This month’s column highlights two important resources that add to clinical expertise and improve the quality of your patient care. The Journal of the American College of Surgeons (JACS) is the premier surgical journal, which is available as a benefit to all members of the American College of Surgeons (ACS); this column outlines the ways in which you can interact with JACS and use it to meet your continuing medical educational (CME) needs.
Just as JACS provides readers with important patient care research and content, the College’s National Surgical Quality Improvement Program (ACS NSQIP®) Surgical Risk Calculator can help you make evidence-based decisions about treatment options. This tool can serve as an important resource to enhance patient interactions in the office and at the bedside.
JACS
The College’s official scientific publication, JACS is a monthly peer-reviewed journal containing original contributions on all aspects of surgery. Free electronic access to JACS is a high-value benefit for all ACS members and can be accessed online or on the go via the mobile app available in the Apple Store and on Google Play.
Valuable resource for CME
JACS is widely recognized as one of the top surgery journals in the world. One of the key indicators of a scientific journal’s importance and relevance to the medical community is its impact factor. In 2015, the impact factor for JACS—reflecting the frequency of average citations for articles published in 2012 and 2013—was 5.122, representing a more than 95 percent increase over the last 10 years. Along with this jump, the number of original scientific manuscripts submitted to JACS has increased significantly.
The JACS CME program is available online as a free benefit to all ACS members online, and is the largest CME program offered by the College. Online quizzes are available for the last 24 months of publication, and members can earn three or more credits for each month by taking exams covering a variety of relevant surgical topics. In 2015, 3,566 individual test takers—the highest number of users to date—earned a total of 82,736 credits.
Embracing the future
Although the College continues to mail the print version of JACS to Fellows who want to receive a physical copy, JACS has begun the process of transforming from a primarily print publication to an electronic journal that meets the needs of surgeon-readers in the 21st century. The JACS staff is working to provide ease of access to online, full text articles for ACS members and to enhance the mobile application and website, as well as provide more supplemental material that cannot be presented in print, such as video and datasets.
The JACS Twitter feed—@JAmCollSurg—continues to feature tweets on research articles, coverage of JACS articles in the news media, and important content trending on social media. In the past year, the number of JACS Twitter followers has increased by more than 400 percent.
Recently, the International General Surgery Journal Club, a popular monthly Twitter discussion forum, featured two JACS articles—one on resident duty hours and one on leadership styles and team behavior in the operating room. (For more information about Twitter and journal clubs, see related article)
JACS also recently began collaborating with the Resident and Associate Society of the ACS (RAS-ACS) via a quarterly literature appraisal forum discussing JACS articles. This project exposes young surgeons to JACS content while encouraging direct social media participation through selecting the articles and discussing them on Facebook. JACS also worked with the RAS-ACS to publish the winning essays from their Spectacular Cases Session at Clinical Congress 2015.
Special issues
JACS has partnered with three distinguished surgical associations to produce special issues that highlight papers from their annual meetings. Each year, the April issue is devoted to papers from the Southern Surgical Association, the June issue to the New England Surgical Society, and papers from the Western Surgical Association are published in July.
Each fall, JACS also publishes all of the abstracts from the ACS Clinical Congress. In addition to the Scientific Forum abstracts published in the September supplement in print, JACS now publishes the remainder of the abstracts from each Clinical Congress online, including Scientific Forum Papers and Scientific Poster Presentations. These abstracts are accessible via the ACS mobile app.
111 years of keeping surgeons informed
By the end of the 19th century, the practice of surgery had been transformed by “anesthesia, asepsis, and a changing understanding of disease.” As an outgrowth of these medical breakthroughs, in 1905 the successful Chicago, IL, gynecologic surgeon, Franklin H. Martin, MD, FACS, launched the monthly peer-reviewed journal Surgery, Gynecology & Obstetrics (SG&O), and served as its managing editor and publisher for 30 years. Dr. Martin envisioned that the journal would be for all surgeons and prospective surgeons throughout the U.S. and would focus on educating the practicing surgeon rather than the academic elite. To further this aim, in 1910 SG&O announced the first Clinical Congress, and these annual meetings formed the basis of the founding of the ACS in 1913. In 1919, SG&O became the College’s official scientific journal, and 75 years later was renamed the Journal of the American College of Surgeons. Even as JACS has evolved in its now 111-year history, it continues Dr. Martin’s vision of educating general surgeons and providing its readership “the highest quality rapid retrieval of information relevant to surgeons.”*
ACS NSQIP Surgical Risk Calculator: A powerful decision-making aid
The ACS NSQIP Surgical Risk Calculator quickly and easily estimates the risks of postoperative complications for thousands of surgical operations based on a patient’s demographics, comorbidities, and the type of procedure to be performed. As such, it has value as a decision-support aid and informed-consent tool, benefiting patients, surgeons, and other providers in the discussion of the risks of surgery and whether surgery is the best possible treatment option for a specific individual. The calculator also may be used to help plan necessary postoperative care, including the likely need for intensive care, cardiac monitoring, and so on.
The ACS NSQIP Surgical Risk Calculator currently uses a platform based on data from more than 2.7 million patient records. These data are collected by trained and audited surgical clinical reviewers in approximately 600 ACS NSQIP-participating hospitals. Almost 2,000 different operations as defined by Current Procedural Terminology (CPT)† codes are available in the calculator. Prediction equations are based on a rigorous statistical methodology and have been thoroughly evaluated in terms of discrimination and calibration—statistical features that describe the quality of prediction.
To date, the ACS NSQIP Surgical Risk Calculator has been used to estimate risk in more than 1 million patients. In May 2016, the ACS NSQIP Risk Calculator underwent numerous advances, including the addition of new postoperative outcomes, improved analytics, and redesign of the website.
Using the Surgical Risk Calculator
Figures 1 through 4 show the main sections of the Surgical Risk Calculator. These sections address: (1) introductory and disclaimer statements; (2) entry of patient-specific information; (3) estimates of risk for each outcome; and (4) reporting options.
Figure 1. Introductory and disclaimer statements
Figure 2. Entry form for patient-specific information
Figure 3. Estimates of risk for each outcome, comparisons to average patient risk, and Surgeon Adjustment of those risks
Figure 4. Reporting options
The calculator allows users to enter the CPT code for the planned operation and 19 standard preoperative risk factors. The Surgical Risk Calculator Web platform provides simplified definitions and instructions so that surgeons and patients can successfully enter data and interpret the results. Based on these risk factors and the prediction equations embedded in the calculator, the user then sees estimated risks for each of approximately 15 postoperative outcomes, including mortality, morbidity, and complications specific to the patient.
In addition to the patient’s risk for each outcome, average risks for all patients in the database who have undergone that specific operation are provided for comparison (see Figure 3). This comparison allows the patient to put his or her predicted risks into the context of other patients who have undergone the procedure. The patient also receives estimates for their length of hospital stay, likelihood of being discharged to a nursing or rehabilitation facility, and risk of hospital readmission.
The surgeon, meanwhile, has the opportunity to adjust the reported risk using a Surgeon Adjustment Score if he or she believes the estimates are inappropriate given the surgeon’s evaluation and experience. The surgeon might use this function if, for example, the patient has a clinically significant risk factor that is not included in the standard list and which affects the likelihood of postoperative complications.
Users have found the Surgical Risk Calculator to be helpful in the informed consent process, providing a platform for objective shared decision making, as well as for documenting the shared information with a hard copy printout or e-mail. The document includes all the risk results, definitions, and disclaimers necessary for the patient to study and absorb the information during as well as after the clinic visit.
Since the ACS NSQIP Surgical Risk Calculator was released in 2013, several new outcomes measures common to all operations have been added, including those mentioned earlier, such as length of stay, discharge to nursing or rehab center, and risk of readmissions. The measure most recently added is procedure-specific complications for colon resection, including risk of anastomotic leak and ileus. When the surgeon enters a CPT code specific to colectomy, the calculator will automatically generate these outcomes.
Future directions
Although the Surgical Risk Calculator was conceived to contribute to surgeons’ ability to evaluate and assess risk, as well as to provide objective numbers to inform patients about that risk, the calculator continues to evolve. ACS NSQIP staff intends to continue to add more outcomes, particularly procedure-specific outcomes, and to improve statistical modeling whenever possible. New outcomes will be added with their appearance in ACS NSQIP quality improvement benchmarking models, and the predictor variable sets will be made more concise when appropriate.
At a technical level, while the Risk Calculator’s predictive accuracy repeatedly has been shown to be excellent, new methods are being implemented to incorporate mathematical recalibration processes that will further improve prediction. Finally, plans are in development to release Surgical Risk Calculator versions in the near future for pediatric patients using the ACS NSQIP Pediatric dataset and for bariatric surgery patients using the ACS Metabolic and Bariatric Surgical Accreditation and Quality Improvement Program dataset. For more information, contact Mark Cohen, PhD, at mcohen@facs.org.
Both of these important programs are available as free benefits of your membership in the ACS. Be sure to take advantage of all they have to offer.
*Nahrwold DL, Kernahan PJ. The Context of the College. In: A Century of Surgeons and Surgery: The American College of Surgeons 1913–2012. Chicago, IL: American College of Surgeons, 2012.
†All specific references to CPT codes and descriptions are ©2015 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.
Bibliography
American College of Surgeons. New ACS NSQIP Surgical Risk Calculator offers personalized estimates of surgical complications. Bull Am Coll Surg. 2013;98(10):72-73.
Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833-842.
Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an ACS NSQIP morbidity and mortality risk calculator for colorectal surgery. J Am Coll Surg. 2009;208(6):1009-1016.
Liu Y, Cohen ME, Hall BL, Ko CY, Bilimoria KY. Evaluation and enhancement of calibration in the ACS NSQIP Surgical Risk Calculator. J Am Coll Surg. In press.
