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Elliott-Dawe C, Chen J, Stucky CH, Zadinsky JK. Retrospective Analysis of Associated Costs and Sources of Variability in OR Utilization Across Weekdays. AORN J 2024; 120:e1-e11. [PMID: 38923500 DOI: 10.1002/aorn.14164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/27/2023] [Accepted: 10/04/2023] [Indexed: 06/28/2024]
Abstract
Few studies have examined variability in OR utilization across weekdays. We conducted a retrospective analysis to determine OR utilization differences by day of the week and the source and financial effects of any variability. We extracted 55 months of data from a surgical data repository to calculate OR utilization, late starts, idle times, and delays for each weekday. Declines in OR utilization occurred as the week progressed and were attributed to compounding changes in late start, delay, and idle time. The average weekly cost for each OR associated with unused staffed minutes below a target OR utilization of 85% was $19,383, and the comparable lost weekly revenue was $60,256. Perioperative leaders should identify sources of OR utilization variability when developing strategies that enhance outcomes for patients, minimize costs, and maximize revenue.
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Aridi HD, Leon B, Murphy MP, Malas M, Schermerhorn ML, Kashyap VS, Wang GJ, Eldrup-Jorgensen J, Gonzalez AA, Motaganahalli RL. Predictors of prolonged length of stay after elective carotid revascularization. J Vasc Surg 2024:S0741-5214(24)01201-1. [PMID: 38763455 DOI: 10.1016/j.jvs.2024.05.022] [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: 03/13/2024] [Revised: 05/12/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. METHODS Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. RESULTS A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). CONCLUSIONS A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.
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Affiliation(s)
- Hanaa D Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brandon Leon
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Grace J Wang
- Division of Vascular and Endovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Andrew A Gonzalez
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Kim AS, Hong JS, Levine JN, Foglia C, Saldinger P, Chao SY. Enhanced Recovery After Surgery protocols mitigate the weekend effect on length of stay following elective colectomy. J Gastrointest Surg 2024; 28:662-666. [PMID: 38704203 DOI: 10.1016/j.gassur.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/19/2024] [Accepted: 02/06/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND This study aimed to determine the effect of Enhanced Recovery After Surgery (ERAS) protocols on the weekend effect after elective colectomies. METHODS This was a retrospective study on all elective colorectal surgeries at a single institution in New York City between January 1, 2015, and December 31, 2020. The length of stay (LOS) by day of the week of surgery and the effect of ERAS using univariable and multivariable analyses were compared. RESULTS A total of 605 patients were included in the study. Of note, 41 cases were performed on Mondays, 197 cases were performed on Tuesdays, 45 cases were performed on Wednesdays, 187 cases were performed on Thursdays, and 135 cases were performed on Fridays. Univariate analysis showed that, for patients who did not undergo ERAS, Monday and Tuesday were significantly associated with decreased LOS (P < .001). For patients who underwent ERAS, there was no statistically significant difference in LOS (P = .06) when operated on early in the week vs later. After controlling for age, race/ethnicity, comorbidities, complications, functional health status, operation type, duration of surgery, presence of ostomy, and albumin level, adhering to the ERAS protocol was significantly associated with a shorter LOS (P < .001). CONCLUSION Our study demonstrated that ERAS can mitigate the weekend effect on LOS. ERAS protocols may provide more structure to the expected hospital course and allow patients to reach recovery milestones earlier, facilitating discharge even by covering teams.
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Affiliation(s)
- Angelina S Kim
- Department of Surgery, NewYork-Presbyterian Queens, Flushing, New York, United States.
| | - Julie S Hong
- Department of Surgery, NewYork-Presbyterian Queens, Flushing, New York, United States
| | - Jared N Levine
- Department of Surgery, NewYork-Presbyterian Queens, Flushing, New York, United States
| | - Christopher Foglia
- Department of Surgery, NewYork-Presbyterian Queens, Flushing, New York, United States; Department of Surgery, Weill Cornell Medicine, New York, New York, United States
| | - Pierre Saldinger
- Department of Surgery, NewYork-Presbyterian Queens, Flushing, New York, United States; Department of Surgery, Weill Cornell Medicine, New York, New York, United States
| | - Steven Y Chao
- Department of Surgery, NewYork-Presbyterian Queens, Flushing, New York, United States; Department of Surgery, Weill Cornell Medicine, New York, New York, United States
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Ghosh AK, Ibrahim S, Lee J, Shapiro MF, Ancker J. Comparing Hospital Length of Stay Risk-Adjustment Models in US Value-Based Physician Payments. Qual Manag Health Care 2023; 32:22-29. [PMID: 35383715 PMCID: PMC9530068 DOI: 10.1097/qmh.0000000000000363] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUNG AND OBJECTIVES Under the Affordable Care Act, the US Centers for Medicare & Medicaid Services created the Physician Value-Based Payment Modifier Program and its successor, the Merit-Based Incentive Payment System, to tie physician payments to quality and cost. The addition of hospital length of stay (LOS) to these value-based physician payment models reflects its increasing importance as a metric of health care cost and efficiency and its association with adverse health outcomes. This study compared the Centers for Medicare & Medicaid Services-endorsed LOS risk-adjustment methodology with a novel methodology that accounts for pre-hospitalization clinical, socioeconomic status (SES), and admission-related factors as influential factors of hospital LOS. METHODS Using the 2014 New York, Florida, and New Jersey State Inpatient Database, we compared the observed-to-expected LOS of 2373102 adult admissions for 742 medical and surgical diagnosis-related groups (DRGs) by 3 models: ( a ) current risk-adjustment model (CRM), which adjusted for age, sex, number of chronic conditions, Elixhauser comorbidity score, and DRG severity weight, ( b ) CRM but modeling LOS using a generalized linear model (C-GLM), and (c) novel risk-adjustment model (NRM), which added to the C-GLM covariates for race/ethnicity, SES, discharge destination, weekend admission, and individual intercepts for DRGs instead of severity weights. RESULTS The NRM disadvantaged physicians for fewer medical and surgical DRGs, compared with both the C-GLM and CRM models (medical DRGs: 0.49% vs 13.17% and 10.89%, respectively; surgical DRGs: 0.30% vs 13.17% and 10.98%, respectively). In subgroup analysis, the NRM reduced the proportion of physician-penalizing DRGs across all racial/ethnic and socioeconomic groups, with the highest reduction among Whites, followed by low SES patients, and the lowest reduction among Hispanic patients. CONCLUSIONS After accounting for pre-hospitalization socioeconomic and clinical factors, the adjusted LOS using the NRM was lower than estimates from the current Centers for Medicare & Medicaid Services-endorsed model. The current model may disadvantage physicians serving communities with higher socioeconomic risks.
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Affiliation(s)
- Arnab K. Ghosh
- Department of Medicine, Weill Cornell Medical College, Cornell University, 525 E 68 St., New York, New York, USA 10065
| | - Said Ibrahim
- Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, 402 E 67 St., New York, NY USA 10065
| | - Jennifer Lee
- Department of Medicine, Weill Cornell Medical College, Cornell University, 525 E 68 St., New York, New York, USA 10065
| | - Martin F. Shapiro
- Department of Medicine, Weill Cornell Medical College, Cornell University, 525 E 68 St., New York, New York, USA 10065
| | - Jessica Ancker
- Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, 402 E 67 St., New York, NY USA 10065
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Sihag S. Commentary: Lobectomy on a Weak Day? Mitigating the "Weekend Effect" on Length of Hospital Stay. Semin Thorac Cardiovasc Surg 2021; 33:904-905. [PMID: 33600969 DOI: 10.1053/j.semtcvs.2021.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Smita Sihag
- Thoracic Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York.
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Pupovac SS, Lee PC, Jurado J, Hyman K, Glassman L, Zeltsman D. Impact That Day of the Week has on Length of Stay for Video-assisted Lobectomy. Semin Thorac Cardiovasc Surg 2021; 33:897-901. [DOI: 10.1053/j.semtcvs.2020.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/17/2020] [Indexed: 11/11/2022]
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Cheng TW, Raulli SJ, Farber A, Levin SR, Kalish JA, Jones DW, Rybin D, Doros G, Siracuse JJ. The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass. Ann Vasc Surg 2020; 73:43-50. [PMID: 33370572 DOI: 10.1016/j.avsg.2020.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss. METHODS The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately. RESULTS There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m2 vs. 28 kg/m2), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05). CONCLUSIONS Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.
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Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Stephen J Raulli
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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Shah AC, Nair B, Lang C, Ma K, Neradilek MB, Zucker FH, Lang JD. Safe on Saturday: Elective abdominal and perineal surgeries can be performed on Saturday without increased risk of poor post-operative outcome. Am J Surg 2019; 218:462-466. [PMID: 31288926 DOI: 10.1016/j.amjsurg.2019.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 02/12/2019] [Accepted: 06/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The "weekend effect," whereby surgeries performed during weekend haven been associated with poorer postoperative outcomes. We explored whether Saturday elective procedures at our hospital were associated with poorer post-operative outcomes when compared with weekday surgeries. METHODS A retrospective cohort study of patients undergoing elective surgery on the abdomen or perineum from 2008 to 2015 was performed. Procedures were classified by day (Group 1: Monday, Tuesday, Wednesday; Group 2: Saturday). Multivariate regression analyses were performed to determine group differences in procedure duration, length-of-stay (LOS) and complications. RESULTS In adjusted analyses, there were no statistically significant differences between Group 1 (n = 816) and Group 2 (n = 269) procedures in terms of procedure duration (Group 2 - Group 1 = 13.6 min, p = .19), LOS (Group 2 - Group 1 = 1.9 days, p = .14) and complications (OR 0.58, p = .46). CONCLUSION Saturday elective procedures were not associated with poorer outcomes.
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Affiliation(s)
- Aalap C Shah
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Bala Nair
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Courtney Lang
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Kevin Ma
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | | | - Frank H Zucker
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - John D Lang
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
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Huang J, Chagpar A. Does the Day of the Week a Mastectomy is Performed Influence Length of Stay? Am Surg 2018. [DOI: 10.1177/000313481808400708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Julian Huang
- Department of Surgery Yale University School of Medicine New Haven, Connecticut
| | - Anees Chagpar
- Department of Surgery Yale University School of Medicine New Haven, Connecticut
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Cheng TW, Farber A, Kalish JA, Jones DW, Castagne M, Rybin D, Raulli SJ, Siracuse JJ. Carotid Endarterectomy Performed before the Weekend is Associated with Increased Length of Stay. Ann Vasc Surg 2018; 48:119-126. [DOI: 10.1016/j.avsg.2017.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 09/13/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
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Tillou J, Nagle D, Poylin V, Cataldo T. The impact of surgeon choices on costs associated with uncomplicated minimally invasive colectomy: you are not as important as you think. Gastroenterol Rep (Oxf) 2017; 6:108-113. [PMID: 29780598 PMCID: PMC5952919 DOI: 10.1093/gastro/gox035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/25/2017] [Accepted: 08/07/2017] [Indexed: 01/17/2023] Open
Abstract
Background There is increasing public discussion about the escalating cost of healthcare in America. There are no published data regarding the contribution of individual surgeons’ choices on the cost of uncomplicated minimally invasive colectomy. Methods A review of a hospital cost-accounting database of the direct costs related to the index operation and post-operative care of all patients who underwent elective minimally invasive segmental colectomy over a 1-year period was performed. Results A total of 111 cases were enrolled in this study, 18 of which were performed robotically. The average direct cost after minimally invasive colectomy was $5536. The cost of robotic colectomy was 53% greater than laparoscopic ($7806 vs $5096, p < 0.001). There was no statistically significant difference in overall costs among laparoscopic cases performed by three surgeons ($5099 vs $5108 vs $5055, p = 0.987). Average operating room supply costs among the three surgeons were $1236, $1105 and $1030, respectively (p = 0.067), with a standard deviation of $328 (6.4% of overall cost). Conclusions No significant difference in overall costs between surgeons was demonstrated despite varied training, experience levels and operative techniques. Total costs are relatively institutionally fixed and minimally influenced by variations in individual surgeon preferences.
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Affiliation(s)
- John Tillou
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Deborah Nagle
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Vitaliy Poylin
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Thomas Cataldo
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Nason GJ, O'Connor EM, O'Neill C, Izzeldin O, Considine SW, O'Brien MF. The impact of day of surgery on the length of stay for major urological procedures. Can Urol Assoc J 2016; 10:E367-E371. [PMID: 28096920 DOI: 10.5489/cuaj.3777] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgery performed later in the week has been associated with longer length of stay (LOS). The aim of this study was to assess if the day of the surgery impacted the LOS for two major urological procedures in a tertiary referral university teaching hospital. METHODS A retrospective review was performed of two major urological procedures consecutively performed by a single surgeon in our unit from March 2012 to December 2015. Patient demographics, histopathological characteristics, operative details, and LOS were obtained from the patients' medical records. Procedures performed on Monday or Tuesday were defined as early in the week and procedures performed on Wednesday, Thursday, or Friday were defined as late in the week. RESULTS During the study period, 140 open radical prostatectomy (ORP) and 42 open partial nephrectomy (OPN) procedures were performed. There was a significant difference in median LOS for major urological procedures performed early in the week compared to late in the week (3 [3-4] days vs. 4 [4-5] days; p= 0.0001). There was a significant difference in median LOS for ORP performed early in the week compared to late in the week (3 [3-4] days vs. 4 [4-5] days; p= 0.0004). There was a similar significant difference in OPN performed early in the week compared to late in the week (4 [3-5.5] days vs. 5 [4-5] days; p= 0.029). CONCLUSIONS The day of surgery impacts LOS for major urological procedures. Major procedures should be performed early in the week, when it is feasible to facilitate prompt safe discharge and better use of hospital resources.
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Affiliation(s)
- Gregory J Nason
- Department of Urology, Cork University Hospital, Cork, Ireland
| | | | | | - Omer Izzeldin
- Department of Urology, Cork University Hospital, Cork, Ireland
| | | | - M Frank O'Brien
- Department of Urology, Cork University Hospital, Cork, Ireland
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Mason S, Van Hemelrijck M, Chandra A, Brown C, Cahill D. Laparoscopic radical prostatectomy outcome data: how should surgeon's performance be reported? A retrospective learning curve analysis of two surgeons. Ecancermedicalscience 2016; 10:651. [PMID: 27563346 PMCID: PMC4970620 DOI: 10.3332/ecancer.2016.651] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Indexed: 11/09/2022] Open
Abstract
Objective To document the learning curve for the laparoscopic radical prostatectomy (LRP) procedure and discuss the optimal usage of prospectively documented outcome data for reporting a surgeon’s performance. Materials and methods Using prospectively collected data from the first series of patients to undergo LRP by two surgeons in the same institution, linear and logistic regression multivariate analyses per 25 patients were carried out to graphically represent the surgical learning curve for operative time, blood loss, complications, length of stay (LOS), and positive margins. Surgeon A carried out 275 operations between 2003–2009; Surgeon B carried out 225 between 2008–2012. Results Learning curves showing continuous improvement of each of the above outcomes were demonstrated for both cohorts. For surgeon A, a plateau was observed for LOS and T2 positive margins after 100 and 150 surgeries respectively. No such plateau was observed for surgeon B. Conclusion On documenting these learning curves and discussion of the reporting methods used, we concluded that the most informative outcome measure, with the least potential observer bias was T2 positive margins. Whether as a single measure or in combination with others, this has potential for use as an objective outcome representative of improvement in a surgeon’s skill over time.
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Affiliation(s)
- Sarah Mason
- King's College London, Division of Cancer Studies, Cancer Epidemiology Group, London, UK
| | - Mieke Van Hemelrijck
- King's College London, Division of Cancer Studies, Cancer Epidemiology Group, London, UK
| | | | | | - Declan Cahill
- King's Health Partners, London SE1 9RT, UK; Royal Marsden Hospital, London SW3 6JJ, UK
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Fardoun T, Mathieu R, Vincendeau S, Della Negra E, Corbel L, Couapel JP, Manunta A, Bensalah K, Verhoest G. [Risk of rectal perforation during intention to treat laser photovaporization of prostate with transrectal ultrasound guidance: a report of 4 cases]. Prog Urol 2014; 25:101-6. [PMID: 25541352 DOI: 10.1016/j.purol.2014.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 11/11/2014] [Accepted: 11/14/2014] [Indexed: 11/25/2022]
Abstract
CONTEXT Transrectal ultrasound guidance (TUG) during prostate endoscopic surgery can optimize the procedure by reducing the risk of capsular perforation and ascertain the treatment completeness. TUG is proposed during photoselective vaporisation of prostate (PVP). OBJECTIVE To report four cases of rectal perforations during PVP with TUG and assess their occurrence. MATERIALS AND METHODS This is a retrospective study including prostate endoscopic surgeries with TUG, performed in two centers between November 2011 and May 2013. Rectal perforations were identified. Surgical data, treatment modalities and postoperative outcomes of rectal perforations were analysed. RESULTS Four rectal perforations were identified among 450 surgical procedures. Median age and prostate volume were 80 years old [62-91] and 40mL [13-150], respectively. Two perforations occurred during PVP with Greenlight(®) XPS 180W. Two perforations occurred during transurethral resection of prostate or cervicoprostatic incision. Patients were treated by systematic urinary drainage associated with colostomy or direct suture. Two patients died from this complication and two patients have satisfying functional outcomes at one year. CONCLUSION TUG during prostate endoscopic surgery could lead to rectal perforation by protusion of the prostate and therefore should be used cautiously. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- T Fardoun
- Service d'urologie, CHU Pontchaillou, 2, avenue Henri-Le-Guilloux, 35033 Rennes, France.
| | - R Mathieu
- Service d'urologie, CHU Pontchaillou, 2, avenue Henri-Le-Guilloux, 35033 Rennes, France
| | - S Vincendeau
- Service d'urologie, CHU Pontchaillou, 2, avenue Henri-Le-Guilloux, 35033 Rennes, France
| | - E Della Negra
- Service d'urologie, polyclinique du Littoral, 58, rue La-Fayette, 22003 St-Brieuc, France
| | - L Corbel
- Service d'urologie, polyclinique du Littoral, 58, rue La-Fayette, 22003 St-Brieuc, France
| | - J P Couapel
- Service d'urologie, CHU Pontchaillou, 2, avenue Henri-Le-Guilloux, 35033 Rennes, France
| | - A Manunta
- Service d'urologie, CHU Pontchaillou, 2, avenue Henri-Le-Guilloux, 35033 Rennes, France
| | - K Bensalah
- Service d'urologie, CHU Pontchaillou, 2, avenue Henri-Le-Guilloux, 35033 Rennes, France
| | - G Verhoest
- Service d'urologie, CHU Pontchaillou, 2, avenue Henri-Le-Guilloux, 35033 Rennes, France
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Lee GC, Fong ZV, Ferrone CR, Thayer SP, Warshaw AL, Lillemoe KD, Fernández-del Castillo C. High performing whipple patients: factors associated with short length of stay after open pancreaticoduodenectomy. J Gastrointest Surg 2014; 18:1760-9. [PMID: 25091843 DOI: 10.1007/s11605-014-2604-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/21/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite the decreasing mortality of pancreaticoduodenectomy (PD), it continues to be associated with prolonged length of postoperative hospital stay (LOS). This study aimed to determine factors that could predict short LOS after PD. Additionally, as preliminary data of minimally invasive PD emerges, we sought to determine the average LOS after open PD at a high-volume center to set a standard to which minimally invasive PD can be compared. METHODS A total of 634 consecutive patients who underwent open PD between January 2007 and December 2012 at the Massachusetts General Hospital comprised the study cohort. "High performers" were defined as patients with postoperative LOS ≤5 days. RESULTS Median LOS was 7 days. A total of 61 patients (9.6%) had LOS ≤5 days and were deemed "high performing." In multivariate logistic regression analysis, male gender (p = 0.032), neoadjuvant chemoradiation (p = 0.001), epidural success (p = 0.019), epidural duration ≤3 days (p = 0.001), lack of complications (p < 0.001), surgery on Thursday or Friday (p = 0.001), and discharge on Monday through Wednesday (p < 0.001) were independently associated with LOS ≤5 days. Readmission rate, time to readmission, and mortality were not different between the two groups. The proportion of patients with pancreatic ductal adenocarcinoma who went on to receive adjuvant therapy was no different if LOS was ≤5 or >5 days, but high performance was predictive of beginning therapy <8 weeks after surgery (p = 0.010). CONCLUSION In our experience, median LOS was 7 days, and early discharge (≤5 days) after open PD is safe and feasible in about 10 % of patients. These high performers are more likely to be male, have received neoadjuvant therapy, and had successful epidural analgesia. High performers with cancer are more likely to start chemotherapy <8 weeks after surgery. Minimally invasive PD should be compared to this high standard for median LOS, among other quality metrics, to justify its increased cost, operative duration, and learning curve.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
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Parés D. Factors influencing clinical results in colon surgical resection: surgeon, volume of cases and now day of the week? Am J Surg 2013; 207:1003. [PMID: 24315381 DOI: 10.1016/j.amjsurg.2013.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 08/07/2013] [Indexed: 10/26/2022]
Affiliation(s)
- David Parés
- Department of General and Digestive Surgery, Universitat de Barcelona, Sant Boi de Llobregat, Spain
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