 11.5% black, 2.3% API, 10.6%

unknown– Ethnicity: 15.8% Hispanic– Inpatients: 42.5%– Age: 49.3 +12.2 yrs– General anesthesia: 95% of cases– Average BMI: 29.0

Gynecology Data 2005-2011Pre-Existing Conditions

• Hypertension: 31.5%• Smoking: 18%• Diabetes: 8.3%• Dyspnea on Exertion: 5% • All other conditions: <1%

Gynecology Data 2005-2011Intra-Operative Variables

• 97% clean/contaminated wound status• ASA class: 13.5% class I, 65% class II• 1.6% were emergency cases• Average operating time was 126.3 minutes

Gynecology Data 2005-2011Post-Operative Status

• 8.2% incidence of any morbidity• 0.18% mortality• 1% return to OR• Most prevalent morbidities

– 3.2% UTI – 1.5% SSI– 1.7% bleed

• LOS 3.1 days, SD 3.5

Gynecology Data SAR 2011Morbidity from 176 Participating Hospitals

Condition Total Cases Total ObservedEvents

Total Rate

Morbidity 27,230 1,696 6.23UTI 27,179 670 2.47SSI 27,201 684 2.51

Gynecology Data SAR for 2011Targeted Cases

Hysterectomy/Myomectomy GynecologicReconstruction

Sites Reporting 44 16

Total Cases 7,468 283

Number/Hospital 169.7 17.7

Mortality Events 12 0

Mortality % 0.2 0

Morbidity Events 508 20

Morbidity % 6.8 7.1

Cases 7,462 283

SSI % 2.9 4.2

SS Plastic Morbidity : 5 observed events and 83 total cases

SS Otolaryngology Morbidity : 1 observed events and 43 total cases

SS Orthopedic SSI : 14 observed events and 645 total cases

SS Orthopedic UTI : 12 observed events and 636 total cases

SS Orthopedic Morbidity : 53 observed events and 646 total cases

SS Neurosurgery SSI : 7 observed events and 251 total cases

SS Neurosurgery Morbidity : 34 observed events and 251 total cases

SS Gynecology SSI : 17 observed events and 594 total cases

SS Gynecology UTI : 11 observed events and 591 total cases

SS Gynecology Morbidity : 36 observed events and 594 total cases

SS Cardiac Morbidity : 16 observed events and 63 total cases

Subspecialties

Winthrop University Hospital SAR

Based on:

Subspecialties

Total Morbidity and SSIHysterectomy/Myomectomy: 1/2011 to 12/2011

Procedure Morbidity (%) SSI (%)

HysterectomyMyomectomy

18/341(5.28)

8/341(2.35)

Targeted - Gynecology

NSQIP Outcomes and Quality Improvement

• Winthrop University Hospital Strategy • Selected dedicated nursing staff

• Adequate number to permit robust data collection• Time for training and practicing extracting data

• Enforced compliance with 30 day follow up

• Obtained adequate representation of the clinical volume to perform self-analysis

NSQIP Outcomes and Quality Improvement• Winthrop University Hospital Strategy

• Established NSQIP Steering Committee• CMO, CQO, Director of Patient Safety, Surgeon

Champions, Surgical Clinical Reviewers, QA staff, biostatistician and ad-hoc members

• Resolved to adopt NSQIP’s established “best practices”

• Multidisciplinary teams have begun investigating outcomes which need improvement

NSQIP Outcomes and Quality Improvement

• Winthrop University Hospital Strategy• Transparency and education

• Report results at Institution-wide QI• Develop Department-specific presentations

• Departmental meetings• Morbidity/mortality conferences • Cancer Institute Executive Committee

• Develop educational products for residents and PAs

NSQIP Outcomes and Quality Improvement

• Winthrop University Hospital Strategy• Action

• Department-led QI activities based on NSQIP data• Implementation of Best Practices via CPOE• Utilization of all QA venues to effect change• CMO directed Peri-Operative Task Force to develop

tool for preoperative risk assessment• Continuous reassessment of outcomes

Future DirectionsGynecology• Link outcomes to other data bases

– National Cancer Data Base

• Utilize for surgeon-specific data– Surgeon case logs

• Personal outcomes• Audits of case log for MOC

– Population of case logs with NSQIP data for analysis

• Work with ACS to produce a robust database of outcomes for major gynecologic procedures

Thank you for your attention