Getting out of the Operating Room:
Understanding Patient Outcome and Recovery
Douglas A Colquhoun, MB ChB, MSc, MPH
Assistant Professor of Anesthesiology
Associate Research Director, Multicenter Perioperative Outcomes Group
July 12
th
2024
Disclosures:
Research Funding:
– National Heart Lung and Blood Institute (K08-HL159327) [PI]
– National Institute on Drug Abuse (R61-DA059168) [Co-PI]
– Foundation for Anesthesia Education and Research (2021) [PI]
– NIH Common Fund (UM1-NS118922) [Co-I]
– Patient Centered Outcomes Research Institute (PLACER-2020C3-21106) [Co-I]
– Agency for Healthcare Research and Quality (R01-HS029172) [Co-I]
Sponsored Research:
– Merck & Co – 2019-2022 [PI]
– GE Healthcare – [PI]
– Chiesi, USA Inc [Co-I]
Speaker/Consulting Fees:
– Medscape, Inc – Honorarium (2022)
Overview/Outline:
• Perioperative Mortality Paradox
• Understanding Postoperative Complications
• Thinking Broadly About Outcomes After Anesthesia Care
• Deepening Understanding of Perioperative Care
Willie Sutton (1901-1980)
“Because that’s where
the money is.”
https://www.fbi.gov/history/famous-cases/willie-sutton
Perioperative Mortality Paradox
Perioperative Risk Paradox:
• Intraoperative mortality is vanishingly rare
• But death within 30 days of the operating room
would be 3
rd
leading cause of death in US
• Explore this and what this means for
understanding patient outcomes
Bartels K, Anesthesiology. 2013
Incidence of Mortality: Current Literature
Study Type Study Outcome Rate
Prospective
Audit
EuSOS: 7 Days in Europe
(Pearse Lancet 2012)
In Hospital Mortality 4% in hospital mortality
(3% elective -> 10% emergency)
Large Between Country Differences
ISOS: 7 days in 27 Countries
(BJA 2016)
In Hospital Mortality
Development of Complications
0.5% In Hospital Mortality
Prospective
Cohort
VISION:
(Spence, CMAJ 2019)
30 Day Mortality 1.8% 30 Day Mortality
Database
Study
Netherlands Pop. Registry
(Noordzij Anesthesiology 2010)
In Hospital Mortality 1.85% In Hospital Mortality
NACOR
(Whitlock Anesthesiology 2015)
48hr Mortality 0.03% within 48hrs
Community Based Anesthesia
(Pollard, Anesth Analg. 2018)
48hr Mortality
Anesthesia Related Mortality
0.08% within 48hr
The VISION Cohort:
• Population:
– 40,004 patients:
– >45 yrs
– 1 night in hospital planned
– Non-cardiac surgeries.
– 28 Hospitals across 14 Countries
• 715 (1.8%) of patients died in the next
30 days
• “Number of deaths was almost evenly
distributed over 30-day follow-up”
(Spence J, CMAJ 2019)
715 Deaths
500 Deaths
During Index
Hospitalization
210 Deaths
After Discharge
5
Intraoperative
Deaths
Intraoperative Mortality:
• Single Institution (MGH)
• All intraoperative deaths over
a 4 year Period (n=41)
• Grouped into:
– Trauma
– Non-Trauma Emergency
– Elective
• Where are the opportunities to
change and improve care?
Gallastegi AD. J Surg Res. 2022
Anesthesia Related Mortality
• Intraoperative mortality is very rare
– Anesthesia related mortality, is rarer
– But death in the next 30 days is quite common
• Anesthesia related mortality has fallen markedly:
– 1940’s: 1 in 1,000
– 1970’s: 1 in 10,000
– 2000’s: 1 in 100,000
• In the context of increasing surgical complexity and
patient comorbidity
• This is a remarkable achievement as a specialty
Li G et al. Anesthesiology. 2009
Understanding Postoperative Complications
Unpacking Perioperative Morbidity
• Morbidity happens in the postoperative
period
– 2/3rds of 30-day deaths are during first
admission
• Complications are common:
– >20% of surgical patients, depending on
complication and population studied
• Failure to Rescue: Translation of
Complication to a Postoperative Death
– Highly variable by institution
Ghaferi A. NEJM 2009
Getting Specific About Perioperative Complications:
• Specific definitions used by clinical trials / registries
• Relatively subtle or subclinical occurrences result in
marked change in patient outcomes:
– Myocardial Injury (Troponin Leak)
– Prolonged Oxygen Requirement
– Acute Kidney Injury
• Each impacts patient outcome and are very common
Morbidity 1: Myocardial Injury (Troponin Leak)
• Myocardial Injury in Non-Cardiac Surgery:
– Biomarker Suggestion of Cardiac Injury/Impairment
– Does not conform to definition of MI
• Incidence is ~20% if all patients are screened
• Co-existing features of ischemia (eg chest pain)
are relatively uncommon (~5%)
• Dose dependent impact on long term outcome
• Powerfully impacts 30 day and 365 day outcome
Devereaux P, JAMA, 2012
Puelacher C. Circulation. 2017
Smilowitz NR, Cardiol Rev. 2019
Morbidity 2: Prolonged Oxygen Requirement
• Supplemental oxygen as part of the “background” of inpatient medical care
• Suggests significant degradation of respiratory function
• Included in definition of PPC’s in
two large cohort studies:
– LAS VEGAS (Eur Jr Anes 2017)
– Fernandez-Bustamante et al
(JAMA Surg 2017)
• Even “Just” supplemental O
2
is associated with, increased
LOS, increased ICU utilization
Fernandez-Bustamante et al. JAMA Surg 2017
Morbidity 3: Acute Kidney Injury
• AKI is common after inpatient surgery:
– 13.4% in meta-analysis
– 72% of this is Stage 1 AKI
– Much will return to baseline
• However:
– Associated with marked increased 30
day mortality
– Also associated with long term
mortality in cardiac surgery patients
O’Connor ME. Intensive Care Medicine. 2015
Long T. Anesth Analg. 2016
Loef B. JASN 2005
Complications drive long term outcomes
• Patients who develop complications
have different long-term outcomes.
• At 1 year:
– Died: 2.3% [no complications] vs
7.5% [complications]
• Difference persists out > 5 years.
• Early inflection point ~ 60 days for
when death rate changes.
Fowler AJ. Br J Anaesth. 2022
Khuri SH. Ann Surg. 2005
Patient Risk
• Complications are not equally distributed
across surgical population
• Specific groups are at particular risk:
– Surgery Type (specialty)
– Emergency Surgery
– Age
– Frailty
• Example: Over half of the relationship
between frailty and mortality is mediated
by the occurrence of complications
McIsaac DI. Anesthesiology 2021
Challenge:
• Identify complications which are occurring during
the inpatient admission
• Identify high risk patients and modifiable
processes of care
• Make these a focus of our care improvement
• Understanding co-responsibilities with surgical
colleagues
Thinking Broadly About Outcomes After Anesthesia Care
Finishing the Race: Outcomes After Anesthesia Care
• Handover to PACU may signify “Anesthesia End”
• Recognizing PACU outcomes is key for intraoperative
technique refinement
• PACU is beginning of patient recovery
• What patients value in recovery from surgery?
– Often expressed in functional terms: return to routine, resolution
of symptoms, regaining independence
Rajabiyazdi F. JAMA Surg 2021
Physiologic Monitoring in Post Operative Period:
• Potential roles for increasing monitoring in the postoperative
period
• Large cohort studies have demonstrated prolonged periods:
– Hypotension
• ~15% of patients will have >15mins of MAP < 65 mmHg
– Hypoxia
• 20% of patients will have >10 mins of SpO2 < 90% in
any hour
• Poorly detected by conventional q4hr vital signs
• Remaining issues on who monitors the monitors...
Zhou S. Anesth Analg. 2015
Turan A. Anesthesiology. 2019
Patient Perspectives On Recovery
• Instruments exist to Quantify patient perspective on
anesthesia + surgical recovery
– Quality of Recovery (QOR15/40)
• Pain, Physical Comfort, Independence, Psychological
Support, Emotional State
• Measures both Physical and Mental Well-Being
– Bauer Patient Satisfaction:
• Includes both physical discomfort present/absent
• Likert-type scaled around specific domains
• Used in mostly research contexts - point to areas of
patient concern
Stark PA. Anesthesiology. 2013
Bauer M. Acta Anaesthesiol Scand. 2001
What Direct Anesthesia Outcomes Do Patients Seek:
• Other researchers have sought to directly
quantify patient perspectives (Top 3):
– Emphasizing most important considerations:
• Unawareness
• Nausea and Vomiting
• Return to normal function
– Or outcomes to be most avoided:
• Vomiting
• Gagging on ETT
• Pain
Tellor-Pennington BR, BMC Anesthesiology, 2023
Macario A. Anesth Analg 1999
What Matters to Patients:
• Pursuit of Patient Centered Outcomes is to Understand
what Matters to Patients and their Caregivers
• Too often we have focused (solely) on what is measurable
and important to physicians or the health system
• Death and complications alone do not capture this
• Lahda proposes:
– Health Related Quality of Life Measure
– Functional Status Measure
– Life Impact Measure
Ladha KS. Anesthesia. 2020
Deepening Understanding Of Perioperative Care
Opportunity to Expand Our Perspective:
• Expansive vision of anesthesia outcome
• Goes well beyond the intraoperative period
• How do we start? Moving towards inpatient
data.
• About a year ago, an opportunity arose to help
speed up this work
Deepening Understanding of Perioperative Care:
• Emerges from Funded R61/R33 Award - National Institute for Drug Abuse (NIDA):
• Unique Mechanism:
– R61: 2 years: Build capacity
– R33: 3 years: Do a project with that new capacity
• HEAL Data2Action Initiative (Helping End Addiction Long Term Initiative)
• Milestone based graduation from R61 to R33 Phases
• Co-PI’s: Eric Sun (Stanford) + Douglas Colquhoun (U-M)
MPOG
Inpatient Data
Medicare Data
Opioid Related
Harm
+
+
R61
MPOG: Inpatient Data
• We got 2 years of funding to support MPOG development
• Need to pursue inpatient data
– Specific project requires inpatient pain data
– Opportunity to reimagine MPOG Data Types and Address
Key limitations
• Prioritized list of data types which would have a good
effort/payoff trade to improve understanding of
postoperative care
MPOG Current State:
Operating Room
Vitals / Monitor Data
Medications
Hospital Admission
Hospital Discharge
Laboratory Data
Administrative Data
1yr Prior to Case
1yr After Case
Structured Documentation
Evolution of MPOG:
• Originally MPOG was in context of freestanding Anesthesia Information
Management Systems (AIMS).
– eg Centricity, MetaVision, Innovian
– Case centric views of anesthesia care
– Varying degrees of connected-ness to rest of hospital
• AIMS morphed into modules of the Electronic Health Record opportunity to change:
– MPOG / EPIC integration is anesthesia case centric
– Opportunity to leverage the rest of the EHR to understand rest of the care
• MPOG Import Manager platform in use is central to this:
– Allows Central + Local to move in slightly different directions
– Agnostic to source of the data files
High Priority Other Data Types Are We Seeking:
Data Type Detail Relevance to MPOG
Medication
Administration
Medications during hospital stay
Lexicon Linked
Understand inpatient patient management, true
perioperative medication
Flowsheet Data Pain Assessments
Inpatient vital signs
Understand inpatient care, fluid balance, respiratory
and cardiovascular support
ADT Data Admission, Discharge and Transfer Understand Length of Stay, ICU Use, Discharge
Disposition
Patient Attributes Information of patient factors including: Race,
Ethnicity, Sexual Orientation, Gender Identity
and High Priority SDH
Understanding impact of SDH on care (BCBS
Priority)
Other Data Types Ex: Microbiology Data, Bedside Procedure
Notes
Support future research and QI work.
Building On Current Approach:
EPIC
MPOG
Local
MPOG
Central
Import
Manager
Clarity/
Other Data
Import Manager is
Source Agnostic:
Links Patients +
Transforms Files
EPIC Controls this:
Changes made q3 yrs
At Each MPOG Site At the Coordinating Center
MPOG Future State:
Operating Room
Vitals / Monitor Data
Medications
Hospital Admission
Hospital Discharge
Laboratory Data
Administrative Data
1yr Prior to Case
1yr After Case
Structured Documentation
Admission, Discharge and Transfer
Patient Attributes
Procedure Notes
MPOG Changes Coming with this:
• Changes are quite “under the hood”
– Places for new data types
– Process of including new data
• Thinking about Patient Linked Data vs Case Linked:
– MPOG Currently Links to a single case
– But we are developing narratives of patient care
– Inpatient medications & flowsheets refers to inpatient timeline
– Keep strict bounds of Anesthesia Start to End for case level items
– Inpatient narrative
• Process for generating new files
How Does Race/Ethnicity/SOGI Data Come Into This?
• Race/Ethnicity/SOGI data is first data elements to be captured through this method
• Strong BCBS/Across CQI imperative for these data elements
• Coordinating Center will provide extract from existing systems available at all MPOG
sites (EPIC) or clear specification of how to supply this data
• State of Michigan first to gain this data type
What’s Next?
• Pretty strong understanding of how to
get this data
– Validating with a Non-UM Sites
• Work on MPOG Infrastructure Changes
to Support New Data types
• Patient Attributes: Race/Ethnicity/SOGI
for the State of Michigan coming soon
• Confident of our approach, leadership
for state of Michigan
Medication Administration
Flowsheet Data
Procedure Notes
ADT Data
Patient Attributes
V1: BCBS Sites,
2025 Rollout
V2: All MPOG Sites
Invited
Summary:
• Intraoperative mortality is rare, but 30 day mortality is not.
• Complications drive inpatient mortality, but also impact 30 and 1 year mortality
• Common “minor” changes actually potent major differences in outcome
• We need to think and work beyond the operating room
• Have an opportunity to do this through expansion of MPOG platform
• Race/Ethnicity/SOGI data will demonstrate this is feasible
Questions?
