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

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.

Simple and Scalable Targets for Prehabilitation: The Potential of Strong for Surgery

“…In this issue of World Journal of Surgery, Liou and colleagues in their novel analysis ''Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population'' evaluate the impact of modifiable risk factors on perioperative outcomes [5]. Through the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database, Liou et al identified 31,285 patients who underwent major elective procedures between 2008 and 2015 in the Veterans Affairs system with preoperative nutrition laboratories, hemoglobin A1c, and smoking status recorded.…”

“…In addition, patients‐adjusted mortality risk increased in a stepwise fashion as they added on risk factors: one risk factor (aOR, 1.34) and two risk factors (aOR, 1.58). Furthermore, this trend held true for postoperative complications as well: The strongest predictor of postoperative complications was the presence of all three risk factors (aOR, 5.20) [5].…”

“…The work of Liou et al suggests that wide adoption of the Strong for Surgery public health campaign has the potential to decrease postoperative morbidity and mortality on a national scale. Their focus on modifiable risk factors allows providers to encourage patients that fixing even one risk factor can decrease their mortality risk significantly [5]. Moving forward, more work needs to focus on effective time-limited interventions that can modify nutritional status, uncontrolled diabetes, and smoking status in the preoperative setting.…”

Optimizing patient health before surgery to improve outcomes

“…Complications in the perioperative period are increasingly being attributed to comorbidities and other patient risk factors (e.g., smoking, suboptimal nutritional status) 1‐3 . Studies have shown that these risk factors in surgical patients have been linked to increased lengths of stay; more emergency department visits; greater need for reoperation; higher rates of readmission, transfusion, and surgical site infections; and increased mortality 2,3 . The timeframe before surgery, when patients may be particularly open to positive behavioral messages, can provide a unique opportunity to address these risk factors 4 .…”