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Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot

Wandling, Michael W. MD; Ko, Clifford Y. MD; Bankey, Paul E. MD, PhD; Cribari, Chris MD; Cryer, H. Gill MD, PhD; Diaz, Jose J. MD; Duane, Therese M. MD; Hameed, S. Morad MD; Hutter, Matthew M. MD; Metzler, Michael H. III MD; Regner, Justin L. MD; Reilly, Patrick M. MD; Reines, H. David MD; Sperry, Jason L. MD; Staudenmayer, Kristan L. MD; Utter, Garth H. MD; Crandall, Marie L. MD; Bilimoria, Karl Y. MD; Nathens, Avery B. MD, PhD

Journal of Trauma and Acute Care Surgery: November 2017 - Volume 83 - Issue 5 - p 837–845
doi: 10.1097/TA.0000000000001670
Original Articles
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BACKGROUND Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered.

METHODS Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases.

RESULTS Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions.

CONCLUSION This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.

LEVEL OF EVIDENCE Care management, level IV; Epidemiologic, level III.

Supplemental digital content is available in the text.

From the Department of Surgery (M.W.W., K.Y.B.), Northwestern University Feinberg School of Medicine; Division of Research and Optimal Patient Care, (M.W.W., C.Y.K., K.Y.B., A.B.N.), American College of Surgeons, Chicago, IL; Department of Surgery (C.Y.K.), University of California-Los Angeles; Department of Surgery (C.Y.K.), VA Greater Los Angeles Healthcare System, Los Angeles, CA; Division of Acute Care Surgery, Department of Surgery (P.E.B.), University of Rochester Medical Center, Rochester, NY; Division of Acute Care Surgery, Department of Surgery (C.C., M.H.M.), Medical Center of the Rockies, University of Colorado Health, Loveland, CO; Department of Surgery (H.G.C.), Ronald Reagan UCLA (University of California, Los Angeles) Medical Center, UCLA David Geffen School of Medicine, Los Angeles, CA; Division of Acute Care Surgery, Program in Trauma (J.J.D.), R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; Department of Surgery (T.M.D.), John Peter Smith Health Network, Fort Worth, TX; Section of Trauma and Acute Care Surgery, Department of Surgery (S.M.H.), University of British Columbia, Vancouver, BC, Canada; Department of Surgery (M.M.H.), Massachusetts General Hospital, Boston, MA; Department of Surgery (J.L.R.), Scott and White Memorial Hospital, Temple, TX; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery (P.M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,; Department of Surgery (H.D.R.), Inova Fairfax Hospital, Falls Church, VA; Division of Trauma and General Surgery, Department of Surgery (J.L.S.), University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Surgery (K.L.S.), Stanford University, Stanford; Department of Surgery (G.H.U.), University of California, Davis, Medical Center, Sacramento, CA; Department of Surgery (M.L.C.), University of Florida College of Medicine-Jacksonville, Jacksonville, FL; and Department of Surgery (A.B.N.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

Submitted: September 11, 2016, Revised: June 16, 2017, Accepted: July 4, 2017, Published online: August 12, 2017.

Presentations: This paper was a podium presentation at the 75th Annual Meeting of the American Association for the Surgery of Trauma on September 16, 2016.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Michael W. Wandling, MD, MS, Department of Surgery, Northwestern University Feinberg School of Medicine, 251 East Huron, Galter 3-150, Chicago, IL 60611; email:

© 2017 Lippincott Williams & Wilkins, Inc.