Notable Faculty and Staff Contributions to Successive Quality Conferences

June 2016

SHEA Conference

Topic areas at the Society for Healthcare Epidemiology of America's (SHEA) Spring 2016 Conference in Atlanta, May 18-21, spotlighted long-term care, research methods, clinical microbiology, patient safety and quality, and implementation science. Joe Sharma, MD, director of thyroid and endocrine surgery for Emory University Hospital and the hospital's National Surgical Quality Improvement Project (NSQIP) Champion, collaborated on the meeting's top abstract with three investigators from the Division of Healthcare Quality Promotion of the CDC: Rishi Parikh, MPH, Daniel Pollock, MD, and Jonathan Edwards, MStat.

"Is there Room for Prevention? Examining the Effect of Outpatient Facility Type on the Risk of Surgical Site Infection" compared the risk for surgical site infection (SSI) following surgical breast procedures between patients whose procedures were performed in ambulatory surgery centers (ASCs) and those whose procedures were performed in hospital-based outpatient facilities. SSIs are among the most common healthcare-associated infections in the U.S., and are a major cause of morbidity, hospital readmission, and mortality.

"Although SSIs among inpatients have received considerable attention, infections and other adverse outcomes in the outpatient setting have been studied less frequently despite the high volume and increasing use of outpatient surgeries," says Sharma. "Breast procedures are among the most common surgeries performed in an outpatient setting, especially ambulatory surgery centers, and contribute to a significant proportion of outpatient SSIs."

The team compiled SSI numerator, denominator, and covariate data for outpatient breast surgeries reported to the CDC's National Healthcare Safety Network (NHSN) by 139 ASCs and 242 hospitals from 2010–2014. They found that SSI risk following breast procedures was significantly lower among ASC patients compared to hospital-based outpatients, with the age of the patient being the only significant effect modifier. For patients aged 51 or under, the adjusted risk ratio was 0.36, and for patients older than 51 years, the adjusted risk ratio was 0.32

"These findings should be placed in the context of study limitations, including the possibility of incomplete ascertainment of SSIs and shortcomings in the data available to control for differences in patient case-mix," Sharma says. "Additional studies are needed to better understand the role of procedural settings in SSI risk following breast procedures and to identify prevention opportunities."

3rd Annual Advancing Healthcare Quality Research at Emory University Conference

Subtitled "quality research to accelerate value and innovation in health care," this May 18th conference was coordinated by Rachel Patzer, PhD, MPH, director of the Emory Transplant Health Services and Outcomes Research Program, and Leslee Shaw, PHD, co-director of the Emory Clinical Cardiovascular Research Institute. Dr. Patzer was also a team member for four posters that analyzed waitlist and disparities issues in kidney transplantation.

Two of the top three posters selected for oral presentation involved Emory Surgery faculty. Virginia Shaffer, MD, of the Division of General and GI Surgery, presented "Home Health Pilot Decreases Readmissions in High Risk Ileostomy Patients," and received a Top Scoring Abstract Award. "Decreasing Length of Stay and Cost in Colorectal Surgery Using an Enhanced Recovery Program," authored by a team led by Patrick Sullivan, MD, of the Division of Surgical Oncology, was also presented.

Shaffer's study aimed to lower the 30-day readmission rate for ileostomy patients released from Emory University Hospital (EUH). Prior to the study, the ileostomy 30-day readmission rate reported by EUH to the University HealthSystem Consortium (UHC) ranged from 15-33%. The study team hoped to reduce that rate by 15% in five months by partnering with the home health program Visiting Nurse Health System (VNHS).

The EUH team and VNHS nurses developed a set of standardized discharge orders that included red-flags for conditions that, when observed, encouraged nurses to contact the EUH surgeons so that corrective action could be taken before possible readmission. In addition, weekly 15 minute discussions were implemented between the EUH and VNHS teams. The readmission rate for VNHS ileostomy patients decreased from 19% to 7%, and the study was extended to one year. By the end of the study, the total sum cost of readmissions for non-VNHS patients receiving standard of care increased by 58.3%. For patients in the pilot, readmission costs decreased by 77.6%. The study is now in the process of being expanded.

In addition to four other posters presented by Emory Surgery faculty, vascular surgeon Shipra Arya, MD, was a plenary speaker, presenting "Peripheral Arterial Disease: A VA Population Experience." Her talk described efforts to develop a reliable algorithm for identifying PAD patients in the VA population, who are often misclassified, and the use of statins to reduce limb loss and mortality in PAD.

9th Annual Emory Healthcare Quality Conference

"Reducing Length of Stay after Carotid Endarterectomy" was one of two posters written by Emory Department of Surgery-affiliated authors that were declared finalists in the top poster category at this conference on June 6. Of the 130 posters presented, only 29 were picked as finalists.

The poster illustrated a project in which lead author and research informatics specialist Sebastian Perez, MSPH; senior author Yazan Duwayri, MD, surgeon and chief quality officer of the Division of Vascular Surgery and Endovascular Therapy; and their coauthors set a goal of decreasing length of stay (LOS) greater than one-day for patients following carotid endarterectomy (CEA) at Emory University Hospital (EUH).

CEA prevents stroke by opening or cleaning the carotid artery, and is the most commonly performed vascular surgical procedure in the United States. LOS has been shown to correlate with CEA perioperative complications and midterm mortality, and has been classified by CMS as a measure for the Physician Quality Reporting System (PQRS). Even in the absence of complications, LOS is associated with increased hospital costs.

By analyzing elective CEA procedures captured in EUH's NSQIP quality database between January 2010 through September 2014, the team established that an average of 46% of patients experienced LOS greater than one-day, and decided to work towards reducing that number to less than 40%. The team then standardized several CEA perioperative protocols and informed all perioperative personnel. These guidelines included reducing the use of urinary catheters, encouraging regional anesthesia vs. general anesthesia, educating trainees about removing drains during first post-op rounds, and other target actions.

By mid-2015, LOS greater than one day fell from 46% for CEA patients to less than 10%, thereby reducing hospital costs and improving hospital bed availability for new patients. The study concluded that eliminating excessive and unnecessary postoperative stays after elective CEA could be done by modifying perioperative variables through a team approach.  

Perez was also lead author of the second poster, 'Reducing Operative Costs for Gastric Bypasses at Emory University Hospital." The gastric bypass OR cost reduction team, led by senior author Edward Lin, DO, chief of the Division of General and GI Surgery and surgical director of the Emory Bariatric Center, set a goal of reducing the average $11,700 cost per case of gastric bypass by 10%.

Upon reviewing operating room data for gastric bypass procedures performed at EUH and EUHM between September 2013 to August 2014, the team found that one surgeon had significantly lower expenses due to using a less expensive stapler. When the team tracked outcomes and determined that the stapler functioned as well as its costlier cousins, the other surgeons switched to the cheaper stapler in October 2014, quickly lowering the cost of the procedure by a mean of $2,000.

The team concluded that careful analysis of costs per case can effectively identify opportunities for cost reductions and quality improvements, and that concentrating on a process or procedure that is already partially standardized simplifies the task of identifying opportunities for variation. They also found that surgeons will not only modify their routine to include cost-effective solutions when presented with proper data, but can be the ideal drivers of change within their practice.

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