Special section: Connecting quality to compensation

Surgeon compensation: “Pay for performance,” the American College of Surgeons National Surgical Quality Improvement Program, the Surgical Care Improvement Program, and other considerations

The primary goal of this study is to determine trends in patient 30-day postoperative readmission and reoperation following elective posterior lumbar fusion (PLF) between 2006–2016.

We retrospectively identified patients in the ACS-NSQIP database who underwent elective, non-emergent PLF from 2006 to 2016. Descriptive statistical and time trend analyses were performed on demographic, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission within 30 days and secondary outcomes were medical and surgical complications reported within 30 days of the operation. Linear and binary logistic regression were performed to adjust for patient specific confounders.

A total of 26,265 patients underwent elective PLF over the study period. Overall case volume increased from 0.02 % (n = 27) of all total cases in ACS-NSQIP in 2006 to 0.82 % (n = 8228) in 2016. Mean age increased from 51.22 [SE: 2.77] in 2006 to 60.57 [SE: 0.14] in 2016 (p < 0.001). For comorbidities, there was a decrease in smokers and increase in hypertension requiring medication and ASA Class 3. A readmission rate of around 5% per year did not vary significantly over the study period (p = 0.531). Unplanned reoperations declined from 7.4 % in 2006 to 3.1 % in 2016, but the overall trend from 2006 to 2016 was not statistically significant (p = 0.139). Reoperation demonstrated a significant association between age and BMI, but did not vary with admission year. Surgical site infections followed by hematomas and seromas were listed as the most common cause of both readmission and reoperation in PLF patients.

Since the establishment of the ACS-NSQIP database, reoperation rates due to complications declined after 2006 and remained relatively stable. Readmissions were added as a variable in 2011 and had no significant changes over time.

Anterior cervical discectomy and fusion (ACDF) is the most common procedure for the treatment of degenerative cervical conditions. The objective of this study is to determine time-dependent trends in patient outcomes following ACDF for degenerative disease from 2006 to 2016.

We used the National Surgical Quality Improvement Program (NSQIP) database to retrospectively review all patients who underwent elective ACDF between 2006 and 2016. A descriptive statistical analysis followed by time trend analysis was performed on demographics, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission rates. Secondary outcomes were medical and surgical complications reported within 30 days of operation.

A total of 36,854 patients underwent elective ACDF from the 2006 to 2016 NSQIP database. Mean age increased from 48.19 years [standard error: 1.49] in 2006 to 54.08 years [standard error: 0.12] in 2016 (P < 0.001). There was a significantly greater number of outpatient procedures from 2012 to 2016 (P < 0.001). The proportion of patients with American Society of Anesthesiologists classes 3/4 significantly increased over time (P < 0.001, P < 0.001, P = 0.005, respectively). Readmission risk, first documented in NSQIP in 2011, increased over time from 2011 to 2016 (P < 0.001). Unplanned reoperations have remained consistent at about 1.4%. Postoperative complications varied over time with no discernable patterns or trends.

Since the establishment of the NSQIP database, there have been no considerable improvements in reoperation or postoperative complication rates based on available data, however, there have been increased rates of readmission. Changes in data collection and an aging patient population with greater burden of comorbidities could confound these trends.

The arthroplasty population increasingly presents with comorbid conditions linked to elevated risk of postsurgical complications. Current quality improvement initiatives require providers to more accurately assess and manage risk presurgically. In this investigation, we assess the effect of metabolic syndrome (MetS), as well as the effect of body mass index (BMI) within MetS, on the risk of complication following hip and knee arthroplasty.

We queried the American College of Surgeons National Surgical Quality Improvement Program database for total hip or knee arthroplasty cases. Thirty-day rates of Centers for Medicare and Medicaid Services (CMS)-reportable complications, wound complications, and readmissions were compared between patients with and without a diagnosis of MetS using multivariate logistic regression. Arthroplasty cases with a diagnosis of MetS were further stratified according to World Health Organization BMI class, and the role of BMI within the context of MetS was assessed.

Of the 107,117 included patients, 11,030 (10.3%) had MetS. MetS was significantly associated with CMS complications (odds ratio [OR] = 1.415; 95% confidence interval [CI], 1.306-1.533; P < .001), wound complications (OR = 1.749; 95% CI, 1.482-2.064; P < .001), and readmission (OR = 1.451; 95% CI, 1.314-1.602; P < .001). When MetS was assessed by individual BMI class, the MetS + BMI >40 group was associated with significantly higher risk of CMS complications, wound complications, and readmission compared to the lower MetS BMI groups.

MetS is an independent risk factor for CMS-reportable complications, wound complications, and readmission following total joint arthroplasty. The risk attributable to MetS exists irrespective of obesity class and increases as BMI increases.

As a widely used absorbable suture with antibacterial property, triclosan- coated polyglactin suture (Vicryl Plus) has been extensively utilized to reduce the occurrence rate of surgical site infections (SSIs) in orthopaedic surgery. However, the potential toxicity and side-effects of triclosan raised increasing concerns about its biological safety. This study aimed to investigate the antimicrobial activity and biocompatibility of quaternised chitosan-coated Vicryl suture (HV) both in vitro and in vivo.

In this study, a modified chitosan derivate, (hydroxypropyltrimethyl ammonium chloride chitosan, HACC), was coated over the surface of the absorbable Vicryl suture. Two standard bacteria strains, Staphylococcus epidermidis (ATCC35984) and methicillin-resistant Staphylococcus aureus (ATCC43300), were selected to evaluate bacterial adhesion and biofilm formation on the sutures at 6, 24 and 48 h in vitro. Additionally, human skin-derived fibroblasts cells were used to test the cytocompatibility of the sutures. Furtherly, sutures contaminated with methicillin-resistant S. aureus were implanted subcutaneously in SD rats in order to confirm the in vivo antibacterial performance and biocompatibility.

We found that HACC-coated Vicryl suture (HV) exhibited significant anti-bacterial effects on the two tested strains. The bacterial attachment and biofilm formation on the surface of the HV sutures were found to be comparable to that of Vicryl Plus sutures (VP). Moreover, all the four tested sutures presented good cytocompatibility with human skin-derived fibroblasts cells. Histology and immunohistochemistry results indicated that the infections and inflammations were significantly inhibited around the HV and VP sutures.

In general, the present study demonstrated that the quaternised chitosan coating is a flexible and cost-effective alternative strategy to prevent the suture related surgical site infections in orthopaedic practices.

Perioperative hair removal using clippers requires lengthy cleanup to remove loose hairs contaminating the operative field. We compared the amount of hair debris and associated microbiologic contamination produced during clipping of surgical sites using standard surgical clippers (SSC) or clippers fitted with a vacuum-assisted hair collection device (SCVAD).

Trained nurses conducted bilateral hair clipping of the chest and groin of 18 male subjects using SSC or SCVAD. Before and during clipping, measurements of particulate matter and bacterial contamination were evaluated on settling plates placed next to each subject's chest and groin. Skin condition after clipping and total clipping/cleanup times were compared between SSC and SCVAD.

The microbial burden recovered from residual hair during cleanup in the SSC group was 3.9 log₁₀ CFU and 4.6 log₁₀ CFU from respective, chest, and groin areas. Use of the SCVAD resulted in a significant (P < .001) reduction in both residual hair and microbial contamination within the operative field compared with SSC.

Use of SCVAD resulted in significant (P < .001) reduction in total time required to clip and clean up residual hair contaminating the operative field compared with standard practice (ie, SSC), eliminating the need to physically remove dispersed hairs, which can harbor a significant microbial burden, from within the operative field.