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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Monday, January 05, 2015

Moderator: Justin B. Dimick, MD, MPH

Featured Article: Brown EG, Burgess D, Li CS, et al. Hospital readmissions: necessary evil or preventable target for quality improvement. Ann Surg. 2014;260:583-589.


This study uses the University HealthSystem Consortium (UHC) database to study patterns of readmission after cancer surgery. This analysis yields several interesting findings that potentially challenge whether readmissions are a valid quality metric for surgery. First, they find that high volume cancer centers and designated cancer centers have higher readmission rates. Since these centers are known to have better clinical outcomes (e.g., mortality and morbidity) in prior studies, this finding raises questions about whether readmission is a proxy for high quality rather than poor quality care. Second, the authors found that “a minority” of early readmissions (within 7 days) were due to “potentially preventable causes”, such as nausea, vomiting, dehydration, and pain (accounting together for 33% together). The biggest cause of readmissions was infectious complications (46%), which the authors deemed non-preventable. The authors therefore conclude that the majority of readmissions are not preventable (or modifiable), suggesting further that they are not a good measure of quality.


(1) Do you agree with the authors that readmissions should be correlated with other quality metrics such as morbidity and mortality? Or can readmissions represent a unique and important domain of quality, even if they do not correlate with traditional metrics?

(2) Do you agree with the authors that infectious complications are not preventable? Their argument that a “minority” of readmissions were due to potentially preventable causes hinges on this assumption.

(3) The authors raise the point that a readmission may sometimes represent high quality care, essentially “rescuing” the patient from downstream complications including death. How could a readmission metric be designed so it would not penalize hospitals for readmitting a patient who needs it?

Please feel free to comment on any or all of the questions. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

Monday, December 01, 2014
Moderator: David Efron, MD
Featured Article: Neal M et al. Prehospital Use of Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Is Associated With a Reduced Incidence of Trauma-Induced Coagulopathy. Ann Surg 260: 378-382, 2014.

Trauma induced coagulopathy (TIC) remains a challenge to the care of the severely injured patient.  Whether it is the result of a large burden of tissue damage or secondary to acute blood loss and the need for massive resuscitation, it is directly associated with clinical outcome morbidities and mortalities.  To date inflammation-modulating therapies have been non-existent, not only because of the inability to predict the onset of injury and septic insult, but also because of the unclear link between the anti-inflammatory medications and the subsequent response to injury.  This study attempts to explore one such potential association.  Identifying a link between the inflammation blunting effects of non-steroidal anti-inflammatory medications (NSAIDs) and the emergence of trauma induced coagulopathy is an attractive prospect for a potentially significant, relatively simple and inexpensive therapeutic intervention.

The Inflammation and the Host Response to Injury Large Scale Collaborative Program remains one of the most comprehensive compilations of data yet available to study questions such as these.  In a multicenter effort, clinical, proteomic and genomic data were prospectively collected regarding adults (aged 18-90) who suffered severe blunt injury.  Patients at the various centers were managed according to strict clinical protocols to minimize treatment variation and clinical history includes pre-injury, injury, in hospital and outcome variables. 

The goal of the study was to analyze patients for an association between pre-injury medication use and the incidence of TIC.  Coagulopathy was defined in two ways: 1) TIC was defined as an admission INR of >1.5 (which was the study’s primary outcome measure) and 2) a clinically relevant coagulopathy defined as transfusion of more than 2 units of fresh frozen plasma or 1 unit of platelets within the first 6 hours of admission.   Medications assessed and recorded as taken or not taken included NSAIDs, aspirin, other antiplatelet agents, beta-blockers, angiotensin receptor blockers,  ACE inhibitors, vasodilators, diuretics, calcium channel blockers, other anti-hypertensive medications (exclusive of the above list), oral contraceptives, amphetamines, statins, corticosteroids and cocaine. 

Spanning the years 2003 through 2010, of the 2007 patients who were captured in the study, 72 were excluded for pre-existing liver disease and 38 were excluded for preadmission warfarin use (the only exclusion criteria in this complete data set).  Of the 1897 patients analyzed, the majority (1455; 76.7%) were not on any pre-injury medications.  The remaining 442 patients were on at least one of the listed medications.  The three most common medication classes in decreasing order were non-specified anti-hypertensives, statins and beta-blockers.  NSAIDs use was identified in 47 patients (10.6% of those taking medications and 2.5% of all patients studied).  Under rigorous multivariate analysis, pre-injury NSAID use was associated with a 72% lower risk of TIC identified on admission and a 66% lower risk of clinically relevant coagulopathy.  NSAIDs were the only medications to demonstrate any beneficial effect and this remained significant when controlling for comorbidities associated with NSAID use.  Interestingly, neither NSAIDs nor other antiplatelet medications were associated with TIC or clinically defined coagulopathy.

The limitations of the study include the retrospective analysis, the relatively low numbers of patients on the listed medications and the inability to assure that patients were actually taking those medications. These are balanced against the high data fidelity of this program and the rigorously applied statistical analysis.  The authors conclude that pre-injury NSAID use was associated with a decreased incidence of early elevated INR or clinically relevant coagulopathy. 


1)      The authors do not report an association between medication use and mortality.  Are the end points of defined trauma induced coagulopathy or clinically relevant coagulopathy as defined in this study valid? 

2)      Is it important to know which specific NSAIDs were being taken?

3)      Should such data be specifically censored for early transfusion secondary to surgically relevant blood loss (non-coagulopathic bleeding as may occur from a splenic injury requiring splenectomy)?

4)      Should we be considering early administration of NSAID medication in the field prior to transport to the hospital?

Please feel free to comment on any or all of the questions. We look forward to hearing from you, the Annals readers. This article can be accessed for free.




Wednesday, November 05, 2014
Moderator: Karl Bilimoria, MD
Featured Article: Hospital Volume and Operative Mortality in the Modern Era by B.N. Reames et al. Ann Surg 2014; 260: 244-251.

The first report of the “volume-outcome” relationship was published in 1979 by Luft and colleagues in the New England Journal of Medicine.  This relationship describes a fairly common sense result: the more you do of something, the better you do it.  Birkmeyer and colleagues subsequently published seminal works demonstrating a volume-outcome relationship for hospitals and for surgeons.  Literally hundreds of studies followed demonstrating that higher surgical volume generally resulted in better outcomes including short-term morbidity and mortality, long-term survival, length of stay, readmissions, patient satisfaction, and virtually any other outcomes.

However, many efforts have been undertaken over the past three decades to improve healthcare quality and safety, and the recent article by LaPar et al in Annals of Surgery suggested that the volume-outcome relationship may be severely attenuated in recent years.  Thus, the authors of the current study, thought leaders in the volume-outcome industry, undertook this evaluation to determine whether the volume-outcome relationship persists in the modern era.

The authors examined national Medicare claims data for the last decade for 8 different high-risk procedures.   Overall, mortality rates generally declined slightly over time as has been seen in many prior studies.  This suggests that safety and quality improvement efforts have had some effect.  However, all eight operations examined had a clear volume-outcome relationship: higher volume was associated with lower mortality rates.  Interestingly, the strength of the association increased over time for 5 of the 8.  This is a novel finding and suggests that the regionalization of complex cases from low-volume to high-volume centers further increased the differences in mortality. 

Thus, despite general improvements in safety and quality (e.g., operative technique, checklists, pay-for-performance, selective referral, and outcomes feedback), there generally remains a considerable mortality benefit for patients to undergo complex surgeries at high-volume centers. 


1. Do these results suggest that we should regionalize all complex surgery to high-volume centers?

2. Melanoma and breast surgery likely would not show a volume-outcome relationship for mortality as the operations are fairly safe.  Should these operations be regionalized?

3. Are there unintended consequences for patient care if complex operations are regionalized?

Answers to these questions can be accessed at "From the editorial office" on the Annals of Surgery home page.

Please feel free to comment on any or all of the questions. We look forward to hearing from you, the Annals readers. This article can be accessed for free.


Sunday, October 05, 2014
Moderator: John Mullen, MD
Featured Article: A Systematic Review of the Effects of Resident Duty Hour Restrictions in Surgery: Impact on Resident Wellness, Training, and Patient Outcomes by Ahmed et al; Ann Surg 2014: 259, 1041.

Ahmed and colleagues conducted a systematic review and meta-analysis of articles published from 1980 – 2013 to evaluate the impact of resident duty hours restrictions in surgery on patient safety, resident well-being, and education.  The authors identified 709 articles addressing one or more of these topics in the fields of general surgery and the surgical subspecialties, of which 135 met the inclusion criteria of the study, and of which only 57 were deemed to be of sufficient quality to conduct further analyses.  All articles examining 16-hour and night float shifts were analyzed separately to assess the effects of these more recent duty hours changes. 


In terms of the impact of resident duty hour restrictions on patient safety, the data are inconclusive, but the perceptions of health care professionals suggest that patients are less safe after the institution of the duty hours limits.  Furthermore, though no significant impact on postoperative mortality has been demonstrated, the majority of studies examining the impact of duty hour restrictions on postoperative morbidity demonstrate an increased risk of complications, particularly in high-acuity patients.


In terms of the impact of resident duty hour restrictions on resident well-being, the 80-hour workweek has lead to an improvement in resident well-being, but the 16-hour duty hours limit for interns has not, especially for more senior trainees to whom much of the work has shifted.


Lastly, in terms of the impact of resident duty hour restrictions on resident education, the majority of studies suggest that resident education has worsened, and objective data such as the increased failure rates on the oral component of the various surgical board examinations since 2003 corroborates this finding.


On the basis of this systematic review, the authors conclude that the implementation of the resident duty hour restrictions in 2003, together with the greater limitations for interns in 2011, has not achieved the goals which they were intended to achieve – namely, improved patient safety, resident well-being, and resident education.  The authors plead for greater flexibility to develop fatigue mitigation strategies tailored to the surgical disciplines in order to preserve their unique training objectives and to optimize patient outcomes.



1.      If the ACGME were to liberalize the current duty hour restrictions, what strategies might your training program institute to support resident wellness measures, such as fatigue mitigation and burnout prevention?


2.      How does your program establish the appropriate balance between the important service functions that residents fulfill and their educational opportunities?


3.      Independent of the duty hour restrictions, given the dramatic expansion of both knowledge and technology in the fields of surgery, it is imperative that we train our residents as efficiently and effectively as possible.  What resources will you need from your hospital and your department to accomplish this?


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.


Saturday, September 06, 2014
Moderator: Gregory D. Kennedy, MD, PhD
Featured Article: Patients’ Perspectives of Care and Surgical Outcomes in Michigan: An analysis using the CAHPS hospital survey. Sheetz, Kyle H.; Waits Seth A.; Girotti, Micah E.; Campbell, Darrell A.; Englesbe, Michael J.  Ann Surg. 2014; 260 (1): 5-9.

In 2001 the Institute of Medicine published their seminal work entitled, “Crossing the quality chasm: a new health system for the 21st century.”(1)  In this report, the authors called for a new agenda that if followed would improve the quality of health care in the United States.  Specifically, they argued that health care should be safe, effective, efficient, timely, equitable and patient centered. 

            The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was developed by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).  The HCAHPS survey is the first standardized survey of patient satisfaction that allows for comparisons of hospitals across the nation.  The goals for the development of the HCAHPS survey were to motivate hospitals to improve the quality of patient centered care provided and to publicly provide hospital scores.  Publicly reported HCAHPS scores are easily accessible for consumers and are easy to interpret.  While patients are somewhat limited in where they can receive care due to insurance providers and costs, when able patients tend to choose providers and hospitals with higher ratings including satisfaction scores on the HCAHPS survey.(2, 3) 

In addition to patient choice driving improvement on surveys, legislation is increasingly linking reimbursement to performance on the HCAHPS survey.  In 2005, the enactment of the Deficit Reduction Act motivated hospitals to publicly report HCAHPS results by requiring hospitals participating in the Inpatient Prospective Payment System (IPPS) to collect and submit HCAHPS data in order to receive full payment. The recent enactment of the Patient Protection and Affordable Care Act in 2010 includes HCAHPS measures in the Value Based Purchasing (VBP) program.  This VBP program ties the payment of IPPS hospitals to clinical processes of care and patient experience.  Performance on HCAHPS surveys are used to determine the patient experience domain of VBP.  HCAHPS scores encompass 30% of VBP performance, which will account for 2% of Medicare reimbursement by 2017.(4)  With these monetary motivations, most health care systems have put emphasis on patient satisfaction surveys.  While delivery of patient centered care is an important part of the goals of improving health care delivery, health care systems cannot lose sight of delivering safe and effective care.  Much work is now focused on determining if performance on these satisfaction surveys correlates with the delivery of safe and effective care.

The article by Sheetz and others utilized the Michigan Surgical Quality Collaborative (MSQC) data to characterize the relationship between HCAHPS performance and risk-adjusted outcomes after surgery.(5)  The MSQC is an association of hospitals in the state of Michigan which has a long history of improving the quality of general and vascular surgical care delivered.  This program is supported by the American College of Surgeons Nation Surgical Quality Improvement Project.  In this study, they used risk-adjusted postoperative outcomes data from the MSQC database combined with HCAHPS data obtained from the Centers for Medicare and Medicaid Services (CMS) that can be downloaded from the Hospital Compare website.(6)

In this study, the authors analyzed data from 32 hospitals including outcomes for over 41,000 patients.  The hospitals were stratified into quintiles of HCAHPS total performance score and outcomes were compared between quintiles.  The authors found a difference in demographics in hospitals with the lowest HCAHPS total performance score (TPS) compared to those with the highest TPS.  For example, patients treated at the hospitals with the highest HCAHPS TPS tended to be older (median age of 75 v 71) and to be listed as part of the white race (15% v 31% nonwhite race) when compared to the hospitals of the lowest quintile.  Interestingly, while the authors found differences between the quintiles in patient comorbidities, the differences appear to be more random and there does not appear to be a difference between the hospitals in the lowest and highest quintiles.

The authors also found a random association between high performance on the HCAHPS survey and measures of patient safety.  They found no significant differences between rates of mortality between low and high HCAHPS performers.  Furthermore, they found no difference in improvement of safety measures over time when stratified by HCAHPS performance.  In other words, hospitals in the lower quintiles of HCAHPS TPS were as likely to improve their surgical outcomes as those hospitals with high performance on the HCAHPS TPS.

The authors conclude that patients’ perspectives of care do not correlate with the incidence of morbidity and mortality after major inpatient surgery.  Because of this lack of correlation, the authors question the use of HCAHPS scores to inform patient decision making and incentivize quality improvement.


1.            Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm : a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001.

2.            Faber M, Bosch M, Wollersheim H, Leatherman S, Grol R. Public reporting in health care: how do consumers use quality-of-care information? A systematic review. Med Care. 2009;47(1):1-8.

3.            Kolstad JT, Chernew ME. Quality and consumer decision making in the market for health insurance and health care services. Med Care Res Rev. 2009;66(1 Suppl):28S-52S.

4.            HCAHPS Fact Sheet.

5.            Sheetz KH, Waits SA, Girotti ME, Campbell DA, Jr., Englesbe MJ. Patients' Perspectives of Care and Surgical Outcomes in Michigan: An Analysis Using the CAHPS Hospital Survey. Ann Surg. 2014;260(1):5-9.

6.            Hospital Compare.


1.       Given the lack of association between patient satisfaction and complications, why should patient satisfaction surveys be used as a measure of quality?

2.       Others have found associations between hospital volume and patient satisfaction.  Why might these associations exist and what is one potential explanation for why Sheetz did not find this association?

3.       What is the demographic variable that is most frequently associated with high patient satisfaction scores, which was also confirmed by Sheetz?  Why might this variable be associated with giving high satisfaction scores?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

About the Author

Justin B. Dimick, MD, MPH
Justin B. Dimick, MD, MPH is the H.K. Ransom Professor of Surgery, Chief of the Division of Minimally Invasive Surgery, and Director of the Center for Healthcare Outcomes & Policy at the University of Michigan. His clinical practice is primarily devoted to advanced laparoscopy, including bariatric surgery. Dr. Dimick’s research, funded by R01 grants from the NIH and AHRQ, focuses on quality measurement, policy evaluation, and large-scale quality improvement interventions. He has more than 200 peer-reviewed publications, including articles in NEJM, JAMA, and other leading clinical journals.