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Liu J, Zhang B, Qi P, Ren X, Zheng D, He Y, Zheng X, Yue Z, Li Y, Yang N, Wang Z, Bao J, Tian J, Yang L, Zhai Z, Zuo L, Hou Z, Wang J, Wang W, Chang H, Ma J, Zhang Y, Dong Z, Dong Z, Zhong G, Cheng H, Lei P, Li Z, Wu G, Shang P. Transperitoneal vs retroperitoneal laparoscopic radical nephrectomy: a double-arm, parallel-group randomized clinical trial. BMC Urol 2024; 24:29. [PMID: 38310213 PMCID: PMC10838419 DOI: 10.1186/s12894-023-01364-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: 08/08/2023] [Accepted: 11/09/2023] [Indexed: 02/05/2024] Open
Abstract
OBJECTIVE To compare the outcomes of patients undergoing Retroperitoneal laparoscopic Radical nephrectomy (RLRN) and Transperitoneal laparoscopic Radical nephrectomy (TLRN). METHODS A total of 120 patients with localized renal cell carcinoma were randomized into either RLRN or TLRN group. Mainly by comparing the patient perioperative related data, surgical specimen integrity, pathological results and tumor results. RESULTS Each group comprised 60 patients. The two group were equivalent in terms of perioperative and pathological outcomes. The mean integrity score was significantly lower in the RLRN group than TLRN group. With a median follow-up of 36.4 months after the operation, Kaplan-Meier survival analysis showed no significant difference between RLRN and TLRN in overall survival (89.8% vs. 88.5%; P = 0.898), recurrence-free survival (77.9% vs. 87.7%; P = 0.180), and cancer-specific survival (91.4% vs. 98.3%; P = 0.153). In clinical T2 subgroup, the recurrence rate and recurrence-free survival in the RLRN group was significantly worse than that in the TLRN group (43.2% vs. 76.7%, P = 0.046). Univariate and multivariate COX regression analysis showed that RLRN (HR: 3.35; 95%CI: 1.12-10.03; P = 0.030), male (HR: 4.01; 95%CI: 1.07-14.99; P = 0.039) and tumor size (HR: 1.23; 95%CI: 1.01-1.51; P = 0.042) were independent risk factor for recurrence-free survival. CONCLUSIONS Our study showed that although RLRN versus TLRN had roughly similar efficacy, TLRN outperformed RLRN in terms of surgical specimen integrity. TLRN was also significantly better than RLRN in controlling tumor recurrence for clinical T2 and above cases. TRIAL REGISTRATION Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=24400 ), identifier: ChiCTR1800014431, date: 13/01/2018.
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Affiliation(s)
- Junyao Liu
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Bin Zhang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Peng Qi
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Xiaowei Ren
- School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Duo Zheng
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Yang He
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Xu Zheng
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Zhongjin Yue
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Ye Li
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Ningqiang Yang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Zhiping Wang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Junsheng Bao
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Junqiang Tian
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Li Yang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Zhenxing Zhai
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Lingjun Zuo
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Zizhen Hou
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Jiaji Wang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Wei Wang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Hong Chang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Junhai Ma
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Yunxin Zhang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Zhichun Dong
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Zhilong Dong
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Ganping Zhong
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Hui Cheng
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China
| | - Pengyuan Lei
- Department of Urology, Xigu Branch of Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Zhongming Li
- Department of Urology, Xigu Branch of Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - GongJin Wu
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China.
| | - Panfeng Shang
- Department of Urology, Lanzhou University Second Hospital, No.82 Cui Ying Gate, Cheng Guan District, Lanzhou, 730030, Gansu, China.
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Gong Y, Chen Q, Zhang Y. The Role of the Clinical Pharmacist on the Health Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD). Int J Chron Obstruct Pulmon Dis 2022; 17:1863-1870. [PMID: 35996393 PMCID: PMC9391938 DOI: 10.2147/copd.s370532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Clinical pharmacists play a significant role in clinical practice, but their work in the clinical pathway (CP) of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) remains undefined. Methods This prospective study included patients who met the discharge criteria during hospitalization at the department of respiratory medicine of the Second Affiliated Hospital of Fujian Medical University from March to December 2017 (no pharmacists involved) and from March 2018 to January 2019 (pharmacists involved). The adverse drug reaction (ADR) reporting rate, the average DDD number of antibacterial drugs, the per capita cost of pharmaceutical services, and the benefit-cost ratio (B/C) were analyzed. Results and Discussion Eighty participants were enrolled during the traditional period and eighty-five participants during the clinical pharmacist period. The average hospital stays (9.2±0.4 vs 10.7±0.6 days, P=0.032), the total cost of hospitalization expenses (¥ 14,058±826 vs ¥ 18,765±1434, P=0.004), the total cost of drugs (¥ 5717±449 vs ¥ 8002±755, P=0.004), and cost of antimicrobial drugs (¥ 3639±379 vs ¥ 5636±641, P=0.007) were all lower in the clinical pharmacist group than in the traditional group. The B/C was 10.38 and 5.05 in the total cost of hospitalization expenses and the total cost of drugs, respectively. The clinical pharmacists’ participation was independently associated with the total cost of hospitalization expenses (β=−0.201, 95% confidence interval: −0.390, −0.055, P=0.010). What is New and Conclusion The participation of the clinical pharmacist in implementing an AECOPD CP significantly reduces patients’ hospitalization days, the total cost of hospitalization expenses, and antibiotic use and improves the B/C of AECOPD management. The clinical pharmacists’ participation was independently associated with the total hospitalization expenses.
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Affiliation(s)
- Yanqing Gong
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China.,Department of Pharmacy, Gaoxin Branch of the First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Qiying Chen
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
| | - Yin Zhang
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
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Hwang J, Tchoe HJ, Chung S, Park E, Choi M. Experiences of using clinical pathways in hospitals: Perspectives of quality improvement personnel. Nurs Open 2022; 10:337-348. [PMID: 35986469 PMCID: PMC9748067 DOI: 10.1002/nop2.1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/24/2022] [Accepted: 07/29/2022] [Indexed: 01/04/2023] Open
Abstract
AIM This study aimed to explore the experiences of quality improvement personnel in implementing clinical pathways (CPs) in Korean hospitals. DESIGN A qualitative study using focus-group interviews was conducted with healthcare professionals in charge of CP development and management in hospitals. METHODS Sixteen quality improvement personnel from eight tertiary and seven general hospitals were recruited using purposive sampling. The verbatim transcribed data were analysed using qualitative content analysis. RESULTS Three key themes emerged: (1) the primary focus of CP development on surgeries through concerted efforts between management and frontline healthcare professionals; (2) CP fidelity management using indicators and feedback to relevant staff or departments; and (3) positive outcomes, despite concerns about system safety. The factors affecting CP use included availability of clinical evidence, flexibility of CPs, top management and clinical leadership, physicians' perceptions of CPs, computerized support systems, and external policies and regulations.
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Affiliation(s)
- Jee‐In Hwang
- Kyung Hee University College of Nursing ScienceSeoulSouth Korea
| | - Ha Jin Tchoe
- National Evidence‐Based Healthcare Collaborating AgencySeoulSouth Korea
| | - Soojin Chung
- Department of NursingSuwon Science CollegeHwaseongSouth Korea
| | - Eunji Park
- National Evidence‐Based Healthcare Collaborating AgencySeoulSouth Korea
| | - Miyoung Choi
- National Evidence‐Based Healthcare Collaborating AgencySeoulSouth Korea
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Guertin L, Earle M, Dardas T, Brown C. Post-Heart Transplant Care Pathway's Impact on Reducing Length of Stay. J Nurs Care Qual 2021; 36:350-354. [PMID: 33534348 DOI: 10.1097/ncq.0000000000000546] [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: 10/22/2022]
Abstract
BACKGROUND Prolonged length of stay (LOS) has undesirable consequences including increased cost, resource consumption, morbidity, and disruptions in hospital flow. LOCAL PROBLEM A high-volume heart transplant center in the Pacific Northwest had a mean index hospital LOS of 23 days, with a goal of 10 days according to the institutional heart transplant care pathway. METHODS A retrospective, regression analysis was used to identify the factors contributing to LOS of 41 post-heart transplant patients. INTERVENTIONS The post-heart transplant care pathway and order set were modified accordingly and reintroduced to the health care team. RESULTS Factors contributing to LOS included number of days (1) until the first therapeutic calcineurin inhibitor level, (2) until intravenous diuretics were no longer required, and (3) outside of a therapeutic calcineurin inhibitor range. The interventions reduced the mean LOS by 8 days. CONCLUSIONS Increased awareness of LOS, education, and consistent use of care pathways can significantly reduce length of stay.
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Affiliation(s)
- Lisa Guertin
- University of Washington Medical Center, Seattle (Ms Guertin and Dr Dardas); Rush University College of Nursing, Chicago, Illinois (Dr Earle); and Decision Patterns, Oakland, California (Dr Brown)
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Open partial nephrectomy with kidney split: Effective surgical approach to resect completely endophytic tumors. Urol Oncol 2021; 39:371.e1-371.e5. [PMID: 33853747 DOI: 10.1016/j.urolonc.2021.02.021] [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: 10/13/2020] [Revised: 01/12/2021] [Accepted: 02/22/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To review perioperative, renal functional, and oncological outcomes of the kidney split technique in performing partial nephrectomy (PN) to resect completely endophytic renal tumors. METHODS All consecutive patients who underwent open PN with kidney split between 2015 and 2019 at our institution were included. In this approach the kidney is incised along Brodel's line in an avascular plane to locate and then resect the endophytic tumor. Clinicopathologic data, perioperative metrics, complications, renal function, recurrence, and mortality were analyzed using descriptive statistics. RESULTS Forty-two open PN with kidney split were performed in 40 patients. No patients required conversion to radical nephrectomy. Most tumors were pT1a renal cell carcinoma (76%), with no recurrences or deaths after a median follow-up of 15 months. All patients had tumors of moderate or high complexity by R.E.N.A.L. nephrometry score. Median cold ischemia time, operative time, estimated blood loss, and inpatient length-of-stay were 34 minutes, 152 minutes, 225 ml, and 2 days, respectively. No patients experienced any Clavien-Dindo grade 4 or 5 complications. Postoperative estimated glomerular filtration rate (eGFR) at last follow-up was >30 ml/min/1.73m2 in all but one patient, and no patients required dialysis. CONCLUSIONS The kidney split represents an effective PN technique to resect complex, endophytic renal tumors. In our experience, this technique affords acceptable perioperative outcomes, preserved renal function, and no short-term recurrences or mortality events. Our series highlights the importance of adapting classical surgical techniques, using cold ischemia, and relying on preoperative and intraoperative ultrasonography to effectively guide this complex kidney-sparing operation.
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6
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Dominique I, Palamara C, Seizilles De Mazancourt E, Ecochard R, Hacquard H, Tremblais B, Morel Journel N, Champetier D, Ruffion A, Paparel P. Enhanced Recovery after Robot-Assisted Partial Nephrectomy for Cancer: Is it Better for Patients to Have a Quick Discharge? Urol Int 2021; 105:499-506. [PMID: 33647899 DOI: 10.1159/000505757] [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: 08/29/2019] [Accepted: 01/04/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of the study was to assess the efficacy and safety of an enhanced recovery program (ERP) after robot-assisted partial nephrectomy (RAPN) for cancer. METHODS It was a monocentric, retrospective, comparative study. An ERP after RAPN was introduced at our institution in 2015 and proposed to all consecutive patients admitted for RAPN. The control group for this study was composed of patients managed immediately before the introduction of the ERP. We collected information on patient characteristics, tumor sizes, ischemia times, biology, hospital length of stays, postoperative (≤30 days) complications, and readmission rates. Group comparisons were made using the Pearson χ2 test for qualitative data and the Student t test for quantitative data. RESULTS Between 2015 and 2017, 112 patients were included in the ERP group. Fifty patients were included in the control group. Ninety patients in the ERP group (80.4%) were discharged at or before postoperative day (POD) 2 versus 10 patients (20%) in the control group (p < 0.001). There was no significant difference between the ERP and control groups for the urinary retention rate (respectively 3.6 vs. 2%; p = 0.593). Resumption of normal bowel function was significantly shorter in the ERP group (94.6% at POD1 vs. 69.6% in the control group, p < 0.001). There were no significant differences for postoperative complications (15.2% in the ERP group vs. 20% in the control group, p = 0.447) or readmissions within 30 days (8.04 vs. 0.2%, p = 0.140). CONCLUSIONS ERP after RAPN seems to reduce postoperative length of stay without increasing postoperative complications or readmissions.
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Affiliation(s)
- Inès Dominique
- Department of Urology, GH Diaconnesses-Croix Saint Simon, Paris, France,
| | | | | | - Rene Ecochard
- Department of Statistics, CHU Lyon Sud, Pierre-Bénite, France
| | | | | | | | | | - Alain Ruffion
- Department of Urology, CHU Lyon Sud, Pierre-Bénite, France
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Hanson G, Lyons KW, Fournier DA, Lollis SS, Martin ED, Rhynhart KK, Handel WJ, McGuire KJ, Abdu WA, Pearson AM. Reducing Radiation and Lowering Costs With a Standardized Care Pathway for Nonoperative Thoracolumbar Fractures. Global Spine J 2019; 9:813-819. [PMID: 31819846 PMCID: PMC6882098 DOI: 10.1177/2192568219831687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Retrospective observational study. OBJECTIVE There is marked variation in the management of nonoperative thoracolumbar (TL) compression and burst fractures. This was a quality improvement study designed to establish a standardized care pathway for TL fractures treated with bracing, and to then evaluate differences in radiographs, length of stay (LOS), and cost before and after the pathway. METHODS A standardized pathway was established for management of nonoperative TL burst and compression fractures (AOSpine classification type A1-A4 fractures). Bracing, radiographs, costs, complications, and LOS before and after pathway adoption were analyzed. Differences between the neurosurgery and orthopedic spine services were compared. RESULTS Between 2012 and 2015, 406 nonoperative burst and compression TL fractures were identified. A total of 183 (45.1%) were braced, 60.6% with a custom-made thoracolumbosacral orthosis (TLSO) and 39.4% with an off-the-shelf TLSO. The number of radiographs significantly reduced after initiation of the pathway (3.23 vs 2.63, P = .010). A total of 98.6% of braces were custom-made before the pathway; 69.6% were off-the-shelf after the pathway. The total cost for braced patients after pathway adoption decreased from $10 462.36 to $8928.58 (P = .078). Brace-associated costs were significantly less for off-the-shelf TSLO versus custom TLSO ($1352.41 vs $3719.53, respectively, P < .001). The mean LOS and complication rate did not change significantly following pathway adoption. The orthopedic spine service braced less frequently than the neurosurgery service (40.7% vs 52.2%, P = .023). CONCLUSIONS Standardized care pathways can reduce cost and radiation exposure without increasing complication rates in nonoperative management of thoracolumbar compression and burst fractures.
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Affiliation(s)
- Gregory Hanson
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Keith W. Lyons
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA,Keith W. Lyons, Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03766, USA.
| | - Debra A. Fournier
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - S. Scott Lollis
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Eric D. Martin
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Kurt K. Rhynhart
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Wanda J. Handel
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Kevin J. McGuire
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - William A. Abdu
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Adam M. Pearson
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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9
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Sentell KT, Badani KK, Paulucci DJ, Hemal AK, Porter J, Eun DD, Bhandari A, Abaza R. A Single Overnight Stay After Robotic Partial Nephrectomy Does Not Increase Complications. J Endourol 2019; 33:1003-1008. [PMID: 31422698 DOI: 10.1089/end.2019.0218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objectives: To evaluate the feasibility of postoperative day 1 (POD1) discharge after robotic partial nephrectomy (RPN) and to determine whether a protocol targeting a shorter length of stay (LOS) is associated with any difference in the rate of postoperative complications. Materials and Methods: We reviewed a prospectively maintained, multi-institutional database of patients who underwent RPN from September 2013 to September 2016. Three of the six participating surgeons used a protocol that targeted discharge on POD1, whereas three surgeons did not. Patient characteristics and postoperative complication rates between the two groups were compared. Results: A total of 665 patients were included, 455 of whom were treated by surgeons utilizing a POD1 discharge protocol, whereas 210 were not. The mean LOS for those in the POD1 protocol group was 1.13 days vs 2.02 days in the non-protocol group. Between groups, there were no differences in age (p = 0.098), body mass index (p = 0.164), tumor size (p = 0.502), or R.E.N.A.L. Nephrometry score (p = 0.974), but POD1 discharge protocol patients had higher age-adjusted Charlson comorbidity score (4 vs 2, p = 0.033), were less likely to have a hilar tumor (15.9% vs 23.1%, p = 0.03), and had a larger percent decrease in discharge estimated glomerular filtration rate (-15.9% vs -7.1%, p < 0.001). There were no differences in the rates of overall (p = 0.715), major (p = 0.164), medical (p = 0.089), or surgical complications (p = 0.301) or in complications by the Clavien-Dindo category (p = 0.13). Conclusion: Discharge on POD1 after RPN is feasible, reproducible by different surgeons, and not associated with an increased risk of postoperative complications.
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Affiliation(s)
- Katherine T Sentell
- OhioHealth Robotic Urologic and Cancer Surgery, Dublin Methodist Hospital, Dublin, Ohio
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David J Paulucci
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Porter
- Department of Urology, Swedish Medical Center, Seattle, Washington
| | - Daniel D Eun
- Department of Urology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Akshay Bhandari
- Division of Urology, Columbia University at Mount Sinai, Miami Beach, Florida
| | - Ronney Abaza
- OhioHealth Robotic Urologic and Cancer Surgery, Dublin Methodist Hospital, Dublin, Ohio
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10
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Lifland B, Wright DR, Mangione-Smith R, Desai AD. The Impact of an Adolescent Depressive Disorders Clinical Pathway on Healthcare Utilization. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2019; 45:979-987. [PMID: 29779180 DOI: 10.1007/s10488-018-0878-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Clinical pathways are known to improve the value of health care in medical and surgical settings but have been rarely studied in the psychiatric setting. This study examined the association between level of adherence to an adolescent depressive disorders inpatient clinical pathway and length of stay (LOS), cost, and readmissions. Patients in the high adherence category had significantly longer LOS and higher costs compared to the low adherence category. There was no difference in the odds of 30-day emergency department return visits or readmissions. Understanding which care processes within the pathway are most cost-effective for improving patient-centered outcomes requires further investigation.
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Affiliation(s)
- Brooke Lifland
- University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Davene R Wright
- Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Rita Mangione-Smith
- University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Arti D Desai
- University of Washington School of Medicine, Seattle, WA, USA. .,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA.
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11
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A Standardized Perioperative Clinical Pathway for Uncomplicated Craniosynostosis Repair Is Associated With Reduced Hospital Resource Utilization. J Craniofac Surg 2019; 30:105-109. [PMID: 30376505 DOI: 10.1097/scs.0000000000004871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hospital resource overutilization can significantly disrupt patient treatment such as cancelling surgical patients due to a lack of intensive care unit (ICU) space. The authors describe a clinical pathway (CP) designed to reduce ICU length of stay (LOS) for nonsyndromic single-suture craniosynostosis (nsSSC) patients undergoing cranial vault reconstruction (CVR) in order to minimize surgical disruptions and improve patient outcomes. METHODS A multidisciplinary team implemented a perioperative CP including scheduled laboratory testing to decrease ICU LOS. Hospital and ICU LOS, interventions, and perioperative morbidity-infection rate, cerebrospinal fluid (CSF) leaks, and unplanned return to the operating room (OR)-were compared using Mann-Whitney U, Fisher exact, and t tests. RESULTS Fifty-one ICU admissions were managed with the standardized CP and compared to 49 admissions in the 12 months prior to pathway implementation. There was a significant reduction in ICU LOS (control: mean 1.84 ± 0.93, median 1.89 ± 0.94; CP: mean 1.15 ± 0.34, median 1.03 ± 0.34 days; P < 0.001 for both). There were similar rates of hypotension requiring intervention (CP: 2, control: 1; P = 0.999), postoperative transfusion (CP: 3, control: 0; P = 0.243), and artificial ventilation (CP: 1, control: 0; P = 0.999). Perioperative morbidity such as infection (CP: 1, control: 0; P = 0.999), return to the OR (CP: 1, control: 0; P = 0.999), and CSF leak (no leaks; P = 0.999) was also similar. CONCLUSION Implementation of a standardized perioperative CP for nsSSC patients resulted in a significantly shorter ICU LOS without a measured change in perioperative morbidity. Pathways such as the one described that improve patient throughput and decrease resource utilization benefit craniofacial teams in conducting an efficient service while providing high-quality care.
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12
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Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review. INT J EVID-BASED HEA 2018; 16:3-24. [PMID: 29176429 DOI: 10.1097/xeb.0000000000000126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews. METHODS We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies. RESULTS Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years. CONCLUSION Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?
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13
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Gas J, Liaigre-Ramos A, Caubet-Kamar N, Beauval JB, Lesourd M, Prudhomme T, Huyghe E, Soulié M, Charpentier S, Gamé X. Evaluation of the impact of a clinical pathway on the progression of acute urinary retention. Neurourol Urodyn 2018; 38:387-392. [PMID: 30418678 DOI: 10.1002/nau.23873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/02/2018] [Indexed: 11/10/2022]
Abstract
AIMS The management of acute urinary retention (AUR) revolves around trial without catheter (TWOC) after prescription of an alpha-blocker. This study evaluates the implementation of a clinical pathway for AUR. METHODS Specific clinical pathways for AUR was established between the Emergency Department and the Department of Urology in order to reduce the duration of bladder drainage that included standard prescriptions, an information sheet, and a note to be faxed to scheduling nurses to organize the trial without catheter (TWOC). The main endpoint was the reduction in the time between the AUR episode and TWOC, without decreasing urination. RESULTS Between April 2015 and December 2016, 248 patients were treated in the Emergency Department, and externally, for AUR. One hundred and seventy patients were enrolled in the pathway group and 78 in the control group. The mean duration of urinary catheterization decreased by 5.5 days as did the number of patients lost to follow-up (32% vs 76%), without decreasing the successful voiding (46% vs 36%). The duration of the urinary catheterization was not related to the chance of successful voiding regardless of the urine volume and a drainage time of over 10 days significantly reduced the chance of success (68%, n = 26 versus 42%, n = 76; P = 0.0038). CONCLUSION The implementation of a clinical pathway for AUR reduced the number of patients lost to follow-up and the catheterization duration, thus optimizing the management of these patients.
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Affiliation(s)
- Jérôme Gas
- Department of Urology, Kidney Transplant and Andrology, Toulouse University Hospital, Toulouse, France
| | - Aline Liaigre-Ramos
- Urgent Care Admissions Department, Toulouse University Hospital, Toulouse, France
| | - Natacha Caubet-Kamar
- Urgent Care Admissions Department, Toulouse University Hospital, Toulouse, France
| | - Jean Baptiste Beauval
- Department of Urology, Kidney Transplant and Andrology, Toulouse University Hospital, Toulouse, France
| | - Marine Lesourd
- Department of Urology, Kidney Transplant and Andrology, Toulouse University Hospital, Toulouse, France
| | - Thomas Prudhomme
- Department of Urology, Kidney Transplant and Andrology, Toulouse University Hospital, Toulouse, France
| | - Eric Huyghe
- Department of Urology, Kidney Transplant and Andrology, Toulouse University Hospital, Toulouse, France
| | - Michel Soulié
- Department of Urology, Kidney Transplant and Andrology, Toulouse University Hospital, Toulouse, France
| | - Sandrine Charpentier
- Urgent Care Admissions Department, Toulouse University Hospital, Toulouse, France
| | - Xavier Gamé
- Department of Urology, Kidney Transplant and Andrology, Toulouse University Hospital, Toulouse, France
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14
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Corradi RB, Vertosick EA, Nguyen DP, Vilaseca A, Sjoberg DD, Benfante N, Nogueira LN, Spaliviero M, Touijer KA, Russo P, Coleman JA. Nephrometry scores and perioperative outcomes following robotic partial nephrectomy. Int Braz J Urol 2018; 43:1075-1083. [PMID: 28727381 PMCID: PMC5734070 DOI: 10.1590/s1677-5538.ibju.2016.0571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 05/16/2017] [Indexed: 01/20/2023] Open
Abstract
Objectives: Based on imaging features, nephrometry scoring systems have been conceived to create a standardized and reproducible way to characterize renal tumor anatomy. However, less is known about which of these individual measures are important with regard to clinically relevant perioperative outcomes such as ischemia time (IT), estimated blood loss (EBL), length of hospital stay (LOS), and change in estimated glomerular filtration rate (eGFR) after robotic partial nephrectomy (PN). We aimed to assess the utility of the RENAL and PADUA scores, their subscales, and C-index for predicting these outcomes. Materials and Methods: We analyzed imaging studies from 283 patients who underwent robotic PN between 2008 and 2014 to assign nephrometry scores (NS): PADUA, RENAL and C-index. Univariate linear regression was used to assess whether the NS or any of their subscales were associated with EBL or IT. Multivariable linear regression and linear regression models were created to assess LOS and eGFR. Results: The three NS were significantly associated with EBL, IT, LOS, and eGFR at 12 months after surgery. All subscales with the exception of anterior/posterior were significantly associated with EBL and IT. Collecting system, renal rim location, renal sinus, exophytic/endophytic, and nearness to collecting system were significant predictors for LOS. Only renal rim location, renal sinus invasion and polar location were significantly associated with eGFR at 12 months. Conclusions: Tumor size and depth are important characteristics for predicting robotic PN outcomes and thus could be used individually as a simplified way to report tumors features for research and patient counseling purposes.
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Affiliation(s)
- Renato B Corradi
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Emily A Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Daniel P Nguyen
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Antoni Vilaseca
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Nicole Benfante
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lucas N Nogueira
- Departamento de Cirurgia, Serviço de Urologia, Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brasil
| | - Massimiliano Spaliviero
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Karim A Touijer
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jonathan A Coleman
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, USA
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15
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Patel MI, Beattie K, Bang A, Gurney H, Smith DP. Cytoreductive nephrectomy for metastatic renal cell carcinoma: inequities in access exist despite improved survival. Cancer Med 2017; 6:2188-2193. [PMID: 28834281 PMCID: PMC5633591 DOI: 10.1002/cam4.1137] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 01/28/2023] Open
Abstract
The use of cytoreductive nephrectomy (CRN) in the targeted therapy era is still debated. We aimed to determine factors associated with reduced use of CRN and determine the effect of CRN on overall survival in patients with metastatic renal cell carcinoma (RCC). All advanced RCC diagnosed between 2001 and 2009 in New South Wales, Australia, were identified from the Central Cancer Registry. Records of treatment and death were electronically linked. Follow-up was to the end of 2011. Multivariable logistic regression analysis was used to determine factors associated with the receipt of CRN. Cox proportional hazards model was used to determine factors associated with survival. A total of 1062 patients were identified with metastatic RCC of whom 289 (27%) received CRN. There was no difference in the use of CRN over the time period of the study. Females (OR 0.68 (95% CI: 0.48-0.96)), unmarried individuals (OR 0.68 (95% CI: 0.48-0.96)), treatment in a nonteaching hospital (OR 0.26 (95% CI: 0.18-0.36)) and individuals without private insurance (OR 0.29 (95% CI: 0.20-0.41)) all had reduced likelihood of receiving CRN. On multivariable analysis, not receiving CRN resulted in a 90% increase in death (HR 1.90 (95% CI: 1.61-2.25)). In addition, increasing age (P < 0.001), increasing Charlson comorbidity status (P = 0.002) and female gender also had a significant independent association with death. Despite a strong association with improved survival, individuals who are elderly, female, have treatment in a nonteaching facility or have no private insurance have a reduced likelihood of receiving CRN.
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Affiliation(s)
- Manish I Patel
- Discipline of Surgery, Westmead Hospital, University of Sydney, Sydney, Australia.,Department of Urology, Westmead Hospital, Westmead, Australia
| | - Kieran Beattie
- Department of Urology, Westmead Hospital, Westmead, Australia
| | - Albert Bang
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | - Howard Gurney
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - David P Smith
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia.,Menzies Health Institute Queensland, Griffith University, Nathan, Australia
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16
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Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2017; 42:E547-E554. [PMID: 28441684 DOI: 10.1097/brs.0000000000001865] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Delphi process with multiple iterative rounds using a nominal group technique. OBJECTIVE The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols. METHODS An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. RESULTS Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge. CONCLUSION We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research. LEVEL OF EVIDENCE 5.
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17
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Kriegel J, Jehle F, Moser H, Tuttle-Weidinger L. Patient logistics management of patient flows in hospitals: A comparison of Bavarian and Austrian hospitals. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2016. [DOI: 10.1080/20479700.2015.1119370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Tan HJ. Survival benefit of partial nephrectomy: Reconciling experimental and observational data. Urol Oncol 2015; 33:505.e21-4. [DOI: 10.1016/j.urolonc.2015.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/03/2015] [Accepted: 08/03/2015] [Indexed: 01/30/2023]
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19
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Chen KH, Wu JM, Ho TW, Yu HJ, Lai F. A cross-hospital cost and quality assessment system by extracting frequent physician order set from a nationwide Health Insurance Research Database. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2015; 120:142-153. [PMID: 25981881 DOI: 10.1016/j.cmpb.2015.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 04/12/2015] [Accepted: 04/13/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE Clinical pathways fall under the process perspective of health care quality. For care providers, clinical pathways can be compared to improve health care quality. The objective of this study was to design a convenient physician order set comparison system based on claim records from the National Health Insurance Research Database (NHIRD) of Taiwan. METHODS Data were retrieved from the NHIRD for the period of 2003-2007 for frequent physician order sets found in hospital surgical hernia repair inpatient claim records. The derived frequent physician order sets were divided into five frequency thresholds: 80%, 85%, 90%, 95% and 100%. A consistency index was defined and calculated to understand each care providers' adherence to clinical pathways. In addition, the average count of physician orders, average amount of cost, Charlson comorbidity index, and recurrence rate were calculated; these variables were considered in frequent physician order sets comparison. RESULTS Records for 3262 patients from 257 hospitals were retrieved. The frequent physician order sets of various frequency thresholds, Charlson comorbidities, and recurrence rates were extracted and computed for comparison among hospitals. A recurrence rate threshold of 2% was established to separate low and high quality of herniorrhaphy at each hospital. Univariable analysis showed that low recurrence rate was associated with high consistency index (70.99±23.88 vs. 52.60±20.30; P<.001), few surgeons at each hospital (3.50±4.41 vs. 7.09±6.57; P<.001), and non-medical center facility type (P=.042). A multivariable Cox regression analysis indicated an association of low recurrence rates with consistency index only (one percentage increased: OR=0.973; CI: 0.957-0.990; P=.002). CONCLUSIONS The proposed system leveraged the claim records to generate frequent physician order sets at hospitals, thus solving the difficulty in obtaining clinical pathway data. This allows medical professionals and management to conveniently and effectively compare and query similarities and differences in clinical pathways among hospitals.
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Affiliation(s)
- Kuo-Hsin Chen
- Department of Surgery, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Jin-Ming Wu
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taiwan; Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Te-Wei Ho
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taiwan
| | - Hwan-Jeu Yu
- Department of Computer Science and Information Engineering, National Taiwan University, Taiwan
| | - Feipei Lai
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taiwan; Department of Computer Science and Information Engineering, National Taiwan University, Taiwan; Department of Electrical Engineering, National Taiwan University, Taiwan
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20
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Wang HQ, Zhou TS, Zhang YF, Chen L, Li JS. Research and Development of Semantics-based Sharable Clinical Pathway Systems. J Med Syst 2015; 39:73. [PMID: 26071207 DOI: 10.1007/s10916-015-0257-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 06/02/2015] [Indexed: 12/14/2022]
Abstract
The clinical pathway (CP) as a novel medical management schema is beneficial for reducing the length of stay, decreasing heath care costs, standardizing clinical activities, and improving medical quality. However, the practicability of CPs is limited by the complexity and expense of adding the standard functions of electronic CPs to existing electronic medical record (EMR) systems. The purpose of this study was to design and develop an independent clinical pathway (ICP) system that is sharable with different EMR systems. An innovative knowledge base pattern was designed with separate namespaces for global knowledge, local knowledge, and real-time instances. Semantic web technologies were introduced to support knowledge sharing and intelligent reasoning. The proposed system, which was developed in a Java integrated development environment, achieved standard functions of electronic CPs without modifying existing EMR systems and integration environments in hospitals. The interaction solution between the pathway system and the EMR system simplifies the integration procedures with other hospital information systems. Five categories of transmission information were summarized to ensure the interaction process. Detailed procedures for the application of CPs to patients and managing exceptional alerts are presented by explicit data flow analysis. Compared to embedded pathway systems, independent pathway systems feature greater feasibility and practicability and are more advantageous for achieving the normalized management of standard CPs.
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Affiliation(s)
- Hua-Qiong Wang
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
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21
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Duarte RM, Ferreira NV, Oliveira AM, Fonseca FP, Vieira-Silva M, Correia-Pinto J. Benefits of radial distortion correction in arthroscopic surgery: a first experimental study on a knee model. Int J Med Robot 2014; 11:341-347. [PMID: 25242547 DOI: 10.1002/rcs.1612] [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: 12/03/2013] [Revised: 07/26/2014] [Accepted: 07/28/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lens probes used in arthroscopy typically have a small diameter and wide field-of-view. This introduces strong radial distortion (RD) into the image, ultimately affecting the surgeon's hand-eye coordination. This study evaluates potential benefits of using distortion-free images in arthroscopic surgery. METHODS Distortion-free images were obtained using RDFixer™ software (Perceive3D, SA) to remove RD in the input video stream. Twelve orthopedic residents performed an arthroscopic task (loose body removal) in a dry-knee model using video with and without distortion. Residents were questioned about image quality, and surgical performance was rated using an adapted Global Rating Scale. RESULTS A statistically significant improvement of all parameters was observed with distortion-free images. Residents perceived distortion-free images as providing a wider field-of-view and a better notion of relative depth and distance. CONCLUSION RD correction improved the surgical performance of residents, potentially decreasing their learning curve. Future work will study whether the benefits are observable in experienced surgeons. Copyright © 2014 John Wiley & Sons, Ltd.
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Affiliation(s)
- Rui M Duarte
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho.,ICVS/3B's PT Government Associate Laboratory.,Orthopedic Surgery Department, Hospital de Braga
| | - Nuno V Ferreira
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho.,ICVS/3B's PT Government Associate Laboratory.,Orthopedic Surgery Department, Hospital de Braga
| | - Armando M Oliveira
- University of Coimbra, Institute of Cognitive Psychology - Faculty of Psychology and Educational Sciences
| | - Fernando P Fonseca
- Orthopedic Surgery Department, Centro Hospitalar da Universidade de Coimbra.,Medical School, University of Coimbra
| | - Manuel Vieira-Silva
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho.,ICVS/3B's PT Government Associate Laboratory.,Orthopedic Surgery Department, Hospital de Braga
| | - Jorge Correia-Pinto
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho.,ICVS/3B's PT Government Associate Laboratory.,Pediatric Surgery Department, Hospital de Braga
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22
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Russo P, Mano R. Open mini-flank partial nephrectomy: an essential contemporary operation. Korean J Urol 2014; 55:557-67. [PMID: 25237456 PMCID: PMC4165917 DOI: 10.4111/kju.2014.55.9.557] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 07/21/2014] [Indexed: 12/24/2022] Open
Abstract
Secondary to the widespread use of the modern imaging techniques of computed tomography, magnetic resonance imaging, and ultrasound, 70% of renal tumors today are detected incidentally with a median tumor size of less than 4 cm. Twenty years ago, all renal tumors, regardless of size were treated with radical nephrectomy (RN). Elective partial nephrectomy (PN) has emerged as the treatment of choice for small renal tumors. The basis of this paradigm shift is three major factors: (1) cancer specific survival is equivalent for T1 tumors (7 cm or less) whether treated by PN or RN; (2) approximately 45% of renal tumors have indolent or benign pathology; and (3) PN prevents or delays the onset of chronic kidney disease, a condition associated with increased cardiovascular morbidity and mortality. Although PN can be technically demanding and associated with potential complications of bleeding, infection, and urinary fistula, the patient derived benefits of this operation far outweigh the risks. We have developed a "mini-flank" open surgical approach that is highly effective and, coupled with rapid recovery postoperative care pathways associated with a 2-day length of hospital stay.
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Affiliation(s)
- Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roy Mano
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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