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Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population

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Abstract

Background

Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population.

Methods

The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared.

Results

A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c > 7, and 4.4% had serum albumin < 3. In the S4S2 group, 87.8% were smokers, 84.8% had HbA1c > 7, and 27.4% had albumin < 3. Major complications, reoperations, length of stay, and 30-day mortality increased progressively from S4S0 to S4S3 groups. S4S3 had the greatest adjusted mortality risk (adjusted odds radio [AOR] 2.56, p = 0.04) followed by S4S2 (AOR 1.58, p = 0.02) and S4S1 (AOR 1.34, p = 0.02).

Conclusion

In the VA population, patients who had all three S4S risk factors, namely active smoking, suboptimal nutritional status, and poor glycemic control, had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors.

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Abbreviations

S4S:

Strong for Surgery

VASQIP:

Veterans Affairs Surgical Quality Improvement Program

VA:

Veterans affairs

ACS:

American College of Surgeons

BMI:

Body mass index

HbA1c:

Hemoglobin A1c

COPD:

Chronic obstructive pulmonary disease

ESRD:

End stage renal disease

ICU:

Intensive care unit

LOS:

Length of stay

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Authors and Affiliations

  1. Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA

    Douglas Z. Liou, Deven C. Patel, Prasha Bhandari, Joseph B. Shrager, Mark F. Berry, Natalie S. Lui & Leah M. Backhus

  2. Department of Surgery, Stanford University, Stanford, CA, USA

    Sherry M. Wren & Alex HS. Harris

  3. VA Palo Alto Health Care System, Palo Alto, CA, USA

    Sherry M. Wren, Nell J. Marshall, Alex HS. Harris, Joseph B. Shrager & Leah M. Backhus

Authors
  1. Douglas Z. Liou
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  2. Deven C. Patel
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  3. Prasha Bhandari
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Correspondence to Leah M. Backhus.

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Liou, D.Z., Patel, D.C., Bhandari, P. et al. Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population. World J Surg 45, 1706–1714 (2021). https://doi.org/10.1007/s00268-021-05979-8

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  • DOI: https://doi.org/10.1007/s00268-021-05979-8

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