1
|
Bhat MY, Ali S, Gupta S, Ahmad Y, Lattoo MR, Ansari MJ, Patel A, Haq MFU, Parveen S. Feasibility, safety and effectiveness of the enhanced recovery after surgery protocol in patients undergoing liver resection. Ann Hepatobiliary Pancreat Surg 2024; 28:344-349. [PMID: 38825759 PMCID: PMC11341879 DOI: 10.14701/ahbps.24-034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/09/2024] [Accepted: 04/18/2024] [Indexed: 06/04/2024] Open
Abstract
Backgrounds/Aims The implementation of enhanced recovery after surgery (ERAS) protocols has demonstrated significant advantages for patients by mitigating surgical stress and expediting recovery across a spectrum of surgical procedures worldwide. This investigation seeks to assess the effectiveness of the ERAS protocol specifically in the context of major liver resections within our geographical region. Methods Our department conducted retrospective analysis of prospectively collected data, gathered from consenting individuals who underwent liver resections from January 2018 to December 2023. The assessment encompassed baseline characteristics, preoperative indications, surgical outcomes, and postoperative complications among patients undergoing liver surgery. Results Among the included 184 patients (73 standard care, 111 ERAS program), the baseline characteristics were similar. Median postoperative hospital stay differed significantly: 5 days (range: 3-13 days) in ERAS, and 11 days (range: 6-22 days) in standard care (p < 0.001). Prophylactic abdominal drainage was less in ERAS (54.9%) than in standard care (86.3%, p < 0.001). Notably, in ERAS, 88.2% initiated enteral feeding orally on postoperative day 1, significantly higher than in standard care (47.9%, p < 0.001). Early postoperative mobilization was more common in ERAS (84.6%) than in standard care (36.9%, p < 0.001). Overall complication rates were 21.9% in standard care, and 8.1% in ERAS (p = 0.004). Conclusions Our investigation highlights the merits of ERAS protocol; adherence to its diverse components results in significant reduction in hospital length of stay, and reduced occurrence of postoperative complications, improving short-term recovery post liver resection.
Collapse
Affiliation(s)
- Mohamad Younis Bhat
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sadaf Ali
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sonam Gupta
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Younis Ahmad
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mohd Riyaz Lattoo
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mohammad Juned Ansari
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ajay Patel
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mohd Fazl ul Haq
- Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Shaheena Parveen
- Department of Medical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| |
Collapse
|
2
|
Munir MM, Woldesenbet S, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Association of Hospital Market Competition with Outcomes of Complex Cancer Surgery. Ann Surg Oncol 2024; 31:4371-4380. [PMID: 38634960 PMCID: PMC11164796 DOI: 10.1245/s10434-024-15278-w] [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: 01/05/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The association of hospital market competition, financial costs, and quality of oncologic care has not been well-defined. This study sought to evaluate variations in patient outcomes and financial expenditures after complex cancer surgery across high- and low-competition markets. METHODS Medicare 100% Standard Analytic Files were used to identify patients with lung, esophageal, gastric, hepatopancreaticobiliary, or colorectal cancer who underwent surgical resection between 2018 and 2021. Data were merged with the annual hospital survey database, and the hospital market Herfindahl-Hirschman index was used to categorize hospitals into low- and high-concentration markets. Multi-level, multivariable regression models adjusting for patient characteristics (i.e., age, sex, comorbidities, and social vulnerability), year of procedure, and hospital factors (i.e., case volume, nurse-bed ratio, and teaching status) were used to assess the association between hospital market competition and outcomes. RESULTS Among 117,641 beneficiaries who underwent complex oncologic surgery, the mean age was 73.8 ± 6.1 years, and approximately one-half of the cohort was male (n = 56,243, 47.8%). Overall, 63.8% (n = 75,041) of the patients underwent care within a high-competition market. Notably, there was marked geographic variation relative to market competition. High versus low market-competition hospitals were more likely to be in high social vulnerability areas (35.1 vs 27.5%; p < 0.001), as well as care for racial/ethnic minority individuals (13.8 vs 7.7%; p < 0.001), and patients with more comorbidities (≥ 2 Elixhauser comorbidities: 63.1 vs 61.1%; p < 0.001). In the multivariable analysis, treatment at hospitals in high- versus low-competition markets was associated with lower odds of achieving a textbook outcome (odds ratio, 0.95; 95% confidence interval, 0.91-0.99; p = 0.009). Patients at high-competition hospitals had greater mean index hospitalization costs ($19,462.2 [16211.9] vs $18,844.7 [14994.7]) and 90-day post-discharge costs ($7807.8 [15431.3] vs $7332.8 [14038.2]) (both p < 0.001) than individuals at low-competition hospitals. CONCLUSIONS Hospital market competition was associated with poor achievement of an optimal postoperative outcome and greater hospitalization costs.
Collapse
Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan Tsai
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
| |
Collapse
|
3
|
Akhtar AB, Ur Rehman S, Ur Rehman S, Bari H. Retrospective Analysis of Postoperative Nonhepatic Outcomes Following Major Liver Resection. Cureus 2024; 16:e60311. [PMID: 38883004 PMCID: PMC11176564 DOI: 10.7759/cureus.60311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/18/2024] Open
Abstract
Background Liver surgery is a major and challenging procedure for the surgeon, the anesthetist, and the patient. The objective of this study was to evaluate the postoperative nonhepatic complications of patients undergoing liver resection surgery with perioperative factors. Methods We retrospectively analyzed 79 patients who underwent liver resection surgeries at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan, from July 2015 to December 2022. Results The mean age at the time of surgery was 53 years (range: 3-77 years), and the mean BMI was 26.43 (range: 15.72-38.0 kg/m2). Of the total patients, 44.3 % (n = 35) had no comorbidities, 26.6% (n=21) had one comorbidity, and 29.1% (n=23) had two or more comorbidities. Patients in whom the blood loss was more than 375 ml required postoperative oxygen inhalation with a significant relative risk of 2.6 (p=0.0392) and an odds ratio of 3.5 (p=0.0327). Similarly, patients who had a surgery time of more than five hours stayed in the hospital for more than seven days, with a statistically significant relative risk of 2.7 (p=0.0003) and odds ratio of 7.64 (p=0.0001). The duration of surgery was also linked with the possibility of requiring respiratory support, with a relative risk of 5.0 (p=0.0134) and odds ratio of 5.73 (p=0.1190). Conclusion Patients in our cohort who had a prolonged duration of surgery received an increased amount of fluids, and a large volume of blood loss was associated with prolonged stay in the ICU (>2 days), hospital admission (>7 days), ICU readmission, and increased incidence of cardiorespiratory, neurological, and renal disturbances postoperatively.
Collapse
Affiliation(s)
- Ahmed Bilal Akhtar
- Anesthesia and Critical Care, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Saad Ur Rehman
- Anesthesiology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | | | - Hassaan Bari
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| |
Collapse
|
4
|
Marckmann M, Krarup PM, Henriksen NA, Christoffersen MW, Jensen KK. Enhanced recovery after robotic ventral hernia repair: factors associated with overnight stay in hospital. Hernia 2024; 28:223-231. [PMID: 37668820 PMCID: PMC10891254 DOI: 10.1007/s10029-023-02871-3] [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: 06/06/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols lead to reduced post-operative stay and improved outcomes after most types of abdominal surgery. Little is known about the optimal post-operative protocol after robotic ventral hernia repair (RVHR), including the potential limits of outpatient surgery. We report the results of an ERAS protocol after RVHR aiming to identify factors associated with overnight stay in hospital, as well as patient-reported pain levels in the immediate post-operative period. METHODS This was a prospective cohort study of consecutive patients undergoing RVHR. Patients were included in a prospective database, registering patient characteristics, operative details, pain and fatigue during the first 3 post-operative days and pre- and 30-day post-operative hernia-related quality of life, using the EuraHS questionnaire. RESULTS A total of 109 patients were included, of which 66 (61%) underwent incisional hernia repair. The most performed procedure was TARUP (robotic transabdominal retromuscular umbilical prosthetic hernia repair) (60.6%) followed by bilateral roboTAR (robotic transversus abdominis release) (19.3%). The mean horizontal fascial defect was 4.8 cm, and the mean duration of surgery was 141 min. In total, 78 (71.6%) patients were discharged on the day of surgery, and factors associated with overnight stay were increasing fascial defect area, longer duration of surgery, and transverse abdominis release. There was no association between post-operative pain and overnight hospital stay. The mean EuraHS score decreased significantly from 38.4 to 6.4 (P < 0.001). CONCLUSION An ERAS protocol after RVHR was associated with a high rate of outpatient procedures with low patient-reported pain levels.
Collapse
Affiliation(s)
- M Marckmann
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark.
| | - P-M Krarup
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - N A Henriksen
- Department of hepatic and gastrointestinal diseases, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M W Christoffersen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - K K Jensen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
5
|
Deslarzes P, Jurt J, Larson DW, Blanc C, Hübner M, Grass F. Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice. J Clin Med 2024; 13:801. [PMID: 38337495 PMCID: PMC10856154 DOI: 10.3390/jcm13030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.
Collapse
Affiliation(s)
- Philip Deslarzes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Jonas Jurt
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - David W. Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Catherine Blanc
- Department of Anesthesiology, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland;
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| |
Collapse
|
6
|
Madsen HJ, Lambert-Kerzner A, Mucharsky E, Gergen AK, Dyas AR, McCarter M, Stewart C, Pratap A, Mitchell J, Randhawa S, Meguid RA. Barriers and Facilitators in Implementation of an Esophagectomy Care Pathway: a Qualitative Analysis. J Gastrointest Surg 2023; 27:213-221. [PMID: 36443554 PMCID: PMC9707093 DOI: 10.1007/s11605-022-05537-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/01/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION A new postoperative esophagectomy care pathway was recently implemented at our institution. Practice pattern change among provider teams can prove challenging; therefore, we sought to study the barriers and facilitators toward pathway implementation at the provider level. METHODS This qualitative study was guided by the Theoretical Domains Framework (TDF) to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen in-depth interviews were conducted with providers involved with the pathway. Matrix analysis was used to analyze the data. RESULTS Providers included attending surgeons (n = 6), advanced practice providers (n = 8), registered dietitian (n = 1), and clinic staff (n = 1). TDF domains that were salient across our findings included knowledge, beliefs about consequences, social influences, and environmental context and resources. Identified facilitators included were electronic health record tools, such as note templates including pathway components and a pathway-specific order set, patient satisfaction, and preliminary data indicating clinical benefits such as a reduced anastomotic leak rate. The major barrier reported was a hesitance to abandon previous practice patterns, most prevalent at the attending surgeon level. CONCLUSION The TDF enabled us to identify and understand the individuals' perceived barriers and facilitators toward adoption and implementation of a postoperative esophagectomy pathway. This analysis can help guide and improve adoption of surgical patient care pathways among providers.
Collapse
Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA. .,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ellison Mucharsky
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anna K Gergen
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Camille Stewart
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Akshay Pratap
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Mitchell
- Department of Surgery, Division of Thoracic Surgery, University of Colorado, Aurora, CO, USA
| | - Simran Randhawa
- Department of Surgery, Division of Thoracic Surgery, University of Colorado, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, Division of Thoracic Surgery, University of Colorado, Aurora, CO, USA
| |
Collapse
|
7
|
Enhanced recovery after surgery in laparoscopic major liver resection: A propensity score matching analysis. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
8
|
Daghash H, Abdullah KL, Ismail MD. The Effect of Care Pathways on Coronary Care Nurses: A Preliminary Study. Qual Manag Health Care 2022; 31:114-121. [PMID: 35180731 DOI: 10.1097/qmh.0000000000000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES A care pathway is a structured care plan based on best clinical practice for a particular patient group. It reorganizes a complex process by providing structured, standardized care and supportive multidisciplinary teamwork. Although care pathways are used worldwide, the impact and benefit of a care pathway for coronary care practices have been minimally debated. This preliminary study aimed to examine the effect of a care pathway on the autonomy, teamwork, and burnout levels among coronary care nurses in a tertiary hospital. METHODS A preliminary study was conducted using a pre/posttest one-group quasi-experimental design. A self-administered questionnaire was provided to 37 registered nurses from the cardiac ward of a tertiary hospital. The care pathway was developed on the basis of the current literature, local guidelines, and expert panel advice. The autonomy, teamwork, and burnout levels at the beginning and 4 months after disseminating the care pathway were measured. Implementing the care pathway included educational sessions, training in using the care pathway, and site visits to monitor nursing practices. RESULTS Most of the respondents were female (94.6%; n = 35), the median age of the respondents was 26.5 years (interquartile range [IQR] = 23-31), and the median length of the clinical experience was 4 years (IQR = 2-8). A statistically significant reduction in the mean burnout score was observed (mean of 58.12 vs 52.69, P < .05). A slight improvement in autonomy level was found, although it was not statistically significant. No statistically significant improvement was found in the teamwork levels. CONCLUSION The care pathway was associated with reduced nurse burnout. The results showed a slight improvement in autonomy level among coronary care nurses after implementing the care pathway. From a practical viewpoint, the current study can help policy makers and managers reduce burnout. This study highlights the importance of using care pathways as a tool to reorganize the care process and improve the working environment. Managers must support nursing decisions and provide continuous education to enhance nurses' autonomy, which may increase understanding of respective roles, leading to higher levels of teamwork. However, with a small sample size, caution must be applied, as the findings might not be generalizable.
Collapse
Affiliation(s)
- Hanan Daghash
- Department of Nursing Science, Al-Ghad International Colleges for Applied Medical Sciences, Tabuk, Saudi Arabia (Ms Daghash); Department of Nursing, School of Medical and Life Sciences, Sunway University, Bandar Sunway, Malaysia (Dr Abdullah); and University Kebangsaan Malaysia, Malaysia (Dr Abdullah); Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (Dr Ismail)
| | | | | |
Collapse
|
9
|
Lei L. Observation on the Effect of Intelligent Machine-Assisted Surgery and Perioperative Nursing. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:6264441. [PMID: 35356612 PMCID: PMC8959971 DOI: 10.1155/2022/6264441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 11/24/2022]
Abstract
Orthopedic surgery and care during the perioperative period are the key to the treatment of orthopedic diseases, which can quickly and effectively treat orthopedic diseases and can quickly recover during the perioperative period. Therefore, this paper focuses on the observation of the effect of intelligent machine-assisted surgery and perioperative care, combined with smart wearable devices and C-arm camera calibration; the details of the bone surgery are assisted by the machine, and then the recognition ability is accelerated by writing into the digital bone bank. Based on machine vision, CNN training and learning are designed to design a machine-assisted perioperative nursing method. This paper also designed a bone surgery test experiment and perioperative adverse event data analysis, combined with the data obtained from the experiment, designed a comparison experiment with traditional surgery and perioperative nursing. The experimental results show that the success rate of machine-assisted surgery is increased by nearly 2%-15% compared with traditional surgery; and the rehabilitation degree of machine-assisted perioperative nursing is 15.83% higher than that of traditional perioperative nursing.
Collapse
Affiliation(s)
- Liping Lei
- Operating Room, The Second Affiliated Hospital of University of South China, Hengyang 421001, Hunan, China
| |
Collapse
|
10
|
Witt RG, Cope B, Chiang YJ, Newhook T, Lillemoe H, Tzeng CWD, Chen IB, Fisher SB, Lucci A, Wargo JA, Lee JE, Ross MI, Gershenwald JE, Robinson J, Keung EZ. Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy. J Surg Oncol 2022; 125:719-729. [PMID: 34904258 PMCID: PMC9108995 DOI: 10.1002/jso.26768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy. METHODS A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed. RESULTS Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001). CONCLUSIONS Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.
Collapse
Affiliation(s)
- Russell G. Witt
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Brandon Cope
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Timothy Newhook
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Heather Lillemoe
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Iris B. Chen
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Sarah B. Fisher
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Anthony Lucci
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jennifer A. Wargo
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Merrick I. Ross
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Gershenwald
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Justine Robinson
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Emily Z. Keung
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| |
Collapse
|
11
|
Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
Collapse
Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Kawaguchi C, Hokuto D, Yasuda S, Yoshikawa T, Kamitani N, Matsuo Y, Sho M. Advantages of skin closure with subcuticular suture for liver resection on postoperative and cosmetic outcomes: a propensity matched analysis. Langenbecks Arch Surg 2022; 407:1121-1129. [PMID: 34988640 DOI: 10.1007/s00423-021-02388-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The effects of subcuticular sutures on postoperative and cosmetic outcomes in patients who underwent liver resection have not been well studied. Here, we investigated the advantages of subcuticular suture compared to skin stapler regarding open liver resection. METHODS We assessed 342 patients who underwent liver resection at Nara Medical University between 2008 and 2015. They were divided into two groups: subcuticular suture and staple groups. Baseline characteristics and perioperative outcomes were retrospectively compared using one-to-one propensity score matching analysis. RESULTS In this period, 179 patients underwent skin closure with subcuticular sutures and 163 patients underwent skin closure with staples. After propensity matching, 85 pairs of cases were matched. The incidence of wound infection was similar in the two groups (3.5% in the subcuticular suture group and 9.4% in the staple group; p = 0.119). The length of hospital stay was significantly shorter in the subcuticular suture group than in the staple group (10 days vs 15 days; p < 0.001). In addition, the rate of patients who were discharged within 7 days after surgery was statistically higher in the subcuticular group (21.1% vs 3.5%, p = 0.001). Hypertrophic scar 6 months after surgery was significantly less frequent in the subcuticular group (9.4% vs 25.9%, p = 0.010). CONCLUSION Subcuticular sutures might be advantageous for liver surgery reducing length of hospital stay and proportion of hypertrophic scar.
Collapse
Affiliation(s)
- Chihiro Kawaguchi
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan.
| | - Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Takahiro Yoshikawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Naoki Kamitani
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| |
Collapse
|
13
|
Langnas EM, Matthay ZA, Lin A, Harbell MW, Croci R, Rodriguez-Monguio R, Chen CL. Enhanced recovery after surgery protocol and postoperative opioid prescribing for cesarean delivery: an interrupted time series analysis. Perioper Med (Lond) 2021; 10:38. [PMID: 34775985 PMCID: PMC8591895 DOI: 10.1186/s13741-021-00209-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/18/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. However, the association between ERAS implementation and discharge opioid prescribing practices is unclear. STUDY DESIGN We conducted a retrospective observational quasi-experimental study of opioid-naïve patients aged 18+ undergoing cesarean delivery between February 2015 and December 2019 at a large academic center. An interrupted time series analysis (ITSA) was used to model the changes in pain medication prescribing associated with the implementation of ERAS to account for pre-existing temporal trends. RESULTS Among the 1473 patients (out of 2249 total) who underwent cesarean delivery after ERAS implementation, 80.72% received a discharge opioid prescription vs. 95.36% at baseline. Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p<0.01). There was a level shift of 35 more OME prescribed (p<0.01), followed by a monthly decrease of 1.4 OMEs per month after ERAS implementation (p<0.01). Among those who received a prescription, 61.35% received a total daily dose greater than 90 OME compared to 11.35% pre-implementation (p<0.01), while prescriptions with a total daily dose less than 50 OME decreased from 79.86 to 25.85% after ERAS implementation(p<0.01). CONCLUSION Although ERAS implementation reduced the overall proportion of patients receiving a discharge opioid prescription after cesarean delivery, for the subset of patients receiving an opioid prescription, ERAS implementation may have inadvertently increased the prescribing of daily doses greater than 90 OME. This finding highlights the importance of early and continued evaluation after new policies are implemented.
Collapse
Affiliation(s)
- E M Langnas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.
| | - Z A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, USA
| | - A Lin
- UCSF School of Medicine, University of California, San Francisco, San Francisco, USA
| | - M W Harbell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - R Croci
- UCSF Health Informatics, University of California, San Francisco, San Francisco, USA
| | - R Rodriguez-Monguio
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, USA.,Medication Outcomes Center, University of California, San Francisco, San Francisco, USA.,Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, San Francisco, USA
| | - C L Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.,Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, San Francisco, USA
| |
Collapse
|
14
|
Reeves JJ, Pageler NM, Wick EC, Melton GB, Tan YHG, Clay BJ, Longhurst CA. The Clinical Information Systems Response to the COVID-19 Pandemic. Yearb Med Inform 2021; 30:105-125. [PMID: 34479384 PMCID: PMC8416224 DOI: 10.1055/s-0041-1726513] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The year 2020 was predominated by the coronavirus disease 2019 (COVID-19) pandemic. The objective of this article is to review the areas in which clinical information systems (CIS) can be and have been utilized to support and enhance the response of healthcare systems to pandemics, focusing on COVID-19. METHODS PubMed/MEDLINE, Google Scholar, the tables of contents of major informatics journals, and the bibliographies of articles were searched for studies pertaining to CIS, pandemics, and COVID-19 through October 2020. The most informative and detailed studies were highlighted, while many others were referenced. RESULTS CIS were heavily relied upon by health systems and governmental agencies worldwide in response to COVID-19. Technology-based screening tools were developed to assist rapid case identification and appropriate triaging. Clinical care was supported by utilizing the electronic health record (EHR) to onboard frontline providers to new protocols, offer clinical decision support, and improve systems for diagnostic testing. Telehealth became the most rapidly adopted medical trend in recent history and an essential strategy for allowing safe and effective access to medical care. Artificial intelligence and machine learning algorithms were developed to enhance screening, diagnostic imaging, and predictive analytics - though evidence of improved outcomes remains limited. Geographic information systems and big data enabled real-time dashboards vital for epidemic monitoring, hospital preparedness strategies, and health policy decision making. Digital contact tracing systems were implemented to assist a labor-intensive task with the aim of curbing transmission. Large scale data sharing, effective health information exchange, and interoperability of EHRs remain challenges for the informatics community with immense clinical and academic potential. CIS must be used in combination with engaged stakeholders and operational change management in order to meaningfully improve patient outcomes. CONCLUSION Managing a pandemic requires widespread, timely, and effective distribution of reliable information. In the past year, CIS and informaticists made prominent and influential contributions in the global response to the COVID-19 pandemic.
Collapse
Affiliation(s)
- J. Jeffery Reeves
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Natalie M. Pageler
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Elizabeth C. Wick
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Genevieve B. Melton
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Yu-Heng Gamaliel Tan
- Department of Orthopedics, Chief Medical Information Officer, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Brian J. Clay
- Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
| | - Christopher A. Longhurst
- Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
| |
Collapse
|
15
|
Pawlik TM. Editorial: Enhanced Recovery after Surgery Pathways: Improving the Perioperative Experience and Outcomes of Cancer Surgery Patients. Ann Surg Oncol 2021; 28:6929-6931. [PMID: 34191179 DOI: 10.1245/s10434-021-10393-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, Columbus, USA.
| |
Collapse
|
16
|
Perioperative Nursing Care of Vascular Decompression for Trigeminal Neuralgia under AR Medical Technology. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:9921094. [PMID: 34249297 PMCID: PMC8238585 DOI: 10.1155/2021/9921094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022]
Abstract
AR technology, also known as AR or virtual reality, refers to a technology that combines and allows interaction of the virtual world on the display system with the real world through the position and angle of the camera video and image analysis technology. This technology is different from VR technology, and its characteristics can be easily explained as follows: when using AR technology, the user's eyes can see not only the real world but also the virtual world derived from the computer through things in the real world. At present, AR has been widely used in education, engineering, entertainment, and medical fields. In order to provide better perioperative care and bring patients a good nursing experience, this article mainly introduces the perioperative care of vascular decompression in the treatment of trigeminal neuralgia by augmented reality medical technology, in order to provide better care for patients with trigeminal neuralgia. This article proposes the perioperative nursing research method of vascular decompression for the treatment of trigeminal neuralgia under AR medical technology, including an overview of trigeminal neuralgia, perioperative related research, and AR medical technology algorithms, and designs related experiments to study whether AR medical technology can bring good news to nursing. Experimental results show that 96% of patients believe that with the enhancement of realistic medical technology, perioperative vascular decompression care for trigeminal neuralgia can help them recover faster and can be gradually popularized.
Collapse
|
17
|
Beal EW, Reyes JPC, Denham Z, Abdel-Rasoul M, Rasoul E, Humeidan ML. Survey of provider perceptions of enhanced recovery after surgery and perioperative surgical home protocols at a tertiary care hospital. Medicine (Baltimore) 2021; 100:e26079. [PMID: 34128845 PMCID: PMC8213318 DOI: 10.1097/md.0000000000026079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/05/2021] [Indexed: 01/04/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) and perioperative surgical home (PSH) initiatives are widely utilized to improve quality of patient care. Despite their established benefits, implementation still has significant barriers. We developed a survey for perioperative clinicians to gather information on perception and knowledge of ERAS/PSH programs to guide future expansion of these programs at our institution. The survey included questions about familiarity with ERAS/PSH and perceived value, perceived barriers to protocol implementation, preferred learning methods and prioritization of various ERAS/PSH protocol elements into care delivery and provider education. Faculty surgeons and anesthesiologists, in addition to advanced practice nurses and postgraduate physician trainees in the Departments of Surgery and Anesthesiology were asked to complete the survey. Overall survey participation was 25% (223/888). About half of survey respondents had provided care to a patient on an ERAS/PSH protocol, and a majority felt at least somewhat knowledgeable about ERAS/PSH protocols. Perception of the value of ERAS/PSH was positive. Participants were enthusiastic about on-going learning, with multimodal pain management being the topic of most interest and learning by direct participation in care of protocol patients being the favored educational approach. A significant majority of participants felt that upcoming health providers should receive formal ERAS/PSH education as part of their training. Based on our survey results, we plan to explore teaching methods that successfully engage learners of all levels of clinical expertise and also overcome the major barriers to gaining knowledge about ERAS/PSH identified by study participants, most notably lack of time for busy clinicians.
Collapse
Affiliation(s)
| | - Joshua-Paolo C. Reyes
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Zachary Denham
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mahmoud Abdel-Rasoul
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Eyad Rasoul
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michelle L. Humeidan
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
18
|
Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
Collapse
|
19
|
Jones CN, Morrison BL, Kelliher LJ, Dickinson M, Scott M, Cecconi Ebm C, Karanjia N, Quiney N. Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial. JMIR Perioper Med 2021; 4:e16829. [PMID: 33522982 PMCID: PMC7884210 DOI: 10.2196/16829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/15/2020] [Accepted: 01/10/2021] [Indexed: 12/20/2022] Open
Abstract
Background The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a
day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.
Collapse
Affiliation(s)
- Chris N Jones
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Ben L Morrison
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Michael Scott
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Nial Quiney
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| |
Collapse
|
20
|
Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
Collapse
Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| |
Collapse
|
21
|
Shah R, Diaz A, Tripepi M, Bagante F, Tsilimigras DI, Machairas N, Sigala F, Moris D, Barreto SG, Pawlik TM. Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition. J Gastrointest Surg 2020; 24:2874-2883. [PMID: 32705613 DOI: 10.1007/s11605-020-04748-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There has been a dramatic increase in worldwide health care spending over the last several decades. Operative procedures and perioperative care in the USA represent some of the most expensive episodes per patient. In view of both the rising cost of health care in general and the rising cost of surgical care specifically, policymakers and stakeholders have sought to identify ways to increase the value-improving quality of care while controlling (or diminishing) costs. In this context, we reviewed data relative to achieving the "value proposition" in the delivery of gastrointestinal surgical care. METHODS The National Library of Medicine online repository (PubMed) was text searched for human studies including "cost," "quality," "outcomes," "health care," "surgery," and "value." Results from this literature framed by the Donabedian conceptual model (identifying structures, processes, and outcomes), and the resulting impact of efforts to improve quality on costs. RESULTS The relationship between quality and costs was nuanced. Better quality care, though associated with better outcomes, was not always reported as concomitant with low costs. Moreover, some centers reported higher costs of surgical care commensurate with higher quality. Conversely, higher costs in health care delivery were not always linked to improved outcomes. While higher quality surgical care can lead to lower costs, higher costs of care were not necessarily associated with better outcomes. Strategies to improve quality, reduce cost, or achieve both simultaneously included regionalization of complex operations to high-volume centers of excellence, overall reduction in complications, introducing evidence-based improvements in perioperative care pathways including as enhanced recovery after surgery (ERAS), and elimination of inefficient or low-value care. CONCLUSIONS The relationship between quality and cost following gastrointestinal surgical procedure is complex. Data from the current study should serve to highlight the various means available to improve the value proposition related to surgery, as well as encourage surgeons to become more engaged in the national conversation around the Triple Aim of better health care quality, lower costs, and improved health care outcomes.
Collapse
Affiliation(s)
- Rohan Shah
- College of Medicine, Ohio State University, Columbus, OH, USA
| | - Adrian Diaz
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Marzia Tripepi
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Fragiska Sigala
- Department of Surgery, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Savio George Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
| |
Collapse
|
22
|
Abstract
The literature overwhelmingly supports standardized, evidence-based care to improve patient safety in the surgical setting, including checklists and enhanced recovery programs. Although local culture, patient complexity, and hospital setting can represent barriers to implanting standardized practices, they can be overcome with thoughtful strategies.
Collapse
Affiliation(s)
- Elizabeth Lancaster
- Department of Surgery, University of California, 513 Parnassus Avenue, S-321, San Francisco, CA 94143, USA
| | - Elizabeth Wick
- Department of Surgery, University of California, 513 Parnassus Avenue, S-321, San Francisco, CA 94143, USA.
| |
Collapse
|
23
|
Sayal NR, Militsakh O, Aurit S, Hufnagle J, Hubble L, Lydiatt W, Lydiatt D, Lindau R, Coughlin A, Osmolak A, Panwar A. Association of multimodal analgesia with perioperative safety and opioid use following head and neck microvascular reconstruction. Head Neck 2020; 42:2887-2895. [PMID: 32686254 DOI: 10.1002/hed.26341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/05/2020] [Accepted: 05/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND This study examines the association of multimodal analgesia (MMA) protocol for head and neck microvascular reconstruction with postoperative safety and opioid use. METHODS Retrospective, intention-to-treat analysis of 226 patients undergoing head and neck microvascular reconstruction between January 1, 2014 and August 30, 2018 at a tertiary-care hospital following MMA protocol implementation. Multivariable models examined outcomes of interest. RESULTS There were no differences between groups in frequency of bleeding, return to operating room, complete flap loss, readmissions, wound complications, and 30-day mortality. Patients in MMA protocol experienced reduced likelihood of partial flap loss (OR 0.18, confidence interval 0.04-0.91), meaningful reduction in postoperative opioid use (cumulative inpatient morphine equivalents [64 vs 141 mg; P < .001], daily morphine equivalents [8 vs 22 mg/d; P < .001]; and 22.5% lower frequency of opioid prescription at discharge [55.6% vs 78.1%; P = .001]). CONCLUSIONS In patients undergoing head and neck microvascular reconstruction, MMA is safe and associated with reduced postoperative opioid use.
Collapse
Affiliation(s)
- Navdeep R Sayal
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Oleg Militsakh
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Sarah Aurit
- Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - John Hufnagle
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Lester Hubble
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - William Lydiatt
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Daniel Lydiatt
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Robert Lindau
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Andrew Coughlin
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Angela Osmolak
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Aru Panwar
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha, Nebraska, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| |
Collapse
|
24
|
The impact of personalized nutritional support on postoperative outcome within the enhanced recovery after surgery (ERAS) program for liver resections: results from the NutriCatt protocol. Updates Surg 2020; 72:681-691. [PMID: 32410162 DOI: 10.1007/s13304-020-00787-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 05/02/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Malnutrition in liver surgery is correlated with higher postoperative complications and longer length of hospital stay (LOHS), the same items that ERAS programs try to optimize. However, to date, standardized dietary protocols have not been defined within ERAS programs. Aim of this study was to evaluate the impact on LOHS and postoperative complications, of a personalized nutritional protocol (NutriCatt) with diet and oral branched-chain amino acid (BCAA) supplementation, adopted within the ERAS program. METHODS 1960 consecutive liver resections were performed from January 2000 to September 2018. EXCLUSION CRITERIA perihilar cholangiocarcinoma, simultaneous colorectal and liver resections. Four groups for analysis: resections before 2009 (1st period); from 2009 to 2016 (2nd period, including laparoscopic resections); between 2016 and September 2017 (ERAS); after September 2017 (ERAS + NutriCatt). RESULTS LOHS declined (p < 0.0001), from a median of 10 days (1st period) to 8, 7 and 6 in 2nd period, ERAS and ERAS + NutriCatt groups, respectively. At multivariable analysis for risk of LOHS > 8 days, the 2nd period, ERAS and ERAS + NutriCatt groups showed a protective effect. These results were confirmed for both minor and major resections. LOHS was significantly lower in ERAS + Nutricatt group than in ERAS group, without increasing risk of postoperative complications, although the rate of laparoscopic resections was similar in these two groups and complexity of liver resections was significantly higher in the last period. CONCLUSIONS Adoption of a personalized nutritional protocol with BCAA supplementation within the ERAS program for liver resections was a safe and effective approach that may impact on reducing the LOHS.
Collapse
|
25
|
Cachemaille M, Grass F, Fournier N, Suter MR, Demartines N, Hübner M, Blanc C. Pain Intensity in the First 96 Hours After Abdominal Surgery: A Prospective Cohort Study. PAIN MEDICINE 2020; 21:803-813. [PMID: 31322667 DOI: 10.1093/pm/pnz156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Multimodal pain management strategies aim to improve postoperative pain control. The purpose of this study was to analyze pain scores and risk factors for acute postoperative pain after various abdominal surgery procedures. METHODS Data on 11 different abdominal surgery procedures were prospectively recorded. Pain intensity (rest, mobilization) and patient satisfaction at discharge were assessed using a visual analog scale (VAS; 0-10), and analgesic consumption was recorded until 96 hours postoperation. Demographic, surgery-related, and pain management-related univariate risk factors for insufficient pain control (VAS ≥ 4) were entered in a multivariate logistic regression model. RESULTS A total of 1,278 patients were included. Overall, mean VAS scores were <3 at all time points, and scores at mobilization were consistently higher than at rest (P < 0.05). Thirty percent of patients presented a prolonged VAS score ≥4 at mobilization at 24 hours, significantly higher than at rest (14%, P < 0.05). High pain scores correlated with high opioid consumption, whereas a variability of pain scores was observed in patients with low opioid consumption. The only independent risk factor for moderate and severe pain (VAS ≥ 4) was younger age (<70 years, P = 0.001). The mean satisfaction score was 8.18 ± 1.29. CONCLUSIONS Among 1,278 patients, pain was controlled adequately during the first four postoperative days, resulting in high levels of patient satisfaction. Pain levels were higher at mobilization. Younger age was the only independent risk factor for insufficient pain control. Preventive treatment in patients <70 years old and before mobilization could be evaluated for potential improvement.
Collapse
Affiliation(s)
- Matthieu Cachemaille
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Pain Center, Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nicolas Fournier
- Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marc R Suter
- Pain Center, Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Catherine Blanc
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
26
|
Church DL, Naugler C. Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model. Crit Rev Clin Lab Sci 2020; 57:323-344. [PMID: 32180485 DOI: 10.1080/10408363.2020.1720591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.
Collapse
Affiliation(s)
- Deirdre L Church
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
27
|
Noba L, Rodgers S, Chandler C, Balfour A, Hariharan D, Yip VS. Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2020; 24:918-932. [PMID: 31900738 PMCID: PMC7165160 DOI: 10.1007/s11605-019-04499-0] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery. METHODS A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance. RESULTS The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = -2.22; CI, -2.77 to -1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65-0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = -0.98; CI, -1.37 to - 0.58; p < 0.0001). CONCLUSION Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes.
Collapse
Affiliation(s)
- L. Noba
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - S. Rodgers
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - C. Chandler
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - A. Balfour
- Surgical Services, NHS Lothian, Edinburgh, EH1 3EG UK
| | - D. Hariharan
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR UK
| | - V. S. Yip
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR UK
| |
Collapse
|
28
|
|
29
|
Cost of Major Complications After Liver Resection in the United States: Are High-volume Centers Cost-effective? Ann Surg 2019; 269:503-510. [PMID: 29232212 DOI: 10.1097/sla.0000000000002627] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of the study was to estimate the cost of major complications after liver resection and determine whether high-volume (HV) centers are cost-effective. METHODS From 2002 to 2011, 96,107 cases of liver resection performed in the United States were identified using Nationwide Inpatient Sample. Hospitals were categorized as HV (150+ cases/yr), medium-volume (51-149 cases/yr), and low-volume (LV) (1-50 cases/yr) centers. Multivariable regression analysis identified predictors of cost. Propensity score matching comparing cases with versus without complications and costs of specific complications were estimated. Cost-effectiveness of HV centers was determined by calculating the incremental cost-effectiveness ratio. RESULTS After propensity score matching, the occurrence of a major complication added $33,855 extra cost, increased mean length of stay by 8.7 [95% confidence interval (CI), 8.4-9] days and increased risk of death by 9.3% (all P < 0.001). The cost of most common complications was wound infection (3.8%, $21,995), renal failure (2.8%, $19,201), respiratory failure (2.7%, $25,169), and hemorrhage (3.3%, $9,180), whereas sepsis (0.8%, $33,009), gastrointestinal bleeding (0.5%, $32,835), fistula (0.2%, $27,079), and foreign body removal (0.1%, $29,404) were most costly, but less frequent. Compared with LV centers, liver resection at HV centers was associated with $5109 (95% CI, 4409-5809, P < 0.001) more cost per case, yet on average 0.54 years (95% CI, 0.23-0.86) longer survival for an incremental cost-effectiveness ratio of $9392. CONCLUSIONS HV centers were cost-effective at performing liver resection compared with LV centers. After liver resection, complications such as surgical site infection, respiratory failure, and renal failure contributed the most to annual cost burden.
Collapse
|
30
|
Boyd C, Shew M, Penn J, Muelleman T, Lin J, Staecker H, Wichova H. Postoperative Opioid Use and Pain Management Following Otologic and Neurotologic Surgery. Ann Otol Rhinol Laryngol 2019; 129:175-180. [PMID: 31625416 DOI: 10.1177/0003489419883296] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The topic of prescription opioid overuse remains a growing concern in the United States. Our objective is to provide insight into pain perception and opioid use based on a patient cohort undergoing common otologic and neurotologic surgeries. STUDY DESIGN Prospective observational study with patient questionnaire. SETTING Single academic medical center. SUBJECTS AND METHODS Adult patients undergoing otologic and neurotologic procedures by two fellowship trained neurotologists between June and November of 2018 were included in this study. During first postoperative follow-up, participants completed a questionnaire assessing perceived postoperative pain and its impact on quality of life, pain management techniques, and extent of prescription opioid use. RESULTS A total of 47 patients met inclusion and exclusion criteria. The median pain score was 3 out of 10 (Interquartile Range [IQR] = 2-6) with no significant gender differences (P = .92). Patients were prescribed a median of 15.0 (IQR = 10.0-15.0) tablets of opioid pain medication postoperatively, but only used a median of 4.0 (IQR = 1.0-11.5) tablets at the time of first follow-up. Measured quality of life areas included sleep, physical activity, work, and mood. Sleep was most commonly affected, with 69.4% of patients noting disturbances. CONCLUSIONS This study suggests that practitioners may over-estimate the need for opioid pain medication following otologic and neurotologic surgery. It also demonstrates the need for ongoing patient education regarding opioid risks, alternatives, and measures to prevent diversion.
Collapse
Affiliation(s)
- Christopher Boyd
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Matthew Shew
- Clinical Fellow, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Kansas City, KS, USA
| | - Joseph Penn
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | | | - James Lin
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Hinrich Staecker
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Helena Wichova
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| |
Collapse
|
31
|
Militsakh O, Lydiatt W, Lydiatt D, Interval E, Lindau R, Coughlin A, Panwar A. Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns. JAMA Otolaryngol Head Neck Surg 2019; 144:1023-1029. [PMID: 30027221 DOI: 10.1001/jamaoto.2018.0987] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Importance Prescription opioid use contributes to drug-related adverse effects and risk for dependence and abuse. Multimodal analgesia (MMA) has been shown to be useful in reducing opioid use following orthopedic, gynecologic, and colorectal surgery, but adoption in head and neck surgery has lagged. Recently, we published findings related to the feasibility of MMA protocols in same-day thyroid, parathyroid, and parotid surgery. However, whether such strategies lead to effective and durable reduction in frequency of opioid prescriptions, and affect physician prescribing practices, remains unclear. Objective To observe trends in adoption and adherence to institutional MMA protocols following thyroid and parathyroid surgery, and to assess the association of institutional multimodal (nonopioid) analgesia protocols with opioid use and physician prescribing patterns following outpatient thyroid and parathyroid surgery. Design, Setting, and Participants Cohort study at a head and neck surgery service at a tertiary care hospital of prescription patterns and retrospective review of patient medical records following implementation of an optional institutional MMA protocol in 2015, based on preoperative administration of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, and postoperative use of acetaminophen and ibuprofen for analgesia after thyroid and parathyroid surgery. There were 528 adult patients who underwent thyroid and parathyroid surgery between January 1, 2015, and June 30, 2017. Main Outcomes and Measures We report on adherence to the MMA protocol over the study period as measure of physician buy-in and adoption of the technique. The frequency of opioid use and physician prescription patterns following thyroid and parathyroid surgery is reported over the study period to study the association of the available MMA pathway with these variables. Results A total of 528 patients (mean [SD] age, 53.1 [15.7] years; 80.3% female) underwent outpatient thyroid and parathyroid surgery. The frequency of postoperative opioid prescriptions decreased during the study period (16 of 122 [13.1%] in 2015, 22 of 244 [9.0%] in 2016, 3 of 162 [1.9%] in 2017). Adherence to the MMA protocol increased (0 of 122 cases in 2015, 106 of 244 [43.4%] cases in 2016, 142 of 162 [87.7%] cases in 2017), with reduced likelihood of opioid prescription on discharge (2017 vs 2015 odds ratio, 0.13; 95% CI, 0.04-0.44). Only 1 postoperative hematoma was recorded in the study cohort, and 352 (66.7%) patients achieved same-day discharge, whereas 176 (33.3%) maintained outpatient status but received overnight observation prior to discharge. Conclusions and Relevance Adoption and adherence to the MMA protocol increased substantially over the study period for patients undergoing thyroid and parathyroid surgery and was associated with a simultaneous significant decline in prescription of postoperative opioid analgesics. Use of nonopioid multimodal agents, incorporating NSAIDs, was safe and did not lead to increased incidence of bleeding. Availability of effective nonopioid MMA pathways may favorably influence physician prescribing practices and avoid unnecessary opioid prescriptions.
Collapse
Affiliation(s)
- Oleg Militsakh
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - William Lydiatt
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Daniel Lydiatt
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Erik Interval
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Robert Lindau
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Andrew Coughlin
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Aru Panwar
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| |
Collapse
|
32
|
Dasari BVM, Pathanki A, Hodson J, Roberts KJ, Marudanayagam R, Mirza DF, Isaac J, Sutcliffe RP, Muiesan P. Propensity-matched analysis of the influence of perioperative statin therapy on outcomes after liver resection. BJS Open 2019; 3:509-515. [PMID: 31388643 PMCID: PMC6677106 DOI: 10.1002/bjs5.50155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/18/2019] [Indexed: 11/11/2022] Open
Abstract
Background Perioperative use of statins is reported to improve postoperative outcomes after cardiac and non‐cardiovascular surgery. The aim of this study was to investigate the influence of statins on postoperative outcomes including complications of grade IIIa and above, posthepatectomy liver failure (PHLF), and 90‐day mortality rates after liver resection. Methods Patients who underwent hepatectomy between 2013 and 2017 were reviewed to identify statin users and non‐users (controls). Propensity matching was conducted for age, BMI, type of surgery and preoperative co‐morbidities to compare subgroups. Univariable and multivariable analyses were performed for the following outcomes: 90‐day mortality, significant postoperative complications and PHLF. Results Of 890 patients who had liver resection during the study period, 162 (18·2 per cent) were taking perioperative statins. Propensity analysis selected two matched groups, each comprising 154 patients. Overall, 81 patients (9·1 per cent) developed complications of grade IIIa or above, and the 90‐day mortality rate was 3·4 per cent (30 patients), with no statistically significant difference when the groups were compared before and after matching. The rate of PHLF was significantly lower in patients on perioperative statins than in those not taking statins (10·5 versus 17·3 per cent respectively; P = 0·033); similar results were found after propensity matching (10·4 versus 20·8 per cent respectively; P = 0·026). Conclusion The rate of PHLF was significantly lower in patients taking perioperative statins, but there was no statistically significant difference in severe complications and mortality rates.
Collapse
Affiliation(s)
- B V M Dasari
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - A Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - J Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - K J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - R Marudanayagam
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - D F Mirza
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - J Isaac
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - R P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - P Muiesan
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| |
Collapse
|
33
|
Lillemoe HA, Marcus RK, Day RW, Kim BJ, Narula N, Davis CH, Gottumukkala V, Aloia TA. Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids. Surgery 2019; 166:22-27. [PMID: 31103198 PMCID: PMC6579699 DOI: 10.1016/j.surg.2019.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/30/2019] [Accepted: 02/06/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake. METHODS For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation. RESULTS Of 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5-12.1; P < .001). CONCLUSION The implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.
Collapse
Affiliation(s)
- Heather A Lillemoe
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Rebecca K Marcus
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Ryan W Day
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Bradford J Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Nisha Narula
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Catherine H Davis
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston.
| |
Collapse
|
34
|
Enhanced Recovery after Surgery Pathway for Microsurgical Breast Reconstruction: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2019; 143:655-666. [PMID: 30589825 DOI: 10.1097/prs.0000000000005300] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The enhanced recovery after surgery pathway was introduced in 1997 as a multimodal approach to reduce preventable postoperative harm and shorten hospital length of stay. However, there is yet no widely accepted enhanced recovery after surgery protocol for microsurgical breast reconstruction. The authors conducted a systematic review and meta-analysis of the current literature on enhanced recovery after surgery for microsurgical breast reconstruction with regard to postoperative length of stay and morbidity. METHODS The PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for all studies published before June of 2016 containing original data on enhanced recovery after surgery in microsurgical breast reconstruction in relation to postoperative length of stay and morbidity. Studies were screened using eligibility criteria. Meta-analysis, odds ratio, and 95 percent confidence interval were used to pool acquired data. RESULTS The initial search identified 86 studies. Two independent screeners identified four original articles with a total of 676 patients. Length of stay was significantly shorter for patients on an enhanced recovery after surgery pathway (mean difference, -1.23; 95 percent CI, -1.50 to -0.96; p < 0.001; I = 0 percent; random effects model). Enhanced recovery was not associated with changes in 30-day postoperative morbidity; specifically, no significant difference was observed in rates of partial flap loss (p = 0.44), total flap loss (p = 0.91), breast hematoma (p = 0.69), donor-site infection (p = 0.53), urinary tract infection (p = 0.29), and pneumonia (p = 0.42). CONCLUSION The authors' review suggests that enhanced recovery after surgery in microsurgical breast reconstruction is associated with a reduced length of stay, and is not associated with increased postoperative morbidity.
Collapse
|
35
|
|
36
|
Grass F, Crippa J, Mathis KL, Kelley SR, Larson DW. Feasibility and safety of robotic resection of complicated diverticular disease. Surg Endosc 2019; 33:4171-4176. [PMID: 30868321 DOI: 10.1007/s00464-019-06727-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/01/2019] [Indexed: 01/17/2023]
Abstract
This study aimed to assess intra- and postoperative outcomes of robotic resection of left-sided complicated diverticular disease. Retrospective analysis of a prospectively maintained institutional database on consecutive patients undergoing elective robotic resection for diverticular disease (2014-2018). All procedures were performed within an enhanced recovery pathway (ERP). Demographic, surgical and ERP-related items were compared between patients with simple and complicated diverticular disease according to intra-operative presentation. Postoperative complications and length of stay were compared between the two groups. Out of 150 patients, 78 (52%) presented with complicated and the remaining 72 (48%) with uncomplicated disease. Both groups were comparable regarding demographic baseline characteristics and overall ERP compliance. Surgery for complicated disease was longer (288 ± 96 vs. 258 ± 72 min, p = 0.04) and more contaminated (≥ class 3: 57.7 vs. 23.6%, p < 0.001) with a trend to higher conversion rates (10.3 vs. 2.8%, p = 0.1). While postoperative overall complications tended to occur more often after resections for complicated disease (28.2 vs. 15.3%, p = 0.075), major, surgical and medical complications did not differ between the two groups, and median length of stay was 3 days in both settings (p = 0.19). Robotic resection of diverticular disease was feasible and safe regardless of disease presentation by the time of surgery.
Collapse
Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
37
|
Kaptain K, Ulsøe ML, Dreyer P. Surgical perioperative pathways-Patient experiences of unmet needs show that a person-centred approach is needed. J Clin Nurs 2019; 28:2214-2224. [PMID: 30786078 DOI: 10.1111/jocn.14817] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/05/2019] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
AIM To explore patients' and healthcare professionals' experiences of patients' surgical pathways in a perioperative setting. BACKGROUND Elective surgical pathways have improved over the past decades due to fast-track programmes, but patients desire more personalised and coordinated care and treatment. There is little knowledge of how healthcare professionals' collaboration and communication affect patients' pathways. DESIGN The overall framework was complex intervention method. A phenomenological-hermeneutic approach was used for data analyses. COREQ checklist was used as a guideline to secure accurate and complete reporting of the study. METHODS Field observations (120 hr) and semi-structured interviews (24 patients) were undertaken during 2016-2017. Healthcare professionals involved in the pathways were interviewed: (a) 13 single interviews and (b) 13 focus group interviews (37 healthcare professionals) were conducted. The Consolidated Criteria for Reporting Qualitative Research checklist was used. RESULTS Patients asked for individualised information adapted to their life and illness experiences. Furthermore, healthcare professionals need access to a quick overview of individual patients and their perioperative pathway in the electronic patient journal (EPJ). Agreements made with patients did not always reach the right receiver, there was poor interpersonal communication and the complex teamwork between many healthcare professionals made pathways incoherent and uncoordinated. Healthcare professionals who had the time to talk about other subjects than the disease with smiles and good humour gave patients a feeling of security. CONCLUSION Patients wanted to be treated as individuals, but often they received standard treatment. Healthcare professionals had the intention of treating patients individually, but the EPJ and information provided to patients were not easy to access. RELEVANCE TO CLINICAL PRACTICE Visible information about the patient's whole pathway could improve healthcare professionals' care and treatment. In addition, systematic feedback from patients' could make it possible to adjust information, care and treatment to achieve a more coherent pathway. Particular attention needs to be paid to how electronic healthcare systems can underpin relational coordination in pathways.
Collapse
Affiliation(s)
- Kirsten Kaptain
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Marie-Louise Ulsøe
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Pia Dreyer
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark.,Institute of Public Health, Section of Nursing, University of Aarhus, Aarhus C, Denmark
| |
Collapse
|
38
|
Brustia R, Monsel A, Conti F, Savier E, Rousseau G, Perdigao F, Bernard D, Eyraud D, Loncar Y, Langeron O, Scatton O. Enhanced Recovery in Liver Transplantation: A Feasibility Study. World J Surg 2019; 43:230-241. [PMID: 30094639 DOI: 10.1007/s00268-018-4747-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT. METHODS We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery. RESULTS Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0-10.5) days versus 18.0 (14.3-24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm. CONCLUSION Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.
Collapse
Affiliation(s)
- Raffaele Brustia
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Filomena Conti
- Liver Transplantation and Hepatology Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.,Sorbonne Universités, Paris, France
| | - Eric Savier
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Geraldine Rousseau
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Fabiano Perdigao
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Denis Bernard
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Daniel Eyraud
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yann Loncar
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Langeron
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Olivier Scatton
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France. .,Sorbonne Universités, Paris, France.
| |
Collapse
|
39
|
Oltman J, Militsakh O, D'Agostino M, Kauffman B, Lindau R, Coughlin A, Lydiatt W, Lydiatt D, Smith R, Panwar A. Multimodal Analgesia in Outpatient Head and Neck Surgery: A Feasibility and Safety Study. JAMA Otolaryngol Head Neck Surg 2019; 143:1207-1212. [PMID: 29049548 DOI: 10.1001/jamaoto.2017.1773] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Justin Oltman
- College of Medicine, University of Nebraska Medical Center, Omaha
| | - Oleg Militsakh
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Mark D'Agostino
- Department of Anesthesiology, Nebraska Methodist Hospital, Omaha
| | - Brittany Kauffman
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Robert Lindau
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Andrew Coughlin
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - William Lydiatt
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Daniel Lydiatt
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Russell Smith
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Aru Panwar
- Department of Head and Neck Surgical Oncology, Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| |
Collapse
|
40
|
Buhrman WC, Lyman WB, Kirks RC, Passeri M, Vrochides D. Current State of Enhanced Recovery After Surgery in Hepatopancreatobiliary Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:1471-1475. [DOI: 10.1089/lap.2018.0314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- William C. Buhrman
- Department of Anesthesiology, Carolinas Medical Center, Charlotte, North Carolina
| | - William B. Lyman
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Russell C. Kirks
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| |
Collapse
|
41
|
Surgical teaching does not increase the risk of intraoperative adverse events. Int J Colorectal Dis 2018; 33:1715-1722. [PMID: 30143855 DOI: 10.1007/s00384-018-3143-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Training and teaching are cornerstones in developing surgical skills. The present study aimed to compare intraoperative outcomes of colonic resections among fellows, consultants, and supervised trainees. METHODS Data of consecutive colonic resections including demographics, surgical details, and intraoperative outcomes were recorded in a prospectively maintained institutional database. All procedures were standardized and divided in three groups according to the main surgeons experience (fellow or consultant) and whether the procedure was taught. After weighting by inverse treatment probability, intraoperative adverse events including reactive conversion, blood loss, and operating time were compared between these three groups. RESULTS Six hundred sixty-four colectomies were analyzed between January 2014 and October 2017. Among them, 289 (43.5%) were taught. After weighted propensity score analysis, there was no difference between the three groups (fellow taken as reference), for intraoperative adverse event rate (odd ratio (OR) consultant 1.448 (IQR 0.728-2.878), p = 0.282; OR teaching 0.689 (IQR 0.295-1.609), p = 0.381), operating time (beta coefficient 0.76 (- 21.91-23.42), p = 0.947; beta coefficient - 10.79 (- 28.34-6.75), p = 0.919), conversion rates (OR 0.748 (0.329-1.515), p = 0.412; OR 1.025 (0.537-1.954), p = 0.940), pre-emptive conversion (OR 1.994 (0.198-20.032), p = 0.552; OR 0.659 (0.145-2.991), p = 0.583), intraoperative blood loss (beta coefficient 21.19 (- 25.87-68.25), p = 0.368; beta coefficient - 12.34 (- 56.13-31.44), p = 0.573), intraoperative transfusion (OR 1.962 (0.813-4.735), p = 0.127; OR 0.670 (0.260-1.727), p = 0.397), and rates of unusual bleeding (OR 1.273 (0.698-2.321), p = 0.422; OR 0.572 (0.290-1.126), p = 0.099). Time to preemptive conversion was shorter when procedures were performed by consultants (beta coefficient - 25.51 (- 47.71 to - 3.31), p = 0.025), while no difference was found for the teaching group (beta coefficient 4.48 (- 30.95-40.62), p = 0.788). CONCLUSION Within a standardized teaching environment, colonic resections were safely performed regardless of the surgical setting in the present cohort. Teaching does not increase intraoperative adverse events.
Collapse
|
42
|
The Cost of Failure: Assessing the Cost-Effectiveness of Rescuing Patients from Major Complications After Liver Resection Using the National Inpatient Sample. J Gastrointest Surg 2018; 22:1688-1696. [PMID: 29855870 DOI: 10.1007/s11605-018-3826-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/17/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To estimate the cost of rescue and cost of failure and determine cost-effectiveness of rescue from major complications at high-volume (HV) and low-volume (LV) centers METHODS: Ninety-six thousand one hundred seven patients undergoing liver resection were identified from the Nationwide Inpatient Sample (NIS) between 2002 and 2011. The incremental cost of rescue and cost of FTR were calculated. Using propensity-matched cohorts, a cost-effectiveness analysis was performed to determine the incremental cost-effectiveness ratio (ICER) between HV and LV hospitals. RESULTS Ninety-six thousand one hundred seven patients were identified in NIS. The overall mortality was 2.3% and was lowest in HV centers (HV 1.4% vs. MV 2.1% vs. LV 2.6%; p < 0.001). Major complications occurred in 14.9% of hepatectomies and were comparable regardless of volume (HV 14.2% vs. MV 14.3% vs. LV 15.4%; p < 0.001). The FTR rate was substantially lower among HV centers (HV 7.7%, MV 11%, LV 12%; p < 0.001). At a willingness to pay benchmark of $50,000 per year of life saved, both HV (ICER = $3296) and MV (ICER = $4182) centers were cost-effective at rescuing patients from a major complication compared to LV hospitals. CONCLUSION Not only was FTR less common at HV hospitals, but the management of most major complications was cost-effective at higher volume centers.
Collapse
|
43
|
Jensen KK, Dressler J, Baastrup NN, Kehlet H, Jørgensen LN. Enhanced recovery after abdominal wall reconstruction reduces length of postoperative stay: An observational cohort study. Surgery 2018; 165:393-397. [PMID: 30195401 DOI: 10.1016/j.surg.2018.07.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced recovery after surgery has been shown to lead to improved postoperative outcomes after several surgical procedures. However, only a few studies have examined the application of enhanced recovery after surgery after abdominal wall reconstruction. The aim of the current observational cohort study was to evaluate the outcomes of enhanced recovery after surgery after abdominal wall reconstruction in a large cohort. METHOD This was a retrospective cohort study comparing patients undergoing abdominal wall reconstruction in a standard care pathway (control group) with patients undergoing abdominal wall reconstruction in an enhanced recovery after surgery pathway. Registered outcomes included 30-day postoperative complications, length of stay, and readmission rate. RESULTS A total of 190 patients undergoing abdominal wall reconstruction for large incisional hernias were included in the study, of which 96 were treated according to standard protocol, and 94 underwent enhanced recovery after surgery pathway. Length of stay was significantly reduced after the introduction of enhanced recovery after surgery (median 4, interquartile range 3-6 days vs. control 5, 4-7 days, P < .001). There was no difference between the cohorts in the incidence of postoperative complications requiring operative intervention (enhanced recovery after surgery 10.6% vs control 10.4%, P = 1.0) or the rate of readmissions (enhanced recovery after surgery 16.0% vs control 12.5%, P = .635). CONCLUSION Enhanced recovery after surgery is feasible after abdominal wall reconstruction, leading to reduced length of stay without increasing the rate of complications or readmissions. Enhanced recovery should be implemented as standard in centers performing abdominal wall reconstruction.
Collapse
Affiliation(s)
- Kristian Kiim Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Denmark.
| | - Jannie Dressler
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Denmark
| | | | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Denmark
| | | |
Collapse
|
44
|
Grass F, Pache B, Petignat C, Moulin E, Hahnloser D, Demartines N, Hübner M. Impact of Teaching on Surgical Site Infection after Colonic Surgery. JOURNAL OF SURGICAL EDUCATION 2018; 75:1287-1291. [PMID: 29500144 DOI: 10.1016/j.jsurg.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/09/2018] [Accepted: 02/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The present study aimed to evaluate whether teaching had an influence on surgical site infections (SSI) after colonic surgery. DESIGN Colonic surgeries between January 2014 and December 2016 were retrospectively reviewed. Demographics, surgical details, and SSI rates were compared between teaching procedures vs. experts. Risk factors for SSI were identified by multinominal logistic regression. SETTING SSI were prospectively assessed by an independent National Surveillance Program (www.swissnoso.ch) at Lausanne University Hospital CHUV, a tertiary academic institution. PARTICIPANTS Included in the present analysis were patients documented in a prospective institutional enhanced recovery after surgery (ERAS) database and who were prospectively monitored by the independent National Infection Surveillance Committee between January 1, 2014 and December 31, 2016. RESULTS In all, 315 patients constituted the study cohort. Demographic and surgical items were comparable between teaching (n = 161) vs. expert operations (n = 135) except for higher occurrence of wound contamination class III-IV (13 vs. 19%, p = 0.046) in patients operated by experts. Overall, 61 patients (19%) developed SSI, namely 25 patients (16%) in the teaching group and 32 patients (24%) in the expert group (p = 0.077). Contamination class III-IV (OR = 3.2; 95% CI: 1.4-7.5, p = 0.005) and open surgery (OR = 3.4; 95% CI: 1.8-6.7, p < 0.001) were independent risk factors for SSI, while teaching had no significant impact (OR = 0.6; 95% CI: 0.3-1.2, p = 0.153). CONCLUSIONS Surgical teaching was feasible and safe after colonic surgery in the present cohort and had no impact on SSI rate.
Collapse
Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Christiane Petignat
- Department of Hospital Preventive Medicine, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Estelle Moulin
- Department of Hospital Preventive Medicine, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| |
Collapse
|
45
|
Brudvik KW, Røsok B, Naresh U, Yaqub S, Fretland ÅA, Labori KJ, Edwin B, Bjørnbeth BA. Survival after resection of colorectal liver metastases in octogenarians and sexagenarians compared to their respective age-matched national population. Hepatobiliary Surg Nutr 2018; 7:234-241. [PMID: 30221151 DOI: 10.21037/hbsn.2017.09.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The aim of the current study was to investigate survival after resection of colorectal liver metastases (CLM) in octogenarians. The survival of octogenarian patients was compared to the survival of the national population of octogenarians and the survival of sexagenarians, the latter representing the average-age patient undergoing resection of CLM. Methods Octogenarian and sexagenarian were defined as person 80-89 and 60-69 years of age, respectively. Survival analyses of patients who underwent resection of CLM between 2002 and 2014 were performed. Data from Statistics Norway were used to estimate the survival of the age-matched national population of octogenarians (ageM-Octo) and the age-matched national population of sexagenarians (ageM-Sexa). Results During the study period, 59 octogenarians underwent resection of CLM. The majority of patients underwent a minor liver resection (n=50). In octogenarians, the 5-year survival was 32.5% and 66.3% [difference, 33.8 percentage points (pp)] in patients and ageM-Octo, respectively. The 10-year survival was 14.1% and 31.2% (difference, 17.1 pp) in patients and ageM-Octo, respectively. In sexagenarians, the 5-year survival was 50.9% and 96.2% (difference, 45.3 pp) in patients and ageM-Sexa, respectively. The 10-year survival was 35.7% and 90.3% (difference, 54.6 pp) in patients and ageM-Sexa, respectively. The 5-year cancer-specific survival and 5-year recurrence-free survival (RFS) after resection of CLM in octogenarians were 43.1% and 32.9%, respectively. Conclusions After resection of CLM, the survival was poorer in octogenarians than in sexagenarians. However, the difference between the survival curves of patients and their age-matched population was smaller in octogenarians. In practice, this finding may indicate a greater benefit of resection in the elderly than the survival rates alone would suggest.
Collapse
Affiliation(s)
| | - Bård Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Usha Naresh
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Sheraz Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Åsmund Avdem Fretland
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
46
|
Morrison B, Kelliher L, Jones C. Enhanced recovery for liver resection-early recovery pathway for hepatectomy: data-driven liver resection care and recovery. Hepatobiliary Surg Nutr 2018; 7:217-220. [PMID: 30046579 DOI: 10.21037/hbsn.2018.03.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Benjamin Morrison
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Leigh Kelliher
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Chris Jones
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| |
Collapse
|
47
|
Qi S, Chen G, Cao P, Hu J, He G, Luo J, He J, Peng X. Safety and efficacy of enhanced recovery after surgery (ERAS) programs in patients undergoing hepatectomy: A prospective randomized controlled trial. J Clin Lab Anal 2018; 32:e22434. [PMID: 29574998 DOI: 10.1002/jcla.22434] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/20/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND AIM Enhanced recovery after surgery (ERAS) programs, following a variety of perioperative treatments with evidence-based medical evidence, has indicated its validity to accelerate rehabilitation in a wide variety of surgical procedures. This randomized controlled trial (RCT) study was implemented to verify the safety and efficacy of the perioperative effects in patients undergoing hepatectomy with ERAS or with conventional surgery (CS). METHODS From August 2016 to November 2017, according to the inclusion criteria, 160 patients with liver diseases were suitable for participating in this experiment. Patients before liver resection were randomized into ERAS group (n = 80) and CS group (n = 80), and then the outcome measures were compared between the two groups. RESULTS Enhanced recovery after surgery group had significantly less complications than CS group (P = .009). Compared with CS group, patients in ERAS group had low peak of WBCs in postoperative day (POD1), ALT in POD1 and POD3 (P < .05), high value of ALB in POD3 and POD5 (P < .05), less pain and higher patient satisfaction (P < .001), earlier exhaust, oral feeding, ambulation and extubation time (P < .05),and also had less hospital stay and cost (P < .001). There were no significant differences in readmission rate (<30 days) between two groups (P = .772). CONCLUSIONS Enhanced recovery after surgery programs applied to patients undergoing hepatectomy can safely and effectively relieve stress response, reduce the incidence of complications, improve patient satisfaction, accelerate patient recovery, reduce financial burden, and bring economic benefits.
Collapse
Affiliation(s)
- Shuo Qi
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| | - Guodong Chen
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| | - Peng Cao
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| | - Jiangping Hu
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| | - Gengsheng He
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| | - Jiaxing Luo
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| | - Jun He
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| | - Xiuda Peng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of University of South China, Hengyang Hunan, China
| |
Collapse
|
48
|
Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery. Ann Surg 2017; 267:57-65. [PMID: 28437313 DOI: 10.1097/sla.0000000000002267] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures. BACKGROUND ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols. METHODS A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs. RESULTS A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis. CONCLUSIONS ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.
Collapse
|
49
|
Cerullo M, Chen SY, Dillhoff M, Schmidt C, Canner JK, Pawlik TM. Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery. JAMA Surg 2017; 152:e172158. [PMID: 28746714 PMCID: PMC5831444 DOI: 10.1001/jamasurg.2017.2158] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 04/09/2017] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges. OBJECTIVE To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017. INTERVENTIONS Hepatic or pancreatic resection. MAIN OUTCOMES AND MEASURES Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection. RESULTS Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (-5.4%; 95% CI, -10.0% to -0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, -14.0% to -2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, -13.0% to -3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, -19.3% to -7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, -16.2% to -4.4%; P = .001) compared with unconcentrated markets. CONCLUSIONS AND RELEVANCE Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.
Collapse
Affiliation(s)
- Marcelo Cerullo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sophia Y. Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
| | - Carl Schmidt
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
| | - Joseph K. Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
- Deputy Editor, JAMA Surgery
| |
Collapse
|
50
|
Hospital Volume and the Costs Associated with Surgery for Pancreatic Cancer. J Gastrointest Surg 2017; 21:1411-1419. [PMID: 28664254 DOI: 10.1007/s11605-017-3479-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/14/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data evaluating the financial implications of volume-based referral are lacking. This study sought to compare in-hospital costs for pancreatic surgery by annual hospital volume. METHODS Eleven thousand and eighty-one patients aged ≥18 years undergoing an elective pancreatic resection for cancer were identified using the Nationwide Inpatient Sample 2002-2011. Multivariable regression analysis was performed to compare length-of-stay (LOS), postoperative morbidity and mortality, failure-to-rescue (FTR), and inpatient costs by annual hospital volume group. RESULTS Patients undergoing surgery at high-volume hospitals (HVH) demonstrated 23% lower odds (odds ratio [OR] = 0.77, 95% confidence interval [95%CI] 0.63-0.95) of developing a postoperative complication, 59% lower odds of experiencing an LOS > 14 days (OR = 0.41, 95%CI 0.34-0.50), 51% lower odds of postoperative mortality (OR = 0.49, 95%CI 0.34-0.71), and 47% lower odds of FTR (OR = 0.53, 95%CI 0.37-0.76; all p<0.05). The overall mean in-hospital cost was $39,012 (SD = $15,214) with minimal differences observed across hospital volume groups. Rather, postoperative complications (no complication vs. complication $26,686 [SD = $5762] vs. $44,633 [SD = $11,637]) and FTR (rescue vs. FTR $42,413 [SD = $8481] vs. $69,546 [SD = $13,131]) were determinant of higher in-hospital costs. While this pattern was observed at all hospital volume groups, costs varied minimally between hospital volume groups after this stratification. CONCLUSIONS Annual hospital surgical volume was not associated with in-hospital costs among patients undergoing pancreatic surgery.
Collapse
|