{"id":40705,"date":"2021-07-23T13:27:17","date_gmt":"2021-07-23T19:27:17","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=40705"},"modified":"2023-06-29T10:48:50","modified_gmt":"2023-06-29T16:48:50","slug":"improving-surgical-outcomes-by-identifying-patient-risk-factors-prior-to-surgery","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/improving-surgical-outcomes-by-identifying-patient-risk-factors-prior-to-surgery\/","title":{"rendered":"Improving surgical outcomes by identifying patient risk factors prior to surgery"},"content":{"rendered":"
<\/div>

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?<\/p>\n

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.<\/p>\n

\"Dr.
Dr. Robert Meguid began work on the SURPAS program to improve surgical outcomes in 2012, with the aim of helping patients understand their surgical risk factors. Photo by UCHealth.<\/figcaption><\/figure>\n

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\u2019d felt little discomfort other than some minor rib pain she attributed to yoga or gardening.<\/p>\n

\u201cI didn\u2019t feel bad. It came out of the blue,\u201d Thulson said.<\/p>\n

Her condition improved under the care of Dr. Tejas Patil<\/a> at the UCHealth Cancer Center \u2013 Anschutz Medical Campus<\/a>. Patil prescribed Tagrisso, an oral medication that targets the gene mutation driving Thulson\u2019s cancer. The treatment banished the cancer from Thulson\u2019s 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.<\/p>\n

To weigh their options, the couple met at the UCHealth Thoracic Surgery Clinic \u2013 Anschutz Medical Campus<\/a> with Dr. Robert Meguid<\/a>, associate professor of Cardiothoracic Surgery with the University of Colorado School of Medicine<\/a>.<\/p>\n

After 30 minutes of discussion with Meguid, Anne was confident in choosing surgery.<\/p>\n

\u201cEverything was crystal clear,\u201d she said. \u201cI\u2019m doing this.\u201d<\/p>\n

\"Anne
Anne Thulson says she appreciated the explanations of the risk factors prior to her surgery for lung cancer at UCHealth. Photo courtesy of Anne Thulson.<\/figcaption><\/figure>\n

Improving surgical outcomes<\/strong><\/h2>\n

She was quick to praise Meguid\u2019s 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\u2019 surgical risks and clearly explain them.<\/p>\n

Dubbed SURPAS<\/a> (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<\/a>. The goal: predict an individual\u2019s 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.<\/p>\n

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.<\/p>\n

\"Biostatistician
Biostatistician Katie Colborn leads a five-year project at UCHealth that uses the electronic health record to pinpoint surgical complications. Photo by UCHealth.<\/figcaption><\/figure>\n

\u201cIt 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,\u201d he said.<\/p>\n

Meguid said he uses SURPAS to inform all of his pre-surgical discussions with patients.<\/p>\n

\u201cIt\u2019s been a great way to improve patient engagement,\u201d he said. \u201cPatients greatly appreciate the elaboration of their risk in an understandable manner.\u201d<\/p>\n

Much-needed assist to patients and providers<\/strong><\/h2>\n

Anne Thulson said the \u201cconcrete\u201d presentation of her risk eased her anxiety in a medical setting that could otherwise be fogged with unfamiliar medical terms.<\/p>\n

\u201cIt\u2019s not like I can\u2019t understand the words, but in that situation, where you are feeling vulnerable and scared [the explanation] had a reassuring quality,\u201d she said.<\/p>\n

Meguid emphasized that most providers assess their patients\u2019 surgical risk, but do so individually, leaving a \u201chuge amount of variability\u201d in their approaches. SURPAS aims to standardize the approach, which helps not only patients, but also providers, he maintained.<\/p>\n

\u201cSURPAS 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,\u201d he said.<\/p>\n

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.<\/p>\n

A level playing field for comparing outcomes<\/strong><\/h2>\n

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\u2019s Surgical Outcomes and Applied Research (SOAR)<\/a> program. Henderson led the development of the ACS NSQIP database.<\/p>\n

An important idea behind NSQIP was that a set of key surgical risk factors would help to \u201clevel the playing field\u201d 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.<\/p>\n

\u201cSurgeons were initially reluctant to join [NSQIP], but they made efforts to improve,\u201d Henderson said. \u201cStandardized care improved outcomes, and we also learned from hospitals that had good outcomes.\u201d<\/p>\n

Impact Clinic puts prehabilitation into practice<\/strong><\/h2>\n

Information from SURPAS can also be used to prepare higher-risk patients for surgery. That\u2019s been underway for more than two years at the UCHealth Pre-procedural Impact Clinic<\/a>, which serves patients from UCHealth\u2019s Poudre Valley Hospital<\/a> in Fort Collins and Medical Center of the Rockies<\/a> in Loveland.<\/p>\n

\"The
The Impact Clinic at UCHealth in northern Colorado uses SURPAS to help patients prepare for elective surgeries. Left to right: clinic nurse practitioners Laura Hildebrand and Julie Deters and nurse manager Charis Kee. Photo courtesy of the Impact Clinic.<\/figcaption><\/figure>\n

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.<\/p>\n

\u201cThe goal is to educate patients to become participants in their own health care outcomes,\u201d said Dr. Annette Vizena<\/a>, an anesthesiologist who is the clinic\u2019s medical director. She said patients who address their pre-operative risks are less likely to have post-operative complications \u2013 and, she hopes, may continue to maintain the positive changes they made preparing for surgery.<\/p>\n

\u201cWe need a level of engagement \u2013 patients who are excited about improving their health care and excited about having some control over their health care,\u201d Vizena said. \u201c[SURPAS] is one way to do both.\u201d<\/p>\n

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.<\/p>\n

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.<\/p>\n

\u201cThe clinic may help surgeons reevaluate patient’s co-morbidities and facilitate mitigation of their risks,\u201d Vizena said.<\/p>\n

Growth and improved outcomes for Impact Clinic<\/strong><\/h2>\n

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.<\/p>\n

Vizena said the clinic\u2019s 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.<\/p>\n

But data show that the clinic\u2019s 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<\/a> (AHRQ) \u2013 such as post-operative respiratory failure and sepsis rates \u2013 the clinic\u2019s actual rates were significantly lower than what was expected.<\/p>\n

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.<\/p>\n

\u201cWe\u2019ve used it as a motivational tool to drive the patient to double down and improve their health care before going to surgery,\u201d she said.<\/p>\n

Computer-driven help in finding surgical complications<\/strong><\/h2>\n

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 \u2013 with the help of artificial intelligence.<\/p>\n

A five-year AHRQ grant co-led by Dr. Kathryn Colborn<\/a>, 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.<\/p>\n

It\u2019s 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.<\/p>\n

The concept isn\u2019t new; nurses have manually extracted such data from patient charts for years. The grant aims to use machine learning and artificial intelligence \u2013 in simplified terms, using computer systems to analyze data and identify specific patterns within a mass of detail \u2013 to do that heavy lifting electronically.<\/p>\n

\u201cWe are testing the machine\u2019s ability to classify outcomes versus nurses\u2019 ability to classify outcomes, which is the gold standard,\u201d 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.<\/p>\n

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<\/a>. The goal: use variables that indicated risk for urinary tract infections (UTIs)<\/a> and surgical site infections (SSIs)<\/a> 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.<\/p>\n

With the new grant, the team is also working with Vanderbilt University on using natural language processing<\/a> (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\u2019 text notes embedded in the medical charts.<\/p>\n

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.<\/p>\n

Listening (better) to patients<\/strong><\/h2>\n

The improvement also rests on hearing how patients perceive their own care. The SOAR team recently published a pilot study<\/a> that tested using patient-reported outcomes (PROs)<\/a> in some 400 surgical patients, with the idea of incorporating these measures consistently in plans of care.<\/p>\n

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?<\/p>\n

\u201cWe want to know functional outcomes in six months to a year,\u201d Meguid said. As of now, UCHealth does not have a PRO database, he acknowledged. \u201cBut 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.\u201d<\/p>\n

In sum, Meguid said his work with SOAR \u201chas 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.\u201d<\/p>\n

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\u2019s now cancer-free, is recovering and plans a bike trip to the West Coast with Peter in July.<\/p>\n

\u201cDr. Meguid gave us information that was specific and easy to understand,\u201d she said. \u201cI came with a list of questions, but realized that so many of them had already been answered.\u201d<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":2143,"featured_media":40708,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[5],"tags":[9092,9093,702],"class_list":["post-40705","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-innovative-care","tag-electronic-health-records","tag-quality-improvement","tag-surgical-care"],"acf":[],"yoast_head":"\nImproving surgical outcomes by identifying patient risk factors prior to surgery - 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