1
|
Kang DW, Zhou S, Niranjan S, Rogers A, Shen C. Predicting operative time for metabolic and bariatric surgery using machine learning models: a retrospective observational study. Int J Surg 2024; 110:1968-1974. [PMID: 38270635 PMCID: PMC11019972 DOI: 10.1097/js9.0000000000001107] [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: 09/11/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Predicting operative time is essential for scheduling surgery and managing the operating room. This study aimed to develop machine learning (ML) models to predict the operative time for metabolic and bariatric surgery (MBS) and to compare each model. METHODS The authors used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2016 and 2020 to develop ML models, including linear regression, random forest, support vector machine, gradient-boosted tree, and XGBoost model. Patient characteristics and surgical features were included as variables in the model. The authors used the mean absolute error, root mean square error, and R 2 score to evaluate model performance. The authors identified the 10 most important variables in the best-performing model using the Shapley Additive exPlanations algorithm. RESULTS In total, 668 723 patients were included in the study. The XGBoost model outperformed the other ML models, with the lowest root mean square error and highest R 2 score. Random forest performed better than linear regression. The relative performance of the ML algorithms remained consistent across the models, regardless of the surgery type. The surgery type and surgical approach were the most important features to predict the operative time; specifically, sleeve gastrectomy (vs. Roux-en-Y gastric bypass) and the laparoscopic approach (vs. robotic-assisted approach) were associated with a shorter operative time. CONCLUSIONS The XGBoost model best predicted the operative time for MBS among the ML models examined. Our findings can be useful in managing the operating room scheduling and in developing software tools to predict the operative times of MBS in clinical settings.
Collapse
Affiliation(s)
- Dong-Won Kang
- Department of Surgery, Penn State College of Medicine
| | - Shouhao Zhou
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Suman Niranjan
- Department of Logistics and Operations Management, G. Brint Ryan College of Business, University of North Texas, Denton, Texas, USA
| | - Ann Rogers
- Department of Surgery, Penn State College of Medicine
| | - Chan Shen
- Department of Surgery, Penn State College of Medicine
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| |
Collapse
|
2
|
Mikhail AR, Daniels L, Cobb D, Kawji Y, Issa C, Danos DM, LeBlanc K. Robotic hernia repair: the trainee "Drag" factor-a single-surgeon 9-year experience. Hernia 2024; 28:241-247. [PMID: 38123830 DOI: 10.1007/s10029-023-02935-4] [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: 09/15/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE The use of robotic assisted surgery is increasing but training residents in its use may be associated with increased operative time and cost. The objective of this study is to compare the operative time of robotic incisional/ventral hernia repair (RIVHR) and robotic inguinal hernia repair (RIHR) when performed with and without a resident or fellow trainee. METHODS A review of prospectively collected data was performed on all patients who underwent RIVHR and RIHR by a single surgeon over a 9-year period (2014-2023). Study variables included presence of trainee (resident or fellow), procedure time, console time, and recurrent hernia. Primary outcomes include procedure time and console time. RESULTS A total of 402 surgeries were included for analysis. Residents assisted in 190 (47%) of the procedures, while fellows assisted in 97 (24%), and 115 (29%) were performed without a trainee. Median (IQR) console times in RIVHR assisted by fellows was 102 (72-145) minutes, compared to 90 (71-129) minutes among surgeries assisted by residents and 65 (52-82) minutes among surgeries performed without a trainee (p < 0.0001), a similar trend was observed for RIHR. The duration of hernia repair assisted by trainees was significantly longer than surgeries performed without a trainee. CONCLUSION Operative time for RIVHR and RIHR is significantly lower when performed without a trainee. However, RIHR assisted by residents showed a consistent decrease in operative time over the 9-year period.
Collapse
Affiliation(s)
- A R Mikhail
- Department of Surgery, Louisiana State University Health Science Center, Room 8105, 8th Floor, 2021 Perdido St, New Orleans, LA, 70112, USA.
| | - L Daniels
- Surgeons Group of Baton Rouge, Franciscan Health Physicians, 7777 Hennessy Blvd Ste 612, Baton Rouge, LA, 70808, USA
| | - D Cobb
- Surgeons Group of Baton Rouge, Franciscan Health Physicians, 7777 Hennessy Blvd Ste 612, Baton Rouge, LA, 70808, USA
| | - Y Kawji
- Department of Surgery, Louisiana State University Health Science Center, Room 8105, 8th Floor, 2021 Perdido St, New Orleans, LA, 70112, USA
| | - C Issa
- Department of Surgery, Louisiana State University Health Science Center, Room 8105, 8th Floor, 2021 Perdido St, New Orleans, LA, 70112, USA
| | - D M Danos
- School of Public, Health Louisiana State University, 3rd Floor, 2020 Gravier St, New Orleans, LA, 70112, USA
| | - K LeBlanc
- Department of Surgery, Louisiana State University Health Science Center, Room 8105, 8th Floor, 2021 Perdido St, New Orleans, LA, 70112, USA
- Surgeons Group of Baton Rouge, Franciscan Health Physicians, 7777 Hennessy Blvd Ste 612, Baton Rouge, LA, 70808, USA
| |
Collapse
|
3
|
Nwokedi U, Graviss EA, Nguyen DT, Pei KY. Work relative value units undervalue the clinical effort associated with teaching cases: An ACS-NSQIP analysis. Am J Surg 2024; 227:117-122. [PMID: 37806890 DOI: 10.1016/j.amjsurg.2023.09.051] [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: 06/23/2023] [Revised: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Work-relative-value-units (wRVUs) are a core metric of faculty effort but do not account for the additional work associated with intraoperative teaching. This study introduces and assesses an indexed effort, wRVU per minute (wRVU index). We hypothesize that there is a significant decrease in the calculated wRVU index among teaching cases. METHODS We queried the ACS-NSQIP database for 7 core Emergency General Surgery procedures and records were stratified into teaching vs non-teaching, and emergent vs non-emergent procedures. We utilized multivariable generalized linear models to determine factors associated with increased operative time and decreased wRVU index. RESULTS Data were available for 953,967 cases from 2005 to 2010. For all cases, teaching vs non-teaching, the median wRVU index was 0.16 vs 0.21 (p < 0.001). There was a positive association between teaching cases and decreased wRVU index for all cases. CONCLUSION The wRVU index was 24% lower for teaching cases when compared to non-teaching cases despite controlling for patient-specific factors. This finding highlights the need for further evaluation of the current wRVU framework.
Collapse
Affiliation(s)
- Ugoeze Nwokedi
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana, USA.
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana, USA
| |
Collapse
|
4
|
Vathulya M, Pasricha A, Mohapatra DP, Jayaprakash PA. Preoperative Preparatory Talk (PPT): Developing Operative Expertise of Plastic Surgery Trainees by Three Rounds of Preceptor-Trainee Discussions. Indian J Plast Surg 2023; 56:421-425. [PMID: 38026765 PMCID: PMC10663083 DOI: 10.1055/s-0043-1772454] [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] [Indexed: 12/01/2023] Open
Abstract
Background Plastic surgery training requires the trainee to assist in surgeries to improve their on-table decision making and hone their surgical skills, but this results in an increased risk of intraoperative complications and increased operative time. It is important to have a training method that orients the trainee toward the surgery to ensure patient safety. Materials and Methods A training method called preoperative preparatory talk (PPT) was devised in which the preceptor orients the trainee toward the planned surgery in three phases. Comparison and statistical analysis of mean operative times of four stages of free flap surgeries after PPT and without PPT were done. Objective Structured Assessment of Technical Skill (OSATS) scores of surgical trainees were also documented for surgeries done with and without PPT and statistical analysis was done for comparing these scores. Results Statistical analysis via unpaired t -test confirmed that after applying PPT, there was a significant decrease in time taken in three out of four stages of free flap surgeries: flap planning and harvesting, recipient site preparation and vessel dissection, and flap division and partial inset. Trainees were found to be better oriented toward the surgery which resulted in a better performance on table that was confirmed by statistical analysis of OSATS score via unpaired t -test. Conclusion PPT ensures better learning for the resident and improves patient safety because of better orientation of the operating team toward the procedure and operating steps. This reduces the operative time of free flap surgeries. We recommend this training method to be incorporated in plastic surgery training programs.
Collapse
Affiliation(s)
- Madhubari Vathulya
- Department of Burns and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
| | - Arush Pasricha
- Department of Burns and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
| | | | - Praveen A. Jayaprakash
- Department of Plastic Cosmetic and Reconstructive Surgery, Rajagiri Hospital, Kochi, Kerala, India
| |
Collapse
|
5
|
Todd AR, Genereux O, Schrag C, Hatchell A, Matthews J. Improved Operative Efficiency and Surgical Times in Autologous Breast Reconstruction: A 15-year Single-center Retrospective Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5231. [PMID: 38152707 PMCID: PMC10752470 DOI: 10.1097/gox.0000000000005231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/07/2023] [Indexed: 12/29/2023]
Abstract
Background Autologous breast reconstruction using a free deep inferior epigastric perforator (DIEP) flap is a complex procedure that requires a dedicated approach to achieve operative efficiency. We analyzed data for DIEP flaps at a single center over 15 years to identify factors contributing to operative efficiency. Methods A single-center, retrospective cohort analysis was performed of consecutive patients undergoing autologous breast reconstruction using DIEP free flaps between January 1, 2005, and December 31, 2019. Data were abstracted a priori from electronic medical records. Analysis was conducted by a medical statistician. Results Analysis of 416 unilateral and 320 bilateral cases (1056 flaps) demonstrated reduction in operative times from 2005 to 2019 (11.7-8.2 hours for bilateral and 8.4-6.2 hours for unilateral, P < 0.000). On regression analysis, factors significantly correlating with reduced operative times include the use of venous couplers (P < 0.000), and the internal mammary versus the thoracodorsal recipient vessels (P < 0.000). Individual surgeon experience correlated with reduced OR times. Post-operative length of stay decreased significantly, without an increase in 30-day readmission or emergency presentations. Flap failure occurred in two cases. Flap take-back rate was 2% (n = 23) with no change between 2005 and 2019. Conclusions Operative times for breast reconstruction have decreased significantly at this center over 15 years. The introduction of venous couplers, use of the internal mammary system, and year of surgery significantly correlated with decreased operative times. Surgeon experience and a shift in surgical workflow for DIEP flap reconstruction likely contributed to the latter finding.
Collapse
Affiliation(s)
- Anna R. Todd
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Olivia Genereux
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Christiaan Schrag
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Hatchell
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Matthews
- From the Section of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
6
|
Thomas G, Long S, Kurtzhals T, Connor E, Anderson DD, Karam M, Kowalski H. A Dedicated Simulator Training Curriculum Improves Resident Performance in Surgical Management of Pediatric Supracondylar Humerus Fractures. JB JS Open Access 2023; 8:e23.00031. [PMID: 37701678 PMCID: PMC10489481 DOI: 10.2106/jbjs.oa.23.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Background The primary goal of including simulation in residency training is to improve technical skills while working outside of the operating room. Such simulation-related skill improvements have seldom been measured in the operating room. This is largely because uncontrolled variables, such as injury severity, patient comorbidity, and anatomical variation, can bias evaluation of an operating surgeon's skill. In this study, performance during the wire navigation phase of pediatric supracondylar humerus fracture fixation was quantitatively compared between 2 groups of orthopaedic residents: a standard training group consisting of residents who participated in a single simulator session of wire navigation training and an expanded training group consisting of residents who participated in a dedicated multifaceted wire navigation simulation training curriculum. Methods To evaluate performance in the operating room, the full sequence of fluoroscopic images collected during wire navigation was quantitatively analyzed. Objective performance metrics included number of fluoroscopic images acquired, duration from placement of the first wire to that of the final wire, and wire spread at the level of the fracture. These metrics were measured from 97 pediatric supracondylar humerus fracture pinning surgeries performed by 28 different orthopaedic residents. Results No differences were observed between the groups for wire spread in the final fluoroscopic images (t(94) = 0.75, p = 0.45), an important clinical objective of the surgery. Residents who received the expanded simulator training used significantly fewer fluoroscopic images (mean of 46 vs. 61 images, t(85) = 2.25, p < 0.03) and required less time from first to final wire placement (mean of 11.2 vs. 14.9 minutes, t(83) = 2.53, p = 0.013) than the standard training group. A post hoc review of Accreditation Council for Graduate Medical Education case logs for 24 cases from the standard training group and for 21 cases from the expanded training group indicated that, at the time of surgeries, residents who received expanded training had completed fewer comparable cases than residents in the standard training group (mean of 13 vs. 21, t(42) = 2.40 p = 0.02). Further regression analysis indicated that the expanded simulator training produced an effect comparable with that associated with completing 10.5 similar surgical case experiences. Conclusions This study demonstrates that training on a wire navigation simulator can lead to improved performance in the operating room on a critical skill for all orthopaedic residents. By taking fewer images and less time while maintaining sufficient pin spread, simulator-trained residents were objectively measured to have improved performance in comparison with residents who had not participated in the pediatric elbow simulator curriculum. Clinical Relevance As programs aim to provide safe and effective training for critical orthopaedic skills such as pinning a pediatric elbow, this study demonstrates a simulator curriculum that has demonstrated the transfer of skill from a learning environment to the operating room.
Collapse
Affiliation(s)
- Geb Thomas
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, Iowa
- Department of Industrial and Systems Engineering, The University of Iowa, Iowa City, Iowa
| | - Steven Long
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, Iowa
| | - Trevor Kurtzhals
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, Iowa
- Department of Industrial and Systems Engineering, The University of Iowa, Iowa City, Iowa
| | - Emily Connor
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, Iowa
| | - Donald D. Anderson
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, Iowa
- Department of Industrial and Systems Engineering, The University of Iowa, Iowa City, Iowa
- Department of Biomedical Engineering, The University of Iowa, Iowa City, Iowa
| | - Matthew Karam
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, Iowa
| | - Heather Kowalski
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, Iowa
| |
Collapse
|
7
|
Benissan-Messan DZ, Tamer R, Pieper H, Meara M, Chen X(P. What factors impact surgical operative time when teaching a resident in the operating room. Heliyon 2023; 9:e16554. [PMID: 37251464 PMCID: PMC10220402 DOI: 10.1016/j.heliyon.2023.e16554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/27/2023] [Accepted: 05/19/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Resident involvement would likely lead to prolonged operative time of a surgical case performed at academic medical centers. However, little is known about factors beneath this phenomenon. The purpose of this study was to investigate whether factors from case (procedure type, surgical case complexity, and surgical approach), teacher (attending surgeon experience and gender), and learner (resident postgraduate training year and gender) would influence operative time of surgical cases involved teaching a resident (SCT). Methods A single-institution retrospective analysis of 3 common general surgery procedures, including cholecystectomies, colectomies, and inguinal hernia, with involvement of general surgery residents between 2016 and 2020 was conducted. Surgical operative time was defined as the "cut-to-close" time from incision to completion of wound closure. Analysis of variance for continuous variables and multivariable linear regression were applied. Results A total of 4,417 eligible SCT were included. The average operative time was 114.8 ± 78.7 min. SCT with male resident involvement showed a significantly longer operative time than those with female residents (117 vs. 112, p = 0.01). Comparable operative time was observed between male and female attending surgeon cases (115.5 vs. 110.8, p = 0.15). SCT operating time decreased with increased resident training level, except for SCT with involvement of Year2 residents. SCT with Year5 residents demonstrated the lowest time to case completion (110.5 min); SCT with major complications took least time to complete (105.7 min). Univariate and multivariate analysis revealed resident training year level, resident gender, and case complexity as factors associated with significant differences in operative time. Attending surgeon experience, surgeon gender, surgical approach, and procedure type did not impact SCT operative time. Conclusion Our study findings suggest resident training level, resident gender, and case complexity are factors significantly associated with SCT operative time of cholecystectomies, colectomies, and inguinal hernia. Attending surgeons are recommended to factor them into pre-operative planning.
Collapse
Affiliation(s)
- Dathe Z. Benissan-Messan
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Robert Tamer
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Heidi Pieper
- Center for Advanced Robotic Surgery and Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Michael Meara
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Xiaodong (Phoenix) Chen
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| |
Collapse
|
8
|
Cousins HC, Cahan EM, Steere JT, Maloney WJ, Goodman SB, Miller MD, Huddleston JI, Amanatullah DF. Assessment of Team Dynamics and Operative Efficiency in Hip and Knee Arthroplasty. JAMA Surg 2023; 158:603-608. [PMID: 36947044 PMCID: PMC10034665 DOI: 10.1001/jamasurg.2023.0168] [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: 07/22/2022] [Accepted: 11/02/2022] [Indexed: 03/23/2023]
Abstract
Importance Surgical team communication is a critical component of operative efficiency. The factors underlying optimal communication, including team turnover, role composition, and mutual familiarity, remain underinvestigated in the operating room. Objective To assess staff turnover, trainee involvement, and surgeon staff preferences in terms of intraoperative efficiency. Design, Setting, and Participants Retrospective analysis of staff characteristics and operating times for all total joint arthroplasties was performed at a tertiary academic medical center by 5 surgeons from January 1 to December 31, 2018. Data were analyzed from May 1, 2021, to February 18, 2022. The study included cases with primary total hip arthroplasties (THAs) and primary total knee arthroplasties (TKAs) comprising all primary total joint arthroplasties performed over the 1-year study interval. Exposures Intraoperative turnover among nonsurgical staff, presence of trainees, and presence of surgeon-preferred staff. Main Outcomes and Measures Incision time, procedure time, and room time for each surgery. Multivariable regression analyses between operative duration, presence of surgeon-preferred staff, and turnover among nonsurgical personnel were conducted. Results A total of 641 cases, including 279 THAs (51% female; median age, 64 [IQR, 56.3-71.5] years) and 362 TKAs (66% [238] female; median age, 68 [IQR, 61.1-74.1] years) were considered. Turnover among circulating nurses was associated with a significant increase in operative duration in both THAs and TKAs, with estimated differences of 19.6 minutes (SE, 3.5; P < .001) of room time in THAs and 14.0 minutes (SE, 3.1; P < .001) of room time in TKAs. The presence of a preferred anesthesiologist or surgical technician was associated with significant decreases of 26.5 minutes (SE, 8.8; P = .003) of procedure time and 12.6 minutes (SE, 4.0; P = .002) of room time, respectively, in TKAs. The presence of a surgeon-preferred vendor was associated with a significant increase in operative duration in both THAs (26.3 minutes; SE, 7.3; P < .001) and TKAs (29.6 minutes; SE, 9.6; P = .002). Conclusions and Relevance This study found that turnover among operative staff is associated with procedural inefficiency. In contrast, the presence of surgeon-preferred staff may facilitate intraoperative efficiency. Administrative or technologic support of perioperative communication and team continuity may help improve operative efficiency.
Collapse
Affiliation(s)
- Henry C. Cousins
- Department of Orthopaedic Surgery, Stanford Health Care, Stanford, California
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
| | - Eli M. Cahan
- Department of Orthopaedic Surgery, Stanford Health Care, Stanford, California
- Department of Pediatrics, University of California, San Francisco
| | - Joshua T. Steere
- Department of Orthopaedic Surgery, Stanford Health Care, Stanford, California
| | - William J. Maloney
- Department of Orthopaedic Surgery, Stanford Health Care, Stanford, California
| | - Stuart B. Goodman
- Department of Orthopaedic Surgery, Stanford Health Care, Stanford, California
| | - Matthew D. Miller
- Department of Orthopaedic Surgery, Stanford Health Care, Stanford, California
| | - James I. Huddleston
- Department of Orthopaedic Surgery, Stanford Health Care, Stanford, California
| | | |
Collapse
|
9
|
Maxfield DG, Bernasek TL, Engel CC, Gill MK. Is it Safe to Continue Clopidogrel in Elective Hip and Knee Arthroplasty? J Arthroplasty 2022; 37:1726-1730. [PMID: 35405265 DOI: 10.1016/j.arth.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/15/2022] [Accepted: 04/05/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND No evidence-based guidelines exist for the perioperative use of clopidogrel in elective hip and knee arthroplasty patients. This study compares the preoperative, intraoperative, and postoperative outcomes of total hip and knee arthroplasty in patients maintained on clopidogrel and with patients whose clopidogrel was held before surgery. METHODS We retrospectively identified 158 patients taking clopidogrel before undergoing elective total hip or knee arthroplasty. Patients were stratified for having clopidogrel held or continued, based on the interval between latest dose and date of surgery. The primary end points were receipt of transfusion and readmission within 90 days of surgery. Secondary end points were the incidence of complications such as bleeding, infection, re-operation, and major cardiac or neurologic events such as myocardial infarction or stroke during the 90-day postoperative period. RESULTS The two cohorts had similar demographics. Patients who continued clopidogrel were more likely to receive a blood transfusion postoperatively (9.1% vs 0%, P = .005), but there was no difference in wound drainage (P = .65), wound infection (P = .24), readmission (P = .74), major complications (P = .64), length of stay (P = .70), or mortality (P = .42). Patients who continued clopidogrel before surgery were more likely to have received general anesthesia (P < .001) per anesthesia protocol, however, three such patients did receive spinal anesthesia without any complications. With cementless implants, blood loss was not different between clopidogrel groups. CONCLUSION Patients undergoing elective total hip and knee arthroplasty may be safely maintained on clopidogrel without an increased risk of wound complications, infections, length of stay, readmission, reoperation, major medical complications, or mortality. Further prospective research is warranted to confirm the effects of continuing clopidogrel in patients undergoing elective hip and knee arthroplasty.
Collapse
Affiliation(s)
| | - Thomas L Bernasek
- Florida Orthopaedic Institute, Adult Reconstruction, Tampa, FL; Department of Orthopaedics, University of South Florida College of Medicine, Tampa, FL
| | - Corey C Engel
- Department of Orthopaedics, University of South Florida College of Medicine, Tampa, FL; Foundation for Orthopaedic Research and Education, Tampa, FL
| | - Meera K Gill
- Department of Orthopaedics, University of South Florida College of Medicine, Tampa, FL; Foundation for Orthopaedic Research and Education, Tampa, FL
| |
Collapse
|
10
|
Pires GR, Moss WD, Memmott S, Wright T, Eddington D, Brintz BJ, Agarwal JP, Kwok AC. Analysis of Readmissions and Reoperations in Pediatric Microvascular Reconstruction. J Reconstr Microsurg 2022; 39:343-349. [PMID: 35952678 DOI: 10.1055/s-0042-1755265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Free tissue transfer is utilized as a reconstructive option for various anatomic defects. While it has long been performed in adults, reconstructive surgeons have used free tissue transfer to a lesser degree in children. As such, there are few analyses of factors associated with complications in free tissue transfer within this population. The aim of this study is to assess factors associated with readmission and reoperation in pediatric free flap patients utilizing the pediatric National Surgical Quality Improvement Program database. METHODS Pediatric patients who underwent microvascular reconstruction between 2015 and 2020 were included. Patients were identified by five microvascular reconstruction Current Procedural Terminology codes and were then stratified by flap site (head and neck, extremities, trunk) and defect etiology (congenital, trauma, infection, neoplasm). Multivariate logistic regression was performed to identify factors associated with readmissions and reoperations. RESULTS The study cohort consisted of 258 patients. The average age was 10.0 ± 4.7 years and the majority of patients were male (n = 149, 57.8%), were of white race (n = 164, 63.6%), and had a normal body mass index. Twenty-two patients (8.5%) experienced an unplanned readmission within 30 days of the initial operation, most commonly for wound disruption (31.8% of readmissions). The overall rate of unplanned reoperation within 30 days was 11.6% (n = 30) for all patients, with an average of 8.9 ± 7.5 days to reoperation. On multivariate regression analysis, each hour increase in operative time was associated with an increased odds of reoperation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.12, 1.45) and readmission (OR: 1.16; 95% CI: 1.02, 1.34). CONCLUSION In pediatric patients undergoing free tissue transfer, higher readmission and reoperation risk was associated with longer operative duration. Overall, free tissue transfer is safe in the pediatric population with relatively low rates of readmission and reoperation.
Collapse
Affiliation(s)
- Giovanna R Pires
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Whitney D Moss
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stanley Memmott
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Thomas Wright
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Devin Eddington
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ben J Brintz
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jayant P Agarwal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alvin C Kwok
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
11
|
Nie JZ, Weber MW, Revelt NJ, Nordmann NJ, Watson VL, Nie JW, Menezes SA, Delfino K, Cozzens JW, Espinosa JA, Amin D, Acakpo-Satchivi L. Comparison of Using Intraoperative Computed Tomography-Based 3-Dimensional Navigation and Fluoroscopy in Anterior Cervical Diskectomy and Fusion for Cervical Spondylosis. World Neurosurg 2022; 161:e740-e747. [PMID: 35231621 DOI: 10.1016/j.wneu.2022.02.089] [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: 12/29/2021] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Anterior cervical diskectomy and fusion (ACDF) is a highly successful procedure to treat spinal cord or nerve root compression; however, complications can still occur. With advancements in imaging, 3-dimensional (3D) reconstruction allows real-time instrument tracking in a surgical field relative to the patient's anatomy. Here, we compare plate positioning and short-term outcomes when using 3D navigation to fluoroscopy in ACDF for degenerative spine disease. METHODS All ACDFs for cervical spondylosis performed by 6 surgeons at a single center between 2010 and 2018 were included. ACDFs were divided into those performed using 3D navigation or fluoroscopy. Records were assessed for patient demographics, American Society of Anesthesiology score, number of operated interspaces, operative time, length of stay, perioperative complications, and 90-day readmissions. Postoperative images were reviewed for lateral and angular plate deviations. RESULTS A total of 193 ACDFs performed with 3D navigation and 728 performed with fluoroscopy were included. After controlling for demographics and surgical characteristics, using 3D navigation was associated with less lateral plate deviation (P = 0.048) and longer operative times per interspace (P < 0.001) but was not associated with angular plate deviation (P = 0.724), length of stay (P = 0.393), perioperative complications (P = 0.844), and 90-day readmissions (P = 0.539). CONCLUSIONS Using 3D navigation in ACDF for degenerative disease is associated with slightly more midline plate positioning and comparable short-term outcomes as using fluoroscopy and can be a suitable alternative. Advantages of using this technology, such as improved visualization of anatomy, should be weighed against disadvantages, such as increased operative time, on a per-patient basis.
Collapse
Affiliation(s)
- Jeffrey Z Nie
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
| | - Matthew W Weber
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Nicolas J Revelt
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Nathan J Nordmann
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Victoria L Watson
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - James W Nie
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA; University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Stephanie A Menezes
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Kristin Delfino
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Jeffrey W Cozzens
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Jose A Espinosa
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Devin Amin
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Leslie Acakpo-Satchivi
- Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA; Neurological Surgery, Springfield Clinic, Springfield, Illinois, USA
| |
Collapse
|
12
|
Toale C, Morris M, Kavanagh DO. Training to proficiency in surgery using simulation: is there a moral obligation? JOURNAL OF MEDICAL ETHICS 2022; 49:medethics-2021-107678. [PMID: 34992083 DOI: 10.1136/medethics-2021-107678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Abstract
A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The 'learning curve' in surgical skill is an observable and measurable phenomenon. Surgical training may therefore carry risk to patients. This can occur directly, through inadvertent harm, or indirectly through theatre inefficiency and associated costs. Trainee surgeon operating, however, is necessary from a utilitarian perspective, with potential risk balanced by the greater societal need to train future independent surgeons.New technology means that the surgical learning curve could take place, at least in part, outside of the operating theatre. Simulation-based deliberate practice could be used to obtain a predetermined level of proficiency in a safe environment, followed by simulation-based assessment of operative competence. Such an approach would require an overhaul of the current training paradigm and significant investment in simulator technology. This may increasingly be viewed as necessary in light of well-discussed pressures on surgical trainees and trainers.This article discusses the obligations to trainees, trainers and training bodies raised by simulation technology, and outlines the current arguments both against and in favour of a simulation-based training-to-proficiency model in surgery. The significant changes to the current training paradigm that would be required to implement such a model are also discussed.
Collapse
Affiliation(s)
- Conor Toale
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie Morris
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
13
|
Myers TG, Marsh JL, Nicandri G, Gorczyca J, Pellegrini VD. Contemporary Issues in the Acquisition of Orthopaedic Surgical Skills During Residency: Competency-Based Medical Education and Simulation. J Bone Joint Surg Am 2022; 104:79-91. [PMID: 34752441 DOI: 10.2106/jbjs.20.01553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Orthopaedic education should produce surgeons who are competent to function independently and can obtain and maintain board certification. ➤ Contemporary orthopaedic training programs exist within a fixed 5-year time frame, which may not be a perfect match for each trainee. ➤ Most modern orthopaedic residencies have not yet fully adopted objective, proficiency-based, surgical skill training methods despite nearly 2 decades of evidence supporting the use of this methodology. ➤ Competency-based medical education backed by surgical simulation rooted in proficiency-based progression has the potential to address surgical skill acquisition challenges in orthopaedic surgery.
Collapse
Affiliation(s)
- Thomas G Myers
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | | | - Gregg Nicandri
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | - John Gorczyca
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | - Vincent D Pellegrini
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
14
|
Wiseman JE, Morris-Wiseman LF, Hsu CH, Riall TS. Attending Surgeon Influences Operative Time More Than Resident Level in Laparoscopic Cholecystectomy. J Surg Res 2021; 270:564-570. [PMID: 34839227 DOI: 10.1016/j.jss.2021.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/23/2021] [Accepted: 09/21/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Prior studies on laparoscopic cholecystectomy (LC) have concluded that resident involvement lengthens operative time without impacting outcomes. However, the lack of effect of resident level on operative duration has not been explained. We hypothesized that attending-specific influence on average operative time for LC is more pronounced than resident post-graduate year level. MATERIALS AND METHODS We retrospectively analyzed all LC cases performed on patients 18 y and older between November 2018 and March 2020 at 2 academic medical center-affiliated hospitals. Regression models were used to compare operative times, conversion to open rates, and complication rates by attending surgeon and resident level. RESULTS Nine hundred twenty-five LCs were performed over the study period, 862 (93.1%) with resident participation. Of the 44.5% variation in operative time was explained by differences in attending surgeon, as compared to 11.0% attributable to differences in resident level (P < 0.0001). This effect persisted after adjusting for patient and disease factors (33.0% versus 7.1%, P < 0.0001). Neither attending surgeon (P = 0.80), nor the level of the involved resident (P = 0.94) demonstrated a significant effect on the conversion-to-open rate (4.9%). Similarly, neither the attending surgeon (P = 0.33), nor resident level (P = 0.81) significantly affected the complication rate (8.58%). CONCLUSIONS Operative time for LC is primarily determined by patient- and disease-specific factors; resident level has no effect on conversion to open or complication rates. Attending influence on operative time was more pronounced than resident level influence. These findings suggest attending surgeon-related factors are more important than resident experience in determining operative duration for LC.
Collapse
Affiliation(s)
- James E Wiseman
- Department of Surgery, The University of Arizona College of Medicine - Tucson, Tucson, Arizona.
| | - Lilah F Morris-Wiseman
- Department of Surgery, The University of Arizona College of Medicine - Tucson, Tucson, Arizona
| | - Chiu-Hsieh Hsu
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Arizona
| | - Taylor S Riall
- Department of Surgery, The University of Arizona College of Medicine - Tucson, Tucson, Arizona
| |
Collapse
|
15
|
Tonelli CM, Lorenzo I, Bunn C, Kulshrestha S, Agnew SP, Abdelsattar ZM, Luchette FA, Baker MS. Does resident autonomy in colectomy procedures result in inferior clinical outcomes? Surgery 2021; 171:598-606. [PMID: 34844760 DOI: 10.1016/j.surg.2021.09.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/08/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The amount of time surgical trainees spend operating independently has been reduced by work-hour restrictions and shifts in the health care environment that impede autonomy. Few studies evaluate the association between clinical outcome and resident autonomy. METHODS The Veterans Affairs Surgical Quality Improvement Program database was queried to identify patients undergoing partial colectomy for neoplasm between 2004 and 2019. Rectal resections, emergency procedures, and those involving postgraduate year 1 and 2 residents were excluded. Records were categorized as performed with the attending scrubbed or not scrubbed. Hierarchical logistic regression was used to identify factors independently associated with operative time, morbidity, and mortality. RESULTS In total, 7,347 patients met inclusion criteria; 6,890 (93.6%) were categorized as attending scrubbed and 457 (6.4%) as attending not scrubbed. The cohorts were similar in terms of patient demographics, including age, race, body mass index, and American Society of Anesthesiologists class. There were no differences between cohorts in terms of operative time (attending not scrubbed 3.02 hours, attending scrubbed 3.07 hours, P = .42). On hierarchical logistic regression adjusted for age, gender, race, body mass index, functional status, cancer location, facility operative level, wound class, American Society of Anesthesiologists class, length of operation, operative modality (open or minimally invasive), postgraduate year of resident, and year, there were no differences in odds of complications, major morbidity, or mortality based on attending involvement. CONCLUSION Colectomies performed by residents with appropriate levels of autonomy are efficient and safe. Our results indicate that attending surgeon judgment regarding resident autonomy is sound and that educational environments can be designed to foster resident independence and preserve clinical quality, safety, and efficiency.
Collapse
Affiliation(s)
- Celsa M Tonelli
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL.
| | - Isabela Lorenzo
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Corinne Bunn
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL. https://twitter.com/CorinneBunn
| | - Sujay Kulshrestha
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL
| | - Sonya P Agnew
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Zaid M Abdelsattar
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL. https://twitter.com/ZaidAbdelsattar
| | - Frederick A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| |
Collapse
|
16
|
Zaubitzer L, Affolter A, Büttner S, Ludwig S, Rotter N, Scherl C, von Wihl S, Weiß C, Lammert A. [Time management in operating rooms-a cross-sectional study to evaluate estimated and objective durations of otorhinolaryngologic surgical procedures]. HNO 2021; 70:436-444. [PMID: 34778901 PMCID: PMC9160095 DOI: 10.1007/s00106-021-01119-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 01/22/2023]
Abstract
Hintergrund Die Gestaltung des Operations(Op.)-Programms im klinischen Alltag ist von hoher Wichtigkeit für die Wirtschaftlichkeit. Gleichzeitig muss die Einhaltung von Arbeitszeiten unterschiedlicher Berufsgruppen berücksichtigt werden. Ziel der Arbeit Um Fehlerquellen bei der Planung aufzudecken, wurden durch Chirurgen geschätzte mit objektiv erhobenen Zeiten (u. a. Schnitt-Naht-Zeit) verglichen. Material und Methoden In einer retrospektiven Analyse wurden 1809 Operationen im Jahr 2018 (22 verschiedene Op.-Arten) durch 31 Operateure (12 Fach- [FÄ] und 19 Assistenzärzte [AÄ]) hinsichtlich ihrer Dauer verglichen und mittels Mann-Whitney-U-Test auf Signifikanz geprüft. Ergebnisse Der Vergleich der objektiven Zeiten von FÄ und AÄ zeigt signifikante Unterschiede in der Schnitt-Naht-Zeit bzw. der Summe aus Schnitt-Naht-Zeit und Zeit der chirurgischen Maßnahmen für 6 von 15 Op.-Arten (p < 0,001). Die durch FÄ geschätzte Nachbereitungszeit wich bei 2 von 22 Op.-Arten von der objektiven Zeit ab (p < 0,05), die durch AÄ geschätzte Zeit bei 7 von 15 Op.-Arten (p < 0,05). Hinsichtlich der Schnitt-Naht-Zeit verschätzten sich FÄ bei 7 von 22 (p < 0,05), AÄ bei 3 von 15 (p < 0,05) Op.-Arten. Die durch FÄ geschätzte Vorbereitungszeit wich bei 16 von 22 Op.-Arten signifikant von der objektiven Zeit ab (p < 0,05), bei AÄ bei 7 von 15 (p < 0,001). Vor- und Nachbereitungszeiten wurden durch FÄ unter‑, Schnitt-Naht-Zeiten überschätzt. AÄ unterschätzten alle Zeiten. Schlussfolgerung Bei der OP-Planung muss die Erfahrung des durchführenden Chirurgen berücksichtigt werden. Eine Verbesserung durch verminderte subjektive Fehleinschätzung kann möglicherweise mithilfe spezieller Algorithmen gelingen.
Collapse
Affiliation(s)
- Lena Zaubitzer
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Annette Affolter
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Sylvia Büttner
- Medizinische Statistik, Biomathematik und Informationsverarbeitung, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Sonja Ludwig
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Nicole Rotter
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Claudia Scherl
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Sonia von Wihl
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Christel Weiß
- Medizinische Statistik, Biomathematik und Informationsverarbeitung, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Anne Lammert
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| |
Collapse
|
17
|
Resident Involvement in Hip Arthroscopy Procedures Does Not Affect Short-Term Surgical Outcomes. Arthrosc Sports Med Rehabil 2021; 3:e1367-e1376. [PMID: 34712975 PMCID: PMC8527250 DOI: 10.1016/j.asmr.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose To evaluate whether the presence of residents in hip arthroscopy (HA) procedures affects short-term surgical outcomes. Methods The American College of Surgeons National Surgical Quality Improvement Program Database was used to identify patients who underwent HA from 2006 to 2012. Demographic and 30-day outcome variables were compared between cohorts of patients with and without residents. Multivariate logistic regression was used to identify whether resident involvement was an independent risk factor for adverse outcomes. Propensity score matching was performed to control for all demographic and intraoperative variables. Results A total of 869 patients (59.7% female) were included in this study, 626 of which reported data on resident involvement. Patients were mostly White (73.4% of cases without a resident, 51.8% with a resident, P < .05). Those with residents were younger (P = .016), had lower modified 5-item frailty index (mFI-5) scores (P = .028), and had fewer cardiac comorbidities (P = .008). There was no difference in diabetic status, dyspnea symptoms, history of chronic obstructive pulmonary disease, renal comorbidity, neurologic comorbidity, cumulative comorbidities, history of bleeding disorders, inpatient vs. outpatient treatment, preoperative functional status, smoking history, and steroid use for chronic conditions. There was no difference in all complications, operative time, length of stay, reoperation, readmission, wound complication, venous thromboembolism, blood transfusions, or sepsis. Propensity score match for demographic and intraoperative differences found no association between resident involvement and increased complications. Resident involvement was not an independent risk factor for all complications studied. Conclusion Resident involvement in HA procedures was not a risk factor for 30-day complications between 2006 and 2012. Resident involvement did not increase the risk of adverse outcomes, readmission, reoperation, or length of stay, nor did it significantly increase operative times.
Collapse
|
18
|
Wellington IJ, Stelzer JW, Silver J, Solovyova O. Operative efficiency: comparison of methods to optimize the use of chlorhexidine gluconate applicators. J Hosp Infect 2021; 118:59-62. [PMID: 34637851 DOI: 10.1016/j.jhin.2021.10.003] [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: 07/12/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND With the high costs of operating room time, minimizing potential causes of time waste is financially beneficial to surgeons and hospitals. The time needed to activate a chlorhexidine gluconate surgical solution applicator presents an opportunity for optimization. Many techniques are employed to expedite the process, but there have been no studies comparing these techniques. AIM To determine the most efficient method for utilizing a chlorhexidine gluconate surgical prep applicator. METHODS Six techniques were tested to determine which caused the sponge of a Chloraprep™ applicator to become saturated quickest. These were a single squeeze (control), up-and-down shaking, side-to-side shaking, pressing the sponge on a surface (dab), pressing with cotton swabs (poke), and continuously squeezing the lever of the applicator. The time between the internal glass breaking in the applicator to the time of sponge saturation with solution was measured for each technique. Times were then compared to determine which technique best expedited the process. FINDINGS The side-to-side shake, up-and-down shake, and 'dab' techniques were each significantly faster than the control group. Side-to-side shaking had the fastest time to sponge saturation on average. The average difference in time to saturation between the side-to-side shake technique and the 'poke' technique may be as much as 27.5 s. CONCLUSIONS Utilization of the side-to-side shake technique, as well as the up-and-down shake and 'dab' techniques, significantly expedite the time it takes to use a chlorhexidine gluconate applicator. The time savings from employing these techniques could result in significant financial benefits.
Collapse
Affiliation(s)
- I J Wellington
- University of Connecticut Department of Orthopaedics, University of Connecticut Health Center, Farmington, CT, USA.
| | - J W Stelzer
- University of Connecticut Department of Orthopaedics, University of Connecticut Health Center, Farmington, CT, USA
| | - J Silver
- University of Connecticut Department of Orthopaedics, University of Connecticut Health Center, Farmington, CT, USA
| | - O Solovyova
- University of Connecticut Department of Orthopaedics, University of Connecticut Health Center, Farmington, CT, USA
| |
Collapse
|
19
|
Senders ZJ, Brady JT, Ladhani HA, Marks J, Ammori JB. Factors Influencing the Entrustment of Resident Operative Autonomy: Comparing Perceptions of General Surgery Residents and Attending Surgeons. J Grad Med Educ 2021; 13:675-681. [PMID: 34721797 PMCID: PMC8527956 DOI: 10.4300/jgme-d-20-01259.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/02/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND General surgery residents may be underprepared for practice, due in part to declining operative autonomy during training. The factors that influence entrustment of autonomy in the operating room are unclear. OBJECTIVE To identify and compare the factors that residents and faculty consider influential in entrustment of operative autonomy. METHODS An anonymous survey of 29-item Likert-type scale (1-7, 1 = strongly disagree, 7 = strongly agree), 9 multiple-choice, and 4 open-ended questions was sent to 70 faculty and 45 residents in a large ACGME-approved general surgery residency program comprised of university, county, and VA hospitals in 2018. RESULTS Sixty (86%) faculty and 38 (84%) residents responded. Faculty were more likely to identify resident-specific factors such as better resident reputation and higher skill level as important in fostering entrustment. Residents were more likely to identify environmental factors such as a focus on efficiency and a litigious malpractice environment as impeding entrustment. Both groups agreed that work hour restrictions do not decrease autonomy and entrustment does not increase risk to patients. More residents considered low faculty confidence level as a barrier to operative autonomy, while more faculty considered lower resident clinical skill as a barrier. Improvement in resident preparation for cases was cited as an important intervention that could enhance entrustment. CONCLUSIONS Differences in perspectives exist between general surgery residents and faculty regarding entrustment of autonomy. Residents cite environmental and attending-related factors, while faculty cite resident-specific factors as most influential. Residents and faculty both agree that entrustment is integral to surgical training.
Collapse
Affiliation(s)
- Zachary J. Senders
- Zachary J. Senders, MD, is a General Surgery Resident, Department of Surgery, University Hospitals (UH) Cleveland Medical Center
| | - Justin T. Brady
- Justin T. Brady, MD, is a General Surgery Resident, Department of Surgery, UH Cleveland Medical Center
| | - Husayn A. Ladhani
- Husayn A. Ladhani, MD, is a General Surgery Resident, Department of Surgery, UH Cleveland Medical Center
| | - Jeffrey Marks
- Jeffrey Marks, MD, FACS, is Professor of Surgery and Associate Program Director, General Surgery Residency, UH Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - John B. Ammori
- John B. Ammori, MD, FACS, is Associate Professor of Surgery and Program Director, General Surgery Residency, UH Cleveland Medical Center, Case Western Reserve University School of Medicine
| |
Collapse
|
20
|
Alweis R, Donato A, Terry R, Goodermote C, Qadri F, Mayo R. Benefits of developing graduate medical education programs in community health systems. J Community Hosp Intern Med Perspect 2021; 11:569-575. [PMID: 34567443 PMCID: PMC8462840 DOI: 10.1080/20009666.2021.1961381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.
Collapse
Affiliation(s)
- Richard Alweis
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Anthony Donato
- Department of Medicine, Tower Health, West Reading, Pennsylvania, United States
| | - Richard Terry
- Academic Affairs, Lake Erie College of Medicine at Elmira, Elmira, New York, United States
| | - Christina Goodermote
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Farrah Qadri
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Robert Mayo
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| |
Collapse
|
21
|
Traven SA, McGurk KM, Althoff AD, Walton ZJ, Leddy LR, Potter BK, Slone HS. Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care. JOURNAL OF SURGICAL EDUCATION 2021; 78:1755-1761. [PMID: 33903063 DOI: 10.1016/j.jsurg.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 01/01/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care. SETTING Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. PARTICIPANTS A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures. DESIGN Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden. RESULTS As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR. CONCLUSIONS This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.
Collapse
Affiliation(s)
- Sophia A Traven
- Medical University of South Carolina, Charleston, South Carolina.
| | - Kathy M McGurk
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Zeke J Walton
- Medical University of South Carolina, Charleston, South Carolina
| | - Lee R Leddy
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Harris S Slone
- Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
22
|
The Opportunity Cost of Resident Involvement in Adult Craniofacial Surgery: An Analysis of Relative Value Units. J Craniofac Surg 2021; 33:125-128. [PMID: 34456286 DOI: 10.1097/scs.0000000000008104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Within the academic surgical setting resident involvement may confer longer operative times. The increasing pressures to maximize clinical productivity and decreasing reimbursement rates, however, may conflict with these principles. This study calculates the opportunity cost of resident involvement in craniofacial surgery. METHODS Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology codes for craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables included patient demographics, operative time, and presence or absence of resident trainee. Average relative value units were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. RESULTS In total, 2096 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P < 0.001) for facial reanimation, facial trauma, orthognathic surgery, and head and neck reconstruction. The opportunity costs per case associated with resident involvement were the highest for head and neck reconstruction ($1468.04), followed by orthognathic surgery ($1247.03), facial trauma ($533.03), and facial reanimation ($358.32). Resident involvement was associated with higher rate of complications for head and neck reconstruction (P < 0.043). CONCLUSIONS Resident involvement is associated with longer operative times, higher complications, and higher re-operations, compared to attending exclusive surgical care. Future studies may consider how reimbursements should align incentives to promote resident education and training.
Collapse
|
23
|
Johnson J, Misch E, Chung MT, Hotaling J, Folbe A, Svider PF, Cabrera-Muffly C, Johnson AP. Flipping the Classroom: An Evaluation of Teaching and Learning Strategies in the Operating Room. Ann Otol Rhinol Laryngol 2021; 131:573-578. [PMID: 34350805 DOI: 10.1177/00034894211036859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES With increasing restraints on resident's experiences in the operating room, with causes ranging from decreased time available to increasing operating room costs, focus has been placed on how to improve resident's education. The objectives of our study are to (1) determine barriers in education in the operating room, (2) identify effective learning and teaching strategies for residents in the operating room with a focus on the tonsillectomy procedure. METHODS An online survey was sent to all otolaryngology residents and residency programs for which contact information was available from January 2016 to March 2016 with 139 respondents. The 12-question survey focused on information regarding limitations to learning how to perform tonsillectomies as well as difficulties with teaching the same procedure. Resident responses were separated based on PGY level, and analysis was performed using t-tests and Chi squared analysis. RESULTS Common themes emerged from responses for both teaching and learning how to perform tonsillectomies. A significant limitation in learning the procedure was lack of visualization during the surgery (57% learning vs 60% teaching). For both learners and teachers, the monopolar cautery instrument was found to be the most preferred instrument to use during tonsillectomy (80% each). The majority of resident respondents (93%) felt that an instructional video would be beneficial for both learning and teaching the procedure. CONCLUSIONS Significant limitations for learning and teaching in the operating room were identified for performing tonsillectomies. Future endeavors will focus on resolving these limitations to improve surgical education. EVIDENCE LEVEL Level IV.
Collapse
Affiliation(s)
- Jared Johnson
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, MI, USA
| | - Emily Misch
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael T Chung
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, MI, USA
| | - Jeffrey Hotaling
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, MI, USA
| | - Adam Folbe
- Department of Otolaryngology, William Beaumont Hospital - Royal Oak, Royal Oak, MI, USA
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, MI, USA
| | - Cristina Cabrera-Muffly
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrew P Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
24
|
Sousa JHBDE, Tustumi F, Steinman M, Santos OFPD. Laparoscopic cholecystectomy performed by general surgery residents. Is it safe? How much does it cost? Rev Col Bras Cir 2021; 48:e20202907. [PMID: 34008798 PMCID: PMC10683462 DOI: 10.1590/0100-6991e-20202907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/06/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE to evaluate the effectiveness and safety of laparoscopic cholecystectomies performed by residents of the first and second-year of a general surgery residency program. We studied the primary total cost of treatment and complication rates as primary outcomes, comparing the groups operated by senior and resident surgeons. METHODS this was a retrospective cohort study of patients who underwent laparoscopic cholecystectomy performed in a training hospital of large surgical volume in Brazil, in the period between June 1, 2018 and May 31, 2019. The study population comprised patients who underwent elective cholecystectomy due to uncomplicated chronic calculous cholecystitis or to the presence of gallbladder polyps with surgical indication. We divided the cases into three groups, based on the graduation of the main surgeon at the time of the procedure: first-year residents (R1), second-year residents (R2), and trained general surgeons (GS). RESULTS during the study period, 1,052 laparoscopic cholecystectomies were performed, of which 1,035 procedures met the inclusion criteria, with 78 (7.5%) patients operated on with the participation of first-year residents (R1), 500 (48.3%) patients with the participation of second-year residents (R2), and 457 (44.2%) with the participation of senior surgeons only. There was no difference in conversion rates, complications, and reporting of adverse events between groups. We observed a significant difference regarding hospitalization costs (p = 0.003), with a higher mean for the patients operated with the participation of R1, of US$ 2,671.13, versus US$ 2,414.60 and US$ 2,396.24 for the procedures performed by senior surgeons and R2, respectively. CONCLUSIONS laparoscopic cholecystectomy with the participation of residents is safe, even in their first years of training. There is an additional cost of about 10% in the treatment of patient operated with the participation of first-year residents. There was no significant difference in the cost of the group operated by second-year residents.
Collapse
Affiliation(s)
| | - Francisco Tustumi
- - Hospital Israelita Albert Einstein, Serviço de Cirurgia Geral - São Paulo - SP - Brasil
| | - Milton Steinman
- - Hospital Israelita Albert Einstein, Serviço de Cirurgia Geral - São Paulo - SP - Brasil
| | | |
Collapse
|
25
|
Cahan EM, Cousins HC, Steere JT, Segovia NA, Miller MD, Amanatullah DF. Influence of team composition on turnover and efficiency of total hip and knee arthroplasty. Bone Joint J 2021; 103-B:347-352. [PMID: 33517742 DOI: 10.1302/0301-620x.103b2.bjj-2020-0170.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty. METHODS We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score. RESULTS Turnover among specific types of operating room staff, including the anaesthesiologist (p = 0.011), circulating nurse (p = 0.027), and scrub nurse (p = 0.006), was significantly associated with increased operative duration. Furthermore, the presence of medical students and nursing students were associated with improved intraoperative efficiency in TKA (p = 0.048) and THA (p = 0.015), respectively. The presence of surgical fellows (p > 0.05), vendor representatives (p > 0.05), and physician assistants (p > 0.05) had no effect on intraoperative efficiency. Finally, the presence of the surgeon's 'preferred' staff did not significantly shorten operative duration, except in the case of residents (p = 0.043). CONCLUSION Our findings suggest that active management of surgical team turnover and composition may provide a means of improving intraoperative efficiency during THA and TKA. Cite this article: Bone Joint J 2021;103-B(2):347-352.
Collapse
Affiliation(s)
- Eli M Cahan
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, California, USA.,New York University School of Medicine, New York, New York, USA
| | - Henry C Cousins
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, California, USA
| | - Joshua T Steere
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, California, USA
| | - Nicole A Segovia
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, California, USA
| | - Matthew D Miller
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, California, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, California, USA
| |
Collapse
|
26
|
Abstract
Background Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost. Methods We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC. Results Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor). Conclusion Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.
Collapse
|
27
|
Hidden Costs in Resident Training: Financial Cohort Analysis of First Assistants in Reduction Mammaplasty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3333. [PMID: 33564574 PMCID: PMC7859249 DOI: 10.1097/gox.0000000000003333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/28/2020] [Indexed: 11/06/2022]
Abstract
Graduate medical education (GME) programs are vital to developing future plastic surgeons. However, their cost-efficiency has yet to be contextualized. This cohort quality improvement (QI) project aimed to measure the indirect costs an institution assumes in training surgical residents, by comparing the differences in operative time and procedural charges between a resident and a physician assistant (PA) first-assisting during adolescent reduction mammaplasty.
Collapse
|
28
|
He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: A narrative review. Am J Surg 2021; 221:65-71. [PMID: 32680622 PMCID: PMC7308777 DOI: 10.1016/j.amjsurg.2020.06.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/30/2020] [Accepted: 06/06/2020] [Indexed: 12/04/2022]
Abstract
BACKGROUND With increased attention on the federal budget deficit, graduate medical education (GME) funding has in particular been targeted as a potential source of cost reduction. Reduced GME funding can further deteriorate the compensation of physicians during their residency training. METHODS In order to understand the GME funding mechanisms and current challenges, as well as the value of the work accomplished by residents, we searched peer-reviewed, English language studies published between 2000 and 2019. RESULTS Direct and indirect GME funding is intended to support resident reimbursement and the higher costs associated with supporting a teaching program. However, policy efforts have aimed to reduce federal funding for GME. Furthermore, evidence suggests that residents are inadequately compensated because their salaries do not reflect the number of hours worked and are not comparable to those of other medical staff. CONCLUSIONS Our review suggests that creative solutions are needed to diversify GME funding and improve resident compensation.
Collapse
Affiliation(s)
- Katherine He
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Whang
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gentian Kristo
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
29
|
Grunzweig KA, Son J, Kumar AR. Regional Anesthetic Blocks for Donor Site Pain in Burn Patients: A Meta-Analysis on Efficacy, Outcomes, and Cost. Plast Surg (Oakv) 2020; 28:222-231. [PMID: 33215037 DOI: 10.1177/2292550320928562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Skin graft donor site pain significantly affects pain management, narcotic use, and hospital length of stay. This study is intended to evaluate the efficacy of regional anesthesia in the burn population to decrease narcotic consumption and to assess the impact on hospitalization costs. Methods PubMed/MEDLINE, Embase, and ScienceDirect were searched with the following inclusion criteria: comparative studies, adult populations, burn patients, autologous skin grafting, regional nerve blocks, and traditional narcotic regimens. Outcomes assessed included narcotic consumption, pain scores, and opioid side effects. Meta-analysis obtained pooled values for morphine consumption and side effects. Cost analysis was performed using published data in the literature. Results Final analysis included 101 patients. Cumulative morphine consumption at 72 hours was lower for patients treated with regional anesthesia versus patient-controlled analgesia (PCA; single shot 25 ± 12 mg, continuous regional 23 ± 16 mg, control 91.5 ± 24.5 mg; P < .05). Regional anesthesia decreased nausea/vomiting (P < .05) and lowered subjective pain scores. Regional anesthesia interventions cost less than PCA, single shot less than continuous (P < .05). Conclusion Regional anesthesia at skin graft donor sites significantly decreases narcotic consumption in burn patients. Regional anesthesia is cost-effective, decreases side effects, and may result in shorter hospital stays due to improved pain management.
Collapse
Affiliation(s)
- Katherine A Grunzweig
- Department of Plastic & Reconstructive Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ji Son
- Department of Plastic & Reconstructive Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anand R Kumar
- Department of Plastic & Reconstructive Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| |
Collapse
|
30
|
Alsyouf M, Hur D, Stokes P, Groegler J, Amasyali A, Li A, Thomas S, Hajiha M, Shah M, Baldwin DD. The Impact of Patient, Procedural, and Staffing Factors Upon Ureteroscopy Cost. J Endourol 2020; 34:746-751. [PMID: 31964178 DOI: 10.1089/end.2019.0709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction: The purpose of this study was to evaluate factors during ureteroscopy that can potentially impact procedure cost. Materials and Methods: A retrospective review of 129 consecutive elective ureteroscopy cases was performed to determine direct procedure cost. Direct cost was defined as cost incurred because of operating room expenses, including operating room time, staffing expenses, equipment, and supply costs. Data regarding patient, procedural, and operating room staffing characteristics were compared between the most and least expensive cases. Univariate and logistic regression analysis were performed to identify factors predictive of higher costs. Results: The average direct ureteroscopy cost was $3298/case. On univariate analysis, ureteroscopies in the highest 50th cost percentile had larger stone burden (170.1 vs 146 mm2; p = 0.03) and longer operative times (95.3 vs 49.9 minutes; p < 0.01), were more likely performed for non-stone indications (21.4% vs 7.2%; p = 0.03), more likely to include a resident (65.5% vs 43.6%; p = 0.02), and less likely to have a dedicated urology scrub technician (38.2% vs 61.8%; p = 0.01) compared to cases in the lowest 50th percentile. The presence of a resident, larger stone burden, absence of a dedicated scrub technician, and longer operative time were associated with an average cost increase of $516, $700, $1122, and $1401, respectively. Logistic regression analysis showed that operating room time was the only factor predicting higher cost (OR [odds ratio] 12.8, 95% confidence interval [CI] 2.0-84.0). A post-hoc logistic regression analysis demonstrated that the presence of a resident during ureteroscopy (OR 2.9, 95% CI 1.1-8.0) and larger stone burden (OR 1.01, 95% CI 1.0-1.013) were significantly associated with longer operative times. Conclusion: Operating room time is the primary determinant of ureteroscopy case cost. All efforts should be made to decrease operative time, although balancing patient safety and maintaining a quality training environment.
Collapse
Affiliation(s)
- Muhannad Alsyouf
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Dawn Hur
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Phillip Stokes
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Jason Groegler
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Akin Amasyali
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Ashley Li
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Seth Thomas
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Mohammad Hajiha
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - Milan Shah
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| | - D Duane Baldwin
- Department of Urology, Loma Linda University Health, Loma Linda, California, USA
| |
Collapse
|
31
|
Madni TD, Imran JB, Clark AT, Cunningham HB, Taveras L, Arnoldo BD, Phelan HA, Wolf SE. Prospective Evaluation of Operating Room Inefficiency. J Burn Care Res 2020; 39:977-981. [PMID: 29659854 DOI: 10.1093/jbcr/iry016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Previously, they identified that 60 per cent of their facility's total operative time is nonoperative. They performed a review of their operating room to determine where inefficiencies exist in nonoperative time. Live video of operations performed in a burn operating room from June 23, 2017 to August 16, 2017 was prospectively reviewed. Preparation (end of induction to procedure start) and turnover (patient out of room to next patient in room) were divided into the following activities: 1) Preparation: remove dressing, position patient, clean patient, drape patient, and 2) Turnover: clean operating room, scrub tray setup, anesthesia setup. Ideal preparation time was calculated as the sum of time needed to perform preparation activities consecutively. Ideal turnover time was calculated as the sum of time needed to clean the operating room and to set up either the scrub tray or anesthesia (the larger of the two times as these can be done in parallel). They reviewed 101 consecutive operations. An average of 2.4 ± 0.8 cases per day were performed. Ideal preparation and turnover time were 16.6 and 30.1 minutes, a 38.3 and 32.5 per cent reduction compared with actual times. Attending surgeon presence in the operating room within 10 minutes of a patient's arrival was found to significantly decrease time to incision by 33 per cent (52.7 ± 14.3 minutes down to 35.7 ± 20.4, P < .0001). A reduction in preparation and turnover time could save $1.02 million and generate $1.76 million in additional revenue annually. Reducing preparation and turnover to ideal times could increase caseload to 4 per day, leading to millions of dollars of savings annually.
Collapse
Affiliation(s)
- Tarik D Madni
- UT Southwestern Department of Surgery, Dallas, Texas
| | | | - Audra T Clark
- UT Southwestern Department of Surgery, Dallas, Texas
| | | | - Luis Taveras
- UT Southwestern Department of Surgery, Dallas, Texas
| | - Brett D Arnoldo
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, Texas
| | - Herb A Phelan
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, Texas
| | - Steven E Wolf
- UT Southwestern Division of Burns/Trauma/Critical Care, Dallas, Texas
| |
Collapse
|
32
|
Benefits and Limitations of Transurethral Resection of the Prostate Training With a Novel Virtual Reality Simulator. Simul Healthc 2019; 15:14-20. [PMID: 31743314 DOI: 10.1097/sih.0000000000000396] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Profound endourological skills are required for optimal postoperative outcome parameters after transurethral resection of the prostate (TURP). We investigated the Karl Storz (Tuttlingen, Germany) UroTrainer for virtual simulation training of the TURP. MATERIALS AND METHODS Twenty urologists underwent a virtual reality (VR) TURP training. After a needs analysis, performance scores and self-rated surgical skills were compared before and after the curriculum, the realism of the simulator was assessed, and the optimal level of experience for VR training was evaluated. Statistical testing was done with SPSS 25. RESULTS Forty percent of participants indicated frequent intraoperative overload during real-life TURP and 80% indicated that VR training might be beneficial for endourological skills development, underlining the need to advance classical endourological training. For the complete cohort, overall VR performance scores (P = 0.022) and completeness of resection (P < 0.001) significantly improved. Self-rated parameters including identification of anatomical structures (P = 0.046), sparing the sphincter (P = 0.002), and handling of the resectoscope (P = 0.033) became significantly better during the VR curriculum. Participants indicated progress regarding handling of the resectoscope (70%), bleeding control (55%), and finding the correct resection depth (50%). Although overall realism and handling of the resectoscope was good, virtual bleeding control and correct tissue feedback should be improved in future VR simulators. Seventy percent of participants indicated 10 to 50 virtual TURP cases to be optimal and 80% junior residents to be the key target group for VR TURP training. CONCLUSIONS There is a need to improve training the TURP and VR simulators might be a valuable supplement, especially for urologists beginning with the endourological desobstruction of the prostate.
Collapse
|
33
|
Peterson EC, Ghosh TD, Qureshi AA, Myckatyn TM, Tenenbaum MM. Impact of Residents on Operative Time in Aesthetic Surgery at an Academic Institution. Aesthet Surg J Open Forum 2019; 1:ojz026. [PMID: 33791617 PMCID: PMC7671284 DOI: 10.1093/asjof/ojz026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background Duration of surgery is a known risk factor for increased complication rates. Longer operations may lead to increased cost to the patient and institution. While previous studies have looked at the safety of aesthetic surgery with resident involvement, little research has examined whether resident involvement increases operative time of aesthetic procedures. Objectives We hypothesized that resident involvement would potentially lead to an increase in operative time as attending physicians teach trainees during aesthetic operations. Methods A retrospective cohort analysis was performed from aesthetic surgery cases of two surgeons at an academic institution over a 4-year period. Breast augmentation and abdominoplasty with liposuction were examined as index cases for this study. Demographics, operative time, and resident involvement were assessed. Resident involvement was defined as participating in critical portions of the cases including exposure, dissection, and closure. Results A total of 180 cases fit the inclusion criteria with 105 breast augmentation cases and 75 cases of abdominoplasty with liposuction. Patient demographics were similar for both procedures. Resident involvement did not statistically affect operative duration in breast augmentation (41.8 ± 9.6 min vs 44.7 ± 12.4 min, P = 0.103) or cases for abdominoplasty with liposuction (107.3 ± 20.5 min vs 122.2 ± 36.3 min, P = 0.105). Conclusions There was a trend toward longer operative times that did not reach statistical significance with resident involvement in two aesthetic surgery cases at an academic institution. This study adds to the growing literature on the effect resident training has in aesthetic surgery. Level of Evidence: 2 ![]()
Collapse
Affiliation(s)
- Erin C Peterson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Trina D Ghosh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ali A Qureshi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Terence M Myckatyn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Marissa M Tenenbaum
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
34
|
Telescopic dissection versus balloon dissection for laparoscopic totally extraperitoneal inguinal hernia repair (TEP): a registry-based randomized controlled trial. Hernia 2019; 23:1105-1113. [PMID: 31388790 DOI: 10.1007/s10029-019-02001-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Laparoscopic totally extraperitoneal inguinal hernia repair (TEP) can be performed using either telescopic (TD) or balloon dissection (BD). The use of a disposable balloon dissector increases the cost of TEP. However, it remains unclear whether BD saves enough time to justify its cost. We hypothesized that BD would consistently save 15 min in operative time. To test this hypothesis, we designed a registry-based randomized controlled trial (RB-RCT) embedded into the Americas Hernia Society Quality Collaborative. METHODS A single-blinded, parallel, RB-RCT was conducted. Adults with inguinal hernias presenting for elective repair were screened. Patients with unilateral hernias deemed fit to undergo TEP were eligible; those with bilateral hernias (BIH) or undergoing open repair were excluded. Individuals were randomized to TD or BD with a disposable device. TEP was performed with synthetic mesh and tacks. Subjects were blinded and followed up for 30 day. Main outcome was operative time. RESULTS 207 patients were screened: 166 were excluded and 41 were randomized (21 BD, 20 TD). One patient (TD group) was excluded due to the incidental finding of BIH. 40 patients were analyzed (median age 56, median BMI 26 kg/m2, 98% males). Hernias were 72% indirect, 17% direct, 10% pantaloon, and 8% recurrent. Other than obesity (26.5% vs. 0, p = 0.018), there were no baseline differences between the groups. Median operative times were similar (TD 43 min, IQR 33-63; BD 46 min, IQR 35-90, p = 0.490). There were 2 seromas and 2 hematomas in the BD group, and none in the TD (p = 0.108). CONCLUSIONS BD does not consistently result in 15-min time saving during TEP. Use of a disposable balloon dissector can be deferred in the experienced hands. TRIAL REGISTRATION ClinicalTrials.gov (NCT03276871).
Collapse
|
35
|
Katafigiotis I, Sabler IM, Heifetz EM, Isid A, Sfoungaristos S, Lorber A, Yutkin V, Hidas G, Latke A, Landau EH, Pode D, Gofrit ON, Duvdevani M. Factors Predicting Operating Room Time in Ureteroscopy and Ureterorenoscopy. Curr Urol 2019; 12:195-200. [PMID: 31602185 DOI: 10.1159/000499306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022] Open
Abstract
Backgrounds/Aims Operation room (OR) time is of great value affecting surgical outcome, complications and the daily surgical program with financial implications. Methods We retrospectively evaluated 570 consecutive patients submitted to ureteroscopy or ureterorenoscopy for the treatment of ureteral or renal stones. Demographic parameters, patient's stones characteristics, type of ureteroscope, surgeon experience and surgical theater characteristics were analyzed. OR time was calculated from the initiation of anesthesia to patient extubation. Multivariate analysis was conducted using a linear regression test with multiple parameters to identify predictors of OR time. Results Eight factors were identified as significant. These include total stones volume, ureteroscope used, stone number, nurses experience, radio-opacity of the stone on kidney-ureter-bladder X-ray, main surgeon experience, operating room type, and having a nephrostomy tube prior to surgery. Conclusions The surgical team experience and familiarity with endourological procedure, and the surgical room characteristics has a crucial impact on OR time and effectiveness.
Collapse
Affiliation(s)
- Ioannis Katafigiotis
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,1st University Urology Clinic, Laiko Hospital, Athens, Greece
| | - Itay M Sabler
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Eliyahu M Heifetz
- Department of Health Informatics, Jerusalem College of Technology, Jerusalem, Israel
| | - Ayman Isid
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Stavros Sfoungaristos
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,1st Department of Urology, Aristotle University, G. Gennimatas Hospital, Thessaloniki, Greece
| | - Amitay Lorber
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Vladimir Yutkin
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Guy Hidas
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Arie Latke
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ezekiel H Landau
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Dov Pode
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ofer N Gofrit
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mordechai Duvdevani
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
36
|
Redmann AJ, Yuen SN, VonAllmen D, Rothstein A, Tang A, Breen J, Collar R. Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology–Head and Neck Surgery? Otolaryngol Head Neck Surg 2019; 161:629-634. [DOI: 10.1177/0194599819861524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives (1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission. Study Design Retrospective case series. Setting Tertiary academic hospital. Subjects and Methods The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology–head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate. Results In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6. Conclusion For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.
Collapse
Affiliation(s)
- Andrew J. Redmann
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sonia N. Yuen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Douglas VonAllmen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Rothstein
- UC Health, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alice Tang
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joseph Breen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ryan Collar
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
37
|
Abstract
OBJECTIVE There are no direct comparisons between the success of collagen allografts versus traditional autografts for tympanic membrane (TM) repair. We sought to compare success rates in a large series of patients undergoing tympanoplasty using collagen allografts versus autologous tissues. STUDY DESIGN Retrospective review. SETTING Academic medical center. SUBJECTS AND METHODS Single institution retrospective chart review was performed for adult subjects with TM perforation undergoing tympanoplasty. Demographic, clinical, and surgical data were collected. Statistical analysis was completed using Rstudio. Each factor was examined to assess effect on graft success rate using logistic regression. RESULTS Two hundred sixty-five surgeries met criteria with four main grafting materials or combinations thereof. The overall graft success rate was 81.1% with failure rate of 18.9%. There was no significant association between failure rates and: age, sex, perforation cause, size, and location, primary or revision status, middle ear status (wet or dry), concomitant procedures (mastoidectomy or ossiculoplasty), presence of active cholesteatoma, or surgical technique. Although not statistically significant, the odds of success for perichondrium + cartilage were 7.5 times higher than collagen allografts (p = 0.07, 95% confidence interval [CI] = 0.81-69.6). The odds of success for the postauricular (odds ratio [OR] = 6.4) and transcanal approaches (OR = 24.8) were significantly greater than for endaural (p = 0.007 and p = 0.008, respectively). CONCLUSION In tympanoplasty surgeries performed on patients with TM perforation, we found no statistically significant difference in graft failure rates between collagen allograft and other grafting materials or combinations, though the higher odds ratio of success with cartilage + perichondrium may be clinically relevant.
Collapse
|
38
|
Abstract
IMPORTANCE Spreader grafts are commonly used for nasal valve stenosis. There is debate among practitioners regarding the optimal approach for spreader graft placement. OBJECTIVE This study aimed to determine whether an endonasal spreader graft placement leads to equivalent postoperative outcomes using a standardized nasal obstruction symptom score and whether there is a significant difference in operative time between the 2 approaches. DESIGN A retrospective review of functional rhinoplasties by a single facial plastic surgeon over a 2-year period was conducted. SETTING Facial plastic surgery practice at a tertiary academic medical center. PARTICIPANTS Fifty patients with a single surgeon over a 22-month period with a minimum of 1-year follow-up were included in the study. Age, sex, and preoperative Nasal Obstruction Symptom Evaluation (NOSE) scores of patients were equivalent between the 2 groups. For time analysis, 56 of 107 patients were analyzed, with exclusion of patients undergoing combined procedures and autologous cartilage grafting from sites besides the nasal septum. INTERVENTIONS Patients who underwent functional rhinoplasty through either an open or an endonasal (closed) approach were compared. Preoperative approach decision was based on the need for cosmetic tip, dorsal, or anterior septal work, and all decisions were made before the development of this study. Main outcome measures were as follows: improvement in NOSE scores recorded preoperatively and at 1-year minimum postoperative follow-up as well as difference in operative times. RESULTS No significant difference (P = 0.92) was found between patients having open or endonasal spreader graft placement in NOSE score improvement. Open rhinoplasty was associated with significantly longer operative times (P < 0.001), and performance of additional maneuvers such as strut grafts, osteotomies, and dorsal hump reduction was not found to independently affect operative times significantly. CONCLUSIONS AND RELEVANCE Spreader grafts can be placed through an endonasal or open approach with similar outcomes in a standardized measure. Open rhinoplasty is associated with prolonged operative times and therefore increased operative costs. In properly selected patients, endonasal spreader graft placement may lead to significant cost savings when open rhinoplasty is not otherwise indicated.
Collapse
|
39
|
Lindquist NR, Leach M, Simpson MC, Antisdel JL. Evaluating Simulator-Based Teaching Methods for Endoscopic Sinus Surgery. EAR, NOSE & THROAT JOURNAL 2019; 98:490-495. [PMID: 31018690 DOI: 10.1177/0145561319844742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A multitude of simulator systems for endoscopic sinus surgery (ESS) are available as training tools for residents preparing to enter the operating room. These include human cadavers, virtual reality, realistic anatomic models, and low-fidelity gelatin molds. While these models have been validated and evaluated as independent tools for surgical trainees, no study has performed direct comparison of their outcomes. To address this deficiency, we aimed to evaluate the utility of high-fidelity and low-fidelity trainers as compared to a traditional control (no simulator exposure) for novice trainees acquiring basic ESS skills. Thirty-four first-year medical students were randomized to 3 groups and taught basic sinus anatomy and instrumentation. Two groups received training with either the high-fidelity or low-fidelity trainer, while 1 group served as control. These groups were then tested with cadaveric specimens. These sessions were recorded and graded by an expert. There was no statistical difference in performance between the 3 study groups with regard to identification of anatomy, endoscopic competency, or completion of basic tasks. When the high-fidelity and low-fidelity arms were grouped into a single "trained" cohort, they demonstrated significantly improved time to completion for basic anatomy (P = .043) and total time (P = .041). This is the first study to perform a direct comparison of performance between high-fidelity and low-fidelity ESS simulators and controls. Although we found no difference in performance of novice trainees with regard to basic anatomical identification or procedural tasks associated with ESS, the use of ESS simulators may improve time to completion.
Collapse
Affiliation(s)
- Nathan R Lindquist
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew Leach
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Matthew C Simpson
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Jastin L Antisdel
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| |
Collapse
|
40
|
Ourian AJ, Doval AF, Zavlin D, Chegireddy V, Echo A. Evaluating Patient Outcomes in Breast and Abdominal Cosmetic Plastic Surgery Procedures Involving Residents. Aesthet Surg J 2019; 39:572-578. [PMID: 30561504 DOI: 10.1093/asj/sjy329] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hands-on training and exposure to cosmetic surgery is an integral part of plastic surgery residency. However, resident participation in cosmetic surgical cases is often limited in many training programs. Furthermore, the effect of resident participation in cosmetic surgery is poorly defined. OBJECTIVES The aim of this study was to analyze the impact of resident involvement on outcomes in cosmetic plastic surgery procedures, with a focus on breast and abdominal surgeries. METHODS A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing cosmetic breast and abdominal surgical procedures by plastic surgeons over a 4-year period (2009-2012). Multivariate regression models were constructed to determine any association between resident participation and surgical outcomes. RESULTS A total of 6982 patients were included in the analysis. Cases with resident involvement had higher rates of superficial surgical site infection (P < 0.0001), wound dehiscence (P = 0.014), and an increase in mean length of hospital stay (P = 0.001). Multivariate analysis revealed that the increased rate of superficial surgical site infection was associated with a higher body mass index and with the involvement of a resident during the surgical procedure. CONCLUSIONS This study provides further evidence to support the claim that resident involvement in cosmetic surgery is safe, with little effect on the rates of major complications. Any increase in minor complication rates must be critically analyzed with respect to the valuable surgical experience gathered by the next generation of surgeons. LEVEL OF EVIDENCE: 2
Collapse
Affiliation(s)
- Ariel J Ourian
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Andres F Doval
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Dmitry Zavlin
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Vishwanath Chegireddy
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Anthony Echo
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| |
Collapse
|
41
|
First Case On-Time Starts Measured by Incision On-Time and No Grace Period: A Case Study of Operating Room Management. J Healthc Manag 2019; 64:111-121. [PMID: 30845060 DOI: 10.1097/jhm-d-17-00203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
EXECUTIVE SUMMARY A delay in first case on-time starts (FCOTS) can lead to less operating room (OR) utilization, greater facility costs, and dissatisfaction among staff and patients. FCOTS is usually measured by the patient in-room metric with a small grace period. For this study, the partnering hospital elected to target and improve delays by aggressively defining FCOTS as time of incision with no grace period. Metric standardization, goal setting, and organizational focus contributed to a 9-month implementation plan to improve the newly defined FCOTS metric. The target was achieved during implementation, with 73.6% of first cases starting on time. Annual impact showed 80,587 min, or 1,343 hr, of saved OR time, which led to $771,000 in annual savings for variable OR labor costs. This redefined metric and related interventions contributed to significant reduction in delays and savings to the hospital. Engaged physician leadership played a key role in this improvement initiative, as well. The methods employed here can be used in other hospitals looking to improve FCOTS metrics in their procedural areas.
Collapse
|
42
|
Quick JA, Bukoski AD, Doty J, Bennett BJ, Crane M, Randolph J, Ahmad S, Barnes SL. Case Difficulty, Postgraduate Year, and Resident Surgeon Stress: Effects on Operative Times. JOURNAL OF SURGICAL EDUCATION 2019; 76:354-361. [PMID: 30146460 DOI: 10.1016/j.jsurg.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/30/2018] [Accepted: 08/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE We aimed to evaluate resident operative times in relation to postgraduate year (PGY), case difficulty and resident stress while performing a single surgical procedure. DESIGN We prospectively examined operative times for 268 laparoscopic cholecystectomies, and analyzed relationships between PGY, case difficulty, and resident surgeon stress utilizing electrodermal activity. Each case operative times were divided into 3 separate time periods. Case Start and End times were recorded, as well as the time between the start of the operation and the time until the cystic structures were divided (Division). Case difficulty was determined by multiple trained observers with a high inter-rater concordance. SETTING University of Missouri, a tertiary academic medical institution. PARTICIPANTS All categorical general surgery residents at our institution. RESULTS For each operative time period examined during laparoscopic cholecystectomy, operative time increased, with each incremental increase in difficulty resulting in approximately 130% longer times. Minimal differences in operative times were seen between PGY levels, except during the easiest cases (Start-End times: 38.5 ± 10.4 minutes vs 34.2 ± 10.8 minutes vs 28.9 ± 10.9 minutes, p 0.002). Resident stress poorly correlated with operative times regardless of case difficulty (Pearson coefficient range 0.0-0.22). CONCLUSIONS Operative times are longer with increasing case difficulty. PGY level and resident surgeon stress appear to have minimal to no correlation with operative times, regardless of case difficulty.
Collapse
Affiliation(s)
- Jacob A Quick
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri.
| | - Alex D Bukoski
- University of Missouri, College of Veterinary Medicine, Columbia, Missouri
| | - Jennifer Doty
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Bethany J Bennett
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Megan Crane
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Jennifer Randolph
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Salman Ahmad
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Stephen L Barnes
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| |
Collapse
|
43
|
|
44
|
Abstract
Wide Awake surgery under Local Anesthesia with No Tourniquet (WALANT) has revolutionized clinical hand surgery, improving clinical outcomes and reducing postoperative pain and morbidity. It can also be used to deepen scientific knowledge, because the unsedated patient, with sensation intact and without the adverse effects of tourniquet neurapraxia or paralysis, can follow commands and actively move the limb after tendon and nerve surgery. These movements can be correlated with fingertip force, tendon tension, nerve conduction and amplitude, and muscle sarcomere length measurements to develop new insights into the effectiveness of many different tendon and nerve procedures in the hand.
Collapse
Affiliation(s)
- Verena J.M.M. Festen-Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States,Department of Plastic, Reconstructive and Hand surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter C. Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
45
|
Pontarelli EM, Grinberg GG, Isaacs RS, Morris JP, Ajayi O, Yenumula PR. Regional cost analysis for laparoscopic cholecystectomy. Surg Endosc 2018; 33:2339-2344. [DOI: 10.1007/s00464-018-6526-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/11/2018] [Indexed: 10/27/2022]
|
46
|
Dewane MP, Thomas DC, Longo WE, Yoo PS. Paying the Price: Understanding the Opportunity Cost of Dedicated Research Time during Surgical Training. Am Surg 2018. [DOI: 10.1177/000313481808401125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pursuit of dedicated research time during surgical residency prolongs training and delays entry into practice. Currently, there is a lack of research quantifying the financial implication of this delay and trainees’ understanding of its impact on career earnings. An opportunity cost analysis was performed regarding the impact of delay due to training within general surgery and selected subspecialties. An anonymous survey was distributed to general surgery categorical junior trainees in 2017 at a large academic hospital in the Northeast to determine understanding and beliefs regarding dedicated training on career earnings. For all specialties analyzed, dedicated research time was shown to negatively affect career earnings. The net cost was highest among those intending to pursue cardiothoracic surgery and lowest for those intending to pursue surgical oncology. A total of 26 of 35 (74%) present research residents and clinical residents intending to perform dedicated research time responded to an anonymous survey. On average, survey respondents underestimated the impact of dedicated research time on career earnings by $1.4 million. Dedicated research time during general surgery residency carries a substantial opportunity cost to overall career earnings. General surgery residents lack understanding of both the direction and the magnitude of this opportunity cost.
Collapse
Affiliation(s)
- Michael P. Dewane
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel C. Thomas
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Walter E. Longo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter S. Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
47
|
Kempenich JW, Willis RE, Campi HD, Schenarts PJ. The Cost of Compliance: The Financial Burden of Fulfilling Accreditation Council for Graduate Medical Education and American Board of Surgery Requirements. JOURNAL OF SURGICAL EDUCATION 2018; 75:e47-e53. [PMID: 30122641 DOI: 10.1016/j.jsurg.2018.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/25/2018] [Accepted: 07/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE There has been a significant increase in the number of regulatory requirements for general surgery graduate medical education (GME) programs over the last 20 years from the governing bodies of the American Board of Surgery (ABS) and the Accreditation Council of Graduate Medical Education (ACGME). We endeavored to calculate the cost to general surgery GME programs of regulatory requirements. DESIGN We examined the requirements for General Surgery ABS Certification as well as the 2017 ACGME Program Requirements in General Surgery for all mandates that require funding by the surgery program to achieve. The requirements requiring funding include certification in Advanced Cardiac Life Support, Advanced Trauma Life Support, Fundamentals of Laparoscopic Surgery, Fundamentals of Endoscopic Surgery; access to medical references; simulation capability, program director protected time (30%); program coordinator salary (Association for Hospital Medical Education reported mean); and faculty time devoted to morbidity and mortality conference, journal club, Clinical Competency Committee, and Program Evaluation Committee. We then identified the cost of each mandate based on the average program in the United States of 5 residents per year in 5 clinical years. RESULTS Total cost for the average program per year as the result of ABS or ACGME mandate equaled a minimum of $227,043. The ABS associated costs are $8900 per year. The ACGME associated costs are $218,143. The cost of program director and faculty time to meet the minimum ACGME requirements equaled $159,600. CONCLUSIONS The most significant cost associated with mandates set forth by the ABS and ACGME are program director and faculty time devoted to resident education and evaluation. Recognition of this cost burden by institutions and policymakers for the allocation of funds is important to maintain strong general surgery GME programs.
Collapse
Affiliation(s)
- Jason W Kempenich
- University of Texas Health Science Center at San Antonio, San Antonio, Texas.
| | - Ross E Willis
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Haisar Dao Campi
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | |
Collapse
|
48
|
Buitrago DH, Majid A, Alape DE, Wilson JL, Parikh M, Kent MS, Gangadharan SP. Single-Center Experience of Tracheobronchoplasty for Tracheobronchomalacia: Perioperative Outcomes. Ann Thorac Surg 2018; 106:909-915. [DOI: 10.1016/j.athoracsur.2018.03.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
|
49
|
Perioperative Complication Rates After Colpopexy in African American and Hispanic Women. Female Pelvic Med Reconstr Surg 2018; 26:597-602. [DOI: 10.1097/spv.0000000000000633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Khelemsky R, Powers D, Greenberg S, Suresh V, Silver EJ, Turner M. The Hybrid Arch Bar Is a Cost-Beneficial Alternative in the Open Treatment of Mandibular Fractures. Craniomaxillofac Trauma Reconstr 2018; 12:128-133. [PMID: 31073362 DOI: 10.1055/s-0038-1639351] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/02/2017] [Indexed: 10/17/2022] Open
Abstract
Obtaining maxillomandibular fixation (MMF) to achieve fracture reduction and functional occlusion is essential in the management of maxillofacial trauma. The aims of this retrospective review were to compare the total time spent in the operating room (OR) when using the Erich arch bar (EAB) versus the bone anchored hybrid arch bar (HAB) as well as performing a cost-benefit analysis (CBA). The study sample comprised patients older than 18 years who underwent open reduction internal fixation of mandible fractures at two separate institutions over a 5-year period. The primary outcome variable was total surgical time in minutes, defined as the time from incision to the completion of closure. Average operative time was significantly longer for the EAB than for the HAB (186.74 ± 70.73 vs. 135.98 ± 2.69 minutes, p < 0.001). A significant amount of time was saved by using the HAB for unilateral (37.17 ± 13.19 minutes; p = 0.007) and bilateral fractures (55.83 ± 18.89 minutes; p = 0.005). In-depth CBA showed that, for average OR fees of $60 per minute, the HAB produced savings of at least 4.01 and 11.63% of the total cost of surgery for unilateral and bilateral fractures. These results support the hypothesis that the HAB is a time-saving maneuver in the open treatment of mandible fractures. The HAB saves more time in bilateral fracture cases despite the longer overall operative times. This study shows the differential time-saving effect of the HAB regardless of fracture laterality as well as its cost minimization benefit compared with the EAB.
Collapse
Affiliation(s)
- Renata Khelemsky
- Division of Oral & Maxillofacial Surgery, Mount Sinai Beth Israel Hospital, New York, New York
| | - David Powers
- Division of Plastic, Reconstructive, Maxillofacial & Oral Surgery, Department of Surgery, Duke University Hospital, Durham, North Carolina
| | - Seth Greenberg
- Division of Oral & Maxillofacial Surgery, Mount Sinai Beth Israel Hospital, New York, New York
| | - Visakha Suresh
- Duke University School of Medicine, Durham, North Carolina
| | | | - Michael Turner
- Division of Oral & Maxillofacial Surgery, Mount Sinai Beth Israel Hospital, New York, New York
| |
Collapse
|