Show Me the Money, I'll Show You My Complications: Impacts of Incentivized Incident Self-Reporting Among Surgeons

INTRODUCTION

Trial and error have the propensity to generate knowledge. Near misses and adverse event reporting can improve patient care. Professional ridicule or litigation risks after an incident may lead to decreased reporting by physicians; however, the lack of incident reporting can negatively affect patient safety and halt scientific advancements. This study compares reporting patterns after distribution of financial incentives to surgeons for self-reporting quality incidents.

METHODS

Retrospective review of an internal incident reporting system, RL6, from September 2018 to September 2019 was performed. Incident reporting patterns after incentive distributions across professional classifications and surgical specialties were evaluated. Engagement surveys on incident reporting were completed by physicians. The primary outcomes were changes in reporting patterns and perceptions after distribution of incentives.

RESULTS

Two hundred and eighteen surgical patients were identified in the incidents reported. Financial incentives significantly increased incidents reported (35 to 183) by physicians (37.1% to 67.8%; P < 0.001) and physician assistants (2.9% to 18.6%; P < 0.001). Acute care surgery displayed the largest increase in incidents reported among surgical specialties (5.7% to 20.2%; P = 0.040). Surgeons exhibited an increase in reporting (60.0% to 94.5%; P < 0.001) compared with witnesses after incentivization (2.9% to 1.6%).

CONCLUSIONS

Financial incentives were associated with increased incident reporting. After the establishment of incentives, physicians were more likely to report their incidents, which may dispel professional embarrassment and display incident ownership. Institutions must encourage reporting while supporting providers. Future quality-improvement studies targeting reporting should incorporate incentives aimed to engage and empower health-care providers.

Impact of Body Mass Index (BMI) on perioperative outcomes following minimally invasive retromuscular abdominal wall reconstruction: a comparative analysis

BACKGROUND

Morbidity and recurrence rates are higher in obese patients undergoing open abdominal wall reconstruction (AWR). Historically, body mass index (BMI) ≥ 40 has served as a relative contraindication to open AWR. The purpose of this study is to evaluate the impact of minimally invasive surgery (MIS) on outcomes after AWR for higher versus lower BMI patients.

METHODS

A retrospective review of a prospectively maintained database was conducted of all patients who underwent MIS AWR between September 2015 and April 2019 at our institution. Patients were subdivided into two groups based on their BMI: BMI ≤ 35 kg/m² and BMI > 35 kg/m². Patient demographics and perioperative data were evaluated using univariate and multivariate analysis.

RESULTS

461 patients were identified and divided into two groups: BMI ≤ 35 (n = 310) and BMI > 35 (n = 151). The two groups were similar in age (BMI ≤ 35: 56.3 ± 14.1 years vs. BMI > 35: 54.4 ± 11.9, p = .154). BMI > 35 group had more patients with ASA score of 3 (81% vs. 32%, p < .001) and comorbid conditions such as hypertension (70% vs. 45%, p < .001), diabetes mellitus (32% vs. 15%, p < .001), and history of recurrent abdominal wall hernia (34% vs. 23%, p = .008). BMI > 35 group underwent a robotic approach at higher rates (74% vs. 45%, p < .001). Patients who underwent a Rives-Stoppa repair from the higher BMI cohort also had a larger defect size (5.6 ± 2.4 cm vs. 6.7 ± 2.4 cm, p = .004). However, there were no differences in defect size in patients who underwent a transversus abdominus release (BMI ≤ 35: 9.7 ± 4.9 cm vs. BMI > 35: 11.1 ± 4.6 cm, p = .069). Both groups benefited similarly from a short length of stay, similar hospital charges, and lower postoperative complications.

CONCLUSION

Initial findings of our data support the benefits of elective MIS approach to AWR for patients with higher BMI. These patients derive similar benefits, such as faster recovery with low recurrence rates, when compared to lower BMI patients, while avoiding preoperative hernia incarceration, postoperative wound complications, and hernia recurrences. Future follow-up is required to establish long-term perioperative and quality of life outcomes in this patient cohort.

Hybrid versus open retromuscular abdominal wall repair: early outcomes

BACKGROUND

The hybrid approach to abdominal wall reconstruction (AWR) for abdominal wall hernias combines minimally invasive posterior component separation and retromuscular dissection with open fascial closure and mesh implantation. This combination may enhance patient outcomes and recovery compared to the open approach alone. The purpose of this study is to evaluate the operative outcomes of hybrid vs. open abdominal wall reconstruction.

METHODS

A retrospective review was conducted to compare patients who underwent open versus hybrid AWR between September 2015 and August of 2018 at Anne Arundel Medical Center. Patient demographics and perioperative data were collected and analyzed using univariate analysis.

RESULTS

Sixty-five patients were included in the final analysis: 10 in the hybrid and 55 in the open groups. Mean age was higher in the hybrid vs. open group (65.1 vs. 56.2 years, p < 0.05). The hybrid and open groups were statistically similar (p > 0.05) in gender distribution, mean BMI, and ASA score. Intraoperative comparison found hybrid patients parallel to open patients (p > 0.05) in mean operative time (294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area, and drain placement. The mean total hospital cost was lower in the hybrid group compared to the open group ($16,426 vs. $19,054, p = 0.43). The hybrid group had a shorter length of stay (5.3 vs. 3.6 days, p = 0.03) after surgery and was followed for a similar length of time (12.3 vs. 12.6 months, p = 0.91). The hybrid group showed a lower trend of seroma, hematoma, wound infection, ileus, and readmission rates after surgery.

CONCLUSION

A review of patient outcomes after hybrid AWR highlights a trend towards shorter length of stay, lower hospital cost, and fewer complications without significant addition to operative time. Long-term studies on a larger number of patients are definitively needed to characterize the comprehensive benefits of this approach.

The impact of laparoscopic anti-reflux surgery on quality of life: do patients with atypical symptoms benefit?

INTRODUCTION

Gastroesophageal reflux disease (GERD) may manifest atypically as cough, hoarseness or difficulty breathing. However, it is difficult to diagnostically establish a cause-and-effect between atypical symptoms and GERD. In addition, the benefit of laparoscopic anti-reflux surgery (LARS) in patients with laryngopharyngeal manifestations of GERD are not well characterized. We report the largest series reported to date assessing operative and quality of life (QOL) outcomes after LARS in patients experiencing extraesophageal manifestations of GERD and discuss recommendations for this patient population.

METHODS

A retrospective review of patients with extraesophageal symptoms and pathologic reflux that underwent LARS between February 2012 and July 2019 was conducted. Inclusion criteria consisted of patients with atypical manifestations of GERD as defined by preoperative survey in addition to physiological diagnosis of pathological reflux. Patient QOL outcomes was analyzed using four validated instruments: the Reflux Symptom Index (RSI), Laryngopharyngeal Reflux QOL, Swallowing QOL (SWAL), and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQOL) surveys.

RESULTS

420 patients (24% male, 76% female) with a mean age of 61.7 ± 13.0 years and BMI of 28.6 ± 5.0 kg/m² were included in this study. Thirty-day wound (0.2%) and non-wound (6.74%) related complication rates were recorded in addition to thirty-day readmission rate (2.6%). Patients reported significant improvements in laryngopharyngeal symptoms at mean follow-up of 18.9 ± 16.6 months post LARS reflected by results of four QOL instruments (RSI - 64%, LPR - 75%, GERD-HRQOL - 80%, SWAL + 18%). The majority of patients demonstrated complete resolution of symptoms upon subsequent encounters with 68% of patients reporting no atypical extraesophageal manifestations during follow-up survey (difficulty breathing - 86%, chronic cough - 81%, hoarseness - 66%, globus sensation - 68%) and 68% of patients no longer taking anti-reflux medication. Seventy-two percent of patients reported being satisfied with their symptom control at latest follow-up.

CONCLUSIONS

In appropriately selected candidates with atypical GERD symptomatology and objective diagnosis of GERD LARS may afford significant QOL improvements with minimal operative or long-term morbidity.

Age-related outcomes in laparoscopic hiatal hernia repair: Is there a "too old" for antireflux surgery?

BACKGROUND

Minimally invasive antireflux surgery has been shown to be safe and effective for the treatment of gastroesophageal reflux (GERD) in elderly patients. However, there is a paucity of data on the influence of advanced age on long-term quality of life (QoL) and perioperative outcomes after laparoscopic antireflux surgery (LARS).

METHOD

A retrospective study of patients undergoing LARS between February 2012 and June 2018 at a single institution was conducted. Patients were divided into four age categories. Perioperative data and quality of life (QOL) outcomes were collected and analyzed.

RESULTS

A total of 492 patients, with mean follow-up of 21 months post surgery, were included in the final analysis. Patients were divided into four age-determined subgroups (< 50:75, 50-65:179, 65-75:144, ≥ 75:94). Advancing age was associated with increasing likelihood of comorbid disease. Older patients were significantly more likely to require Collis gastroplasty (OR 2.09), or concurrent gastropexy (OR 3.20). Older surgical patients also demonstrated increased operative time (ß 6.29, p < .001), length of hospital stay (ß 0.56, p < .001) in addition to increased likelihood of intraoperative complications (OR 2.94, p = .003) and reoperations (OR 2.36, p < .05). However, postoperative QoL outcomes and complication rates were parallel among all age groups.

CONCLUSIONS

Among older patients, there is a greater risk of intraoperative complications, reoperation rates as well as longer operative time and LOS after LARS. However, a long-term QoL benefit is demonstrated among elderly patients who have undergone this procedure. Rather than serving as an exclusion criterion for surgical intervention, advanced age among chronic reflux patients should instead represent a comorbidity addressed in the planning stages of LARS.

Update on the Durability and Performance of Collis Gastroplasty For Chronic GERD and Hiatal Hernia Repair At 4-Year Post-Intervention

BACKGROUND

Collis gastroplasty (CG) remains an important procedure to lengthen the esophagus when indicated in patients undergoing fundoplication for longstanding refractory gastroesophageal reflux disease (GERD) or large hiatal hernias. Concerns over potential sequelae of CG such as dysphagia and worsening heartburn as well as questions regarding the durability of the procedure remain a subject of debate. In this study, 3 and 4-year postoperative data is presented assessing patient quality of life (QOL) measures for those undergoing laparoscopic antireflux surgery (LARS) with and without CG.

METHODS

Comparative review of a prospectively maintained GERD patient database was conducted between patients undergoing LARS with CG versus non-CG (NC) at two institutions between October 2004 and February 2019. Patient demographic, perioperative, and QOL data was analyzed at 3 and 4 years postoperatively using four validated instruments: the Reflux Symptom Index (RSI), Laryngopharyngeal Reflux QOL (LPR-QOL), Swallowing QOL (SWAL), and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQOL) surveys.

RESULTS

A total of 214 CG and 798 NC patients were included in this study. The CG group was older (66.1 ± 12.9 vs. 59.0 ± 14.1, p < 0.001), had a higher frequency of ASA class 3 patients (39.7% vs. 29.7%), and had greater proportion of comorbid disease compared to NG. The groups were parallel in BMI (Collis 28.4 ± 5.2 kg/m² vs. non-Collis 28.6 ± 5.3 kg/m², p = 0.673). Subset analysis revealed persistent benefits through 4 years reflected by survey results in both groups. There were no statistically significant differences in QOL outcomes between CG and NC. A majority of patients in both groups reported discontinuation of antireflux medications and satisfaction with surgical outcomes and symptom control.

CONCLUSION

Long-term QOL outcomes after laparoscopic CG are comparable to patients treated with fundoplication alone in cases of long-standing GERD and hiatal hernias. Furthermore, CG patients enjoyed equivalent durability of the procedure without risk of subsequent dysphagia. Collis gastroplasty remains an important tool in the armamentarium of foregut surgeons.

Resolution of anemia and improved quality of life following laparoscopic hiatal hernia repair

BACKGROUND

Cameron lesions (CL) are common complications of large hiatal hernia (HH) disease and are known to result in chronic blood loss with resultant microcytic anemia. There is support in the literature that repair of HH may lead to resolution of CL and restore normal hemoglobin levels. This study aimed to determine the impact of elective HH repair on resolution of anemia and the quality of life (QOL) in patients with CL.

METHOD

A single-institution, retrospective review analyzed all patients with history of CL or anemia (hemoglobin < 12.0 gm/dl in women, < 13.5 gm/dl in men) who underwent HH repair from January 2012 to May 2019. Four validated surveys were used to assess QOL: Reflux Symptom Index (RSI), gastroesophageal reflux disease health-related QOL (GERD-HRQL), laryngopharyngeal reflux health-related QOL (LPR-HRQL), and QOL and swallowing disorders (SWAL) survey. History of iron supplements and perioperative hemoglobin were also noted.

RESULT

Ninety-six patients were included in this study. The mean age was 67.4 ± 10.8 years and 79% of patients were female. CL were endoscopically identified in 61.5% of patients preoperatively, and the rest of the patients experienced anemia of undiagnosed origin but had a high suspicion for CL. Mean follow-up after HH repair was 17.3 months (range, 1 month-5 years). Mean preoperative hemoglobin was 11.01 ± 2.9 gm/dl and 13.23 ± 1.6 gm/dl postoperatively (p < 0.01). Forty-two (73.7%) patients had resolution of anemia during follow-up and 94.5% stopped supplemental oral iron. Finally, QOL scores significantly improved after surgical intervention: RSI (63%), GERD-HRQL (77%), LPR-HRQOL (72%), and SWAL (13%).

CONCLUSION

Elective HH repair in patients with chronic anemia secondary to CL may potentially resolve CL and anemia and contribute to significant QOL improvements. Future studies will prospectively assess the resolution of CL with biochemical and endoscopic follow-up to confirm the preliminary findings of our analysis.

Analysis of CARD15/NOD2 haplotypes fails to identify common variants associated with rheumatoid arthritis susceptibility

OBJECTIVES

The CARD15/NOD2 gene product plays an important role in host response to bacterial lipopolysaccharides and bacterial muramyl dipeptide via activation of NF-kappaB in monocytes. Mutations in CARD15 are associated with Crohn's disease (CD), a chronic inflammatory bowel disease. In this study we sought to determine whether CD-associated mutations or any common variants of this gene might contribute to susceptibility to another chronic inflammatory disease, rheumatoid arthritis (RA).

METHODS

We genotyped 376 Caucasian RA cases and 376 ethnically matched healthy controls for three CD-associated CARD15 mutations. We also genotyped these 752 individuals for 12 common CARD15 single nucleotide polymorphisms (SNPs), determined the linkage disequilibrium structure of the gene, and compared the frequencies of the common CARD15 haplotypes in the RA cases and controls.

RESULTS

None of the CD-associated mutations or the CARD15 SNPs was associated with susceptibility to RA. We also found no significant difference in the frequencies of any of the common haplotypes of the CARD15 gene in RA patients and controls. Our haplotype analysis was consistent with earlier observations that all three CD-associated variants independently arose on the same ancestral haplotype.

CONCLUSIONS

These data suggest that CARD15 variants are not associated with RA susceptibility.

Influence of the N-methyl-D-aspartate antagonist memantine on human motor cortex excitability

The aim of our study was to investigate the effect of the N-methyl-D-aspartate (NMDA) antagonist memantine on motor excitability in humans. Seven healthy volunteers received memantine or placebo, respectively, over a period of 8 days. At day 8, transcranial magnetic stimulation (TMS) was performed using a paired pulses paradigm in order to assess intracortical inhibition and facilitation. Additionally, motor threshold and silent period duration after TMS were measured as well as M waves, F waves and peripheral silent period after electrical peripheral nerve stimulation. Intracortical inhibition was enhanced, and intracortical facilitation reduced after memantine ingestion in comparison to placebo, whereas no significant difference could be observed regarding the other neurophysiological parameters. We conclude that the NMDA receptor is involved in the regulation of excitability of intracortical interneuronal circuits.

Comparison of a digestion-sedimentation technique with the Kato-Katz technique in the detection and quantification of S. mansoni eggs in light to moderate infections

A comparison between a digestion-sedimentation technique (DST) and the Kato-Katz thick smear technique (KKT) in the detection and quantification of Schistosoma eggs in stool was carried out in 551 subjects. Specimen were collected one or two years after treatment with praziquantel from subjects living in a schistosomiasis endemic area of Mali. One hundred infections missed by the KKT were detected by the DST. Conversely, 35 infections missed by the DST were detected by the KKT (88% were light infections). More subjects were classified as lightly infected by the DST (p < 10(-3)) and more subjects were classified as moderately infected (101-400 epg) by the KKT (p = 0.02). The KKT produced higher counts than the DST among the youngest age group which was also the most infected. The principal advantage of the DST over the KKT was its better sensitivity to detect light infections resulting from a larger amount of stool processed.

Specific antibody detection in human aspergillosis: a GEMO* multicentre evaluation of a rapid immunoelectrophoresis method (Paragon). Group d'Etude des Mycoses Opportunistes

A new immunoelectrophoresis system, the Paragon system, was evaluated in three different hospital centres with the aim of improving standardization of the serodiagnosis of human aspergillosis. To select the most efficient antigen, various commercial and home-made antigens were first tested on 19 sera from 19 patients with highly probable aspergillosis. The value measured using the Paragon anti-Aspergillus antibody detection system was then compared with the results obtained by conventional serological diagnostic methods (conventional immunoelectrophoresis, enzyme linked-immunosorbent assay, indirect immunofluorescence): this step was performed using the first 19 sera as well as 16 other sera from 13 patients with suspected aspergillosis. Concordant results were obtained in 28 cases. The discrepancies observed with seven sera were probably related to differences in the nature of the antigens. Paragon immunoelectrophoresis proved to be a practicable technique requiring only a small amount of serum and giving results within a shorter time than competitive methods (24-48 h). Its major drawbacks compared with conventional immunoelectrophoresis are some difficulties in reading, fewer precipitin lines and the relatively high cost of routine analysis.

Phytophotodermatitis mimicking child abuse

A 13-month-old girl presented with red finger marks on both shoulders thought initially to be secondary to child abuse. The appearance of the marks was not typical of bruising of the stated age and there were no social concerns or other medical features of child abuse. Direct questioning revealed that the mother had been gardening on a sunny day and had picked the child up prior to the appearance of the marks. The marks are thought to represent a phytophotodermatitis. Many paediatric skin conditions can mimic child abuse. Recognition of this further possibility will prevent avoidable errors of diagnosis.

Ovicidal effects of albendazole in human ascariasis, ancylostomiasis and trichuriasis

Albendazole, a broad spectrum anthelmintic, was administered as a 400 mg single dose to 20 patients harbouring Ascaris (ten cases), hookworms (four cases each of Ancylostoma duodenale and Necator americanus) and trichuriasis (ten cases). Faeces were obtained before treatment and during the following five days. Coprocultures were made for 90 days for Ascaris and Trichuris eggs, hookworm eggs were cultured by the Harada-Mori technique for at least eight days. Albendazole was ovicidal against all four genera of nematodes.