Immune checkpoint inhibitors (ICPIs) are monoclonal antibodies that target downregulators of the anti-cancer immune response: cytotoxic T-lymphocyte antigen-4, programmed cell death protein-1, and its ligand PD-L1. ICPIs are now approved for the treatment of a wide array of malignancies, with rates of durable responses in the metastatic setting far exceeding what would be expected from conventional chemotherapy. ICPIs have also been associated with rare but serious immune-related adverse events due to over-activation of the immune system that can affect any organ, including the gastrointestinal tract and liver. As the use of ICPIs in oncology continues to increase, ICPI-associated colitis and hepatitis will be encountered frequently by gastroenterologists and hepatologists. This review will focus on the diagnosis and management of ICPI-associated colitis and hepatitis. We will also compare these ICPI-related toxicities with sporadic inflammatory bowel disease and autoimmune liver disease.

INTRODUCTION Within a large, statewide collaborative, significant improvement in surgical quality have been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative (MSQC), variations in outcomes among hospitals, and variations in adherence to evidence based process measures. Overall, these data will form a basis for a broad based quality improvement initiative within Michigan. METHODS We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (n= 190,826) within 34 hospitals participating in the MSQC from 2005 to 2010. Adjusted hospital specific outcomes were calculated using a step-wise multivariable logistic regression model. Adjustment covariates included patient specific co-morbidities and case complexity. Hospitals were also compared based on their adherence to evidence based process measures (measures at the patient level for each case – SCIP 1 and 2 compliance). RESULTS Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was $126 million for emergency cases and $329 million for elective cases. Adjusted patient outcomes varied widely within MSQC hospitals; morbidity and mortality rates ranged from 16.3% to 33.9% and 4.0% to 12.4%, respectively. The variation among hospitals was not correlated with volume of emergency cases and case complexity. Hospital performance in emergency surgery was found to not depend on its share of emergent cases, but rather was found to directly correlate with its performance in elective surgery. For emergency colectomies, there was wide variation in compliance with SCIP 1 and 2 measures, and overall compliance (42.0%) was markedly lower than elective colon surgery (81.7%). CONCLUSION(S) Emergency surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.

Background In the setting of a statewide quality collaborative approach to the review of cardiac surgical mortalities in intensive care units (ICUs), variations in complication-related outcomes became apparent. Utilizing “failure to rescue” methodology, (FTR; the probability of death after a complication), we compared FTR rates after adult cardiac surgery in low, medium, and high mortality centers from a voluntary, 33-center quality collaborative. Methods We identified 45,904 patients with a Society of Thoracic Surgeons predicted risk of mortality who underwent cardiac surgery between 2006 and 2010. The 33 centers were ranked according to observed-to-expected (O/E) ratios for mortality and were categorized into 3 equal groups. We then compared rates of complications and FTR. Results Overall unadjusted mortality was 2.6%, ranging from 1.5% in the low-mortality group to 3.6% in the high group. The rate of 17 complications ranged from 19.1% in the low group to 22.9% in the high group while FTR rates were 6.6% in the low group, 10.4% in the medium group, and 13.5% in the high group (p<0.001). The FTR rate was significantly better in the low mortality group for the majority of complications (11 of 17) with the most significant findings for cardiac arrest, dialysis, prolonged ventilation, and pneumonia. Conclusion Low mortality hospitals have superior ability to rescue patients from complications after cardiac surgery procedures. Outcomes review incorporating a collaborative multi-hospital approach can provide an ideal opportunity to review processes that anticipate and manage complications in the ICU and help recognize and share “differentiators” in care.