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Hulse K. Consequences of minimum surgeon volumes in ENT. Clin Otolaryngol 2024; 49:529-530. [PMID: 38689451 DOI: 10.1111/coa.14174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/05/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Kate Hulse
- Department of Otolaryngology, University Hospital Monklands, NHS Lanarkshire, Airdrie, UK
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Joyner J, Ayyaz FM, Cheetham M, Briggs TWR, Gray WK. Factors associated with conversion from day-case to in-patient elective inguinal hernia repair surgery across England: an observational study using administrative data. Hernia 2024; 28:555-565. [PMID: 38347244 DOI: 10.1007/s10029-023-02949-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/16/2023] [Indexed: 04/06/2024]
Abstract
PURPOSE Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, some patients planned for day-case surgery have to stay in hospital for at least one night. The aim of this study was to identify the factors associated with conversion from day-case to in-patient management for elective inguinal hernia repair surgery. METHODS This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 that was planned as day-case surgery were identified. The exposure of interest was discharged on the day of admission (day-case) or requiring overnight stay. The primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level. RESULTS A total of 351,528 planned day-case elective primary inguinal hernia repairs were identified over the eight-year study period. Of these, 45,305 (12.9%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions. Patients who converted to in-patient stay were older, had more comorbidities, and were more likely to have bilateral surgery and be operated on by a low-annual volume surgeon. Post-procedural complications were strongly associated with conversion. Across the 42 ICBs in England, model-adjusted conversion rates varied from 3.3% to 21.3%. CONCLUSIONS There was considerable variation in conversion to in-patient stay rates for inguinal hernia repair across ICBs in England. Our findings should help surgical teams to better identify patients suitable for day-case inguinal hernia repair and plan discharge services more effectively. This should help to reduce the variation in conversion rates.
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Affiliation(s)
- J Joyner
- Getting It Right First Time Programme, NHS England and NHS Improvement, London, UK.
- Department of General Surgery, Croydon Health Services NHS Trust, Croydon University Hospital, 530 London Road, Croydon, CR7 7YE, UK.
| | - F M Ayyaz
- Getting It Right First Time Programme, NHS England and NHS Improvement, London, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - M Cheetham
- Getting It Right First Time Programme, NHS England and NHS Improvement, London, UK
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - T W R Briggs
- Getting It Right First Time Programme, NHS England and NHS Improvement, London, UK
- Royal National Orthopaedic Hospital, London, UK
| | - W K Gray
- Getting It Right First Time Programme, NHS England and NHS Improvement, London, UK
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3
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Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Silber JH, Fleisher LA. Assessing the Ambulatory Surgery Center Volume-Outcome Association. JAMA Surg 2024; 159:397-403. [PMID: 38265816 PMCID: PMC10809135 DOI: 10.1001/jamasurg.2023.7161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/01/2023] [Indexed: 01/25/2024]
Abstract
Importance In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US. Objective To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity. Design, Setting, and Participants This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019. Main Outcomes and Measures Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures). Results Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity. Conclusions and Relevance In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.
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Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Statistics and Data Science, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Omar I. Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- The Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Lee A. Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia
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Wright K, Squires S, Cisco R, Trickey A, Kebebew E, Suh I, Seib CD. Disparities in access to high-volume parathyroid surgeons in the United States: A call to action. Surgery 2024; 175:48-56. [PMID: 37940435 PMCID: PMC10942749 DOI: 10.1016/j.surg.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/13/2023] [Accepted: 03/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Parathyroidectomy by a high-volume surgeon is associated with a reduced risk of perioperative complications and of failure to cure primary and secondary hyperparathyroidism. There are limited data on disparities in access to high-volume parathyroid surgeons in the United States. METHODS We used publicly available 2019 Medicare Provider Utilization and Payment data to identify all surgeons who performed >10 parathyroidectomies for Medicare fee-for-service beneficiaries, anticipating that fee-for-service beneficiaries likely represent only a subset of their high-volume practices. High-volume parathyroid surgeon characteristics and geographic distribution were evaluated. Inequality in the distribution of surgeons was measured by the Gini coefficient. The association between neighborhood disadvantage, based on the Area Deprivation Index, and proximity to high-volume parathyroid surgeons was evaluated using a one-way analysis of variance with Bonferroni-corrected pairwise comparisons. A sensitivity analysis was performed restricting to high-volume parathyroid surgeons within each hospital referral region, evidence-based regional markets for tertiary medical care. RESULTS We identified 445 high-volume parathyroid surgeons who met inclusion criteria with >10 parathyroidectomies for Medicare fee-for-service beneficiaries. High-volume parathyroid surgeons were 71% male sex, and 59.8% were general surgeons. High-volume parathyroid surgeons were more likely to practice in a Metropolitan Statistical Area with a population >1 million than in less populous metropolitan or rural areas. The number of high-volume parathyroid surgeons per 100,000 fee-for-service Medicare beneficiaries in the 53 most populous Metropolitan Statistical Areas ranged from 0 to 4.94, with the highest density identified in Salt Lake City, Utah. In 2019, 50% of parathyroidectomies performed by high-volume parathyroid surgeons were performed by 20% of surgeons in this group, suggesting unequal distribution of surgical care (Gini coefficient 0.41). Patients in disadvantaged neighborhoods were farther from high-volume parathyroid surgeons than those in advantaged neighborhoods (median distance: disadvantaged 27.8 miles, partially disadvantaged 20.7 miles, partially advantaged 12.1 miles, advantaged 8.4 miles; P < .001). This association was also shown in the analysis of distance to high-volume parathyroid surgeons within the hospital referral region (P < .001). CONCLUSION Older adults living in disadvantaged neighborhoods have less access to high-volume parathyroid surgeons, which may adversely affect treatment and outcomes for patients with primary and secondary hyperparathyroidism. This disparity highlights the need for actionable strategies to provide equitable access to care, including improved regionalization of high-volume parathyroid surgeon services and easing travel-related burdens for underserved patients.
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Affiliation(s)
- Kyla Wright
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Robin Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Amber Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA.
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Gao TP, Green RL, Kuo LE. Disparities in Access to High-Volume Surgeons and Specialized Care. Endocrinol Metab Clin North Am 2023; 52:689-703. [PMID: 37865482 DOI: 10.1016/j.ecl.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
The significant volume-outcome relationship has triggered interest in improving quality of care by directing patients to high-volume centers and surgeons. However, significant disparities exist for different racial/ethnic, geographic, and socioeconomic groups for thyroid, parathyroid, adrenal, and pancreatic neuroendocrine surgical diseases disease.
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Affiliation(s)
- Terry P Gao
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA
| | - Rebecca L Green
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA
| | - Lindsay E Kuo
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA.
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Arwyn-Jones J, Ross T, Navaratnam A, George M, Machin JT, Briggs TWR, Tolley N. Litigation in thyroid surgery: a pan-specialty review of National Health Service (UK) data. J Laryngol Otol 2023; 137:1200-1206. [PMID: 37283184 DOI: 10.1017/s0022215123001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Thyroid surgery carries risks that significantly impact patients. This paper describes the landscape of thyroid surgery related litigation claims in the National Health Service from April 2015 to April 2020, to establish learning points in order to improve patient care and minimise litigation risk. METHODS Data were requested from National Health Service Resolution and Hospital Episode Statistics. Claims were classified into operative and non-operative causes. Subspecialty information, incident details and claim costings were analysed. RESULTS Sixty claims were identified. Thirty-eight claims (63.3 per cent) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349. Claims related to diagnostic issues were most common (n = 19); of claims associated with operative causes (n = 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited. CONCLUSION Utilisation of well-established protocols will likely reduce litigation in thyroid surgery, as we move towards a landscape in which the patient journey is thoroughly scrutinised for targeted improvements.
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Affiliation(s)
| | - Talisa Ross
- Otolaryngology, Royal London Hospital, London, UK
- University College London, London, UK
| | | | | | - John T Machin
- Orthopaedics, King's College Hospital, London, UK
- Getting It Right First Time Programme, NHS England, London, UK
| | - Tim W R Briggs
- Getting It Right First Time Programme, NHS England, London, UK
- Royal National Orthopaedic Hospital, London, UK
| | - Neil Tolley
- Otolaryngology, St Mary's Hospital, London, UK
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Nomine-Criqui C, Nguyen-Thi PL, Van Slycke S, Makay O, Brunaud L, Bergenfelz A. Role of hospital and patient factors in the outcome of reoperations for primary hyperparathyroidism: a retrospective multicenter cohort study. Int J Surg 2023; 109:3441-3449. [PMID: 37578454 PMCID: PMC10651301 DOI: 10.1097/js9.0000000000000613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/11/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND There are few data on outcomes after reintervention for persistent or recurrent primary hyperparathyroidism (PHPT). The authors hypothesized that the variation in outcomes at the hospital level after reoperation would be significant. After accounting for this variability, some patient-level clinical criteria could be identified to help inform treatment decisions in this patient population. The aim of this study was to determine whether there is significant variation in outcomes after reoperation for PHPT between hospitals (hospital-level analysis) and identify clinical factors (patient-level analysis) that influence postoperative outcomes. MATERIALS AND METHODS This retrospective multicenter cohort study was performed using the Eurocrine registry. Data from 11 countries and 76 hospitals from January 2015 to October 2020 were extracted. A generalized linear mixed model was used to assess the variation in outcomes at the hospital level and to identify risk factors of postoperative outcomes at the patient level. The primary endpoint (textbook outcome) was achieved when all six of the following postoperative conditions were met: no hypocalcemia or persistent hypercalcemia, no laryngeal nerve injury, no negative exploration, no normal parathyroid gland only on histopathology, and no postoperative death. RESULTS Among 13 593 patients who underwent parathyroidectomy for PHPT, 617 (4.5%) underwent reoperative parathyroidectomy. At follow-up, 231 patients (37.4%) were hypocalcemic, 346 (56.1%) were normocalcemic without treatment, and 40 (6.5%) had persistent hypercalcemia. Textbook outcomes were achieved in 321 (52.0%) patients. The hospital-level variation in textbook outcome rates was significant ( P <0.001), and this variation could explain 29.1% of the observed outcomes. The criterion that remained significant after controlling for inter-hospital variation was 'a single lesion on sestamibi scan or positron emission tomography (PET) imaging' (odds ratio 2.08, 95% confidence interval 1.24-3.48; P =0.005). CONCLUSION Outcomes after reoperation are significantly associated with hospital-related factors. A 'single lesion observed on preoperative sestamibi scan or PET' appears relevant to select patients before reoperation.
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Affiliation(s)
- Claire Nomine-Criqui
- Department of Gastrointestinal and Metabolic Surgery (CVMC), University of Lorraine, CHRU Nancy – Hospital Brabois Adultes, and Faculty of Medicine, INSERM NGERE, «Nutrition, Genetics, Environmental Risks», Vandoeuvre-les-Nancy
| | - Phi-Linh Nguyen-Thi
- Department of Medical Informatics and Evaluation, University of Lorraine, CHU Nancy, Nancy, France
| | - Sam Van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw Hospital Aalst, Aalst, Belgium
| | - Ozer Makay
- Department of Surgery, Ege University Hospital, Izmir, Turkey
| | - Laurent Brunaud
- Department of Gastrointestinal and Metabolic Surgery (CVMC), University of Lorraine, CHRU Nancy – Hospital Brabois Adultes, and Faculty of Medicine, INSERM NGERE, «Nutrition, Genetics, Environmental Risks», Vandoeuvre-les-Nancy
| | - Anders Bergenfelz
- Department of Clinical Sciences, Lund University, and Department of Surgery and Gastroenterology, Skane University Hospital, Lund, Sweden
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Murruste M, Kivilo M, Kase K, Kirsimägi Ü, Tähepõld A, Tammiksaar K. The Utility of 4D-CT Imaging in Primary Hyperparathyroidism Management in a Low-Volume Center. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1415. [PMID: 37629704 PMCID: PMC10456658 DOI: 10.3390/medicina59081415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023]
Abstract
Background: Ultrasonography (US) and the 99mTc-sestamibi parathyroid scan (SPS) may have suboptimal accuracy when detecting the localization of enlarged parathyroid gland(s) (PTG). Therefore, the more accurate four-dimensional computed tomography scan (4D-CT) has been employed for PTG imaging. Currently, there is a paucity of data evaluating the utility of 4D-CT in low caseload settings. Aim and Objectives: To evaluate the impact of PTG imaging, using 4D-CT in conjunction with its intraoperatively displayed results, on the outcomes of surgical PTX. Materials and Methods: A single-center retrospective analysis of surgically treated patients with pHPT from 01/2010 to 01/2021 was conducted. An evaluation of the impact of the preoperative imaging modalities on the results of surgical treatment was carried out. Results: During the study period, 290 PTX were performed; 45 cases were excluded due to surgery for secondary, tertiary or recurrent HPT, or due to the use of alternative imaging techniques. The remaining 245 patients were included in the study. US was carried out for PTG imaging in 236 (96.3%), SPS in 93 (38.0%), and 4D-CT in 52 patients (21.2%). The use of 4D-CT was associated with a significantly higher rate of successful localization of enlarged PTG (49 cases, 94.2%) compared to US and SPS (74 cases, 31.4%, and 54 cases, 58.1%, respectively). We distinguished between three groups of patients based on preoperative imaging: (1) PTG lateralization via US or SPS in 106 (43.3%) cases; (2) precise localization of PTG via 4D-CT in 49 (20.0%) patients; and (3) in 90 cases (36.7%), PTG imaging failed to localize an enlarged gland. The group of 4D-CT localization had significantly shorter operative time, lower rate of simultaneous thyroid resections, as well as lower rate of removal of ≥2 PTG, compared to the other groups. The 4D-CT imaging was also associated with the lowest perioperative morbidity and with the lowest median PTH in the one month follow-up; however, compared to the other groups, these differences were statistically not significant. The implementation of 4D-CT (since 01/2018) was associated with a decrease in the need for redo surgery (from 11.5% to 7.3%) and significantly increased the annual case load of PTX at our institution (from 15.3 to 41.0) compared to the period before 4D-CT diagnostics. Conclusions: 4D-CT imaging enabled to precisely locate almost 95% of enlarged PTG in patients with pHPT. Accurate localization and intraoperatively displayed imaging results are useful guides for surgeons to make PTX a faster and safer procedure in a low-volume center.
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Affiliation(s)
- Marko Murruste
- Surgery Clinic of Tartu University Hospital, 50406 Tartu, Estonia; (K.K.); (Ü.K.)
| | - Martin Kivilo
- Faculty of Medicine, University of Tartu, 50406 Tartu, Estonia;
| | - Karri Kase
- Surgery Clinic of Tartu University Hospital, 50406 Tartu, Estonia; (K.K.); (Ü.K.)
- Faculty of Medicine, University of Tartu, 50406 Tartu, Estonia;
| | - Ülle Kirsimägi
- Surgery Clinic of Tartu University Hospital, 50406 Tartu, Estonia; (K.K.); (Ü.K.)
| | - Annika Tähepõld
- Radiology Clinic of Tartu University Hospital, 50406 Tartu, Estonia;
| | - Kaia Tammiksaar
- Internal Medicine Clinic of Tartu University Hospital, 50406 Tartu, Estonia;
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Gray WK, Navaratnam AV, Rennie C, Mendoza N, Briggs TWR, Phillips N. The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery for benign neoplasm: analysis of an administrative dataset for England. Br J Neurosurg 2023:1-8. [PMID: 36740733 DOI: 10.1080/02688697.2023.2175783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/23/2023] [Accepted: 01/28/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England. METHODS Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10-19, 20-29, 30-39 and ≥40 procedures for surgeon volume and < 20, 20-39, 40-59, 60-79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure. RESULTS Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982-1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967-0.987)) and length of stay greater than the median (0.716 (0.597-0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985-0.999)), but with none of the other patient outcomes studied. CONCLUSIONS A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.
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Affiliation(s)
| | - Annakan V Navaratnam
- NHS England and NHS Improvement, London, UK
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Catherine Rennie
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel Mendoza
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Nick Phillips
- NHS England and NHS Improvement, London, UK
- Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Rajan S, Gracie D, Aspinall S. Does Surgeon Volume Impact Morbidity Following Parathyroidectomy? A Study of 16,140 Parathyroidectomies from the UK Registry of Endocrine and Thyroid Surgery (UKRETS) Database. World J Surg 2023; 47:1221-1230. [PMID: 36593341 DOI: 10.1007/s00268-022-06863-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Outcomes in endocrine surgery have been shown to improve with surgeon volume. We aimed to study the effect of surgeon volume on morbidity following parathyroidectomy. METHODS UKRETS data from 2004 to 2019 was studied. Parathyroidectomies for primary hyperparathyroidism with complete data were included. Exclusion criteria were age <18 or >80 years; surgeons contributing <10 cases overall; and length of stay >28 days. Multivariable analysis was performed. Primary outcome was persistent hypercalcaemia; secondary outcomes were haemorrhage, length of stay, need for re-admission, post-operative hypocalcaemia, and need for calcium/vitamin D supplements to maintain eucalcaemia at 6 months. RESULTS 153 surgeons undertook mean 22.5 (median 17, range 2-115) parathyroidectomies/year. Persistent hypercalcaemia affected 4.8% (776/16140) overall; 5.7% (71/1242) in surgeons undertaking < 10 cases/year; 5.1% (3339/6617) for 10-30 cases/year; 5.0% (270/5397) for 30-50 cases; and 3.3% (96/2884) for >50 cases/year. High-volume (>50 parathyroidectomies/year) surgeons operated 23.4% (809/3464) of negative localisation cases compared to 16.4% (2074/12676) of positive localisation cases. Persistent hypercalcaemia was almost twice as common in image negative (7.9%) compared to image-positive (4%) cases. Persistent hypercalcaemia was significantly more likely to occur in the low volume (<10 parathyroidectomies/year) group than high volume (>50 parathyroidectomies/year), regardless of image positivity (p = 0.0006). Surgeon volume significantly reduced persistent hypercalcaemia on multivariable analysis (OR = 0.878, 95%CI 0.842-0.914, p < 0.001), along with age, sex, and positive localisation. BNE and re-operation significantly increased persistent hypercalcaemia. Post-operative hypocalcaemia occurred in 3.2% (509/16040) and was reduced with increasing surgeon volume (OR = 0.951, 95%CI 0.910-0.993, p < 0.001). Haemorrhage and length of stay were not significantly associated with surgeon volume. CONCLUSION The incidence of persistent hypercalcaemia, post-operative hypocalcaemia, and persistent hypoparathyroidism decreased with increasing surgeon volume. The relative reduction in persistent hypercalcaemia with surgeon volume was similar in image negative and positive groups, but the absolute reduction was higher in image negative cases. Restricting image negative parathyroidectomy to high-volume surgeons could be considered.
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Affiliation(s)
- Sendhil Rajan
- General and Endocrine Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN, UK
| | - Dale Gracie
- Paediatric Surgery, Royal Hospital of Children and Young People, Edinburgh, UK
| | - Sebastian Aspinall
- General and Endocrine Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN, UK.
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11
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Margin Free Resection Achieves Excellent Long Term Outcomes in Parathyroid Cancer. Cancers (Basel) 2022; 15:cancers15010199. [PMID: 36612195 PMCID: PMC9818355 DOI: 10.3390/cancers15010199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Long-term outcomes of parathyroid cancer remain poorly documented and unsatisfactory. This cohort includes 25 consecutive parathyroid cancer patients with median follow-up of 10.7 years (range 4.1−26.5 years). Pre-operative work-up in the center identified a suspicion of parathyroid cancer in 17 patients. En bloc resection, including the recurrent laryngeal nerve in 4/17 (23.5%), achieved cancer-free resection margins (R0) in 82.4% and lasting loco-regional disease control in 94.1%. Including patients referred after initial surgery elsewhere, R0 resection was achieved in merely 17/25 (68.0%) of patients. Cancer-positive margins (R1) in 8 patients led to local recurrence in 50%. On multivariate analysis, only margin status prevailed as independent predictor of recurrence free survival (χ2 19.5, p < 0.001). Local excision alone carried a 3.5-fold higher risk of positive margins than en bloc resection (CI95: 1.1−11.3; p = 0.03), and a 6.4-fold higher risk of locoregional recurrence (CI95: 0.8−52.1; p = 0.08). R1-status was associated with an 18.0-fold higher risk of recurrence and redo surgery (CI95: 1.1−299.0; p = 0.04), and a 22.0-fold higher probability of radiation (CI95: 1.4−355.5; p = 0.03). In patients at risk, adjuvant radiation reduced the actuarial risk of locoregional recurrence (p = 0.05). When pre-operative scrutiny resulted in upfront oncological surgery achieving cancer free margins, it afforded 100% recurrence free survival at 5- and 10-year follow-up, whilst failure to achieve clear margins caused significant burden by outpatient admissions (176 vs. 4 days; χ2 980, p < 0.001) and exposure to causes for concern (1369 vs. 0 days; χ2 11.3, p = 0.003). Although limited by cohort size, our study emphasizes the paradigm of getting it right the first time as key to improve survivorship in a cancer with excellent long-term prognosis.
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Mediastinal Parathyroid Cancer. Cancers (Basel) 2022; 14:cancers14235852. [PMID: 36497335 PMCID: PMC9739626 DOI: 10.3390/cancers14235852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Parathyroid cancer (PC) is rare, but its pre-operative recognition is important to choose appropriate access strategies and achieve oncological clearance. This study characterizes features of mediastinal parathyroid cancer (MPC) and explores criteria aiding in the pre-operative recognition of malignancy. We assembled data from 502 patients with mediastinal parathyroid neoplasms (MPNs) from a systematic review of the literature 1968−2020 (n = 467) and our own patient cohort (n = 35). Thirty-two of the 502 MPNs (6.4%) exhibited malignancy. Only 23% of MPC patients underwent oncological surgery. Local persistence and early recurrence at a median delay of 24 months were frequent (45.8%), and associated with a 21.7-fold (95%CI 1.3−351.4; p = 0.03) higher risk of death due to disease. MPCs (n = 30) were significantly larger than cervical PC (n = 330), at 54 ± 36 mm vs. 35 ± 18 mm (χ2 = 20; p < 0.0001), and larger than mediastinal parathyroid adenomas (MPA; n = 226) at 22 ± 15 mm (χ2 = 33; p < 0.01). MPC occurred more commonly in males (60%; p < 0.01), with higher calcium (p < 0.01) and parathyroid hormone (PTH) levels (p < 0.01) than MPA. Mediastinal lesions larger than 3.0 cm and associated with a corrected calcium ≥ 3.0 mM are associated with a more than 100-fold higher odds ratio of being malignant (OR 109.2; 95%CI 1.1−346; p < 0.05). The composite 3 + 3 criterion recognized 74% of all MPC with an accuracy of 83%. Inversely, no MPN presenting with a calcium < 3.0 mM and size < 3.0 cm was malignant. When faced with pHPT in mediastinal location, consideration of the 3 + 3 rule may trigger an oncological team approach based on simple, available criteria.
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Ullmann TM, Adam MA, Sosa JA. Surgeon Volume and Outcomes in Primary Hyperparathyroidism-What Is Old Is New Again. JAMA Surg 2022; 157:589. [PMID: 35507376 DOI: 10.1001/jamasurg.2022.1359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco
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