Study Finds Written Standardized Protocol Leads to Better Surgical Outcomes

A recent study published online ahead of print in the Journal of the American College of Surgeons found that a safety-net hospital in Florida could perform an esophagectomy, a highly complex operation, with fewer complications and shorter hospital stays than the national average.

In a press release, the lead author of the study, Lori Gurien, MD, MPH, chief surgical resident at the University of Florida College of Medicine-Jacksonville, credited the use of a written standardized protocol for the hospital's superior outcomes.

Gurien explained that the clinical pathway surgeon, Ziad T. Awad, MD, FACS, and the rest of the surgical team maintain detailed step-by-step instructions for the procedure, including everything from the planning and scheduling of the operation to the postoperative follow-up.

“What we think and what we discovered is that it’s not because the hospital gives us more money and resources for the surgical oncology portion; it is that we figured out a way to use resources in a smarter way than other places that may not have the limitations that we have at our hospital,” said Gurien.

The study investigated results of 78 esophagectomies performed at the University of Florida Health-Jacksonville (UFH) from September 2013 to January 2017 compared with 1825 of the same procedure in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. An esophagectomy is an operation that involves removing a portion of the esophagus, usually as a treatment for esophageal cancer.

Researchers reviewed 3 primary outcomes: complications, number of second and third operations, and length of hospital stay. UFH had significantly better numbers than the NSQIP average, with a complication rate of 16.7% compared with 33.3%, respectively (P = .003); a reoperation rate of 6.4% compared with 14.5% (P = .046); and an average hospital stay of 10.3 days compared with 13.1 days (P = .001). Other key quality measures, such as death rates, hospital readmission, what type of care setting patients go to after leaving the hospital, and average time spent in the operation, were similar between the 2 study groups. Notably, the ACS NSQIP data used in the study did not distinguish between different types of hospitals.

The study noted that safety-net hospitals, which are often found in inner cities with a high share of uninsured and Medicaid patients, face challenges as healthcare moves from a “fee-for-service model” to value-based payments, which impose payment penalties on institutions that perform poorly.

“The takeaway from this study is that good outcomes are more a result of the process," said Gurien. "I do think other hospitals can perform this process, especially safety-net hospitals like ours that have limited financial resources."