Implantation of a synthetic midurethral sling (SMUS) is the most commonly performed anti-incontinence operation in women worldwide. The effectiveness of the SMUS is comparable to that of the historical gold standards--autologous fascial slings and the Burch colposuspension. Much controversy, however, has evolved regarding the safety of this type of sling. Overall, the quality of the studies with respect to assessing risks of SMUS-associated complications is currently poor. The most common risks in patients with SMUS include urethral obstruction requiring surgery (2.3% of patients with SMUS), vaginal, bladder and/or urethral erosion requiring surgery (1.8%) and refractory chronic pain (4.1%); these data likely represent the minimum risks. In addition, the failure rate of SMUS implantation surgery is probably at least 5% in patients with stress urinary incontinence (SUI). Furthermore, at least one-third of patients undergoing sling excision surgery develop recurrent SUI. Considering the additional risks of refractory overactive bladder, fistulas and bowel perforations, among others, the overall risk of a negative outcome after SMUS implantation surgery is ≥15%.

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.

These data suggest that clinical nodal stage is a critical parameter for outcomes in PUC.