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Fitzgerald K, Bindra R, Canning S, Tansley G, Lloyd DG, Zheng M, Quinn A, Maharaj J, Perevoshchikova N, Saxby DJ. A human-centred design approach to hybrid manufacturing of a scapholunate interosseous ligament medical practice rig. ANNALS OF 3D PRINTED MEDICINE 2022. [DOI: 10.1016/j.stlm.2022.100084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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THE SPECIALTY OF SURGICAL CRITICAL CARE: A WHITE PAPER FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA CRITICAL CARE COMMITTEE. J Trauma Acute Care Surg 2022; 93:e80-e88. [PMID: 35319544 DOI: 10.1097/ta.0000000000003629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Martin RS, Lester ELW, Ross SW, Davis KA, Tres Scherer LR, Minei JP, Staudenmayer KL. Value in acute care surgery, Part 1: Methods of quantifying cost. J Trauma Acute Care Surg 2022; 92:e1-e9. [PMID: 34570063 DOI: 10.1097/ta.0000000000003419] [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: 11/26/2022]
Abstract
BACKGROUND With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.
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Affiliation(s)
- R Shayn Martin
- From the Department of Surgery (R.S.M.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Surgery (E.L.W.L.), University of Alberta, Edmonton, Alberta, Canada; Department of Surgery (S.W.R.), Atrium Health, Charlotte, NC; Department of Surgery (K.A.D.), Yale School of Medicine, New Haven, Connecticut; North Star Pediatric Surgery (L.R.T.S.), Carmel, Indiana; Department of Surgery (J.P.M.), University of Texas Southwestern Medical School, Dallas, Texas; and Department of Surgery (K.L.S.), Stanford School of Medicine, Stanford, California
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Fallat ME. Fifteen years beyond Institute of Medicine and the future of emergency care in the US health system: Illusions, delusions, and situational awareness. J Trauma Acute Care Surg 2021; 91:6-13. [PMID: 34144555 DOI: 10.1097/ta.0000000000003242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mary E Fallat
- From the Division of Pediatric Surgery Hiram C. Polk, Jr., Department of Surgery, University of Louisville, Louisville, Kentucky
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Mouch CA, Cain-Nielsen AH, Hoppe BL, Giudici MP, Montgomery JR, Scott JW, Machado-Aranda DA, Hemmila MR. Validation of the American Association for the Surgery of Trauma grading system for acute appendicitis severity. J Trauma Acute Care Surg 2020; 88:839-846. [PMID: 32459449 DOI: 10.1097/ta.0000000000002674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking. METHODS Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.-Clinical Modification codes to determine presence of perforation for comparison. RESULTS A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied. CONCLUSION Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes. LEVEL OF EVIDENCE Prospective/Epidemiologic, Level III.
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Affiliation(s)
- Charles A Mouch
- From the Department of Surgery (C.A.M., J.R.M., J.W.S., D.A.M.-A., M.R.H.), and Center for Health Outcomes and Policy (A.H.C.-N., B.L.H., M.P.G., J.W.S., M.R.H.), University of Michigan, Ann Arbor, Michigan
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Barriers to improving health care value in emergency general surgery: A nationwide analysis. J Trauma Acute Care Surg 2020; 89:289-300. [PMID: 32332256 DOI: 10.1097/ta.0000000000002762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is a growing need to improve the quality of care while decreasing health care costs in emergency general surgery (EGS). Health care value includes costs and quality and is a targeted metric by improvement programs. The aim of our study was to evaluate the trend of health care value in EGS over time and to identify barriers to high-value surgical care. METHODS The (2012-2015) National Readmission Database was queried for patients 18 years or older who underwent an EGS procedure (according to the American Association for the Surgery of Trauma definition). Health care value (V = quality metrics/cost) was calculated from the rates of freedom from readmission, major complications, reoperation, and failure to rescue (FTR) indexed over inflation-adjusted hospital costs. Outcomes were the trends in the quality metrics: 6-month readmission, major complications, reoperation, FTR, hospital costs, and health care value over the study period. Multivariable linear regression was performed to determine the predictors of lower health care value. RESULTS We identified 887,013 patients who underwent EGS. Mean ± SD age was 51 ± 20 years, and 53% were male. The rates of 6-month readmission, major complications, reoperation, and FTR increased significantly over the study period. The median hospital costs also increased over the study period (2012, US $9,600 to 2015, US $13,000; p < 0.01). However, the health care value has decreased over the study period (2012, 0.35; 2013, 0.30; 2014, 0.28; 2015, 0.25; p < 0.01). Predictors of decreased health care value in EGS are age 65 years or older (β = -0.568 [-0.689 to -0.418], more than three comorbidities (β = -0.292 [-0.359 to -0.21]), readmission to a different hospital (β = -0.755 [-0.914 to -0.558]), admission to low volume centers (β = -0.927 [-1.126 to -0.682]), lack of rehabilitation (β = -0.004 [-0.005 to -0.003]), and admission on a weekend (β = -0.318 [-0.366 to -0.254]). CONCLUSION Health care value in EGS appears to be declining over time. Some of the factors leading to decreased health care value in EGS are potentially modifiable. Health care value could potentially be improved by reducing fragmentation of care and promoting regionalization. LEVEL OF EVIDENCE Economic, level IV.
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Smith-Singares E. Thoracolaparoscopic management of a traumatic subacute transdiaphragmatic intercostal hernia. Second case reported. Trauma Case Rep 2020; 28:100314. [PMID: 32509954 PMCID: PMC7264079 DOI: 10.1016/j.tcr.2020.100314] [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] [Accepted: 05/16/2020] [Indexed: 11/05/2022] Open
Abstract
Background Transdiaphragmatic intercostal hernias are extremely rare. Their physiopathology is different from traumatic diaphragmatic ruptures, and their clinical presentation and management strategies place them in a different category than abdominal intercostal hernias. Case presentation A 56 yo female presented to the outpatient trauma clinic with a symptomatic, subacute left sided transdiaphragmatic intercostal hernia secondary to a motor vehicle crash almost 3 months prior to presentation. The injury was managed with a combined thoracoscopic and laparoscopic approach, only the second time ever this has been reported. She was discharged on POD#3, and after 6 months of follow up continues to do well, without clinical evidence of hernia recurrence. Conclusion Minimally invasive management of this rare pathology is possible and should be encouraged.
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Affiliation(s)
- Eduardo Smith-Singares
- Washington University School of Medicine in St Louis, Memorial Hospital of Carbondale - The Barnes Jewish Collaborative, United States of America
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Bérubé M, Moore L, Lauzier F, Côté C, Vogt K, Tremblay L, Martel MO, Pagé G, Tardif PA, Pinard AM, Hameed SM, Perreault K, Sirois C, Bélanger C, Turgeon AF. Strategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping review protocol. BMJ Open 2020; 10:e035268. [PMID: 32295777 PMCID: PMC7200027 DOI: 10.1136/bmjopen-2019-035268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Globally every year, millions of patients sustain traumatic injuries and require acute care surgeries. A high incidence of chronic opioid use (up to 58%) has been documented in these populations with significant negative individual and societal impacts. Despite the importance of this public health issue, optimal strategies to limit the chronic use of opioids after trauma and acute care surgery are not clear. We aim to identify existing strategies to prevent chronic opioid use in these populations. METHODS AND ANALYSIS We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify studies, reviews, recommendations and guidelines on strategies aimed at preventing chronic opioid use in patients after trauma and acute care surgery. We will search MEDLINE, EMBASE, PsycINFO, CINHAL, Cochrane Central Register of Controlled Trials, Web of Science, ProQuest and websites of trauma and acute care surgery, pain, government and professional organisations. Databases will be searched for papers published from 1 January 2005 to a maximum of 6 months before submission of the final manuscript. Two reviewers will independently evaluate studies for eligibility and extract data from included studies using a standardised data abstraction form. Preventive strategies will be classified according to their types and targeted trauma populations and acute care surgery procedures. ETHICS AND DISSEMINATION Research ethics approval is not required as this study is based on the secondary use of published data. This work will inform research and clinical stakeholders on the required next steps towards the uptake of effective strategies aimed at preventing chronic opioid use in trauma and acute care surgery patients.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Faculty of Nursing, Université Laval, Québec, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec, Canada
| | - Caroline Côté
- Faculty of Nursing, Université Laval, Québec, Québec, Canada
| | - Kelly Vogt
- Department of Surgery, London Health Sciences Centre (Victoria Hospital), London, Ontario, Canada
| | - Lorraine Tremblay
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Departement of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Marc-Olivier Martel
- Faculty of Dentistry & Department of Anesthesia, McGill University, Montréal, Québec, Canada
| | - Gabrielle Pagé
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Québec, Canada
- Research center of the Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
| | - Anne-Marie Pinard
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec, Canada
| | - S Morad Hameed
- Department of Surgery, Vancouver Costal Health (Vancouver General Hospital), Vancouver, British Columbia, Canada
| | - Kadija Perreault
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Caroline Sirois
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Carole Bélanger
- Faculty of Nursing, Université Laval, Québec, Québec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec, Canada
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Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume. J Trauma Acute Care Surg 2020; 88:619-628. [PMID: 32039972 DOI: 10.1097/ta.0000000000002611] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE Epidemiological, level III.
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