1
|
Abbitt D, Choy K, Robinson TN, Jones EL, Horney C, Sommerville S, Jones TS. Preoperative Risk Factors for Discharge to Facility After Surgery in Geriatric Patients. Am Surg 2024:31348241256056. [PMID: 38788760 DOI: 10.1177/00031348241256056] [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: 05/26/2024]
Abstract
BACKGROUND The Geriatric Surgery Verification Program (GSV) was developed to address perioperative care for patients ≥75 years, with a goal of improving outcomes and functional abilities after surgery. We sought to evaluate preoperative factors that place patients at risk for inability to return home (ie, discharge to a facility). METHODS Retrospective review of patients ≥75 years old who underwent inpatient surgery from January 2018 to December 2022 at a referral Veterans Administration Medical Center enrolled in the GSV program. Preoperative factors included fall history, mobility aids, housing status, function, cognition, and nutritional status. Postoperative outcomes were discharge designations as home and home with services compared to a facility (skilled nursing facility and acute rehab). Exclusion criteria included preoperative facility residence, cardiac surgery, hospital transfer, postoperative complications, hospice discharge, or in-hospital mortality. RESULTS 605 patients met inclusion criteria and 173 (29%) excluded as above. Of the remaining 432 patients, mean age was 79 ± 5 and the majority were male, 426 (99%). The majority of patients were discharged home, 388 (90%), compared to a facility, 44 (10%). Patients with a fall history (OR: 2.95, 95% CI: 1.56, 5.57), utilizing a mobility aid (OR: 6.0, 95% CI: 2.8, 12.83), were partial or totally dependent (OR: 4.83, 95% CI: 2.29, 10.17), or who lived alone (OR: 2.57, 95% CI: 1.08, 6.07) had higher rates of discharge to a facility. DISCUSSION Preoperative mobility compromise and functional dependence are associated with higher rates of discharge to a facility. These preoperative factors are possibly modifiable with multidisciplinary care teams to decrease risks of facility placement.
Collapse
Affiliation(s)
- Danielle Abbitt
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kevin Choy
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Thomas N Robinson
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
| | - Edward L Jones
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
| | - Carolyn Horney
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
| | - Shala Sommerville
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
| | - Teresa S Jones
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
| |
Collapse
|
2
|
Abella MKIL, Angeles JPM, Finlay AK, Amanatullah DF. Is Operative Time Associated With Obesity-related Outcomes in TKA? Clin Orthop Relat Res 2024; 482:801-809. [PMID: 37820225 PMCID: PMC11008657 DOI: 10.1097/corr.0000000000002888] [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] [Received: 02/10/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Obesity-based cutoffs in TKA are premised on higher rates of postoperative complications. However, operative time may be associated with postoperative complications, leading to an unnecessary restriction of TKA in patients with obesity. If operative time is associated with these obesity-related outcomes, it should be accounted for in order to ensure all measurable factors associated with negative outcomes are examined for patients with obesity after TKA. QUESTIONS/PURPOSES We asked: (1) Is operative time, controlling for BMI class, associated with readmission, reoperation, and postoperative major and minor complications? (2) Is operative time associated with a difference in the direction or strength of obesity-related adverse outcomes? METHODS In this comparative study, we extracted all records on elective, unilateral TKA between January 2014 and December 2020 in the American College of Surgeons National Surgical Quality Improvement Program database, resulting in an initial sample of 394,381 TKAs. Patients with emergency procedures (0.1% [270]) and simultaneous bilateral TKAs (2% [8736]), missing or null data (1% [4834]), and those with operative times less than 25 minutes (0.1% [548]) were excluded, leaving 96% (379,993) of our original sample size. The National Surgical Quality Improvement Program database was selected because of its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight (BMI < 18.5 kg/m 2 , < 1% [719]), normal weight (BMI 18.5 to 24.9 kg/m 2 , 9% [34,513]), overweight (BMI 25.0 to 29.9 kg/m 2 , 27% [101,538]), Class I obesity (BMI 30.0 to 34.9 kg/m 2 , 29% [111,712]), Class II obesity (BMI 35.0 to 39.9 kg/m 2 , 20% [76,605]), and Class III obesity (BMI ≥ 40.0 kg/m 2 , 14% [54,906]). The mean operative time was 91 ± 36 minutes, 61% of patients were women (233,062 of 379,993), and the mean age was 67 ± 9 years. Patients with obesity tended to be younger and more likely to have preoperative comorbidities and longer operative times than patients with normal weight. Multivariable logistic regression models examined the main effects of operative time with respect to 30-day readmission, reoperation, and major and minor medical complications, while adjusting for BMI class and other covariates including age, sex, race, smoking status, and number of preoperative comorbidities. We then evaluated the potential interaction effect of BMI class and operative time. This interaction term helps determine whether the association of BMI with postoperative outcomes changes based on the duration of the surgery, and vice versa. If the interaction term is statistically significant, it implies the association of BMI with adverse postoperative outcomes is inconsistent across all patients. Instead, it varies with the operative time. Adjusted odds ratios and 95% confidence intervals were calculated, and interaction effects were plotted. RESULTS After controlling for obesity, longer procedure duration was independently associated with higher odds of all outcomes (30-minute estimates; adjusted ORs are per minute), including readmission (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), reoperation (15% per half-hour of surgical duration; adjusted OR 1.005 [95% CI 1.004 to 1.005]; p < 0.001), postoperative major complications (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), and postoperative minor complications (18% per half-hour of surgical duration; adjusted OR 1.006 [95% CI 1.006 to 1.007]; p < 0.001). The interaction effect indicates that patients with obesity had lower odds of reoperation than patients with normal weight when operative times were shorter, but higher odds of reoperation with a longer operative duration. CONCLUSION We found that operative time, a proxy for surgical complexity, had a moderate, differential association with obesity over a 30-minute period. Perioperative modification of surgical complexity such as surgical techniques, training, and team dynamics may make safe TKA possible for certain patients who might have otherwise been denied surgery. Decisions to refuse TKA to patients with obesity should be based on a holistic assessment of a patient's operative complexity, rather than strictly assessing a patient's weight or their ability to lose weight. Future studies should assess patient-specific characteristics that are associated with operative time, which can further push the development of techniques and strategies that reduce surgical complexity and improve TKA outcomes. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Maveric K. I. L. Abella
- Stanford University, Department of Orthopaedic Surgery, Stanford, CA, USA
- University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - John P. M. Angeles
- Stanford University, Department of Orthopaedic Surgery, Stanford, CA, USA
- Wright State University Boonshoft School of Medicine, Fairborn, OH, USA
| | - Andrea K. Finlay
- Stanford University, Department of Orthopaedic Surgery, Stanford, CA, USA
| | | |
Collapse
|
3
|
McNevin K, Nicassio L, Rice-Townsend SE, Katz CB, Goldin A, Avansino J, Calkins CM, Durham MM, Page K, Ralls MW, Reeder RW, Rentea RM, Rollins MD, Saadai P, Wood RJ, van Leeuwen KD, Smith CA. Comparison of the PCPLC Database to NSQIP-P: A Patient Matched Comparison of Surgical Complications Following Repair of Anorectal Malformation. J Pediatr Surg 2024; 59:997-1002. [PMID: 38365475 DOI: 10.1016/j.jpedsurg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/27/2023] [Accepted: 01/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Anorectal malformations (ARM) are rare and heterogenous which creates a challenge in conducting research and offering recommendations for best practice. The Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) was formed in 2016 to address this challenge and created a shared national data registry to collect information about pediatric colorectal patients. There has been no external validation of the data collected. We sought to evaluate the database by performing a patient matched analysis comparing 30-day outcomes identified in the PCPLC registry with the NSQIP-P database for patients undergoing surgical repair of ARM. METHODS Patients captured in the PCPLC database from 2016 to 2021 at institutions also participating in NSQIP-P who underwent ARM repair younger than 12 months old were reviewed for 30-day complications. These patients were matched to their NSQIP-P record using their hospital identification number, and records were compared for concordance in identified complications. RESULTS A total of 591 patient records met inclusion criteria in the PCPLC database. Of these, 180 patients were also reviewed by NSQIP-P. One hundred and fifty-six patient records had no complications recorded. Twenty-four patient records had a complication listed in one or both databases. There was a 91 % concordance rate between databases. When excluding complications not tracked in the PCPLC registry, this agreement improved to 93 %. CONCLUSION Including all patients evaluated for this subpopulation, a 91 % concordance rate was observed when comparing PCPLC collected complications to NSQIP-P. Future efforts can focus on further validating the data within the PCPLC for other patient populations. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Kathryn McNevin
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
| | - Lauren Nicassio
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Samuel E Rice-Townsend
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Cindy B Katz
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Adam Goldin
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Jeffrey Avansino
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, 999 N 92 St Suite 320, Milwaukee, WI 53226, USA
| | - Megan M Durham
- Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Rd NE, Atlanta, GA 30322, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Matthew W Ralls
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E Hospital Drive Level 4, Ann Arbor, MI 48109, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Dr., Ste 3800 Salt Lake City, UT 84112, USA
| | - Payam Saadai
- Department of Surgery, UC Davis Children's Hospital, University of California Davis, 2521 Stockton Blvd, 4th Floor Suite 4100, Sacramento, CA 95817, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Kathleen D van Leeuwen
- Department of Surgery, Phoenix Children's Hospital, University of Arizona, 1919 E. Thomas Rd, Phoenix, AZ 85016, USA
| | - Caitlin A Smith
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| |
Collapse
|
4
|
Allaway MGR, Pham H, Zeng M, Sinclair JLB, Johnston E, Richardson A, Hollands M. Failure to rescue following oesophagectomy in Australia: a multi-site retrospective study using American College of Surgeons National Surgical Quality Improvement Program. ANZ J Surg 2024. [PMID: 38644757 DOI: 10.1111/ans.19004] [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: 02/07/2024] [Revised: 03/19/2024] [Accepted: 03/27/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Failure to rescue (FTR), defined as death after a major complication, is increasingly being used as a surrogate for assessing quality of care following major cancer resection. The aim of this paper is to determine the failure to rescue (FTR) rate after oesophagectomy and explore factors that may contribute to FTR within Australia. METHODS A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2023 at five Australian hospitals was conducted to identify patients who underwent an oesophagectomy. The primary outcome was FTR rate. Perioperative parameters were examined to evaluate predictive factors for FTR. Secondary outcomes include major complications, overall morbidity, mortality, length of stay and 30-day readmissions. RESULTS A total of 155 patients were included with a median age of 65.2 years, 74.8% being male. The FTR rate was 6.3%. In total, 50.3% of patients (n = 78) developed at least one postoperative complication with the most common complication being pneumonia (20.6%) followed by prolonged intubation (12.9%) and organ space SSI/anastomotic leak (11.0%). Multivariate logistic regression analysis was performed to determine any factors that were predictive for FTR however none reached statistical significance. CONCLUSION This study is the first to evaluate the FTR rates following oesophagectomy within Australia, with FTR rates and complication profile comparable to international benchmarks. Integration of multi-institutional national databases such as ACS NSQIP into units is essential to monitor and compare patient outcomes following major cancer surgery, especially in low to moderate volume centres.
Collapse
Affiliation(s)
- Matthew G R Allaway
- Department of Upper Gastrointestinal Surgery, Westmead Hospital, Westmead, New South Wales, Australia
- School of Medicine, Blacktown & Mount Druitt Medical School, Western Sydney University, Blacktown, New South Wales, Australia
| | - Helen Pham
- Department of Upper Gastrointestinal Surgery, Westmead Hospital, Westmead, New South Wales, Australia
- Faculty of Medicine and Health, Western Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mingjuan Zeng
- The George Institute for Global Health, University of NSW, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Jane-Louise B Sinclair
- Department of Upper Gastrointestinal Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Emma Johnston
- Department of Upper Gastrointestinal Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Arthur Richardson
- Department of Upper Gastrointestinal Surgery, Westmead Hospital, Westmead, New South Wales, Australia
- Faculty of Medicine and Health, Western Clinical School, University of Sydney, Sydney, New South Wales, Australia
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Michael Hollands
- Department of Upper Gastrointestinal Surgery, Westmead Hospital, Westmead, New South Wales, Australia
- Faculty of Medicine and Health, Western Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
5
|
Mohanty S, Lindroth H, Timsina L, Holler E, Jenkins P, Ortiz D, Hur J, Gillio A, Zarzaur B, Boustani M. A Mediation Analysis Examining High Risk, Anticholinergic Medication Use, Delirium, and Dementia After Major Surgery. J Surg Res 2024; 298:222-229. [PMID: 38626720 DOI: 10.1016/j.jss.2024.03.018] [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: 08/29/2023] [Revised: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Anticholinergic medications are known to cause adverse cognitive effects in community-dwelling older adults and medical inpatients, including dementia. The prevalence with which such medications are prescribed in older adults undergoing major surgery is not well described nor is their mediating relationship with delirium and dementia. We sought to determine the prevalence of high-risk medication use in major surgery patients and their relationship with the subsequent development of dementia. METHODS This was a retrospective cohort study which used data between January 2013 and December 2019, in a large midwestern health system, including sixteen hospitals. All patients over age 50 undergoing surgery requiring an inpatient stay were included. The primary exposure was the number of doses of anticholinergic medications delivered during the hospital stay. The primary outcome was a new diagnosis of Alzheimer's disease and related dementias at 1-y postsurgery. Regression methods and a mediation analysis were used to explore relationships between anticholinergic medication usage, delirium, and dementia. RESULTS There were 39,665 patients included, with a median age of 66. Most patients were exposed to anticholinergic medications (35,957/39,665; 91%), and 7588/39,665 (19.1%) patients received six or more doses during their hospital stay. Patients with at least six doses of these medications were more likely to be female, black, and with a lower American Society of Anesthesiologists class. Upon adjusted analysis, high doses of anticholinergic medications were associated with increased odds of dementia at 1 y relative to those with no exposure (odds ratio 2.7; 95% confidence interval 2.2-3.3). On mediation analysis, postoperative delirium mediated the effect of anticholinergic medications on dementia, explaining an estimated 57.6% of their association. CONCLUSIONS High doses of anticholinergic medications are common in major surgery patients and, in part via a mediating relationship with postoperative delirium, are associated with the development of dementia 1 y following surgery. Strategies to decrease the use of these medications and encourage the use of alternatives may improve long-term cognitive recovery.
Collapse
Affiliation(s)
- Sanjay Mohanty
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Center for Health Innovation and Implementation Science, Indianapolis, Indiana.
| | - Heidi Lindroth
- Nursing Research Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Emma Holler
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana
| | - Peter Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Damaris Ortiz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Center for Health Innovation and Implementation Science, Indianapolis, Indiana
| | - Jennifer Hur
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anna Gillio
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ben Zarzaur
- Division of Acute Care and Regional General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Malaz Boustani
- Center for Health Innovation and Implementation Science, Indianapolis, Indiana; Regenstrief Institute, Indiana University Center of Aging Research, Indianapolis, Indiana
| |
Collapse
|
6
|
Guerra-Londono CE, Cata JP, Nowak K, Gottumukkala V. Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness. Curr Oncol 2024; 31:2185-2200. [PMID: 38668065 PMCID: PMC11049527 DOI: 10.3390/curroncol31040162] [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: 03/21/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Cancer surgery places a significant burden on a patients' functional status and quality of life. In addition, cancer surgery is fraught with postoperative complications, themselves influenced by a patient's functional status. Prehabilitation is a unimodal or multimodal strategy that aims to increase a patient's functional capacity to reduce postoperative complications and improve postoperative recovery and quality of life. In most cases, it involves exercise, nutrition, and anxiety-reducing interventions. The impact of prehabilitation has been explored in several types of cancer surgery, most commonly colorectal and thoracic. Overall, the existing evidence suggests prehabilitation improves physiological outcomes (e.g., lean body mass, maximal oxygen consumption) as well as clinical outcomes (e.g., postoperative complications, quality of life). Notably, the benefit of prehabilitation is additional to that of enhanced recovery after surgery (ERAS) programs. While safe, prehabilitation programs require multidisciplinary coordination preoperatively. Despite the existence of numerous systematic reviews and meta-analyses, the certainty of evidence demonstrating the efficacy and safety of prehabilitation is low to moderate, principally due to significant methodological heterogeneity and small sample sizes. There is a need for more large-scale multicenter randomized controlled trials to draw strong clinical recommendations.
Collapse
Affiliation(s)
- Carlos E. Guerra-Londono
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI 48202, USA; (C.E.G.-L.); (K.N.)
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Katherine Nowak
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI 48202, USA; (C.E.G.-L.); (K.N.)
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| |
Collapse
|
7
|
Wenzel AN, Marrache M, Schmerler J, Kinney J, Khanuja HS, Hegde V. Impact of Postoperative COVID-19 Infection Status on Outcomes in Elective Primary Total Joint Arthroplasty. J Arthroplasty 2024; 39:871-877. [PMID: 37852450 DOI: 10.1016/j.arth.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Although Coronavirus disease 2019 (COVID-19) infection causes major morbidity and mortality, it is unclear what the impact of postoperative COVID-19 infection is on 30-day outcomes after total joint arthroplasty (TJA). METHODS There were 2,340 patients who underwent TJA in 2021, identified using the National Surgical Quality Improvement Program database, with 925 total hip arthroplasty (THA) patients (39.5%) and 1,415 total knee arthroplasty (TKA) patients (60.5%), overall. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for postoperative COVID-19-positive and COVID-19-negative patients who underwent TKA or THA. RESULTS Postoperative COVID-19-positive THA patients were found to have a significantly increased risk of pneumonia (odds ratio [OR] 42.57), sepsis (OR 12.77), readmission (OR 12.06), non-home discharge (OR 3.78), and longer length of stay (hazard ratio 1.62). Postoperative COVID-19-positive TKA patients had an increased risk of 30-day mortality (OR 14.17), superficial infection (OR 3.17), pneumonia (OR 34.68), unplanned intubation (OR 18.31), ventilator use for more than 48 hours (OR 18.31), pulmonary embolism (OR 11.98), urinary tract infection (OR 5.16), myocardial infarction (OR 16.02), deep vein thrombosis (OR 4.69), non-home discharge (OR 1.79), reoperation (OR 3.17), readmission (OR 9.61), and longer length of stay (hazard ratio 1.49). CONCLUSIONS Patients who contracted COVID-19 within 30 days after TJA were at increased risk of mortalities, medical complications, readmissions, reoperations, and non-home discharges. It is important for orthopedic surgeons to understand these adverse outcomes to better counsel patients and mitigate these risks, particularly in higher risk populations.
Collapse
Affiliation(s)
- Alyssa N Wenzel
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason Kinney
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
8
|
Hughes G, Stephens TJ, Seuren LM, Pearse RM, Shaw SE. Clinical context and communication in shared decision-making about major surgery: Findings from a qualitative study with colorectal, orthopaedic and cardiac patients. Health (London) 2024:13634593241238857. [PMID: 38514999 DOI: 10.1177/13634593241238857] [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: 03/23/2024]
Abstract
Increasing numbers of older people undergo major surgery in the United Kingdom (UK), with many at high risk of complications due to age, co-morbidities or frailty. This article reports on a study of such patients and their clinicians engaged in shared decision-making. Shared decision-making is a collaborative approach that seeks to value and centre patients' preferences, potentially addressing asymmetries of knowledge and power between clinicians and patients by countering medical authority with greater patient empowerment. We studied shared decision-making practices in the context of major surgery by recruiting 16 patients contemplating either colorectal, cardiac or joint replacement surgery in the UK National Health Service (NHS). Over 18 months 2019-2020, we observed and video-recorded decision-making consultations, studied the organisational and clinical context for consultations, and interviewed patients and clinicians about their experiences of making decisions. Linguistic ethnography, the study of communication and interaction in context, guided us to analyse the interplay between interactions (during consultations between clinicians, patients and family members) and clinical and organisational features of the contexts for those interactions. We found that the framing of consultations as being about life-saving or life-enhancing procedures was important in producing three different genres of consultations focused variously on: resolving problems, deliberation of options and evaluation of benefits of surgery. We conclude that medical authority persists, but can be used to create more deliberative opportunities for decision-making through amending the context for consultations in addition to adopting appropriate communication practices during surgical consultations.
Collapse
Affiliation(s)
- Gemma Hughes
- University of Leicester, UK
- University of Oxford, UK
| | | | | | | | | |
Collapse
|
9
|
Abbitt D, Choy K, Castle R, Bollinger D, Jones TS, Wikiel KJ, Barnett CC, Moore JT, Robinson TN, Jones EL. Telehealth for general surgery postoperative care. Am J Surg 2024; 229:156-161. [PMID: 38158263 DOI: 10.1016/j.amjsurg.2023.12.025] [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: 08/10/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Telehealth utilization rapidly increased following the pandemic. However, it is not widely used in the Veteran surgical population. We sought to evaluate postoperative telehealth in patients undergoing general surgery. METHODS Retrospective review of Veterans undergoing general surgery at a level 1A VA Medical Center from June 2019 to September 2021. Exclusions were concomitant procedure(s), discharge with drains or non-absorbable sutures/staples, complication prior to discharge or pathology positive for malignancy. RESULTS 1075 patients underwent qualifying procedures, 124 (12 %) were excluded and 162 (17 %) did not have follow-up. 443 (56 %) patients followed-up in-person (56 %) vs 346 (44 %) via telehealth. Telehealth patients had a lower rate of complications, 6 % vs 12 %, p = 0.013. There were no significant differences in ED visits, 30-day readmission, postoperative procedures or missed adverse events. CONCLUSION Telehealth follow-up after general surgical procedures is safe and effective. Postoperative telehealth care should be considered after low-risk general surgery procedures.
Collapse
Affiliation(s)
- Danielle Abbitt
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA.
| | - Kevin Choy
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA
| | - Rose Castle
- School of Medicine, University of Colorado, 13001 E 17th Pl, Aurora, CO, USA
| | - Dan Bollinger
- School of Medicine, University of Colorado, 13001 E 17th Pl, Aurora, CO, USA
| | - Teresa S Jones
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA; Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, Aurora, CO, USA
| | - Krzysztof J Wikiel
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA; Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, Aurora, CO, USA
| | - Carlton C Barnett
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA; Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, Aurora, CO, USA
| | - John T Moore
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA; Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, Aurora, CO, USA
| | - Thomas N Robinson
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA; Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, Aurora, CO, USA
| | - Edward L Jones
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave, Aurora, CO, USA; Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, Aurora, CO, USA
| |
Collapse
|
10
|
Chen VW, Rosen T, Dong Y, Richardson PA, Kramer JR, Petersen LA, Massarweh NN. Case Sampling for Evaluating Hospital Postoperative Morbidity in US Surgical Quality Improvement Programs. JAMA Surg 2024; 159:315-322. [PMID: 38150240 PMCID: PMC10753439 DOI: 10.1001/jamasurg.2023.6524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/04/2023] [Indexed: 12/28/2023]
Abstract
Importance US surgical quality improvement (QI) programs use data from a systematic sample of surgical cases, rather than universal review of all cases, to assess and compare risk-adjusted hospital postoperative complication rates. Given decreasing postoperative complication rates over time and the types of cases eligible for abstraction, it is unclear whether case sampling is robust for identifying hospitals with higher than expected complications. Objective To compare the assessment of hospital 30-day complication rates derived from sampling strategy used by some US surgical QI programs relative to universal review of all cases. Design, Setting, and Participants This US hospital-level analysis took place from January 1, 2016, through September 30, 2020. Data analysis was performed from July 1, 2022, through December 21, 2022. Quarterly, risk-adjusted, 30-day complication observed to expected (O-E) ratios were calculated for each hospital using the sample (n = 502 730) and universal review (n = 1 725 364). Outlier hospitals (ie, those with higher than expected mortality) were identified using an O-E ratio significantly greater than 1.0. Patients 18 years and older who underwent a noncardiac operation at US Department of Veterans Affairs (VA) hospitals with a record in the VA Surgical Quality Improvement Program (systematic sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases) were included. Main Outcome Measure Thirty-day complications. Results Most patients in both the representative sample and the universal sample were men (90.2% vs 91.2%) and White (74.7% vs 74.5%). Overall, 30-day complication rates were 7.6% and 5.3% for the sample and universal review cohorts, respectively (P < .001). Over 2145 hospital quarters of data, hospitals were identified as an outlier in 15.0% of quarters using the sample and 18.2% with universal review. Average hospital quarterly complication rates were 4.7%, 7.2%, and 7.4% for outliers identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly complication rates were 7.0% at outliers and 4.4% at nonoutliers. Among outlier hospital quarters in the sample, 54.2% were concurrently identified with universal review. For those identified with universal review, 44.6% were concurrently identified using the sample. Conclusion In this observational study, case sampling identified less than half of hospitals with excess risk-adjusted postoperative complication rates. Future work is needed to ascertain how to best use currently collected data and whether alternative data collection strategies may be needed to better inform local QI efforts.
Collapse
Affiliation(s)
- Vivi W. Chen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
| | - Yongquan Dong
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
| | - Peter A. Richardson
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Laura A. Petersen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| |
Collapse
|
11
|
Simmonds A, Keller-Biehl L, Khader A, Timmerman W, Amendola M. Comparing Outcomes in Patients Undergoing Colectomy at Veteran Affairs Hospitals and Non-Veteran Affairs Hospitals: A Multiinstitutional Study. J Surg Res 2024; 295:449-456. [PMID: 38070259 DOI: 10.1016/j.jss.2023.11.034] [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: 04/14/2023] [Revised: 10/15/2023] [Accepted: 11/13/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION The Veteran Affairs Surgical Quality Improvement Program (VASQIP) and National Surgical Quality Improvement Program (NSQIP) are large databases designed to measure surgical outcomes for their respective populations. We sought to compare surgical outcomes in patients undergoing colectomies at Veterans Affairs (VA) hospitals versus non-VA hospitals. METHODS After institutional review baord approval, records for 271,523 colectomies from NSQIP and 11,597 from VASQIP between the years 2015 and 2019 were compiled. Demographics, comorbidity, 30-d mortality, and other outcomes were examined using Chi-squared, analysis of variance, Mann Whitney U, and Fisher's Exact Test within SPSS version 26. RESULTS VASQIP patients were more likely to be male (94.3% versus 48.4%, P < 0.001) and older (median 63, 52-72 versus 67, 60-72 P < 0.001). Veterans were also more likely to have diabetes (25.3% versus 15.8%, P < 0.001), chronic obstructive pulmonary disease (15.4% versus 5.5%, P < 0.001), and congestive heart failure (17.0% versus 1.3%, P < 0.001). Veterans had slightly better 30-d mortality (2.4% versus 2.8%, P = 0.003), less organ space infections (2.8% versus 5.8%, P < 0.001), or postoperative sepsis (3.4% versus 5.3%). Non-VA patients were more likely to be having emergent surgery (13.4% versus 9.6%, P < 0.001) or undergo a laparoscopic approach (57.9% versus 50.2%, P < 0.001). Non-VA patients had shorter postoperative length of stay (5.99 d versus 7.32 d, P < 0.001) and were less likely to return to the operating room (5.3% versus 8.4%, P < 0.001) CONCLUSIONS: Despite increased comorbidity, VA hospitals and hospitals enrolled in NSQIP have managed to achieve markedly similar rates of 30-d mortality following colectomy. Further study is needed to better understand the differences between both the populations and surgical outcomes between VA hospitals and non-VA hospitals.
Collapse
Affiliation(s)
- Alexander Simmonds
- Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia.
| | - Lucas Keller-Biehl
- Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
| | - Adam Khader
- Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
| | - William Timmerman
- Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
| | - Michael Amendola
- Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Surgery, Central Virginia VA Health Care System, Richmond, Virginia
| |
Collapse
|
12
|
Zhao E, Shinn DJ, Basilious M, Subramanian T, Shahi P, Amen TB, Maayan O, Dalal S, Araghi K, Song J, Sheha ED, E Dowdell J, Iyer S, Qureshi SA. Impact of Metabolic Syndrome on Early Postoperative Outcomes After Cervical Disk Replacement: A Propensity-matched Analysis. Clin Spine Surg 2024:01933606-990000000-00257. [PMID: 38321612 DOI: 10.1097/bsd.0000000000001567] [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] [Received: 02/01/2023] [Accepted: 11/29/2023] [Indexed: 02/08/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare the demographics, perioperative variables, and complication rates following cervical disk replacement (CDR) among patients with and without metabolic syndrome (MetS). SUMMARY OF BACKGROUND DATA The prevalence of MetS-involving concurrent obesity, insulin resistance, hypertension, and hyperlipidemia-has increased in the United States over the last 2 decades. Little is known about the impact of MetS on early postoperative outcomes and complications following CDR. METHODS The 2005-2020 National Surgical Quality Improvement Program was queried for patients who underwent primary 1- or 2-level CDR. Patients with and without MetS were divided into 2 cohorts. MetS was defined, according to other National Surgical Quality Improvement Program studies, as concurrent diabetes mellitus, hypertension requiring medication, and body mass index ≥30 kg/m2. Rates of 30-day readmission, reoperation, complications, length of hospital stay, and discharge disposition were compared using χ2 and Fisher exact tests. One to 2 propensity-matching was performed, matching for demographics, comorbidities, and number of operative levels. RESULTS A total of 5395 patients were included for unmatched analysis. Two hundred thirty-six had MetS, and 5159 did not. The MetS cohort had greater rates of 30-day readmission (2.5% vs. 0.9%; P=0.023), morbidity (2.5% vs. 0.9%; P=0.032), nonhome discharges (3% vs. 0.6%; P=0.002), and longer hospital stays (1.35±4.04 vs. 1±1.48 days; P=0.029). After propensity-matching, 699 patients were included. All differences reported above lost significance (P>0.05) except for 30-day morbidity (superficial wound infections), which remained higher for the MetS cohort (2.5% vs. 0.4%, P=0.02). CONCLUSIONS We identified MetS as an independent predictor of 30-day morbidity in the form of superficial wound infections following single-level CDR. Although MetS patients experienced greater rates of 30-day readmission, nonhome discharge, and longer lengths of stay, MetS did not independently predict these outcomes after controlling for baseline differences in patient characteristics. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Eric Zhao
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | - Daniel J Shinn
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | | | | | | | | | - Omri Maayan
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Lee AJ, Kim SY, Jang EB, Hyun JA, Yang EJ, So KA, Lee SJ, Lee JY, Kim TJ, Kang SB, Shim SH. Impact of resident participation on surgical outcomes in laparoscopically assisted vaginal hysterectomy. Int J Gynaecol Obstet 2024; 164:587-595. [PMID: 37675800 DOI: 10.1002/ijgo.15087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To compare surgical outcomes in patients with benign diseases who underwent laparoscopically assisted vaginal hysterectomy (LAVH) to determine the association between surgical outcomes and resident participation in the gynecologic field. METHODS A single-center retrospective study was conducted of patients diagnosed with benign gynecologic diseases who underwent LAVH between January 2010 and December 2015. Clinicopathologic characteristics and surgical outcomes were compared between the resident involvement and non-involvement groups. The primary endpoint was the 30-day postoperative morbidity. Observers were propensity matched for 17 covariates for resident involvement or non-involvement. RESULTS Of the 683 patients involved in the study, 165 underwent LAVH with resident involvement and 518 underwent surgery without resident involvement. After propensity score matching (157 observations), 30-day postoperative morbidity occurred in 6 (3.8%) and 4 (2.5%) patients in the resident involvement and non-involvement groups, respectively (P = 0.501). The length of hospital stay differed significantly between the two groups: 5 days in the resident involvement group and 4 days in the non-involvement group (P < 0.001). On multivariate analysis, Charlson Comorbidity Index >2 (odds ratio [OR] 8.01, 95% confidence interval [CI] 2.68-23.96; P < 0.001), operative time (OR 1.02, 95% CI 1.01-1.03; P < 0.001), and estimated blood loss (OR 1.00, 95% CI 1.00-1.00; P < 0.001) were significantly associated with 30-day morbidity, but resident involvement was not statistically significant. CONCLUSION There was no significant difference in the 30-day morbidity rate when residents participated in LAVH. These findings suggest that resident participation in LAVH may be a viable approach to ensure both residency education and patient safety.
Collapse
Affiliation(s)
- A Jin Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seo-Yeon Kim
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Bi Jang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jeong-Ah Hyun
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Eun Jung Yang
- Department of Obstetrics and Gynecology, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Kyeong A So
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sun Joo Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Ji Young Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Tae Jin Kim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Soon-Beom Kang
- Department of Obstetrics and Gynecology, Hosan Women's Hospital, Gangnam-gu, Seoul, Republic of Korea
| | - Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| |
Collapse
|
14
|
Elbuzidi M, Wenzel AN, Harris A, Marrache M, Oni JK, Khanuja HS, Hegde V. Preoperative COVID-19 infection status negatively impacts postoperative outcomes of geriatric hip fracture surgery. Injury 2024; 55:111201. [PMID: 37980857 DOI: 10.1016/j.injury.2023.111201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/04/2023] [Accepted: 11/12/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Compare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. DESIGN Retrospective propensity score matched cohort. METHODS Patients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts. RESULTS After matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 - 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 - 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 - 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 - 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 - 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 - 3.06). CONCLUSIONS Active COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Mohamed Elbuzidi
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alyssa N Wenzel
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Andrew Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Julius K Oni
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| |
Collapse
|
15
|
Shahait A, Pearl A, Saleh KJ. Outcomes of Colectomy in United States Veterans With Cirrhosis: Predicting Outcomes Using Nomogram. J Surg Res 2024; 293:570-577. [PMID: 37832308 DOI: 10.1016/j.jss.2023.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION With growing incidence of liver cirrhosis worldwide, there is more need for a risk assessment tool to aid in perioperative management of cirrhotic patients undergoing colorectal procedures. We aim to assess the association of open (OC) versus laparoscopic (LC) approach with colorectal procedures' outcomes and develop an easy-to-use nomogram to predict outcomes. METHODS We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent colorectal procedures from 2008 to 2015. Model for End-stage Liver Disease score was calculated as well as five-items modified frailty index. The chi-square test was utilized to analyze categorical variables. Two-sided unpaired Student's t-test or Mann-Whitney U-test were used for numerical variables as appropriate. Multivariate logistic regression adjusting for demographics, comorbidities, and other preoperative factors was used to analyze postoperative outcomes. A predictive nomogram was constructed and internally validated. RESULTS A total of 731 patients were identified. Overall, complications occurred in 48.2% of patients, and 30-d mortality was 24.8%, with 57.5% were performed emergently. Malignant neoplasm was the most common indication (25.4%). LC was performed in 22.4%, with shorter operative time, less blood transfusions, shorter length of stay, and lower morbidity compared to OC. Overall, Model for End-stage Liver Disease score was an independent factor of mortality, while laparoscopic approach had a protective effect on morbidity. An easy-to-use nomogram was generated for morbidity and 30-d mortality with calculated area under cure of 74.5% and 77.9%, respectively, indicating reliability. CONCLUSIONS Although colectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing colectomy is proposed.
Collapse
Affiliation(s)
- Awni Shahait
- Departement of Surgery, Southern Illinois University School of Medicine, Carbondale, Illinois; Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan.
| | - Adam Pearl
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Khaled J Saleh
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan
| |
Collapse
|
16
|
Ludwiczak A, Stephens TJ, Prowle J, Pearse R, Osman M. Supporting effective shared decision-making in surgical context: Why framing of choices matters for high-risk patients and clinicians. Colorectal Dis 2024; 26:110-119. [PMID: 38009965 DOI: 10.1111/codi.16805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/25/2023] [Accepted: 09/17/2023] [Indexed: 11/29/2023]
Abstract
AIM In the context of high-risk surgery, shared decision-making (SDM) is important. However, the effectiveness of SDM can be hindered by misalignment between patients and clinicians in their expectations of postoperative outcomes. This study investigated the extent and the effects of this misalignment, as well as its amenability to interventions that encourage perspective-taking. METHOD Lay participants with a Charlson Comorbidity Index of ≥4 (representing patients) and surgeons and anaesthetists (representing doctors) were recruited. During an online experiment, subjects in both groups forecast their expectations regarding short-term (0, 1 and 3 months after treatment) and long-term (6, 9 and 12 months after treatment) outcomes of different treatment options for one of three hypothetical clinical scenarios - ischaemic heart disease, colorectal cancer or osteoarthritis of the hip - and then chose between surgical or non-surgical treatment. Subjects in both groups were asked to consider the scenarios from their own perspective (Estimation task), and then to adopt the perspective of subjects in the other study group (Perspective task). The decisions of all participants (surgery vs. non-surgical alternative) were analysed using binomial generalized linear mixed models. RESULTS In total, 55 lay participants and 54 doctors completed the online experiment. Systematic misalignment in expectations between high-risk patients and doctors was observed, with patients expecting better surgical outcomes than clinicians. Patients forecast a significantly higher likelihood of engaging in normal activities in the long term (β = -1.09, standard error [SE] = 0.20, t = -5.38, p < 0.001), a lower likelihood of experiencing complications in the long term (β = 0.92, SE = 0.21, t = 4.45, p < 0.001) and a lower likelihood of experiencing depression in both the short term and the long term (β = 1.01, SE = 0.19, t = 5.38, p < 0.001), than did doctors. Compared with doctors, patients forecast higher estimates of experiencing complications in the short term when a non-surgical alternative was selected (β = -0.91, SE = 0.26, t = -3.50, p = 0.003). Despite this misalignment, in both groups surgical treatment was strongly preferred (estimation task: 88.7% of doctors and 80% of patients; perspective task: 82.2% of doctors and 90.1% of patients). CONCLUSION When high-risk surgery is discussed, a non-surgical option may be viewed as 'doing nothing', hence reducing the sense of agency and control. This biases the decision-making process, regardless of the expectations that doctors and patients might have about the outcomes of surgery. Therefore, to improve SDM and to increase the agency and control of patients regarding decisions about their care, we advocate framing the non-surgical treatment options in a way that emphasizes action, agency and change.
Collapse
Affiliation(s)
- Agata Ludwiczak
- Biological and Experimental Psychology, School of Biological and Chemical Sciences, Queen Mary University of London, London, UK
- Psychology and Counselling, School of Human Sciences, University of Greenwich, Old Royal Naval College, London, UK
| | - Timothy J Stephens
- Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John Prowle
- Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rupert Pearse
- Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Magda Osman
- Biological and Experimental Psychology, School of Biological and Chemical Sciences, Queen Mary University of London, London, UK
- Centre for Science and Policy, University of Cambridge, Cambridge, UK
| |
Collapse
|
17
|
Dorken-Gallastegi A, El Hechi M, Amram M, Naar L, Maurer LR, Gebran A, Dunn J, Zhuo YD, Levine J, Bertsimas D, Kaafarani HMA. Use of artificial intelligence for nonlinear benchmarking of surgical care. Surgery 2023; 174:1302-1308. [PMID: 37778969 DOI: 10.1016/j.surg.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/07/2023] [Accepted: 08/16/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Existent methodologies for benchmarking the quality of surgical care are linear and fail to capture the complex interactions of preoperative variables. We sought to leverage novel nonlinear artificial intelligence methodologies to benchmark emergency surgical care. METHODS Using a nonlinear but interpretable artificial intelligence methodology called optimal classification trees, first, the overall observed mortality rate at the index hospital's emergency surgery population (index cohort) was compared to the risk-adjusted expected mortality rate calculated by the optimal classification trees from the American College of Surgeons National Surgical Quality Improvement Program database (benchmark cohort). Second, the artificial intelligence optimal classification trees created different "nodes" of care representing specific patient phenotypes defined by the artificial intelligence optimal classification trees without human interference to optimize prediction. These nodes capture multiple iterative risk-adjusted comparisons, permitting the identification of specific areas of excellence and areas for improvement. RESULTS The index and benchmark cohorts included 1,600 and 637,086 patients, respectively. The observed and risk-adjusted expected mortality rates of the index cohort calculated by optimal classification trees were similar (8.06% [95% confidence interval: 6.8-9.5] vs 7.53%, respectively, P = .42). Two areas of excellence and 4 for improvement were identified. For example, the index cohort had lower-than-expected mortality when patients were older than 75 and in respiratory failure and septic shock preoperatively but higher-than-expected mortality when patients had respiratory failure preoperatively and were thrombocytopenic, with an international normalized ratio ≤1.7. CONCLUSION We used artificial intelligence methodology to benchmark the quality of emergency surgical care. Such nonlinear and interpretable methods promise a more comprehensive evaluation and a deeper dive into areas of excellence versus suboptimal care.
Collapse
Affiliation(s)
- Ander Dorken-Gallastegi
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Center for Outcomes and Patient Safety in Surgery, Massachusetts General Hospital, Boston, MA
| | - Majed El Hechi
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Center for Outcomes and Patient Safety in Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Leon Naar
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Center for Outcomes and Patient Safety in Surgery, Massachusetts General Hospital, Boston, MA
| | - Lydia R Maurer
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Center for Outcomes and Patient Safety in Surgery, Massachusetts General Hospital, Boston, MA
| | - Anthony Gebran
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Center for Outcomes and Patient Safety in Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | | | | | - Haytham M A Kaafarani
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Center for Outcomes and Patient Safety in Surgery, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
18
|
Snarskis C, Banerjee A, Franklin A, Weavind L. Systems of Care Delivery and Optimization in the Postoperative Care Wards. Anesthesiol Clin 2023; 41:875-886. [PMID: 37838390 DOI: 10.1016/j.anclin.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
A third of all patients are at risk for a serious adverse event, including death, in the first month after undergoing a major surgery. Most of these events will occur within 24 hours of the operation but are unlikely to occur in the operating room or postanesthesia care unit. Most opioid-induced respiratory depression events in the postoperative period resulted in death (55%) or anoxic brain injury (22%). A future state of mature artificial intelligence and machine learning will improve situational awareness of acute clinical deterioration, minimize alert fatigue, and facilitate early intervention to minimize poor outcomes.
Collapse
Affiliation(s)
- Connor Snarskis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arna Banerjee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Andrew Franklin
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liza Weavind
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
19
|
Samad M, Angel M, Rinehart J, Kanomata Y, Baldi P, Cannesson M. Medical Informatics Operating Room Vitals and Events Repository (MOVER): a public-access operating room database. JAMIA Open 2023; 6:ooad084. [PMID: 37860605 PMCID: PMC10582520 DOI: 10.1093/jamiaopen/ooad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/18/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
Objectives Artificial intelligence (AI) holds great promise for transforming the healthcare industry. However, despite its potential, AI is yet to see widespread deployment in clinical settings in significant part due to the lack of publicly available clinical data and the lack of transparency in the published AI algorithms. There are few clinical data repositories publicly accessible to researchers to train and test AI algorithms, and even fewer that contain specialized data from the perioperative setting. To address this gap, we present and release the Medical Informatics Operating Room Vitals and Events Repository (MOVER). Materials and Methods This first release of MOVER includes adult patients who underwent surgery at the University of California, Irvine Medical Center from 2015 to 2022. Data for patients who underwent surgery were captured from 2 different sources: High-fidelity physiological waveforms from all of the operating rooms were captured in real time and matched with electronic medical record data. Results MOVER includes data from 58 799 unique patients and 83 468 surgeries. MOVER is available for download at https://doi.org/10.24432/C5VS5G, it can be downloaded by anyone who signs a data usage agreement (DUA), to restrict traffic to legitimate researchers. Discussion To the best of our knowledge MOVER is the only freely available public data repository that contains electronic health record and high-fidelity physiological waveforms data for patients undergoing surgery. Conclusion MOVER is freely available to all researchers who sign a DUA, and we hope that it will accelerate the integration of AI into healthcare settings, ultimately leading to improved patient outcomes.
Collapse
Affiliation(s)
- Muntaha Samad
- Department of Computer Science, University of California, Irvine, Irvine, CA 92697, United States
- Institute for Genomics and Bioinformatics, University of California, Irvine, Irvine, CA 92697, United States
| | - Mirana Angel
- Department of Computer Science, University of California, Irvine, Irvine, CA 92697, United States
- Institute for Genomics and Bioinformatics, University of California, Irvine, Irvine, CA 92697, United States
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, Irvine, CA 92697, United States
| | - Yuzo Kanomata
- Department of Computer Science, University of California, Irvine, Irvine, CA 92697, United States
- Institute for Genomics and Bioinformatics, University of California, Irvine, Irvine, CA 92697, United States
| | - Pierre Baldi
- Department of Computer Science, University of California, Irvine, Irvine, CA 92697, United States
- Institute for Genomics and Bioinformatics, University of California, Irvine, Irvine, CA 92697, United States
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA 90095, United States
| |
Collapse
|
20
|
Chen VW, Chidi AP, Rosen T, Dong Y, Richardson PA, Kramer J, Axelrod DA, Petersen LA, Massarweh NN. Case Sampling vs Universal Review for Evaluating Hospital Postoperative Mortality in US Surgical Quality Improvement Programs. JAMA Surg 2023; 158:1312-1319. [PMID: 37755869 PMCID: PMC10535011 DOI: 10.1001/jamasurg.2023.4532] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/04/2023] [Indexed: 09/28/2023]
Abstract
Importance Representative surgical case sampling, rather than universal review, is used by US Department of Veterans Affairs (VA) and private-sector national surgical quality improvement (QI) programs to assess program performance and to inform local QI and performance improvement efforts. However, it is unclear whether case sampling is robust for identifying hospitals with safety or quality concerns. Objective To evaluate whether the sampling strategy used by several national surgical QI programs provides hospitals with data that are representative of their overall quality and safety, as measured by 30-day mortality. Design, Setting, and Participants This comparative effectiveness study was a national, hospital-level analysis of data from adult patients (aged ≥18 years) who underwent noncardiac surgery at a VA hospital between January 1, 2016, and September 30, 2020. Data were obtained from the VA Surgical Quality Improvement Program (representative sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases). Data analysis was performed from July 1 to December 21, 2022. Main Outcomes and Measures The primary outcome was postoperative 30-day mortality. Quarterly, risk-adjusted, 30-day mortality observed-to-expected (O-E) ratios were calculated separately for each hospital using the sample and universal review cohorts. Outlier hospitals (ie, those with higher-than-expected mortality) were identified using an O-E ratio significantly greater than 1.0. Results In this study of data from 113 US Department of Veterans Affairs hospitals, the sample cohort comprised 502 953 surgical cases and the universal review cohort comprised 1 703 140. The majority of patients in both the representative sample and the universal sample were men (90.2% vs 91.1%) and were White (74.7% vs 74.5%). Overall, 30-day mortality was 0.8% and 0.6% for the sample and universal review cohorts, respectively (P < .001). Over 2145 quarters of data, hospitals were identified as an outlier in 11.7% of quarters with sampling and in 13.2% with universal review. Average hospital quarterly 30-day mortality rates were 0.4%, 0.8%, and 0.9% for outlier hospitals identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly 30-day mortality rates were 1.0% at outlier hospitals and 0.5% at nonoutliers. Among outlier hospital quarters in the sample, 47.4% were concurrently identified with universal review. For those identified with universal review, 42.1% were concurrently identified using the sample. Conclusions and Relevance In this national, hospital-level study, sampling strategies employed by national surgical QI programs identified less than half of hospitals with higher-than-expected perioperative mortality. These findings suggest that sampling may not adequately represent overall surgical program performance or provide stakeholders with the data necessary to inform QI efforts.
Collapse
Affiliation(s)
- Vivi W. Chen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alexis P. Chidi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Yongquan Dong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Peter A. Richardson
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Laura A. Petersen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta Veterans Affairs Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| |
Collapse
|
21
|
Gong JH, Sastry R, Koh DJ, Soliman L, Sobti N, Oyelese AA, Gokaslan ZL, Fridley J, Woo AS. Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis. World Neurosurg 2023; 180:e392-e407. [PMID: 37769839 DOI: 10.1016/j.wneu.2023.09.078] [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: 07/23/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database. METHODS We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure. RESULTS A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P = 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P = 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05). CONCLUSIONS Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.
Collapse
Affiliation(s)
- Jung Ho Gong
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Rahul Sastry
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel J Koh
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luke Soliman
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nikhil Sobti
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jared Fridley
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Albert S Woo
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
22
|
Hones KM, Hao KA, Cueto RJ, Wright JO, King JJ, Wright TW, Friedman RJ, Schoch BS. The Obesity Paradox: A Nonlinear Relationship Between 30-Day Postoperative Complications and Body Mass Index After Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2023; 31:1165-1172. [PMID: 37656955 DOI: 10.5435/jaaos-d-23-00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 07/24/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND An inverse relationship coined the "obesity paradox" has been propositioned, in which body mass index (BMI) may be contradictorily protective in patients undergoing surgery or treatment of chronic disease. This study sought to investigate the BMI associated with the lowest rate of medical complications after total shoulder arthroplasty (TSA). METHODS The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify adults who underwent elective primary TSA between January 2012 and December 2020. Thirty-day postoperative medical complications were extracted, which included death, readmission, pneumonia, pulmonary embolism, renal failure, and cardiac arrest, among others. BMI was classified into five categories (underweight [BMI <18.5 kg/m 2 ], normal weight [BMI ≥18.5 and <25 kg/m 2 ], overweight [BMI ≥25 and <30 kg/m 2 ], obese [BMI ≥30 and <40 kg/m 2 ], and morbidly obese [BMI ≥40 kg/m 2 ]). We examined the risk of any 30-day postoperative complications and BMI categorically and on a continuous basis using multivariable logistic regression controlling for age, sex, procedure year, and comorbidities. RESULTS Of the 31,755 TSAs, 84% were White, 56% were female, and the average age of patients was 69.2 ± 9.3 years. Thirty-day postoperative medical complications occurred in 4.53% (n = 1,440). When assessed on a continuous basis, the lowest risk was in patients with a BMI between 30 and 35 kg/m 2 . Underweight individuals (BMI <18.5 kg/m 2 ) had the highest postoperative complication rates overall. The probability of medical complications increased with age and was greater for female patients. CONCLUSION The relationship between BMI and complication risk in TSA is nonlinear. A BMI between 30 and 35 kg/m 2 was associated with the lowest risk of medical complications after TSA, and BMI<18.5 kg/m 2 had the highest risk overall, indicating some protective aspects of BMI against 30-day medical complications. Thus, obesity alone should not preclude patients from TSA eligibility, rather surgical candidacy should be evaluated in the context of patients' overall health and likelihood of benefit from TSA. LEVEL OF EVIDENCE III, Retrospective Comparative Study.
Collapse
Affiliation(s)
- Keegan M Hones
- From the College of Medicine, University of Florida, Gainesville, FL (Hones, Hao, and Cueto), the Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL (Jonathan O. Wright, King, and Thomas W. Wright), the Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC (Friedman), and the Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL (Schoch)
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Chen VW, Chidi AP, Dong Y, Richardson PA, Axelrod DA, Petersen LA, Massarweh NN. Risk-Adjusted Cumulative Sum for Early Detection of Hospitals With Excess Perioperative Mortality. JAMA Surg 2023; 158:1176-1183. [PMID: 37610743 PMCID: PMC10448363 DOI: 10.1001/jamasurg.2023.3673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/03/2023] [Indexed: 08/24/2023]
Abstract
Importance National surgical quality improvement programs lack tools for early detection of quality or safety concerns, which risks patient safety because of delayed recognition of poor performance. Objective To compare the risk-adjusted cumulative sum (CUSUM) with episodic evaluation for early detection of hospitals with excess perioperative mortality. Design, Setting, and Participants National, observational, hospital-level, comparative effectiveness study of 697 566 patients. Identification of hospitals with excess, risk-adjusted, quarterly 30-day mortality using observed to expected ratios (ie, current criterion standard in the Veterans Affairs Surgical Quality Improvement Program) was compared with the risk-adjusted CUSUM. Patients included in the study underwent a noncardiac operation at a Veterans Affairs hospital, had a record in the Veterans Affairs Surgical Quality Improvement Program (January 1, 2011, through December 31, 2016), and were aged 18 years or older. Main Outcome and Measure Number of hospitals identified as having excess risk-adjusted 30-day mortality. Results The cohort included 697 566 patients treated at 104 hospitals across 24 quarters. The mean (SD) age was 60.9 (13.2) years, 91.4% were male, and 8.6% were female. For each hospital, the median number of quarters detected with observed to expected ratios, at least 1 CUSUM signal, and more than 1 CUSUM signal was 2 quarters (IQR, 1-4 quarters), 8 quarters (IQR, 4-11 quarters), and 3 quarters (IQR, 1-4 quarters), respectively. During 2496 total quarters of data, outlier hospitals were identified 33.3% of the time (830 quarters) with at least 1 CUSUM signal within a quarter, 12.5% (311 quarters) with more than 1 CUSUM signal, and 11.0% (274 quarters) with observed to expected ratios at the end of the quarter. The CUSUM detection occurred a median of 49 days (IQR, 25-63 days) before observed to expected ratio reporting (1 signal, 35 days [IQR, 17-54 days]; 2 signals, 49 days [IQR, 26-61 days]; 3 signals, 58 days [IQR, 44-69 days]; ≥4 signals, 49 days [IQR, 42-69 days]; trend test, P < .001). Of 274 hospital quarters detected with observed to expected ratios, 72.6% (199) were concurrently detected by at least 1 CUSUM signal vs 42.7% (117) by more than 1 CUSUM signal. There was a dose-response relationship between the number of CUSUM signals in a quarter and the median observed to expected ratio (0 signals, 0.63; 1 signal, 1.28; 2 signals, 1.58; 3 signals, 2.08; ≥4 signals, 2.49; trend test, P < .001). Conclusions This study found that with CUSUM, hospitals with excess perioperative mortality can be identified well in advance of standard end-of-quarter reporting, which suggests episodic evaluation strategies fail to detect out-of-control processes and place patients at risk. Continuous performance evaluation tools should be adopted in national quality improvement programs to prevent avoidable patient harm.
Collapse
Affiliation(s)
- Vivi W. Chen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alexis P. Chidi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Yongquan Dong
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Peter A. Richardson
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David A. Axelrod
- Division of Transplantation, Department of Surgery, University of Iowa, Iowa City
| | - Laura A. Petersen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| |
Collapse
|
24
|
Balentine C. Can We Improve the Quality of Quality Improvement? JAMA Surg 2023; 158:1184. [PMID: 37610763 DOI: 10.1001/jamasurg.2023.3684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Affiliation(s)
- Courtney Balentine
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin-Madison, Madison
| |
Collapse
|
25
|
Weinstein EJ, Stephens-Shields AJ, Newcomb CW, Silibovsky R, Nelson CL, O'Donnell JA, Glaser LJ, Hsieh E, Hanberg JS, Tate JP, Akgün KM, King JT, Lo Re V. Incidence, Microbiological Studies, and Factors Associated With Prosthetic Joint Infection After Total Knee Arthroplasty. JAMA Netw Open 2023; 6:e2340457. [PMID: 37906194 PMCID: PMC10618849 DOI: 10.1001/jamanetworkopen.2023.40457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/18/2023] [Indexed: 11/02/2023] Open
Abstract
Importance Despite the frequency of total knee arthroplasty (TKA) and clinical implications of prosthetic joint infections (PJIs), knowledge gaps remain concerning the incidence, microbiological study results, and factors associated with these infections. Objectives To identify the incidence rates, organisms isolated from microbiological studies, and patient and surgical factors of PJI occurring early, delayed, and late after primary TKA. Design, Setting, and Participants This cohort study obtained data from the US Department of Veterans Affairs (VA) Corporate Data Warehouse on patients who underwent elective primary TKA in the VA system between October 1, 1999, and September 30, 2019, and had at least 1 year of care in the VA prior to TKA. Patients who met these criteria were included in the overall cohort, and patients with linked Veterans Affairs Surgical Quality Improvement Program (VASQIP) data composed the VASQIP cohort. Data were analyzed between December 9, 2021, and September 18, 2023. Exposures Primary TKA as well as demographic, clinical, and perioperative factors. Main Outcomes and Measures Incident hospitalization with early, delayed, or late PJI. Incidence rate (events per 10 000 person-months) was measured in 3 postoperative periods: early (≤3 months), delayed (between >3 and ≤12 months), and late (>12 months). Unadjusted Poisson regression was used to estimate incidence rate ratios (IRRs) with 95% CIs of early and delayed PJI compared with late PJI. The frequency of organisms isolated from synovial or operative tissue culture results of PJIs during each postoperative period was identified. A piecewise exponential parametric survival model was used to estimate IRRs with 95% CIs associated with demographic and clinical factors in each postoperative period. Results The 79 367 patients (median (IQR) age of 65 (60-71) years) in the overall cohort who underwent primary TKA included 75 274 males (94.8%). A total of 1599 PJIs (2.0%) were identified. The incidence rate of PJI was higher in the early (26.8 [95% CI, 24.8-29.0] events per 10 000 person-months; IRR, 20.7 [95% CI, 18.5-23.1]) and delayed periods (5.4 [95% CI, 4.9-6.0] events per 10 000 person-months; IRR, 4.2 [95% CI, 3.7-4.8]) vs the late postoperative period (1.3 events per 10 000 person-months). Staphylococcus aureus was the most common organism isolated overall (489 [33.2%]); however, gram-negative infections were isolated in 15.4% (86) of early PJIs. In multivariable analyses, hepatitis C virus infection, peripheral artery disease, and autoimmune inflammatory arthritis were associated with PJI across all postoperative periods. Diabetes, chronic kidney disease, and obesity (body mass index of ≥30) were not associated factors. Other period-specific factors were identified. Conclusions and Relevance This cohort study found that incidence rates of PJIs were higher in the early and delayed vs late post-TKA period; there were differences in microbiological cultures and factors associated with each postoperative period. These findings have implications for postoperative antibiotic use, stratification of PJI risk according to postoperative time, and PJI risk factor modification.
Collapse
Affiliation(s)
- Erica J Weinstein
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Real-World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alisa J Stephens-Shields
- Center for Real-World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Craig W Newcomb
- Center for Real-World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Randi Silibovsky
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Charles L Nelson
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Judith A O'Donnell
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Laurel J Glaser
- Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Evelyn Hsieh
- Veterans Affairs (VA) Connecticut Health System, West Haven
- Section of Rheumatology, Allergy and Immunology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer S Hanberg
- Veterans Affairs (VA) Connecticut Health System, West Haven
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Janet P Tate
- Veterans Affairs (VA) Connecticut Health System, West Haven
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kathleen M Akgün
- Section of Pulmonary, Critical Care, and Sleep Medicine, VA Connecticut Health System, West Haven
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph T King
- Veterans Affairs (VA) Connecticut Health System, West Haven
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Real-World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
26
|
Greco M, Calgaro G, Cecconi M. Management of hospital admission, patient information and education, and immediate preoperative care. Saudi J Anaesth 2023; 17:517-522. [PMID: 37779563 PMCID: PMC10540991 DOI: 10.4103/sja.sja_592_23] [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: 07/03/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 10/03/2023] Open
Abstract
An increasing proportion of surgical procedures involves elderly and frail patients in high-income countries, leading to an increased risk of postoperative complications. Complications significantly impact patient outcomes and costs, due to prolonged hospitalization and loss of autonomy. Consequently, it is crucial to evaluate preoperative functional status in older patients, to tailor the perioperative plan, and evaluate risks. The hospital environment often exacerbates cognitive impairments in elderly and frail patients, also increasing the risk of infection, falls, and malnutrition. Thus, it is essential to work on dedicated pathways to reduce hospital readmissions and favor discharges to a familiar environment. In this context, the use of wearable devices and telehealth has been promising. Telemedicine can be used for preoperative evaluations and to allow earlier discharges with continuous monitoring. Wearable devices can track patient vitals both preoperatively and postoperatively. Preoperative education of patient and caregivers can improve postoperative outcomes and is favored by technology-based approach that increases flexibility and reduce the need for in-person clinical visits and associated travel; moreover, such approaches empower patients with a greater understanding of possible risks, moving toward shared decision-making principles. Finally, caregivers play an integral role in patient improvement, for example, in the prevention of delirium. Hence, their inclusion in the care process is not only advantageous but essential to improve perioperative outcomes in this population.
Collapse
Affiliation(s)
- Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giulio Calgaro
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| |
Collapse
|
27
|
Abella MKIL, Angeles JPM, Finlay AK, Amanatullah DF. Does Operative Time Modify Obesity-related Outcomes in THA? Clin Orthop Relat Res 2023; 481:1917-1925. [PMID: 37083564 PMCID: PMC10499082 DOI: 10.1097/corr.0000000000002659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/22/2023] [Accepted: 03/17/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Most orthopaedic surgeons refuse to perform arthroplasty on patients with morbid obesity, citing the higher rate of postoperative complications. However, that recommendation does not account for the relationship of operative time (which is often longer in patients with obesity) to obesity-related arthroplasty outcomes, such as readmission, reoperation, and postoperative complications. If operative time is associated with these obesity-related outcomes, it should be accounted for and addressed to properly assess the risk of patients with obesity undergoing THA. QUESTIONS/PURPOSES We therefore asked: (1) Is the increased risk seen in overweight and obese patients, compared with patients in a normal BMI class, associated with increased operative time? (2) Is increased operative time independent of BMI class a risk factor for readmission, reoperation, and postoperative medical complications? (3) Does operative time modify the direction or strength of obesity-related adverse outcomes? METHODS This retrospective, comparative study examined 247,108 patients who underwent THA between January 2014 and December 2020 in the National Surgical Quality Improvement Project (NSQIP). Of those, emergency cases (1% [2404]), bilateral procedures (1% [1605]), missing and/or null data (1% [3280]), extreme BMI and operative time outliers (1% [2032]), and patients with comorbidities that are not typical of an elective procedure, such as disseminated cancer, open wounds, sepsis, and ventilator dependence (1% [2726]), were excluded, leaving 95% (235,061) of elective, unilateral THA cases for analysis. The NSQIP was selected due to its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight, normal weight, overweight, Class I obesity, Class II obesity, and Class III obesity. Of the patients with a normal weight, 69% (30,932 of 44,556) were female and 36% (16,032 of 44,556) had at least one comorbidity, with a mean operative time of 86 ± 32 minutes and a mean age of 68 ± 12 years. Patients with obesity tend to be younger, male, more likely to have preoperative comorbidities, with longer operative times. Multivariable logistic regression models examined the effects of obesity on 30-day readmission, reoperation, and medical complications, while adjusting for age, sex, race, smoking status, and number of preoperative comorbidities. After we repeated this analysis after adjusting for operative time, an interaction model was conducted to test whether operative time changes the direction or strength of the association of BMI class and adverse outcomes. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were calculated, and the interaction effects were plotted. RESULTS A comparison of patients with Class III obesity to patients with normal weight showed that the odds of readmission went from 45% (AOR 1.45 [95% CI 1.32 to 1.59]; p < 0.001) to 27% after adjusting for operative time (AOR 1.27 [95% CI 1.01 to 1.62]; p = 0.04), the odds of reoperation went from 93% (AOR 1.93 [95% CI 1.72 to 2.17]; p < 0.001) to 81% after adjusting for operative time (AOR 1.81 [95% CI 1.61 to 2.04]; p < 0.001), and the odds of a postoperative complication went from 96% (AOR 1.96 [95% CI 1.58 to 2.43]; p < 0.001) to 84% after adjusting for operative time (AOR 1.84 [95% CI 1.48 to 2.28]; p < 0.001). Each 15-minute increase in operative time was associated with a 7% increase in the odds of a readmission (AOR 1.07 [95% CI 1.06 to 1.08]; p < 0.001), a 10% increase in the odds of a reoperation (AOR 1.10 [95% CI 1.09 to 1.12]; p < 0.001), and 10% increase in the odds of a postoperative complication (AOR 1.10 [95% CI 1.08 to 1.13]; p < 0.001). There was a positive interaction effect of operative time and BMI for readmission and reoperation, which suggests that longer operations accentuate the risk that patients with obesity have for readmission and reoperation. CONCLUSION Operative time is likely a proxy for surgical complexity and contributes modestly to the adverse outcomes previously attributed to obesity alone. Hence, focusing on modulating the accentuated risk associated with lengthened operative times rather than obesity is imperative to increasing the accessibility and safety of THA. Surgeons may do this with specific surgical techniques, training, and practice. Future studies looking at THA outcomes related to obesity should consider the association with operative time to focus on independent associations with obesity to facilitate more equitable access. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Maveric K. I. L. Abella
- Stanford University Department of Orthopaedic Surgery, Stanford, CA, USA
- University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - John P. M. Angeles
- Stanford University Department of Orthopaedic Surgery, Stanford, CA, USA
- Wright State University Boonshoft School of Medicine, Fairborn, OH, USA
| | - Andrea K. Finlay
- Stanford University Department of Orthopaedic Surgery, Stanford, CA, USA
| | | |
Collapse
|
28
|
Roennegaard AB, Gundtoft PH, Tengberg PT, Viberg B. Completeness and validity of the Danish fracture database. Injury 2023; 54:110769. [PMID: 37179202 DOI: 10.1016/j.injury.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To calculate completeness of the Danish Fracture Database (DFDB) overall and stratified by hospital volume and to calculate the validity of independently assessed variables in the DFDB. STUDY DESIGN AND SETTING In this completeness and validation study, cases registered in the DFDB with fracture-related surgery in 2016 were retrospectively reviewed. All cases had undergone fracture-related surgery at a Danish hospital reporting to the DFDB in 2016. The Danish health care system is fully tax-funded providing equal and free access to all residents. Completeness was calculated as sensitivity and validity was calculated as positive predictive values (PPVs). RESULTS OVERALL COMPLETENESS WAS 55.4% (95% CI: : 54.7-56.0). For small-volume hospitals it was 60% (95% CI: 58.9-61.1), and for large-volume hospitals, it was 52.9% (95% CI: 52.0-53.7). The PPV for variables of interest ranged from 81% to 100%. The PPV of key variables was 98% (95% CI: 95-98) for operated side, 98% (95% CI: 96-98) for date of surgery, and 98% (95% CI: 98-100) for surgery type. CONCLUSION We found low completeness of data reported to the DFDB in 2016; however, in the same period, the validity of data in the DFDB was high.
Collapse
Affiliation(s)
- Anders Bo Roennegaard
- Department of Orthopedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt, Denmark.
| | - Per Hviid Gundtoft
- Department of Orthopedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt, Denmark; Department of Orthopedic Surgery, Aarhus University Hospital, Denmark
| | | | - Bjarke Viberg
- Department of Orthopedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt, Denmark; Department of Orthopedic Surgery and Traumatology, Odense University Hospital
| |
Collapse
|
29
|
Mercier MR, Koucheki R, Lex JR, Khoshbin A, Park SS, Daniels TR, Halai MM. The association between preoperative COVID-19-positivity and acute postoperative complication risk among patients undergoing orthopedic surgery. Bone Jt Open 2023; 4:704-712. [PMID: 37704204 PMCID: PMC10499528 DOI: 10.1302/2633-1462.49.bjo-2023-0053] [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] [Indexed: 09/15/2023] Open
Abstract
Aims This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures. Methods Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events. Conclusion COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic.
Collapse
Affiliation(s)
| | - Robert Koucheki
- University of Toronto Faculty of Medicine, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Johnathan R. Lex
- University of Toronto Division of Orthopaedic Surgery, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Amir Khoshbin
- University of Toronto Division of Orthopaedic Surgery, Toronto, Canada
- Department of Orthopaedic Surgery, St Michael's Hospital, Toronto, Canada
| | - Sam S. Park
- University of Toronto Division of Orthopaedic Surgery, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Timothy R. Daniels
- University of Toronto Division of Orthopaedic Surgery, Toronto, Canada
- Department of Orthopaedic Surgery, St Michael's Hospital, Toronto, Canada
| | - Mansur M. Halai
- University of Toronto Division of Orthopaedic Surgery, Toronto, Canada
- Department of Orthopaedic Surgery, St Michael's Hospital, Toronto, Canada
| |
Collapse
|
30
|
Mehl SC, Portuondo JI, Tian Y, Raval MV, Shah SR, Vogel AM, Wesson D, Massarweh NN. Hospital Variation in Mortality After Inpatient Pediatric Surgery. Ann Surg 2023; 278:e598-e604. [PMID: 36259769 DOI: 10.1097/sla.0000000000005729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim was to determine the association between risk adjusted hospital perioperative mortality rates, postoperative complications, and failure to rescue (FTR) after inpatient pediatric surgery. BACKGROUND FTR has been identified as a possible explanatory factor for hospital variation in perioperative mortality in adults. However, the extent to which this may be the case for hospitals that perform pediatric surgery is unclear. METHODS The Pediatric Health Information System database (2012-2020) was used to identify patients who underwent one of 57 high-risk operations associated with significant perioperative mortality (n=203,242). Academic, pediatric hospitals (n=48) were stratified into quintiles based on risk adjusted inpatient mortality [lower than average, quintile 1 (Q1); higher than average, quintile 5 (Q5)]. Multivariable hierarchical regression was used to evaluate the association between hospital mortality rates, complications, and FTR. RESULTS Inpatient mortality, complication, and FTR rates were 2.3%, 8.8%, and 8.8%, respectively. Among all patients who died after surgery, only 34.1% had a preceding complication (Q1, 36.1%; Q2, 31.5%; Q3, 34.7%; Q4, 35.7%; Q5, 32.2%; trend test, P =0.49). The rates of observed mortality significantly increased across hospital quintiles, but the difference was <1% (Q1, 1.9%; Q5; 2.6%; trend test, P <0.01). Relative to Q1 hospitals, the odds of complications were not significantly increased at Q5 hospitals [odds ratio (OR): 1.02 (0.87-1.20)]. By comparison, the odds of FTR was significantly increased at Q5 hospitals [OR: 1.60 (1.30-1.96)] with a dose-response relationship across hospital quintiles [Q2-OR: 0.99 (0.80-1.22); Q3-OR: 1.26 (1.03-1.55); Q4-OR: 1.33 (1.09-1.63)]. CONCLUSIONS The minority of pediatric surgical deaths are preceded by a postoperative complication, but variation in risk adjusted mortality across academic, pediatric hospitals may be partially explained by differences in the recognition and management of postoperative complications. Additional work is needed to identify children at greatest risk of postoperative death from perioperative complications as opposed to those at risk from pre-existing chronic conditions.
Collapse
Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Yao Tian
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine; Chicago, IL
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine; Chicago, IL
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sohail R Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - David Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, GA
- Department of Surgery, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA
| |
Collapse
|
31
|
Glance LG, Smith DI, Joynt Maddox KE. Do Anesthesiologists Have a Role in Promoting Equitable Health Care? Anesthesiology 2023; 139:244-248. [PMID: 37552097 DOI: 10.1097/aln.0000000000004672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York; Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; RAND Health, RAND, Boston, Massachusetts
| | - Daryl I Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Karen E Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri; Center for Health Economics and Policy at the Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
32
|
Hebballi NB, DeSantis S, Brown EL, Markham C, Tsao K. Body Mass Index Is Associated With Pediatric Complicated Appendicitis and Postoperative Complications. Ann Surg 2023; 278:337-346. [PMID: 37317845 DOI: 10.1097/sla.0000000000005965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To investigate the association between body mass index (BMI) spectrum and complicated appendicitis and postoperative complications in pediatric patients. BACKGROUND Despite the impact of being overweight and obese on complicated appendicitis and postoperative complications, the implications of being underweight are unknown. METHODS A retrospective review of pediatric patients was conducted using NSQIP (2016-2020) data. Patient's BMI percentiles were categorized into underweight, normal weight, overweight, and obese. The 30-day postoperative complications were grouped into minor, major, and any. Univariate and multivariable logistic regression models were performed. RESULTS Among 23,153 patients, the odds of complicated appendicitis were 66% higher in underweight patients [odds ratio (OR)=1.66; 95% CI: 1.06-2.59] and 28% lower in overweight patients (OR=0.72; 95% CI: 0.54-0.95) than normal-weight patients. A statistically significant interaction between overweight and preoperative white blood cells (WBCs) increased the odds of complicated appendicitis (OR=1.02; 95% CI: 1.00-1.03). Compared to normal-weight patients, obese patients had 52% higher odds of minor (OR=1.52; 95% CI: 1.18-1.96) and underweight patients had 3 times the odds of major (OR=2.77; 95% CI: 1.22-6.27) and any (OR=2.82; 95% CI: 1.31-6.10) complications. A statistically significant interaction between underweight and preoperative WBC lowered the odds of major (OR=0.94; 95% CI: 0.89-0.99) and any complications (OR=0.94; 95% CI: 0.89-0.98). CONCLUSIONS Underweight, overweight, and interaction between overweight and preoperative WBC were associated with complicated appendicitis. Obesity, underweight, and interaction between underweight and preoperative WBC were associated with minor, major, and any complications. Thus, personalized clinical pathways and parental education targeting at-risk patients can minimize postoperative complications.
Collapse
Affiliation(s)
- Nutan B Hebballi
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Stacia DeSantis
- Department of Biostatistics and Data Science, The University of Texas School of Public Health, Houston, Texas
| | - Eric L Brown
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Christine Markham
- Department of Health Promotion & Behavioral Sciences The University of Texas School of Public Health, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| |
Collapse
|
33
|
Abella MKIL, Lee AY, Kitamura RK, Ahn HJ, Woo RK. Disparities and Risk Factors for Surgical Complication in American Indians and Native Hawaiians. J Surg Res 2023; 288:99-107. [PMID: 36963299 DOI: 10.1016/j.jss.2023.02.016] [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: 12/02/2022] [Revised: 01/25/2023] [Accepted: 02/18/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION American Indian and Alaskan Natives (AIAN) and Native Hawaiian and Pacific Islanders (NHPI) research is limited, particularly in postoperative surgical outcomes. This study analyzes disparities in AIAN and NHPI surgical complications across all surgical types and identifies factors that contribute to postoperative complications. METHODS This retrospective cohort study examined all surgeries from 2011 to 2020 in the National Surgical Quality Improvement Program, queried by race. Multivariable models analyzed the association of race and ethnicity and 30-day postoperative complication. Next, multivariable models were used to identify preoperative variables associated with postoperative complications, specifically in AIAN and NHPI patients. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated. RESULTS AIAN patients were associated with higher odds of postoperative complication (AOR: 1.008 [CI: 1.005-1.011], P < 0.001) compared to non-Hispanic white patients. The comorbidities that were of higher incidence in AIAN patients, which also adversely contributed to postoperative complication, included dependent functional status, diabetes, congestive heart failure (CHF), open wounds, preoperative weight loss, bleeding disorders, preoperative transfusion, sepsis, hypoalbuminemia, along with an active smoking status and ASA ≥3. In NHPI patients, dependent functional status, CHF, renal failure, preoperative transfusion, open wounds, and sepsis were of higher incidence and significantly contributed to postoperative complication. CONCLUSIONS Surgical outcome disparities exist particularly in AIAN patients. Identification of modifiable patient risk factors may benefit perioperative care for AIAN and NHPI patients, which are historically understudied racial groups.
Collapse
Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Riley K Kitamura
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Queen's Medical Center, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
| |
Collapse
|
34
|
Dyas AR, Bronsert MR, Henderson WG, Stuart CM, Pradhan N, Colborn KL, Cleveland JC, Meguid RA. A comparison of the National Surgical Quality Improvement Program and the Society of Thoracic Surgery Cardiac Surgery preoperative risk models: a cohort study. Int J Surg 2023; 109:2334-2343. [PMID: 37204450 PMCID: PMC10442082 DOI: 10.1097/js9.0000000000000490] [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: 02/28/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Cardiac surgery prediction models and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have not been reported. The authors sought to develop preoperative prediction models and estimates of postoperative outcomes for cardiac surgery using the ACS-NSQIP and compare these to the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD). METHODS In a retrospective analysis of the ACS-NSQIP data (2007-2018), cardiac operations were identified using cardiac surgeon primary specialty and sorted into cohorts of coronary artery bypass grafting (CABG) only, valve surgery only, and valve+CABG operations using CPT codes. Prediction models were created using backward selection of the 28 non-laboratory preoperative variables in ACS-NSQIP. Rates of nine postoperative outcomes and performance statistics of these models were compared to published STS 2018 data. RESULTS Of 28 912 cardiac surgery patients, 18 139 (62.8%) were CABG only, 7872 (27.2%) were valve only, and 2901 (10.0%) were valve+CABG. Most outcome rates were similar between the ACS-NSQIP and STS-ACSD, except for lower rates of prolonged ventilation and composite morbidity and higher reoperation rates in ACS-NSQIP (all P <0.0001). For all 27 comparisons (9 outcomes × 3 operation groups), the c-indices for the ACS-NSQIP models were lower by an average of ~0.05 than the reported STS models. CONCLUSIONS The ACS-NSQIP preoperative risk models for cardiac surgery were almost as accurate as the STS-ACSD models. Slight differences in c-indexes could be due to more predictor variables in STS-ACSD models or the use of more disease- and operation-specific risk variables in the STS-ACSD models.
Collapse
Affiliation(s)
- Adam R. Dyas
- Department of Surgery
- Surgical Outcomes and Applied Research Program
| | - Michael R. Bronsert
- Surgical Outcomes and Applied Research Program
- Adult and Child Center for Health Outcomes Research and Delivery Science
| | - William G. Henderson
- Surgical Outcomes and Applied Research Program
- Adult and Child Center for Health Outcomes Research and Delivery Science
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | | | | | - Kathryn L. Colborn
- Department of Medicine, University of Colorado School of Medicine
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | | | - Robert A. Meguid
- Department of Surgery
- Surgical Outcomes and Applied Research Program
- Adult and Child Center for Health Outcomes Research and Delivery Science
| |
Collapse
|
35
|
Abella MKIL, Lee AY, Agonias K, Maka P, Ahn HJ, Woo RK. Racial Disparities in General Surgery Outcomes. J Surg Res 2023; 288:261-268. [PMID: 37030184 DOI: 10.1016/j.jss.2023.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/21/2023] [Accepted: 03/09/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION While disparities in Black and Hispanic and Latino patients undergoing general surgeries are well described, most analyses leave out Asian, American Indian or Alaskan Native (AIAN), and native Hawaiian or Pacific Islander patients. This study identified general surgery outcomes for each racial group in the National Surgical Quality Improvement Program. METHODS National Surgical Quality Improvement Program was queried to identify all procedures conducted by a general surgeon from 2017 to 2020 (n = 2,664,197). Multivariable regression models were used to investigate the impact of race and ethnicity on 30-day mortality, readmission, reoperation, major and minor medical complications, and non-home discharge destinations. Adjusted odds ratios (AOR) and 95% confidence intervals were calculated. RESULTS Compared to non-Hispanic White patients, Black patients had higher odds of readmission and reoperation, and Hispanic and Latino patients had higher odds of major and minor complications. AIAN patients had higher odds of mortality (AOR: 1.003 (1.002-1.005), P < 0.001), major complication (AOR: 1.013 (1.006-1.020), P < 0.001), reoperation (AOR: 1.009, (1.005-1.013), P < 0.001), and non-home discharge destination (AOR: 1.006 (1.001-1.012), P = 0.025), while native Hawaiian or Pacific Islander patients had lower odds of readmission (AOR: 0.991 (0.983-0.999), P = 0.035) and non-home discharge destination (AOR: 0.983 (0.975-0.990), P < 0.001) compared to non-Hispanic White patients. Asian patients had lower odds of each adverse outcome. CONCLUSIONS Black, Hispanic and Latino, and AIAN patients are at higher odds for poor postoperative results than non-Hispanic White patients. AIANs had some of the highest odds of mortality, major complications, reoperation, and non-home discharge. Social health determinants and policy adjustments must be targeted to ensure optimal operative results for all patients.
Collapse
Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Keinan Agonias
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Piueti Maka
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
| |
Collapse
|
36
|
Carey ET, Moore KJ, McClurg AB, Degaia A, Tyan P, Schiff L, Dieter AA. Racial Disparities in Hysterectomy Route for Benign Disease: Examining Trends and Perioperative Complications from 2007 to 2018 Using the NSQIP Database. J Minim Invasive Gynecol 2023; 30:627-634. [PMID: 37037283 DOI: 10.1016/j.jmig.2023.03.024] [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: 12/29/2022] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
STUDY OBJECTIVE To examine national trends among race and ethnicity and route of benign hysterectomy from 2007 to 2018. DESIGN This is a retrospective analysis of the prospective National Surgical Quality Improvement Program cohort program. SETTING This study included data from the National Surgical Quality Improvement Program database including data from the 2014 to 2018 targeted hysterectomy files. PATIENTS Adult patients undergoing hysterectomy. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: Current Procedural Terminology codes identified women undergoing benign hysterectomy and perioperative data including race and ethnicity were obtained. To determine relative trends in hysterectomy among race and ethnicity cohorts (White, Black, Hispanic), we calculated the proportion of each procedure performed annually within each race and ethnicity group and compared it across groups. From 2007 to 2018, 269 794 hysterectomies were collected (190 154 White, 45 756 Black, and 33 884 Hispanic). From 2007 to 2018, rates of laparoscopic hysterectomy increased in all cohorts (30.2%-71.6% for White, 23.9%-58.5% for Black, 19.9%-64.0% for Hispanic; ptrend <0.01 for all). For each year from 2007 to 2018, the proportion of women undergoing open abdominal hysterectomy remained twice as high in Black Women compared with White women (33.1%-14.4%, p <.01). Data from the 2014 to 2018 targeted files showed Black and Hispanic women undergoing benign hysterectomy were generally younger, had larger uteri, were more likely to be current smokers, have diabetes and/or hypertension, have higher body mass index, and have undergone previous pelvic surgery (p ≤.01 for all). CONCLUSION Compared with White women, Black and Hispanic women are less likely to undergo benign hysterectomy via a minimally invasive approach. Although larger uteri and comorbid conditions may attribute to higher rates of open abdominal hysterectomy, the higher prevalence of abdominal hysterectomy among younger Black and Hispanic women highlights potential racial disparities in women's health and access to care.
Collapse
Affiliation(s)
- Erin T Carey
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Kristin J Moore
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Asha B McClurg
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ayana Degaia
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul Tyan
- Capital Women's Care, Ashburn, Virginia
| | - Lauren Schiff
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alexis A Dieter
- Department of Obstetrics and Gynecology , University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC
| |
Collapse
|
37
|
Shaw SE, Hughes G, Pearse R, Avagliano E, Day JR, Edsell ME, Edwards JA, Everest L, Stephens TJ. Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study. Br J Anaesth 2023; 131:56-66. [PMID: 37117099 PMCID: PMC10308437 DOI: 10.1016/j.bja.2023.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery. METHODS This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery. RESULTS Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory. CONCLUSIONS Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment.
Collapse
Affiliation(s)
- Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rupert Pearse
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Ester Avagliano
- Hammersmith Hospital Imperial College Healthcare NHS Trust London, London, UK
| | - James R Day
- Department of Anaesthesia, Oxford University Hospitals Foundation Trust, Oxford, UK
| | - Mark E Edsell
- Department of Anaesthesia, The Royal Brompton & Harefield Hospitals, London, UK
| | | | | | - Timothy J Stephens
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
38
|
Beloborodov V, Vorobev V, Hovalyg T, Seminskiy I, Sokolova S, Lapteva E, Mankov A. Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty. Adv Urol 2023; 2023:2205306. [PMID: 37214228 PMCID: PMC10195176 DOI: 10.1155/2023/2205306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/08/2023] [Accepted: 04/09/2023] [Indexed: 05/24/2023] Open
Abstract
Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy, designed to reduce the disability period and improve the medical care quality. The study aims to analyze the enhanced recovery protocol effectiveness in a comparative study of elective urethral stricture surgery. A prospective study included 54 patients with an established diagnosis of urethral stricture in 2019-2020 in the urological hospital of the Irkutsk City Clinical Hospital No. 1. All 54 patients have completed the study. There were two groups of patients FTS-group (group II, n = 25) and standard group (group I, n = 29). In terms of preoperative parameters, the comparison groups have statistical homogeneity. The comparative intergroup efficacy analysis of the treatment based on the criteria established in the study demonstrated good treatment results for 5 (17.2%) patients of group I and 20 (80%) patients of group II (p=0.004). The overall efficacy of urethroplasty surgeries, regardless of the treatment protocol, was comparable (86.2% vs 92%; p=0.870), as well as the likelihood of relapse within two years (p=0.512). The predictors of recurrence were technical complications and urethral suture failure (OR 4.36; 95% CI 1.6; 7.11; p=0.002). The FTS protocol reduced the treatment period (p < 0.001) and decreased the severity of postoperative pain (p < 0.001). The use of the "fast track surgery" protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization.
Collapse
Affiliation(s)
- Vladimir Beloborodov
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Vladimir Vorobev
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Temirlan Hovalyg
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Igor Seminskiy
- Department of Phatology, Irkutsk State Medical University, Irkutsk, Russia
| | - Svetlana Sokolova
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Ekaterina Lapteva
- Department of Geriatrics, Propaedeutics and Management in Nursing, North-Western State Medical University Named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Aleksandr Mankov
- Department of Anesthesiology-Resuscitation, Irkutsk State Medical University, Irkutsk, Russia
| |
Collapse
|
39
|
Anic K, Flohr F, Schmidt MW, Krajnak S, Schwab R, Schmidt M, Westphalen C, Eichelsbacher C, Ruckes C, Brenner W, Hasenburg A, Battista MJ. Frailty assessment tools predict perioperative outcome in elderly patients with endometrial cancer better than age or BMI alone: a retrospective observational cohort study. J Cancer Res Clin Oncol 2023; 149:1551-1560. [PMID: 35579719 PMCID: PMC10020300 DOI: 10.1007/s00432-022-04038-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Five commonly used global health assessment tools have been evaluated to identify and assess the preoperative frailty status and its relationship with perioperative in-hospital complications and transfusion rates in older women with endometrial cancer (EC). METHODS Preoperative frailty status was examined by the G8 questionnaire, the Eastern Cooperative Oncology Group performance status, the Charlson Comorbidity Index and the American Society of Anesthesiologists Physical Status System, as well as the Lee-Schonberg prognostic index. The main outcome measures were perioperative laboratory values, intraoperative surgical parameters and immediately postoperative complications. RESULTS 153 consecutive women ≥ 60 years with all stages of EC, who received primary elective surgery at the University Medical Center Mainz between 2008 and 2019 were classified with selected global health assessment tools according to their preoperative performance status. In contrast to conventional prognostic parameters like older age and higher BMI, increasing frailty was significantly associated with preoperative anemia and perioperative transfusions (p < 0.05). Moreover, in patients preoperatively classified as frail significantly more postoperative complications (G8 Score: frail: 20.7% vs. non-frail: 6.7%, p = 0.028; ECOG: frail: 40.9% vs. non-frail: 2.8%, p = 0.002; and CCI: frail: 25.0% vs. non-frail: 7.4%, p = 0.003) and an increased length of hospitalization were recorded. According to propensity score matching, the risk for developing postoperative complications for frail patients was approximately two-fold higher, depending on which global health assessment tool was used. CONCLUSIONS Preoperatively assessed frailty significantly predicts post-surgical morbidity rates in contrast to conventionally used single prognostic parameters such as age or BMI. A standardized preoperative assessment of frailty in the routine work-up might be beneficial in older cancer patients before major surgery to include these patients in a prehabilitation program with nutrition counseling and physiotherapy to adequately assess the perioperative risk.
Collapse
Affiliation(s)
- Katharina Anic
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Friedrich Flohr
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Mona Wanda Schmidt
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Slavomir Krajnak
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Roxana Schwab
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Marcus Schmidt
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Christiane Westphalen
- Department of Geriatric Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Clemens Eichelsbacher
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Christian Ruckes
- Interdisciplinary Center Clinical Trials, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Walburgis Brenner
- Management of the Scientific Laboratories, University Medical Center of Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Annette Hasenburg
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Marco Johannes Battista
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| |
Collapse
|
40
|
Zhuang T, Fox P, Curtin C, Shah KN. Is Hand Surgery in the Procedure Room Setting Associated with Increased Surgical Site Infection? A Cohort Study of 2,717 Patients in the Veterans Affairs Population. J Hand Surg Am 2023:S0363-5023(23)00117-X. [PMID: 36973100 DOI: 10.1016/j.jhsa.2023.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/11/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Procedure rooms (PRs) are increasingly used for hand surgeries, but few studies have directly compared surgical site infection (SSI) rates between the PR and operating room. We tested the hypothesis that procedure setting is not associated with an increased SSI incidence in the VA population. METHODS We identified carpal tunnel, trigger finger, and first dorsal compartment releases performed at our VA institution from 1999 to 2021 of which 717 were performed in the main operating room and 2,000 were performed in the PR. The incidence of SSI, defined as signs of wound infection within 60 days of the index procedure, which was treated with oral antibiotics, intravenous antibiotics, and/or operating room irrigation and debridement, was compared. We constructed a multivariable logistic regression analysis to assess the association between procedure setting and SSI incidence, adjusting for age, sex, procedure type, and comorbidities. RESULTS Surgical site infection incidence was 55/2,000 (2.8%) in the PR cohort and 20/717 (2.8%) in the operating room cohort. In the PR cohort, five (0.3%) cases required hospitalization for intravenous antibiotics of which two (0.1%) cases required operating room irrigation and debridement. In the operating room cohort, two (0.3%) cases required hospitalization for intravenous antibiotics of which one (0.1%) case required operating room irrigation and debridement. All other SSIs were treated with oral antibiotics alone. The procedure setting was not independently associated with SSI (adjusted odds ratio, 0.84 [95% confidence interval, 0.49, 1.48]). The only risk factor for SSI was trigger finger release (odds ratio, 2.13 [95% confidence interval, 1.32, 3.48] compared with carpal tunnel release), which was independent of setting. CONCLUSIONS Minor hand surgeries can be performed safely in the PR without an increased rate of SSI. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
Collapse
Affiliation(s)
- Thompson Zhuang
- Department of Orthopedic Surgery, University of Pennsylvannia, Philadelphia, PA
| | - Paige Fox
- Department of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA
| | - Catherine Curtin
- Department of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA
| | - Kalpit N Shah
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA.
| |
Collapse
|
41
|
Abbitt D, Choy K, Castle R, Jones TS, Wikiel KJ, Barnett CC, Moore JT, Robinson TN, Jones EL. Telehealth Follow-Up After Inguinal Hernia Repair in Veterans. J Surg Res 2023; 287:186-192. [PMID: 36940640 DOI: 10.1016/j.jss.2023.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/13/2023] [Accepted: 02/17/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Telehealth has been increasingly utilized with a renewed interest by surgical specialties given the COIVD-19 pandemic. Limited data exists evaluating the safety of routine postoperative telehealth follow-up in patients undergoing inguinal hernia repair, especially those who present urgent/emergently. Our study sought to evaluate the safety and efficacy of postoperative telehealth follow-up in veterans undergoing inguinal hernia repair. METHODS Retrospective review of all Veterans who underwent inguinal hernia repair at a tertiary Veterans Affairs Medical Center over a 2-year period (9/2019-9/2021). Outcome measures included postoperative complications, emergency department (ED) utilization, 30-day readmission, and missed adverse events (ED utilization or readmission occurring after routine postoperative follow-up). Patients undergoing additional procedure(s) requiring intraoperative drains and/or nonabsorbable sutures were excluded. RESULTS Of 338 patients who underwent qualifying procedures, 156 (50.6%) were followed-up by telehealth and 152 (49.4%) followed-up in-person. There were no differences in age, sex, BMI, race, urgency, laterality nor admission status. Patients with higher American Society of Anesthesiologists (ASA) classification [ASA class III 92 (60.5%) versus class II 48 (31.6%), P = 0.019] and open repair [93 (61.2%) versus 67 (42.9%), P = 0.003] were more likely to follow-up in-person. There was no difference in complications, [telehealth 13 (8.3%) versus 20 (13.2%), P = 0.17], ED visits, [telehealth 15 (10%) versus 18 (12%), P = 0.53], 30-day readmission [telehealth 3 (2%) versus 0 (0%), P = 0.09], nor missed adverse events [telehealth 6 (33.3%) versus 5 (27.8%), P = 0.72]. CONCLUSIONS There were no differences in postoperative complications, ED utilization, 30-day readmission, or missed adverse events for those who followed-up in person versus telehealth after elective or urgent/emergent inguinal hernia repair. Veterans with a higher ASA class and who underwent open repair were more likely to be seen in person. Telehealth follow-up after inguinal hernia repair is safe and effective.
Collapse
Affiliation(s)
- Danielle Abbitt
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado.
| | - Kevin Choy
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Rose Castle
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Teresa S Jones
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Krzysztof J Wikiel
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Carlton C Barnett
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - John T Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Thomas N Robinson
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Edward L Jones
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| |
Collapse
|
42
|
Nguyen AT, Anjaria DJ, Sadeghi-Nejad H. Advancing Urology Resident Surgical Autonomy. Curr Urol Rep 2023; 24:253-260. [PMID: 36917339 PMCID: PMC10011787 DOI: 10.1007/s11934-023-01152-x] [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] [Accepted: 02/22/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE OF REVIEW This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy. RECENT FINDINGS Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.
Collapse
Affiliation(s)
- Anh T Nguyen
- Division of Urology Rutgers New Jersey Medical School, Newark, NJ, 07103, USA.
| | - Devashish J Anjaria
- East Orange Department of Surgery, Veteran Affairs New Jersey Healthcare System East Orange, East Orange, NJ, USA
| | - Hossein Sadeghi-Nejad
- East Orange Department of Surgery, Veteran Affairs New Jersey Healthcare System East Orange, East Orange, NJ, USA
- Hackensack University Medical Center, Hackensack, NJ, USA
| |
Collapse
|
43
|
"Evolving Trends in Pancreatic Cystic Tumors: A 3-Decade Single-Center Experience With 1290 Resections". Ann Surg 2023; 277:491-497. [PMID: 34353996 DOI: 10.1097/sla.0000000000005142] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to describe our institutional experience with resected cystic tumors of the pancreas with emphasis on changes in clinical presentation and accuracy of preoperative diagnosis. SUMMARY BACKGROUND DATA Incidental discovery of pancreatic cystic lesions has increased and has led to a rise in pancreatic resections. It is important to analyze surgical outcomes from these procedures, and the prevalence of malignancy, pre-malignancy and resections for purely benign lesions, some of which may be unintended. METHODS Retrospective review of a prospective database spanning 3 decades. Presence of symptoms, incidental discovery, diagnostic studies, type of surgery, postoperative outcomes, and concordance between presumptive diagnosis and final histopathology were recorded. RESULTS A total of 1290 patients were identified, 62% female with mean age of 60 years. Fifty-seven percent of tumors were incidentally discovered. Ninety-day operative mortality was 0.9% and major morbidity 14.4%. There were 23 different diagnosis, but IPMN, MCN, and serous cystadenoma comprised 80% of cases. Concordance between preoperative and final histopathological diagnosis increased by decade from 45%, to 68%, and is presently 80%, rising in parallel with the use of endoscopic ultrasound, cytology, and molecular analysis. The addition of molecular analysis improved accuracy to 91%. Of misdiagnosed cases, half were purely benign and taken to surgery with the presumption of malignancy or premalignancy. The majority of these were serous cystadenomas. CONCLUSIONS Indications and diagnostic work-up of cystic tumors of the pancreas have changed over time. Surgical resection can be performed with very low mortality and acceptable morbidity and diagnostic accuracy is presently 80%. About 10% of patients are still undergoing surgery for purely benign lesions that were presumed to be malignant or premalignant. Further refinements in diagnostic tests are required to improve accuracy.
Collapse
|
44
|
Meier J, Stevens A, Berger M, Makris KI, Bramos A, Reisch J, Cullum CM, Lee SC, Sugg Skinner C, Zeh H, Brown CJ, Balentine CJ. Comparison of Postoperative Outcomes of Laparoscopic vs Open Inguinal Hernia Repair. JAMA Surg 2023; 158:172-180. [PMID: 36542394 PMCID: PMC9857280 DOI: 10.1001/jamasurg.2022.6616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/04/2022] [Indexed: 12/24/2022]
Abstract
Importance Advocates of laparoscopic surgery argue that all inguinal hernias, including initial and unilateral ones, should be repaired laparoscopically. Prior work suggests outcomes of open repair are improved by using local rather than general anesthesia, but no prior studies have compared laparoscopic surgery with open repair under local anesthesia. Objective To evaluate postoperative outcomes of open inguinal hernia repair under general or local anesthesia compared with laparoscopic repair. Design, Setting, and Participants This retrospective cohort study identified 107 073 patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent unilateral initial inguinal hernia repair from 1998 to 2019. Data were analyzed from October 2021 to March 2022. Exposures Patients were divided into 3 groups for comparison: (1) open repair with local anesthesia (n = 22 333), (2) open repair with general anesthesia (n = 75 104), and (3) laparoscopic repair with general anesthesia (n = 9636). Main Outcomes and Measures Operative time and postoperative morbidity were compared using quantile regression and inverse probability propensity weighting. A 2-stage least-squares regression and probabilistic sensitivity analysis was used to quantify and address bias from unmeasured confounding in this observational study. Results Of 107 073 included patients, 106 529 (99.5%) were men, and the median (IQR) age was 63 (55-71) years. Compared with open repair with general anesthesia, laparoscopic repair was associated with a nonsignificant 0.15% (95% CI, -0.39 to 0.09; P = .22) reduction in postoperative complications. There was no significant difference in complications between laparoscopic surgery and open repair with local anesthesia (-0.05%; 95% CI, -0.34 to 0.28; P = .70). Operative time was similar for the laparoscopic and open general anesthesia groups (4.31 minutes; 95% CI, 0.45-8.57; P = .048), but operative times were significantly longer for laparoscopic compared with open repair under local anesthesia (10.42 minutes; 95% CI, 5.80-15.05; P < .001). Sensitivity analysis and 2-stage least-squares regression demonstrated that these findings were robust to bias from unmeasured confounding. Conclusions and Relevance In this study, laparoscopic and open repair with local anesthesia were reasonable options for patients with initial unilateral inguinal hernias, and the decision should be made considering both patient and surgeon factors.
Collapse
Affiliation(s)
- Jennie Meier
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
- North Texas VA Healthcare System, Dallas
- University of Texas Southwestern Surgical Center for Outcomes, Implementation, and Novel Interventions (S-COIN), Dallas
| | - Audrey Stevens
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
- North Texas VA Healthcare System, Dallas
- University of Texas Southwestern Surgical Center for Outcomes, Implementation, and Novel Interventions (S-COIN), Dallas
| | - Miles Berger
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Konstantinos I. Makris
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Operative Care Line, Houston, Texas
| | - Athanasios Bramos
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Operative Care Line, Houston, Texas
| | - Joan Reisch
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas
| | - C. Munro Cullum
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Simon C. Lee
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Celette Sugg Skinner
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Herbert Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | | | - Courtney J. Balentine
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
- North Texas VA Healthcare System, Dallas
- University of Texas Southwestern Surgical Center for Outcomes, Implementation, and Novel Interventions (S-COIN), Dallas
- Department of Surgery, University of Wisconsin–Madison
- Wisconsin Surgical Outcomes Research Program (WiSOR), Madison
| |
Collapse
|
45
|
Oleru OO, Shah NV, Zhou PL, Sedaghatpour D, Mistry JB, Wham BC, Kurtzman J, Mithani SK, Koehler SM. Recent Smoking History Is Not Associated with Adverse 30-Day Standardized Postoperative Outcomes following Microsurgical Reconstructive Procedures of the Upper Extremity. Plast Surg (Oakv) 2023; 31:61-69. [PMID: 36755815 PMCID: PMC9900040 DOI: 10.1177/22925503211024755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/30/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Upper extremity (UE) microsurgical reconstruction relies upon proper wound healing for optimal outcomes. Cigarette smoking is associated with wound healing complications, yet conclusions vary regarding impact on microsurgical outcomes (replantation, revascularization, and free tissue transfer). We investigated how smoking impacted 30-day standardized postoperative outcomes following UE microsurgical reconstruction. Methods: Utilizing the National Surgical Quality Improvement Program, all patients who underwent (1) UE free flap transfer (n = 70) and (2) replantation/revascularization (n = 270) were identified. For each procedure, patients were stratified by recent smoking history (current smoker ≤1-year preoperatively). Baseline demographics and standardized 30-day complications, reoperations, and readmissions were compared between smokers and nonsmokers. Results: Replantation/revascularization patients had no differences in sex, race, or body mass index between smokers (n = 77) and nonsmokers. Smokers had a higher prevalence of congestive heart failure (5.2% vs 1.0%, P = .036) and nonsmokers were more often on hemodialysis (15.6% vs 10.4%, P = .030). Free flap transfer patients had no differences in age, sex, or race between smokers (n = 14) and nonsmokers. Smokers had a longer length of stay (6.6 vs 4.2 days, P = .001) and a greater prevalence of chronic obstructive pulmonary disorder (COPD; 7.1% vs 0%, P = .044). Recent smoking was not associated with increased odds of any 30-day minor and major standardized surgical complications, readmissions, or reoperations following UE microsurgical reconstruction via free flap transfer or replantation/revascularization. Baseline diagnosis of COPD was also not a predictor of adverse 30-day outcomes following free flap transfer. Conclusion: Recent smoking history was not associated with any 30-day adverse outcomes following UE microsurgical reconstruction via replantation/revascularization or free flap transfer. In light of these findings, further investigation is warranted, with particular focus on adverse events specific to free flaps and replantation/revascularization.
Collapse
Affiliation(s)
- Olachi O. Oleru
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| | - Neil V. Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| | - Peter L. Zhou
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| | - Dillon Sedaghatpour
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| | - Jaydev B. Mistry
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| | - Bradley C. Wham
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| | - Joey Kurtzman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| | - Suhail K. Mithani
- Department of Plastic, Maxillofacial, and Oral Reconstructive
Surgery, Duke University Medical
Center, Durham, NC, USA
| | - Steven M. Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY)
Downstate Medical Center, Brooklyn, NY, USA
| |
Collapse
|
46
|
Tong Y, Khachane A, Ibrahim M, Jacob T, Shiferson A, Almadani M, Rhee RY, Pu Q. Open abdominal aortic repair in the current era has more complications for occlusive disease than for aneurysm repair. J Vasc Surg 2023; 77:432-439.e1. [PMID: 36130697 DOI: 10.1016/j.jvs.2022.09.010] [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: 12/31/2021] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Endovascular intervention has become the first-line treatment of patients with abdominal aortic aneurysms (AAAs) or aortoiliac occlusive disease (AIOD). However, open abdominal aortic repair remains a valuable treatment option for patients who are younger, those with unfavorable anatomy, and patients for whom endovascular intervention has failed. The cohort of patients undergoing open repair has become highly selected; nevertheless, updated outcomes or patient selection recommendations have been unavailable. In the present study, we explored and compared the characteristics and postoperative outcomes of patients who had undergone open abdominal aortic repair from 2009 to 2018. METHODS Patients who had undergone open AAA (n = 9481) or AIOD (n = 9257) repair were collected from the National Surgical Quality Improvement Program database. The primary outcome was the 30-day mortality. The secondary outcomes included 30-day return to the operating room, total operative time, total hospital stay, and postoperative complications. Unmatched and matched differences between the two groups and changes over time were analyzed. Univariate and multivariate regression analyses were conducted to assess the risk factors predicting for 30-day mortality. RESULTS After propensity matching (n = 4980), those in the AIOD group had had a higher 30-day mortality rate (5.1% vs 4.1%; P = .021), a higher incidence of wound complications (7.4% vs 5.1%; P<.0001) and an increased 30-day return to the operating room (14.2% vs 9.1%; P < .0001). More open AIOD cases (P = .02) and fewer open AAA cases (P = .04) had been treated in the second half of the decade than in the first. The factors associated with an increased odds of 30-day mortality included advanced age, American Society of Anesthesiologists score ≥III, functional dependence, blood transfusion <72 hours before surgery, weight loss in previous 6 months, and a history of chronic obstructive pulmonary disease. CONCLUSIONS From 2009 to 2018, the number of open AAA repairs decreased and the proportion of open abdominal AIOD cases increased. Open AIOD surgery was associated with higher 30-day mortality, increased return to the operating room, and increased wound complications vs open AAA repair. Multiple risk factors increased the odds for perioperative mortality. Thus, open abdominal aortic repair should be selectively applied to patients with fewer risk factors.
Collapse
Affiliation(s)
- Yi Tong
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Asha Khachane
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Mudathir Ibrahim
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Theresa Jacob
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | - Mahmoud Almadani
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Robert Y Rhee
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Qinghua Pu
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY.
| |
Collapse
|
47
|
Postoperative Intensive Care Unit Overtriage: An Application of Machine Learning. Ann Surg 2023; 277:186-187. [PMID: 35730429 DOI: 10.1097/sla.0000000000005541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
48
|
Cervical Total Disc Replacement and Anterior Cervical Discectomy and Fusion: Comparison of 30-Day Population Comorbidities and Perioperative Complications Using 6 Years of American College of Surgeons National Surgical Quality Improvement Program Participant Use File Data. World Neurosurg 2023; 170:e79-e114. [PMID: 36283651 DOI: 10.1016/j.wneu.2022.10.072] [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: 08/09/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE American College of Surgeons National Surgical Quality Improvement Program Participant Use File data from 2014 through 2019 were used to compare 1- and 2-level anterior cervical discectomy and fusion (ACDF) and cervical total disc replacement (cTDR) with respect to: patient demographics, comorbidities, adverse events, and 30-day morbidity rates. METHODS One- and 2-level ACDF and cTDR patients were identified by current procedural terminology codes. Demographics, comorbidities, and adverse events were summarized. Unmatched cohorts were compared using Wilcoxon Rank Sum test for continuous variables, Pearson χ2 test for categorical variables, and 30-day morbidity using inverse probability of treatment weighted log-binomial regression. RESULTS American College of Surgeons National Surgical Quality Improvement Program 2014 through 2019 Participant Use File datasets represent 4,862,497 unique patients, identifying 13,347 1-level, 6933 2-level ACDF, 3114 1-level, and 862 2-level cTDR patient cohorts. Statistically significant differences between cohorts are extensive: age, sex, race, admission status, patient origin, discharge disposition, emergent surgery, surgical specialty, American Society of Anesthesiologists classification, wound class, operative time, hospital LOS, BMI, functional status, smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, congestive heart failure, hypertension, renal failure, dialysis, cancer, steroid use, anemia, bleeding disorders, systemic sepsis, and number of concurrent comorbid conditions. Inverse probability of treatment weighted log-binomial models, demonstrated increased risk of deep venous thrombosis/thrombophlebitis, pulmonary embolism, deep incisional surgical site infection, pneumonia, and unplanned return to operating room associated with ACDF while increased risk of cerebral vascular accident/stroke with neurological deficit and myocardial infarction associated with cTDR. The composite complications outcome favors cTDR over ACDF for 30-day morbidity. No mortalities occurred within the cTDR cohort. CONCLUSIONS Adjusting for demographics and comorbidities; ACDF has a higher average risk of adverse event. When ACDF and cTDR are equipoise, consideration for cTDR may be indicated in populations with higher rates of comorbid conditions.
Collapse
|
49
|
Soliman C, Sathianathen NJ, Thomas BC, Giannarini G, Lawrentschuk N, Wuethrich PY, Dundee P, Nair R, Furrer MA. A Systematic Review of Intra- and Postoperative Complication Reporting and Grading in Urological Surgery: Understanding the Pitfalls and a Path Forward. Eur Urol Oncol 2023:S2588-9311(23)00003-2. [PMID: 36697322 DOI: 10.1016/j.euo.2023.01.002] [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: 03/18/2022] [Revised: 11/30/2022] [Accepted: 01/02/2023] [Indexed: 01/25/2023]
Abstract
CONTEXT Surgical outcomes and patient morbidity are often surrogate markers of health care quality and efficiency. These parameters can only be used with confidence if the reporting and grading of intra- and postoperative complications are reliable and reproducible. Without uniformity and regulation, the risk of under-reporting, and thus significant underestimation of the burden of intra- and postoperative morbidity, is high and should be of great concern to the international surgical community. OBJECTIVE To assess the quality and utility of currently available reporting and classification systems for intra- and postoperative complications, recognise their advantages and pitfalls, discuss the overall implications of these systems for urological surgery, and identify potential solutions for future reporting and classification systems. EVIDENCE ACQUISITION A comprehensive search was performed using multiple reputable databases and trial registries up to October 25, 2022. Only studies that adhered to predefined inclusion criteria were included. Study selection and data extraction were independently performed by two review authors. The review was performed according to strict methodological guidelines in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. EVIDENCE SYNTHESIS A total of 13 papers highlighting 13 various complication systems were critically assessed in this review. All studies proposed an intra- or postoperative complication reporting or grading system that was surgically related. At present, there is no single instrument in clinical practice to account for all relevant complication data. Six of the 13 studies were clinically validated (46%) and only three studies were urology-focused (23%). Meta-analysis was not possible. CONCLUSIONS Current individual complication tools are flawed, so there is a need for a novel, all-inclusive, specialty-specific reporting and classification system for intra- and postoperative complications. If successfully validated and integrated worldwide, such an instrument would have the potential to play a significant role in reshaping efficiency in health care systems and improving surgical and patient quality of care. PATIENT SUMMARY Current tools for reporting and classifying complications during and after surgery underestimate how burdensome such complications can be for patients. We summarise the reporting and classification tools currently available, discuss their advantages and drawbacks, and propose potential solutions for future systems. Our review can help in better understanding the changes required for future tools and how to improve overall surgical outcomes for patients.
Collapse
Affiliation(s)
- Christopher Soliman
- Department of Urology, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia.
| | - Niranjan J Sathianathen
- Department of Urology, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia
| | - Benjamin C Thomas
- Department of Urology, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia
| | - Gianluca Giannarini
- Unit of Urology, Santa Maria della Misericordia Academic Medical Center, Udine, Italy
| | - Nathan Lawrentschuk
- Department of Urology, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philip Dundee
- Department of Urology, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia
| | - Rajesh Nair
- Department of Urology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Marc A Furrer
- Department of Urology, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia; Department of Urology, Guy's and St. Thomas' NHS Foundation Trust, London, UK; Department of Urology, University of Bern, Bern, Switzerland; Department of Urology, Solothurner Spitäler AG, Olten and Solothurn, Switzerland
| |
Collapse
|
50
|
Association Between Postoperative Complications and Long-term Survival After Non-cardiac Surgery Among Veterans. Ann Surg 2023; 277:e24-e32. [PMID: 33630458 DOI: 10.1097/sla.0000000000004749] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the relationship between postoperative complications and long-term survival. SUMMARY AND BACKGROUND Postoperative complications remain a significant driver of healthcare costs and are associated with increased perioperative mortality, yet the extent to which they are associated with long-term survival is unclear. METHODS National cohort study of Veterans who underwent non-cardiac surgery using data from the Veterans Affairs Surgical Quality Improvement Program (2011-2016). Patients were classified as having undergone outpatient, low-risk inpatient, or high-risk inpatient surgery. Patients were categorized based on number and type of complications. The association between the number of complications (or the specific type of complication) and risk of death was evaluated using multivariable Cox regression with robust standard errors using a 90-day survival landmark. RESULTS Among 699,002 patients, complication rates were 3.0%, 6.1%, and 18.3% for outpatient, low-risk inpatient, and high-risk inpatient surgery, respectively. There was a dose-response relationship between an increasing number of complications and overall risk of death in all operative settings [outpatient surgery: no complications (ref); one-hazard ratio (HR) 1.30 (1.23 - 1.38); multiple-HR 1.61 (1.46 - 1.78); low-risk inpatient surgery: one-HR 1.34 (1.26 - 1.41); multiple-HR 1.69 (1.55 - 1.85); high-risk inpatient surgery: one-HR 1.14 (1.10 - 1.18); multiple-HR 1.42 (1.36 - 1.48)]. All complication types were associated with risk of death in at least 1 operative setting, and pulmonary complications, sepsis, and clostridium difficile colitis were associated with higher risk of death across all settings. Conclusions: Postoperative complications have an adverse impact on patients' long-term survival beyond the immediate postoperative period. Although most research and quality improvement initiatives primarily focus on the perioperative impact of complications, these data suggest they also have important longer-term implications that merit further investigation.
Collapse
|