Surgical Palliative Care Column (Original Article)
American College of Surgeons National Surgical Quality Improvement Program as a quality-measurement tool for advanced cancer patients
Abstract
Background: Multiple studies have shown the significantly increased post-operative morbidity and mortality of patients undergoing palliative operations. It has been proposed by some authors that the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database can be used reliably to develop risk-calculators or as an aid for clinical decision-making in advanced cancer patients. ACS-NSQIP is a population-based database that by design only captures outcomes data for the first 30-day following an operation. We considered the suitability of these data as a tool for decision-making in the advanced cancer patient.
Methods: Six-year retrospective review of a single institution’s ACS-NSQIP database for cases identified as “Disseminated Cancer”. Procedures performed with palliative intent were identified and analyzed.
Results: Of 7,763 patients within the ACS-NSQIP database, 138 (1.8%) were identified as having “Disseminated Cancer”. Of the remaining 7,625 entries only 4,486 contained complete survival data for analysis. Thirty-day mortality within the “Disseminated Cancer” group was higher when compared to all other surgical patients (7.9% vs. 0.9%, P<0.001). Explicit chart review of these 138 patients revealed that 32 (23.2%) had undergone operations with palliative intent. Overall survival for palliative and non-palliative operations was significantly different (104 vs. 709 days, P<0.001). When comparing palliative to non-palliative procedures using ACS-NSQIP data, we were unable to detect a difference in 30-day mortality (9.4% vs. 7.5%, P=0.72).
Conclusions: Calculations utilizing ACS-NSQIP data fail to demonstrate the increased mortality associated with palliative operations. Patients diagnosed with advanced cancer are not adequately represented within the database due to the limited number of cases collected. Also, more suitable outcomes measures for palliative operations such as pain relief, functional status, and quality of life, are not captured. Therefore, the sole use of thirty-day morbidity and mortality data contained in the ACS-NSQIP database is insufficient to make sound decisions for surgical palliation.
Methods: Six-year retrospective review of a single institution’s ACS-NSQIP database for cases identified as “Disseminated Cancer”. Procedures performed with palliative intent were identified and analyzed.
Results: Of 7,763 patients within the ACS-NSQIP database, 138 (1.8%) were identified as having “Disseminated Cancer”. Of the remaining 7,625 entries only 4,486 contained complete survival data for analysis. Thirty-day mortality within the “Disseminated Cancer” group was higher when compared to all other surgical patients (7.9% vs. 0.9%, P<0.001). Explicit chart review of these 138 patients revealed that 32 (23.2%) had undergone operations with palliative intent. Overall survival for palliative and non-palliative operations was significantly different (104 vs. 709 days, P<0.001). When comparing palliative to non-palliative procedures using ACS-NSQIP data, we were unable to detect a difference in 30-day mortality (9.4% vs. 7.5%, P=0.72).
Conclusions: Calculations utilizing ACS-NSQIP data fail to demonstrate the increased mortality associated with palliative operations. Patients diagnosed with advanced cancer are not adequately represented within the database due to the limited number of cases collected. Also, more suitable outcomes measures for palliative operations such as pain relief, functional status, and quality of life, are not captured. Therefore, the sole use of thirty-day morbidity and mortality data contained in the ACS-NSQIP database is insufficient to make sound decisions for surgical palliation.
