imageBy Christina Frangou

Surgeons in Washington state are targeting surgical complications by focusing on something often overlooked in quality initiatives: the things that patients can do to improve their outcomes in the weeks and days before they come into the operating room.

Surgeons in the state have launched a new program called Strong for Surgery. The first large-scale program to target the preoperative well-being of patients, it is designed to educate health care providers and patients about things patients can do to better prepare themselves for elective surgery.

“Most things we’ve done to improve quality are based on the idea that it’s what we do once the patients get into the hospital that makes the difference in outcomes, but that’s not the whole story. We can often identify patients who are going to have a good outcome or a bad outcome when we see them in the office and that’s the time to intervene,” said David Flum, MD, a general surgeon at the University of Washington who came up with the idea for Strong for Surgery.

Dr. Flum, who led the creation of the state’s quality program, the Surgical Care and Outcomes Assessment Program (SCOAP), is partnering in the Strong for Surgery initiative together with the University of Washington’s Comparative Effectiveness Research Translation Network and the American College of Surgeons’ Education Division.

Strong for Surgery aims to get patients in peak shape for surgery by targeting the known patient risk factors for poor outcomes, specifically those risk factors that can be addressed in a period of several weeks or months. The initiative is focused on four key areas: preoperative nutritional status and the use of immunonutrition, glycemic control and diabetes management, smoking cessation and medication use.

Preoperative counseling and patient engagement are things that bariatric surgeons have done for years. But outside of bariatric surgery, surgeons have not routinely required patients to modify their high-risk factors.

Organizers hope that patients can help bring about a “move-the-needle kind of improvement in outcomes that we’ve been looking for, for 20 years,” said Dr. Flum.


Other quality initiative programs such as SCOAP and the National Surgical Quality Improvement Program have whittled away at surgical complication rates by targeting the actions of surgeons and hospital staff once a patient is admitted, said Dr. Flum. By doing so, they have missed some of the most critical elements when it comes to patient outcomes. Study after study has shown that the modifiable factors that bear the greatest influence on outcomes are not always things like surgeon volume and operative times; rather, they are patient characteristics like smoking, nutritional status, glycemic control and medication use.

For instance, malnourished patients undergoing surgery for gastrointestinal (GI) cancer have more than 10-fold increased morbidity. That’s often a problem that can be identified on a standardized screening and addressed with a nutritionist’s intervention. Another example: Among patients who do not have malnutrition but are planning to have GI surgery, a five-day course of a nutrition formula with arginine and omega-6 fatty acids can decrease the risk for complications dramatically, according to a meta-analysis looking at 3,104 patients across 28 randomized controlled trials. This type of supplementation, often referred to as immunonutrition, is associated with a 41% reduction in risk for infectious complications after elective surgery (J Parenter Enteral Nutr 2010;34:378-388).

“That’s the kind of game changer that we have been looking for,” said Dr. Flum.

Surgical experts not affiliated with the program said they expect surgeons will offer broad support for the initiative. Strong for Surgery will encourage patients to be more proactive about reducing their surgical risk, which should translate into better outcomes and better informed consent.

“Times have changed and cultures have changed. Now, patients know that they are an integral part of the operation and they, too, can contribute to better things happening to them rather than them just coming to the plate and asking to be taken care of,” said Julie A. Freischlag, MD, William Stewart Halsted professor and surgeon-in-chief, The Johns Hopkins Hospital, Baltimore.

“At the same time, we also feel empowered to tell people that there are things they need to do to. In the end, if we can get patients to do it, I think this will be a game changer.”

Tom Varghese Jr, MD, director of Strong for Surgery, a patient-centered approach to improving the health of patients in the pre-surgical clinic.

After being tested in a pilot project last year, Strong for Surgery is being rolled out to about 55 partner offices throughout Washington state for more testing. SCOAP hospitals will report use of the different measures and organizers will use those results to develop a standardized checklist that can be integrated into every surgeon’s office.

“'Strong for Surgery' takes the idea of checklists and moves them to where decisions are mostly being made, before the patient gets to the hospital,” said Dr. Flum. “There would never be an airplane that would start a checklist when it is already moving down the runway, and the same concept applies to surgery. The doctor’s office is the last opportunity to have those important discussions about whether the patient is ready for an operation.”

In this next phase, the campaign will address the nutritional status of all patients before surgery through implementation of nutritional screening and use of evidence-based nutritional support. Results from SCOAP show that one marker of nutritional level (preoperative albumin levels) less than 3.0 g/dL are associated with higher postoperative complication rates: 25% with levels of 2.5 to 2.9 and 50% with levels of 2.0 to 2.4 g/dL.

From there, the campaign will move on to the other modifiable factors like smoking, diabetes control, use of herbal preparations that can increase bleeding risk or anesthesia complications, and the use of medications like aspirin and β-blockers that patients may be taking chronically, said Richard P. Billingham, MD, clinical professor of surgery, University of Washington, and medical director for quality and education in colorectal surgery at Swedish Cancer Institute and Medical Center in Seattle. He will retire this winter after instituting the Strong for Surgery program in Swedish Hospital.

Dr. Billingham noted that important research questions must be answered before the nutrition program expands beyond the test hospitals. Much of the existing research was conducted with industry sponsorship and authorship. “Therefore, the objectivity of the results is a little bit in question.” Investigators also need to assess the effectiveness of nutritional supplements in the real world and their cost-effectiveness. Right now, patients pay about $60 for the immunonutrition supplements.

More information about the program is available at the Strong for Surgery website (​strong_for_surgery).

Strong for Surgery receives support from the ACS Division of Education, the Agency for Healthcare Research and Quality, the Life Sciences Discovery Fund and Nestlé HealthCare Nutrition. The latter does not provide funding to promote a specific product.