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Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass

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Abstract

Objective

Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB).

Methods

A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland–Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared.

Results

The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t = 57.9, p < 0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p < 0.001) except for small bowel division details (p = 0.530). Accuracy was significantly higher for SR than NR (94.2% ± SD 4.31% vs. 53.6% ± SD 9.82%, respectively, p < 0.001). Rater agreement was excellent for both SR (0.11, 95% LOA −0.53 to 0.75) and NR (−0.26, 95% LOA −4.85 to 4.33) (p = 0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55 min ± SD 1:26 min and 4:50 min ± SD 0:50 min, respectively, p = 0.007).

Conclusion

The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

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References

  1. Chambers AJ, Pasieka JL, Temple WJ (2009) Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system. Surgery 146:1090–1098

    Article  PubMed  Google Scholar 

  2. Edhemovic I, Temple WJ, de Gara CJ, Stuart GC (2004) The computer synoptic operative report–a leap forward in the science of surgery. Ann Surg Oncol 11:941–947

    Article  PubMed  Google Scholar 

  3. Gardner GJ, Leitao MM, Mitchell M, Levine DA, Brown CL, Sonoda Y, Abu-Rustum NR, Chi DS, Barakat RR, Hoskins WJ (2009) Prototype of a synoptic electronic operative note for gynecologic oncology surgical procedures. Gynecol Oncol (1):S64–S65

  4. Gur I, Gur D, Recabaren JA (2012) The computerized synoptic operative report: a novel tool in surgical residency education. Arch Surg 147:71–74

    Article  PubMed  Google Scholar 

  5. Harvey A, Zhang H, Nixon J, Brown CJ (2007) Comparison of data extraction from standardized versus traditional narrative operative reports for database-related research and quality control. Surgery 141:708–714

    Article  CAS  PubMed  Google Scholar 

  6. Hoffer DN, Finelli A, Chow R, Liu J, Truong T, Lane K, Punnen S, Knox JJ, Legere L, Kurban G, Gallie B, Jewett MA (2012) Structured electronic operative reporting: comparison with dictation in kidney cancer surgery. Int J Med Inform 81:182–191

    Article  PubMed  Google Scholar 

  7. Maniar RL, Hochman DJ, Wirtzfeld DA, McKay AM, Yaffe CS, Yip B, Silverman R, Park J (2014) Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports. Ann Surg Oncol 21:3592–3597

    Article  PubMed  Google Scholar 

  8. Maniar RL, Sytnik P, Wirtzfeld DA, Hochman DJ, McKay AM, Yip B, Hebbard PC, Park J (2015) Synoptic operative reports enhance documentation of best practices for rectal cancer. J Surg Oncol 112:555–560

    Article  PubMed  Google Scholar 

  9. Park J, Pillarisetty VG, Brennan MF, Jarnagin WR, D’Angelica MI, DeMatteo RP, Coit DG, Janakos M, Allen PJ (2010) Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection. J Am Coll Surg 211:308–315

    Article  PubMed  Google Scholar 

  10. Paterson GI, Christie S, Bonney W, Thibault-Halman G (2015) Synoptic operative reports for spinal cord injury patients as a tool for data quality. Health Inform J

  11. Cowan DA, Sands MB, Rabizadeh SM, Amos CS, Ford C, Nussbaum R, Stein D, Liegeois NJ (2007) Electronic templates versus dictation for the completion of Mohs micrographic surgery operative notes. Dermatol Surg 33:588–595

    CAS  PubMed  Google Scholar 

  12. Laflamme MR, Dexter PR, Graham MF, Hui SL, McDonald CJ (2005) Efficiency, comprehensiveness and cost-effectiveness when comparing dictation and electronic templates for operative reports. In: AMIA annual symposium proceedings/AMIA SymposiumAMIA Symposium, pp 425–429

  13. Nicopoullos JDM, Karrar S, Gour A, Panter K (2003) Significant improvement in quality of caesarean section documentation with dedicated operative proforma—completion of the audit cycle. J Obstet Gynaecol 23:381–386

    Article  CAS  PubMed  Google Scholar 

  14. Thomson DR, Baldwin MJ, Bellini MI, Silva MA (2016) Improving the quality of operative notes for laparoscopic cholecystectomy: assessing the impact of a standardized operation note proforma. Int J Surg 27:17–20

    Article  CAS  PubMed  Google Scholar 

  15. Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N (2015) Bariatric surgery worldwide 2013. Obes Surg 25(10):1822–1832

    Article  CAS  PubMed  Google Scholar 

  16. Parikh JA, Yermilov I, Jain S, McGory ML, Ko CY, Maggard MA (2007) How much do standardized forms improve the documentation of quality of care? J Surg Res 143:158–163

    Article  PubMed  Google Scholar 

  17. Kennedy ED, Milot L, Fruitman M, Al-Sukhni E, Heine G, Schmocker S, Brown G, McLeod RS (2014) Development and implementation of a synoptic MRI report for preoperative staging of rectal cancer on a population-based level. Dis Colon Rectum 57:700–708

    Article  PubMed  Google Scholar 

  18. Chan NG, Duggal A, Weir MM, Driman DK (2008) Pathological reporting of colorectal cancer specimens: a retrospective survey in an academic Canadian pathology department. Can J Surg 51(284–288):285p

    Google Scholar 

  19. Gillman LM, Vergis A, Park J, Minor S, Taylor M (2010) Structured operative reporting: a randomized trial using dictation templates to improve operative reporting. Am J Surg 199:846–850

    Article  PubMed  Google Scholar 

  20. Vergis A, Gillman L, Minor S, Taylor M, Park J (2008) Structured assessment format for evaluating operative reports in general surgery. Am J Surg 195:24–29

    Article  PubMed  Google Scholar 

  21. Buchwald H, Oien DM (2013) Metabolic/bariatric surgery worldwide 2011. Obes Surg 23(4):427–436

    Article  PubMed  Google Scholar 

  22. Vergis A, Stogryn S, Mullan MJ, Hardy K (2017) Electronic synoptic reporting: assessing the completeness of synoptic and narrative reports for Roux-en-Y gastric bypass. Surg Obes Relat Dis. doi:10.1016/j.soard.2017.02.027

    Google Scholar 

  23. Stogryn S, Hardy K, Park J, Vergis A (2017) Bariatric operative reporting: perceptions of quality amongst Canadian bariatric surgeons. Surg Obes Relat Dis 13(3):429–435

    Article  PubMed  Google Scholar 

  24. Maggard MA, Ml McGory, Pg Shekelle, Ko CY (2006) Quality indicators in bariatric surgery: improving quality of care. Surg Obes Relat Dis 2:423–430

    Article  PubMed  Google Scholar 

  25. Stogryn S, Hardy K, Park J, Vergis A (2017) Development of consensus-derived quality indicators for bariatric surgery. Surg Obes Relat Dis 13(2):198–203

    Article  PubMed  Google Scholar 

  26. Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1:307–310

    Article  CAS  PubMed  Google Scholar 

  27. Edhemovic I, Temple WJ, de Gara CJ, Stuart GC (2004) The computer synoptic operative report–a leap forward in the science of surgery. Ann Surg Oncol 11:941–947

    Article  PubMed  Google Scholar 

  28. Urquhart R, Porter GA, Sargeant J, Jackson L, Grunfeld E (2014) Multi-level factors influence the implementation and use of complex innovations in cancer care: a multiple case study of synoptic reporting. Implement Sci 9:121

    Article  PubMed  PubMed Central  Google Scholar 

  29. DeOrio JK (2002) Surgical templates for orthopedic operative reports. Orthopedics 25:639–642

    PubMed  Google Scholar 

  30. Novitsky YW, Sing RF, Kercher KW, Griffo ML, Matthews BD, Heniford BT, Flynn MB, Reiling RB, Rhoads JE Jr, Field RJ Jr, Korndorffer JR (2005) Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents. Am Surg 71:627–632

    PubMed  Google Scholar 

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Acknowledgements

The authors would like to acknowledge Dr. Bryce Lowry for his contribution to the data collection for the additional analyses of this study.

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Authors and Affiliations

  1. Department of Surgery, University of Manitoba, Winnipeg, MB, Canada

    Shannon E. Stogryn, Krista Hardy, Michael J. Mullan, Jason Park, Christopher Andrew & Ashley Vergis

  2. St. Boniface Hospital, Z3039-409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada

    Ashley Vergis

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  1. Shannon E. Stogryn
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  2. Krista Hardy
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Correspondence to Ashley Vergis.

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Disclosures

Dr.’s Shannon E. Stogryn, Krista Hardy, Michael J. Mullan, Jason Park, Christopher Andrew, and Ashley Vergis have no conflicts of interest or financial ties to disclose.

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Stogryn, S.E., Hardy, K., Mullan, M.J. et al. Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass. Surg Endosc 32, 1729–1739 (2018). https://doi.org/10.1007/s00464-017-5855-8

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