Y. Alimi1, A. Asemota1, R. Stone3, B. Safar1, S. Fang1, S. Gearhart1, J. Efron1, E. Wick2 3Johns Hopkins University,Department Of Obstetrics And Gynecology,Baltimore, MD, USA 1Johns Hopkins University,Department Of Surgery,Baltimore, MARYLAND, USA 2UCSF,Department Of Surgery,San Francisco, CALIFORNIA, USA
Introduction: There is intense pressure to deliver high value surgical care by optimizing patient outcomes and reducing costs. Surgical site infections (SSIs) are the leading cause of morbidity after colorectal surgery. Most of the quality improvement efforts have focused on general surgeons but other surgical specialists, particularly gynecologic oncologists also perform colorectal resections as part of their practice. Therefore, the objective of this study is to assess the impact of surgeon specialty on morbidity after colorectal surgery to determine the potential impact of broader, transdisciplinary collaboration in colorectal quality improvement.
Methods: The American College of Surgeons National Surgical Quality Improvement Program (Jan 1, 2006 – Dec 31, 2013) was used to identify female patients undergoing colorectal surgery with a diagnosis of a solid organ malignancy. Logistic regression was used to analyze patient and procedure factors in cases with and without SSIs. The primary surgeon specialty was categorized as either general (general, colorectal or surgical oncologist) or gynecologic. Proportion odds ratio of any documented SSI (Superficial, Deep, Organ Space) and readmission occurrence; relative risk hospital length of stay. The National inpatient sample was used to project potential cost savings.
Results: Among the 108,415 patients identified undergoing colorectal surgery for solid organ malignancy, 106,130 were operated on by general surgeons and 2,285 by gynecologists. Patients operated on by gynecologists were, compared to those operated on by general surgeons: younger (64.1 vs 67.3 yrs, p<0.001), more likely to have contaminated/dirty wounds (12.2% vs 9.1%, p<0.001), be more complex (ASA 3/4 61.6% vs 57.5%, p<0.001), have longer mean operative time (264.0 vs 166.2 min, p<0.001), less likely to receive preoperative radiation (3.2% vs 0.57%, p = 0.002); but more likely to receive preoperative chemotherapy (1.9% vs 2.5%, p<0.001). The unadjusted rate of SSIs was higher for cases performed by gynecologists than for cases performed by general surgeons (17.3 vs 10.9, p <0.001). On multivariate analysis, patients operated on by gynecologists remained more likely to have SSIs than did their general surgery counterparts [any SSI: 1.15 (1.05 – 1.27), p <0.001].
Conclusion: Although gynecologists only perform a small subset of colorectal surgery procedures, their patients are at higher risk of developing an SSI. These elevated rates of infections results in a potential cost savings of $31,254,070. Further study is needed to understand if this difference is related to a gap in translating best practice evidence into practice, or to surgical technique.
