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Saarinen IH, Malmivaara A, Huhtala H, Kaipia A. Creating an inexpensive hospital-wide surgical complication register for performance monitoring: a cohort study. BMJ Open Qual 2022; 11:bmjoq-2021-001804. [PMID: 35788053 PMCID: PMC9255416 DOI: 10.1136/bmjoq-2021-001804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/31/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectivesBasic tools that measure a hospital’s performance are required in order to benchmark or compare hospitals, but multispecialty institutional registries are rarely reported, and there is no consensus on their standard definitions and methodology. This study aimed to describe the setting up and first results of a hospital-wide surgical complication register that uses a minimal set of patient-related risk factors based on bedside data and produces outcomes data based on severity of complications.DesignCohort study.SettingPerioperative data related to all adult surgical procedures in a tertiary referral centre in Finland for 3 years (2016–2018) were included in the study. Complications were recorded according to a modified Clavien-Dindo classification, and the preoperative risk factors were compiled based on the literature and coded as numerical measures. The associations of preoperative risk factors with postoperative complications were analysed using the χ2 test or Fisher’s exact test.ResultsIn total, 19 158 operations were performed between 2016 and 2018. Data on complications (Clavien 0–9) were recorded for 4529 surgical patients (23.6%), and 779 complications were reported (Clavien 1–9), leading to an overall complication rate of 17.2%. Of these, 4.6% were graded as major (Clavien 4–7). Patient-related risk factors with the strongest association with complications were growing American Society of Anesthesiologists Physical Status Classification System score (p<0.001), growing Charlson Index (p<0.001), poor nutritional status (Nutritional Risk Screening 2002), p=0.041) and urgency of surgery (p<0.001).ConclusionsWe describe an inexpensive hospital-wide surgical complication monitoring system that can produce valid numerical data for monitoring risk-adjusted surgical quality. The results showed that only a few patient-related risk factors were sufficient to account for the case mix.
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Affiliation(s)
- Ira H Saarinen
- Surgery, Satakunnan Sairaanhoitopiiri, Pori, Finland
- Surgery, Etelä-Pohjanmaan Sairaanhoitopiiri, Seinajoki, Finland
| | - Antti Malmivaara
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Antti Kaipia
- Urology, Tampere University Hospital, Tampere, Finland
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McAuliffe PB, Hsu JY, Broach RB, Borovskiy Y, Christopher AN, Morris MP, Fischer JP. Systematic variable reduction for simplification of incisional hernia risk prediction instruments. Am J Surg 2022; 224:576-583. [DOI: 10.1016/j.amjsurg.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/14/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022]
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Ullrich SJ, Kisa P, Muzira A, Kakembo N, Nabukenya M, Tumukunde J, Sekabira J, Chang DC, Ozgediz D. Pediatric surgical quality improvement in low- and middle-income countries: What data to collect? Surgery 2022; 171:1067-1072. [PMID: 35078626 DOI: 10.1016/j.surg.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND As surgical access expands in low- and middle-income countries, risk-adjusted outcomes data are needed to measure and improve surgical quality. Existing data collection tools in high-income countries are complex and may be burdensome to implement in low and middle income countries. This study determined the minimum dataset needed for adequate risk adjustment to predict perioperative mortality using data collected in a low- and middle-income countries. METHODS All patients admitted to the pediatric surgery ward at Mulago National Referral Hospital in Kampala, Uganda, from January 1, 2014 through December 31, 2018 were included. Studies were performed modelling the effects of reducing data granularity and reducing number of variables on the area under the receiver operating curve. RESULTS Of the 3,194 patients included, 1,941(61%) were male, 957(30%) were neonates, 1,714 (54%) had an operation, and the overall mortality rate was 14%. Granularity reduction analyses found that measuring age in ranges was equivalent to recording age in days (area under the receiver operating curve = 0.776; 95% confidence interval, 0.754%-0.798%, vs 0.815, 95% confidence interval, 0.794%-0.837%). Variable reduction analyses found that models with 3 predictor variables (diagnosis, procedure, and district) reached a maximum area under the receiver operating curve of 0.915 (95% confidence interval, 0.903%-0.928%), which was equivalent to the model using all available predictor variables (area under the receiver operating curve = 0.932; 95% confidence interval, 0.922%-0.943%). For all 3-variable models, the primary diagnosis contributed most to predictive ability (P < .001). CONCLUSION Effective risk adjustment for perioperative mortality can be performed in low and middle income countries using minimal, objective variables often already part of the patient's medical record. This approach can be used by clinicians, hospital administrators, and policymakers low- and middle-income countries looking to begin data collection to track and improve patient outcomes.
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Affiliation(s)
- Sarah J Ullrich
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | - Phyllis Kisa
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Arlene Muzira
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Nasser Kakembo
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Mary Nabukenya
- Department of Anesthesia, Mulago National Referral Hospital, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anesthesia, Mulago National Referral Hospital, Kampala, Uganda
| | - John Sekabira
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Doruk Ozgediz
- Department of Surgery, University of California San Francisco, San Francisco, CA
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Cossa M, Rose J, Berndtson AE, Noormahomed E, Bickler SW. Assessment of Surgical Care Provided in National Health Services Hospitals in Mozambique: The Importance of Subnational Metrics in Global Surgery. World J Surg 2021; 45:1306-1315. [PMID: 33521876 PMCID: PMC8530447 DOI: 10.1007/s00268-020-05925-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Surgery plays a critical role in sustainable healthcare systems. Validated metrics exist to guide implementation of surgical services, but low-income countries (LIC) struggle to report recommended metrics and this poses a critical barrier to addressing unmet need. We present a comprehensive national sample of surgical encounters from a LIC by assessing the National Health Services of Mozambique. MATERIAL AND METHODS A prospective cohort of all surgical encounters from Mozambique's National Health Service was gathered for all provinces between July and December 2015. Primary outcomes were timely access, provider densities for surgery, anesthesiology, and obstetrics (SAO) per 100,000 population, annualized surgical procedure volume per 100,000, and postoperative mortality (POMR). Secondary outcomes include operating room density and efficiency. RESULTS Fifty-four hospitals had surgical capacity in 11 provinces with 47,189 surgeries. 44.9% of Mozambique's population lives in Districts without access to surgical services. National SAO density was 1.2/100,000, ranging from 0.4/100,000 in Manica Province to 9.8/100,000 in Maputo City. Annualized national surgical case volume was 367 procedures/100,000 population, ranging from 180/100,000 in Zambezia Province to 1,897/100,000 in Maputo City. National POMR was 0.74% and ranged from 0.23% in Maputo Province to 1.78% in Niassa Province. DISCUSSION Surgical delivery in Mozambique falls short of international targets. Subnational deficiencies and variations between provinces pose targets for quality improvement in advancing national surgical plans. This serves as a template for LICs to follow in gathering surgical metrics for the WHO and the World Bank and offers short- and long-term targets for surgery as a component of health systems strengthening.
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Affiliation(s)
- Matchecane Cossa
- Department of Surgery, Maputo Central Hospital, Eduardo Mondlane University, Maputo, Mozambique
| | - John Rose
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA, USA
| | - Emilia Noormahomed
- Microbiology Department, Parasitology Laboratory, Department of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Mozambique Institute of Health Education and Research, Maputo, Mozambique
- Department of Medicine, Division of Infectious Diseases, University of California, San Diego, CA, USA
| | - Stephen W Bickler
- Division of Pediatric Surgery, Rady Children's Hospital, University of California, San Diego, CA, USA
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Abstract
OBJECTIVE Nationwide initiatives have focused on improving patient safety through greater use of health information technology. We examined the association of hospitals' electronic health record (EHR) adoption and occurrence rates of adverse events among exposed patients. METHODS We conducted a retrospective analysis of patient discharges using data from the 2012 and 2013 Medicare Patient Safety Monitoring System. The sample included patients age 18 and older that were hospitalized for one of 3 conditions: acute cardiovascular disease, pneumonia, or conditions requiring surgery. The main outcome measures were in-hospital adverse events, including hospital-acquired infections, adverse drug events (based on selected medications), general events, and postprocedural events. Adverse event rates and patient exposure to a fully electronic EHR were determined through chart abstraction. RESULTS Among the 45,235 patients who were at risk for 347,281 adverse events in the study sample, the occurrence rate of adverse events was 2.3%, and 13.0% of patients were exposed to a fully electronic EHR. In multivariate modeling adjusted for patient and hospital characteristics, patient exposure to a fully electronic EHR was associated with 17% to 30% lower odds of any adverse event for cardiovascular (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.72-0.90), pneumonia (OR, 0.70; CI, 0.62-0.80), and surgery (OR, 0.83; CI, 0.72-0.96) patients. The associations of EHR adoption and adverse events varied by event type and by medical condition. CONCLUSIONS Cardiovascular, pneumonia, and surgery patients exposed to a fully electronic EHR were less likely to experience in-hospital adverse events.
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Dekker A, Crawford HA, Stott NS. How Do Complications Within the First 30 days after Spinal Deformity Surgery in Children with Cerebral Palsy Affect Length of Stay? Clin Orthop Relat Res 2021; 479:366-375. [PMID: 32398555 PMCID: PMC7899524 DOI: 10.1097/corr.0000000000001290] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 04/14/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgery for spinal deformity in patients with cerebral palsy is reported to have high perioperative complication rates. However, minor complications are not generally reported and the influence of the varied severity of complications on length of stay is not known. Understanding the risk factors for both minor and major perioperative complications and their effect on length of stay is important information for clinicians who seek to improve care for this group of children. QUESTIONS/PURPOSES (1) What is the prevalence of postoperative complications in the first 30 days after surgery for spinal deformity in a New Zealand national cohort of children with cerebral palsy using the Clavien-Dindo classification? (2) What are the patient and operative predictive risk factors for minor and major perioperative complications? (3) What is the effect of year of operation on risk of minor and major perioperative complications? (4) What is the effect of perioperative complications on length of stay? METHODS We conducted a retrospective cohort study, identifying all children in New Zealand with a confirmed diagnosis of cerebral palsy who had surgery for a spinal deformity from January 1997 to January 2018. Two hundred-three patients with cerebral palsy (102 boys) were surgically treated for a spinal deformity, at a mean age of 14 ± 3 years, at one of three centers in New Zealand. Six children had Gross Motor Function Classification System Level II or III, 66 had Gross Motor Function Classification System Level IV, and 131 had Gross Motor Function Classification System Level V. Thirty-day perioperative complications were extracted from the patients' health records and classified according to the Clavien-Dindo system. Univariate and multivariate analyses were performed to identify patient and operative risk factors for complications, and the effect on length of stay. RESULTS In all, 85% of patients experienced at least one perioperative complication. There were 300 Clavien-Dindo Grade I complications in 141 patients, 156 Clavien-Dindo Grade II complications in 102 patients, 25 Clavien-Dindo Grade III complications in 22 patients, 29 Clavien-Dindo Grade IV complications in 28 patients, and one Clavien-Dindo Grade V complication (death; 0.5%). Univariate analysis showed that multiple independent factors, Gross Motor Function Classification System Level V ability (odds ratio 2.13 [95% confidence interval 1.15 to 3.95]; p = 0.02), seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01), preoperative Cobb angle of greater than 70° (OR 2.40 [95% CI 1.20 to 4.78]; p < 0.01), and anterior approach to surgery (OR 3.29 [95% CI 1.21 to 8.90]; p = 0.02), were associated with Grade I complications but, of these factors, only the presence of a seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01) was associated with Grade I complications on multivariate analysis. Previous recurrent respiratory infections predicted an increased risk of Clavien-Dindo Grade II complications (OR 3.6 [95% CI 1.81 to 7.0]; p = 0.03). The presence of a feeding gastrostomy was associated with an increased risk of Clavien-Dindo Grade IV complications (OR 2.6 [95% CI 1.19 to 5.87]; p = 0.02). The year of operation did not influence the frequency of any grade of complication, but the presence of any complication led to an increased length of stay. CONCLUSION Overall, 85% of patients with cerebral palsy had at least one complication after spinal deformity surgery and 25% had major complications (Grades III, IV, and V), with proportionate increases in the postoperative length of stay. Patient-specific factors aid in the identification of complication risk. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Annabel Dekker
- A Dekker, H. A. Crawford, N. S. Stott, Department of Paediatric Orthopaedics, Starship Children's Hospital, Auckland, New Zealand
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The preoperative risk tool SURPAS accurately predicts outcomes in emergency surgery. Am J Surg 2021; 222:643-649. [PMID: 33485618 DOI: 10.1016/j.amjsurg.2021.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/28/2020] [Accepted: 01/04/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Surgical Risk Preoperative Assessment System (SURPAS) uses eight variables to accurately predict postoperative complications but has not been sufficiently studied in emergency surgery. We evaluated SURPAS in emergency surgery, comparing it to the Emergency Surgery Score (ESS). METHODS SURPAS and ESS estimates of 30-day mortality and overall morbidity were calculated for emergency operations in the 2009-2018 ACS-NSQIP database and compared using observed-to-expected plots and rates, c-indices, and Brier scores. Cases with incomplete data were excluded. RESULTS In 205,318 emergency patients, SURPAS underestimated (8.1%; 35.9%) while ESS overestimated (10.1%; 43.8%) observed mortality and morbidity (8.9%; 38.8%). Each showed good calibration on observed-to-expected plots. SURPAS had better c-indices (0.855 vs 0.848 mortality; 0.802 vs 0.755 morbidity), while the Brier score was better for ESS for mortality (0.0666 vs. 0.0684) and for SURPAS for morbidity (0.1772 vs. 0.1950). CONCLUSIONS SURPAS accurately predicted mortality and morbidity in emergency surgery using eight predictor variables.
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Cheung M, Kakembo N, Rizgar N, Grabski D, Ullrich S, Muzira A, Kisa P, Sekabira J, Ozgediz D. Epidemiology and mortality of pediatric surgical conditions: insights from a tertiary center in Uganda. Pediatr Surg Int 2019; 35:1279-1289. [PMID: 31324976 DOI: 10.1007/s00383-019-04520-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION/PURPOSE The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited. METHODS Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016. RESULTS 2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung's, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%). CONCLUSION There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.
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Affiliation(s)
- Maija Cheung
- Department of Surgery, Yale University School of Medicine, 330 Cedar Street, FMB 107, New Haven, CT, 06510, USA.
| | - Nasser Kakembo
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Nensi Rizgar
- Yale University School of Medicine, New Haven, CT, USA
| | - David Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Sarah Ullrich
- Department of Surgery, Yale University School of Medicine, 330 Cedar Street, FMB 107, New Haven, CT, 06510, USA
| | - Arlene Muzira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - John Sekabira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, Yale University School of Medicine, 330 Cedar Street, FMB 107, New Haven, CT, 06510, USA
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Hwang DW, Kim HJ, Lee JH, Song KB, Kim MH, Lee SK, Choi KT, Jun IG, Bang JY, Kim SC. Effect of Enhanced Recovery After Surgery program on pancreaticoduodenectomy: a randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:360-369. [PMID: 31152686 DOI: 10.1002/jhbp.641] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD). METHODS In this single-center trial, we randomly assigned 276 adult patients who underwent open PD into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. The primary endpoint was the incidence of overall morbidity until postoperative 3 months. The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay (LOS), nutritional status and overall hospital costs. RESULTS Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference [RD] -2.81 percentage points (pp); 90% two-sided confidence interval -13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in median postoperative LOS (both 11 days; RD -8.46 pp), body mass index (22.4 ± 2.75 vs. 22.4 ± 2.65 kg/m2 ; RD -3.48 pp), Patient-Generated Subjective Global Assessment score over 4 (45 [40.5%] vs. 50 [43.1%] patients; RD -2.56 pp), and median overall hospital cost (15.61 vs. 16.04, ×106 KRW; RD -6.08 pp). CONCLUSIONS Even in PD, modified ERAS protocol was not inferior to conventional protocol, while reducing treatment burden.
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Affiliation(s)
- Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Myeong-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyu Taek Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji-Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
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Hearing loss in humans drinking tube well water with high levels of iron in arsenic-polluted area. Sci Rep 2019; 9:9028. [PMID: 31227759 PMCID: PMC6588562 DOI: 10.1038/s41598-019-45524-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/10/2019] [Indexed: 11/25/2022] Open
Abstract
Well water for drinking with increased levels of iron in arsenic-polluted areas has been reported worldwide. Oral exposure to arsenic has been shown to be associated with hearing loss, while there is no evidence for an association between excessive exposure to iron and hearing loss in humans. In this study, we determined iron and arsenic levels in biological samples and hearing levels by pure tone audiometry (PTA) in subjects in a control area and an arsenic-polluted area in Bangladesh. The iron level in well water in the arsenic-polluted area was significantly higher than that in piped supply water in the control area. Subjects in the polluted area (n = 109), who had higher iron and arsenic levels in hair and toenails than those in subjects in the control area (n = 36), had an increased risk of hearing loss at 8 kHz and 12 kHz after adjustments for age, gender, smoking and BMI. Significant associations of the exposure group with hearing loss at 8 kHz and 12 kHz remained after further adjustment for arsenic levels in toenails and hair. Thus, this pilot study showed that excessive exposure to iron via drinking water is a potential risk for hearing loss in humans.
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Holmer H, Bekele A, Hagander L, Harrison EM, Kamali P, Ng-Kamstra JS, Khan MA, Knowlton L, Leather AJM, Marks IH, Meara JG, Shrime MG, Smith M, Søreide K, Weiser TG, Davies J. Evaluating the collection, comparability and findings of six global surgery indicators. Br J Surg 2018; 106:e138-e150. [PMID: 30570764 PMCID: PMC6790969 DOI: 10.1002/bjs.11061] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/01/2018] [Accepted: 10/30/2018] [Indexed: 01/18/2023]
Abstract
Background In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates. Methods Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates. Results Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed. Conclusion Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.
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Affiliation(s)
- H Holmer
- WHO Collaborating Centre for Surgery and Public Health, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Karolinska University Hospital, Solna, Stockholm, Sweden
| | - A Bekele
- Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.,University of Global Health Equity, Kigali, Rwanda
| | - L Hagander
- WHO Collaborating Centre for Surgery and Public Health, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Paediatric Surgery, Skåne University Hospital Children's Hospital, Lund, Sweden
| | - E M Harrison
- Department of Clinical Surgery, Royal Infirmary of Edinburgh and Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - P Kamali
- Division of Plastic and Reconstructive Surgery, Medisch Spectrum Twente, Enschede, the Netherlands.,InciSioN, International Student Surgical Network, Leuven, Belgium
| | - J S Ng-Kamstra
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M A Khan
- InciSioN, International Student Surgical Network, Leuven, Belgium.,CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan
| | - L Knowlton
- Department of Surgery, Stanford University, Stanford, California, USA
| | - A J M Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - I H Marks
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.,InciSioN, International Student Surgical Network, Leuven, Belgium
| | - J G Meara
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA
| | - M G Shrime
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, USA
| | - M Smith
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of General Surgery, Chris Hani Baragwaneth Academic Hospital, Johannesburg, South Africa
| | - K Søreide
- Department of Clinical Surgery, Royal Infirmary of Edinburgh and Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - T G Weiser
- Department of Clinical Surgery, Royal Infirmary of Edinburgh and Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Surgery, Stanford University, Stanford, California, USA
| | - J Davies
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Institute for Applied Health Research, University of Birmingham, Birmingham, UK.,MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of Witwatersrand, Parktown, South Africa
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Citron I, Saluja S, Amundson J, Ferreira RV, Ljungman D, Alonso N, Moutinho V, Meara JG, Steer M. Surgical quality indicators in low-resource settings: A new evidence-based tool. Surgery 2018; 164:946-952. [PMID: 30076026 DOI: 10.1016/j.surg.2018.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/26/2018] [Accepted: 05/01/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Worldwide efforts to improve access to surgical care must be accompanied by improvements in the quality of surgical care; however, these efforts are contingent on the ability to measure quality. This report describes a novel, evidence-based tool to measure quality of surgical care in low-resource settings. METHODS We defined a widely applicable, multidimensional conceptual framework for quality. The suitability of currently available quality metrics to low-resource settings was evaluated. Then we developed new indicators with sufficient supportive evidence to complete the framework. The complete set of metrics was condensed into four collection sources and tools. RESULTS The following 15 final evidence-based indicators were defined: (1) Safe structure: morbidity and mortality conference; (2) safe process: use of the safe surgery checklist; (3) (4) safe outcomes: perioperative mortality rate and proportion of cases with complications graded >2 on the Clavien-Dindo scale; (5) effective structure: provider density; (6) effective process: procedure rate; (7) effective outcome: rate of caesarean sections; (8) patient-centered process: use of informed consent; (9) patient-centered outcome: patient hospital satisfaction questionnaire; (10) timely structure: travel time to hospital; (11) timely process: time from emergency department presentation to non-elective abdominal surgery; (12) timely outcome: patient follow-up plan; (13) efficient process: daily operating room usage; (14) equitable outcome: comparative income of patients compared with population; and (15) proportion of patients facing catastrophic expenditure because of surgical care. CONCLUSION This tool provides an evidence-based conceptual tool to assess the quality of surgical care in diverse low-resource settings.
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Affiliation(s)
- Isabelle Citron
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.
| | - Saurabh Saluja
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, Weill Cornell Medicine, New York, NY
| | - Julia Amundson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | | | - David Ljungman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Nivaldo Alonso
- Department of Plastic Surgery, University of Sao Paulo, Brazil
| | - Vitor Moutinho
- General Surgery Department, Hospital Militar de Área de São Paulo - HMASP, Brazilian Army
| | - John G Meara
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, MA
| | - Michael Steer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
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Li X, Ohgami N, Yajima I, Xu H, Iida M, Oshino R, Ninomiya H, Shen D, Ahsan N, Akhand AA, Kato M. Arsenic level in toenails is associated with hearing loss in humans. PLoS One 2018; 13:e0198743. [PMID: 29975704 PMCID: PMC6033376 DOI: 10.1371/journal.pone.0198743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 05/24/2018] [Indexed: 11/18/2022] Open
Abstract
Arsenic (As) pollution in drinking water is a worldwide health risk for humans. We previously showed hearing loss in young people who live in areas of As-polluted drinking water and in young mice orally treated with As. In this study, we epidemiologically examined associations between As levels in toenails and hearing in 145 Bangladeshi aged 12-55 years in 2014. Levels of As in toenails, but not those in urine, were shown to be significantly correlated with hearing loss at 4 kHz [odds ratio (OR) = 4.27; 95% confidence interval (CI): 1.51, 12.05], 8 kHz (OR = 3.91; 95% CI: 1.47, 10.38) and 12 kHz (OR = 4.15; 95% CI: 1.55, 11.09) by multivariate analysis with adjustments for age, sex, smoking and BMI. Our experimental study further showed a significant association between As levels in inner ears and nails (r = 0.8113, p = 0.0014) in mice orally exposed to As, suggesting that As level in nails is a suitable index to assess As level in inner ears. Taken together, the results of our study suggest that As level in nails could be a convenient and non-invasive biomarker for As-mediated hearing loss in humans.
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Affiliation(s)
- Xiang Li
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobutaka Ohgami
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
| | - Ichiro Yajima
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
| | - Huadong Xu
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Machiko Iida
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
| | - Reina Oshino
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
| | - Hiromasa Ninomiya
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
| | - Dandan Shen
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nazmul Ahsan
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
- Department of Genetic Engineering and Biotechnology, University of Dhaka, Bangladesh
| | - Anwarul Azim Akhand
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
- Department of Genetic Engineering and Biotechnology, University of Dhaka, Bangladesh
| | - Masashi Kato
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Voluntary Body for International Health Care in Universities, Nagoya, Japan
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Anderson GA, Bohnen J, Spence R, Ilcisin L, Ladha K, Chang D. Data Improvement Through Simplification: Implications for Low-Resource Settings. World J Surg 2018; 42:2725-2731. [PMID: 29404754 DOI: 10.1007/s00268-018-4535-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The focus of many data collection efforts centers on creation of more granular data. The assumption is that more complex data are better able to predict outcomes. We hypothesized that data are often needlessly complex. We sought to demonstrate this concept by examination of the American Society of Anesthesiologists (ASA) scoring system. METHODS First, we created every possible consecutive two, three and four category combinations of the current five category ASA score. This resulted in 14 combinations of simplified ASA. We compared the predictive ability of these simplified scores for postoperative outcomes for 2.3 million patients in the NSQIP database. Individual model performance was assessed by comparing receiver operator characteristic (ROC) curves for each model with the standard ASA. RESULTS Two of our 4-category models and one of our 3-category models had ability to predict all outcomes equivalent to standard ASA. These results held for all outcomes and on all subgroups tested. The performance of the three best performing simplified ASA scores were also equivalent to the standard ASA score in the univariate analysis and when included in a multivariate model. CONCLUSIONS It is assumed that the most granular data and use of the largest number of variables for risk-adjusted predictions will increase accuracy. This complexity is often at the expense of utility. Using the single best predictor in surgical outcomes research, we have shown this is not the case. In this example, we demonstrate that one can simplify ASA into a 3-category variable without losing any ability to predict outcomes.
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Affiliation(s)
- Geoffrey A Anderson
- Massachusetts General Hospital, GRB 425, 55 Fruit St, Boston, MA, 02114, USA.
| | - Jordan Bohnen
- Massachusetts General Hospital, GRB 425, 55 Fruit St, Boston, MA, 02114, USA
| | | | | | - Karim Ladha
- Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - David Chang
- Massachusetts General Hospital, GRB 425, 55 Fruit St, Boston, MA, 02114, USA
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Liu C, Kayima P, Riesel J, Situma M, Chang D, Firth P. Brief surgical procedure code lists for outcomes measurement and quality improvement in resource-limited settings. Surgery 2017; 162:1163-1176. [PMID: 28864101 DOI: 10.1016/j.surg.2017.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/23/2017] [Accepted: 07/04/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The lack of a classification system for surgical procedures in resource-limited settings hinders outcomes measurement and reporting. Existing procedure coding systems are prohibitively large and expensive to implement. We describe the creation and prospective validation of 3 brief procedure code lists applicable in low-resource settings, based on analysis of surgical procedures performed at Mbarara Regional Referral Hospital, Uganda's second largest public hospital. METHODS We reviewed operating room logbooks to identify all surgical operations performed at Mbarara Regional Referral Hospital during 2014. Based on the documented indication for surgery and procedure(s) performed, we assigned each operation up to 4 procedure codes from the International Classification of Diseases, 9th Revision, Clinical Modification. Coding of procedures was performed by 2 investigators, and a random 20% of procedures were coded by both investigators. These codes were aggregated to generate procedure code lists. RESULTS During 2014, 6,464 surgical procedures were performed at Mbarara Regional Referral Hospital, to which we assigned 435 unique procedure codes. Substantial inter-rater reliability was achieved (κ = 0.7037). The 111 most common procedure codes accounted for 90% of all codes assigned, 180 accounted for 95%, and 278 accounted for 98%. We considered these sets of codes as 3 procedure code lists. In a prospective validation, we found that these lists described 83.2%, 89.2%, and 92.6% of surgical procedures performed at Mbarara Regional Referral Hospital during August to September of 2015, respectively. CONCLUSION Empirically generated brief procedure code lists based on International Classification of Diseases, 9th Revision, Clinical Modification can be used to classify almost all surgical procedures performed at a Ugandan referral hospital. Such a standardized procedure coding system may enable better surgical data collection for administration, research, and quality improvement in resource-limited settings.
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Affiliation(s)
- Charles Liu
- Stanford University Medical Center, Stanford, CA.
| | - Peter Kayima
- Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Johanna Riesel
- Harvard Combined Plastic Surgery Residency, Brigham and Women's Hospital, Boston, MA
| | - Martin Situma
- Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | | | - Paul Firth
- Massachusetts General Hospital, Boston, MA
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Short and Long-Term Outcomes After Surgical Procedures Lasting for More Than Six Hours. Sci Rep 2017; 7:9221. [PMID: 28835620 PMCID: PMC5569056 DOI: 10.1038/s41598-017-09833-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
Long-term all-cause mortality and dependency after complex surgical procedures have not been assessed in the framework of value-based medicine. The aim of this study was to investigate the postoperative and long-term outcomes after surgical procedures lasting for more than six hours. Retrospective cohort study of patients undergoing a first elective complex surgical procedure between 2004 and 2013. Heart and transplant surgery was excluded. Mortality and dependency from the healthcare system were selected as outcome variables. Gender, age, ASA, creatinine, albumin kinetics, complications, benign vs malignant underlying condition, number of drugs at discharge, and admission and length of stay in the ICU were recorded as predictive variables. Some 620 adult patients were included in the study. Postoperative, <1year and <5years cumulative mortality was 6.8%, 17.6% and 45%, respectively. Of patients discharged from hospital after surgery, 76% remained dependent on the healthcare system. In multivariate analysis for postoperative, <1year and <5years mortality, postoperative albumin concentration, ASA score and an ICU stay >7days, were the most significant independent predictive variables. Prolonged surgery carries a significant short and long-term mortality and disability. These data may contribute to more informed decisions taken concerning major surgery in the framework of value-based medicine.
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Anderson GA, Ilcisin L, Ngonzi J, Ttendo S, Twesigye D, Benitez NP, Firth P, Nehra D. Validation of an Electronic Surgical Outcomes Database at Mbarara Regional Referral Hospital, Uganda. World J Surg 2017; 42:54-60. [DOI: 10.1007/s00268-017-4172-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Anderson GA, Ilcisin L, Abesiga L, Mayanja R, Portal Benetiz N, Ngonzi J, Kayima P, Shrime MG. Surgical volume and postoperative mortality rate at a referral hospital in Western Uganda: Measuring the Lancet Commission on Global Surgery indicators in low-resource settings. Surgery 2017; 161:1710-1719. [PMID: 28259351 DOI: 10.1016/j.surg.2017.01.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery recommends that every country report its surgical volume and postoperative mortality rate. Little is known, however, about the numbers of operations performed and the associated postoperative mortality rate in low-income countries or how to best collect these data. METHODS For one month, every patient who underwent an operation at a referral hospital in western Uganda was observed. These patients and their outcomes were followed until discharge. Prospective data were compared with data obtained from logbooks and patient charts to determine the validity of using retrospective methods for collecting these metrics. RESULTS Surgical volume at this regional hospital in Uganda is 8,515 operations/y, compared to 4,000 operations/y reported in the only other published data. The postoperative mortality rate at this hospital is 2.4%, similar to other hospitals in low-income countries. Finding patient files in the medical records department was time consuming and yielded only 62% of the files. Furthermore, a comparison of missing versus found charts revealed that the missing charts were significantly different from the found charts. Logbooks, on the other hand, captured 99% of the operations and 94% of the deaths. CONCLUSION Our results describe a simple, reproducible, accurate, and inexpensive method for collection of the Lancet Commission on Global Surgery variables using logbooks that already exist in most hospitals in low-income countries. While some have suggested using risk-adjusted postoperative mortality rate as a more equitable variable, our data suggest that only a limited amount of risk adjustment is possible given the limited available data.
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Affiliation(s)
- Geoffrey A Anderson
- Department of Surgery, Massachusetts General Hospital, Boston, MA; Program in Global Surgery and Social Medicine, Department of Global Health and Social Medicine, Harvard University, Boston, MA
| | - Lenka Ilcisin
- Program in Global Surgery and Social Medicine, Department of Global Health and Social Medicine, Harvard University, Boston, MA
| | - Lenard Abesiga
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ronald Mayanja
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Peter Kayima
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark G Shrime
- Program in Global Surgery and Social Medicine, Department of Global Health and Social Medicine, Harvard University, Boston, MA.
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Spence RT, Hampton M, Pluke K, Kahn M, Chinyepi N, Elmusbahi M, van Wyngaard T, Panieri E. Factors associated with adverse events after emergency laparotomy in Cape Town, South Africa: identifying opportunities for quality improvement. J Surg Res 2016; 206:363-370. [PMID: 27884330 DOI: 10.1016/j.jss.2016.08.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 05/23/2016] [Accepted: 08/04/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Surgical outcomes research is limited in areas of the world with the greatest unmet surgical need and likely greatest variation in outcomes. Measurement alone may improve outcomes-the so-called Hawthorne effect. The purpose of this multicenter cohort study was to identify factors that are both feasible to collect and are associated with a major adverse event following a targeted procedure in Cape Town, South Africa. METHODS A collaborative of four acute care surgical units was formed to develop a data set with minimal data burden describing outcomes after an emergency exploratory laparotomy during a 3-mo period (February-April 2015). Controlling for patient, problem, provider, procedure and process predictors, multivariate models were built to identify risk factors for a major adverse event and higher resource use after surgery in our collaborative. RESULTS The outcomes of 450 exploratory laparotomies from the four participating hospitals were audited, 319 (70.9%) were for non-trauma and 131 (29.1%) were for trauma. The major adverse event rate was 15.7% (95% CI 12.6-19.4). In the multivariate analysis, factors associated with the primary outcome included age, American Society of Anesthesia score of greater than 2, bowel resection, preoperative CT scan, and a nontherapeutic laparotomy. A major adverse event was associated with all three outcomes assessing increased resource utilization. CONCLUSIONS This study supports the comparative outcome assessment of a high-volume or high-risk procedure as a proxy for measuring the quality of care provided in a surgical collaborative. Such an exercise can identify opportunities for quality improvement.
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Affiliation(s)
- Richard Trafford Spence
- Codman Center for Clinical Effectiveness, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - Mark Hampton
- Department of General Surgery, Victoria Hospital, Cape Town, South Africa
| | - Kent Pluke
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Miriam Kahn
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Nkhabe Chinyepi
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mohamed Elmusbahi
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Tirsa van Wyngaard
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Eugenio Panieri
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Augustin T, Schneider E, Alaedeen D, Kroh M, Aminian A, Reznick D, Walsh M, Brethauer S. Emergent Surgery Does Not Independently Predict 30-Day Mortality After Paraesophageal Hernia Repair: Results from the ACS NSQIP Database. J Gastrointest Surg 2015; 19:2097-104. [PMID: 26467561 DOI: 10.1007/s11605-015-2968-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/22/2015] [Indexed: 01/31/2023]
Abstract
AIM Patients undergoing emergency surgery for paraesophageal hernia (PEH) repair have a higher adjusted mortality risk based on Nationwide Inpatient Sample (NIS). We sought to examine this relationship in the National Surgical Quality Improvement Program (NSQIP), which adjusts for patient-level risk factors, including factors contributing to patient frailty. METHODS This is a retrospective analysis of the NSQIP from 2009 through 2011. A modified frailty index was created based on previously validated methodology. RESULTS Of 3498 patients with PEH repair, 175 (5 %) underwent emergent surgery. Older age, lower BMI, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), current dialysis, SIRS, and sepsis were significantly more common among emergent patients. These patients also had a poorer functional status, higher American Society of Anesthesiologists (ASA), and higher frailty scores and more likely to undergo open surgery. Postoperative complications were proportionally more common, and LOS was longer (8.5 vs. 3.4 days) among emergent patients (all p < 0.05). In univariate analysis, emergent patients demonstrated ten times greater mortality than the elective surgery group (8 vs. 0.8 %). On adjusted analysis, emergent surgery was no longer independently associated with mortality. Frailty score 2 or above and preoperative sepsis significantly predicted increased mortality while laparoscopic repair and BMI 25-50 and BMI ≥30 (vs. BMI <18.5) were significantly protective in the entire group of patients. CONCLUSION Increased mortality among patients undergoing emergent PEH repair may be related to severity of disease and other preoperative comorbid illness. Without an emergent indication, some of these patients likely would have been excluded as candidates for elective surgical intervention.
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Affiliation(s)
- Toms Augustin
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Eric Schneider
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Diya Alaedeen
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Matthew Kroh
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Ali Aminian
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - David Reznick
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Matthew Walsh
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Stacy Brethauer
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Rose J, Bendix P, Funzamo C, Vaz F, da Costa AA, Bickler S, Noormahomed EV. Universities form research partnership to improve care in Mozambique. BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 2015; 100:27-34. [PMID: 25626263 PMCID: PMC5454477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Mozambique, a country in sub-Saharan Africa, has experienced a severe physician shortage for many years, with patients having particularly limited access to surgical care. Medical education and surgical research partnerships formed in 2010 between Universidade Eduardo Mondlane (UEM) in Mozambique and the University of California, San Diego (UCSD), is developing potential solutions to the nation’s surgical care crisis. The findings that have emerged from this initiative, which are aimed at scaling up surgical services, will likely have important implications for improving surgical care in Mozambique and other underserved nations.
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