The prospect of surgery is not easy or pleasant for anyone. Uncertainty can loom large. What could go wrong? How will I emerge from a bodily intrusion, however necessary it may be?
An unexpected illness intensifies these questions. Anne Thulson found herself in that position in May 2020 when she was diagnosed with non-small cell lung cancer that had spread to her bones.
As a non-smoker, Thulson was shocked. She was active, with a satisfying full-time job at Metro State University of Denver teaching art and art education to students learning to teach it to others. She’d felt little discomfort other than some minor rib pain she attributed to yoga or gardening.
“I didn’t feel bad. It came out of the blue,” Thulson said.
Her condition improved under the care of Dr. Tejas Patil at the UCHealth Cancer Center – Anschutz Medical Campus. Patil prescribed Tagrisso, an oral medication that targets the gene mutation driving Thulson’s cancer. The treatment banished the cancer from Thulson’s bones, making her a candidate for surgery to remove the remaining cancer from the upper lobe of her left lung. A tumor board team at the Cancer Center recommended that to Thulson and her husband, Peter.
To weigh their options, the couple met at the UCHealth Thoracic Surgery Clinic – Anschutz Medical Campus with Dr. Robert Meguid, associate professor of Cardiothoracic Surgery with the University of Colorado School of Medicine.
After 30 minutes of discussion with Meguid, Anne was confident in choosing surgery.
“Everything was crystal clear,” she said. “I’m doing this.”
Improving surgical outcomes
She was quick to praise Meguid’s patience and openness in answering her questions, but the real key to her decision was a tool Meguid and a team of colleagues developed to assess patients’ surgical risks and clearly explain them.
Dubbed SURPAS (Surgical Risk Preoperative Assessment System), the system draws on clinical information from over 6 million surgeries performed in some 700 participating hospitals compiled in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The goal: predict an individual’s surgical risk of key complications, like infection and stroke. The predictions are based on factors that increase risk, such as age, functional status, and type of surgery. With SURPAS, patients get a printed handout with easy-to-grasp picture representations of their complication risk versus the national average.
Meguid, who began developing SURPAS with colleagues soon after arriving at CU in 2012, said the idea for it emerged from his experiences with patients and their families.
“It dawned on me that patients and their families were not getting a good idea of the risk that [an individual] was going to undergo when they were going to go through surgery,” he said.
Meguid said he uses SURPAS to inform all of his pre-surgical discussions with patients.
“It’s been a great way to improve patient engagement,” he said. “Patients greatly appreciate the elaboration of their risk in an understandable manner.”
Much-needed assist to patients and providers
Anne Thulson said the “concrete” presentation of her risk eased her anxiety in a medical setting that could otherwise be fogged with unfamiliar medical terms.
“It’s not like I can’t understand the words, but in that situation, where you are feeling vulnerable and scared [the explanation] had a reassuring quality,” she said.
Meguid emphasized that most providers assess their patients’ surgical risk, but do so individually, leaving a “huge amount of variability” in their approaches. SURPAS aims to standardize the approach, which helps not only patients, but also providers, he maintained.
“SURPAS also came from the idea that if we as providers better understand the risks of specific complications, then we can prepare better, either pre-op, to optimize a patient, or to use our knowledge of their specific risks to guide them in their post-operative care,” he said.
For example, Meguid explained, an accurate pre-op risk assessment allows the hospital to better allocate its resources to meet the needs of each patient, such as readying ICU beds or telemetry units to monitor those at risk for heart attack.
A level playing field for comparing outcomes
A standardized approach to assessing risk also allows surgeons and hospitals to compare more accurately their outcomes to one another, said Dr. William Henderson, a biostatistician with the CU Department of Surgery’s Surgical Outcomes and Applied Research (SOAR) program. Henderson led the development of the ACS NSQIP database.
An important idea behind NSQIP was that a set of key surgical risk factors would help to “level the playing field” so that surgeons had a meaningful way to appraise their outcomes and either make changes or stick with successful techniques, Henderson said. That is, surgeons handling complex surgical cases could compare their outcomes to other surgeons doing similar cases, after adjusting for differences in patient characteristics.
“Surgeons were initially reluctant to join [NSQIP], but they made efforts to improve,” Henderson said. “Standardized care improved outcomes, and we also learned from hospitals that had good outcomes.”
Impact Clinic puts prehabilitation into practice
Information from SURPAS can also be used to prepare higher-risk patients for surgery. That’s been underway for more than two years at the UCHealth Pre-procedural Impact Clinic, which serves patients from UCHealth’s Poudre Valley Hospital in Fort Collins and Medical Center of the Rockies in Loveland.
The clinic serves elective surgery patients referred by their surgeons or service lines. The clinic uses SURPAS to help them understand their surgical risk and involve them in taking the steps necessary to prepare for surgery. That might mean losing weight, quitting smoking, improving their cardiopulmonary function, increasing their physical strength, managing their blood sugars and so on.
“The goal is to educate patients to become participants in their own health care outcomes,” said Dr. Annette Vizena, an anesthesiologist who is the clinic’s medical director. She said patients who address their pre-operative risks are less likely to have post-operative complications – and, she hopes, may continue to maintain the positive changes they made preparing for surgery.
“We need a level of engagement – patients who are excited about improving their health care and excited about having some control over their health care,” Vizena said. “[SURPAS] is one way to do both.”
Patients referred to the Impact Clinic must have at least three weeks to get ready for surgery, Vizena said. The specific requirements vary with their level of risk, and the clinic coordinates care based on their specific needs, such as cardiopulmonary workups, physical therapy, sleep studies, and so on.
The assessment routine helps to drive conversations between the clinic and surgeons about the most appropriate course of care for a patient and the level of risk surgeons feel they can accept for their patients, Vizena said.
“The clinic may help surgeons reevaluate patient’s co-morbidities and facilitate mitigation of their risks,” Vizena said.
Growth and improved outcomes for Impact Clinic
Since officially launching in January 2019, the Impact Clinic has steadily grown. Through the end of April, it was on track to see 1,300 to 1,600 patients for 2021, a significant increase over the previous year, and has added a third nurse practitioner to accommodate the volume.
Vizena said the clinic’s original goal was to save resources by minimizing surgery cancellations, decreasing hospital length of stay and preventing unnecessary post-operative emergency department visits and hospital readmissions.
But data show that the clinic’s work may also help to improve the quality of care. For example, for five of six safety indicators from the federal Agency for Healthcare Research and Quality (AHRQ) – such as post-operative respiratory failure and sepsis rates – the clinic’s actual rates were significantly lower than what was expected.
There are undoubtedly many reasons for that success, but Vizena believes SURPAS has been a useful tool for the clinic and the hospitals in improving care.
“We’ve used it as a motivational tool to drive the patient to double down and improve their health care before going to surgery,” she said.
Computer-driven help in finding surgical complications
Back on the Anschutz Medical Campus, Meguid noted he and his SOAR colleagues are working on extending the concept of SURPAS from assessing risk to identifying a set of post-operative complications in patients – with the help of artificial intelligence.
A five-year AHRQ grant co-led by Dr. Kathryn Colborn, a biostatistician with the Department of Surgery, and Meguid, drives the work. The idea of the project, now in year one, is to develop a system that combs the UCHealth electronic health record for surgical patients with specific complications, including surgical and urinary tract infections, sepsis and pneumonia.
It’s a deep, but not blind, dive into a nearly bottomless data repository. The approach relies on clues to complications, like ICD-10 disease classification and CPT procedural codes; lab test results; and specific antibiotics and other medications administered two to 30 days after surgery, Colborn said.
The concept isn’t new; nurses have manually extracted such data from patient charts for years. The grant aims to use machine learning and artificial intelligence – in simplified terms, using computer systems to analyze data and identify specific patterns within a mass of detail – to do that heavy lifting electronically.
“We are testing the machine’s ability to classify outcomes versus nurses’ ability to classify outcomes, which is the gold standard,” Colborn said, emphasizing that the goal is not to replace nurses, but rather to free them to analyze the cases that are most difficult to determine an outcome.
Colborn, along with a team of colleagues that includes Meguid and Henderson, laid the groundwork for the new grant with a pair of preliminary projects to test and validate the concept. The studies each looked at thousands of patients who had surgery at University of Colorado Hospital on the Anschutz Medical Campus. The goal: use variables that indicated risk for urinary tract infections (UTIs) and surgical site infections (SSIs) to electronically ferret out the patients who had them. With that guide, the system pored through the EHR and in both cases accurately identified both UTIs and SSIs when the results were compared to outcomes data from NSQIP.
With the new grant, the team is also working with Vanderbilt University on using natural language processing (NLP) as another tool to scour patient records for signs of complications, Colborn said. With NLP, which uses computer programs to learn and understand human text and speech, the system could pick up additional relevant information from providers’ text notes embedded in the medical charts.
Ultimately the whole thrust is not simply to develop a system that can handle massive amounts of data quickly, but one that can give surgeons reliable outcomes data that are accurate and in a form that they can use to improve their practice, Colborn said.
Listening (better) to patients
The improvement also rests on hearing how patients perceive their own care. The SOAR team recently published a pilot study that tested using patient-reported outcomes (PROs) in some 400 surgical patients, with the idea of incorporating these measures consistently in plans of care.
Understanding PROs relies on standardized measures that help providers glean from patients how they perceive the care they receive. Do they still have pain after surgery? Has their ability to function in their everyday lives improved? If not, how can those concerns be addressed?
“We want to know functional outcomes in six months to a year,” Meguid said. As of now, UCHealth does not have a PRO database, he acknowledged. “But that is one of the things where we have potential to guide policy at the national level, and it could be hugely advantageous to patients.”
In sum, Meguid said his work with SOAR “has opened my eyes to the reality that patients are absolutely the most critical people in guiding care. We need to focus on what our patients want and not on old-fashioned metrics that surgeons and other physicians came up with for patients.”
Anne Thulson would surely add that Meguid was critical in guiding her care. In late May, he performed successful robotic thoracoscopic surgery to remove her cancerous lung lobe. She’s now cancer-free, is recovering and plans a bike trip to the West Coast with Peter in July.
“Dr. Meguid gave us information that was specific and easy to understand,” she said. “I came with a list of questions, but realized that so many of them had already been answered.”