BACKGROUND/RATIONALE:
Approximately 375,000 surgical procedures per year are performed in the VHA, most being monitored by VA Surgical Quality Improvement Program (VASQIP, formerly NSQIP). A study using VASQIP data from FY-04 found 3.1% 30-day mortality, 10.7% at one year, and 43% at five years. While the VASQIP was initially successful in reducing peri-operative morbidity and mortality, further improvement has slowed. To continue improvement, new research must be pursued in two directions, exploiting new sources data and applying improved analytic methods to identify subgroups at risk for adverse outcomes.

OBJECTIVE(S):
The objectives of this study are to a) identify novel predictors of adverse outcomes with a focus on physiologic dynamics, b) Implement and evaluate Atul Gawande's "Surgical Apgar" risk score using VASQIP data, c) compare the predictive capabilities of models incorporating new measures and the Surgical Apgar to the currently used VASQIP models, d) explore additional modeling and classification methods, e) assess whether these additional methods and measures significantly improve predictive performance.

METHODS:
The VASQIP data has been collecting comprehensive pre-operative and outcomes data on a substantial sample of surgeries in VA nationwide since 1994. An ongoing study (VA HSR&D IIR 05-229, PI Dr. Terri Monk) is collecting and standardizing AIMS data from multiple VA facilities and merging it with VASQIP data for approximately 30,000 surgeries. Novel summary measures of the AIMS data will be identified, focusing on physiologic dynamics and will be incorporated into standard predictive models. Additional prediction methods will be applied including classification and regression trees (CART), hybrid CART/logistic regression, random forests, support vector machines, and boosting. Last, Gawande's surgical Apgar will be implemented using the VASQIP data and the relative merits of all methods and predictors will be assessed using cross-validation.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Improved risk modeling and prediction can ultimately result in further reducing the rates of post-operative morbidity and mortality within the VA, thereby positively impacting Veterans' health.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Hollis RH, Graham LA, Richman JS, Deierhoi RJ, Hawn MT. Adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systematic review. American journal of surgery. 2012 Oct 1; 204(4):494-501. [view]
2. Pletcher MJ, Vittinghoff E, Kalhan R, Richman J, Safford M, Sidney S, Lin F, Kertesz S. Association between marijuana exposure and pulmonary function over 20 years. JAMA. 2012 Jan 11; 307(2):173-81. [view]
3. Altom LK, Deierhoi RJ, Grams J, Richman JS, Vick CC, Henderson WG, Itani KM, Hawn MT. Association between Surgical Care Improvement Program venous thromboembolism measures and postoperative events. American journal of surgery. 2012 Nov 1; 204(5):591-7. [view]
4. Moorman JR, Delos JB, Flower AA, Cao H, Kovatchev BP, Richman JS, Lake DE. Cardiovascular oscillations at the bedside: early diagnosis of neonatal sepsis using heart rate characteristics monitoring. Physiological measurement. 2011 Nov 1; 32(11):1821-32. [view]
5. Pisu M, Kratt P, Faught E, Martin RC, Kim Y, Clements K, Knowlton R, Funkhouser E, Richman JS. Geographic variation of epilepsy for older Americans: how close to the geographic variation of stroke? Epilepsia. 2012 Dec 1; 53(12):2186-93. [view]
6. Toneva GD, Deierhoi RJ, Morris M, Richman J, Cannon JA, Altom LK, Hawn MT. Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery. Journal of the American College of Surgeons. 2013 Apr 1; 216(4):756-62; discussion 762-3. [view]
7. Cannon JA, Altom LK, Deierhoi RJ, Morris M, Richman JS, Vick CC, Itani KM, Hawn MT. Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections. Diseases of The Colon and Rectum. 2012 Nov 1; 55(11):1160-6. [view]
8. Singh JA, Houston TK, Ponce BA, Maddox G, Bishop MJ, Richman J, Campagna EJ, Henderson WG, Hawn MT. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis care & research. 2011 Oct 1; 63(10):1365-74. [view]
9. Hawn MT, Vick CC, Richman J, Holman W, Deierhoi RJ, Graham LA, Henderson WG, Itani KM. Surgical site infection prevention: time to move beyond the surgical care improvement program. Annals of surgery. 2011 Sep 1; 254(3):494-9; discussion 499-501. [view]
10. Hawn MT, Graham LA, Richman JR, Itani KM, Plomondon ME, Altom LK, Henderson WG, Bryson CL, Maddox TM. The incidence and timing of noncardiac surgery after cardiac stent implantation. Journal of the American College of Surgeons. 2012 Apr 1; 214(4):658-66; discussion 666-7. [view]
11. Hawn MT, Richman JS, Vick CC, Deierhoi RJ, Graham LA, Henderson WG, Itani KM. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA surgery. 2013 Jul 1; 148(7):649-57. [view]
12. Richman JS, Hosokawa PW, Min SJ, Tomeh MG, Neumayer L, Campbell DA, Henderson WG, Hawn MT. Toward prospective identification of high-risk surgical patients. The American surgeon. 2012 Jul 1; 78(7):755-60. [view]
13. Kertesz SG, Khodneva Y, Richman J, Tucker JA, Safford MM, Jones B, Schumacher J, Pletcher MJ. Trajectories of drug use and mortality outcomes among adults followed over 18 years. Journal of general internal medicine. 2012 Jul 1; 27(7):808-16. [view]

Conference Presentations

1. Richman JS, Henderson WG, Itani LM, Vick CC, Hawn MT. Association between Perioperative Beta-blocker Use and Surgical Outcomes. Paper presented at: American College of Surgeons Annual Surgical Forum Session; 2012 Oct 3; Chicago, IL. [view]
2. Richman JS. Towards Prospective Identification of High-Risk Surgical Patients. Paper presented at: Southeastern Surgical Annual Congress; 2012 Feb 13; Birmingham, AL. [view]

DRA: Health Systems Science
DRE: Treatment - Comparative Effectiveness, Technology Development and Assessment
Keywords: none
MeSH Terms: none