Improving Hip Fractures Outcomes for COPD PatientsElizabeth A. Regan,1,2,4 Tiffany A. Radcliff,1,4,7 William G. Henderson,1,4 Diane C. Cowper Ripley,3 Matthew L. Maciejewski,5, 6 W. Bruce Vogel,3 and Evelyn Hutt1,4
1 VA Eastern Colorado Healthcare System, Denver, Colorado, USA
2 National Jewish Health, Denver, Colorado, USA
3 Malcolm Randall VA Medical Center, Gainesville, Florida, USA
4 University of Colorado Denver, Aurora, Colorado, USA
5 Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, North Carolina, USA
6 Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
7 Texas A&M Health Sciences Center, College Station, Texas, USA
Keywords: COPD, Hip fracture, Mortality, Osteoporosis, Steroid use, Surgical omplications, Pneumonia, Spinal anesthesia, General anesthesia, Current smoking.
Correspondence to: Elizabeth Regan, Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA, phone: 303-398-1355, fax: 303-270-2249, Email: [email protected]
Abstract
Hip fractures in the elderly have high rates of mortality and perioperative
complications. Both men and COPD patients have worse mortality and complications
but this may be due to more co-morbid disease. We assessed mortality and
complications in a large cohort (n = 12,646) of men undergoing hip fracture
surgery within the Veteran’s Health Affairs (VHA) to defi ne the association of COPD
to these outcomes after adjusting for other key factors. We looked for opportunities
to improve outcomes for COPD patients. Methods: Using the VA Surgical Quality
Improvement Program (VASQIP), and administrative databases, we determined
COPD status, types of co-morbid conditions and surgical factors, and compared
these to outcomes of surgical complications, 30-day and one-year mortality for
patients who underwent hip fracture repair during 1998 to 2005. Results: COPD
was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the
COPD was “severe: (indicated by functional disability, previous hospitalization
for exacerbation, chronic drug treatment or record of FEV1 <75% predicted), and
in 2,736 (21%) cases it was considered “mild” (any previous outpatient visit or
hospitalization with a coded diagnosis of COPD). Severe COPD patients had one
year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD
subjects. Current smoking, use of general anesthesia and delays to surgery were
signifi cant modifi able risk factors identifi ed in adjusted models. Osteoporosis was
known pre-fracture in only 3% of subjects. Conclusions: COPD was very common in
male veterans with hip fractures and was associated with increased risk of death
and complications. Increased use of regional anesthesia and urgent scheduling of
hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis
was rarely identifi ed preoperatively. Improving diagnosis and treatment of
osteoporosis in COPD patients could reduce the incidence of hip fractures.
Hip fractures are common in aging populations, largely due to the combined eff ect of reduced bone strength and an increased propensity to fall. Th e occurrence of a hip fracture often precipitates death, both in the immediate perioperative period and during the following year (1–3). Specifi c factors associated with mortality include advancing age, male gender (2, 7), co-morbid diseases (4), delays getting patients into surgery (3) and choice of anesthetic (5, 6).
Co-morbid chronic obstructive pulmonary disease (COPD) appears to be associated with worse 30-day and 1-year mortality after hip fracture. A large population based study from Denmark found COPD patients had 60–70%
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ly due to the combinedd propensity to fall. Th e
death, both in the immediateng year (1–3). Specifi c factors
cing age, male gender (2, 7), co-ients into surgery (3) and choice of
pulmonary disease (COPD) appears to bend 1-year mortality after hip fracture. A large
increase in mortality at 1 year after hip fracture but did not study surgical factors or adjust for other factors such as co-morbid disease or baseline functional status (8). Previous work with VA datasets found increased peri-operative complications in COPD subjects after adjust-ment for demographics and other co-morbid conditions, but found adjusted 30 day mortality was not increased in COPD (6). Other publications have identifi ed the nega-tive impact of COPD on hip fracture outcomes but have not controlled for surgical and perioperative patient factors (8-10). Although the eff ect of COPD and other co-morbid conditions cannot be eliminated at the time of hip fracture, perioperative management strategies may improve surgical outcomes. Furthermore, given the association of osteoporosis to both COPD (11) and hip fractures (12), primary prevention of hip fractures may also improve population outcomes.
Th e present study primarily focused on COPD as it pertains to hip fracture repair outcomes. It included identifying cases with mild COPD and also two addi-tional years of data as well as 1-year mortality out-comes for the cohort. We postulated that men with COPD would have worse mortality and higher compli-cations following hip fractures, and that pre-operative diagnosis of osteoporosis would be low. We were par-ticularly interested in identifying surgical aspects of hip fracture care in the context of co-existent COPD that might reduce risks for this subset of high-risk patients.
Methods
Study designTh is was a retrospective cohort study using data from the U.S. Department of Veterans Aff airs Surgical Quality Improvement Program (VASQIP) from 1998-2005. Investigators received institutional review board approval, a waiver of informed consent, and approval from the VA Surgical Quality Data Use Group prior to accessing or analyzing any data.
CohortWe selected male patients who underwent acute hip fracture repair surgery during fi scal years 1998 to 2005 in any VA hospital. Patients were identifi ed by CPT codes 27235, 27236, 27244, or 27245 indicating open or closed treatment of a hip fracture. We also included CPT codes 27125 (hemiarthroplasty) and 27130 (total hip arthro-plasty) when the patient had a concurrent diagnosis code consistent with an acute hip fracture (ICD-9 codes 820.x, 820.2x, or 820.8) (Table 1). We excluded patients with disseminated cancer because the etiology and prognosis for these cases is likely to diff er from other hip fractures.
Data collectionTh e data collection methods for the VASQIP have been described in detail previously (13). Nearly all patients who are scheduled to undergo major non-cardiac proce-
dures with use of general, spinal, or epidural anesthesia in VA hospitals are included in the database.
Outcome variablesTh irty-day and 1-year mortality and 30-day periopera-tive complications were the outcome measures. Mor-tality was ascertained through a combination of the VASQIP data and the VA Vital Status fi le.
Assessing diagnosis of Chronic Obstructive Pulmonary DiseaseHistory of severe COPD is defi ned in VASQIP as “emphy-sema and/or chronic bronchitis resulting in any one or more of the following: functional disability (e.g., dyspnea, inability to perform activities of daily living), hospitalization in the past for treatment of COPD, need for chronic bronchodilator therapy with oral or inhaled agents, or a recorded FEV
1 of <75% of predicted on pul-
monary function testing.” (excluding asthma, interstitial fi brosis and sarcoidosis). We defi ned a second group of subjects as having mild COPD; these subjects had COPD recorded as a diagnosis during a previous clinic visit or hospitalization but did not meet the VASQIP criteria for severe COPD. We postulated that this group would have increased perioperative risks compared to those without any previous diagnosis of COPD. It was not possible to utilize the GOLD criteria (14) in this study of adminis-trative data for COPD severity.
CovariatesVASQIP provided the following covariates: age, gender, and race; preoperative co-morbidities; pre-fracture risk factors (smoking, alcohol use, recent signifi cant weight loss, steroid use), key laboratory values; pre-fracture functional status (independent, partially dependent, or completely dependent); surgical Current Procedural Terminology (CPT) codes; operative times; anesthesia technique; American Society of Anesthesiologists (ASA) class. Th e Elixhauser co-morbidity index was calculated from ICD-9 diagnosis codes within 5 years of surgery from the VA’s PTF inpatient and outpatient fi les (15).
Statistical analysisWe compared demographic and clinical variables using Chi-square or Fisher exact tests for categorical vari-ables, as appropriate, and a t-test or analysis of variance
Table 1. Description of CPT codes.
Description
CPT code 27125 Hemiarthroplasty not femoral neck fracture
CPT code 27235 Percutaneous fi xation of femoral neck fracture
CPT code 27236 Femoral Neck fracture treated with prosthesis or internal fi xation
CPT code 27244 Intertrochanteric fractures and sliding hip screw
CPT code 27245 Intertrochanteric fracture treated with Intramedullary rod
CPT code 27130 Total hip arthroplasty
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for continuous variables between subjects with and without COPD. Guided by these statistical results, we constructed logistic regression models to predict out-comes of mortality and the occurrence of at least one complication. Data were compiled using the Statistical Analysis Software (SAS) (Version 9.1 SAS Corporation, Cary, North Carolina), and analyzed using Stata (release 10.2 SE, StataCorpLP, College Station, Texas).
Results
A total of 12,646 hip fracture repair records were analyzed from VASQIP from 1998 to 2005. Nearly half (47.6%) of patients with hip fractures had COPD. Approximately 26% (3,261 cases) were classifi ed as severe COPD and an additional 2,736 (21.6%) were
classifi ed as mild COPD. Th e annual overall proportion of hip fracture subjects with either mild or severe COPD remained fairly constant over the study period.
Cohort characteristics and surgical details A description of the entire cohort and the COPD sub-groups is presented in Table 2. Th ere were no signifi -cant age diff erences between groups.
Th ere were progressively more White subjects in the mild and severe COPD groups compared to the group without COPD. Pre-morbid functional status was sig-nifi cantly worse only in the severe COPD group. Both current smoking status (24%, 35%, and 43%) and fre-quent alcohol use (13%, 15%, 18%) were progressively more common in the mild and severe COPD groups compared to no COPD. Ten percent of the severe
Table 2. Patient characteristics by COPD status** (1998–2005).
No COPD Mild COPD Severe COPD P-value*
Number of Cases (n) 6,649 2,736 3,261
Age, years (mean)1 72.8 73.7 74.4 0.11
Age <65 (% of sample) 24 21 15 0.40
Age 65–74 (% of sample) 24 26 30
Age 75–84 (% of sample) 42 44 47
Age 85+ (% of sample) 11 10 8
Race Category1
White (% of sample) 72 76 81 <0.001
Black (% of sample) 12 11 7
Hispanic (% of sample) 5 4 3
Other (% of sample) 1 0 0
Unknown (% of sample) 10 8 8
Current Smoker* (% of sample)1 24 35 43 <0.001
Frequent Alcohol* (% of sample)1 13 15 18 <0.001
Steroid Use (% of sample)1 2 2 10 <0.001
Premorbid Functional Status1
Independent (% of sample) 59 59 51 <0.001
Partial Dependence (% of sample) 32 33 40
Dependent (% of sample) 9 8 9
Other Pre-Fracture Diagnoses:
Count of Co-morbidities (Elixhauser)2 4.3 5.7 5.5 <0.001
Osteoporosis (% of sample)2 2.7 2.9 2.6 0.3
Dementia2 19 18 14 <0.001
Recent Signifi cant weight loss1 3 4 8 <0.001
Diabetes1 22 20 18 <0.001
CHF1 4 6 11 <0.001
*P-values refl ect results of Chi-Square tests of differences across categories for discrete measures or ANOVA with post-estimation tests across COPD categories for continuous measures.** Severe COPD is identifi ed by VASQIP interview as: “emphysema and/or chronic bronchitis resulting in any one or more of the following: functional disability (e.g., dys-pnea, inability to perform activities of daily living), hospitalization in the past for treatment of COPD, need for chronic bronchodilator therapy with oral or inhaled agents, or an FEV1 of <75% of predicted on pulmonary function testing”.Mild COPD are those subjects who had a previous clinic visit or hospitalization with an ICD-9 code for COPD but did not meet the VASQIP criteria.1 Information derived from the VASQIP data2 Information derived from patient medical records.
COPD patients used steroids for a chronic condition compared to 2% in the mild COPD and non-COPD groups. Both mild and severe COPD subjects had sig-nifi cantly more co-morbidities (15, 16) with mean Elix-hauser scores of 5.7 and 5.5 respectively compared to 4.3 (p < 0.001) for patients without a history of COPD. Of interest, the severe COPD subjects had signifi cantly less dementia and diabetes but more congestive heart failure (CHF) and more recent weight loss compared to the other two groups. Prior knowledge of osteoporosis in all of the groups was infrequent, with less than 3% of the subjects having a recorded diagnosis in their medi-cal records.
Details of the surgical procedures were informative (Table 3). ASA class was incrementally higher (imply-ing sicker patients) in both the mild and severe COPD subjects. Both mild and severe COPD subjects were signifi cantly less likely to have general anesthesia (GA) compared to the group without COPD (No COPD - 68% had GA; mild COPD - 63% had GA; severe COPD - 55% had GA, p < 0.001). Th e mean operating time was signifi cantly lower in both the mild and severe COPD subjects (p < 0.001). However, there were no diff erences
identifi ed between relative work units (RVU) reported per case, nor pre-op wound classifi cations.
Mortality and complicationsMortality at 30 days and 1-year as well as post-operative complications for the cohort are shown in Figure 1. Subjects with COPD had nearly double (6.8% to 11.7%, p < .001) the 30-day mortality compared to those without COPD; 1-year mortality rose from 24.5% to 37.6% between subjects without COPD and those with severe COPD. Perioperative complications were simi-larly increased in COPD subjects compared to those without. COPD subjects had more cardiopulmonary related complications – pneumonia, failure to wean, reintubation for respiratory and cardiac complications and cardiac arrest (See Table 4). Severe COPD patients had more wound infections and were signifi cantly more likely to develop sepsis than those with mild or no COPD (1.4%, 1.3% vs. 3.3%, p < 0.001). Th ere was no signifi cant diff erence between the two groups in myocardial infarc-tion (MI), stroke, deep vein thrombosis/pulmonary embolism (DVT/PE), major blood loss nor peripheral nerve injury (data not shown).
Table 3. Operative characteristics by COPD status** (1998–2005).
No COPD Mild COPD Severe COPD P-value*
Number of Cases (n) 6,649 2,736 3,261
Operating Time (mean hours) 1.6 1.5 1.5 <0.001
Work RVU’s/complexity (higher -> more complex) 15.8 15.8 15.8 0.795
Wound Class (% of cases)
clean 97.6 97.7 96.7
clean contaminated 2.2 2.1 3.2 0.068
contaminated 0.1 0.1 0.1
infected 0.1 0.1 0.0
general anesthesia (vs. other method) (% of cases) 68 63 55 <0.001
Operation Delayed 4+ days (%) 25.8 29.4 31.7 <0.001
Days from Admit to Surgery (avg) 5.1 5.0 4.1 0.85
*P-values refl ect results of Chi-Square tests of differences across categories for discrete measures or ANOVA with post-estimation tests across COPD categories for continuous measures.** Severe COPD is identifi ed by VASQIP interview as: “emphysema and/or chronic bronchitis resulting in any one or more of the following: functional disability (e.g., dys-pnea, inability to perform activities of daily living), hospitalization in the past for treatment of COPD, need for chronic bronchodilator therapy with oral or inhaled agents, or an FEV1 of <75% of predicted on pulmonary function testing”.Mild COPD are those subjects who had a previous clinic visit or hospitalization with an ICD-9 code for COPD but did not meet the VASQIP criteria.All data for Table 3 was derived from the VASQIP non-cardiac fi le.
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Th e logistic regression models (see Table 5) confi rmed that severe COPD vs. no COPD was a signifi cant risk factor for 30-day and 1-year mortality after adjusting for the covariates shown. C-statistics for these models suggested good model fi t. Age, Caucasian race, steroid use, dementia, lack of functional independence, use of general anesthesia, ASA class 3 and 4 and recent weight loss were also signifi cant predictors of 30-day and 1 year
mortality. A delay in surgery of greater than 4 days was strongly associated with 30-day mortality, 1 year mor-tality and increased complications. Early discharge after surgery and heavy alcohol use were associated with reduced odds ratios for mortality. Dementia, steroid use and co morbidity count were signifi cantly related to 30-day and 1-year mortality. Variables predicting 1-year mortality were similar to 30-day, except that current smoking, race, early discharge and use of general anes-thesia were not predictive. Interestingly, current smok-ing was only signifi cant as a predictor of 30-daymortality but not complications or 1-year mortality.
Perioperative complications showed many of the same predictive factors as the mortality models. Severe COPD was a signifi cant predictor of complications within 30 days after adjusting for other variables. Age, race, ASA class, functional pre-morbid status, recent weight loss, history of congestive heart failure and the co-morbidities count were also important predictors for post operative complications in the model. Heavy alcohol use and choice of general anesthesia were both associated with peri-operative complications.
Discussion
In this analysis of 12,646 men with hip fractures treated surgically within the VA hospital system we found that COPD was strongly associated with increased mortality after hip fracture surgery. Th e association of COPD with death persisted after adjusting for other factors including lower baseline physical function. Males with hip fracture have previously been reported to have worse outcomes than females (21–23), and our cohort’s 1-year mortality rates (24–38%) are similar to those previously reported for men. Th is study confi rms previous fi ndings that COPD is a major factor predicting mortality and complications.
Beyond the patient characteristics of age, co-morbid disease and worse ASA class, important predictors of hip fracture outcomes are: current smoking, pre-morbid functional status and pre-existing dementia. Th ese patient characteristics are not modifi able in the peri-operative period. However, after adjustment for these factors, the eff ect of operative delays greater than 4 days on both short term and long term mortality remained signifi cant. Likewise, use of general anesthesia remained a predictor of short term mortality and complications after adjustment, and 55% of severe COPD subjects had a general anesthetic. Th us, operative delays and anesthetic choice appeared to represent opportunities for improved management of hip fracture patients and especially those with COPD.
Reasons for surgical delays included acute medical problems that require treatment and lack of operating room/staff availability. Recent work suggests that lack of standardization in preparing patients for surgery plays a role in the variation related to delays from medical prob-lems (17). Quality improvement projects and further research are needed to establish critical factors for hip
Figure 1. Outcomes of hip fractures in men. Three major outcomes of hip fractures in men treated within the VAH system were studied in detail: 30 day mortality, one or more perioperative complications and 1 year mortality. Unadjusted percentages for 30 day mortality (A), complications (B) and 1 year mortality (C) are shown. Severe COPD (that required chronic medication or impacted function) was associated with greater mortality and more complications (p<0.0001 for each outcome in both the unadjusted comparisons and the adjusted logistic regression model). In adjusted models there was no signifi cant difference for mild COPD compared to no COPD. Unadjusted comparisons of mild COPD compared to no COPD indicated no signifi cant difference in the 30-day rates of mortality or complications, but a higher 1-year mortality rate for patients with mild COPD (t-test p<0.001).
fracture patients that must be rapidly corrected (severe anemia, untreated infections and metabolic abnormali-ties) and those which cannot be corrected and must be accepted and managed during the perioperative period (underlying heart or lung disease). Addressing these issues may allow guidelines to be established for ensuring that patients are treated quickly and appropriately. Individual hospitals should monitor and address the delays related to lack of timely operating room capacity for hip fractures.
A critical diff erence between the COPD and non-COPD groups was in anesthesia choice. General anes-thesia remains a signifi cant predictor of increased mor-tality and greater perioperative complications in our adjusted models. Th e non-COPD group was much more likely to have received general anesthesia (68% compared to 55%). Previous work from the VASQIP project had already suggested that general anesthesia was associated with higher mortality and complication rates in hip frac-tures, which may be refl ected in the lower rates we see in the COPD patients (6).
In the United Kingdom more than 70% of hip frac-tures surgeries are performed with spinal or other regional anesthesia techniques (18) and a study from Spain reports greater than 90% of hip fracture patients receiving regional anesthesia (17), suggesting random-ized trials of anesthetic choice for hip fracture patients with and without COPD would be helpful to determine if decreased use of general anesthesia would improve hip fracture outcomes.
Classifying VA hip fracture cases with COPD as mild or severe is an innovation of this study. Th e mild sub-jects were identifi ed from within the “control group” of subjects without clearcut COPD. We found that mild disease that has not resulted in functional limitations
or required chronic medication is still associated with more co-morbid conditions and non-signifi cant increases in mortality and complications after adjusting for other covariates. Because our analysis was based on administrative data we are not able to defi ne the degree of obstruction in these patients but rather rely on coded diagnoses where presumably the physician was aware of the diagnosis.
Th e group of mild COPD may represent early or mild disease that may not be clearly characterized in a usual or standard pre-op risk assessment. More widespread screening of former smokers might improve risk assess-ment for COPD and lead to greater selection of spinal anesthesia, good post-operative pulmonary toilet and other measures to prevent complications in this group. Although up to half of the population in the United States (and an even larger percentage of veterans) are current or former smokers with potential risk of COPD (19, 20), screening for occult lung disease lags behind screening for cardiovascular disease (21, 22).
Primary prevention of deaths from hip fracture may be eff ected by early identifi cation of osteoporosis in high-risk groups — because treatment of osteoporosis could reduce the risk of and complications following hip fractures. Osteoporosis was infrequently (<3%) identi-fi ed prior to hip fracture in this population. We would advocate for more intensive screening and treatment for patients with current smoking history or signifi cant past history of tobacco use, as well as in known or suspected COPD.
Diagnosis and treatment of osteoporosis has been shown to reduce fracture risk by up to 25% (23). Several studies have shown high rates of osteoporosis in COPD subjects, including men (24–26). Men with COPD have
Table 4. Complications by COPD status** (1998–2005).
No COPD Mild COPD Severe COPD P-value*
Number of Cases (n) 6,649 2,736 3,261
Reintubation (% of cases) 2.4 2.9 4.9 <0.001
Failure to Wean (% of cases) 1.3 1.35 3.4 <0.001
Pneumonia (% of cases) 5.5 5.7 9.4 <0.001
Wound Infection (% of cases) 2.4 2.3 3.3 0.009
Sepsis (% of cases) 1.4 1.6 2.8 <0.001
Bleeding requiring >4 units transfusion (% of cases) 0.66 0.44 0.58 0.44
DVT (% of cases) 0.9 1.2 0.6 0.05
CVA (% of cases) 0.5 0.6 0.6 0.85
Cardiac arrest (% of cases) 1.7 1.7 2.4 0.027
MI (% of cases) 0.99 0.91 1.38 0.14
*P-values refl ect results of Chi-Square tests of differences across COPD categories.** Severe COPD is identifi ed by VASQIP interview as: “emphysema and/or chronic bronchitis resulting in any one or more of the following: functional disability (e.g., dyspnea, inability to perform activities of daily living), hospitalization in the past for treatment of COPD, need for chronic bronchodilator therapy with oral or inhaled agents, or an FEV1 of <75% of predicted on pulmonary function testing”.Mild COPD are those subjects who had a previous clinic visit or hospitalization with an ICD-9 code for COPD but did not meet the VASQIP criteria.Presence of these complications within 30-days of surgery was derived from the VASQIP non-cardiac data fi le.
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high rates of fractures, but are not commonly screened for osteoporosis (27). Other recent studies suggest that diagnosis and treatment for osteoporosis in COPD patients is poor (28), making them an important group for prevention strategies.
Strengths of this study include the large number of subjects and the extensive perioperative data available in the VASQIP data collection that allowed more detailed understanding of surgical details than is typically off ered
in observational studies. Th e study was limited to men because of the small numbers of female VA patients identifi ed with hip fracture surgeries. However, since other studies have found that men typically have worse outcomes after hip fracture, the sample for this study may present the best opportunity for improving out-comes in this understudied group. A longitudinal study of hip fractures in New York City during a similar time frame reported only 8.5% of their subjects with COPD
*p-values are based on 95% confi dence intervals for odds ratios. Standard errors were calculated using robust regression.** “Severe” COPD and “Mild” COPD are defi ned in text but are not based on GOLD criteria. Bolded values highlight variables that are signifi cant with a p-value <0.05.1 Variable derived from the patient medical record (vs. VASQIP).
and a marginally signifi cant hazard ratio of COPD for mortality (29). Our larger sample size and higher preva-lence of disease may have improved our ability to detect this eff ect in our cohort.
Our fi ndings indicate several opportunities for future research. Th e presence and impact of pre-existing lung disease in hip fracture subjects needs further explora-tion in a prospective study. Formally testing the impact of spinal and general anesthesia on mortality and the incidence of pulmonary and infectious complications in a randomized clinical trial would address what is now a largely empiric choice by surgeons and anesthesiolo-gists. Hip fracture is a sentinel event that poses many subsequent health challenges for patients. Results of our study indicate that hip fracture patients with COPD face even more challenges to recovery.
Acknowledgments
Th e authors also acknowledge the VA Surgical Quality Data Use Group (SQDUG) for its role as scientifi c advi-sors and for the critical review of data use and analysis presented in this manuscript. Th e opinions expressed are those of the authors and not necessarily those of the Department of Veterans Aff airs or the United States Government.
Declaration of Interest
Th e authors report no confl icts of interest. Th e authors alone are responsible for the content and writing of the paper.
Th is research was supported by the Department of Veterans Aff airs, Veterans Health Administra-tion, Offi ce of Research and Development, Health Services Research and Development Service through the Research Enhancement Award Program and an investigator-initiated grant (IIR 04-173). Drs. Radcliff , Cowper Ripley, and Hutt received salary support from the VA.
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