1
|
Toro-Tobon D, Brito JP. Controversies in the Management of Intermediate-Risk Differentiated Thyroid Cancer. Endocr Pract 2024; 30:879-886. [PMID: 38876179 DOI: 10.1016/j.eprac.2024.06.003] [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: 04/12/2024] [Revised: 05/30/2024] [Accepted: 06/06/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Intermediate-risk thyroid cancer accounts for up to two-thirds of all cases of differentiated thyroid cancer (DTC), yet it is subject to substantial variations in risk stratification and management strategies. METHODS This comprehensive review examines the current controversies regarding diagnosis and management of intermediate risk DTC. RESULTS The evolution of risk stratification systems is discussed, highlighting limitations such as heterogeneity in patient cohorts, variability in outcome definitions, and the need for more precise risk estimation tools incorporating genetic profiles and individual risk modifiers. The role of radioactive iodine therapy in intermediate-risk DTC is examined, considering evolving evidence, conflicting study results, and the necessity for personalized treatment decisions based on risk modifiers, potential morbidity, and patient preferences. Furthermore, the shift from total thyroidectomy to lobectomy in certain intermediate-risk cases is explored, emphasizing the need for tailored surgical approaches and the impact on long-term outcomes, recurrence rates, and quality of life. CONCLUSION Management of intermediate-risk DTC remains controversial. This review summarizes current evidence to aid decision-making. Further research, prospective trials, and collaboration are crucial to address these complexities and personalize care for patients.
Collapse
Affiliation(s)
- David Toro-Tobon
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester; Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
2
|
O'Connell RM, Hardy N, Ward L, Hand F, Maguire D, Stafford A, Gallagher TK, Hoti E, O'Sullivan AW, Ó Súilleabháin CB, Gall T, McEntee G, Conneely J. Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study. Surgeon 2024:S1479-666X(24)00085-4. [PMID: 39142970 DOI: 10.1016/j.surge.2024.08.004] [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: 12/14/2023] [Revised: 06/25/2024] [Accepted: 08/05/2024] [Indexed: 08/16/2024]
Abstract
INTRODUCTION Acute cholecystitis is a common general surgical emergency, accounting for 3-10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland. AIM The aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed. METHODS All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively. RESULTS 20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3-8) v 6 days (interquartile range (IQR) 3-10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome. CONCLUSION Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.
Collapse
Affiliation(s)
- R M O'Connell
- Department of Hepatopancreaticobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - N Hardy
- Department of Hepatopancreaticobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - L Ward
- Department of Hepatopancreaticobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - F Hand
- Department of Hepatopancreaticobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - D Maguire
- Department of Hepatopancreaticobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - A Stafford
- Department of Hepatopancreaticobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - T K Gallagher
- Department of Hepatopancreaticobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - E Hoti
- Department of Hepatopancreaticobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - A W O'Sullivan
- Department of Hepatopancreatobiliary Surgery, Mercy University Hospital, Cork, Ireland
| | - C B Ó Súilleabháin
- Department of Hepatopancreatobiliary Surgery, Mercy University Hospital, Cork, Ireland
| | - T Gall
- Department of Hepatopancreaticobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - G McEntee
- Department of Hepatopancreaticobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - J Conneely
- Department of Hepatopancreaticobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| |
Collapse
|
3
|
Messenger DE, Rajaretnam N, Slade DAJ. CLosure of Abdominal MidlineS Survey (CLAMSS): A national survey investigating current practice in the closure of abdominal midline incisions in UK surgical practice. Colorectal Dis 2024; 26:1617-1631. [PMID: 38937910 DOI: 10.1111/codi.17081] [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: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/29/2024]
Abstract
AIM Incisional herniation (IH) is a frequent complication following midline abdominal closure with significant associated morbidity. Randomized controlled trials have demonstrated that the small bites technique (SBT) and prophylactic mesh augmentation (PMA) may reduce IH compared to mass closure techniques, but data are lacking on their implementation in contemporary surgical practice. This survey aimed to evaluate the use of the SBT and PMA and to identify factors associated with their adoption. METHOD Between 22 January 2023 and 16 March 2023, consultant surgeons across the UK were asked to complete a 25-question survey on closure of an elective primary midline incision. RESULTS Responses were received from 267 of 675 eligible surgeons (39.6%) in 38 NHS Trusts. Respondents were evenly split between tertiary centres (47.6%) and district general hospitals (49.4%). SBT and PMA were used by 19.9% and 3.0% of respondents, respectively. Compared to other techniques, surgeons using the SBT were more likely to close the anterior aponeurotic layer only, use single suture filaments, 2-0 gauge sutures and sharp needle points and routinely dissect abdominal layers to aid closure (all p < 0.001). Attendance at lectures/conferences on SBT (p = 0.043) and basing practice on available evidence (p < 0.001) were independently associated with use of the SBT. The commonest barriers to adopting SBT were a perceived lack of evidence (23.8%) and belief that personal IH rates were low (16.8%). CONCLUSION A minority of UK consultant surgeons have adopted the SBT or PMA. Practice change should be driven by more widespread dissemination of current evidence and procedural information.
Collapse
Affiliation(s)
- David E Messenger
- Department of Coloproctology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Niroshini Rajaretnam
- Department of Colorectal Surgery, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Dominic A J Slade
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
| |
Collapse
|
4
|
Tan HJ, Spratte BN, Deal AM, Heiling HM, Nazzal EM, Meeks W, Fang R, Teal R, Vu MB, Bennett AV, Blalock SJ, Chung AE, Gotz D, Nielsen ME, Reuland DS, Harris AH, Basch E. Clinical Decision Support for Surgery: A Mixed Methods Study on Design and Implementation Perspectives From Urologists. Urology 2024; 190:15-23. [PMID: 38697362 PMCID: PMC11344670 DOI: 10.1016/j.urology.2024.04.033] [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: 01/25/2024] [Revised: 04/08/2024] [Accepted: 04/20/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To assess urologist attitudes toward clinical decision support (CDS) embedded into the electronic health record (EHR) and define design needs to facilitate implementation and impact. With recent advances in big data and artificial intelligence (AI), enthusiasm for personalized, data-driven tools to improve surgical decision-making has grown, but the impact of current tools remains limited. METHODS A sequential explanatory mixed methods study from 2019 to 2020 was performed. First, survey responses from the 2019 American Urological Association Annual Census evaluated attitudes toward an automatic CDS tool that would display risk/benefit data. This was followed by the purposeful sampling of 25 urologists and qualitative interviews assessing perspectives on CDS impact and design needs. Bivariable, multivariable, and coding-based thematic analysis were applied and integrated. RESULTS Among a weighted sample of 12,366 practicing urologists, the majority agreed CDS would help decision-making (70.9%, 95% CI 68.7%-73.2%), aid patient counseling (78.5%, 95% CI 76.5%-80.5%), save time (58.1%, 95% CI 55.7%-60.5%), and improve patient outcomes (42.9%, 95% CI 40.5%-45.4%). More years in practice was negatively associated with agreement (P <.001). Urologists described how CDS could bolster evidence-based care, personalized medicine, resource utilization, and patient experience. They also identified multiple implementation barriers and provided suggestions on form, functionality, and visual design to improve usefulness and ease of use. CONCLUSION Urologists have favorable attitudes toward the potential for clinical decision support in the EHR. Smart design will be critical to ensure effective implementation and impact.
Collapse
Affiliation(s)
- Hung-Jui Tan
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Brooke N Spratte
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Hillary M Heiling
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Elizabeth M Nazzal
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - William Meeks
- American Urological Association Data Management and Statistical Services
| | - Raymond Fang
- American Urological Association Data Management and Statistical Services
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC
| | - Maihan B Vu
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Antonia V Bennett
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Susan J Blalock
- Pharmaceutical Outcomes & Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Arlene E Chung
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Bioinformatics, Duke University, Durham, NC
| | - David Gotz
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; School of Information and Library Science, University of North Carolina, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Alex Hs Harris
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
5
|
Bottle A, Kristensen PK. Variation in quality of care between hospitals: how to identify learning opportunities. BMJ Qual Saf 2024; 33:413-415. [PMID: 38458746 DOI: 10.1136/bmjqs-2024-017071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Alex Bottle
- School of Public Health, Imperial College London Faculty of Medicine, London, UK
| | - Pia Kjær Kristensen
- Clinical Epidemiology, Aarhus Universitetshospital, Aarhus, Denmark
- Orthopedic, Region Hospital Horsens, Horsens, Denmark
| |
Collapse
|
6
|
Innes K, Ahmed I, Hudson J, Hernández R, Gillies K, Bruce R, Bell V, Avenell A, Blazeby J, Brazzelli M, Cotton S, Croal B, Forrest M, MacLennan G, Murchie P, Wileman S, Ramsay C. Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones: the C-GALL RCT. Health Technol Assess 2024; 28:1-151. [PMID: 38943314 PMCID: PMC11228691 DOI: 10.3310/mnby3104] [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: 07/01/2024] Open
Abstract
Background Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease. Objectives To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care. Design Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease. Setting Secondary care elective settings. Participants Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion. Interventions Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management. Main outcome measures The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation. Results Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p-value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -£1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals. Conclusions The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery. Trial registration This trial is registered as ISRCTN55215960. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Karen Innes
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Irfan Ahmed
- Department of Surgery, NHS Grampian, Aberdeen, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Bruce
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Bell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jane Blazeby
- Center for Surgical Research, NIHR Bristol and Western Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
7
|
Ng SC, McCombie A, Frizelle F, Eglinton T. Influence of the type of anatomic resection on anastomotic leak after surgery for colon cancer. ANZ J Surg 2024; 94:424-428. [PMID: 37990637 DOI: 10.1111/ans.18782] [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: 06/05/2023] [Accepted: 11/04/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Anastomotic leak (AL) after colon cancer resection is feared by surgeons because of its associated morbidity and mortality. Considerable research has been directed at predictive factors for AL, but not the anatomic type of colonic resection. Anecdotally, certain types of resection are associated with higher leak rates although there remains a paucity of data on this. This study aimed to determine the AL rate for different types of colon cancer resection to inform decisions regarding the choice of operation. METHODOLOGY Retrospective analysis of Bowel Cancer Outcome Registry (BCOR) for all colonic cancer resections with anastomosis between January 2007 and December 2020. Demographic, patient, tumour and outcome data were analysed. AL rates were compared among the different colonic procedures with both univariate and multivariate analysis. RESULTS 20 191 patients who underwent resection with anastomosis for cancer were included in this study. Of these 535 (2.6%) suffered ALs. While the univariate analysis found male sex, procedure type, symptomatic cancers, emergency surgery, unsupervised registrars, conversion to open surgery, medical complications and higher TNM staging were associated with AL, multivariate analysis, found only procedure type remained a significant predictor of AL (total colectomy (OR 4.049, P<0.001), subtotal colectomy (OR 2.477, P<0.001) and extended right hemicolectomy (OR 2.171, P < 0.001)). CONCLUSION AL is more common in extended colonic resections. With growing evidence of similar oncological outcomes between subtotal colectomy and left hemicolectomy for splenic flexure cancers, more limited resections should be considered. The type of colonic resection should be integrated into prediction tools for AL.
Collapse
Affiliation(s)
- Suat Chin Ng
- Colorectal Department, Eastern Health and St Vincent's Health, Melbourne, Australia
| | - Andrew McCombie
- Colorectal Department, University of Otago, Christchurch, New Zealand
| | - Frank Frizelle
- Colorectal Department, University of Otago, Christchurch, New Zealand
| | - Tim Eglinton
- Colorectal Department, University of Otago, Christchurch, New Zealand
| |
Collapse
|
8
|
Ginzberg SP, Wirtalla CJ, Keele LJ, Wachtel H, Kaufman EJ, Kelz RR. An acute care surgeon's dilemma: Operative vs. non-operative management of emergency general surgery conditions in patients with recent colorectal cancer treatment. Am J Surg 2024; 227:15-21. [PMID: 37741802 PMCID: PMC10841180 DOI: 10.1016/j.amjsurg.2023.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/03/2023] [Accepted: 09/10/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND This comparative effectiveness study examined outcomes of operative vs. non-operative management for emergency general surgery (EGS) conditions in patients with recent cancer treatment (RT). METHODS Medicare beneficiaries with a history of colorectal cancer hospitalized for an EGS condition (2016-2018) were identified. RT was defined as chemotherapy/radiation within 3 months prior to admission. Instrumental variable analysis assessed the impact of management on mortality and readmissions among survivors (30d, 60d, and 90d), for patients in whom there was clinical equipoise regarding optimal management strategy. RESULTS Of 26,097 patients, 13% had undergone RT. In both the RT and non-RT groups, the optimal management strategy was uncertain in 14%. Operative management conferred increased risk of mortality but not readmission in patients with RT compared to those without (90d mortality:+43%, p = 0.03; 90d readmission:+7.1%, p = 0.776). CONCLUSIONS In patients with RT for whom there is clinical equipoise regarding EGS management, operative intervention increases risk of mortality.
Collapse
Affiliation(s)
- Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Abramson Cancer Center, University of Pennsylvania Health System, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Luke J Keele
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Abramson Cancer Center, University of Pennsylvania Health System, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Abramson Cancer Center, University of Pennsylvania Health System, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
9
|
Ippolito GM, Reines K, Meeks WD, Mbassa R, Ellimoottil C, Faris A, Reuland DS, Nielsen ME, Teal R, Vu M, Clemens JQ, Tan HJ. Perceived vs Actual Shared Decision-Making Behavior Among Urologists: A Convergent, Parallel, Mixed-Methods Study of Self-Reported Practice. Urology 2024; 183:78-84. [PMID: 37996015 DOI: 10.1016/j.urology.2023.10.026] [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: 05/31/2023] [Revised: 08/30/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE To evaluate the association between self-perceived use of shared decision-making among urologists with use of validated prediction tools and self-described surgical decision-making. METHODS This is a convergent mixed methods study of these parallel data from two modules (Shared Decision Making and Validated Prediction tools) within the 2019 American Urological Association (AUA) Annual Census. The shared decision-making (SDM) module queried aspects of SDM that urologists regularly used. The validated prediction tools module queried whether urologists regularly used, trusted, and found prediction tools helpful. Selected respondents to the 2019 AUA Annual Census underwent qualitative interviews on their surgical decision-making. RESULTS In the weight sampled of 12,312 practicing urologists, most (77%) reported routine use of SDM, whereas only 30% noted regular use of validated prediction tools. On multivariable analysis, users of prediction tools were not associated with regular SDM use (31% vs 28%, P = .006) though was associated with use of decision aids f (32% vs 26%, P < .001). Shared decision-making emerged thematically with respect to matching treatment options, prioritizing goals, and navigating challenging decisions. However, the six specific components of shared decision-making ranged in their mentions within qualitative interviews. CONCLUSION Most urologists report performing SDM as supported by its thematic presence in surgical decision-making. However, only a minority use validated prediction tools and urologists infrequently mention specific SDM components. This discrepancy provides an opportunity to explore how urologists perform SDM and can be used to support integrated strategies to implement SDM more effectively in clinical practice.
Collapse
Affiliation(s)
- Giulia M Ippolito
- Department of Urology, University of Michigan, Ann Arbor, MI; Ann Arbor VA Medical Center, Ann Arbor, MI.
| | - Katy Reines
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - William D Meeks
- American Urological Association (AUA), Data Management and Statistical Analysis, Linthicum, MD; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Rachel Mbassa
- American Urological Association (AUA), Data Management and Statistical Analysis, Linthicum, MD; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Anna Faris
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Daniel S Reuland
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Maihan Vu
- Lineberger Comprehensive Cancer Center, Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - J Quentin Clemens
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
10
|
Geurkink TH, Marang-van de Mheen PJ, Nagels J, Wessel RN, Poolman RW, Nelissen RG, van Bodegom-Vos L. Substantial Variation in Decision Making to Perform Subacromial Decompression Surgery for Subacromial Pain Syndrome Between Orthopaedic Shoulder Surgeons for Identical Clinical Scenarios: A Case-Vignette Study. Arthrosc Sports Med Rehabil 2023; 5:100819. [PMID: 38023445 PMCID: PMC10661501 DOI: 10.1016/j.asmr.2023.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To provide further insight into the variation in decision making to perform subacromial decompression (SAD) surgery in patients with subacromial pain syndrome (SAPS) and its influencing factors. Methods Between November 2021 and February 2022, we invited 202 Dutch Shoulder and Elbow Society members to participate in a cross-sectional Web-based survey including 4 clinical scenarios of SAPS patients. Scenarios varied in patient characteristics, clinical presentation, and other contextual factors. For each scenario, respondents were asked (1) to indicate whether they would perform SAD surgery, (2) to indicate the probability of benefit of SAD surgery (i.e., pain reduction), (3) to indicate the probability of harm (i.e., complications), and (4) to rank the 5 most important factors influencing their treatment decision. Results A total of 78 respondents (39%) participated. The percentage of respondents who would perform SAD surgery ranged from 4% to 25% among scenarios. The median probability of perceived benefit ranged between 70% and 79% across scenarios for respondents indicating to perform surgery compared with 15% to 29% for those indicating not to perform surgery. The difference in the median probability of perceived harm ranged from 3% to 9% for those indicating to perform surgery compared with 8% to 13% for those indicating not to perform surgery. Surgeons who would perform surgery mainly reported patient-related factors (e.g., complaint duration and response to physical therapy) as the most important factors to perform SAD surgery, whereas surgeons who would not perform surgery mainly reported guideline-related factors. Conclusions Overall, Dutch orthopaedic shoulder surgeons are reluctant to perform SAD surgery in SAPS patients. There is substantial variation among orthopaedic surgeons regarding decisions to perform SAD surgery for SAPS even when evaluating identical scenarios, where particularly the perceived benefit of surgery differed between those who would perform surgery and those who would not. Surgeons who would not perform SAD surgery mainly referred to guideline-related factors as influential factors for their decision, whereas those who would perform SAD surgery considered patient-related factors more important. Clinical Relevance There is substantial variation in decision making to perform SAD surgery for SAPS between individual orthopaedic surgeons for identical case scenarios.
Collapse
Affiliation(s)
- Timon H. Geurkink
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Perla J. Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem Nagels
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ronald N. Wessel
- Department of Orthopaedics, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
11
|
Sacks GD, Shin P, Braithwaite RS, Soares KC, Kingham TP, D'Angelica MI, Drebin JA, Jarnagin WR, Wei AC. Risk Perceptions and Risk Thresholds Among Surgeons in the Management of Intraductal Papillary Mucinous Neoplasms. Ann Surg 2023; 278:e1073-e1079. [PMID: 37796751 PMCID: PMC11265933 DOI: 10.1097/sla.0000000000005827] [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: 02/24/2023]
Abstract
OBJECTIVES We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasm (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. BACKGROUND Surgeons vary widely in management of IPMN. METHODS We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. RESULTS One hundred fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs 5%) more likely to recommend resection than those who were below the median (95% CI: 11%-4%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs 15.0, P =0.06; V2: 7.0 vs 15.0, P =0.05). CONCLUSIONS The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.
Collapse
Affiliation(s)
- Greg D Sacks
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
- VA New York Harbor Healthcare System, New York, NY
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Shin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Jeffrey A Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Alice C Wei
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| |
Collapse
|
12
|
Edge C, Widmeyer J, Hampton H, Satalich J, Hampton D, Vap A, Golladay G. Comparing surgeon perception to publicly reported data using NSQIP. J Orthop 2023; 42:34-39. [PMID: 37449024 PMCID: PMC10338147 DOI: 10.1016/j.jor.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023] Open
Abstract
Background Past studies have demonstrated that surgeons' perceptions of their own postsurgical complications may not be accurate. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database is a nationally validated, risk-adjusted, outcomes-based program created to measure and improve the quality of surgical care. Using information acquired through survey data, the purpose of this study is to determine how surgeons' perceptions of their own postoperative complications rates compare to the NSQIP database that tracks these outcome metrics. Hypothesis/purpose We hypothesize that surgeons underestimate their rates of morbidity, readmission, and reoperation within thirty days postoperatively when compared to NSQIP data. Study design Data elements such as perceived morbidity, readmission, and reoperation were collected through surveys distributed at a large level one trauma center. Survey respondents were asked how their rates compared to their peers and physician survey responses were then compared to institutional NSQIP data. Results 87.5% of surgeons underestimated their rates of morbidity, 35.4% underestimated their rates of readmission, 22.9% underestimated their rates of reoperation. When comparing themselves to their departmental averages, 57.78% accurately estimated their morbidity rates, 75.56% accurately estimated readmission rates, and 86.67% accurately estimated reoperation rates. Conclusion Surgeons are poor predictors of individual 30-day postoperative complication rates including morbidity, readmission, and reoperation. However, surgeons are more accurate in estimating these same outcomes when asked to compare to the average of their department.
Collapse
Affiliation(s)
- Carl Edge
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Jonathan Widmeyer
- Virginia Commonwealth University Medical School, Richmond, VA, 23219, USA
| | - Hailey Hampton
- Virginia Commonwealth University Medical School, Richmond, VA, 23219, USA
| | - James Satalich
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Dallas Hampton
- Eastern Virginia Medical School, Norfolk, VA, 23507, USA
| | - Alexander Vap
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Gregory Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| |
Collapse
|
13
|
Handzel RM, Huckaby LV, Dadashzadeh ER, Silver D, Rieser C, Sivagnanalingam U, Rosengart MR, van der Windt DJ. Sex, race, and socioeconomic distinctions in incisional hernia management. Am J Surg 2023; 226:202-206. [PMID: 37032236 DOI: 10.1016/j.amjsurg.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/16/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND We sought to explore the impact of sex, race, and insurance status on operative management of incisional hernias. METHODS A retrospective cohort study was conducted to explore adult patients diagnosed with an incisional hernia. Adjusted odds for non-operative versus operative management and time to repair were queried. RESULTS Of the 29,475 patients with an incisional hernia, 20,767 (70.5%) underwent non-operative management. In relation to private insurance, Medicaid (aOR 1.40, 95% CI 1.27-1.54), Medicare (aOR 1.53, 95% CI 1.42-1.65), and uninsured status (aOR 1.99, 95% CI 1.71-2.36) were independently associated with non-operative management. African American race (aOR 1.30, 95% CI 1.17-1.47) was associated with non-operative management while female sex (aOR 0.81, 95% CI 0.77-0.86) was predictive of elective repair. For patients who underwent elective repair, both Medicare (aOR 1.40, 95% CI 1.18-1.66) and Medicaid (aOR 1.49, 95% CI 1.29-1.71) insurance, but not race, were predictive of delayed repair (>90 days after diagnosis). CONCLUSIONS Sex, race, and insurance status influence incisional hernia management. Development of evidence-based management guidelines may help to ensure equitable care.
Collapse
Affiliation(s)
- Robert M Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Esmaeel R Dadashzadeh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Silver
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline Rieser
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Pittsburgh Surgical Outcomes Research Center (PittSORCe), University of Pittsburgh, Pittsburgh, PA, USA
| | - Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
14
|
Fowler AJ, Wahedally MAH, Abbott TEF, Prowle JR, Cromwell DA, Pearse RM. Long-term disease interactions amongst surgical patients: a population cohort study. Br J Anaesth 2023:S0007-0912(23)00237-4. [PMID: 37400340 PMCID: PMC10375505 DOI: 10.1016/j.bja.2023.04.041] [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: 05/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND The average age of the surgical population continues to increase, as does prevalence of long-term diseases. However, outcomes amongst multi-morbid surgical patients are not well described. METHODS We included adults undergoing non-obstetric surgical procedures in the English National Health Service between January 2010 and December 2015. Patients could be included multiple times in sequential 90-day procedure spells. Multi-morbidity was defined as presence of two or more long-term diseases identified using a modified Charlson comorbidity index. The primary outcome was 90-day postoperative death. Secondary outcomes included emergency hospital readmission within 90 days. We calculated age- and sex-adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression. We compared the outcomes associated with different disease combinations. RESULTS We identified 20 193 659 procedure spells among 13 062 715 individuals aged 57 (standard deviation 19) yr. Multi-morbidity was present among 2 577 049 (12.8%) spells with 195 965 deaths (7.6%), compared with 17 616 610 (88.2%) spells without multi-morbidity with 163 529 deaths (0.9%). Multi-morbidity was present in 1 902 859/16 946 808 (11.2%) elective spells, with 57 663 deaths (2.7%, OR 4.9 [95% CI: 4.9-4.9]), and 674 190/3 246 851 (20.7%) non-elective spells, with 138 302 deaths (20.5%, OR 3.0 [95% CI: 3.0-3.1]). Emergency readmission followed 547 399 (22.0%) spells with multi-morbidity compared with 1 255 526 (7.2%) without. Multi-morbid patients accounted for 57 663/114 783 (50.2%) deaths after elective spells, and 138 302/244 711 (56.5%) after non-elective spells. The rate of death varied five-fold from lowest to highest risk disease pairs. CONCLUSION One in eight patients undergoing surgery have multi-morbidity, accounting for more than half of all postoperative deaths. Disease interactions amongst multi-morbid patients is an important determinant of patient outcome.
Collapse
Affiliation(s)
- Alexander J Fowler
- School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal College of Surgeons of England, London, UK.
| | | | - Tom E F Abbott
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John R Prowle
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - David A Cromwell
- Royal College of Surgeons of England, London, UK; London School of Hygiene and Tropical Medicine, London, UK
| | - Rupert M Pearse
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
15
|
Cochrun SL, Herbey I, Ivankova N, Nikolian VC, Jansen JO, Parmar AD. Surgeon perspectives on the STITCH trial: a mixed methods study. Surg Endosc 2023:10.1007/s00464-023-10086-x. [PMID: 37129637 DOI: 10.1007/s00464-023-10086-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Incisional hernia prevention strategies related to fascial closure technique during laparotomy are well described yet poorly implemented in practice. The factors hindering the surgeon's adoption of evidence-based techniques for fascial closure are poorly understood and characterized. METHODS Using an exploratory sequential mixed methods design, we first collected 139 responses to a validated quantitative survey based on a Theoretical Domain Framework for adoption of healthcare practices. Mean scores from survey responses were tabulated, and the findings were used to develop an interview guide for subsequent qualitative individual semi-structured phone interviews. Fourteen practicing surgeons were purposively sampled from social media outlets and our institution. The interviews were recorded and transcribed verbatim for coding and thematic analysis using NVivo 12 Plus. Data from the surveys and interviews were integrated using joint displays. RESULTS Quantitative and qualitative analyses from surveys and semi-structured interviews revealed various themes related to surgeon decision-making related to fascial closure technique. Surgeons cited limitations of prior studies, applicability of findings, anecdotal experiences, and situation-specific environments that influence their decision-making. Peer influence and lack of training also affected surgeons' perspectives on integrating small bite technique into practice. CONCLUSION Trial design limitations, peer influence, and patient-specific factors impacted surgeon decision-making in the choice of fascial closure technique. Future clinical trials in diverse patient populations may improve surgeons' confidence in implementing technique for fascial closure.
Collapse
Affiliation(s)
- Steven L Cochrun
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 8Th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA.
| | - Ivan Herbey
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 8Th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
| | - Nataliya Ivankova
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vahagn C Nikolian
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Jan O Jansen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Abhishek D Parmar
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 8Th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
| |
Collapse
|
16
|
Proaño-Zamudio JA, Argandykov D, Gebran A, Renne A, Paranjape CN, Maroney SJ, Onyewadume L, Kaafarani HMA, King DR, Velmahos GC, Hwabejire JO. Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality. J Surg Res 2023; 287:160-167. [PMID: 36933547 DOI: 10.1016/j.jss.2023.02.005] [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: 07/09/2022] [Revised: 10/26/2022] [Accepted: 02/15/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Elderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied. METHODS The 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR). RESULTS A total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/μL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%. CONCLUSIONS In elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.
Collapse
Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephanie J Maroney
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Louisa Onyewadume
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David R King
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
17
|
Chesney TR, Daza JF, Wong CL. Geriatric assessment and treatment decision-making in surgical oncology. Curr Opin Support Palliat Care 2023; 17:22-30. [PMID: 36695865 DOI: 10.1097/spc.0000000000000635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW Present an approach for surgical decision-making in cancer that incorporates geriatric assessment by building upon the common categories of tumor, technical, and patient factors to enable dual assessment of disease and geriatric factors. RECENT FINDINGS Conventional preoperative assessment is insufficient for older adults missing important modifiable deficits, and inaccurately estimating treatment intolerance, complications, functional impairment and disability, and death. Including geriatric-focused assessment into routine perioperative care facilitates improved communications between clinicians and patients and among interdisciplinary teams. In addition, it facilitates the detection of geriatric-specific deficits that are amenable to treatment. We propose a framework for embedding geriatric assessment into surgical oncology practice to allow more accurate risk stratification, identify and manage geriatric deficits, support decision-making, and plan proactively for both cancer-directed and non-cancer-directed therapies. This patient-centered approach can reduce adverse outcomes such as functional decline, delirium, prolonged hospitalization, discharge to long-term care, immediate postoperative complications, and death. SUMMARY Geriatric assessment and management has substantial benefits over conventional preoperative assessment alone. This article highlights these advantages and outlines a feasible strategy to incorporate both disease-based and geriatric-specific assessment and treatment when caring for older surgical patients with cancer.
Collapse
Affiliation(s)
- Tyler R Chesney
- Division of General Surgery, Department of Surgery
- Li Ka Shing Knowledge Institute
| | - Julian F Daza
- Division of General Surgery, Department of Surgery
- Institute of Health Policy, Management, and Evaluation, University of Toronto
| | - Camilla L Wong
- Li Ka Shing Knowledge Institute
- Division of Geriatric Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| |
Collapse
|
18
|
Yang GN, Roberts PK, Gardner-Russell J, Shah MH, Couper TA, Zhu Z, Pollock GA, Dusting GJ, Daniell M. From bench to clinic: Emerging therapies for corneal scarring. Pharmacol Ther 2023; 242:108349. [PMID: 36682466 DOI: 10.1016/j.pharmthera.2023.108349] [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: 11/13/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
Corneal diseases are one of the leading causes of moderate-to-severe visual impairment and blindness worldwide, after glaucoma, cataract, and retinal disease in overall importance. Given its tendency to affect people at a younger age than other blinding conditions such as cataract and glaucoma, corneal scarring poses a huge burden both on the individuals and society. Furthermore, corneal scarring and fibrosis disproportionately affects people in poorer and remote areas, making it a significant ophthalmic public health problem. Traditional medical strategies, such as topical corticosteroids, are not effective in preventing fibrosis or scars. Corneal transplantation, the only effective sight-restoring treatment for corneal scars, is curbed by challenges including a severe shortage of tissue, graft rejection, secondary conditions, cultural barriers, the lack of well-trained surgeons, operating rooms, and well-equipped infrastructures. Thanks to tremendous research efforts, emerging therapeutic options including gene therapy, protein therapy, cell therapy and novel molecules are in development to prevent the progression of corneal scarring and compliment the surgical options currently available for treating established corneal scars in clinics. In this article, we summarise the most relevant preclinical and clinical studies on emerging therapies for corneal scarring in recent years, showing how these approaches may prevent scarring in its early development.
Collapse
Affiliation(s)
- Gink N Yang
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia.
| | - Philippe Ke Roberts
- Department of Ophthalmology, Medical University Vienna, 18-20 Währinger Gürtel, Vienna 1090, Austria
| | - Jesse Gardner-Russell
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia
| | - Manisha H Shah
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia
| | - Terry A Couper
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia; Lions Eye Donation Service, level 7, Smorgon Family Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia
| | - Zhuoting Zhu
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia
| | - Graeme A Pollock
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia; Lions Eye Donation Service, level 7, Smorgon Family Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia
| | - Gregory J Dusting
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia
| | - Mark Daniell
- Centre for Eye Research Australia, level 7, Peter Howson Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne and Royal Victorian Eye and Ear Hospital, East Melbourne 3002, Australia; Lions Eye Donation Service, level 7, Smorgon Family Wing, 32 Gisborne Street, East Melbourne, Victoria 3002, Australia
| |
Collapse
|
19
|
Predictors for failure after surgery for lumbar spinal stenosis: a prospective observational study. Spine J 2023; 23:261-270. [PMID: 36343913 DOI: 10.1016/j.spinee.2022.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND/CONTEXT Some patients do not improve after surgery for lumbar spinal stenosis (LSS), and surgical treatment implies a risk for complications and deterioration. Patient selection is of paramount importance to improve the overall clinical results and identifying predictive factors for failure is central in this work. PURPOSE We aimed to explore predictive factors for failure and worsening after surgery for LSS. STUDY DESIGN /SETTING Retrospective observational study on prospectively collected data from a national spine registry with a 12-month follow-up. PATIENT SAMPLE We analyzed 11,873 patients operated for LSS between 2007 and 2017 in Norway, included in the Norwegian registry for spine surgery (NORspine). Twelve months after surgery, 8919 (75.1%) had responded. OUTCOME MEASURES Oswestry Disability Index (ODI) 12 months after surgery. METHODS Predictors were assessed with uni- and multivariate logistic regression, using backward conditional stepwise selection and a significance level of 0.01. Failure (ODI>31) and worsening (ODI>39) were used as dependent variables. RESULTS Mean (95%CI) age was 66.6 (66.4-66.9) years, and 52.1% were females. The mean (95%CI) preoperative ODI score was 39.8 (39.4-40.1). All patients had decompression, and 1494 (12.6%) had an additional fusion procedure. Twelve months after surgery, the mean (95%CI) ODI score was 23.9 (23.5-24.2), and 2950 patients (33.2%) were classified as failures and 1921 (21.6%) as worse. The strongest predictors for failure were duration of back pain > 12 months (OR [95%CI]=2.24 [1.93-2.60]; p<.001), former spinal surgery (OR [95%CI]=2.21 [1.94-2.52]; p<.001) and age>70 years (OR (95%CI)=1.97 (1.69-2.30); p<.001). Socioeconomic variables increased the odds of failure (ORs between 1.36 and 1.62). The strongest predictors for worsening were former spinal surgery (OR [95%CI]=2.04 [1.77-2.36]; p<.001), duration of back pain >12 months (OR [95%CI]=1.83 [1.45-2.32]; p<.001) and age >70 years (OR [95%CI]=1.79 [1.49-2.14]; p<.001). Socioeconomic variables increased the odds of worsening (ORs between 1.33-1.67). CONCLUSIONS After surgery for LSS, 33% of the patients reported failure, and 22% reported worsening as assessed by ODI. Preoperative duration of back pain for longer than 12 months, former spinal surgery, and age above 70 years were the strongest predictors for increased odds of failure and worsening after surgery.
Collapse
|
20
|
Association Between Postoperative Complications and Long-term Survival After Non-cardiac Surgery Among Veterans. Ann Surg 2023; 277:e24-e32. [PMID: 33630458 DOI: 10.1097/sla.0000000000004749] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the relationship between postoperative complications and long-term survival. SUMMARY AND BACKGROUND Postoperative complications remain a significant driver of healthcare costs and are associated with increased perioperative mortality, yet the extent to which they are associated with long-term survival is unclear. METHODS National cohort study of Veterans who underwent non-cardiac surgery using data from the Veterans Affairs Surgical Quality Improvement Program (2011-2016). Patients were classified as having undergone outpatient, low-risk inpatient, or high-risk inpatient surgery. Patients were categorized based on number and type of complications. The association between the number of complications (or the specific type of complication) and risk of death was evaluated using multivariable Cox regression with robust standard errors using a 90-day survival landmark. RESULTS Among 699,002 patients, complication rates were 3.0%, 6.1%, and 18.3% for outpatient, low-risk inpatient, and high-risk inpatient surgery, respectively. There was a dose-response relationship between an increasing number of complications and overall risk of death in all operative settings [outpatient surgery: no complications (ref); one-hazard ratio (HR) 1.30 (1.23 - 1.38); multiple-HR 1.61 (1.46 - 1.78); low-risk inpatient surgery: one-HR 1.34 (1.26 - 1.41); multiple-HR 1.69 (1.55 - 1.85); high-risk inpatient surgery: one-HR 1.14 (1.10 - 1.18); multiple-HR 1.42 (1.36 - 1.48)]. All complication types were associated with risk of death in at least 1 operative setting, and pulmonary complications, sepsis, and clostridium difficile colitis were associated with higher risk of death across all settings. Conclusions: Postoperative complications have an adverse impact on patients' long-term survival beyond the immediate postoperative period. Although most research and quality improvement initiatives primarily focus on the perioperative impact of complications, these data suggest they also have important longer-term implications that merit further investigation.
Collapse
|
21
|
Ruiz de Angulo Martín D. El arte de tomar decisiones en cirugía oncológica. Cir Esp 2023. [DOI: 10.1016/j.ciresp.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
22
|
Abstract
A number of factors should be considered when performing an intestinal anastomosis in the setting of surgery for Crohn's disease. Preoperative risk factors, such as malnutrition, abdominal sepsis, and immunosuppressive medications, may increase the risk of postoperative anastomotic complications and alter surgical decision-making. The anatomical configuration and technique of constructing the anastomosis may have an impact on postoperative function and risk of recurrence, particularly in the setting of ileocolic resection, where the Kono-S anastomosis has gained popularity in recent years. There may be circumstances in which it may be more appropriate to perform an ostomy either without an anastomosis or to temporarily divert an anastomosis when the risk of anastomotic complications is felt to be high. In the setting of total abdominal colectomy or proctocolectomy for Crohn's colitis, restorative procedures may appropriate in lieu of a permanent stoma in certain scenarios.
Collapse
Affiliation(s)
- Brian R. Kann
- Department of Colon & Rectal Surgery, Ochsner Health, New Orleans, Louisiana,Address for correspondence Brian R. Kann, MD, FACS, FASCRS Department of Colon & Rectal Surgery, Ochsner Health1514 Jefferson Highway, New Orleans, LA 70121
| |
Collapse
|
23
|
Walsh JP, Hsiao MS, LeCavalier D, McDermott R, Gupta S, Watson TS. Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials. Foot Ankle Surg 2022; 28:836-844. [PMID: 35339374 DOI: 10.1016/j.fas.2022.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/30/2022] [Accepted: 03/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures. METHODS A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union. RESULTS The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates. CONCLUSION This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations. LEVEL OF EVIDENCE Systematic review and meta-analysis of level I evidence.
Collapse
Affiliation(s)
- John P Walsh
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA; The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA.
| | - Mark S Hsiao
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA.
| | - Daniel LeCavalier
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA.
| | - Ryland McDermott
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA; Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA.
| | - Shivali Gupta
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA.
| | - Troy S Watson
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA; The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA.
| |
Collapse
|
24
|
Filiberto AC, Efron PA, Frantz A, Bihorac A, Upchurch GR, Loftus TJ. Personalized decision-making for acute cholecystitis: Understanding surgeon judgment. Front Digit Health 2022; 4:845453. [PMID: 36339515 PMCID: PMC9632988 DOI: 10.3389/fdgth.2022.845453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 08/30/2022] [Indexed: 12/07/2022] Open
Abstract
Background There is sparse high-level evidence to guide treatment decisions for severe, acute cholecystitis (inflammation of the gallbladder). Therefore, treatment decisions depend heavily on individual surgeon judgment, which is highly variable and potentially amenable to personalized, data-driven decision support. We test the hypothesis that surgeons' treatment recommendations misalign with perceived risks and benefits for laparoscopic cholecystectomy (surgical removal) vs. percutaneous cholecystostomy (image-guided drainage). Methods Surgery attendings, fellows, and residents applied individual judgement to standardized case scenarios in a live, web-based survey in estimating the quantitative risks and benefits of laparoscopic cholecystectomy vs. percutaneous cholecystostomy for both moderate and severe acute cholecystitis, as well as the likelihood that they would recommend cholecystectomy. Results Surgeons predicted similar 30-day morbidity rates for laparoscopic cholecystectomy and percutaneous cholecystostomy. However, a greater proportion of surgeons predicted low (<50%) likelihood of full recovery following percutaneous cholecystostomy compared with cholecystectomy for both moderate (30% vs. 2%, p < 0.001) and severe (62% vs. 38%, p < 0.001) cholecystitis. Ninety-eight percent of all surgeons were likely or very likely to recommend cholecystectomy for moderate cholecystitis; only 32% recommended cholecystectomy for severe cholecystitis (p < 0.001). There were no significant differences in predicted postoperative morbidity when respondents were stratified by academic rank or self-reported ability to predict complications or make treatment recommendations. Conclusions Surgeon recommendations for severe cholecystitis were discordant with perceived risks and benefits of treatment options. Surgeons predicted greater functional recovery after cholecystectomy but less than one-third recommended cholecystectomy. These findings suggest opportunities to augment surgical decision-making with personalized, data-driven decision support.
Collapse
Affiliation(s)
- Amanda C. Filiberto
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Philip A. Efron
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Amanda Frantz
- Department of Anesthesiology, University of Florida Health, Gainesville, FL, United States
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, FL, United States
- Intelligent Critical Care Center, University of Florida Health, Gainesville, FL, United States
| | - Gilbert R. Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Tyler J. Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
- Intelligent Critical Care Center, University of Florida Health, Gainesville, FL, United States
- Correspondence: Tyler J. Loftus
| |
Collapse
|
25
|
Rutzen AT, Annes RD, da Silva SG. Clinical and functional outcomes in patients submitted to early versus late surgery for lumbar disc herniation: A systematic review. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
26
|
Affiliation(s)
- Andrew S Little
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Sherry J Wu
- 2Anderson School of Management, Behavioral Decision Making and Management and Organizations, University of California, Los Angeles, California
| |
Collapse
|
27
|
Sharif A. Risk Aversion, Organ Utilization and Changing Behavior. Transpl Int 2022; 35:10339. [PMID: 35462791 PMCID: PMC9021374 DOI: 10.3389/ti.2022.10339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/18/2022] [Indexed: 01/20/2023]
Abstract
Improving organ acceptance and utilization rates is critical to ensure we maximize usage of donated organs as a scarce resource. Many factors underlie unnecessary discard of viable organs. Declined transplantation opportunities for candidates is associated with increased wait-list mortality. Technological advancements in organ preservation may help bridge the gap between donation and utilization, but an overlooked obstacle is the practice of risk aversion by transplant professionals when decision-making under risk. Lessons from behavioral economics, where experimental work has outlined the impact of loss or risk aversion on decision-making, have not been translated to transplantation. Many external factors can influence decision-making when accepting or utilizing organs, which are potentially amendable if external conditions are improved. However, attitudes and perceptions to risk for transplant professionals can pervade decision-making and influence behaviour. If we wish to change this behavior, then the underlying nature of decision-making under risk when accepting or utilizing organs must be studied to facilitate the design of targeted behavior change interventions to convert risk aversion to risk tolerance. To ensure optimal use of donated organs, we need more research into decision-making under risk.
Collapse
Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Adnan Sharif, , orcid.org/0000-0002-7586-9136
| |
Collapse
|
28
|
Schumm MA, Shu ML, Kim J, Tseng CH, Zanocco K, Livhits MJ, Leung AM, Yeh MW, Sacks GD, Wu JX. Perception of risk and treatment decisions in the management of differentiated thyroid cancer. J Surg Oncol 2022; 126:247-256. [PMID: 35316538 DOI: 10.1002/jso.26858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The recent de-escalation of care for differentiated thyroid cancer (DTC) has broadened the range of initial treatment options. We examined the association between physicians' perception of risk and their management of DTC. METHODS Thyroid specialists were surveyed with four clinical vignettes: (1) indeterminate nodule (2) tall cell variant papillary thyroid cancer (PTC), (3) papillary thyroid microcarcinoma (mPTC), and (4) classic PTC. Participants judged the operative risks and likelihood of structural cancer recurrence associated with more versus less aggressive treatments. A logistic mixed effect model was used to predict treatment choice. RESULTS Among 183 respondents (13.4% response rate), 44% were surgical and 56% medical thyroid specialists. Risk estimates and treatment recommendation varied markedly in each case. Respondents' estimated risk of 10-year cancer recurrence after lobectomy for a 2.0-cm PTC ranged from 1% to 53% (interquartile range [IQR]: 3%-12%), with 66% recommending lobectomy and 34% total thyroidectomy. Respondents' estimated 5-year risk of metastastic disease during active surveillance of an 0.8-cm mPTC ranged from 0% to 95% (IQR: 4%-15%), with 36% choosing active surveillance. Overall, differences in perceived risk reduction explained 10.3% of the observed variance in decision-making. CONCLUSIONS Most of the variation in thyroid cancer treatment aggressiveness is unrelated to perceived risk of cancer recurrence.
Collapse
Affiliation(s)
- Max A Schumm
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Michelle L Shu
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Jiyoon Kim
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Kyle Zanocco
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA.,Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Greg D Sacks
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - James X Wu
- Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| |
Collapse
|
29
|
FUSE-ML: development and external validation of a clinical prediction model for mid-term outcomes after lumbar spinal fusion for degenerative disease. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2629-2638. [PMID: 35188587 DOI: 10.1007/s00586-022-07135-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/25/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Indications and outcomes in lumbar spinal fusion for degenerative disease are notoriously heterogenous. Selected subsets of patients show remarkable benefit. However, their objective identification is often difficult. Decision-making may be improved with reliable prediction of long-term outcomes for each individual patient, improving patient selection and avoiding ineffective procedures. METHODS Clinical prediction models for long-term functional impairment [Oswestry Disability Index (ODI) or Core Outcome Measures Index (COMI)], back pain, and leg pain after lumbar fusion for degenerative disease were developed. Achievement of the minimum clinically important difference at 12 months postoperatively was defined as a reduction from baseline of at least 15 points for ODI, 2.2 points for COMI, or 2 points for pain severity. RESULTS Models were developed and integrated into a web-app ( https://neurosurgery.shinyapps.io/fuseml/ ) based on a multinational cohort [N = 817; 42.7% male; mean (SD) age: 61.19 (12.36) years]. At external validation [N = 298; 35.6% male; mean (SD) age: 59.73 (12.64) years], areas under the curves for functional impairment [0.67, 95% confidence interval (CI): 0.59-0.74], back pain (0.72, 95%CI: 0.64-0.79), and leg pain (0.64, 95%CI: 0.54-0.73) demonstrated moderate ability to identify patients who are likely to benefit from surgery. Models demonstrated fair calibration of the predicted probabilities. CONCLUSIONS Outcomes after lumbar spinal fusion for degenerative disease remain difficult to predict. Although assistive clinical prediction models can help in quantifying potential benefits of surgery and the externally validated FUSE-ML tool may aid in individualized risk-benefit estimation, truly impacting clinical practice in the era of "personalized medicine" necessitates more robust tools in this patient population.
Collapse
|
30
|
Boreskie KF, Hay JL, Boreskie PE, Arora RC, Duhamel TA. Frailty-aware care: giving value to frailty assessment across different healthcare settings. BMC Geriatr 2022; 22:13. [PMID: 34979966 PMCID: PMC8722007 DOI: 10.1186/s12877-021-02722-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/15/2021] [Indexed: 12/14/2022] Open
Abstract
Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.
Collapse
Affiliation(s)
- Kevin F Boreskie
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada.
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada.
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Jacqueline L Hay
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Patrick E Boreskie
- Department of Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd A Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| |
Collapse
|
31
|
Jones TS, Jones EL, Barnett CC, Moore JT, Wikiel KJ, Horney CP, Unruh M, Levy CR, Robinson TN. A Multidisciplinary High-Risk Surgery Committee May Improve Perioperative Decision Making for Patients and Physicians. J Palliat Med 2021; 24:1863-1866. [PMID: 34851187 DOI: 10.1089/jpm.2021.0141] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Surgeons must evaluate and communicate the risk associated with operative procedures for patients at high risk of poor postoperative outcomes. Multidisciplinary approaches to complex decision making are needed. Objective: To improve physician decision making for high-risk surgical patients. Design: This is a retrospective review of patients presented to a multidisciplinary committee for three years. Setting/Subjects: Evaluation of patients was done in a single-center U.S. veterans affairs (VA) hospital. All patients who were considered for surgery had a VA Surgical Quality Improvement Program (VASQIP) risk calculator 30-day mortality >5%. Measurements: Thirty-day and one-year mortality were measured. Results: Seventy-six patients were reviewed with an average expected 30-day mortality of 14.2%. Forty-two patients (57%) had a recommended change in the care plan before surgery. Fifty-four patients (71%) proceeded with surgery and experienced a 30-day mortality of 7.4%. Conclusions and Relevance: Multidisciplinary discussion of high-risk surgical patients may help surgeons make perioperative recommendations for patients. Implementation of a multidisciplinary high-risk committee should be considered at facilities that manage high-risk surgical patients.
Collapse
Affiliation(s)
- Teresa S Jones
- Department of Surgery, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Geriatric Research Education and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Edward L Jones
- Department of Surgery, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Carlton C Barnett
- Department of Surgery, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John T Moore
- Department of Surgery, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Krzysztof J Wikiel
- Department of Surgery, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Carolyn P Horney
- Geriatrics Section, Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Morgan Unruh
- Palliative Care Section, Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cari R Levy
- Palliative Care Section, Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, Colorado, USA.,Division of Health Care Policy and Research, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Thomas N Robinson
- Department of Surgery, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
32
|
Kulkarni SS, Briggs A, Sacks OA, Rosengart MR, White DB, Barnato AE, Peitzman AB, Mohan D. Inner Deliberations of Surgeons Treating Critically-ill Emergency General Surgery Patients: A Qualitative Analysis. Ann Surg 2021; 274:1081-1088. [PMID: 31714316 PMCID: PMC7944485 DOI: 10.1097/sla.0000000000003669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND 30% of elderly patients who require emergency general surgery (EGS) die in the year after the operation. Preoperative discussions can determine whether patients receive preference-sensitive care. Theoretically, surgeons frame their conversations after systematically assessing the risks and benefits of management options based on the clinical characteristics of each case. However, little is known about how surgeons actually deliberate about those options. OBJECTIVE To identify variables that influence surgeons' assessment of management options for critically-ill EGS patients. METHODS We conducted semi-structured interviews with 40 general surgeons in western Pennsylvania who worked in a variety of hospital settings. Interviews explored perioperative decision-making by asking surgeons to think aloud about selected memorable cases and a standardized case vignette of a frail patient with acute mesenteric ischemia. We used constant comparative methods to analyze interview transcripts and inductively developed a framework for the decision-making process. RESULTS Surgeons averaged 13 years (standard deviation (SD) 10.4) of experience; 40% specialized in trauma/acute care surgery. Important themes regarding the main topic of "perioperative decision-making" included many considerations beyond the clinical characteristics of cases. Surgeons described the importance of variables ranging from the availability of institutional resources to professional norms. Surgeons often remarked on their desire to achieve individual flow, team efficiency, and concordant expectations of treatment and prognosis with patients. CONCLUSIONS This is the first study to explore how surgeons decide among management options for critically-ill EGS patients. Surgeons' decision-making reflected a broad array of clinical, personal, and institutional variables. Effective interventions to ensure preference-sensitive care for EGS patients must address all of these variables.
Collapse
Affiliation(s)
| | - Alexandra Briggs
- Division of Trauma & Acute Care Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Olivia A. Sacks
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Douglas B. White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
33
|
O'Toole SM, Hornby C, Sze WCC, Hannon MJ, Akker SA, Druce MR, Waterhouse M, Dawnay A, Sahdev A, Matson M, Parvanta L, Drake WM. Performance evaluation of scoring systems for predicting post-operative hypertension cure in primary aldosteronism. Clin Endocrinol (Oxf) 2021; 95:576-586. [PMID: 34042196 DOI: 10.1111/cen.14534] [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: 03/01/2021] [Revised: 04/20/2021] [Accepted: 05/13/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hypertension cure following adrenalectomy in unilateral primary aldosteronism is not guaranteed. Its likelihood is associated with pre-operative parameters, which have been variably combined in six different predictive scoring systems. The relative performance of these systems is currently unknown. The objective of this work was to identify the best performing scoring system for predicting hypertension cure following adrenalectomy for primary aldosteronism. DESIGN Retrospective analysis in a single tertiary referral centre. PATIENTS Eighty-seven adult patients with unilateral primary aldosteronism who had undergone adrenalectomy between 2004 and 2018 for whom complete data sets were available to calculate all scoring systems. MEASUREMENTS Prediction of hypertension cure by each of the six scoring systems. RESULTS Hypertension cure was achieved in 36/87 (41.4%) patients within the first post-operative year, which fell to 18/71 (25.4%) patients at final follow-up (median 53 months, P = .002). Analysis of receiver operating characteristic area under the curves for the different scoring systems identified a difference in performance at early, but not late, follow-up. For all systems, the area under the curve was lower at early compared with late follow-up and compared to performance in the cohorts in which they were originally defined. CONCLUSIONS No single scoring system performed significantly better than all others when applied in our cohort, although two did display particular advantages. It remains to be determined how best such scoring systems can be incorporated into the routine clinical care of patients with PA.
Collapse
Affiliation(s)
- Samuel Matthew O'Toole
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
- The London School of Medicine and Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Catherine Hornby
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
| | | | - Mark John Hannon
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
- Department of Endocrinology and Diabetes, Bantry General Hospital, Bantry, Cork, Ireland
| | - Scott Alexander Akker
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
- The London School of Medicine and Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Maralyn Rose Druce
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
- The London School of Medicine and Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Mona Waterhouse
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
| | - Anne Dawnay
- Department of Clinical Biochemistry, Barts Health NHS Trust, London, UK
| | - Anju Sahdev
- Department of Radiology, St Bartholomew's Hospital, London, UK
| | - Matthew Matson
- Department of Radiology, St Bartholomew's Hospital, London, UK
| | - Laila Parvanta
- Department of Endocrine Surgery, St Bartholomew's Hospital, London, UK
| | - William Martyn Drake
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
- The London School of Medicine and Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
| |
Collapse
|
34
|
Sacks GD, Dawes AJ, Tsugawa Y, Brook RH, Russell MM, Ko CY, Maggard-Gibbons M, Ettner SL. The Association Between Risk Aversion of Surgeons and Their Clinical Decision-Making. J Surg Res 2021; 268:232-243. [PMID: 34371282 DOI: 10.1016/j.jss.2021.06.056] [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: 04/26/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk ("risk aversion") influences their surgical decisions and whether the relationship can be explained by differences in surgeons' perception of treatment risks and benefits. MATERIALS AND METHODS We presented a series of detailed clinical vignettes to a national sample of surgeons (n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation. RESULTS Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons' perception of the likelihood of complications versus recovery, there was no longer a significant association between surgeons' risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96). CONCLUSIONS Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues.
Collapse
Affiliation(s)
- Greg D Sacks
- Department of Surgery, NYU Langone Health, New York, New York.
| | - Aaron J Dawes
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California
| | - Yusuke Tsugawa
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Robert H Brook
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; RAND Corporation, Los Angeles, California
| | - Marcia M Russell
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Clifford Y Ko
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Melinda Maggard-Gibbons
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Susan L Ettner
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| |
Collapse
|
35
|
Chesney TR, Coburn N, Mahar AL, Davis LE, Zuk V, Zhao H, Hsu AT, Wright F, Haas B, Hallet J. All-Cause and Cancer-Specific Death of Older Adults Following Surgery for Cancer. JAMA Surg 2021; 156:e211425. [PMID: 33978695 PMCID: PMC8117065 DOI: 10.1001/jamasurg.2021.1425] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/14/2021] [Indexed: 12/30/2022]
Abstract
Importance Cancer care has inherent complexities in older adults, including balancing risks of cancer and noncancer death. A poor understanding of cause-specific outcomes may lead to overtreatment and undertreatment. Objective To examine all-cause and cancer-specific death throughout 5 years for older adults after cancer resection. Design, Setting, and Participants This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). All adults 70 years or older who underwent resection for a new diagnosis of cancer between January 1, 2007, and December 31, 2017, were included. Patients were followed up until death or censored at date of last contact of December 31, 2018. Exposures Cancer resection. Main Outcome and Measures Using a competing risks approach, the cumulative incidence of cancer and noncancer death was estimated and stratified by important prognostic factors. Multivariable subdistribution hazard models were fit to explore prognostic factors. Results Of 82 037 older adults who underwent surgery (all older than 70 years; 52 119 [63.5%] female), 16 900 of 34 044 deaths (49.6%) were cancer related at a median (interquartile range) follow-up of 46 (23-80) months. At 5 years, estimated cumulative incidence of cancer death (20.7%; 95% CI, 20.4%-21.0%) exceeded noncancer death (16.5%; 95% CI, 16.2%-16.8%) among all patients. However, noncancer deaths exceeded cancer deaths starting at 3 years after surgery in breast, prostate, and melanoma skin cancers, patients older than 85 years, and those with frailty. Cancer type, advancing age, and frailty were independently associated with cause-specific death. Conclusions and Relevance At the population level, the relative burden of cancer deaths exceeds noncancer deaths for older adults selected for surgery. No subgroup had a higher burden of noncancer death early after surgery, even in more vulnerable patients. This cause-specific overall prognosis information should be used for patient counseling, to assess patterns of over- or undertreatment in older adults with cancer at the system level, and to guide targets for system-level improvements to refine selection criteria and perioperative care pathways for older adults with cancer.
Collapse
Affiliation(s)
- Tyler R. Chesney
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre–Odette Cancer Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Alyson L. Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Amy T. Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Frances Wright
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre–Odette Cancer Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre–Odette Cancer Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre–Odette Cancer Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| |
Collapse
|
36
|
Ringel B, Kraus D. Observation Rather than Surgery for Benign Parotid Tumors: Why, When, and How. Otolaryngol Clin North Am 2021; 54:593-604. [PMID: 34024486 DOI: 10.1016/j.otc.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Surgery is the preferred treatment of benign parotid lesions, but it carries a risk of complications. Therefore, the approach toward the surgery of these lesions should seek to avoid complications. There are no guidelines or recommendations for when not to operate. Integration of comorbidities and other factors shift the scales from surgery toward observation in a small subset of patients presenting with parotid tumors. When observation is chosen, the patient should be followed frequently and cautiously, and the surgeon should be prepared to change strategy to surgical excision if in doubt.
Collapse
Affiliation(s)
- Barak Ringel
- The Department of Otolaryngology-Head & Neck Surgery, Lenox Hill Hospital / Northwell Health, 130 East 77th Street - Black Hall 10th Floor, New York, NY 10075, USA
| | - Dennis Kraus
- The Department of Otolaryngology-Head & Neck Surgery, Lenox Hill Hospital / Northwell Health, 130 East 77th Street - Black Hall 10th Floor, New York, NY 10075, USA.
| |
Collapse
|
37
|
Abu Shakra I, Bez M, Ganam S, Francis R, Muati A, Bickel A, Merei F, Talmi Z, Kamal K, Kakiashvili E. The volume of general surgery emergency cases in a government hospital during the COVID-19 pandemic and two other periods: a comparative, retrospective study. BMC Surg 2021; 21:119. [PMID: 33685436 PMCID: PMC7938269 DOI: 10.1186/s12893-021-01131-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background During March and April 2020, reductions in non-COVID-19 hospital admissions were observed around the world. Elective surgeries, visits with general practitioners, and diagnoses of medical emergencies were consequently delayed. Objective
To compare the characteristics of patients admitted to a northern Israeli hospital with common surgical complaints during three periods: the lockdown due to the COVID-19 outbreak, the Second Lebanon War in 2006, and a regular period. Methods Demographic, medical, laboratory, imaging, intraoperative, and pathological data were collected from electronic medical files of patients who received emergency treatment at the surgery department of a single hospital in northern Israel. We retrospectively compared the characteristics of patients who were admitted with various conditions during three periods. Results
Patients’ mean age and most of the clinical parameters assessed were similar between the periods. However, pain was reportedly higher during the COVID-19 than the control period (8.7 vs. 6.4 on a 10-point visual analog scale, P < 0.0001). During the COVID-19 outbreak, the Second Lebanon War, and the regular period, the mean numbers of patients admitted daily were 1.4, 4.4, and 3.0, respectively. The respective mean times from the onset of symptoms until admission were 3, 1, and 1.5 days, P < 0.001. The respective proportions of surgical interventions for appendiceal disease were 95%, 96%, and 69%; P = 0.03. Conclusions Compared to a routine period, patients during the COVID-19 outbreak waited longer before turning to hospitalization, and reported more pain at arrival. Patients during both emergency periods were more often treated surgically than non-operatively.
Collapse
Affiliation(s)
- Ibrahim Abu Shakra
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Maxim Bez
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel.,Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Rola Francis
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Amir Muati
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Fahed Merei
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Ziv Talmi
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Khatib Kamal
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel. .,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
| |
Collapse
|
38
|
Zaboli A, Ausserhofer D, Pfeifer N, Magnarelli G, Ciccariello L, Siller M, Turcato G. Acute abdominal pain in triage: A retrospective observational study of the Manchester triage system's validity. J Clin Nurs 2021; 30:942-951. [PMID: 33434346 DOI: 10.1111/jocn.15635] [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: 09/09/2020] [Revised: 11/04/2020] [Accepted: 12/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Roughly 5% to 10% of patients admitted to the emergency department suffer from acute abdominal pain. Triage plays a key role in patient stratification, identifying patients who need prompt treatment versus those who can safely wait. In this regard, the aim of this study was to estimate the performance of the Manchester Triage System in classifying patients with acute abdominal pain. METHODS A total of 9,851 patients admitted at the Emergency Department of the Merano Hospital with acute abdominal pain were retrospectively enrolled between 1 January 2017 and 30 June 2019. The study was conducted and reported according to the STROBE statement. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by the patients and their survival at seven days or the need for acute surgery within 72 h after emergency department access. RESULTS Among the patients with acute abdominal pain (median age 50 years), 0.4% died within seven days and 8.9% required surgery within 72 hours. The sensitivity was 44.7% (29.9-61.5), specificity was 95.4% (94.9-95.8), and negative predictive value was 99.7% (99.2-100) in relation to death at seven days. CONCLUSIONS The Manchester Triage System shows good specificity and negative predictive value. However, its sensitivity was low due to the amount of incorrect triage prediction in patients with high-priority codes (red/orange), suggesting overtriage in relation to seven-day mortality. This may be a protective measure for the patient. In contrast, the need for acute surgery within 72 h was affected by under-triage. RELEVANCE TO CLINICAL PRACTICE The triage nurse using Manchester Triage System can correctly prioritise the majority of patients with acute abdominal pain, especially in low acuity patients. The Manchester Triage System is safe and does not underestimate the severity of the patients.
Collapse
Affiliation(s)
- Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Dietmar Ausserhofer
- College of Health Care Professions Claudiana, Bolzano-Bozen, Italy.,Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | | | - Laura Ciccariello
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | | | - Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| |
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW To provide an overview of the recent advancements in predicting toxicity associated with cancer treatment in older patients. RECENT FINDINGS Various screening tools and validated risk calculators have been shown to help predict toxicity from surgery and chemotherapy. Radiation therapy has been more challenging to select the appropriate tool to reliably predict patients at risk for toxicity and noncompliance. Ongoing work on electronic geriatric assessment tools is showing promise in making comprehensive assessment more feasible. SUMMARY Selecting appropriate cancer therapy is particularly important in older patients, and validated tools have been developed to guide clinicians for surgery and chemotherapy; however, radiotherapy toxicity remains an area for further development, as does the uptake of existing tools into routine oncology practice.
Collapse
|
40
|
Chudgar NP, Yan S, Hsu M, Tan KS, Gray KD, Molena D, Nobel T, Adusumilli PS, Bains M, Downey RJ, Huang J, Park BJ, Rocco G, Rusch VW, Sihag S, Jones DR, Isbell JM. Performance Comparison Between SURPAS and ACS NSQIP Surgical Risk Calculator in Pulmonary Resection. Ann Thorac Surg 2020; 111:1643-1651. [PMID: 33075322 DOI: 10.1016/j.athoracsur.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/06/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Accurate preoperative risk assessment is critical for informed decision making. The Surgical Risk Preoperative Assessment System (SURPAS) and the National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator (SRC) predict risks of common postoperative complications. This study compares observed and predicted outcomes after pulmonary resection between SURPAS and NSQIP SRC. METHODS Between January 2016 and December 2018, 2514 patients underwent pulmonary resection and were included. We entered the requisite patient demographics, preoperative risk factors, and procedural details into the online NSQIP SRC and SURPAS formulas. Performance of the prediction models was assessed by discrimination and calibration. RESULTS No statistically significant differences were found between the 2 models in discrimination performance for 30-day mortality, urinary tract infection, readmission, and discharge to a nursing or rehabilitation facility. The ability to discriminate between a patient who will develop a complication and a patient who will not was statistically indistinguishable between NSQIP and SURPAS, except for renal failure. With a C index closer to 1.0, the NSQIP performed significantly better than the SURPAS SRC in discriminating risk of renal failure (C index, 0.798 vs 0.694; P = .003). The calibration curves of predicted and observed risk for each model demonstrate similar performance with a tendency toward overestimation of risk, apart from renal failure. CONCLUSIONS Overall, SURPAS and NSQIP SRC performed similarly in predicting outcomes for pulmonary resections in this large, single-center validation study with moderate to good discrimination of outcomes. Notably, SURPAS uses a smaller set of input variables to generate the preoperative risk assessment. The addition of thoracic-specific input variables may improve performance.
Collapse
Affiliation(s)
- Neel P Chudgar
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shi Yan
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; Key Laboratory of Carcinogenesis and Translational Research, Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing, China
| | - Meier Hsu
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kay See Tan
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine D Gray
- Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York
| | - Daniela Molena
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tamar Nobel
- Department of Surgery, Mount Sinai Hospital, New York, New York
| | - Prasad S Adusumilli
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Manjit Bains
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J Downey
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Huang
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bernard J Park
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gaetano Rocco
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Valerie W Rusch
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Smita Sihag
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David R Jones
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James M Isbell
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
| |
Collapse
|
41
|
Loftus TJ, Tighe PJ, Filiberto AC, Efron PA, Brakenridge SC, Mohr AM, Rashidi P, Upchurch GR, Bihorac A. Artificial Intelligence and Surgical Decision-making. JAMA Surg 2020; 155:148-158. [PMID: 31825465 DOI: 10.1001/jamasurg.2019.4917] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Surgeons make complex, high-stakes decisions under time constraints and uncertainty, with significant effect on patient outcomes. This review describes the weaknesses of traditional clinical decision-support systems and proposes that artificial intelligence should be used to augment surgical decision-making. Observations Surgical decision-making is dominated by hypothetical-deductive reasoning, individual judgment, and heuristics. These factors can lead to bias, error, and preventable harm. Traditional predictive analytics and clinical decision-support systems are intended to augment surgical decision-making, but their clinical utility is compromised by time-consuming manual data management and suboptimal accuracy. These challenges can be overcome by automated artificial intelligence models fed by livestreaming electronic health record data with mobile device outputs. This approach would require data standardization, advances in model interpretability, careful implementation and monitoring, attention to ethical challenges involving algorithm bias and accountability for errors, and preservation of bedside assessment and human intuition in the decision-making process. Conclusions and Relevance Integration of artificial intelligence with surgical decision-making has the potential to transform care by augmenting the decision to operate, informed consent process, identification and mitigation of modifiable risk factors, decisions regarding postoperative management, and shared decisions regarding resource use.
Collapse
Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville
| | - Patrick J Tighe
- Departments of Anesthesiology, Orthopedics, and Information Systems/Operations Management, University of Florida Health, Gainesville
| | | | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville
| | | | - Alicia M Mohr
- Department of Surgery, University of Florida Health, Gainesville
| | - Parisa Rashidi
- Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville
| | | | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville
| |
Collapse
|
42
|
Jiang M, Li CL, Pan CQ, Lv WZ, Ren YF, Cui XW, Dietrich CF. Nomogram for predicting transmural bowel infarction in patients with acute superior mesenteric venous thrombosis. World J Gastroenterol 2020; 26:3800-3813. [PMID: 32774059 PMCID: PMC7383843 DOI: 10.3748/wjg.v26.i26.3800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/23/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The prognosis of acute mesenteric ischemia (AMI) caused by superior mesenteric venous thrombosis (SMVT) remains undetermined and early detection of transmural bowel infarction (TBI) is crucial. The predisposition to develop TBI is of clinical concern, which can lead to fatal sepsis with hemodynamic instability and multi-organ failure. Early resection of necrotic bowel could improve the prognosis of AMI, however, accurate prediction of TBI remains a challenge for clinicians. When determining the eligibility for explorative laparotomy, the underlying risk factors for bowel infarction should be fully evaluated.
AIM To develop and externally validate a nomogram for prediction of TBI in patients with acute SMVT.
METHODS Consecutive data from 207 acute SMVT patients at the Wuhan Tongji Hospital and 89 patients at the Guangzhou Nanfang Hospital between July 2005 and December 2018 were included in this study. They were grouped as training and external validation cohort. The 207 cases (training cohort) from Tongji Hospital were divided into TBI and reversible intestinal ischemia groups based on the final therapeutic outcomes. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for TBI using the training data, and a nomogram was subsequently developed. The performance of the nomogram was evaluated with respect to discrimination, calibration, and clinical usefulness in the training and external validation cohort.
RESULTS Univariate and multivariate logistic regression analyses identified the following independent prognostic factors associated with TBI in the training cohort: The decreased bowel wall enhancement (OR = 6.37, P < 0.001), rebound tenderness (OR = 7.14, P < 0.001), serum lactate levels > 2 mmol/L (OR = 3.14, P = 0.009) and previous history of deep venous thrombosis (OR = 6.37, P < 0.001). Incorporating these four factors, the nomogram achieved good calibration in the training set [area under the receiver operator characteristic curve (AUC) 0.860; 95%CI: 0.771-0.925] and the external validation set (AUC 0.851; 95%CI: 0.796-0.897). The positive and negative predictive values (95%CIs) of the nomogram were calculated, resulting in positive predictive values of 54.55% (40.07%-68.29%) and 53.85% (43.66%-63.72%) and negative predictive values of 93.33% (82.14%-97.71%) and 92.24% (85.91%-95.86%) for the training and validation cohorts, respectively. Based on the nomogram, patients who had a Nomo-score of more than 90 were considered to have high risk for TBI. Decision curve analysis indicated that the nomogram was clinically useful.
CONCLUSION The nomogram achieved an optimal prediction of TBI in patients with AMI. Using the model, the risk for an individual patient inclined to TBI can be assessed, thus providing a rational therapeutic choice.
Collapse
Affiliation(s)
- Meng Jiang
- Sino-German Tongji-Caritas Research Center of Ultrasound in Medicine, Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Chang-Li Li
- Department of Geratology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Wuhan 430015, Hubei Province, China
| | - Chun-Qiu Pan
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Wen-Zhi Lv
- Department of Artificial Intelligence, Julei Technology Company, Wuhan 430030, Hubei Province, China
| | - Yu-Fei Ren
- Department of Computer Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Xin-Wu Cui
- Sino-German Tongji-Caritas Research Center of Ultrasound in Medicine, Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | | |
Collapse
|
43
|
Locatello LG, Comini LV, Bettiol A, Vannacci A, Spinelli G, Mannelli G. A model to predict postoperative complications for otorhinolaryngology and maxillofacial surgery procedures in elderly patients. Eur Arch Otorhinolaryngol 2020; 277:3459-3467. [PMID: 32494949 DOI: 10.1007/s00405-020-06084-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/22/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE All kinds of ear, nose, and throat and maxillofacial surgery (ENT/MFS) procedures are being increasingly performed in the elderly although old age is a major risk factor for increased postoperative complications. With only scarce evidence on the topic, surgeons are asked to critically evaluate their procedures' indications and outcomes to balance the treatment risks and benefits. Our primary aim was to identify predictive factors for surgical outcomes in this setting and to create a predictive model for a tailored risk assessment. METHODS We analyzed a case series of 435 patients from an institutional clinical database at our academic tertiary care center. Multivariate logistic regression was used to identify all possible covariates and nomograms using stepwise backward method were generated. The performance was assessed by calibration curves and c-index. RESULTS Overall complication rate was 18.3% within the first 30 days and the need for re-intervention was 5.9%. For those under general anesthesia, we identified specific risk factors and developed three risk-predicting models of overall, early, and late complications. All of the nomograms showed satisfactory accuracy with a c-index of 0.83, 0.75, 0.86, and 0.82, respectively. CONCLUSION Using clinical preoperative variables, we constructed a model for predicting major adverse events in ENT/MFS patients. In our experience, patients over 65 showed a non-negligible risk for postoperative complications depending on several factors. Such tools might help in decision-making, by increasing the risk-awareness of clinicians, to better address peri-operative and post-operative care of these patients.
Collapse
Affiliation(s)
- Luca Giovanni Locatello
- Department of Otorhinolaryngology, Careggi University Hospital, Largo Brambilla, 3, 50134, Florence, Italy.
| | - Lara Valentina Comini
- Department of Otorhinolaryngology, Careggi University Hospital, Largo Brambilla, 3, 50134, Florence, Italy
| | - Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Giuseppe Spinelli
- Department of Maxillofacial Surgery, Careggi University Hospital, Largo Brambilla, 3, Florence, 50134, Italy
| | - Giuditta Mannelli
- Head and Neck and Robotic Surgery, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| |
Collapse
|
44
|
Selwood A, Blakely B, Senthuran S, Lane P, North J, Clay-Williams R. Variability in clinicians' understanding and reported methods of identifying high-risk surgical patients: a qualitative study. BMC Health Serv Res 2020; 20:427. [PMID: 32414412 PMCID: PMC7227052 DOI: 10.1186/s12913-020-05316-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
Background High-risk patients presenting for surgery require complex decision-making and perioperative management. However, given there is no gold standard for identifying high-risk patients, doing so may be challenging for clinicians in practice. Before a gold standard can be established, the state of current practice must be determined. This study aimed to understand how working clinicians define and identify high-risk surgical patients. Methods Clinicians involved in the care of high-risk surgical patients at a public hospital in regional Australia were interviewed as part of an ongoing study evaluating a new shared decision-making process for high-risk patients. The new process, Patient-Centred Advanced Care Planning (PC-ACP) engages patients, families, and clinicians from all relevant specialties in shared decision-making in line with the patient’s goals and values. The semi-structured interviews were conducted before the implementation of the new process and were coded using a modified form of the ‘constant comparative method’ to reveal key themes. Themes concerning patient risk, clinician’s understanding of high risk, and methods for identifying high-risk surgical patients were extricated for close examination. Results Thirteen staff involved in high-risk surgery at the hospital at which PC-ACP was to be implemented were interviewed. Analysis revealed six sub-themes within the major theme of factors related to patient risk: (1) increase in high-risk patients, (2) recognising frailty, (3) risk-benefit balance, (4) suitability and readiness for surgery, (5) avoiding negative outcomes, and (6) methods in use for identifying high-risk patients. There was considerable variability in clinicians’ methods of identifying high-risk patients and regarding their definition of high risk. This variability occurred even among clinicians within the same disciplines and specialties. Conclusions Although clinicians were confident in their own ability to identify high-risk patients, they acknowledged limitations in recognising frail, high-risk patients and predicting and articulating possible outcomes when consenting these patients. Importantly, little consistency in clinicians’ reported methods for identifying high-risk patients was found. Consensus regarding the definition of high-risk surgical patients is necessary to ensure rigorous decision-making.
Collapse
Affiliation(s)
- Amanda Selwood
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia.
| | - Brette Blakely
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia
| | - Siva Senthuran
- Townsville Hospital and Health Service, 100 Angus Smith Drive, Douglas, QLD, 4814, Australia.,College of Medicine & Dentistry, James Cook University, Townsville, QLD, 4811, Australia
| | - Paul Lane
- Townsville Hospital and Health Service, 100 Angus Smith Drive, Douglas, QLD, 4814, Australia
| | - John North
- Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
| | - Robyn Clay-Williams
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia
| |
Collapse
|
45
|
Ingram M, Short HL, Sathya C, Fevrier H, Raval MV. Hospital-level factors associated with nonoperative management in common pediatric surgical procedures. J Pediatr Surg 2020; 55:609-614. [PMID: 31708206 DOI: 10.1016/j.jpedsurg.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/18/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Our purpose was to examine patient- and hospital-level factors associated with nonoperative management in common pediatric surgical diagnoses. METHODS Using the 2012 Kid's Inpatient Database (KID), we identified patients <20 years old diagnosed with cholecystitis (CHOL), bowel obstruction (BO), perforated appendicitis (PA), or spontaneous pneumothorax (SPTX). Logistic regression models were used to identify factors associated with nonoperative management. RESULTS Of 36,026 admissions for the diagnoses of interest, 7472 (20.7%) were managed nonoperatively. SPTX had the highest incidence of NONOP (55.9%; n = 394), while PA had the lowest incidence (9.2%; n = 1641). Utilization of operative management varied significantly between hospitals. Patients diagnosed with BO (OR 0.41; 95% CI 0.30-0.56) and SPTX (OR 0.28; 95% CI 0.14-0.56) had decreased odds of operative management when treated at an urban, teaching hospital compared to a rural hospital. Patients with PA had increased odds of operative management when treated at an urban, teaching hospital (OR 2.42; 95% CI 1.78-3.30). Hospital-level factors associated with decreased odds of nonoperative management included urban, nonteaching status (OR 0.54; 95% CI 0.31-0.91) and location in the South (OR 0.53; 95% CI 0.34-83) and West (OR 0.47; 95% CI 0.30-0.74). CONCLUSIONS Despite representing more than 20% of pediatric surgical care for several conditions, nonoperative management is an understudied aspect of care with significant variation that warrants further research. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Martha Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chethan Sathya
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Helene Fevrier
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| |
Collapse
|
46
|
Report of a Quality Improvement Program for Reducing Postoperative Complications by Using a Surgical Risk Calculator in a Cohort of General Surgery Patients. World J Surg 2020; 44:1745-1754. [PMID: 32052105 DOI: 10.1007/s00268-020-05393-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE The study investigates whether postoperative complications in elective surgery can be reduced by using a risk calculator via raising the awareness of the surgeon in a preoperative briefing. Postoperative complications like wound infections or pneumonia result in a high burden for healthcare systems. Multiple quality improvement programs address this problem like the ACS NSQIP Surgical Risk Calculator® (SRC). METHODS To determine whether the preoperative usage of the SRC could reduce inpatient postoperative complications, two groups of 832 patients each were compared using propensity score matching. The SRC was employed retrospectively in the period 2012/2013 in one group ("Retro") and prospectively in the other group ("Prosp") in the period 2014/2015. Actual inpatient postoperative complications were classified by SRC complication categories and compared with the Clavien-Dindo complication classification system (Dindo et al. in Ann Surg 240:205-213, 2004). RESULTS Comparing SRC "serious complication" and SRC "any complication," a nonsignificant increase in the "Prosp"-group was apparent (serious complication: 6.6% vs. 8.5%, p = 0.164; any complication: 8.5% vs. 9.7%, p = 0.444). CONCLUSION Use of the SRC neither reduces inpatient postoperative complications nor the severity of complications. The calculations of the SRC rely on a 30-day postoperative follow-up. Poor sensitivity and medium specificity of the SRC showed that the SRC could not make accurate predictions in a short follow-up time averaging 6 days. Alternatively, since the observed complication rate was low in our study, in an environment of already highly implemented risk management tools, reductions in complications are not easily achieved.
Collapse
|
47
|
Pinto-Lopes R, Thahir A, Halahakoon VC. An Analysis of the Decision-Making Process After “Decision not to Operate” in Acutely Unwell, High-Risk General Surgery Patients. Am J Hosp Palliat Care 2019; 37:632-635. [DOI: 10.1177/1049909119893598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: The purpose of this study was to analyze the decision-making process in emergency general surgery in an attempt to ascertain whether surgeons make the correct decision when decisions not to operate in high-risk acutely unwell surgical patients are taken. Background: A decision not to operate is sometimes associated with a certain degree of uncertainty as to the accuracy of the decision. Difficulty lies with the fact that the decisions are made on assumptions, and the tools available are not fool proof. Methods: We retrospectively evaluated “decisions not to operate” over a period of 32 months from April 2013 to August 2015 in a district general hospital in United Kingdom and compared with consecutive similar number of patients who had an operation as recorded in the National Emergency Laparotomy Audit (NELA) database (from January 2014 to August 2015). We looked at the demographics, American Society of Anesthesiologists grade, Portsmouth–Physiological and Operative Severity Score for enumeration of Mortality and Morbidity (P-POSSUM) score, functional status, and 30-day mortality. Results: Two groups (operated [n = 43] and conservative [n = 42]) had similar characteristics. Patients for conservative management had a higher P-POSSUM score ( P < .001) and a poorer functional status ( P < .001) at the time of decision-making compared to those who had surgery. Mortality at 30 days was significantly higher for patients decided for conservative management when compared with those who had surgery (76.2% and 18.6%, respectively). Conclusions: Elderly patients with poorer functional status and predicted risks more often drive multidisciplinary discussions on whether to operate. Within the limitations of not knowing the outcome otherwise, it appears surgeons take a reasonable approach when deciding not to operate.
Collapse
Affiliation(s)
- Rui Pinto-Lopes
- Department of General Surgery, Colchester General Hospital, East Sussex and North Essex NHS Foundation Trust, Colchester, Essex, United Kingdom
| | - Azeem Thahir
- Department of General Surgery, Colchester General Hospital, East Sussex and North Essex NHS Foundation Trust, Colchester, Essex, United Kingdom
| | - V. Chandima Halahakoon
- Department of General Surgery, Colchester General Hospital, East Sussex and North Essex NHS Foundation Trust, Colchester, Essex, United Kingdom
| |
Collapse
|
48
|
Dilaver NM, Gwilym BL, Preece R, Twine CP, Bosanquet DC. Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk. BJS Open 2019; 4:16-26. [PMID: 32011813 PMCID: PMC6996626 DOI: 10.1002/bjs5.50233] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The accuracy with which surgeons can predict outcomes following surgery has not been explored in a systematic way. The aim of this review was to determine how accurately a surgeon's 'gut feeling' or perception of risk correlates with patient outcomes and available risk scoring systems. METHODS A systematic review was undertaken in accordance with PRISMA guidelines. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. Studies comparing surgeons' preoperative or postoperative assessment of patient outcomes were included. Studies that made comparisons with risk scoring tools were also included. Outcomes evaluated were postoperative mortality, general and operation-specific morbidity and long-term outcomes. RESULTS Twenty-seven studies comprising 20 898 patients undergoing general, gastrointestinal, cardiothoracic, orthopaedic, vascular, urology, endocrine and neurosurgical operations were included. Surgeons consistently overpredicted mortality rates and were outperformed by existing risk scoring tools in six of seven studies comparing area under receiver operating characteristic (ROC) curves (AUC). Surgeons' prediction of general morbidity was good, and was equivalent to, or better than, pre-existing risk prediction models. Long-term outcomes were poorly predicted by surgeons, with AUC values ranging from 0·51 to 0·75. Four of five studies found postoperative risk estimates to be more accurate than those made before surgery. CONCLUSION Surgeons consistently overestimate mortality risk and are outperformed by pre-existing tools; prediction of longer-term outcomes is also poor. Surgeons should consider the use of risk prediction tools when available to inform clinical decision-making.
Collapse
Affiliation(s)
- N M Dilaver
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK.,Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - B L Gwilym
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| | - R Preece
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - C P Twine
- Division of Population Medicine, Cardiff University, Cardiff, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D C Bosanquet
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| |
Collapse
|
49
|
Yang SU, Park EJ, Baik SH, Lee KY, Kang J. Modified Colon Leakage Score to Predict Anastomotic Leakage in Patients Who Underwent Left-Sided Colorectal Surgery. J Clin Med 2019; 8:jcm8091450. [PMID: 31547283 PMCID: PMC6780090 DOI: 10.3390/jcm8091450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/17/2022] Open
Abstract
Colon leakage score (CLS) was introduced as a clinical tool to predict anastomotic leakage (AL) in patients who underwent left-sided colorectal surgery, but its clinical validity has not been widely studied. We evaluated the clinical utility of CLS and developed a modified CLS (m-CLS). In total, 566 patients who underwent left-sided colorectal surgery were enrolled and categorized into training (n = 396) and validation (n = 170) sets via random sampling. Using CLS variables, the least absolute shrinkage and selection operator (LASSO) regression model was applied for variable selection and predictive signature building in the training set. The model's performance was validated in the validation set. The predictive powers of m-CLS and CLS were compared by the area under the receiver operating characteristic (AUROC) curve in the overall group. Twenty-three AL events (4.1%) were noted. The AL group had a significantly higher mean CLS than the No Leakage group (12.5 vs. 9.6, p = 0.001). Five clinical variables were selected and used to generate m-CLS. The predictive performance of m-CLS was similar in training and validation sets (AUROC 0.838 vs. 0.803, p = 0.724). In the overall set, m-CLS was significantly predictive of AL and performed better than CLS (AUROC 0.831 vs. 0.701, p = 0.008). In conclusion, LASSO-model-generated m-CLS could predict AL more accurately than CLS.
Collapse
Affiliation(s)
- Seung Up Yang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
| | - Eun Jung Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
| | - Seung Hyuk Baik
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
| | - Kang Young Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jeonghyun Kang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
| |
Collapse
|
50
|
Lal BK, Meschia JF, Roubin GS, Jankowitz B, Heck D, Jovin T, White CJ, Rosenfield K, Katzen B, Dabus G, Gray W, Matsumura J, Hopkins LN, Luke S, Sharma J, Voeks JH, Howard G, Brott TG. Factors influencing credentialing of interventionists in the CREST-2 trial. J Vasc Surg 2019; 71:854-861. [PMID: 31353274 DOI: 10.1016/j.jvs.2019.05.035] [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] [Received: 12/11/2018] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is a pair of randomized trials assessing the relative efficacy of carotid revascularization in the setting of intensive medical management (IMM) in patients with asymptomatic high-grade atherosclerotic stenosis. One of the trials assesses IMM with or without carotid artery stenting (CAS). Given the low risk of stroke in nonrevascularized patients receiving IMM, it is essential that there be low periprocedural risk of stroke for CAS if it is to show incremental benefit. Thus, credentialing of interventionists to ensure excellence is vital. This analysis describes the protocol-driven approach to credentialing of CAS interventionists for CREST-2 and its outcomes. METHODS To be eligible to perform stenting in CREST-2, interventionists needed to be credentialed on the basis of a detailed Interventional Management Committee (IMC) review of data from their last 25 consecutive cases during the past 24 months along with self-reported lifetime experience case numbers. When necessary, additional prospective cases performed in a companion registry were requested after webinar training. Here we review the IMC experience from the first formal meeting on March 21, 2014 through October 14, 2017. RESULTS The IMC had 102 meetings, and 8311 cases submitted by 334 interventionists were evaluated. Most were either cardiologists or vascular surgeons, although no single specialty made up the majority of applicants. The median total experience was 130 cases (interquartile range [IQR], 75-266; range, 25-2500). Only 9% (30/334) of interventionists were approved at initial review; approval increased to 46% (153/334) after submission of new cases with added training and re-review. The median self-reported lifetime case experience for those approved was 211.5 (IQR, 100-350), and the median number of cases submitted for review was 30 (IQR, 27-35). The number of CAS procedures performed per month (case rate) was the only factor associated with approval during the initial cycle of review (P < .00001). CONCLUSIONS Identification of interventionists who were deemed sufficiently skilled for CREST-2 has required substantial oversight and a controlled system to judge current skill level that controls for specialty-based practice variability, procedural experience, and periprocedural outcomes. High-volume interventionists, particularly those with more recent experience, were more likely to be approved to participate in CREST-2. Primary approval was not affected by operator specialty.
Collapse
Affiliation(s)
- Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md.
| | | | - Gary S Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/Brookwood, Baptist Medical Center, Birmingham, Ala
| | - Brian Jankowitz
- Department of Neurosurgery, UPMC Presbyterian University Hospital, Pittsburgh, Pa
| | - Donald Heck
- Department of Radiology, Novant Health Clinical Research, Winston-Salem, NC
| | - Tudor Jovin
- Department of Neurology, UPMC Presbyterian University Hospital, Pittsburgh, Pa
| | | | | | - Barry Katzen
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Fla
| | - Guilherme Dabus
- Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Fla
| | - William Gray
- Department of Cardiology, Lankenau Medical Center, Wynnewood, Pa
| | - Jon Matsumura
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisc
| | | | - Sothear Luke
- Department of Neurology, Mayo Clinic, Jacksonville, Fla
| | - Jashank Sharma
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Ala
| | | | | |
Collapse
|