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Zhang B, Huang S, Zhou C, Zhu J, Chen T, Feng S, Huang C, Wang Z, Wu S, Liu C, Zhan X. Prediction of additional hospital days in patients undergoing cervical spine surgery with machine learning methods. Comput Assist Surg (Abingdon) 2024; 29:2345066. [PMID: 38860617 DOI: 10.1080/24699322.2024.2345066] [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] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Machine learning (ML), a subset of artificial intelligence (AI), uses algorithms to analyze data and predict outcomes without extensive human intervention. In healthcare, ML is gaining attention for enhancing patient outcomes. This study focuses on predicting additional hospital days (AHD) for patients with cervical spondylosis (CS), a condition affecting the cervical spine. The research aims to develop an ML-based nomogram model analyzing clinical and demographic factors to estimate hospital length of stay (LOS). Accurate AHD predictions enable efficient resource allocation, improved patient care, and potential cost reduction in healthcare. METHODS The study selected CS patients undergoing cervical spine surgery and investigated their medical data. A total of 945 patients were recruited, with 570 males and 375 females. The mean number of LOS calculated for the total sample was 8.64 ± 3.7 days. A LOS equal to or <8.64 days was categorized as the AHD-negative group (n = 539), and a LOS > 8.64 days comprised the AHD-positive group (n = 406). The collected data was randomly divided into training and validation cohorts using a 7:3 ratio. The parameters included their general conditions, chronic diseases, preoperative clinical scores, and preoperative radiographic data including ossification of the anterior longitudinal ligament (OALL), ossification of the posterior longitudinal ligament (OPLL), cervical instability and magnetic resonance imaging T2-weighted imaging high signal (MRI T2WIHS), operative indicators and complications. ML-based models like Lasso regression, random forest (RF), and support vector machine (SVM) recursive feature elimination (SVM-RFE) were developed for predicting AHD-related risk factors. The intersections of the variables screened by the aforementioned algorithms were utilized to construct a nomogram model for predicting AHD in patients. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve and C-index were used to evaluate the performance of the nomogram. Calibration curve and decision curve analysis (DCA) were performed to test the calibration performance and clinical utility. RESULTS For these participants, 25 statistically significant parameters were identified as risk factors for AHD. Among these, nine factors were obtained as the intersection factors of these three ML algorithms and were used to develop a nomogram model. These factors were gender, age, body mass index (BMI), American Spinal Injury Association (ASIA) scores, magnetic resonance imaging T2-weighted imaging high signal (MRI T2WIHS), operated segment, intraoperative bleeding volume, the volume of drainage, and diabetes. After model validation, the AUC was 0.753 in the training cohort and 0.777 in the validation cohort. The calibration curve exhibited a satisfactory agreement between the nomogram predictions and actual probabilities. The C-index was 0.788 (95% confidence interval: 0.73214-0.84386). On the decision curve analysis (DCA), the threshold probability of the nomogram ranged from 1 to 99% (training cohort) and 1 to 75% (validation cohort). CONCLUSION We successfully developed an ML model for predicting AHD in patients undergoing cervical spine surgery, showcasing its potential to support clinicians in AHD identification and enhance perioperative treatment strategies.
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Affiliation(s)
- Bin Zhang
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Orthopaedics, The Guizhou Hospital of Beijing Jishuitan Hospital, Guiyang, China
| | - Shengsheng Huang
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chenxing Zhou
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jichong Zhu
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Tianyou Chen
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Sitan Feng
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chengqian Huang
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zequn Wang
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shaofeng Wu
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chong Liu
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xinli Zhan
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Yeung J, Jhanji S, Braun J, Dunn J, Eggleston L, Frempong S, Hiller L, Jacques C, Jefford M, Mason J, Moonesinghe R, Pearse R, Shelley B, Vindrola C. Volatile vs Total intravenous Anaesthesia for major non-cardiac surgery: a pragmatic randomised triaL (VITAL). Trials 2024; 25:414. [PMID: 38926770 PMCID: PMC11210167 DOI: 10.1186/s13063-024-08159-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/07/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Improving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety. METHODS A multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia. DISCUSSION Given the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments. TRIAL REGISTRATION ISRCTN62903453. September 09, 2021.
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Affiliation(s)
- Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.
| | | | - John Braun
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Janet Dunn
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Lucy Eggleston
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Samuel Frempong
- Centre for Health Economics at Warwick, Warwick Medical School, University of Warwick, Coventry, UK
| | - Louise Hiller
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Jacques
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - James Mason
- Centre for Health Economics at Warwick, Warwick Medical School, University of Warwick, Coventry, UK
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Jules-Elysee KM, Sigmund AE, Tsai MH, Simmons JW. Expanding the perioperative lens: Does the end justify the means? J Clin Anesth 2024; 97:111522. [PMID: 38870702 DOI: 10.1016/j.jclinane.2024.111522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/26/2024] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
In 1994, Fischer et al. established the preoperative clinic for the perioperative services at Stanford University Medical Center. By lowering the risk of cancellation and reducing morbidity and mortality against the push to move surgeries to an outpatient, basis, they demonstrated a return on investment. In the 2000s, Aronson et al. designed the prehabilitation clinics at Duke University with the notion that the preoperative process should not only ensure that patients were appropriately risk-stratified, but also clinically optimized before surgery. With a trend towards ambulatory procedures due to current reimbursement structures, hospital administrators should be searching for potential avenues to bolster sagging profits. In this narrative review, we argue that the perioperative services needs to extend beyond the hospital into the postoperative period.
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Affiliation(s)
- Kethy M Jules-Elysee
- Hospital for Special Surgery, Department of Anesthesiology, Critical Care, and Pain Management, New York, NY, USA.
| | - Alana E Sigmund
- Hospital for Special Surgery, Department of Internal Medicine, Division of Perioperative Medicine, New York, NY, USA.
| | - Mitchell H Tsai
- Department of Anesthesiology and Perioperative Medicine, Heersink School of Medicine, University of Alabama Birmingham, Birmingham, AL, USA; Department of Anesthesiology, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA; Department of Anesthesiology, University of Vermont, Larner College of Medicine, Burlington, VT, USA; Department of Orthopedics and Rehabilitation (by courtesy), Department of Surgery (by courtesy), Larner College of Medicine, University of Vermont, Burlington, VT, USA.
| | - Jeff W Simmons
- Department of Anesthesiology and Perioperative Medicine, Heersink School of Medicine, University of Alabama Birmingham, Birmingham, AL, USA.
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Bøgh M, Gade S, Larsen DG, Schytte S, Pedersen U, Kjærgaard T. Predictors in the treatment of malignant central airway obstruction with silicone stents. Eur Arch Otorhinolaryngol 2024; 281:1457-1462. [PMID: 38183453 PMCID: PMC10858089 DOI: 10.1007/s00405-023-08365-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/19/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE To examine the role of the silicone stent in palliation of malignant central airway obstruction and identify potential preprocedural predictors for postprocedural outcome. METHODS Patients treated with endoscopic insertion of tracheobronchial silicone stents for malignant central airway obstruction at Aarhus University Hospital from 2012 to 2022 were identified from electronic medical records. Statistical analyses were carried out to identify factors affecting Days Alive and Out of Hospital, complications and overall survival. RESULTS 81 patients underwent a total of 90 tracheobronchial stent insertions. Days Alive and Out of Hospital (DAOH) for the first 30 days were affected negatively by urgent intervention, p < 0.001, preprocedural non-invasive respiratory support, p < 0.001, and preprocedural intubation, p = 0.02. Post-procedural oncological treatment was associated with a significant improved DAOH, p = 0.04. Symptomatology and lesion characteristics were not significantly associated with any impact on DAOH. Overall survival was poor (mean survival was 158 days), and only significantly affected by severe degree of dyspnea, p = 0.02, and postprocedural oncological treatment, p < 0.001. Complication where registered in 25.6% of cases within the first 30 days was observed. Procedure-related mortality was 3.7%. Based on chart annotations by an ENT-surgeon, 95% of the patients experienced relief of symptoms following stent insertion. CONCLUSIONS Palliative tracheobronchial airway stenting with silicone stents is found to have a beneficial impact, more research is required for identification of predictors for postprocedural outcome based on preprocedural classifications.
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Affiliation(s)
- Mads Bøgh
- Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Gade
- Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sten Schytte
- Otorhinolaryngology, Head and Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Ulrik Pedersen
- Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Kjærgaard
- Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark.
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van Wilpe R, van Zuylen ML, Hermanides J, DeVries JH, Preckel B, Hulst AH. Preoperative Glycosylated Haemoglobin Screening to Identify Older Adult Patients with Undiagnosed Diabetes Mellitus-A Retrospective Cohort Study. J Pers Med 2024; 14:219. [PMID: 38392652 PMCID: PMC10890067 DOI: 10.3390/jpm14020219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 02/24/2024] Open
Abstract
More than 25% of older adults in Europe have diabetes mellitus. It is estimated that 45% of patients with diabetes are currently undiagnosed, which is a known risk factor for perioperative morbidity. We investigated whether routine HbA1c screening in older adult patients undergoing surgery would identify patients with undiagnosed diabetes. We included patients aged ≥65 years without a diagnosis of diabetes who visited the preoperative assessment clinic at the Amsterdam University Medical Center and underwent HbA1c screening within three months before surgery. Patients undergoing cardiac surgery were excluded. We assessed the prevalence of undiagnosed diabetes (defined as HbA1c ≥ 48 mmol·mol-1) and prediabetes (HbA1c 39-47 mmol·mol-1). Using a multivariate regression model, we analysed the ability of HbA1c to predict days alive and at home within 30 days after surgery. From January to December 2019, we screened 2015 patients ≥65 years at our clinic. Of these, 697 patients without a diagnosis of diabetes underwent HbA1c screening. The prevalence of undiagnosed diabetes and prediabetes was 3.7% (95%CI 2.5-5.4%) and 42.9% (95%CI 39.2-46.7%), respectively. Preoperative HbA1c was not associated with days alive and at home within 30 days after surgery. In conclusion, we identified a small number of patients with undiagnosed diabetes and a high prevalence of prediabetes based on preoperative HbA1c screening in a cohort of older adults undergoing non-cardiac surgery. The relevance of prediabetes in the perioperative setting is unclear. Screening for HbA1c in older adult patients undergoing non-cardiac surgery does not appear to help predict postoperative outcome.
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Affiliation(s)
- Robert van Wilpe
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Mark L van Zuylen
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
- Department of Paediatric Intensive Care, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Abraham H Hulst
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
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Habermann A, Widaeus M, Soltani N, Myles PS, Hallqvist L, Bell M. Days at home alive after major surgery in patients with and without diabetes: an observational cohort study. Perioper Med (Lond) 2024; 13:4. [PMID: 38254223 PMCID: PMC10802053 DOI: 10.1186/s13741-023-00357-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE We hypothesized that days at home alive up to 30 days after surgery (DAH30), a novel patient-centered outcome metric, as well as long-term mortality, would be impaired in patients with type 1 or 2 diabetes mellitus (DM) undergoing major surgery. METHODS This cohort study investigated patients > 18 years with and without DM presenting for major non-cardiovascular, non-ambulatory surgical procedures at 23 hospitals in Sweden between 2007 and 2014. We identified 290,306 patients. Data were matched with various quality registers. The primary outcome was the composite score, DAH30. The secondary outcome was mortality from 31 to 365 days. Using multivariable logistic regression, significant independent risk factors influencing the primary and secondary outcomes were identified, and their adjusted odds ratios were calculated. RESULTS Patients with DM type 1 and 2 had significantly lower DAH30 as compared to non-diabetics. Patients with DM were older, had higher co-morbid burden, and needed more emergency surgery. After adjustment for illness severity and age, the odds of having a DAH30 less than 15, indicating death and/or complications, were significantly increased for both type 1 and type 2 diabetes. In the year after surgery, DM patients had a higher mortality as compared to those without diabetes. CONCLUSIONS The results of this large cohort study are likely broadly generalizable. To optimize patient and societal outcomes, specific perioperative care pathways for patients with diabetes should be evaluated.
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Affiliation(s)
- Amanda Habermann
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Matilda Widaeus
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Navid Soltani
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Linn Hallqvist
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Max Bell
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
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Naumann DN, Bhangu A, Brooks A, Martin M, Cotton BA, Khan M, Midwinter MJ, Pearce L, Bowley DM, Holcomb JB, Griffiths EA. Novel Textbook Outcomes following emergency laparotomy: Delphi exercise. BJS Open 2024; 8:zrad128. [PMID: 38284399 PMCID: PMC10823418 DOI: 10.1093/bjsopen/zrad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/16/2023] [Accepted: 11/03/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy. METHODS A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1-5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round. RESULTS A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into 'early' and 'longer-term'. For non-trauma patients the proposed early Textbook Outcome was 'Discharged from hospital without serious postoperative complications (Clavien-Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was 'Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien-Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)'. The longer-term Textbook Outcome for both non-trauma and trauma was 'Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year'. CONCLUSION Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.
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Affiliation(s)
- David N Naumann
- Department of Trauma and Emergency General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aneel Bhangu
- Department of Trauma and Emergency General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- NIHR Global Health Unit on Global Surgery, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Adam Brooks
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham, UK
| | - Matthew Martin
- Division of Trauma and Acute Care Surgery, Department of Surgery, Los Angeles County & USC Medical Center, Los Angeles, California, USA
| | - Bryan A Cotton
- The Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mansoor Khan
- Department of General Surgery, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Mark J Midwinter
- School of Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Lyndsay Pearce
- Department of General Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Douglas M Bowley
- Department of Trauma and Emergency General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John B Holcomb
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ewen A Griffiths
- Department of Trauma and Emergency General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Bruce MR, Frasco PE, Sell-Dottin KA, Cuevas CV, Chang YHH, Lim ES, Rosenthal JL, DeValeria PA, Smith BB. Days Alive and Out of the Hospital After Heart Transplantation: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:93-100. [PMID: 38197788 DOI: 10.1053/j.jvca.2023.09.039] [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: 07/27/2023] [Revised: 09/04/2023] [Accepted: 09/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Evaluate days alive and out of the hospital (DAOH) as an outcome measure after orthotopic heart transplantation in patients with mechanical circulatory support (MCS) as a bridge to transplant compared to those patients without prior MCS. DESIGN A retrospective observational study of adult patients who underwent cardiac transplantation between January 1, 2015, and January 1, 2020. The primary outcome was DAOH at 365 days (DAOH365) after an orthotopic heart transplant. A Poisson regression model was fitted to detect the association between independent variables and DAOH365. SETTING An academic tertiary referral center. PARTICIPANTS A total of 235 heart transplant patients were included-103 MCS as a bridge to transplant patients, and 132 direct orthotopic heart transplants without prior MCS. MEASUREMENTS AND MAIN RESULTS The median DAOH365 for the entire cohort was 348 days (IQR 335.0-354.0). There was no difference in DAOH365 between the MCS patients and patients without MCS (347.0 days [IQR 336.0-353.0] v 348.0 days [IQR 334.0-354.0], p = 0.43). Multivariate analysis identified patients who underwent a transplant after the 2018 heart transplant allocation change, pretransplant pulmonary hypertension, and increased total ischemic time as predictors of reduced DAOH365. CONCLUSIONS In this analysis of patients undergoing orthotopic heart transplantation, there was no significant difference in DAOH365 in patients with prior MCS as a bridge to transplant compared to those without MCS. Incorporating days alive and out of the hospital into the pre-transplant evaluation may improve understanding and conceptualization of the post-transplantation patient experience and aid in shared decision-making with clinicians.
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Affiliation(s)
- Marcus R Bruce
- Department of Anesthesiology and Perioperative Medicine, Cardiothoracic Division, University of California San Diego, San Diego, CA
| | - Peter E Frasco
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | | | | | - Yu-Hui H Chang
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ
| | - Elisabeth S Lim
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ
| | | | | | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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Li J. Home Health Agencies With High Quality of Patient Care Star Ratings Reduced Short-Term Hospitalization Rates and Increased Days Independently at Home. Med Care 2024; 62:11-20. [PMID: 37796230 PMCID: PMC10842573 DOI: 10.1097/mlr.0000000000001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND Critics argue that Medicare's Quality of Patient Care home health star ratings are inaccurate. Valid ratings are essential to help patients find high-quality care. OBJECTIVE The aim of this study was to determine whether using the highest-rated home health agency available in a ZIP code improves outcomes. RESEARCH DESIGN A retrospective study of 1,870,080 Medicare fee-for-service beneficiaries using home health care from July 2015 through July 2016 in the United States. An instrumental variables approach is used to address the endogeneity of agency choice, where the instrument is the differential proximity of the patient to the closest highest-rated and closest lower-rated agency. OUTCOMES Days independently at home; health care setting-specific days and death; hospitalization, emergency department use, and institutionalization risk. RESULTS Treatment by the highest-rated agencies available decreased risks (in percentage points) of hospitalization (-3.2; 95% CI, -4.1 to -2.3), emergency department use (-2.2; 95% CI, -3.2 to -1.1), and institutionalization (-0.9; 95% CI, -1.3 to -0.5) during the initial episode, and increased days independently at home by 2.6% or 3.75 (95% CI, 2.20-5.29) days in the 180 days after the end of the initial episode. Treatment effects were more pronounced for agencies that were above-average (6.51 d; 95% CI, 4.15-8.87), had ≥1 more star than the next-best agency (7.80 d; 95% CI, 4.13-11.47), and nonrural residents (4.57 d; 95% CI, 2.75-6.40). Effects were positive for both postacute (3.40; 95% CI, 1.80-5.00) and community-entry (5.60; 95% CI, 2.30-8.89) patients. CONCLUSIONS Medicare's Quality of Patient Care star rating correlates with reduced short-term hospitalizations and emergency department use and increased days independently at home in the longer term.
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Affiliation(s)
- Jun Li
- Department of Public Administration and International Affairs, Maxwell School of Citizenship and Public Affairs, Syracuse University, Syracuse, NY
- Aging Studies Institute, Syracuse University, Syracuse NY
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10
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Sharif L, Gunaseelan V, Lagisetty P, Bicket M, Waljee J, Englesbe M, Brummett CM. High-risk Prescribing Following Surgery Among Payer Types for Patients on Chronic Opioids. Ann Surg 2023; 278:1060-1067. [PMID: 37335197 DOI: 10.1097/sla.0000000000005938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance. BACKGROUND Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance. METHODS In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber. RESULTS Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402). CONCLUSIONS Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality.
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Affiliation(s)
- Limi Sharif
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | - Pooja Lagisetty
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Center for Clinical Management and Research, Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
| | - Mark Bicket
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
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11
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Dennis PA, Stechuchak KM, Van Houtven CH, Decosimo K, Coffman CJ, Grubber JM, Lindquist JH, Sperber NR, Hastings SN, Shepherd‐Banigan M, Kaufman BG, Smith VA. Informing a home time measure reflective of quality of life: A data driven investigation of time frames and settings of health care utilization. Health Serv Res 2023; 58:1233-1244. [PMID: 37356820 PMCID: PMC10622302 DOI: 10.1111/1475-6773.14196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023] Open
Abstract
OBJECTIVE To evaluate short- and long-term measures of health care utilization-days in the emergency department (ED), inpatient (IP) care, and rehabilitation in a post-acute care (PAC) facility-to understand how home time (i.e., days alive and not in an acute or PAC setting) corresponds to quality of life (QoL). DATA SOURCES Survey data on community-residing veterans combined with multipayer administrative data on health care utilization. STUDY DESIGN VA or Medicare health care utilization, quantified as days of care received in the ED, IP, and PAC in the 6 and 18 months preceding survey completion, were used to predict seven QoL-related measures collected during the survey. Elastic net machine learning was used to construct models, with resulting regression coefficients used to develop a weighted utilization variable. This was then compared with an unweighted count of days with any utilization. PRINCIPAL FINDINGS In the short term (6 months), PAC utilization emerged as the most salient predictor of decreased QoL, whereas no setting predominated in the long term (18 months). Results varied by outcome and time frame, with some protective effects observed. In the 6-month time frame, each weighted day of utilization was associated with a greater likelihood of activity of daily living deficits (0.5%, 95% CI: 0.1%-0.9%), as was the case with each unweighted day of utilization (0.6%, 95% CI: 0.3%-1.0%). The same was true in the 18-month time frame (for both weighted and unweighted, 0.1%, 95% CI: 0.0%-0.3%). Days of utilization were also significantly associated with greater rates of instrumental ADL deficits and fair/poor health, albeit not consistently across all models. Neither measure outperformed the other in direct comparisons. CONCLUSIONS These results can provide guidance on how to measure home time using multipayer administrative data. While no setting predominated in the long term, all settings were significant predictors of QoL measures.
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Affiliation(s)
- Paul A. Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Karen M. Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Courtney H. Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Cynthia J. Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Biostatistics and BioinformaticsDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Janet M. Grubber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Cooperative Studies Program Coordinating Center, Veterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Jennifer H. Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Nina R. Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - S. Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care SystemDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke UniversityDurhamNorth CarolinaUSA
| | - Megan Shepherd‐Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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12
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Barry IP, Turley LP, Gwilym BL, Bosanquet DC, Richards T. Impact of closed-incision negative pressure wound dressings on surgical site infection following groin incisions in vascular surgery; a single-centre experience. Vascular 2023; 31:1128-1133. [PMID: 35759405 DOI: 10.1177/17085381221111007] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Surgical site infection (SSI) is a common complication in vascular surgery, and is associated with increased patient morbidity, readmission and reintervention. The aim of this study was to assess the impact of closed-incision negative pressure wound therapy (CiNPWT) upon rate of SSI and length of hospital stay. METHODS This study was reported in line with the STROBE guidelines. We assessed the baseline incidence of SSI from a 12-month retrospective cohort and, following a change in practice intervention with CiNPWT, compared to a 6-month prospective cohort. The primary endpoint was incidence of SSI (according to CDC-NHSN guidelines) while secondary endpoints included length of hospital stay, readmission, reintervention and Days Alive and Out of Hospital (DAOH) to 90-days. RESULTS A total of 127 groin incisions were performed: 76 (65 patients) within the retrospective analysis and 51 (42 patients) within the prospective analysis (of whom 69% received CiNPWT). The primary endpoint of SSI was seen in 21.1% of the retrospective cohort and 9.8% of the prospective cohort (p = .099). Readmission was found to be significantly associated with the retrospective cohort (p = .016) while total admission (inclusive of re-admission) was significantly longer in those in the retrospective cohort (p = .013). DAOH-90 was 83 days (77-85) following introduction of the CiNPWT protocol as compared to the retrospective cohort (77 days (64-83), p = .04). CONCLUSION Introduction of CiNPWT was associated with a reduced length of hospital stay and improved DAOH-90. Further trials on CINPWT should include patient-centred outcomes and healthcare cost analysis.
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Affiliation(s)
- Ian Patrick Barry
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Luke P Turley
- Department of General Surgery, Sir Charles Gardiner Hospital, Nedlands, WA, Australia
| | - Brenig L Gwilym
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - David C Bosanquet
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - Toby Richards
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
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13
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Leaman EE, Ludbrook GL. The Cost-Effectiveness of Early High-Acuity Postoperative Care for Medium-Risk Surgical Patients. Anesth Analg 2023:00000539-990000000-00663. [PMID: 38009844 DOI: 10.1213/ane.0000000000006743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Initiatives in perioperative care warrant robust cost-effectiveness analysis in a cost-constrained era when high-value care is a priority. A model of anesthesia-led early high-acuity postoperative care, advanced recovery room care (ARRC), has shown benefit in terms of hospital and patient outcomes, but its cost-effectiveness has not yet been formally determined. METHODS Data from a previously published single-center prospective cohort study of ARRC in medium-risk patients were used to generate a Markov model, which described patient transition between care locations, each with different characteristics and costs. The incremental cost-effectiveness ratio (ICER), using days at home (DAH) and hospital costs, was calculated for ARRC compared to usual ward care using deterministic and probabilistic sensitivity analysis. RESULTS The Markov model accurately described patient disposition after surgery. For each patient, ARRC provided 4.3 more DAH within the first 90 days after surgery and decreased overall hospital costs by $1081 per patient. Probabilistic sensitivity analysis revealed that ARRC had a 99.3% probability of increased DAH and a 77.4% probability that ARRC was dominant from the perspective of the hospital, with improved outcomes and decreased costs. CONCLUSIONS Early high-acuity care for approximately 24 hours after surgery in medium-risk patients provides highly cost-effective improvements in outcomes when compared to usual ward care.
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Affiliation(s)
- Esrom E Leaman
- From the Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Guy L Ludbrook
- From the Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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14
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Huang L, Frandsen MN, Kehlet H, Petersen RH. Days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in the era of enhanced recovery. BJS Open 2023; 7:zrad144. [PMID: 38108464 PMCID: PMC10726402 DOI: 10.1093/bjsopen/zrad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/26/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Days alive and out of hospital is proposed as a valid and patient-centred quality measure for perioperative care. However, no procedure-specific data exist after pulmonary wedge resection. The aim of this study was to assess the first 90 days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in an optimized enhanced recovery programme. METHODS A retrospective analysis of prospectively collected data of consecutive patients undergoing enhanced recovery thoracoscopic wedge resections from January 2021 to June 2022 in a high-volume centre was carried out. All factors leading to hospitalization, readmission, and death were evaluated individually. A logistic regression model was used to evaluate predictors. Additionally, a sensitivity analysis was performed. RESULTS A total of 433 patients were included (21.7% (n = 94) with non-small cell lung cancer, 47.6% (n = 206) with metastasis, 26.8% (n = 116) with benign nodules, and 3.9% (n = 17) with other lung cancers). The median duration of hospital stay was 1 day. The median of postoperative 30 and 90 days alive and out of hospital was 28 and 88 days respectively. Air leak (112 patients) and pain (96 patients) were the most frequent reasons for reduced days alive and out of hospital from postoperative day 1 to 30, whereas treatment of the original cancer or metastasis (36 patients) was the most frequent reason for reduced days alive and out of hospital from postoperative day 31 to 90. Male sex, reduced lung function, longer dimension of resection margin, pleural adhesions, and non-small cell lung cancer were independent risks, confirmed by a sensitivity analysis. CONCLUSION Days alive and out of hospital within 90 days after enhanced recovery thoracoscopic wedge resection was only reduced by a median of 2 days, mainly due to air leak and pain.
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Affiliation(s)
- Lin Huang
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mikkel Nicklas Frandsen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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15
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Ekmann-Gade AW, Høgdall C, Seibæk L, Noer MC, Rasmussen A, Schnack TH. Days alive and out of hospital after surgical treatment of epithelial ovarian cancer: A Danish nationwide cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107039. [PMID: 37639861 DOI: 10.1016/j.ejso.2023.107039] [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: 03/10/2023] [Revised: 08/09/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Days alive and out of hospital (DAOH) is a validated outcome measure in perioperative trials integrating information on primary hospitalization, readmissions, and mortality. It is negatively associated with advanced age. However, DAOH has not been described for surgical treatment of epithelial ovarian cancer (EOC), primarily diagnosed in older patients. METHODS We conducted a Danish nationwide cohort study including patients undergoing debulking surgery for EOC from 2013 to 2018. DAOH was explored for 30 (DAOH30), 90 (DAOH90), and 180 (DAOH180) postoperative days in younger (<70 years) and older (≥70 years) patients with advanced-stage disease stratified by surgical modality (primary (PDS) or interval debulking surgery (IDS)). We examined the associations between patient- and surgical outcomes and low or high DAOH30. RESULTS Overall, 1168 patients had stage IIIC-IV disease and underwent debulking surgery. DAOH30 was 22 days [interquartile range (IQR): 18, 25] and 23 days [IQR: 18, 25] for younger and older patients treated with PDS, respectively. For IDS, DAOH30 was 25 days [IQR: 22, 26] for younger and 25 days[IQR: 21, 26] for older patients. We found no significant differences between age cohorts regarding DAOH30, DAOH90, and DAOH180. Low DAOH30 was associated with poor performance status, PDS, extensive surgery, and long duration of surgery in adjusted analysis. CONCLUSIONS DAOH did not differ significantly between age cohorts. Surgical rather than patient-related factors were associated with low DAOH30. Our results likely reflect a high selection of fit older patients for surgery, reducing the patient-related differences between younger and older patients receiving surgical treatment.
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Affiliation(s)
| | - Claus Høgdall
- Department of Gynecology, Rigshospitalet, Copenhagen, Denmark
| | - Lene Seibæk
- Department of Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Calundann Noer
- Department of Gynecology and Obstetrics, Herlev University Hospital, Herlev, Denmark
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16
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Frei DR, Beasley R, Campbell D, Forbes A, Leslie K, Mackle D, Martin C, Merry A, Moore MR, Myles PS, Ruawai-Hamilton L, Short TG, Young PJ. A vanguard randomised feasibility trial comparing three regimens of peri-operative oxygen therapy on recovery after major surgery. Anaesthesia 2023; 78:1272-1284. [PMID: 37531294 DOI: 10.1111/anae.16103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/04/2023]
Abstract
International recommendations encourage liberal administration of oxygen to patients having surgery under general anaesthesia, ostensibly to reduce surgical site infection. However, the optimal oxygen regimen to minimise postoperative complications and enhance recovery from surgery remains uncertain. The hospital operating theatre randomised oxygen (HOT-ROX) trial is a multicentre, patient- and assessor-blinded, parallel-group, randomised clinical trial designed to assess the effect of a restricted, standard care, or liberal peri-operative oxygen therapy regimen on days alive and at home after surgery in adults undergoing prolonged non-cardiac surgery under general anaesthesia. Here, we report the findings of the internal vanguard feasibility phase of the trial undertaken in four large metropolitan hospitals in Australia and New Zealand that included the first 210 patients of a planned overall 2640 trial sample, with eight pre-specified endpoints evaluating protocol implementation and safety. We screened a total of 956 participants between 1 September 2019 and 26 January 2021, with data from 210 participants included in the analysis. Median (IQR [range]) time-weighted average intra-operative Fi O2 was 0.30 (0.26-0.35 [0.20-0.59]) and 0.47 (0.44-0.51 [0.37-0.68]) for restricted and standard care, respectively (mean difference (95%CI) 0.17 (0.14-0.20), p < 0.001). Median time-weighted average intra-operative Fi O2 was 0.83 (0.80-0.85 [0.70-0.91]) for liberal oxygen therapy (mean difference (95%CI) compared with standard care 0.36 (0.33-0.39), p < 0.001). All feasibility endpoints were met. There were no significant patient adverse events. These data support the feasibility of proceeding with the HOT-ROX trial without major protocol modifications.
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Affiliation(s)
- D R Frei
- Department of Anaesthesia and Pain Management, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - R Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - D Campbell
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia and Peri-operative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - A Forbes
- Biostatistics Unit, Division of Research Methodology, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - K Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - D Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - C Martin
- Biostatistics Unit, Division of Research Methodology, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - A Merry
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - M R Moore
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - P S Myles
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital, Melbourne, VIC, Australia
- Department of Anaesthesiology and Peri-operative Medicine, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - L Ruawai-Hamilton
- Department of Anaesthesia and Pain Management, Wellington Hospital, Wellington, New Zealand
| | - T G Short
- Department of Anaesthesia and Peri-operative Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - P J Young
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
- Department of Intensive Care, Wellington Regional Hospital, Wellington, New Zealand
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17
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Widaeus M, Hertzberg D, Hallqvist L, Bell M. Risk factors for new antidepressant use after surgery in Sweden: a nationwide, observational cohort study. BJA OPEN 2023; 7:100218. [PMID: 37638080 PMCID: PMC10457487 DOI: 10.1016/j.bjao.2023.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/21/2023] [Indexed: 08/29/2023]
Abstract
Background Whilst somatic complications after major surgery are being increasingly investigated, the research field has scarce data on psychiatric outcomes such as postoperative depression. This study evaluates the impact of patient and surgical factors on the risk of depression after surgery using the proxy measure of prescribed and collected antidepressants. Methods An observational, registry-based, national multicentre cohort study of individuals ≥18 yr of age who underwent noncardiac surgery between 2007 and 2014. Exclusion criteria included history of antidepressant use defined by collection of a prescription within 5 yr before surgery. Participants were identified using a surgical database from 23 Swedish hospitals and data were linked to National Board of Health and Welfare registers for collection of prescribed antidepressants. Descriptive statistics were used for baseline data and logistic regression for predictive factors. Results Of 223 617 patients, 4.9% had a new prescription of antidepressants collected 31-365 days after surgery. Antidepressant prescription was associated with increasing age, female sex, and more comorbidities. The incidence of antidepressant prescription was highest after neurosurgery, vascular, and thoracic surgery. Affective and anxiety disorders were risk factors. In the whole cohort and within the aforementioned surgical subtypes, acute and cancer surgery increased the risk of antidepressant prescription. Conclusions This study brings novel insights to the epidemiology of postoperative antidepressant treatment in antidepressant-naive patients. One in 20 postoperative patients are prescribed antidepressants but with knowledge of risk factors, interventional strategies can be tested.
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Affiliation(s)
- Matilda Widaeus
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Hertzberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Linn Hallqvist
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Max Bell
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Zogg CK, Cooper Z, Peduzzi P, Falvey JR, Tinetti ME, Lichtman JH. Beyond In-hospital Mortality: Use of Postdischarge Quality-Metrics Provides a More Complete Picture of Older Adult Trauma Care. Ann Surg 2023; 278:e314-e330. [PMID: 36111845 PMCID: PMC10014495 DOI: 10.1097/sla.0000000000005707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the distributions of and extent of variability among 3 new sets of postdischarge quality-metrics measured within 30/90/365 days designed to better account for the unique health needs of older trauma patients: mortality (expansion of the current in-hospital standard), readmission (marker of health-system performance and care coordination), and patients' average number of healthy days at home (marker of patient functional status). BACKGROUND Traumatic injuries are a leading cause of death and loss of independence for the increasing number of older adults living in the United States. Ongoing efforts seek to expand quality evaluation for this population. METHODS Using 100% Medicare claims, we calculated hospital-specific reliability-adjusted postdischarge quality-metrics for older adults aged 65 years or older admitted with a primary diagnosis of trauma, older adults with hip fracture, and older adults with severe traumatic brain injury. Distributions for each quality-metric within each population were assessed and compared with results for in-hospital mortality, the current benchmarking standard. RESULTS A total of 785,867 index admissions (305,186 hip fracture and 92,331 severe traumatic brain injury) from 3692 hospitals were included. Within each population, use of postdischarge quality-metrics yielded a broader range of outcomes compared with reliance on in-hospital mortality alone. None of the postdischarge quality-metrics consistently correlated with in-hospital mortality, including death within 1 year [ r =0.581 (95% CI, 0.554-0.608)]. Differences in quintile-rank revealed that when accounting for readmissions (8.4%, κ=0.029) and patients' average number of healthy days at home (7.1%, κ=0.020), as many as 1 in 14 hospitals changed from the best/worst performance under in-hospital mortality to the completely opposite quintile rank. CONCLUSIONS The use of new postdischarge quality-metrics provides a more complete picture of older adult trauma care: 1 with greater room for improvement and better reflection of multiple aspects of quality important to the health and recovery of older trauma patients when compared with reliance on quality benchmarking based on in-hospital mortality alone.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, CT
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham & Women’s Hospital, Boston, MA
| | - Peter Peduzzi
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Mary E. Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
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Ludbrook G, Grocott MPW, Heyman K, Clarke-Errey S, Royse C, Sleigh J, Solomon LB. Outcomes of Postoperative Overnight High-Acuity Care in Medium-Risk Patients Undergoing Elective and Unplanned Noncardiac Surgery. JAMA Surg 2023:2804485. [PMID: 37133876 PMCID: PMC10157507 DOI: 10.1001/jamasurg.2023.1035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Importance Postoperative complications are increasing, risking patients' health and health care sustainability. High-acuity postoperative units may benefit outcomes, but existing data are very limited. Objective To evaluate whether a new high-acuity postoperative unit, advanced recovery room care (ARRC), reduces complications and health care utilization compared with usual ward care (UC). Design, Setting, and Participants In this observational cohort study, adults who were undergoing noncardiac surgery at a single-center tertiary adult hospital, anticipated to stay in hospital for 2 or more nights, were scheduled for postoperative ward care, and at medium risk (defined as predicted 30-day mortality of 0.7% to 5% by the National Safety Quality Improvement Program risk calculator) were included. Allocation to ARRC was based on bed availability. From 2405 patients assessed for eligibility with National Safety Quality Improvement Program risk scoring, 452 went to ARRC and 419 to UC, with 8 lost to 30-day follow-up. Propensity scoring identified 696 patients with matched pairs. Patients were treated between March and November 2021, and data were analyzed from January to September 2022. Interventions ARRC is an extended postanesthesia care unit (PACU), staffed by anesthesiologists and nurses (1 nurse to 2 patients) collaboratively with surgeons, with capacity for invasive monitoring and vasoactive infusions. ARRC patients were treated until the morning after surgery, then transferred to surgical wards. UC patients were transferred to surgical wards after usual PACU care. Main Outcome and Measures The primary end point was days at home at 30 days. Secondary end points were health facility utilization, medical emergency response (MER)-level complications, and mortality. Analyses compared groups before and after propensity scoring matching. Results Of 854 included patients, 457 (53.5%) were male, and the mean (SD) age was 70.0 (14.4) years. Days at home at 30 days was greater with ARRC compared with UC (mean [SD] time, 17 [11] vs 15 [11] days; P = .04). During the first 24 hours, more patients were identified with MER-level complications in ARRC (43 [12.4%] vs 13 [3.7%]; P < .001), but after return to the ward, these were less frequent from days 2 to 9 (9 [2.6%] vs 22 [6.3%]; P = .03). Length of hospital stay, hospital readmissions, emergency department visits, and mortality were similar. Conclusions and Relevance For medium-risk patients, brief high-acuity care with ARRC allowed enhanced detection and management of early MER-level complications, which was followed by a decreased incidence of subsequent MER-level complications after discharge to the ward and by increased days at home at 30 days.
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Affiliation(s)
- Guy Ludbrook
- Central Adelaide Local Health Network, Adelaide, Australia
- The University of Adelaide, Adelaide, Australia
| | - Michael P W Grocott
- Perioperative and Critical Care Research Theme, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, University of Southampton, Southampton, United Kingdom
| | - Kathy Heyman
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Sandy Clarke-Errey
- Statistical Consulting Centre, The University of Melbourne, Parkville, Australia
| | - Colin Royse
- Department of Surgery, The University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio
| | - Jamie Sleigh
- The University of Auckland, Peter Rothwell Academic Centre, Waikato Hospital, Hamilton West, Hamilton, New Zealand
| | - L Bogdan Solomon
- Central Adelaide Local Health Network, Adelaide, Australia
- The University of Adelaide, Adelaide, Australia
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Taran S, Coiffard B, Huszti E, Li Q, Chu L, Thomas C, Burns S, Robles P, Herridge MS, Goligher EC. Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients. JAMA Netw Open 2023; 6:e233265. [PMID: 36929399 PMCID: PMC10020882 DOI: 10.1001/jamanetworkopen.2023.3265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
IMPORTANCE Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness. OBJECTIVE To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients. DESIGN, SETTING, AND PARTICIPANTS The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022. EXPOSURES Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90). MAIN OUTCOMES AND MEASURES Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality. RESULTS The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28. CONCLUSIONS AND RELEVANCE In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.
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Affiliation(s)
- Shaurya Taran
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Coiffard
- Department of Respiratory Medicine, Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Ella Huszti
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Qixuan Li
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Leslie Chu
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Claire Thomas
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Stacey Burns
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Priscila Robles
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Margaret S. Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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21
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Oh AR, Lee SH, Park J, Min JJ, Lee JH, Yoo SY, Kwon JH, Choi DC, Kim W, Cho HS. Days alive and out of hospital at 30 days and outcomes of off-pump coronary artery bypass grafting. Sci Rep 2023; 13:3359. [PMID: 36849802 PMCID: PMC9971038 DOI: 10.1038/s41598-023-30321-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/21/2023] [Indexed: 03/01/2023] Open
Abstract
Days alive and out of hospital (DAOH) is a simple estimator based on the number of days not in hospital within a defined period. In cases of mortality within the period, DAOH is regarded as zero. It has not been validated solely in off-pump coronary artery bypass grafting (OPCAB). This study aimed to demonstrate a correlation between DAOH and outcome of OPCAB. We identified 2211 OPCAB performed from January 2010 to August 2016. We calculated DAOH at 30 and 60 days. We generated a receiver-operating curve and compared outcomes. The median duration of hospital stay after OPCAB was 6 days. The median DAOH values at 30 and 60 days were 24 and 54 days. The estimated thresholds for 3-year mortality for DAOH at 30 and 60 days were 20 and 50 days. Three-year mortality was higher for short DAOH (1.2% vs. 5.7% and 1.1% vs. 5.6% DAOH at 30 and 60 days). After adjustment, the short DAOH 30 group showed significantly higher mortality during 3-year follow-up (hazard ratio 3.07; 95% confidence interval 1.45-6.52; p = 0.004). DAOH at 30 days after OPCAB showed a correlation with 3-year outcomes. DAOH 30 might be a reliable long-term outcome measure that can be obtained within 30 days after surgery.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.,Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Seung-Hwa Lee
- Wiltse Memorial Hospital, Suwon, Korea.,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea. .,Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea.
| | - Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Seung Yeon Yoo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Dan-Cheong Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Wooksung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Sung Cho
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
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22
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Gregory AJ, Noss CD, Chun R, Gysel M, Prusinkiewicz C, Webb N, Raymond M, Cogan J, Rousseau-Saine N, Lam W, van Rensburg G, Alli A, de Vasconcelos Papa F. Perioperative Optimization of the Cardiac Surgical Patient. Can J Cardiol 2023; 39:497-514. [PMID: 36746372 DOI: 10.1016/j.cjca.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/16/2023] [Accepted: 01/29/2023] [Indexed: 02/06/2023] Open
Abstract
Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.
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Affiliation(s)
- Alexander J Gregory
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Christopher D Noss
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rosaleen Chun
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael Gysel
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Prusinkiewicz
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Webb
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meggie Raymond
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Wing Lam
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Gerry van Rensburg
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmad Alli
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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23
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Murmann M, Sinden D, Hsu AT, Thavorn K, Eddeen AB, Sun AH, Robert B. The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults. J Med Econ 2023; 26:61-69. [PMID: 36514911 DOI: 10.1080/13696998.2022.2156152] [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] [Indexed: 12/15/2022]
Abstract
OBJECTIVE In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult's transition to independent living at home. METHODS This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients ("usual care"). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated. RESULTS TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3-167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3-148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $-6,129-$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care. LIMITATIONS The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals. CONCLUSIONS Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.
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Affiliation(s)
- Maya Murmann
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Danielle Sinden
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Anan Bader Eddeen
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Annie H Sun
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Benoît Robert
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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24
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Frasco PE, Mathur AK, Chang YH, Alvord JM, Poterack KA, Khurmi N, Bauer I, Aqel B. Days alive and out of hospital after liver transplant: comparing a patient-centered outcome between recipients of grafts from donation after circulatory and brain deaths. Am J Transplant 2023; 23:55-63. [PMID: 36695622 DOI: 10.1016/j.ajt.2022.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
We retrospectively compared outcomes between recipients of donation after circulatory death (DCD) and donation after brain death (DBD) liver allografts using days alive and out of hospital (DAOH), a composite outcome of mortality, morbidity, and burden of care from patient perspective. The initial length of stay and duration of any subsequent readmission for the first year after liver transplantation were recorded. Donor category and perioperative and intraoperative characteristics pertinent to liver transplantation were included. The primary outcome was DAOH365. Secondary outcomes included early allograft dysfunction and hepatic arterial and biliary complications. Although the incidence of both early allograft dysfunction (P < .001) and ischemic cholangiopathy (P < .001) was significantly greater in the recipients of DCD, there were no significant differences in the length of stay and DAOH365. The median DAOH365 was 355 days for recipients of DBD allografts and 353 days for recipients of DCD allografts (P = .34). Increased transfusion burden, longer cold ischemic time, and non-White recipients were associated with decreased DAOH. There were no significant differences in graft failure (P = .67), retransplantation (P = .67), or 1-year mortality (P = .96) between the 2 groups. DAOH is a practical and attainable measure of outcome after liver transplantation. This metric should be considered for quality measurement and reporting in liver transplantation.
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Affiliation(s)
- Peter E Frasco
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA.
| | - Amit K Mathur
- Department of Transplantation Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jeremy M Alvord
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Karl A Poterack
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Isabel Bauer
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Bashar Aqel
- Department of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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25
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Watson DI, Bright T. Measuring the quality of surgical care in Australia. Med J Aust 2022; 217:301-302. [DOI: 10.5694/mja2.51684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022]
Affiliation(s)
- David I Watson
- College of Medicine and Public Health Flinders University Adelaide SA
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26
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Reilly JR, Myles PS, Wong D, Heritier SR, Brown WA, Richards T, Bell M. Hospital costs and factors associated with days alive and at home after surgery (DAH 30 ). Med J Aust 2022; 217:311-317. [PMID: 35852009 PMCID: PMC9796479 DOI: 10.5694/mja2.51658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess the relationships of patient and surgical factors and hospital costs with the number of days alive and at home during the 30 days following surgery (DAH30 ). DESIGN Retrospective cohort study; analysis of Medibank Private health insurance hospital claims data, Australia, 1 January 2016 - 31 December 2017. SETTING, PARTICIPANTS Admissions of adults (18 years or older) to hospitals for elective or emergency inpatient surgery with anaesthesia covered by private health insurance, Australia, 1 January 2016 - 31 December 2017. MAIN OUTCOME MEASURES Associations between DAH30 and total hospital costs, and between DAH30 and surgery risk factors. RESULTS Complete data were available for 126 788 of 181 281 eligible patients (69.9%); their median age was 62 years (IQR, 47-73 years), 72 872 were women (57%), and 115 117 had undergone elective surgery (91%). The median DAH30 was 27.1 days (IQR, 24.2-28.8 days), the median hospital cost per patient was $10 358 (IQR, $6624-20 174). The association between DAH30 and total hospital costs was moderate (Spearman ρ = -0.60; P < 0.001). Median DAH30 declined with age, comorbidity score, ASA physical status score, and surgical severity and duration, and was also lower for women. CONCLUSIONS DAH30 is a validated, patient-centred outcome measure of post-surgical outcomes; higher values reflect shorter hospital stays and fewer serious complications, re-admissions, and deaths. DAH30 can be used to benchmark quality of surgical care and to monitor quality improvement programs for reducing the costs of surgical and other peri-operative care.
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Affiliation(s)
| | - Paul S Myles
- Alfred HospitalMelbourneVIC,Monash UniversityMelbourneVIC
| | | | - Stephane R Heritier
- Royal Prince Alfred HospitalSydneyNSW,The George Institute for International HealthSydneyNSW
| | - Wendy A Brown
- Alfred HospitalMelbourneVIC,Monash UniversityMelbourneVIC
| | | | - Max Bell
- Karolinska InstitutetStockholm, Sweden
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27
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Alkadri J, Aucoin SD, McDonald B, Grubic N, McIsaac DI. Association of frailty with days alive at home in critically ill patients undergoing emergency general surgery: a population-based cohort study. Br J Anaesth 2022; 129:536-543. [PMID: 36031415 DOI: 10.1016/j.bja.2022.07.013] [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: 05/18/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Frailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery. METHODS A retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed. RESULTS We identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60-0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64-0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month. CONCLUSIONS In patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.
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Affiliation(s)
- Jamal Alkadri
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; ICES, Ottawa, ON, Canada.
| | - Sylvie D Aucoin
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bernard McDonald
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Nicholas Grubic
- ICES, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; ICES, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
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28
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Wu A, Fahey MT, Cui D, El‐Behesy B, Story DA. An evaluation of the outcome metric 'days alive and at home' in older patients after hip fracture surgery. Anaesthesia 2022; 77:901-909. [PMID: 35489814 PMCID: PMC9543156 DOI: 10.1111/anae.15742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 01/11/2023]
Abstract
'Days alive and at home' is a validated measure that estimates the time spent at home, defined as the place of residence before admission to hospital. We evaluated this metric in older adults after hip fracture surgery and assessed two follow-up durations, 30 and 90 days. Patients aged ≥ 70 years who underwent hip fracture surgery were identified retrospectively via hospital admission and government mortality records. Patients who successfully returned home and were still alive within 90 days of surgery were distinguished from those who were not. Regression models were used to examine which variables were associated with failure to return home and number of days at home among those who did return, within 90 days of surgery. We analysed the records of 825 patients. Median (IQR [range]) number of days at home within 90 days (n = 788) was 54 (0-76 [0-88]) days and within 30 days (n = 797) it was 2 (0-21 [0-28]) days. Out of these, 274 (35%) patients did not return home within 90 days and 374 (47%) within 30 days after surgery. Known peri-operative risk-factors such as older age, pre-operative anaemia and postoperative acute renal impairment were associated with failure to return home. This study supports days alive and at home as a useful patient-centred outcome measure in older adults after hip fracture surgery. We recommend that this metric should be used in clinical trials and measured at 90, rather than 30, postoperative days. As nearly half of this patient population did not return home within 30 days, the shorter time-period catches fewer meaningful events.
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Affiliation(s)
- A. Wu
- Department of AnaestheticsMaroondah Hospital, Eastern HealthMelbourneAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneAustralia
| | - M. T. Fahey
- Department of Health Sciences and BiostatisticsSwinburne University of TechnologyMelbourneAustralia,Department of Biostatistics and Clinical TrialsPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - D. Cui
- Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneAustralia,Department of AnaestheticsMaroondah Hospital, Eastern HealthMelbourneAustralia
| | - B. El‐Behesy
- Department of AnaestheticsMaroondah Hospital, Eastern HealthMelbourneAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneAustralia
| | - D. A. Story
- Department of Critical CareUniversity of Melbourne and Melbourne Academic Centre for HealthMelbourneAustralia
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29
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Kunkel D, Parker M, Casey C, Krause B, Taylor J, Pearce RA, Lennertz R, Sanders RD. Impact of perioperative inflammation on days alive and at home after surgery. BJA OPEN 2022; 2:100006. [PMID: 37588271 PMCID: PMC10430844 DOI: 10.1016/j.bjao.2022.100006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/01/2022] [Indexed: 08/18/2023]
Abstract
Background Perioperative inflammation is associated with perioperative complications, including delirium, that are associated with a reduced number of postoperative days alive and at home at 90 days (DAH90). We tested whether inflammation was associated with DAH90 even when adjusting for perioperative factors, and whether inflammation independently was associated with DAH90 when adjusting for delirium. Methods We conducted a prospective cohort study of major, non-intracranial surgical patients who were older than 65 yr (n=134). We measured postoperative delirium incidence and severity, and changes in interleukin (IL)-8 and IL-10 in blood plasma. Our primary outcome, DAH90, was analysed using quantile regression. Results Before adjusting for delirium, a postoperative day 1 increased IL-8 was associated with fewer DAH90 at the 0.75 quantile (β=-0.082; 95% confidence interval [CI], -0.19 to -0.006) after adjusting for demographic (age and sex) and perioperative factors (cardiovascular surgery, National Surgical Quality Improvement Program risk of death, and operative time). IL-10 was similarly associated with DAH90 at the 0.5 (β=-0.026; 95% CI, -0.19 to -0.001) and 0.75 (β= -0.035; 95% CI, -0.07 to -0.006) quantiles. Neither cytokine was significantly associated with DAH90 once delirium and baseline Trail Making Test B were added to the models. Conclusions Perioperative inflammation predicts DAH90, but when delirium is added to the model inflammation loses significance as a predictor, whereas delirium is significant. Targeting perioperative inflammation may reduce delirium and moderate hospital readmission and mortality. Clinical trial registration NCT03124303.
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Affiliation(s)
- David Kunkel
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Margaret Parker
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Cameron Casey
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Bryan Krause
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Jennifer Taylor
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW, Australia
| | - Robert A. Pearce
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Richard Lennertz
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Robert D. Sanders
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW, Australia
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Freed SS, Kaufman BG, Van Houtven CH, Saunders R. Using a home time measure to differentiate ACO performance for seriously ill populations. J Am Geriatr Soc 2022; 70:2666-2676. [PMID: 35620814 DOI: 10.1111/jgs.17882] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/16/2022] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Alternative Payment Models (APMs) piloted by the Centers for Medicare and Medicaid Services (CMS) such as ACO Realizing Equity, Access and Community Health (REACH) seek to improve care and quality of life among seriously ill populations (SIP). Days at Home (DAH) was proposed for use in this model to evaluate organizational performance. It is important to assess the utility and feasibility of person-centered outcomes measures, such as DAH, as CMS seeks to advance care models for seriously ill beneficiaries. We leverage existing Accountable Care Organization (ACO) contracts to evaluate the feasibility of ACO-level DAH measure and examine characteristics associated with ACOs with more DAH. METHODS We calculated DAH for Medicare fee-for-service beneficiaries aged 68 and over who were retrospectively attributed to a Medicare ACO between 2014 and 2018 and met the seriously ill criteria. We then aggregated to the ACO level DAH for each ACO's seriously ill beneficiaries and risk-adjusted this aggregated measure. Finally, we evaluated associations between risk-adjusted DAH per person-year and ACO, beneficiary, and market characteristics. RESULTS ACOs' seriously ill beneficiaries spent an average of 349.3 risk-adjusted DAH per person-year. Risk-adjusted ACO variation, defined as the interquartile range, was 4.21 days (IQR = 347.32-351.53). Beneficiaries of ACOs are composed of a less racially diverse beneficiary cohort, opting for two-sided risk models, and operating in markets with fewer hospital and Skilled Nursing Facility beds had more DAH. CONCLUSIONS Substantial variation across ACOs in the DAH measure for seriously ill beneficiaries suggests the measure can differentiate between high and low performing provider groups. Key to the success of the metric is accurate risk adjustment to ensure providers have adequate resources to care for seriously ill beneficiaries. Organizational factors, such as the ACO size and level of risk, are strongly associated with more days at home.
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Affiliation(s)
- Salama S Freed
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,National Pharmaceutical Council, Washington, District of Columbia, USA
| | - Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Robert Saunders
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
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Steffens D, Young J, Riedel B, Morton R, Denehy L, Heriot A, Koh C, Li Q, Bauman A, Sandroussi C, Ismail H, Dieng M, Ansari N, Pillinger N, O'Shannassy S, McKeown S, Cunningham D, Sheehan K, Iori G, Bartyn J, Solomon M. PRehabIlitatiOn with pReoperatIve exercise and educaTion for patients undergoing major abdominal cancer surgerY: protocol for a multicentre randomised controlled TRIAL (PRIORITY TRIAL). BMC Cancer 2022; 22:443. [PMID: 35459100 PMCID: PMC9026022 DOI: 10.1186/s12885-022-09492-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 04/06/2022] [Indexed: 12/12/2022] Open
Abstract
Background Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative complications is exceptionally high. The current evidence suggests that improving patients’ fitness during the preoperative period may enhance postoperative recovery. Thus, the primary aim of this study is to establish the effectiveness of prehabilitation with a progressive, individualised, preoperative exercise and education program compared to usual care alone in reducing the proportion of patients with postoperative in-hospital complications. The secondary aims are to investigate the effectiveness of the preoperative intervention on reducing the length of intensive care unit and hospital stay, improving quality of life and morbidity, and reducing costs. Methods This is a multi-centre, assessor-blinded, pragmatic, comparative, randomised controlled trial. A total of 172 patients undergoing pelvic exenteration, cytoreductive surgery, oesophagectomy, hepatectomy, gastrectomy or pancreatectomy will be recruited. Participants will be randomly allocated to prehabilitation with a preoperative exercise and education program (intervention group), delivered over 4 to 8 weeks before surgery by community physiotherapists/exercise physiologists, or usual care alone (control group). The intervention will comprise 12 to 24 individualised, progressive exercise sessions (including aerobic/anaerobic, resistance, and respiratory exercises), recommendations of home exercises (16 to 32 sessions), and daily incidental physical activity advice. Outcome measures will be collected at baseline, the week prior to surgery, during the hospital stay, and on the day of discharge from hospital, and 1 month and 1 months postoperatively. The primary outcome will be the development of in-hospital complications. Secondary outcomes include the length of intensive care unit and hospital stay, quality of life, postoperative morbidity and costs. Discussion The successful completion of this trial will provide robust and high-quality evidence on the efficacy of a preoperative community- and home-based exercise and education intervention on important postoperative outcomes of patients undergoing major gastrointestinal cancer surgery. Trial registration This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12621000617864) on 24th May 2021.
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia. .,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Jane Young
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and the Department of Critical Care, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Rachael Morton
- Department of Health Economics & Health Technology Assessment, NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Linda Denehy
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Qiang Li
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Adrian Bauman
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Charbel Sandroussi
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Hilmy Ismail
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and the Department of Critical Care, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Mbathio Dieng
- Department of Health Economics & Health Technology Assessment, NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Nabila Ansari
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Neil Pillinger
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Sarah O'Shannassy
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sam McKeown
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and the Department of Critical Care, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Kym Sheehan
- Cancer Voices NSW, Sydney, New South Wales, Australia
| | - Gino Iori
- Cancer Voices NSW, Sydney, New South Wales, Australia
| | - Jenna Bartyn
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Improving safety and outcomes in perioperative care: does implementation matter? Br J Anaesth 2022; 128:747-751. [PMID: 35227460 DOI: 10.1016/j.bja.2022.01.026] [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: 12/09/2021] [Revised: 01/22/2022] [Accepted: 01/23/2022] [Indexed: 11/21/2022] Open
Abstract
The IMPROVE study describes a large perioperative quality improvement project with reporting of both compliance with improvement activities and patient outcomes. It highlights the importance of such projects, as well as the challenges in implementing change and proving benefit. Challenges identified include the importance of effective training in practice change, selection of trial design and relevant quality measures, and how the context of quality improvement initiatives may influence outcomes. Quality improvement programmes of this nature, despite the difficulties with implementation and trial design, remain a high priority because of their positive influence on improving clinical practice.
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Gupta A, Eisenhauer EA, Booth CM. The Time Toxicity of Cancer Treatment. J Clin Oncol 2022; 40:1611-1615. [PMID: 35235366 DOI: 10.1200/jco.21.02810] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Arjun Gupta
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN
| | | | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada.,Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada
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Ludbrook GL, Leaman E. Cost-Effectiveness in Perioperative Care: Application of Markov Modeling to Pathways of Perioperative Care. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:215-221. [PMID: 35094794 DOI: 10.1016/j.jval.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/23/2021] [Accepted: 07/30/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to evaluate the application of cost-effectiveness modeling to redesign of perioperative care pathways, from a hospital perspective. METHODS A Markov cost-effectiveness model of patient transition between care locations, each with different characteristics and cost, was developed. Inputs were derived from clinical trials piloting a preoperative call center and a postoperative medium-acuity care unit. The effect chosen was days at home (DAH) after surgery, reflecting quality of in-hospital care, acknowledged financially by fundholders, and relevant to consumers. Cost was from the hospital's perspective. A model cycle time of 4 hours for 30 days reflected relevant timelines and costs. RESULTS A Markov model was successfully created, accounting for the care locations in the 2 pathways as model states and accounting for consequences and costs. Cost-effectiveness analysis allowed the calculation of an incremental cost-effectiveness ratio comparing these pathways, providing a mean incremental cost-effectiveness ratio of -$427 per additional DAH, where incremental costs and DAH were -$644 and +1.51, respectively. Probabilistic sensitivity analysis suggested the new pathway had a 61% probability of reduced costs and a 74% probability of increased DAH and a 58% probability this pathway was dominant. Tornado analysis revealed the major contributor to increased costs as intensive care unit stay and the major contributor to decreased costs as ward stay. For the new pathway, the probability of transfer from ward to home and the probability of staying at home had the greatest impact on DAH. CONCLUSIONS These data suggest Markov modeling may be a useful tool for the cost-effectiveness analysis of initiatives in perioperative care.
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Affiliation(s)
- Guy L Ludbrook
- Department of Anaesthesia, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia.
| | - Esrom Leaman
- Department of Anaesthesia, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
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35
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Bojesen RD, Jørgensen LB, Grube C, Skou ST, Johansen C, Dalton SO, Gögenur I. Fit for Surgery—feasibility of short-course multimodal individualized prehabilitation in high-risk frail colon cancer patients prior to surgery. Pilot Feasibility Stud 2022; 8:11. [PMID: 35063042 PMCID: PMC8781359 DOI: 10.1186/s40814-022-00967-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/05/2022] [Indexed: 12/18/2022] Open
Abstract
Background Prehabilitation is a promising modality for improving patient-related outcomes after major surgery; however, very little research has been done for those who may need it the most: the elderly and the frail. This study aimed to investigate the feasibility of a short course multimodal prehabilitation prior to primary surgery in high-risk, frail patients with colorectal cancer and WHO performance status I and II. Methods The study was conducted as a single-center, prospective one-arm feasibility study of eight patients with colon cancer between October 4, 2018, and January 14, 2019. The intervention consisted of a physical training program tailored to the patients with both high-intensity interval training and resistance training three times a week in sessions of approximately 1 h in length, for a duration of at least 4 weeks, nutritional support with protein and vitamins, a consultation with a dietician, and medical optimization prior to surgery. Feasibility was evaluated regarding recruitment, retention, compliance and adherence, acceptability, and safety. Retention was evaluated as the number of patients that completed the intervention, with a feasibility goal of 75% completing the intervention. Compliance with the high-intensity training was evaluated as the number of sessions in which the patient achieved a minimum of 4 min > 90% of their maximum heart rate and adherence as the attended out of the offered training sessions. Results During the study period, 64 patients were screened for eligibility, and out of nine eligible patients, eight patients were included and seven completed the intervention (mean age 80, range 66–88). Compliance to the high-intensity interval training using 90% of maximum heart rate as the monitor of intensity was difficult to measure in several patients; however, adherence to the training sessions was 87%. Compliance with nutritional support was 57%. Half the patients felt somewhat overwhelmed by the multiple appointments and six out of seven reported difficulties with the dosage of protein. Conclusions This one-arm feasibility study indicates that multimodal prehabilitation including high-intensity interval training can be performed by patients with colorectal cancer and WHO performance status I and II. Trial registration Clinicaltrials.gov: the study current feasibility study was conducted prior to the initiation of a full ongoing randomized trial registered by NCT04167436; date of registration: November 18, 2019. Retrospectively registered. No separate prospectively registration of the feasibility trial was conducted but outlined by the approved study protocol (Danish Scientific Ethical Committee SJ-607). Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-00967-8.
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Spurling LJ, Moonesinghe SR, Oliver CM. Validation of the days alive and out of hospital outcome measure after emergency laparotomy: a retrospective cohort study. Br J Anaesth 2022; 128:449-456. [PMID: 35012739 DOI: 10.1016/j.bja.2021.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/29/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Days alive and out of hospital (DAOH) is a composite, patient-centred outcome measure describing a patient's postoperative recovery, encompassing hospitalisation and mortality. DAOH is the number of days not in hospital over a defined postoperative period; patients who die have DAOH of zero. The Standardising Endpoints in Perioperative Medicine (StEP) group recommended DAOH as a perioperative outcome. However, DAOH has never been validated in patients undergoing emergency laparotomy. Here, we validate DAOH after emergency laparotomy and establish the optimal duration of observation. METHODS Prospectively collected data of patients having emergency laparotomy in England (December 1, 2013-November 30, 2017) were linked to national hospital admission and mortality records for the year after surgery. We evaluated construct validity by assessing DAOH variation with known perioperative risk factors and predictive validity for 1 yr mortality using a multivariate Bayesian mixed-effects logistic regression. The optimal postoperative DAOH period (30 or 90 days) was judged on distributional and pragmatic properties. RESULTS We analysed 78 921 records. The median 30-day DAOH (DAOH30) was 16 (inter-quartile range [IQR], 0-22) days and the median DAOH90 was 75 (46-82) days. DAOH was shorter in the presence of known perioperative risk factors. For patients surviving the first 30 postoperative days, shorter DAOH30 was associated with higher 1-yr mortality (odds ratio=0.94; 95% credible interval, 0.94-0.94). CONCLUSION DAOH is a valid, patient-centred outcome after emergency laparotomy. We recommend its use in clinical trials, quality assurance, and quality improvement, measured at 30 days as mortality heavily skews DAOH measured at 90 days and beyond.
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Affiliation(s)
- Leigh-James Spurling
- Surgical Outcomes Research Centre (SOuRCe), Centre for Perioperative Medicine, Division of Surgical and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK.
| | - S Ramani Moonesinghe
- Surgical Outcomes Research Centre (SOuRCe), Centre for Perioperative Medicine, Division of Surgical and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - C Matthew Oliver
- Surgical Outcomes Research Centre (SOuRCe), Centre for Perioperative Medicine, Division of Surgical and Interventional Science, University College London, London, UK; Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
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37
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6540689. [DOI: 10.1093/ejcts/ezac148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/05/2022] [Accepted: 02/18/2022] [Indexed: 01/12/2023] Open
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Sperber NR, Shapiro A, Boucher NA, Decosimo KP, Shepherd-Banigan M, Whitfield C, Hastings SN, Van Houtven CH. Developing a person-centered, population based measure of "home time": Perspectives of older patients and unpaid caregivers. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2021; 9:100591. [PMID: 34688200 PMCID: PMC10442891 DOI: 10.1016/j.hjdsi.2021.100591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 09/27/2021] [Accepted: 10/03/2021] [Indexed: 12/20/2022]
Abstract
Measuring "home time," number of days not in facility-based care, with medical claims is a promising approach to assess person-centered outcomes on a population level. Generally, spending more time at home matches long-term care preferences and improves quality of life. However, existing "home time" measures have not incorporated key stakeholder perspectives. We sought to understand how patients and family caregivers value time spent in diverse facility-based health care settings (Emergency Department, Nursing Home, Post-Acute Care/Skilled Nursing, Inpatient Hospital) to help determine whether various settings have different effects on quality of life and thus merit different weighting in a "home time" measure. We conducted three focus groups among patients and family caregivers within the U.S. Veterans Health Care System. We identified themes pertaining to patients' quality of life in each of the four facility-based care settings. Discussions about both emergency department and post-acute/skilled nursing care reflected loss of personal control, counterbalanced by temporary stay. Inpatient hospital care evoked discussion about greater loss of personal control due to the intensity of care. Nursing homes ultimately signified decline. These findings illuminate differences in quality of life across health-care settings and help justify the need for different weights in a measure of "home time."
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Affiliation(s)
- Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA.
| | - Abigail Shapiro
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA
| | - Nathan A Boucher
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA; Duke University, Sanford School of Public Policy, Durham, NC, USA; Duke University, Margolis Center for Health Policy, Durham, NC, USA; Duke University School of Medicine, Center for the Study of Aging, Durham, NC, USA; Duke University School of Medicine, Department of Medicine, Division of Geriatrics, Durham, NC, USA
| | - Kasey P Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA; Duke University, Margolis Center for Health Policy, Durham, NC, USA
| | - Chelsea Whitfield
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA; Duke University School of Medicine, Center for the Study of Aging, Durham, NC, USA; Duke University School of Medicine, Department of Medicine, Division of Geriatrics, Durham, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA; Duke University, Margolis Center for Health Policy, Durham, NC, USA
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Wong TH, Tan TXZ, Malhotra R, Nadkarni NV, Chua WC, Loo LM, Iau PTC, Ang ASH, Goo JTT, Chan KC, Matchar DB, Seow DCC, Nguyen HV, Ng YS, Chan A, Fook-Chong S, Tang TY, Ong MEH. Health Services Use and Functional Recovery Following Blunt Trauma in Older Persons - A National Multicentre Prospective Cohort Study. J Am Med Dir Assoc 2021; 23:646-653.e1. [PMID: 34848197 DOI: 10.1016/j.jamda.2021.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/19/2021] [Accepted: 10/23/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Frailty is associated with morbidity and mortality in older injured patients. However, for older blunt-trauma patients, increased frailty may not manifest in longer length of stay at index admission. We hypothesized that owing to time spent in hospital from readmissions, frailty would be associated with less total time at home in the 1-year postinjury period. DESIGN Prospective, nationwide, multicenter cohort study. SETTING AND PARTICIPANTS All Singaporean residents aged ≥55 years admitted for blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS) ≥10 from March 2016 to July 2018. METHODS Frailty (by modified Fried criteria) was assessed at index admission, based on questions on preinjury weight loss, slowness, exhaustion, physical activity, and grip strength at the time of recruitment. Low time at home was defined as >14 hospitalized days within 1 year postinjury. The contribution of planned and unplanned readmission to time at home postinjury was explored. Functional trajectory (by Barthel Index) over 1 year was compared by frailty. RESULTS Of the 218 patients recruited, 125 (57.3%) were male, median age was 72 years, and 48 (22.0%) were frail. On univariate analysis, frailty [relative to nonfrail: odds ratio (OR) 3.45, 95% confidence interval (CI) 1.33-8.97, P = .01] was associated with low time at home. On multivariable analysis, after inclusion of age, gender, ISS, intensive care unit admission, and surgery at index admission, frailty (OR 5.21, 95% CI 1.77-15.34, P < .01) remained significantly associated with low time at home in the 1-year postinjury period. Unplanned readmissions were the main reason for frail participants having low time at home. Frail participants had poorer function in the 1-year postinjury period. CONCLUSIONS AND IMPLICATIONS In the year following blunt trauma, frail older patients experience lower time at home compared to patients who were not frail at baseline. Screening for frailty should be considered in all older blunt-trauma patients, with a view to being prioritized for postdischarge support.
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Affiliation(s)
- Ting-Hway Wong
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore; Department of General Surgery, Singapore General Hospital, Singapore
| | | | - Rahul Malhotra
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - Nivedita V Nadkarni
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | | | - Lynette Ma Loo
- Department of General Surgery, National University Hospital, Singapore
| | | | | | | | - Kim Chai Chan
- Emergency Medicine Department, Ng Teng Fong General Hospital, Singapore
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | | | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, Canada, St. John's, Newfoundland, Canada
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore
| | - Angelique Chan
- Centre for Ageing Research and Education, Duke-NUS Graduate Medical School, Singapore
| | - Stephanie Fook-Chong
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore
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Ludbrook GL. The Hidden Pandemic: the Cost of Postoperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2021; 12:1-9. [PMID: 34744518 PMCID: PMC8558000 DOI: 10.1007/s40140-021-00493-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 12/17/2022]
Abstract
Purpose of Review Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing. Recent Findings Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change. Summary Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.
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Affiliation(s)
- Guy L. Ludbrook
- The University of Adelaide, and Royal Adelaide Hospital, C/O Royal Adelaide Hospital, 3G395, 1 Port Road, Adelaide, South Australia 5000 Australia
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Shen E, Rozema EJ, Haupt EC, Henry M, Scholle SH, Wang SE, Lynn J, Mularski RA, Nguyen HQ. Assessing the concurrent validity of days alive and at home metric. J Am Geriatr Soc 2021; 70:2630-2637. [PMID: 34676885 DOI: 10.1111/jgs.17506] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Most patients living with serious illness value spending time at home. Emerging data suggest that days alive and at home (DAH) may be a useful metric, however more research is needed. We aimed to assess the concurrent validity of DAH with respect to clinically significant changes in patient- and caregiver-reported outcomes (PROs). METHODS We drew data from a study that compared two models of home-based palliative care among seriously ill patients and their caregivers in two Kaiser Permanente regions (Southern California and Northwest). We included participants aged 18 years or older (n = 3533) and corresponding caregivers (n = 463). We categorized patients and caregivers into three groups based on whether symptom burden (Edmonton Symptom Assessment System, ESAS) or caregiving preparedness (Preparedness for Caregiving Scale, CPS) showed improvements, deterioration, or no change from baseline to 1 month later. We measured DAH across four time windows: 30, 60, 90, and 180 days, after admission to home palliative care. We used two-way ANOVA to compare DAH across the PRO groups. RESULTS Adjusted pairwise comparisons showed that DAH was highest for patients whose ESAS scores improved or did not change compared with those with worsening symptoms. Although the mean differences ranged from less than a day to about 3 weeks, none exceeded 0.3 standard deviations. ESAS change scores had weak negative correlations (r = -0.11 to -0.21) with DAH measures. CPS change scores also showed weak, positive correlations (r = 0.23-0.24) with DAH measures. CONCLUSION DAH measures are associated, albeit weakly, with clinically important improvement or maintenance of patient symptom burden in a diverse, seriously ill population.
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Affiliation(s)
- Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Emily J Rozema
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Eric C Haupt
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Sarah H Scholle
- National Committee for Quality Assurance, NCQA, Washington DC, USA
| | - Susan E Wang
- Kaiser Permanente Southern California, West Los Angeles Medical Center, Los Angeles, California, USA
| | | | - Richard A Mularski
- Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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Robinson KN, Cassady BA, Hegazi RA, Wischmeyer PE. Preoperative carbohydrate loading in surgical patients with type 2 diabetes: Are concerns supported by data? Clin Nutr ESPEN 2021; 45:1-8. [PMID: 34620304 DOI: 10.1016/j.clnesp.2021.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 12/17/2022]
Abstract
Currently, there is a lack of consensus on the provision of preoperative carbohydrate loading in patients with type 2 diabetes mellitus (T2DM) due to theoretical concerns including the possibility of delayed gastric emptying, perioperative hyperglycemia, and poor surgical outcomes. This narrative review summarizes the accumulating evidence on preoperative carbohydrate loading in this population and whether these concerns are supported by preliminary evidence. In general, the available research suggests that carbohydrate loading may be implemented in those with T2DM without increased risk for intra- and postoperative hyperglycemia or surgical complications. However, there is strong justification for future research to definitively study this highly debated and timely topic. Ultimately, the inclusion of preoperative carbohydrate loading for surgical patients with DM should be guided by the surgical team's clinical judgment and individualized based on patient needs and characteristics.
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Affiliation(s)
- Katie N Robinson
- Scientific and Medical Affairs, Abbott Nutrition, 2900 Easton Square Place, Columbus, OH, 43219 USA.
| | - Bridget A Cassady
- Scientific and Medical Affairs, Abbott Nutrition, 2900 Easton Square Place, Columbus, OH, 43219 USA.
| | - Refaat A Hegazi
- Scientific and Medical Affairs, Abbott Nutrition, 2900 Easton Square Place, Columbus, OH, 43219 USA.
| | - Paul E Wischmeyer
- Duke University School of Medicine, Department of Anesthesiology and Surgery, Center for Perioperative Organ Protection (CPOP), DUMC, Box 3094 Mail # 41, 2301 Erwin Road, 5692 HAFS, Durham, NC, 27710 USA.
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Larsen MHH, Scott SI, Channir HI, Madsen AKØ, Charabi BW, Rubek N, Tvedskov JF, Kehlet H, von Buchwald C. Days alive and out of hospital following transoral robotic surgery: Cohort study of 262 patients with head and neck cancer. Head Neck 2021; 43:3866-3874. [PMID: 34605110 DOI: 10.1002/hed.26880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/20/2021] [Accepted: 09/13/2021] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Days alive and out of hospital (DAOH) is a validated outcome in clinical trials, since it reflects procedure-associated morbidity and mortality. Transoral robotic surgery (TORS) has become a widely adopted procedure with increasing demand for knowledge and data on morbidity. METHODS Retrospective single-center assessment of a prospective TORS database comprising patients treated for malignancy between 2013 and 2018 using DAOH to describe procedure- and disease-related morbidity the first 12-postoperative months. RESULTS For 262 patients, median DAOH365 was 357 days (IQR 351-360). Indications for TORS were (i) primary curative resection (61%), (ii) salvage resection (15%), and (iii) diagnostic work-up of cancer of unknown primary in the head and neck (24%). Median DAOH365 was 359 days (IQR 351-361 days), 348 days (IQR 233-355), and 357 days (351-361), respectively. Pneumonia had the highest impact in DAOH365 reduction. CONCLUSION Total median DAOH365 after TORS was 357 days. The main cause leading to DAOH365 reduction was pneumonia.
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Affiliation(s)
- Mikkel H H Larsen
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Susanne I Scott
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hani I Channir
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne K Ø Madsen
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Birgitte W Charabi
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niclas Rubek
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper F Tvedskov
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Kunkel D, Parker M, Casey C, Krause B, Pearce RA, Lennertz R, Sanders RD. Impact of postoperative delirium on days alive and at home after surgery: a prospective cohort study. Br J Anaesth 2021; 127:e205-e207. [PMID: 34598782 DOI: 10.1016/j.bja.2021.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 08/28/2021] [Accepted: 08/29/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- David Kunkel
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Margaret Parker
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Cameron Casey
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Bryan Krause
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Robert A Pearce
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Richard Lennertz
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Robert D Sanders
- Specialty of Anaesthetics, University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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Buggy DJ, Nolan R, Coburn M, Columb M, Hermanides J, Hollman MW, Zarbock A. Protocol for a prospective, international cohort study on the Management and Outcomes of Perioperative Care among European Diabetic Patients (MOPED). BMJ Open 2021; 11:e044394. [PMID: 34489264 PMCID: PMC8422310 DOI: 10.1136/bmjopen-2020-044394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Diabetes is common (about 20 million patients in Europe) and patients with diabetes have more surgical interventions than the general population. There are plausible pathophysiological and clinical mechanisms suggesting that patients with diabetes are at an increased risk of postoperative complications. When postoperative complications occur in the general population, they increase major adverse events and subsequently increase 1-year mortality. This is likely to be worse in patients with diabetes. There is variation in practice guidelines in different countries in the perioperative management of patients with diabetes undergoing major surgery and whether this may affect postoperative outcome has not been investigated on a large scale. Neither is it known whether different strata of preoperative glycaemic control affects outcome. METHODS AND ANALYSIS A prospective, observational, international, multicentre cohort study, recruiting 5000 patients with diabetes undergoing elective or emergency surgery in at least n=50 centres. Inclusion criteria are any patient with diabetes undergoing surgery under any substantive anaesthetic technique. Exclusion criteria are not being a confirmed diabetic patient and patients with diabetes undergoing procedures under monitored sedation or local anaesthetic infiltration only. Follow-up duration is 30 days after surgery. Primary outcome is days at home at 30 days. Secondary outcomes are Comprehensive Complications Index, Quality of Recovery (QoR-15) score on Day 1 postoperatively, 30-day mortality, length of hospital stay and incidence of specific major adverse events (Myocardial Infarction (MI), Myocardial Injury after Non-cardiac Surgery (MINS), Acute Kidney Injury (AKI), Postoperative Pulmonary Complications (PPC), Cerebrovascular Accident (CVA), Pulmonary Embolism (PE), DVT, surgical site infection, postoperative pulmonary infection). Tertiary outcomes include time to resumption of normal diabetes therapy, incidence of diabetic ketoacidosis or hypoglycaemia, incidence and duration of use of intravenous insulin infusion therapy and change in diabetic management at 30 days. ETHICS AND DISSEMINATION This study will adhere to the principles of the Declaration of Helsinki (amendment 2013) by the World Medical Association and the ICH-Good Clinical Practice (GCP) Guidelines E6(R2). Specific national and local regulatory authority requirements will be followed as applicable. Ethical approval has been granted by the Institutional Review Board of the Mater Misericordiae University Hospital, Dublin, Ireland (Reference: 1/378/2167). As enrolment for this study is ongoing, ethical approval from additional centres is being added continuously. The main results of Management and Outcomes of Perioperative Care among European Diabetic Patients and its substudies will be published in peer-reviewed international medical journals and presented at Euroanaesthesia congress and other international and national meetings. TRIAL REGISTRATION NUMBER NCT04511312.
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Affiliation(s)
- Donal J Buggy
- Dept. Anaesthesiology, Mater University Hospital, University College Dublin, Dublin, Ireland
- Mater University Hospital, University College Dublin, Dublin, Ireland
- Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Rachel Nolan
- Dept. Anaesthesiology, Mater University Hospital, University College Dublin, Dublin, Ireland
| | | | - Malachy Columb
- Wythenshawe Hospital Acute Intensive Care Unit, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Center, Duivendrecht, Noord-Holland, The Netherlands
| | - Markus W Hollman
- Department of Anesthesiology, Amsterdam University Medical Center, Duivendrecht, Noord-Holland, The Netherlands
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Myles PS, Richards T, Klein A, Smith J, Wood EM, Heritier S, McGiffin D, Zavarsek S, Symons J, McQuilten ZK, Baker RA, Karkouti K, Wallace S. Rationale and design of the intravenous iron for treatment of anemia before cardiac surgery trial. Am Heart J 2021; 239:64-72. [PMID: 34033804 DOI: 10.1016/j.ahj.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/15/2021] [Indexed: 12/13/2022]
Abstract
Background Approximately 20% to 30% of patients awaiting cardiac surgery are anemic. Anemia increases the likelihood of requiring a red cell transfusion and is associated with increased complications, intensive care, and hospital stay following surgery. Iron deficiency is the commonest cause of anemia and preoperative intravenous (IV) iron therapy thus may improve anemia and therefore patient outcome following cardiac surgery. We have initiated the intravenous iron for treatment of anemia before cardiac surgery (ITACS) Trial to test the hypothesis that in patients with anemia awaiting elective cardiac surgery, IV iron will reduce complications, and facilitate recovery after surgery. Methods ITACS is a 1,000 patient, international randomized trial in patients with anemia undergoing elective cardiac surgery. The patients, health care providers, data collectors, and statistician are blinded to whether patients receive IV iron 1,000 mg, or placebo, at 1-26 weeks before their planned date of surgery. The primary endpoint is the number of days alive and at home up to 90 days after surgery. Results To date, ITACS has enrolled 615 patients in 30 hospitals in 9 countries. Patient mean (SD) age is 66 (12) years, 63% are male, with a mean (SD) hemoglobin at baseline of 118 (12) g/L; 40% have evidence (ferritin <100 ng/mL and/or transferrin saturation <25%) suggestive of iron deficiency. Most (59%) patients have undergone coronary artery surgery with or without valve surgery. Conclusions The ITACS Trial will be the largest study yet conducted to ascertain the benefits and risks of IV iron administration in anemic patients awaiting cardiac surgery.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Toby Richards
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Klein
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Julian Smith
- Department of Cardiothoracic Surgery, Monash Health, Clayton, Victoria, Australia; Department of Surgery, Monash University, Clayton, Victoria, Australia
| | - Erica M Wood
- Department of Clinical Haematology, Monash Health and University, Clayton, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University; Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University; Melbourne, Victoria, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Silva Zavarsek
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Joel Symons
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zoe K McQuilten
- Department of Clinical Haematology, Monash Health and University, Clayton, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University; Melbourne, Victoria, Australia
| | - Robert A Baker
- Cardiothoracic Quality and Outcomes, SALHN Perfusion Service, Flinders Medical Centre and Flinders University, Adelaide, South Australia, Australia
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sophia Wallace
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
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Brusco NK, Ekegren CL, Taylor NF, Hill KD, Lee AL, Somerville L, Lannin NA, Wade D, Abdelmotaleb R, Callaway L, Whittaker SL, Morris ME. Self-managed occupational therapy and physiotherapy for adults receiving inpatient rehabilitation ('My Therapy'): protocol for a stepped-wedge cluster randomised trial. BMC Health Serv Res 2021; 21:811. [PMID: 34384427 PMCID: PMC8361638 DOI: 10.1186/s12913-021-06462-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Ensuring patients receive an effective dose of therapeutic exercises and activities is a significant challenge for inpatient rehabilitation. My Therapy is a self-management program which encourages independent practice of occupational therapy and physiotherapy exercises and activities, outside of supervised therapy sessions. METHODS This implementation trial aims to determine both the clinical effectiveness of My Therapy on the outcomes of function and health-related quality of life, and cost-effectiveness per minimal clinically important difference (MCID) in functional independence achieved and per quality adjusted life year (QALY) gained, compared to usual care. Using a stepped-wedge cluster randomised design, My Therapy will be implemented across eight rehabilitation wards (inpatient and home-based) within two public and two private Australian health networks, over 54-weeks. We will include 2,160 patients aged 18 + years receiving rehabilitation for any diagnosis. Each ward will transition from the usual care condition (control group receiving usual care) to the experimental condition (intervention group receiving My Therapy in addition to usual care) sequentially at six-week intervals. The primary clinical outcome is achievement of a MCID in the Functional Independence Measure (FIM™) at discharge. Secondary outcomes include improvement in quality of life (EQ-5D-5L) at discharge, length of stay, 30-day re-admissions, discharge accommodation, follow-up rehabilitation services and adverse events (falls). The economic outcomes are the cost-effectiveness per MCID in functional independence (FIM™) achieved and per QALY gained, for My Therapy compared to usual care, from a health-care sector perspective. Cost of implementation will also be reported. Clinical outcomes will be analysed via mixed-effects linear or logistic regression models, and economic outcomes will be analysed via incremental cost-effectiveness ratios. DISCUSSION The My Therapy implementation trial will determine the effect of adding self-management within inpatient rehabilitation care. The results may influence health service models of rehabilitation including recommendations for systemic change to the inpatient rehabilitation model of care to include self-management. Findings have the potential to improve patient function and quality of life, and the ability to participate in self-management. Potential health service benefits include reduced hospital length of stay, improved access to rehabilitation and reduced health service costs. TRIAL REGISTRATION This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true ).
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Affiliation(s)
- Natasha K Brusco
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, 47-49 Moorooduc Hwy, VIC, 3199, Frankston, Australia.
- La Trobe University Centre for Sport and Exercise Medicine Research, Plenty Road & Kingsbury Drive, 3086, Bundoora, Australia.
| | - Christina L Ekegren
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, 47-49 Moorooduc Hwy, VIC, 3199, Frankston, Australia
- Alfred Health, 55 Commercial Rd, 3004, Melbourne, Australia
| | - Nicholas F Taylor
- La Trobe University Centre for Sport and Exercise Medicine Research, Plenty Road & Kingsbury Drive, 3086, Bundoora, Australia
- Eastern Health, 5 Arnold St, 3128, Box Hill, Australia
| | - Keith D Hill
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, 47-49 Moorooduc Hwy, VIC, 3199, Frankston, Australia
| | - Annemarie L Lee
- Cabrini Health, 154 Wattletree Rd, 3144, Malvern, Australia
- School of Physiotherapy, Monash University, 47-49 Moorooduc Hwy, VIC, 3199, Frankston, Australia
| | - Lisa Somerville
- La Trobe University Centre for Sport and Exercise Medicine Research, Plenty Road & Kingsbury Drive, 3086, Bundoora, Australia
- Alfred Health, 55 Commercial Rd, 3004, Melbourne, Australia
| | - Natasha A Lannin
- La Trobe University Centre for Sport and Exercise Medicine Research, Plenty Road & Kingsbury Drive, 3086, Bundoora, Australia
- Alfred Health, 55 Commercial Rd, 3004, Melbourne, Australia
- Department of Neuroscience, Monash University, Central Clinical School, 99 Commercial Rd, 3004, Melbourne, Australia
| | - Derick Wade
- Physiotherapy and Rehabilitation, Faculty of Health and Life Sciences, Oxford Brookes University, Headington Campus, OX3 0BP, Oxford, United Kingdom
| | | | - Libby Callaway
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, 47-49 Moorooduc Hwy, VIC, 3199, Frankston, Australia
- School of Occupational Therapy, Monash University, 47-49 Moorooduc Hwy, VIC, 3199, Frankston, Australia
| | - Sara L Whittaker
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, 47-49 Moorooduc Hwy, VIC, 3199, Frankston, Australia
| | - Meg E Morris
- La Trobe University Centre for Sport and Exercise Medicine Research, Plenty Road & Kingsbury Drive, 3086, Bundoora, Australia
- Healthscope ARCH, The Victorian Rehabilitation Centre, 499 Springvale Road, 3150, Glen Waverley, Australia
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Moore MR, Mitchell SJ, Weller JM, Cumin D, Cheeseman JF, Devcich DA, Hannam JA, Merry AF. A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist. Anaesthesia 2021; 77:185-195. [PMID: 34333761 DOI: 10.1111/anae.15554] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 11/28/2022]
Abstract
We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Māori and 2047/51,921 (3.9%) for non-Māori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Māori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Māori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Māori patients had worse outcomes than non-Māori.
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Affiliation(s)
- M R Moore
- University of Auckland, Auckland, New Zealand
| | - S J Mitchell
- University of Auckland, Auckland, New Zealand.,Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - J M Weller
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand.,Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand
| | - D Cumin
- University of Auckland, Auckland, New Zealand
| | | | - D A Devcich
- Department of Psychology, Auckland University of Technology, Auckland, New Zealand
| | - J A Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - A F Merry
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Schick V, Boensch M, van Edig M, Alfitian J, Pola T, Ecker H, Lindacher F, Shah-Hosseini K, Wetsch WA, Riedel B, Schier R. Impaired vascular endothelial function as a perioperative risk predictor - a prospective observational trial. BMC Anesthesiol 2021; 21:190. [PMID: 34266384 PMCID: PMC8281450 DOI: 10.1186/s12871-021-01400-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/14/2021] [Indexed: 11/18/2022] Open
Abstract
Background In the recent years, an increasing number of patients with multiple comorbidities (e.g. coronary artery disease, diabetes, hypertension) presents to the operating room. The clinical risk factors are accompanied by underlying vascular-endothelial dysfunction, which impairs microcirculation and may predispose to end-organ dysfunction and impaired postoperative outcome. Whether preoperative endothelial dysfunction identifies patients at risk of postoperative complications remains unclear. In this prospective observational study, we tested the hypothesis that impaired flow-mediated dilation (FMD), a non-invasive surrogate marker of endothelial function, correlates with Days at Home within 30 days after surgery (DAH30). DAH30 is a patient-centric metric that captures postoperative complications and importantly also hospital re-admissions. Methods Seventy-one patients scheduled for major abdominal surgery were enrolled. FMD was performed pre-operatively prior to major abdominal surgery and patients were dichotomised at a threshold value of 10%. FMD was then correlated with DAH30 (primary endpoint) and postoperative complications (secondary endpoints). Results DAH30 did not differ between patients with reduced FMD and normal FMD (14 (4) (median (IQR)) vs. 15 (8), P = 0.8). Similary, no differences between both groups were found for CCI (normal FMD: 21 (30) (median (IQR)), reduced FMD: 26 (38), P = 0.4) or frequency of major complications (normal FMD: 7 (19%) (n (%)), reduced FMD: 12 (35%), P = 0.12). The regression analyses revealed that FMD in combination with ASA status and surgery duration had no additional significant predictive effect for DAH30, CCI or Clavien-Dindo score. Conclusion FMD does not add predictive value with regards to DAH30, CCI or Clavien-Dindo score within our study cohort of patients undergoing abdominal surgery. Trial registration The study was registered in the German Clinical Trials Register (DRKS00005472), prospectively registered on 25/11/2013.
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Affiliation(s)
- Volker Schick
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Marc Boensch
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Milan van Edig
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Jonas Alfitian
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Tülay Pola
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Hannes Ecker
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Falko Lindacher
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Kija Shah-Hosseini
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Wolfgang A Wetsch
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and The University of Melbourne, Melbourne, Australia
| | - Robert Schier
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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50
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Santa Mina D, Sellers D, Au D, Alibhai SMH, Clarke H, Cuthbertson BH, Darling G, El Danab A, Govindarajan A, Ladha K, Matthew AG, McCluskey S, Ng KA, Quereshy F, Karkouti K, Randall IM. A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations. Front Oncol 2021; 11:629207. [PMID: 33777780 PMCID: PMC7987917 DOI: 10.3389/fonc.2021.629207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022] Open
Abstract
Background Experimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies. Methods This is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (e.g., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a 'virtual program' using only telephone or internet-based communication for screening, assessments, or intervention was introduced. Conclusion This pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.
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Affiliation(s)
- Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Daniel Sellers
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Darren Au
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gail Darling
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Alaa El Danab
- Clinical Nutrition, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Anand Govindarajan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Sinai Health System, Toronto, ON, Canada
| | - Karim Ladha
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew G Matthew
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Stuart McCluskey
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Karen A Ng
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Geriatrics, Sinai Health System, Toronto, ON, Canada
| | - Fayez Quereshy
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Keyvan Karkouti
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Ian M Randall
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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