1
|
Sataloff RT, Ranjbar PA, Balouch B, Barna A, Al Omari AI, Martha V, Alnouri G. Overlapping otolaryngologic surgery: Safety and efficacy. Am J Otolaryngol 2024; 45:104292. [PMID: 38640813 DOI: 10.1016/j.amjoto.2024.104292] [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: 01/10/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Surgical procedures scheduled staggered between two operating rooms increase efficiency by eliminating turnover time. However, the practice might increase the surgeon's fatigue. Overlapping surgery has been assumed to be safe because no critical portions of procedures are performed simultaneously in two rooms, but there is little evidence in the literature to support that assumption for otolaryngologic surgery, and there is no evidence comparing non-overlapping and overlapping surgical outcomes for a single surgeon with all confounding factors controlled. METHODS Retrospective cohort study that included a consecutive sample of adult subjects who underwent otolaryngologic laryngeal or otologic surgery between June 2013 and March 2016. All procedures were performed by the same surgical team and surgeon who had block time with 2-rooms every other week and 1-room on alternate weeks. The incidence of surgical complications was assessed in the perioperative period. Duration of surgery and time-in-room also were evaluated, as were surgical outcomes. RESULTS A total of 496 surgeries were assigned to either overlapping-surgery (n = 346) or non-overlapping-surgery (n = 150) cohorts. Overlapping-surgery was a significant predictor for increased time-in-room on multivariate analysis but was not a significant predictor for surgery duration. Rate of complications, hospital readmission, emergency department visit, reoperation, mortality, and patient satisfaction did not differ significantly between cohorts. CONCLUSIONS Overlapping surgery does not hinder patient safety or functional outcomes in patients undergoing otolaryngologic operations such as voice or ear surgery.
Collapse
Affiliation(s)
- Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine, Philadelphia, PA, United States.
| | - Parastou Azadeh Ranjbar
- Department of Otolaryngology - Head and Neck Surgery, Tulane University, New Orleans, LA, United States
| | - Bailey Balouch
- Division of Otolaryngology - Head and Neck Surgery, Cooper University Health Care, Camden NJ, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Alexander Barna
- Medical Student, Drexel University College of Medicine, United States
| | - Ahmad Issa Al Omari
- Department of Otolaryngology - Head and Neck Surgery, UPMC Memorial Hospital, York, PA, United States; Department of Special Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Vishnu Martha
- Department of Otolaryngology-Head & Neck Surgery, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India; Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, United States
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Ohio University Heritage Collage of Osteopathic Medicine, Athens, OH, United States
| |
Collapse
|
2
|
Chauhan MZ, Soliman MK, Pace NL, Mathis MR, Schonberger RB, Sallam AB. Anesthesia Techniques for Vitreoretinal Surgery in the United States: A Report from the Multicenter Perioperative Outcomes Group Research Consortium. Am J Ophthalmol 2024; 267:30-40. [PMID: 38871268 DOI: 10.1016/j.ajo.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 05/28/2024] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
PURPOSE To explore the patterns of anesthesia use and their determinants during vitreoretinal (VR) surgeries in academic and community hospitals across the US, using data from the Multicenter Perioperative Outcomes Group (MPOG). DESIGN A retrospective, multicenter, cohort study. METHODS We queried the MPOG database of 107,066 patients undergoing VR surgeries. Patients (≥18 years) undergoing VR surgery with monitored anesthesia care (MAC) or general anesthesia (GA) from January 1, 2015 to December 31, 2021 were included. Patient-level, case-based, and institutional-level covariates were collected. We performed multivariable mixed-effects models to determine predictors of anesthesia type use. The primary outcome was the type of anesthesia (MAC or GA) used during VR surgeries. As a secondary outcome, MAC cases were further classified based on the additional use of sedation into MAC with or without sedation. RESULTS We found that 67.45% of VR surgery cases received MAC, and 73.63% of institutions administered MAC to more than half of cases. Random effect modeling revealed that 47.76% of the variation in MAC use was attributed to institutions. A trend toward increased use of MAC with increasing age was observed. Patients diagnosed with chronic pulmonary disease, liver disease, or a history of drug abuse were less likely to receive MAC. Conversely, we found that patients with reported alcohol abuse disorder, diabetes with complications, and those with American Society of Anesthesiologists (ASA) physical status of 4 (vs. 1, 2, or 3) were more likely to use MAC. Compared to non-complex VR surgeries, there was a notably decreased likelihood of MAC use in complex PPV (P = .004), PPV + scleral buckle (SB) for retinal detachment (P < .0001), and primary SB surgery (P < .0001). CONCLUSIONS Approximately 2/3 of VR anesthesia is under MAC, but GA is still preferred for SBs, complex vitrectomy, and younger patients. We show that large interinstitutional variation for using MAC in practice exists.
Collapse
Affiliation(s)
- Muhammad Z Chauhan
- From the Department of Ophthalmology, University of Arkansas for Medical Sciences (M.Z.C., A.B.S.), Little Rock, Arkansas, USA.
| | - Mohamed K Soliman
- Department of Ophthalmology and Visual Sciences, University Hospitals Eye Institute, Case Western Reserve University (M.K.S.), Cleveland, Ohio, USA; Department of Ophthalmology, Faculty of Medicine, Assiut University Hospitals (M.K.S.), Assiut, Egypt
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah (N.L.P.), Salt Lake City, Utah, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan (M.R.M.), Ann Arbor, Michigan, USA
| | - Robert B Schonberger
- Department of Anesthesiology, Yale School of Medicine (R.B.S.), New Haven, Connecticut, USA
| | - Ahmed B Sallam
- From the Department of Ophthalmology, University of Arkansas for Medical Sciences (M.Z.C., A.B.S.), Little Rock, Arkansas, USA.
| |
Collapse
|
3
|
Chow MS, Givi B. In Response to The RVU Compensation Model and Head and Neck Surgical Education. Laryngoscope 2024; 134:E2. [PMID: 37665114 DOI: 10.1002/lary.31007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Michael S Chow
- New York University Department of Otolaryngology-Head and Neck Surgery, New York, New York, U.S.A
| | - Babak Givi
- Memorial Sloan Kettering Cancer Center, Head and Neck Service, New York, New York, U.S.A
| |
Collapse
|
4
|
Kamyszek RW, Newman N, Ragheb JW, Sjoding MW, Joo H, Maile MD, Cassidy RB, Golbus JR, Engoren MC, Mathis MR. Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure. J Clin Anesth 2023; 90:111226. [PMID: 37549434 PMCID: PMC11221412 DOI: 10.1016/j.jclinane.2023.111226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/29/2023] [Accepted: 07/30/2023] [Indexed: 08/09/2023]
Abstract
STUDY OBJECTIVE To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis. DESIGN Observational cohort study. SETTING Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019. PATIENTS 40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed. INTERVENTIONS Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses. MEASUREMENTS Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis. MAIN RESULTS Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria. CONCLUSIONS Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.
Collapse
Affiliation(s)
- Reed W Kamyszek
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Noah Newman
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jacqueline W Ragheb
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hyeon Joo
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ruth B Cassidy
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jessica R Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
5
|
Kendale S, Bishara A, Burns M, Solomon S, Corriere M, Mathis M. Machine Learning for the Prediction of Procedural Case Durations Developed Using a Large Multicenter Database: Algorithm Development and Validation Study. JMIR AI 2023; 2:e44909. [PMID: 38875567 PMCID: PMC11041482 DOI: 10.2196/44909] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/14/2023] [Accepted: 07/02/2023] [Indexed: 06/16/2024]
Abstract
BACKGROUND Accurate projections of procedural case durations are complex but critical to the planning of perioperative staffing, operating room resources, and patient communication. Nonlinear prediction models using machine learning methods may provide opportunities for hospitals to improve upon current estimates of procedure duration. OBJECTIVE The aim of this study was to determine whether a machine learning algorithm scalable across multiple centers could make estimations of case duration within a tolerance limit because there are substantial resources required for operating room functioning that relate to case duration. METHODS Deep learning, gradient boosting, and ensemble machine learning models were generated using perioperative data available at 3 distinct time points: the time of scheduling, the time of patient arrival to the operating or procedure room (primary model), and the time of surgical incision or procedure start. The primary outcome was procedure duration, defined by the time between the arrival and the departure of the patient from the procedure room. Model performance was assessed by mean absolute error (MAE), the proportion of predictions falling within 20% of the actual duration, and other standard metrics. Performance was compared with a baseline method of historical means within a linear regression model. Model features driving predictions were assessed using Shapley additive explanations values and permutation feature importance. RESULTS A total of 1,177,893 procedures from 13 academic and private hospitals between 2016 and 2019 were used. Across all procedures, the median procedure duration was 94 (IQR 50-167) minutes. In estimating the procedure duration, the gradient boosting machine was the best-performing model, demonstrating an MAE of 34 (SD 47) minutes, with 46% of the predictions falling within 20% of the actual duration in the test data set. This represented a statistically and clinically significant improvement in predictions compared with a baseline linear regression model (MAE 43 min; P<.001; 39% of the predictions falling within 20% of the actual duration). The most important features in model training were historical procedure duration by surgeon, the word "free" within the procedure text, and the time of day. CONCLUSIONS Nonlinear models using machine learning techniques may be used to generate high-performing, automatable, explainable, and scalable prediction models for procedure duration.
Collapse
Affiliation(s)
- Samir Kendale
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Andrew Bishara
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, United States
| | - Michael Burns
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Stuart Solomon
- Department of Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Matthew Corriere
- Department of Surgery, Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States
- Center for Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, United States
| |
Collapse
|
6
|
Bews HJ, Pilkey JL, Malik AA, Tam JW. Alternatives to Hospitalization: Adding the Patient Voice to Advanced Heart Failure Management. CJC Open 2023; 5:454-462. [PMID: 37397619 PMCID: PMC10314144 DOI: 10.1016/j.cjco.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/31/2023] [Indexed: 07/04/2023] Open
Abstract
Advanced heart failure (HF) is associated with the extensive use of acute care services, especially at the end of life, often in stark contrast to the wishes of most HF patients to remain at home for as long as possible. The current Canadian model of hospital-centric care is not only inconsistent with patient goals, but also unsustainable in the setting of the current hospital-bed availability crisis across the country. Given this context, we present a narrative to discuss factors necessary for the avoidance of hospitalization in advanced HF patients. First, patients eligible for alternatives to hospitalization should be identified through comprehensive, values-based, goals-of-care discussions, including involvement of both patients and caregivers, and assessment of caregiver burnout. Second, we present pharmaceutical interventions that have shown promise in reducing HF hospitalizations. Such interventions include strategies to combat diuretic resistance, as well as nondiuretic treatments of dyspnea, and the continuation of guideline-directed medical therapies. Finally, to successfully care for advanced HF patients at home, care models, such as transitional care, telehealth, collaborative home-based palliative care programs, and home hospitals, must be robust. Care must be individualized and coordinated through an integrated care model, such as the spoke-hub-and-node model. Although barriers exist to the implementation of these models and strategies, they should not prevent clinicians from striving to provide individualized person-centred care. Doing so will not only alleviate strain on the healthcare system, but also prioritize patient goals, which is of the utmost importance.
Collapse
Affiliation(s)
- Hilary J. Bews
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jana L. Pilkey
- Section of Palliative Care Medicine, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amrit A. Malik
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James W. Tam
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
7
|
Liu Y, Chen S, Hammack-Aviran CM, Drolet BC, Perdikis G. Overlapping Surgeries From the Patient's Perspective. J Surg Res 2023; 286:85-95. [PMID: 36803878 DOI: 10.1016/j.jss.2022.10.073] [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: 03/21/2022] [Revised: 09/11/2022] [Accepted: 10/16/2022] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Overlapping surgery (OS) occurs when a single surgeon is concurrently caring for patients in multiple operating rooms (OR) but is present for all critical portions of each surgery. Although this is common practice, most studies have found public disapproval of OS. This study aims to better understand attitudes toward OS of patients who gave informed consent for OS. METHODS Participant interviews covered topics including trust, OR personnel roles, and attitudes toward OS. Four representative transcripts were distributed among researchers for independent code identification. These were aggregated into a codebook, applied by two coders. Iterative and emergent thematic analyses were done. RESULTS Twelve participants were interviewed to reach thematic saturation. Three themes shaped how participants felt about OS: trust in their surgeon, worries about OS, and understanding of OR personnel roles. Factors contributing to trust included personal research and the surgeon's experience. Frequently cited concerns were unpredictability of complications during operations and the surgeon's divided attention. Two participants inaccurately understood personnel roles, believing the surgeon did most or all the hands-on work while trainees were observers. Most participants felt a high or neutral level of comfort toward OS and indicated trust as the reason. CONCLUSIONS In contrast to prior research, this study found that most participants had a neutral or positive view of OS. This suggests that a trusting relationship with their surgeon and informed consent are important factors in increasing comfort for OS. Participants who misunderstood OR roles felt less comfortable toward OS. This highlights an opportunity for patient education on trainee roles.
Collapse
Affiliation(s)
- Yangzi Liu
- Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Shirley Chen
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Brian C Drolet
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
8
|
Pitts CC, Ponce BA, Arguello AM, Willis JG, McGwin G, Vatsia S, Parks CT, Wills BW. Impact of the Percentage of Overlapping Surgery on Patient Outcomes: A Retrospective Cohort Study of 87,000 Surgical Cases. Ann Surg 2023; 277:756-760. [PMID: 36538641 DOI: 10.1097/sla.0000000000005739] [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: 12/24/2022]
Abstract
OBJECTIVES The primary objective of this study was to analyze the relationship of percentage of surgical overlap with patient outcomes to determine if a detrimental level of overlap exists. BACKGROUND Overlapping surgery is defined as 1 attending physician supervising 2 or more operative cases simultaneously, without the critical portions of the cases occurring concurrently. To date, no study has examined the relationship of percent overlap, or the percentage of 1 case that is spent overlapping with another, to outcomes, efficiency, safety, and complications. METHODS This study is a retrospective cohort study conducted at a large tertiary referral center. The primary outcomes of interest included operative duration, in-hospital mortality, 30-day readmission, and patient safety indicators (PSIs). The Cochran-Armitage test for trend was used to evaluate the outcomes of interest. P values of ≤0.05 were considered statistically significant. RESULTS A total of 87,426 cases were included in this study. There were 62,332 cases without overlap (Group 0), 10,514 cases with 1% to 25% overlap (Group 1), 5303 cases with 26% to 50% overlap (Group 2), 4296 cases with 51% to 75% overlap (Group 3), and 4981 cases with >75% overlap (Group 4). In-hospital mortality decreased as overlap increased ( Ptrend <0.0001). Operative time increased with increasing overlap ( Ptrend <0.0001) while readmission rates showed no statistical significance between groups ( Ptrend =0.5078). Rates of PSIs were lower for Groups 1, 2, and 3 (1.69%, 2.01%, and 2.08%) when compared to Group 0 (2.24%). Group 4 had the highest rate of PSIs at 2.35% ( P =0.0086). CONCLUSION Overlapping surgery was shown to have reduced in-hospital mortality and similar PSI and readmission rates when compared to nonoverlapping cases. Operative time was shown to increase in overlapping surgeries when compared to nonoverlapping surgeries. The results from this study indicate that the percentage of surgical overlap does not detrimentally affect most patient outcomes, especially with overlap of <75%.
Collapse
Affiliation(s)
- Charles C Pitts
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, AL
| | - Brent A Ponce
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, AL
- Department of Orthopaedic Surgery, Hughston Clinic, Columbus, GA
| | - Alexandra M Arguello
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, AL
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN
| | - Joseph G Willis
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, AL
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, AL
| | - Sohrab Vatsia
- Department of Orthopaedic Surgery, Hughston Clinic, Columbus, GA
| | - Chris T Parks
- Department of Orthopaedic Surgery, The Orthopaedic Center, Huntsville, AL
| | - Brad W Wills
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, AL
- Department of Orthopaedic Surgery, The Orthopaedic Center, Huntsville, AL
| |
Collapse
|
9
|
Kumarapuram S, Elmogazy O, Mokhtari P, Goldstein I, Tayebi Meybodi A. Do overlapping neurosurgical procedures affect patient outcomes? A systematic review and meta-analysis. Neurosurg Rev 2023; 46:92. [PMID: 37072635 DOI: 10.1007/s10143-023-01993-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 04/20/2023]
Abstract
Overlapping surgery (OS) is a common practice in neurosurgery that has recently come under scrutiny. This study includes a systematic review and meta-analysis on articles evaluating the effects of OS on patient outcomes. PubMed and Scopus were searched for studies that analyzed outcome differences between overlapping and non-overlapping neurosurgical procedures. Study characteristics were extracted, and random-effects meta-analyses were performed to analyze the primary outcome (mortality) and secondary outcomes (complications, 30-day readmissions, 30-day operating room returns, home discharge, blood loss, and length of stay). Mantel-Haenszel tests were completed for binary outcomes, whereas the inverse variance tests were conducted for continuous outcomes. Heterogeneity was measured using the I2 and X2 tests. The Egger's test was conducted to evaluate publication bias. Eight of 61 non-duplicate studies were included. Overall, 21,249 patients underwent non-OS (10,504 female) and 15,863 patients underwent OS (8393 female). OS was associated with decreased mortality (p = 0.002), 30-day returns to OR (p < 0.001), and blood loss (p < 0.001) along with increased home discharges (p < 0.001). High heterogeneity was observed for home discharge (p = 0.002) and length of stay (p < 0.001). No publication bias was observed. OS was not associated with worse patient outcomes compared to non-OS. However, considering multiple sources of limitation in the methodology of the included studies (such as limited number of studies, reports originating from mostly high-volume academic centers, discrepancy in the definition of "critical portion(s)" of the surgery across studies, and selection bias), extra caution is advised in interpretation of our results and further focused studies are warranted.
Collapse
Affiliation(s)
- Siddhant Kumarapuram
- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers University, New Brunswick, NJ, USA
| | | | - Pooneh Mokhtari
- Department of Neurosurgery, Rutgers New Jersey Medical School, 90 Bergen Street, Newark, NJ, 07103, USA
| | - Ira Goldstein
- Department of Neurosurgery, Rutgers New Jersey Medical School, 90 Bergen Street, Newark, NJ, 07103, USA
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, 90 Bergen Street, Newark, NJ, 07103, USA.
| |
Collapse
|
10
|
Privratsky JR, Fuller M, Raghunathan K, Ohnuma T, Bartz RR, Schroeder R, Price TM, Martinez MR, Sigurdsson MI, Mathis MR, Naik B, Krishnamoorthy V. Postoperative Acute Kidney Injury by Age and Sex: A Retrospective Cohort Association Study. Anesthesiology 2023; 138:184-194. [PMID: 36512724 PMCID: PMC10439699 DOI: 10.1097/aln.0000000000004436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) after noncardiac surgery is common and has substantial health impact. Preclinical and clinical studies examining the influence of sex on AKI have yielded conflicting results, although they typically do not account for age-related changes. The objective of the study was to determine the association of age and sex groups on postoperative AKI. The authors hypothesized that younger females would display lower risk of postoperative AKI than males of similar age, and the protection would be lost in older females. METHODS This was a multicenter retrospective cohort study across 46 institutions between 2013 and 2019. Participants included adult inpatients without pre-existing end-stage kidney disease undergoing index major noncardiac, nonkidney/urologic surgeries. The authors' primary exposure was age and sex groups defined as females 50 yr or younger, females older than 50 yr, males 50 yr or younger, and males older than 50 yr. The authors' primary outcome was development of AKI by Kidney Disease-Improving Global Outcomes serum creatinine criteria. Exploratory analyses included associations of ascending age groups and hormone replacement therapy home medications with postoperative AKI. RESULTS Among 390,382 patients, 25,809 (6.6%) developed postoperative AKI (females 50 yr or younger: 2,190 of 58,585 [3.7%]; females older than 50 yr: 9,320 of 14,4047 [6.5%]; males 50 yr or younger: 3,289 of 55,503 [5.9%]; males older than 50 yr: 11,010 of 132,447 [8.3%]). When adjusted for AKI risk factors, compared to females younger than 50 yr (odds ratio, 1), the odds of AKI were higher in females older than 50 yr (odds ratio, 1.51; 95% CI, 1.43 to 1.59), males younger than 50 yr (odds ratio, 1.90; 95% CI, 1.79 to 2.01), and males older than 50 yr (odds ratio, 2.06; 95% CI, 1.96 to 2.17). CONCLUSIONS Younger females display a lower odds of postoperative AKI that gradually increases with age. These results suggest that age-related changes in women should be further studied as modifiers of postoperative AKI risk after noncardiac surgery. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Jamie R. Privratsky
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Matthew Fuller
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
- Durham VA Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Raquel R. Bartz
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Rebecca Schroeder
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
- Durham VA Medical Center, Durham, NC, USA
| | - Thomas M. Price
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Michael R. Martinez
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Martin I. Sigurdsson
- Division of Anesthesia and Intensive Care Medicine, Landspitali -The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik Iceland
| | - Michael R. Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Bhiken Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| |
Collapse
|
11
|
Monaghan R, Hoey M, Lavelle A. The effect of overlapping surgical scheduling on operating theatre productivity. Anaesthesia 2023; 78:264-265. [PMID: 36256735 DOI: 10.1111/anae.15893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 01/11/2023]
Affiliation(s)
| | - M Hoey
- Saint James's Hospital, Dublin, Ireland
| | - A Lavelle
- Saint James's Hospital, Dublin, Ireland
| |
Collapse
|
12
|
Surgical informed consent: new challenges. Curr Probl Surg 2023; 60:101258. [PMID: 36813352 DOI: 10.1016/j.cpsurg.2022.101258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
|
13
|
Adashi EY, Brown EC, Elberg JT. Overlapping Surgery-In DeBakey's Shadow. JAMA Surg 2023; 158:8-9. [PMID: 36223103 DOI: 10.1001/jamasurg.2022.3947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This Viewpoint discusses the future of the practice of overlapping surgeries.
Collapse
Affiliation(s)
- Eli Y Adashi
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Jacob T Elberg
- Center for Health & Pharmaceutical Law, Seton Hall University School of Law, Seton Hall University, Newark, New Jersey
| |
Collapse
|
14
|
Golbus JR, Joo H, Janda AM, Maile MD, Aaronson KD, Engoren MC, Cassidy RB, Kheterpal S, Mathis MR. Preoperative clinical diagnostic accuracy of heart failure among patients undergoing major noncardiac surgery: a single-centre prospective observational analysis. BJA OPEN 2022; 4:100113. [PMID: 36643721 PMCID: PMC9835767 DOI: 10.1016/j.bjao.2022.100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/16/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
Background Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses. Methods We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard. Results Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3-16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6-95.1%), sensitivity 57.4% (53.1-61.7%), specificity 98.3% (97.1-99.4%), positive predictive value 83.5% (80.3-86.8%), and negative predictive value 93.8% (91.7-95.9%). Conclusions Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.
Collapse
Affiliation(s)
- Jessica R. Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Hyeon Joo
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Allison M. Janda
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael D. Maile
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Keith D. Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Milo C. Engoren
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Ruth B. Cassidy
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael R. Mathis
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
- Department of Computational Bioinformatics, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
15
|
Pandit JJ, Ramachandran SK, Pandit M. The effect of overlapping surgical scheduling on operating theatre productivity: a narrative review. Anaesthesia 2022; 77:1030-1038. [PMID: 35863080 PMCID: PMC9543504 DOI: 10.1111/anae.15797] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 01/11/2023]
Abstract
This article reviews the background to overlapping surgery, in which a single senior surgeon operates across two parallel operating theatres; anaesthesia is induced and surgery commenced by junior surgeons in the second operating theatre while the lead surgeon completes the operation in the first. We assess whether there is any theoretical basis to expect increased productivity in terms of number of operations completed. A review of observational studies found that while there is a perception of increased surgical output for one surgeon, there is no evidence of increased productivity compared with two surgeons working in parallel. There is potential for overlapping surgery to have some positive impact in situations where turnover times between cases are long, operations are short (<2 h) and where 'critical portions' of surgery constitute about half of the total operation time. However, any advantages must be balanced against safety, ethical and training concerns.
Collapse
Affiliation(s)
- J. J. Pandit
- University of OxfordUK,Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - S. K. Ramachandran
- Department of AnesthesiaBeth Israel Deaconess Medical CenterBostonMAUSA,Harvard Medical SchoolBostonMAUSA
| | - M. Pandit
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| |
Collapse
|
16
|
Chiu C, Fong N, Lazzareschi D, Mavrothalassitis O, Kothari R, Chen LL, Pirracchio R, Kheterpal S, Domino KB, Mathis M, Legrand M. Fluids, vasopressors, and acute kidney injury after major abdominal surgery between 2015 and 2019: a multicentre retrospective analysis. Br J Anaesth 2022; 129:317-326. [PMID: 35688657 DOI: 10.1016/j.bja.2022.05.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Practice patterns related to intraoperative fluid administration and vasopressor use have potentially evolved over recent years. However, the extent of such changes and their association with perioperative outcomes, such as the development of acute kidney injury (AKI), have not been studied. METHODS We performed a retrospective analysis of major abdominal surgeries in adults across 26 US hospitals between 2015 and 2019. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes definition (KDIGO) using only serum creatinine criteria. Univariable linear predictive additive models were used to describe the dose-dependent risk of AKI given fluid administration or vasopressor use. RESULTS Over the study period, we observed a decrease in the volume of crystalloid administered, a decrease in the proportion of patients receiving more than 10 ml kg-1 h-1 of crystalloid, an increase in the amount of norepinephrine equivalents administered, and a decreased duration of hypotension. The incidence of AKI increased between 2016 and 2019. An increase of crystalloid administration from 1 to 10 ml kg-1 h-1 was associated with a 58% decreased risk of AKI. CONCLUSIONS Despite decreased duration of hypotension during the study period, decreased fluid administration and increased vasopressor use were associated with increased incidence of AKI. Crystalloid administration below 10 ml kg-1 h-1 was associated with an increased risk of AKI. Although no causality can be concluded, these data suggest that prevention and treatment of hypotension during abdominal surgery with liberal use of vasopressors at the expense of fluid administration is associated with an increased risk of postoperative AKI.
Collapse
Affiliation(s)
- Catherine Chiu
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Nicholas Fong
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Lazzareschi
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Orestes Mavrothalassitis
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Rishi Kothari
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Lee-Lynn Chen
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Romain Pirracchio
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Karen B Domino
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Matthieu Legrand
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA.
| |
Collapse
|
17
|
Lange N, Stadtmüller T, Scheibel S, Reischer G, Wagner A, Meyer B, Gempt J. Analysis of risk factors for perioperative complications in spine surgery. Sci Rep 2022; 12:14350. [PMID: 35999446 PMCID: PMC9399240 DOI: 10.1038/s41598-022-18417-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 08/10/2022] [Indexed: 11/09/2022] Open
Abstract
Complications in spine surgery can arise in the intraoperative or the immediate postoperative period or in a delayed manner. These complications may lead to severe or even permanent morbidity if left undiagnosed and untreated. We prospectively interviewed 526 patients out of 1140 patients who consecutively underwent spinal surgery in our department between November 2017 and November 2018 and analysed the outcome and complication rates. A 12 months follow-up period was also adopted. We analysed the patients' clinical characteristics, comorbidities, surgical management, survival rates, and outcomes. Risk factor analyses for the development of complications were also performed. Patients' median age was 67 years (range: 13-96). The main diagnoses were as follows: degenerative in 50%, tumour in 22%, traumatic fractures in 13%, infections in 10%, reoperations in 3%, and others in 2%. Surgeries were emergency procedures (within 24 h) in 12%. Furthermore, 59% required instrumentation. The overall postoperative complication rate was 26%. Revision surgery was required in 12% of cases within 30 postoperative days (median time to revision 11 days [IQR 5-15 days]). The most frequent complications included wound healing disorders, re-bleeding, and CSF leakage. Thereby, the risk factor analysis revealed age-adjusted CCI (p = 0.01), metastatic tumour (p = 0.01), and atrial fibrillation (p = 0.02) as significant risk factors for postoperative complications. Additionally, postoperative KPS (p = 0.004), postoperative anaemia (p = 0.001), the length of hospital stay (p = 0.02), and duration of surgery (p = 00.002) were also identified as associated factors. Complication rates after spinal surgeries are still high, especially in patients with metastatic tumour disease and poor clinical status (KPS), requiring revision surgeries in several cases. Therefore, specific risk factors should be determined to carefully select surgery groups.
Collapse
Affiliation(s)
- Nicole Lange
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany.
| | - Thomas Stadtmüller
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Stefanie Scheibel
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Gerda Reischer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| |
Collapse
|
18
|
Burns ML, Saager L, Cassidy RB, Mentz G, Mashour GA, Kheterpal S. Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality. JAMA Surg 2022; 157:807-815. [PMID: 35857304 DOI: 10.1001/jamasurg.2022.2804] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Recent studies have investigated the effect of overlapping surgeon responsibilities or nurse to patient staffing ratios on patient outcomes, but the association of overlapping anesthesiologist responsibilities with patient outcomes remains unexplored to our knowledge. Objective To examine the association between different levels of anesthesiologist staffing ratios and surgical patient morbidity and mortality. Design, Setting, and Participants A retrospective, matched cohort study consisting of major noncardiac inpatient surgical procedures performed from January 1, 2010, to October 31, 2017, was conducted in 23 US academic and private hospitals. A total of 866 453 adult patients (aged ≥18 years) undergoing major inpatient surgery within the Multicenter Perioperative Outcomes Group electronic health record registry were included. Anesthesiologist sign-in and sign-out times were used to calculate a continuous time-weighted average staffing ratio variable for each operation. Propensity score-matching methods were applied to create balanced sample groups with respect to patient-, operative-, and hospital-level confounders and resulted in 4 groups based on anesthesiologist staffing ratio. Groups consisted of patients receiving care from an anesthesiologist covering 1 operation (group 1), more than 1 to no more than 2 overlapping operations (group 1-2), more than 2 to no more than 3 overlapping operations (group 2-3), and more than 3 to no more than 4 overlapping operations (group 3-4). Data analysis was performed from October 2019 to October 2021. Exposure Undergoing a major inpatient surgical operation that involved an anesthesiologist providing care for up to 4 overlapping operations. Main Outcomes and Measures The primary composite outcome was 30-day mortality and 6 major surgical morbidities (cardiac, respiratory, gastrointestinal, urinary, bleeding, and infectious complications) derived from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision discharge diagnosis codes. Results In all, 578 815 adult patients (mean [SD] age, 55.7 [16.2] years; 55.1% female) were analyzed. After matching operations according to anesthesiologist staffing ratio, 48 555 patients were in group 1; 247 057, group 1-2; 216 193, group 2-3; and 67 010, group 3-4. Increasing anesthesiologist coverage responsibilities was associated with an increase in risk-adjusted surgical patient morbidity and mortality. Compared with patients in group 1-2, those in group 2-3 had a 4% relative increase in risk-adjusted mortality and morbidity (5.06% vs 5.25%; adjusted odds ratio [AOR], 1.04; 95% CI, 1.01-1.08; P = .02) and those in group 3-4 had a 14% increase in risk-adjusted mortality and morbidity (5.06% vs 5.75%; AOR, 1.15; 95% CI, 1.09-1.21; P < .001). Conclusions and Relevance This study's findings suggest that increasing overlapping coverage by anesthesiologists is associated with increased surgical patient morbidity and mortality. Therefore, the potential effects of staffing ratios in perioperative team models should be considered in clinical coverage efforts.
Collapse
Affiliation(s)
- Michael L Burns
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Leif Saager
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Ruth B Cassidy
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | | | | |
Collapse
|
19
|
Sun EC, Mello MM, Vaughn MT, Kheterpal S, Hawn MT, Dimick JB, Jena AB. Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before. JAMA Intern Med 2022; 182:720-728. [PMID: 35604661 PMCID: PMC9127708 DOI: 10.1001/jamainternmed.2022.1563] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE The association between physician fatigue and patient outcomes is important to understand but has been difficult to examine given methodological and data limitations. Surgeons frequently perform urgent procedures overnight and perform additional procedures the following day, which could adversely affect outcomes for those daytime operations. OBJECTIVE To examine the association between an attending surgeon operating overnight and outcomes for operations performed by that surgeon the next day. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, a retrospective analysis of a large multicenter registry of surgical procedures was done using a within-surgeon analysis to address confounding, with data from 20 high-volume US institutions. This study included 498 234 patients who underwent a surgical procedure during the day (between 7 am and 5 pm) between January 1, 2010, and August 30, 2020. EXPOSURES Whether the attending surgeon for the current day's procedures operated between 11 pm and 7 am the previous night. Two exposure measures were examined: whether the surgeon operated at all the previous night and the number of hours spent operating the previous night (including having performed no work at all). MAIN OUTCOMES AND MEASURES The primary composite outcome was in-hospital death or major complication (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke). Secondary outcomes included operation length and individual outcomes of death, major complications, and minor complications (surgical site infection or urinary tract infection). RESULTS Among 498 234 daytime operations performed by 1131 surgeons, 13 098 (2.6%) involved an attending surgeon who operated the night before. The mean (SD) age of the patients who underwent an operation was 55.3 (16.4) years, and 264 740 (53.1%) were female. After adjusting for operation type, surgeon fixed effects, and observable patient characteristics (ie, age and comorbidities), the adjusted incidence of in-hospital death or major complications was 5.89% (95% CI, 5.41%-6.36%) among daytime operations when the attending surgeon operated the night before compared with 5.87% (95% CI, 5.85%-5.89%) among daytime operations when the same surgeon did not (absolute adjusted difference, 0.02%; 95% CI, -0.47% to 0.51%; P = .93). No significant associations were found between overnight work and secondary outcomes except for operation length. Operating the previous night was associated with a statistically significant decrease in length of daytime operations (adjusted length, 112.7 vs 117.4 minutes; adjusted difference, -4.7 minutes; 95% CI, -8.7 to -0.8, P = .02), although this difference is unlikely to be meaningful. CONCLUSIONS AND RELEVANCE The findings of this cross-sectional study suggest that operating overnight was not associated with worse outcomes for operations performed by surgeons the subsequent day. These results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform operations the following morning.
Collapse
Affiliation(s)
- Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,Department of Health Policy, Stanford University School of Medicine, Stanford, California
| | - Michelle M Mello
- Department of Health Policy, Stanford University School of Medicine, Stanford, California.,Stanford Law School, Stanford, California.,Freeman Spogli Institute for International Studies, Stanford University, Stanford, California
| | - Michelle T Vaughn
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Massachusetts General Hospital, Boston.,National Bureau of Economic Research, Cambridge, Massachusetts
| |
Collapse
|
20
|
Kim RG, An VVG, Lee SLK, Khadra SM, Petchell JF. Overlapping surgery in arthroplasty - a systematic review and meta-analysis. Orthop Traumatol Surg Res 2022; 109:103299. [PMID: 35472455 DOI: 10.1016/j.otsr.2022.103299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 01/31/2022] [Accepted: 03/30/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Planned overlapping surgery can improve efficiency, reduce costs and help manage long waiting lists; yet, this practice has been questioned due to patient safety concerns. A systematic review and meta-analysis were performed to answer the question: (1) are there any differences in the risk of postoperative adverse outcomes; and (2) are there any differences in length of stay or length of surgery, in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed either as non-overlapping surgery (NOS) or overlapping surgery (OS). PATIENTS AND METHODS A systematic search of literature in the databases of MEDLINE, PubMed, Embase and Cochrane from dates of inception was performed. All studies published in English were included. Risk of Bias in Non-randomised Studies-of Interventions (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05. RESULTS A total of nine studies with 120,625 patients were included for analyses. There were no statistically significant differences for overall rates of postoperative complications, dislocations, fractures, infections, readmissions or revision surgery nor with length of stay or length of surgery (p>0.05). Patient characteristics between groups were similar (p>0.05). DISCUSSION There were no differences in postoperative adverse outcomes for elective orthopaedic THA and TKA performed as NOS when compared to OS. Operating schedules for OS in elective lower limb arthroplasty appear to be safe, given appropriate patient selection processes and may be a useful method to improve hospital efficiency. Informed consent and preoperative patient education should remain paramount. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Raymond G Kim
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Road, 2050 Camperdown, NSW, Australia.
| | - Vincent V G An
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Road, 2050 Camperdown, NSW, Australia
| | - Sun Loong K Lee
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Road, 2050 Camperdown, NSW, Australia
| | - Sam M Khadra
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Road, 2050 Camperdown, NSW, Australia
| | - Jeffrey F Petchell
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Road, 2050 Camperdown, NSW, Australia
| |
Collapse
|
21
|
Illescas A, Zhong H, Cozowicz C, Gonzalez Della Valle A, Liu J, Memtsoudis SG, Poeran J. Health Services Research in Anesthesia: A Brief Overview of Common Methodologies. Anesth Analg 2022; 134:540-547. [PMID: 35180171 DOI: 10.1213/ane.0000000000005884] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of large data sources such as registries and claims-based data sets to perform health services research in anesthesia has increased considerably, ultimately informing clinical decisions, supporting evaluation of policy or intervention changes, and guiding further research. These observational data sources come with limitations that must be addressed to effectively examine all aspects of health care services and generate new individual- and population-level knowledge. Several statistical methods are growing in popularity to address these limitations, with the goal of mitigating confounding and other biases. In this article, we provide a brief overview of common statistical methods used in health services research when using observational data sources, guidance on their interpretation, and examples of how they have been applied to anesthesia-related health services research. Methods described involve regression, propensity scoring, instrumental variables, difference-in-differences, interrupted time series, and machine learning.
Collapse
Affiliation(s)
- Alex Illescas
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Haoyan Zhong
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Jiabin Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York.,Department of Health Policy and Research, Weill Cornell Medical College, New York, New York
| | - Jashvant Poeran
- Department of Population Health Science & Policy/Department of Orthopedics, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
22
|
Grant MC, Anderson TA. Laying the First Brick: A Foundation for Medical Investigation Through Big Data. Anesth Analg 2022; 134:5-7. [PMID: 34908540 DOI: 10.1213/ane.0000000000005710] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michael C Grant
- From the Department of Anesthesiology and Critical Care Medicine.,Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Thomas A Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
23
|
Janda AM, Spence J, Dubovoy T, Belley-Côté E, Mentz G, Kheterpal S, Mathis MR. Multicentre analysis of practice patterns regarding benzodiazepine use in cardiac surgery. Br J Anaesth 2022; 128:772-784. [PMID: 35101244 PMCID: PMC9074791 DOI: 10.1016/j.bja.2021.11.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is controversy regarding optimal use of benzodiazepines during cardiac surgery, and it is unknown whether and to what extent there is variation in practice. We sought to describe benzodiazepine use and sources of variation during cardiac surgeries across patients, clinicians, and institutions. METHODS We conducted an analysis of adult cardiac surgeries across a multicentre consortium of USA academic and private hospitals from 2014 to 2019. The primary outcome was administration of a benzodiazepine from 2 h before anaesthesia start until anaesthesia end. Institutional-, clinician-, and patient-level variables were analysed via multilevel mixed-effects models. RESULTS Of 65 508 patients cared for by 825 anaesthesiology attending clinicians (consultants) at 33 institutions, 58 004 patients (88.5%) received benzodiazepines with a median midazolam-equivalent dose of 4.0 mg (inter-quartile range [IQR], 2.0-6.0 mg). Variation in benzodiazepine dosage administration was 54.7% attributable to institution, 14.7% to primary attending anaesthesiology clinician, and 30.5% to patient factors. The adjusted median odds ratio for two similar patients receiving a benzodiazepine was 2.68 between two randomly selected clinicians and 4.19 between two randomly selected institutions. Factors strongly associated (adjusted odds ratio, <0.75, or >1.25) with significantly decreased likelihoods of benzodiazepine administration included older age (>80 vs ≤50 yr; adjusted odds ratio=0.04; 95% CI, 0.04-0.05), university affiliation (0.08, 0.02-0.35), recent year of surgery (0.42, 0.37-0.49), and low clinician case volume (0.44, 0.25-0.75). Factors strongly associated with significantly increased likelihoods of benzodiazepine administration included cardiopulmonary bypass (2.26, 1.99-2.55), and drug use history (1.29, 1.02-1.65). CONCLUSIONS Two-thirds of the variation in benzodiazepine administration during cardiac surgery are associated with institutions and attending anaesthesiology clinicians (consultants). These data, showing wide variations in administration, suggest that rigorous research is needed to guide evidence-based and patient-centred benzodiazepine administration.
Collapse
Affiliation(s)
- Allison M Janda
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
| | - Jessica Spence
- Departments of Anesthesia and Critical Care, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Timur Dubovoy
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Emilie Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Divisions of Cardiology and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
24
|
Outcomes and Patient Safety in Overlapping vs. Nonoverlapping Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Am Acad Orthop Surg 2021; 29:e1387-e1395. [PMID: 34874337 DOI: 10.5435/jaaos-d-20-01130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/24/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Overlapping surgery is defined as two cases occurring in separate operating rooms (ORs), where the same attending surgeon conducts the critical surgical portions of each case at different times. Although it has been suggested that this established practice may improve the utilization of resources, allow for more opportunities to teach surgical trainees, and facilitate timely access to care, there is still no consensus on its use in elective orthopaedic surgery, such as total joint arthroplasty (TJA). METHODS A systematic review and meta-analysis of the literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles investigating the use of overlapping and single operating room TJA. Relevant data, including surgical time, intraoperative complications, postoperative complications, mortality rate, revision rate, and readmission rate, were extracted and recorded. RESULTS Six articles were included (35,938 patients: 17,677 overlapping and 18,261 nonoverlapping). Overall revision rates were 1.2% and 1.1% for the overlapping and nonoverlapping cohorts, respectively (odds ratio [OR] = 1.19; 95% confidence interval [CI]: 0.93 to 1.53). The overall intraoperative complication rate was 1.6% for both cohorts (OR = 0.98; 95% CI: 0.79 to 1.23), and the overall postoperative orthopaedic complication rates were 2.0% and 1.95% within the overlapping and nonoverlapping OR cohorts, respectively (OR = 1.07; 95% CI: 0.89 to 1.29). The readmission rate was 4.6% in the overlapping group and 4.2% in the nonoverlapping group (OR = 0.88; 95% CI: 0.70 to 1.11). Two studies with comparable groups reported markedly increased surgical time in the overlapping group compared with the nonoverlapping group. DISCUSSION Overlapping surgery was found to be as safe as nonoverlapping surgery in patients undergoing TJA. Although overlapping TJA surgery is associated with satisfactory short-term revision rates, prolonged follow-up is required to further assess the medium-term and long-term outcomes of overlapping surgery compared with nonoverlapping surgery. Finally, although overlapping TJA surgery might be associated with increased OR time, this difference is not clinically relevant.
Collapse
|
25
|
Comment on "Responsibilities and Expectations: Considerations of Disclosure of Overlapping Operations". Ann Surg 2021; 274:e725-e726. [PMID: 32516234 DOI: 10.1097/sla.0000000000004016] [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]
|
26
|
Bardia A, Treggiari MM, Michel G, Dai F, Tickoo M, Wai M, Schuster K, Mathis M, Shah N, Kheterpal S, Schonberger RB. Adherence to Guidelines for the Administration of Intraoperative Antibiotics in a Nationwide US Sample. JAMA Netw Open 2021; 4:e2137296. [PMID: 34905007 PMCID: PMC8672234 DOI: 10.1001/jamanetworkopen.2021.37296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Despite widespread adherence to Surgical Care Improvement Project antibiotic measures, prevention of surgical site infections (SSIs) remains a clinical challenge. Several components of perioperative antibiotic prophylaxis guidelines are incompletely monitored and reported within the Surgical Care Improvement Project program. OBJECTIVES To describe adherence to each component of perioperative antibiotic prophylaxis guidelines in regard to procedure-specific antibiotic choice, weight-adjusted dosing, and timing of first and subsequent administrations in a nationwide, multicenter cohort of patients undergoing noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS This cohort study included adult patients undergoing general, urological, orthopedic, and gynecological surgical procedures involving skin incision between January 1, 2014, and December 31, 2018, across 31 academic and community hospitals identified within the Multicenter Perioperative Outcomes Group registry. Data were analyzed between April 2 and April 21, 2021. MAIN OUTCOMES AND MEASURES The primary end point was overall adherence to Infectious Diseases Society of America guidelines, including (1) appropriateness of antibiotic choice, (2) weight-based dose adjustment, (3) timing of administration with respect to surgical incision, and (4) timing of redosing when indicated. Data were analyzed using mixed-effects regression to investigate patient, clinician, and institutional factors associated with guideline adherence. RESULTS In the final cohort of 414 851 encounters across 31 institutions, 51.8% of patients were women, the mean (SD) age was 57.5 (15.7) years, 1.2% of patients were of Hispanic ethnicity, and 10.2% were Black. In this cohort, 148 804 encounters (35.9%) did not adhere to guidelines: 19.7% for antibiotic choice, 17.1% for weight-adjusted dosing, 0.6% for timing of first dose, and 26.8% for redosing. In adjusted analyses, overall nonadherence was associated with emergency surgery (odds ratio [OR], 1.35; 95% CI, 1.29-1.41; P < .001), surgery requiring blood transfusions (OR, 1.30; 95% CI, 1.25-1.36; P < .001), off-hours procedures (OR, 1.08; 95% CI, 1.04-1.13; P < .001), and procedures staffed by a certified registered nurse anesthetist (OR, 1.14; 95% CI, 1.11-1.17; P < .001). Overall adherence to guidelines for antibiotic administration improved over the study period from 53.1% (95% CI, 52.7%-53.5%) in 2014 to 70.2% (95% CI, 69.8%-70.6%) in 2018 (P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, although adherence to perioperative antibiotic administration guidelines improved over the study period, more than one-third of surgical encounters remained discordant with Infectious Diseases Society of America recommendations. Future quality improvement efforts targeting gaps in practice in relation to guidelines may lead to improved adherence and possibly decreased SSIs.
Collapse
Affiliation(s)
- Amit Bardia
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Miriam M. Treggiari
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - George Michel
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Feng Dai
- Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Mayanka Tickoo
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mabel Wai
- Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut
| | - Kevin Schuster
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor
| | | |
Collapse
|
27
|
Perez AW, Brelsford KM, Diehl CJ, Langerman AJ. Surgeon Perspectives on Benefits and Downsides of Overlapping Surgery: In-depth, Qualitative Interviews. Ann Surg 2021; 274:e403-e409. [PMID: 32282374 DOI: 10.1097/sla.0000000000003722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The aim of the study was to characterize surgeon perspectives regarding the benefits and downsides of conducting overlapping surgery. BACKGROUND Although surgeons are key stakeholders in current discussions surrounding overlapping surgery, little has been published regarding their opinions on the practice. Further characterization of surgeon perspectives is needed to guide future studies and policy development regarding overlapping surgery. METHODS Study information was sent to all members of 3 professional surgical societies. Interested individuals were eligible to participate if they identified as attending surgeons in an academic setting who work with trainees. Purposive selection was used to diversify surgeons interviewed across multiple dimensions, including subspecialty and opinion regarding appropriateness of overlapping surgery. In-depth, qualitative interviews were conducted with participants regarding their opinions on overlapping surgery. RESULTS The 51 surgeons interviewed identified a wide array of potential benefits and disadvantages of overlapping surgery, some of which have not previously been measured, including downsides to surgeon wellness and patient experience, less surgeon control over procedures, and difficulty in scheduling cases. Interviewees often disagreed as to whether overlapping surgery negatively or positively affects each dimension discussed, particularly regarding the impact on resident training. CONCLUSIONS The utilization of the novel perspectives presented here will allow for targeted assessment of physician perspectives in future quantitative studies and increase the likelihood that variables measured encompass the range of factors that surgeons find meaningful and relevant. Priority areas of future research should include examining effects of overlapping surgery on surgical training and surgeon wellness.
Collapse
Affiliation(s)
| | - Kathleen M Brelsford
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Carolyn J Diehl
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander J Langerman
- Program in Surgical Ethics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
28
|
|
29
|
de Oliveira LFMM, Ramallo DA, Möller JVS, Leal AC, Ribeiro GA, Guimarães JAM. The Role of the Resident Doctor in Orthopedics and Traumatology in a Large Hospital of the Unified Health System: What is the User's view? Rev Bras Ortop 2021; 56:438-445. [PMID: 34483386 PMCID: PMC8405263 DOI: 10.1055/s-0040-1718513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/06/2020] [Indexed: 11/10/2022] Open
Abstract
Objective
To assess the knowledge of patients seen at a teaching hospital about the academic and professional training of the resident doctor in orthopedics and traumatology, as well as his area of expertise, and determine the perception of the patients of comfort and safety in relation to being assisted by the resident doctor at different stages of treatment.
Methods
A cross-sectional study was conducted with patients admitted to a large orthopedics hospital of the Brazilian Unified Health System (SUS, in the Portuguese acronym). Data were collected through the application of a questionnaire containing 19 objective questions that assessed sociodemographic parameters and the perception of the patient of the performance of the resident. The data were analyzed to assess the frequency of responses obtained.
Results
152 participants were evaluated, predominantly male (62.6%) and aged between 36 and 55 years old (41.3%). Only 43.3% were aware of the academic background of the resident. Patients reported feeling safer and more comfortable being assisted by the doctor together with the resident in the outpatient consultation (43.3%), in the nursing ward (39.3%) and during surgery (61%). As for the performance of the resident, 80.2% stated that the resident doctor improves communication between the patient and the main surgeon; however, only 11% said they would feel safe and comfortable being cared for exclusively by residents in the surgical environment, if allowed.
Conclusion
The participation of resident physicians in the care is well received by the patients if they are in the company of the attending physician. Patients identify residents as a facilitating bridge in the communication with attending physicians.
Collapse
Affiliation(s)
| | - Daniel Alves Ramallo
- Centro de Atenção Especializada em Cirurgia da Coluna Vertebral, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brasil.,Centro de Atenção Especializada em Trauma Ortopédico, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brasil
| | - João Victor Silveira Möller
- Centro de Atenção Especializada em Trauma Ortopédico, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brasil
| | - Ana Carolina Leal
- Divisão de Ensino e Pesquisa, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brasil
| | - Gabriel Araujo Ribeiro
- Centro de Atenção Especializada em Trauma Ortopédico, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brasil
| | - João Antonio Matheus Guimarães
- Centro de Atenção Especializada em Trauma Ortopédico, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brasil
| |
Collapse
|
30
|
Mlambo B, Shih IF, Li Y, Wren SM. The impact of operative approach on postoperative outcomes and healthcare utilization after colectomy. Surgery 2021; 171:320-327. [PMID: 34362589 DOI: 10.1016/j.surg.2021.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/05/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND To evaluate national trends in adoption of different surgical approaches for colectomy and compare clinical outcomes and resource utilization between approaches. METHODS Retrospective study of patients aged ≥18 years who underwent elective inpatient left or right colectomy between 2010 and 2019 from the Premier Healthcare Database. Patients were classified by operative approach: open, minimally invasive: either laparoscopic or robotic. Postoperative outcomes assessed within index hospitalization include operating room time, hospital length of stay, rates of conversion to open surgery, reoperation, and complications. Post-discharge readmission, hospital-based encounters, and costs were collected to 30 days post-discharge. Multivariable regression models were used to compare outcomes between operative approaches adjusted for patient baseline characteristics and clustering within hospitals. RESULTS Among 206,967 patients, the robotic approach rates increased from 2.1%/1.6% (2010) to 32.6%/26.8% (2019) for left/right colectomy, offset by a decrease in both open and laparoscopic approaches. Median length of stay for both left and right colectomies was significantly longer in open (6 days) and laparoscopic (5 days) compared to robotic surgery (4 days; all P values <.001). Robotic surgery compared to open and laparoscopic was associated with a significantly lower conversion rate, development of ileus, overall complications, and 30-day hospital encounters. Robotic surgery further demonstrated lower mortality, reoperations, postoperative bleeding, and readmission rates for left and right colectomies than open. Robotic surgery had significantly longer operating room times and higher costs than either open or laparoscopic. CONCLUSIONS Robotic surgery is increasingly being used in colon surgery, with outcomes equivalent and in some domains superior to laparoscopic.
Collapse
Affiliation(s)
- Busisiwe Mlambo
- Department of Surgery, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Yanli Li
- Intuitive Surgical, Inc, Sunnyvale, CA
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.
| |
Collapse
|
31
|
Wang P, Yuan Y, Xu K, Zhong H, Yang Y, Jin S, Yang K, Qi X. Biological applications of copper-containing materials. Bioact Mater 2021; 6:916-927. [PMID: 33210018 PMCID: PMC7647998 DOI: 10.1016/j.bioactmat.2020.09.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 12/11/2022] Open
Abstract
Copper is an indispensable trace metal element in the human body, which is mainly absorbed in the stomach and small intestine and excreted into the bile. Copper is an important component and catalytic agent of many enzymes and proteins in the body, so it can influence human health through multiple mechanisms. Based on the biological functions and benefits of copper, an increasing number of researchers in the field of biomaterials have focused on developing novel copper-containing biomaterials, which exhibit unique properties in protecting the cardiovascular system, promoting bone fracture healing, and exerting antibacterial effects. Copper can also be used in promoting incisional wounds healing, killing cancer cells, Positron Emission Tomography (PET) imaging, radioimmunological tracing and radiotherapy of cancer. In the present review, the biological functions of copper in the human body are presented, along with an overview of recent progress in our understanding of the biological applications and development of copper-containing materials. Furthermore, this review also provides the prospective on the challenges of those novel biomaterials for future clinical applications.
Collapse
Affiliation(s)
- Peng Wang
- Key Laboratory of Diagnostic Imaging and Interventional Radiology of Liaoning Province, Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110001, China
| | - Yonghui Yuan
- Clinical Research Center for Malignant Tumor of Liaoning Province, Cancer Hospital of China Medical University Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, 110042, China
| | - Ke Xu
- Key Laboratory of Diagnostic Imaging and Interventional Radiology of Liaoning Province, Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110001, China
| | - Hongshan Zhong
- Key Laboratory of Diagnostic Imaging and Interventional Radiology of Liaoning Province, Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110001, China
| | - Yinghui Yang
- Suzhou Silvan Medical Co., Ltd, Suzhou 215006, China
| | - Shiyu Jin
- Key Laboratory of Diagnostic Imaging and Interventional Radiology of Liaoning Province, Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110001, China
| | - Ke Yang
- Institute of Metal Research, Chinese Academy of Science, Shenyang 110016, China
| | - Xun Qi
- Key Laboratory of Diagnostic Imaging and Interventional Radiology of Liaoning Province, Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110001, China
| |
Collapse
|
32
|
Mathis MR, Duggal NM, Janda AM, Fennema JL, Yang B, Pagani FD, Maile MD, Hofer RE, Jewell ES, Engoren MC. Reduced Echocardiographic Inotropy Index after Cardiopulmonary Bypass Is Associated With Complications After Cardiac Surgery: An Institutional Outcomes Study. J Cardiothorac Vasc Anesth 2021; 35:2732-2742. [PMID: 33593647 DOI: 10.1053/j.jvca.2021.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Despite advances in echocardiography and hemodynamic monitoring, limited progress has been made to effectively quantify left ventricular function during cardiac surgery. Traditional measures, including left ventricular ejection fraction (LVEF) and cardiac index, remain dependent on loading conditions; more complex measures remain impractical in a dynamic surgical setting. However, the Smith-Madigan Inotropy Index (SMII) and potential-to-kinetic energy ratio (PKR) offer promise as measures calculable during cardiac surgery and potentially predictive of outcomes. Using echocardiographic and hemodynamic monitoring data, the authors aimed to calculate SMII and PKR values after cardiopulmonary bypass and understand associations with postoperative outcomes, adjusting for previously identified risk factors. DESIGN Observational cohort study. SETTING Tertiary care academic hospital. PATIENTS The study comprised 189 elective adult cardiac surgical procedures from 2015-2016. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The primary outcome was postoperative mortality or organ system complication (stroke, prolonged ventilation, reintubation, cardiac arrest, acute kidney injury, new-onset atrial fibrillation). After adjustment, SMII <0.83 W/m2 independently predicted the primary outcome (adjusted odds ratio 2.19, 95% confidence interval 1.08-4.42); whereas PKR, LVEF, and cardiac index demonstrated no associations. When SMII and PKR were incorporated into a EuroSCORE II risk model, predictive performance improved (net reclassification index improvement 0.457; p = 0.001); whereas a model incorporating LVEF and cardiac index demonstrated no improvement (0.130; p = 0.318). CONCLUSION The present study demonstrated that SMII, but not PKR, as a measure of cardiac function was associated with major complications. The study's data may guide investigations of more suitable perioperative goal-directed therapies to reduce complications after cardiac surgery.
Collapse
Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI; Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, MI.
| | - Neal M Duggal
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Jordan L Fennema
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Ryan E Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth S Jewell
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| |
Collapse
|
33
|
Mitchell MB, Hammack-Aviran CM, Clayton EW, Langerman A. A Survey of Overlapping Surgery Policies at U.S. Hospitals. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2021; 49:64-73. [PMID: 33966659 DOI: 10.1017/jme.2021.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The authors surveyed hospitals across the country on their policies regarding overlapping surgery, and found large variation between hospitals in how this practice is regulated. Specifically, institutions chose to define "critical portions" in a variety of ways, ultimately affecting not only surgical efficiency but also the autonomy of surgical trainees and patient experiences at these different hospitals.
Collapse
|
34
|
Thudium M, Hoeft A, Coburn M. [Hot topics in anesthesiology 2019/2020]. Anaesthesist 2021; 70:73-77. [PMID: 33294949 DOI: 10.1007/s00101-020-00899-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Marcus Thudium
- Klinik für Anästhesie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
| | - Andreas Hoeft
- Klinik für Anästhesie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - Mark Coburn
- Klinik für Anästhesie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| |
Collapse
|
35
|
Nabavizadeh R, Higgins MI, Patil D, Biebighauser Bens KC, Traorè E, Master VA, Ogan K. Overlapping Urological Surgeries at a Tertiary Academic Center. Urology 2020; 148:118-125. [PMID: 33232693 DOI: 10.1016/j.urology.2020.09.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/06/2020] [Accepted: 09/13/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether the practice of procedure-time overlapping surgery (OS) is associated with inferior outcomes compared to nonoverlapping surgery (NOS) in urology, to address the paucity of data surrounding urologic surgeries to support or refute this practice. MATERIALS AND METHODS We performed a retrospective review of all urological surgeries at a single tertiary-level academic center, Emory University Hospital, from July 2016 to July 2018. Patients who received OS were matched 1:2 to patients who had NOS. The primary outcomes were perioperative and postoperative complications and mortality. RESULTS We reviewed 8535 urological surgeries. In-room time overlap was seen in 50.5% of cases and procedure-time overlap in 7.4%. Eleven out of the 13 attending urologists performed OS. The average time in the operating room was greater for OS by an average of 14 minutes. The average operative time was greater for OS than NOS by 11 minutes, but this did not reach statistical significance. There was no significant difference between the cohorts for rate of blood transfusions, ICU stay, need for postoperative invasive procedures, length of postoperative hospital stay, discharge location, Emergency Room visits, hospital readmission rate, 30 and 90-day rates of postoperative complications, and mortality. CONCLUSION Procedure-time overlapping surgeries constituted a minority of urological cases. OS were associated with greater in-room time. We found no increased risk of perioperative or postoperative adverse outcomes in OS compared to matched NOS.
Collapse
Affiliation(s)
- Reza Nabavizadeh
- Department of Urology, Emory University School of Medicine, Atlanta, GA.
| | | | - Dattatraya Patil
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | | | - Elizabeth Traorè
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - Viraj A Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - Kenneth Ogan
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
36
|
Lan L, Qiu Y, Zhang C, Ma T, Cen Y. Comparison of single-stage and two-stage bilateral video-assisted thoracic surgery. J Int Med Res 2020; 48:300060520967558. [PMID: 33131358 PMCID: PMC7653298 DOI: 10.1177/0300060520967558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Single-stage sequential bilateral video-assisted thoracoscopic surgery (VATS) is a controversial procedure. In the present study, we retrospectively compared the outcomes of single-stage and two-stage VATS. METHODS This study involved patients who underwent single-stage sequential bilateral VATS (SS-VATS group) or two-stage VATS at a 3-month interval (TS-VATS group) for treatment of non-small cell lung cancer from 2010 to 2018. The major outcome was the comparison of intraoperative changes. RESULTS The inspiratory peak pressure was higher, the incidences of intraoperative hypoxia and unstable hemodynamics were higher, the surgical time was longer, and the durations of the intensive care unit stay and postoperative hospitalization were longer in the SS-VATS group than in the TS-VATS group. However, the chest tube duration, incidence of postoperative mechanical ventilation, and clinical complications were not different between the two groups. CONCLUSIONS Compared with two-stage VATS, single-stage sequential bilateral VATS can be performed for successful treatment of bilateral pulmonary lesions with a shorter total time and higher cost-effectiveness in terms of anesthesia and hospitalization but with a higher incidence of intraoperative adverse effects and a longer hospital stay.
Collapse
Affiliation(s)
- Lan Lan
- Department of Anesthesiology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yuan Qiu
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, People's Republic of China
| | - Canzhou Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Tongtong Ma
- Department of Anesthesiology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yanyi Cen
- Department of Anesthesiology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| |
Collapse
|
37
|
Chen EY, Michel G, Zhou B, Dai F, Akhtar S, Schonberger RB. An Analysis of Anesthesia Induction Dosing in Female Older Adults. Drugs Aging 2020; 37:435-446. [PMID: 32300966 DOI: 10.1007/s40266-020-00760-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND/OBJECTIVES In the context of an aging surgical population, appropriate anesthetic induction dose adjustments for the older adult remain poorly defined. In the present study, we describe the prevalence of excess induction agent dose in reference to US Food and Drug Administration (FDA) guidance and seek to investigate the possible association of such excess dose with postinduction hypotension and postoperative acute kidney injury (AKI). STUDY DESIGN A retrospective observational study was conducted in a large tertiary teaching hospital in accordance with our a priori analytic protocol as registered on ClinicalTrials.gov (NCT03699696). For inclusion, patients had to be 65 years or older and to have received general anesthesia with propofol induction for gynecologic oncology surgery between December 1, 2014 and July 8, 2018. Descriptive variables of the patients, machine-captured perioperative vital signs, induction anesthetic, and vasopressor/inotrope administrations were recorded. MAIN OUTCOME MEASURES A total of 541 female patients met inclusion criteria. The mean (standard deviation) age of the cohort was 72.20 (5.93) years. Regarding the primary outcome, 65.43% (354 patients, 95% confidence interval 61.2-69.4) of the cohort received more than the FDA recommended 1-1.5 mg/kg induction dose for patients of advanced age undergoing general anesthesia. RESULTS The percentage of patients receiving doses in excess of the FDA guidance remained substantial across all age groups, but decreased progressively with increasing 5-year age intervals (from 74% among those aged 65-69 years to 44% among those aged > 80 years). Excess propofol dose in the present cohort was not associated with our a priori definition of postinduction hypotension. Regarding AKI, among the 30 patients suffering this outcome, it occurred less often in patients who received higher propofol doses (4.1% [9/217] vs. 15.3% [21/138], p < 0.001), a result that may have been confounded by differential rates of missingness. CONCLUSIONS Older adults commonly receive propofol induction doses in excess of the FDA guidance. The immediate hemodynamic effects of these doses on postinduction hypotension were not seen in the present cohort, suggesting that propofol dose adjustments may serve as a marker of physicians' judgments as to the frailty of patients. The relevance of the AKI association is difficult to interpret due to the non-differential missingness of AKI data between the two groups.
Collapse
Affiliation(s)
- Eric Y Chen
- Department of Anesthesiology, Yale School of Medicine, 789 Howard Avenue, New Haven, CT, USA, 06519.
| | - George Michel
- Center For Medical Informatics, Yale School of Medicine, 300 George Street, Suite 501, New Haven, CT, USA, 06510
| | - Bin Zhou
- Yale Center for Analytical Sciences, Yale School of Public Health, 300 George Street, Suite 555, New Haven, CT, USA, 06510
| | - Feng Dai
- Yale Center for Analytical Sciences, Yale School of Public Health, 300 George Street, Suite 555, New Haven, CT, USA, 06510
| | - Shamsuddin Akhtar
- Department of Anesthesiology, Yale School of Medicine, 789 Howard Avenue, New Haven, CT, USA, 06519
| | - Robert B Schonberger
- Department of Anesthesiology, Yale School of Medicine, 789 Howard Avenue, New Haven, CT, USA, 06519
| |
Collapse
|
38
|
Pirracchio R, Mavrothalassitis O, Mathis M, Kheterpal S, Legrand M. Response of US hospitals to elective surgical cases in the COVID-19 pandemic. Br J Anaesth 2020; 126:e46-e48. [PMID: 33187635 PMCID: PMC7572110 DOI: 10.1016/j.bja.2020.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Romain Pirracchio
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Orestes Mavrothalassitis
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; F-CRIN INI-CRCT Network, Nancy, France.
| |
Collapse
|
39
|
Aoyama K, Pinto R, Ray JG, Hill A, Scales DC, Fowler RA. Determining Associations and Estimating Effects with Regression Models in Clinical Anesthesia. Anesthesiology 2020; 133:500-509. [PMID: 32788557 DOI: 10.1097/aln.0000000000003425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There are an increasing number of "big data" studies in anesthesia that seek to answer clinical questions by observing the care and outcomes of many patients across a variety of care settings. This Readers' Toolbox will explain how to estimate the influence of patient factors on clinical outcome, addressing bias and confounding. One approach to limit the influence of confounding is to perform a clinical trial. When such a trial is infeasible, observational studies using robust regression techniques may be able to advance knowledge. Logistic regression is used when the outcome is binary (e.g., intracranial hemorrhage: yes or no), by modeling the natural log for the odds of an outcome. Because outcomes are influenced by many factors, we commonly use multivariable logistic regression to estimate the unique influence of each factor. From this tutorial, one should acquire a clearer understanding of how to perform and assess multivariable logistic regression.
Collapse
Affiliation(s)
- Kazuyoshi Aoyama
- From the Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada (K.A.) the Program in Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada (K.A.) the Department of Critical Care Medicine (R.P., A.H., D.C.S., R.A.F.) the Sunnybrook Research Institute (K.A., R.P., A.H., D.C.S., R.A.F.), Sunnybrook Health Science Center, Toronto, Ontario, Canada the Keenan Research Centre of the Li Ka Shing Knowledge Institute (J.G.R.) the Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada (J.G.R.) the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (K.A., J.G.R., D.C.S., R.A.F.)
| | | | | | | | | | | |
Collapse
|
40
|
Myers LC, Gartland RM, Skillings J, Heard L, Bittner EA, Einbinder J, Metlay JP, Mort E. An Examination of Medical Malpractice Claims Involving Physician Trainees. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1215-1222. [PMID: 31833853 DOI: 10.1097/acm.0000000000003117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE To identify patient-, provider-, and claim-related factors of medical malpractice claims in which physician trainees were directly involved in the harm events. METHOD The authors performed a case-control study using medical malpractice claims closed between 2012-2016 and contributed to the Comparative Benchmarking System database by teaching hospitals. Using the service extender flag, they classified claims as cases if physician trainees were directly involved in the harm events. They classified claims as controls if they were from the same facilities, but trainees were not directly involved in the harm events. They performed multivariable regression with predictor variables being patient and provider characteristics. The outcome was physician trainee involvement in harm events. RESULTS From the original pool of 30,973 claims, there were 581 cases and 2,610 controls. The majority of cases involved residents (471, 81%). Cases had a statistically significant higher rate of having a trainee named as defendants than controls (184, 32% vs 233, 9%; P < .001). The most common final diagnosis for cases was puncture or laceration during surgery (62, 11%). Inadequate supervision was a contributing factor in 140 (24%) cases overall, with the majority (104, 74%) of these claims being procedure related. Multivariable regression analysis revealed that trainees were most likely to be involved in harm events in specialties such as oral surgery/dentistry and obstetrics-gynecology (OR = 7.99, 95% CI 2.93, 21.83 and OR = 1.85, 95% CI 1.24, 2.66, respectively), when performing procedures (OR = 1.58, 95% CI 1.27, 1.96), or when delivering care in the emergency room (OR = 1.65, 95% CI 1.43, 1.91). CONCLUSIONS Among claims involving physician trainees, procedures were common and often associated with inadequate supervision. Training directors of surgical specialties can use this information to improve resident supervision policies. The goal is to reduce the likelihood of future harm events.
Collapse
Affiliation(s)
- Laura C Myers
- L.C. Myers is a research fellow, Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts; ORCID: http://orcid.org/0000-0002-2872-3388
| | - Rajshri M Gartland
- R.M. Gartland is a surgical resident, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jillian Skillings
- J. Skillings is data analyst, Controlled Risk Insurance Company, Boston, Massachusetts
| | - Lisa Heard
- L. Heard is senior program director, Patient Safety and Education, Controlled Risk Insurance Company, Boston, Massachusetts
| | - Edward A Bittner
- E.A. Bittner is associate professor of anesthesia, Harvard Medical School, and program director, Critical Care Anesthesiology Fellowship, Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Einbinder
- J. Einbinder is instructor of medicine, Harvard Medical School, member, Division of General Internal Medicine, Brigham and Women's Hospital, and assistant vice president, Advanced Data Analytics and Coding, Controlled Risk Insurance Company, Boston, Massachusetts
| | - Joshua P Metlay
- J.P. Metlay is professor, Department of Medicine, Harvard Medical School, professor of health policy and management, Harvard School of Public Health, and chief, General Internal Medicine Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth Mort
- E. Mort is assistant professor in health care policy, Harvard Medical School, member, Division of General Internal Medicine, and chief quality officer, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
41
|
Classification of Current Procedural Terminology Codes from Electronic Health Record Data Using Machine Learning. Anesthesiology 2020; 132:738-749. [PMID: 32028374 DOI: 10.1097/aln.0000000000003150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Accurate anesthesiology procedure code data are essential to quality improvement, research, and reimbursement tasks within anesthesiology practices. Advanced data science techniques, including machine learning and natural language processing, offer opportunities to develop classification tools for Current Procedural Terminology codes across anesthesia procedures. METHODS Models were created using a Train/Test dataset including 1,164,343 procedures from 16 academic and private hospitals. Five supervised machine learning models were created to classify anesthesiology Current Procedural Terminology codes, with accuracy defined as first choice classification matching the institutional-assigned code existing in the perioperative database. The two best performing models were further refined and tested on a Holdout dataset from a single institution distinct from Train/Test. A tunable confidence parameter was created to identify cases for which models were highly accurate, with the goal of at least 95% accuracy, above the reported 2018 Centers for Medicare and Medicaid Services (Baltimore, Maryland) fee-for-service accuracy. Actual submitted claim data from billing specialists were used as a reference standard. RESULTS Support vector machine and neural network label-embedding attentive models were the best performing models, respectively, demonstrating overall accuracies of 87.9% and 84.2% (single best code), and 96.8% and 94.0% (within top three). Classification accuracy was 96.4% in 47.0% of cases using support vector machine and 94.4% in 62.2% of cases using label-embedding attentive model within the Train/Test dataset. In the Holdout dataset, respective classification accuracies were 93.1% in 58.0% of cases and 95.0% among 62.0%. The most important feature in model training was procedure text. CONCLUSIONS Through application of machine learning and natural language processing techniques, highly accurate real-time models were created for anesthesiology Current Procedural Terminology code classification. The increased processing speed and a priori targeted accuracy of this classification approach may provide performance optimization and cost reduction for quality improvement, research, and reimbursement tasks reliant on anesthesiology procedure codes.
Collapse
|
42
|
Feng JE, Anoushiravani AA, Schoof LH, Gabor JA, Padilla J, Slover J, Schwarzkopf R. Barriers to Revision Total Hip Service Lines: A Surgeon's Perspective Through a Deterministic Financial Model. Clin Orthop Relat Res 2020; 478:1657-1666. [PMID: 32574471 PMCID: PMC7310415 DOI: 10.1097/corr.0000000000001273] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 04/01/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs. QUESTIONS/PURPOSES Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA? METHODS Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts. RESULTS Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day. CONCLUSIONS In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists. LEVEL OF EVIDENCE Level III, economic and decision analysis.
Collapse
Affiliation(s)
- James E Feng
- J. E. Feng, L. H. Schoof, J. A. Gabor, J. Padilla, J. Slover, R. Schwarzkopf, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
- J. E. Feng, Department of Orthopedic Surgery, Beaumont Health, Royal Oak, MI, USA
| | - Afshin A Anoushiravani
- A. A. Anoushiravani, Department of Orthopedic Surgery, Albany Medical Center, Albany, NY, USA
| | - Lauren H Schoof
- J. E. Feng, L. H. Schoof, J. A. Gabor, J. Padilla, J. Slover, R. Schwarzkopf, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Jonathan A Gabor
- J. E. Feng, L. H. Schoof, J. A. Gabor, J. Padilla, J. Slover, R. Schwarzkopf, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Jorge Padilla
- J. E. Feng, L. H. Schoof, J. A. Gabor, J. Padilla, J. Slover, R. Schwarzkopf, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
- J. Padilla, Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra Northwell Health, East Garden City, NY, USA
| | - James Slover
- J. E. Feng, L. H. Schoof, J. A. Gabor, J. Padilla, J. Slover, R. Schwarzkopf, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- J. E. Feng, L. H. Schoof, J. A. Gabor, J. Padilla, J. Slover, R. Schwarzkopf, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| |
Collapse
|
43
|
Agarwal P, Glauser G, Malhotra NR. In Reply: Association of Overlapping Neurosurgery With Patient Outcomes at a Large Academic Medical Center. Neurosurgery 2020; 86:E586. [PMID: 32133528 DOI: 10.1093/neuros/nyaa048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Gregory Glauser
- Department of Neurosurgery Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Department of Neurosurgery Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| |
Collapse
|
44
|
Kheterpal S, Vaughn MT, Dubovoy TZ, Shah NJ, Bash LD, Colquhoun DA, Shanks AM, Mathis MR, Soto RG, Bardia A, Bartels K, McCormick PJ, Schonberger RB, Saager L. Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis. Anesthesiology 2020; 132:1371-1381. [PMID: 32282427 PMCID: PMC7864000 DOI: 10.1097/aln.0000000000003256] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications. METHODS Twelve U.S. Multicenter Perioperative Outcomes Group hospitals were included in a multicenter observational matched-cohort study of surgical cases between January 2014 and August 2018. Adult patients undergoing elective inpatient noncardiac surgical procedures with general anesthesia and endotracheal intubation receiving a nondepolarizing neuromuscular blockade agent and reversal were included. Exact matching criteria included institution, sex, age, comorbidities, obesity, surgical procedure type, and neuromuscular blockade agent (rocuronium vs. vecuronium). Other preoperative and intraoperative factors were compared and adjusted in the case of residual imbalance. The composite primary outcome was major postoperative pulmonary complications, defined as pneumonia, respiratory failure, or other pulmonary complications (including pneumonitis; pulmonary congestion; iatrogenic pulmonary embolism, infarction, or pneumothorax). Secondary outcomes focused on the components of pneumonia and respiratory failure. RESULTS Of 30,026 patients receiving sugammadex, 22,856 were matched to 22,856 patients receiving neostigmine. Out of 45,712 patients studied, 1,892 (4.1%) were diagnosed with the composite primary outcome (3.5% sugammadex vs. 4.8% neostigmine). A total of 796 (1.7%) patients had pneumonia (1.3% vs. 2.2%), and 582 (1.3%) respiratory failure (0.8% vs. 1.7%). In multivariable analysis, sugammadex administration was associated with a 30% reduced risk of pulmonary complications (adjusted odds ratio, 0.70; 95% CI, 0.63 to 0.77), 47% reduced risk of pneumonia (adjusted odds ratio, 0.53; 95% CI, 0.44 to 0.62), and 55% reduced risk of respiratory failure (adjusted odds ratio, 0.45; 95% CI, 0.37 to 0.56), compared to neostigmine. CONCLUSIONS Among a generalizable cohort of adult patients undergoing inpatient surgery at U.S. hospitals, the use of sugammadex was associated with a clinically and statistically significant lower incidence of major pulmonary complications.
Collapse
Affiliation(s)
- Sachin Kheterpal
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (S.K., M.T.V., T.Z.D., N.J.S., D.A.C., A.M.S., M.R.M., L.S.) Center for Observational and Real World Evidence, Merck & Co. Inc, Kenilworth, New Jersey (L.D.B.) Department of Anesthesiology, Beaumont Health, Royal Oak, Michigan (R.G.S.) Department of Anesthesiology, Yale University, New Haven, Connecticut (A.B., R.B.S.) Department of Anesthesiology, University of Colorado, Aurora, Colorado (K.B.) Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York (P.J.M.). Current position: Department of Anesthesiology, University Medical Center Goettingen, Lower Saxony, Germany (L.S.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Banja J. Reasonable Persons, Autonomous Persons, and Lady Hale: Determining a Standard for Risk Disclosure. Hastings Cent Rep 2020; 50:25-34. [PMID: 32311125 DOI: 10.1002/hast.1099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Among various kinds of disclosures typically required in research as well as in clinical scenarios, risk information figures prominently. A key question is, what kinds of risk information would the reasonable person want to know? I will argue, however, that the reasonable person construct is and always has been incapable of settling this very question. After parsing the nebulous if not "contentless" character of the reasonable person, I will explain how Western courts have actually adjudicated cases of "negligent nondisclosure," that is, cases in which patient-plaintiffs allege that their informed consent rights were violated by the failure of their health providers to inform them of reasonably foreseeable risks that subsequently materialized. To support my argument, I will scrutinize the landmark decision by the United Kingdom's Supreme Court in Montgomery v. Lanarkshire Health Board and, in particular, Justice Brenda Hale's concurrence.
Collapse
|
46
|
Glauser G, Osiemo B, Goodrich S, McClintock SD, Weber KL, Levin LS, Malhotra NR. Assessment of Short-Term Patient Outcomes Following Overlapping Orthopaedic Surgery at a Large Academic Medical Center. J Bone Joint Surg Am 2020; 102:654-663. [PMID: 32058352 DOI: 10.2106/jbjs.19.00554] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Overlapping surgery is a long-standing practice that has not been well studied. The aim of this study was to assess whether overlapping surgery is associated with untoward outcomes for orthopaedic patients. METHODS Coarsened exact matching was used to assess the impact of overlap on outcomes among elective orthopaedic surgical interventions (n = 18,316) over 2 years (2014 and 2015) at 1 health-care system. Overlap was categorized as any overlap, and subcategories of exclusively beginning overlap and exclusively end overlap. Study subjects were matched on the Charlson comorbidity index score, duration of surgery, surgical costs, body mass index, length of stay, payer, and race, among others. Serious unanticipated events were studied. RESULTS A total of 3,395 patients had any overlap and were matched (a match rate of 90.8% of 3,738). For beginning and end overlap, matched groups were created, with a match rate of 95.2% of 1043 and 94.7% of 863, respectively. Among matched patients, any overlap did not predict an unanticipated return to surgery at 30 days (8.2% for any overlap and 8.3% for no overlap; p = 0.922) or 90 days (14.1% and 14.1%, respectively; p = 1.000). Patients who had surgery with any overlap demonstrated no difference compared with controls with respect to reoperation, readmission, or emergency room (ER) visits at 30 or 90 days (a reoperation rate of 3.1% and 3.2%, respectively [p = 0.884] at 30 days and 4.2% and 3.5% [p = 0.173] at 90 days; a readmission rate of 10.3% and 11.0% [p = 0.352] at 30 days and 5.5% and 5.2% [p = 0.570] at 90 days; and an ER visit rate of 5.2% and 4.6% [p = 0.276] at 30 days and 4.8% and 4.3% [p = 0.304] at 90 days). Patients with surgical overlap showed reduced mortality compared with controls during follow-up (1.8% and 2.6%, respectively; p = 0.029). Patients with beginning and/or end overlap had a similar lack of association with serious unanticipated events; however, patients with end overlap showed an increased unexpected rate of return to the operating room after reoperation at 90 days (13.3% versus 9.7%; p = 0.015). CONCLUSIONS Nonconcurrent overlapping surgery was not associated with adverse outcomes in a large, matched orthopaedic surgery population across 1 academic health system. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Gregory Glauser
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Osiemo
- McKenna EpiLog Program in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania.,The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Stephen Goodrich
- McKenna EpiLog Program in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania.,The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Scott D McClintock
- The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Kristy L Weber
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - L Scott Levin
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
47
|
Shakir S, Kozak GM, Nathan SL, Davis H, Whitely C, Broach RB, Fosnot J. The Role of a Resident Aesthetic Clinic in Addressing the Trainee Autonomy Gap. Aesthet Surg J 2020; 40:NP301-NP311. [PMID: 31724036 DOI: 10.1093/asj/sjz324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. OBJECTIVES The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. METHODS A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. RESULTS In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. CONCLUSIONS The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.
Collapse
Affiliation(s)
- Sameer Shakir
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Geoffrey M Kozak
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Shelby L Nathan
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Harrison Davis
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Cutler Whitely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
48
|
Glauser G, Goodrich S, McClintock SD, Dimentberg R, Guzzo TJ, Malhotra NR. Evaluation of Short-term Outcomes Following Overlapping Urologic Surgery at a Large Academic Medical Center. Urology 2020; 138:30-36. [DOI: 10.1016/j.urology.2019.12.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/21/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022]
|
49
|
Corey KM, Helmkamp J, Simons M, Curtis L, Marsolo K, Balu S, Gao M, Nichols M, Watson J, Mureebe L, Kirk AD, Sendak M. Assessing Quality of Surgical Real-World Data from an Automated Electronic Health Record Pipeline. J Am Coll Surg 2020; 230:295-305.e12. [DOI: 10.1016/j.jamcollsurg.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 11/17/2022]
|
50
|
Glauser G, Goodrich S, McClintock SD, Szeto WY, Atluri P, Acker MA, Malhotra NR. Association of overlapping cardiac surgery with short-term patient outcomes. J Thorac Cardiovasc Surg 2020; 162:155-164.e2. [PMID: 32014329 DOI: 10.1016/j.jtcvs.2019.11.136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 11/14/2019] [Accepted: 11/29/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study seeks to assess the safety of overlap in cardiac surgery. METHODS Coarsened exact matching was used to assess the impact of overlap on outcomes among cardiac surgical interventions (n = 4463) over 2 years (2014-2016). Overlap was categorized as any, beginning, or end overlap. Study subjects were matched 1:1 on 11 variables, including Charlson comorbidity score, surgical costs, body mass index, length of postoperative hospitalization, and race, among others. Serious unanticipated events were studied, including readmission, unplanned return to the operating room, and mortality. RESULTS A total of 984 patients had any overlap and were matched to similar patients without overlap (n = 1501). For beginning/end overlap, separate matched groups were created (n = 462, n = 329 patients, respectively). Among matched patients, any overlap did not predict unanticipated return to surgery at 30 or 90 days. Any overlap did not predict increased readmission, reoperation, or emergency department visits at 30 or 90 days. Overlap did not predict higher rates of death over follow-up. Beginning/end overlap had results similar to any overlap. CONCLUSIONS Nonconcurrent, overlapping surgery is not associated with an increase in adverse outcomes in a large, matched cardiac surgery population.
Collapse
Affiliation(s)
- Gregory Glauser
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Stephen Goodrich
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, Pa; The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pa
| | - Scott D McClintock
- The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| |
Collapse
|