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Emanuelson RD, Brown SJ, Termuhlen PM. Interhospital Transfer (IHT) in Emergency General Surgery Patients (EGS): A Scoping Review. Surg Open Sci 2022; 9:69-79. [PMID: 35706931 PMCID: PMC9190042 DOI: 10.1016/j.sopen.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 11/26/2022] Open
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Ogawa T, Jinno T, Moriwaki M, Yoshii T, Nazarian A, Fushimi K, Okawa A. Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study. Injury 2021; 52:3002-3010. [PMID: 33714546 DOI: 10.1016/j.injury.2021.02.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/24/2021] [Accepted: 02/28/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND For displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF. METHODS A nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge. RESULTS By visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients' propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively). CONCLUSION Our research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.
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Affiliation(s)
- Takahisa Ogawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan; Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Tetsuya Jinno
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan; Department of Orthopaedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan.
| | - Mutsuko Moriwaki
- Department of Tokyo Metropolitan Health Policy Advisement, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
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Philip JL, Yang DY, Wang X, Fernandes-Taylor S, Hanlon BM, Schumacher J, Saucke MC, Havlena J, Santry HP, Ingraham AM. Effect of Transfer Status on Outcomes of Emergency General Surgery Patients. Surgery 2020; 168:280-286. [PMID: 32456785 DOI: 10.1016/j.surg.2020.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/02/2020] [Accepted: 01/10/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database. METHODS We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design. RESULTS We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay. CONCLUSIONS EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.
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Affiliation(s)
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Xing Wang
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Bret M Hanlon
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Megan C Saucke
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Heena P Santry
- Department of Surgery, Ohio State University, Columbus, OH
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Santry H, Kao LS, Shafi S, Lottenberg L, Crandall M. Pro-con debate on regionalization of emergency general surgery: controversy or common sense? Trauma Surg Acute Care Open 2019; 4:e000319. [PMID: 31245623 PMCID: PMC6560666 DOI: 10.1136/tsaco-2019-000319] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.
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Affiliation(s)
- Heena Santry
- Department of Surgery and Center for Surgical Health Assessment, Research and Policy, Ohio State University, Columbus, Ohio, USA
| | - Lillian S Kao
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Shahid Shafi
- Department of Surgery, Baylor Health Care System, Dallas, Texas, USA
| | - Lawrence Lottenberg
- Department of Surgery, Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Marie Crandall
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
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Khubchandani JA, Ingraham AM, Daniel VT, Ayturk D, Kiefe CI, Santry HP. Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis. JAMA Surg 2018; 153:150-159. [PMID: 28979986 PMCID: PMC5838713 DOI: 10.1001/jamasurg.2017.3799] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/25/2017] [Indexed: 01/14/2023]
Abstract
Importance Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood. Objective To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging. Design, Setting, and Participants A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached. Interventions Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS. Main Outcomes and Measures We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access). Results Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities. Conclusions and Relevance Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.
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Affiliation(s)
| | | | - Vijaya T. Daniel
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Didem Ayturk
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Catarina I. Kiefe
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
| | - Heena P. Santry
- University of Massachusetts Medical School, Department of Surgery, Worcester
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
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Pincus D, Morrison S, Gargan MF, Camp MW. Informal regionalization of pediatric fracture care in the Greater Toronto Area: a retrospective cross-sectional study. CMAJ Open 2017; 5:E468-E475. [PMID: 28619746 PMCID: PMC5498182 DOI: 10.9778/cmajo.20160156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Operative management of pediatric fractures is an expected competency in the specialty of Orthopedic Surgery. However, specialized pediatric centres may be providing care for increasing numbers of patients with fractures previously treated at community hospitals. The primary objective of this study was to examine trends in presentation of children with fractures to a specialized pediatric centre. METHODS We performed a detailed chart review to examine trends in presentation of children aged 14 years or less with supracondylar humerus or femur fractures to a specialized pediatric centre (Hospital for Sick Children, Toronto) from anywhere in the Greater Toronto Area between Apr. 1, 2008, and Mar. 31, 2015. Consecutive patients admitted to hospital and requiring operative intervention for a supracondylar humerus or femur fracture were considered. We calculated changes in operation incidence rates per year using multivariable negative binomial regression models. RESULTS A total of 945 children with supracondylar humerus fractures and 421 with femur fractures underwent operative intervention during the study period. The baseline characteristics of the 2 groups were similar irrespective of which year fixation occurred. The annual incidence rate of supracondylar humerus fractures increased from 108 to 169 (56.5%) over the study period, at an adjusted rate of 7.5% per year (adjusted incidence rate ratio [IRR] 1.075, 95% confidence interval [CI] 1.072-1.079, p < 0.001). The annual incidence rate of femur fractures increased from 49 to 69 (40.8%), at an adjusted rate of 5.3% per year (adjusted IRR 1.053, 95% CI 1.044-1.062, p < 0.001). Significant increases were observed independent of fracture classification, stabilization method, whether patients were transferred from an outside hospital or presented directly, patient geographic location or the season in which the fracture occurred. INTERPRETATION Adjusted annual incidence rates of supracondylar humerus and femur fractures increased significantly over the study period. Further work is needed to assess the clinical impact of informal regionalization of care and to determine whether the phenomenon occurs in other specialties.
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Affiliation(s)
- Daniel Pincus
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
| | - Steven Morrison
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
| | - Martin F Gargan
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
| | - Mark W Camp
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
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Nagarajan N, Selvarajah S, Gani F, Alshaikh HN, Giuliano K, Zogg CK, Schneider EB, Haider AH. "Halo effect" in trauma centers: does it extend to emergent colectomy? J Surg Res 2016; 203:231-7. [PMID: 27125867 DOI: 10.1016/j.jss.2016.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/15/2016] [Accepted: 01/27/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trauma centers (TCs) have been demonstrated to improve outcomes for some nontrauma surgical conditions, such as appendicitis, but it remains unclear if this extends to all emergency general surgery procedures. Using emergent colectomy in patients with diverticulitis as index condition, this study compared outcomes between TCs and nontrauma centers (NTCs). MATERIALS AND METHODS The Nationwide Emergency Department Sample (2006-2011) was queried for patients ≥16 y with diverticulitis who underwent emergency surgical intervention. Outcomes included mortality, total charges, and length of stay (LOS). Mortality in TC and NTC was compared using logistic regression, controlling for patient, procedure, and hospital-level characteristics. Adjusted total charges and LOS were analyzed using generalized linear models with gamma and Poisson distributions, respectively. RESULTS A total of 25,396 patients were included, 5189 (20.4%) were treated at TC and 20,207 (79.6%) at NTC. Median age and sex distribution were similar. Unadjusted proportional in-hospital mortality did not differ between TC and NTC; median charges and LOS were greater in TC. After adjusting, the odds of mortality were significantly higher in TC (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.02-1.51; P = 0.003) as were mean charges and LOS (P < 0.001). CONCLUSIONS The improved outcomes reported for other nontrauma conditions in TC were not observed for patients undergoing an emergent colectomy for diverticulitis after accounting for patient, procedure, and hospital-level characteristics. Future research is needed to assess differences in case mix between TC versus NTC and possible case-mix effects on outcomes to elucidate potential benefit of surgical care in a TC across the breadth of emergency general surgery conditions.
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Affiliation(s)
- Neeraja Nagarajan
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shalini Selvarajah
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Husain N Alshaikh
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Cheryl K Zogg
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric B Schneider
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
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Collins CE, Pringle PL, Santry HP. Innovation or rebranding, acute care surgery diffusion will continue. J Surg Res 2015; 197:354-62. [PMID: 25891673 DOI: 10.1016/j.jss.2015.03.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/11/2015] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patterns of adoption of acute care surgery (ACS) as a strategy for emergency general surgery (EGS) care are unknown. METHODS We conducted a qualitative study comprising face-to-face interviews with senior surgeons responsible for ACS at 18 teaching hospitals chosen to ensure diversity of opinions and practice environment (three practice types [community, public or charity, and university] in each of six geographic regions [Mid-Atlantic, Midwest, New England, Northeast, South, and West]). Interviews were recorded, transcribed, and analyzed using NVivo (QSR International, Melbourne, Australia). We applied the methods of investigator triangulation using an inductive approach to develop a final taxonomy of codes organized by themes related to respondents' views on the future of ACS as a strategy for EGS. We applied our findings to a conceptual model on diffusion of innovation. RESULTS We found a paradox between ACS viewed as a health care delivery innovation versus a rebranding of comprehensive general surgery. Optimism for the future of ACS because of increased desirability for trauma and critical care careers as well as improved EGS outcomes was tempered by fear over lack of continuity, poor institutional resources, and uncertainty regarding financial viability. Our analysis suggests that the implementation of ACS, whether a true health care delivery innovation or an innovative rebranding, fits into the Rogers' diffusion of innovation theory. CONCLUSIONS Despite concerns over resource allocation and the definition of the specialty, from the perspective of senior surgeons deeply entrenched in executing this care delivery model, ACS represents the new face of general surgery that will likely continue to diffuse from these early adopters.
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Affiliation(s)
- Courtney E Collins
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patricia L Pringle
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Heena P Santry
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
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Variations in the implementation of acute care surgery: results from a national survey of university-affiliated hospitals. J Trauma Acute Care Surg 2015; 78:60-7; discussion 67-8. [PMID: 25539204 DOI: 10.1097/ta.0000000000000492] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To date, no studies have reported nationwide adoption of acute care surgery (ACS) or identified structural and/or process variations for the care of emergency general surgery (EGS) patients within such models. METHODS We surveyed surgeons responsible for EGS coverage at University Health Systems Consortium hospitals using an eight-page postal/e-mail questionnaire querying respondents on hospital and EGS structure/process measures. Survey responses were analyzed using descriptive statistics, univariate comparisons, and multivariable regression models. RESULTS Of 319 potential respondents, 258 (81%) completed the surveys. A total of 81 hospitals (31%) had implemented ACS, while 134 (52%) had a traditional general surgeon on-call (GSOC) model. Thirty-eight hospitals (15%) had another model (hybrid). Larger-bed, university-based, teaching hospitals with Level 1 trauma center verification status located in urban areas were more likely to have adopted ACS. In multivariable modeling, hospital type, setting, and trauma center verification predicted ACS implementation. EGS processes of care varied, with 28% of the GSOC hospitals having block time versus 67% of the ACS hospitals (p < 0.0001), 45% of the GSOC hospitals providing ICU [intensive care unit] care to EGS patients in a surgical/trauma ICU versus 93% of the ACS hospitals (p < 0.0001), 5.7 ± 3.2 surgeons sharing call at GSOC hospitals versus 7.9 ± 2.3 surgeons at ACS hospitals (p < 0.0001), and 13% of the GSOC hospitals requiring in-house EGS call versus 75% of the ACS hospitals (p < 0.0001). Among ACS hospitals, there were variations in patient cohorting (EGS patients alone, 25%; EGS + trauma, 21%; EGS + elective, 17%; and EGS + trauma + elective, 30%), data collection (26% had prospective EGS registries), patient hand-offs (56% had attending surgeon presence), and call responsibilities (averaging 4.8 ± 1.3 calls per month, with 60% providing extra call stipend and 40% with no postcall clinical duties). CONCLUSION The potential of the ACS on the national crisis in access to EGS care is not fully met. Variations in EGS processes of care among adopters of ACS suggest that standardized criteria for ACS implementation, much like trauma center verification criteria, may be beneficial.
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Ravi B, Jenkinson R, Austin PC, Croxford R, Wasserstein D, Escott B, Paterson JM, Kreder H, Hawker GA. Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study. BMJ 2014; 348:g3284. [PMID: 24859902 PMCID: PMC4032026 DOI: 10.1136/bmj.g3284] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified. DESIGN Propensity score matched cohort study. SETTING Ontario, Canada. PARTICIPANTS 37,881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery. MAIN OUTCOME MEASURE The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery. RESULTS Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤ 35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204). CONCLUSIONS In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.
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Affiliation(s)
- Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Richard Jenkinson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Ruth Croxford
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - David Wasserstein
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Benjamin Escott
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - J Michael Paterson
- Institute for Clinical Evaluative Sciences, Toronto, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Hans Kreder
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada Institute for Clinical Evaluative Sciences, Toronto, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Gillian A Hawker
- Institute for Clinical Evaluative Sciences, Toronto, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada Division of Rheumatology, Department of Medicine, Women's College Hospital, Toronto, Canada
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Ciesla DJ, Cha JY, Smith JS, Llerena LE, Smith DJ. Implementation of an acute care surgery service at an academic trauma center. Am J Surg 2012; 202:779-85; discussion 785-6. [PMID: 22137137 DOI: 10.1016/j.amjsurg.2011.06.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The establishment of acute care surgery is rapidly becoming a solution to meet emergency surgical needs. Challenges include competition for emergency surgery opportunities and the ability to economically sustain a practice. METHODS Clinical activity was measured by reviewing the institutional and practice plan databases. Work relative value units and practice plan collection rates defined clinical activity and revenue. RESULTS Operative procedures and intensive care unit activity accounted for 52% and 36% of activity, respectively. Although procedures on the digestive tract accounted for half of the operative activity, significant activity was observed in nearly all other systems. Overall clinical productivity remained constant but did demonstrate a 25% increase in operative work relative value units. Current billing activity supports 4.0 clinical full-time equivalents, but estimated collections would cover <73% of physician direct costs. CONCLUSIONS The authors describe the implementation of an acute care surgery service that combines trauma, emergency general surgery, and surgical critical care in an established academic surgery department. Developing a sustainable economic model must include income sources other than patient service revenue.
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Affiliation(s)
- David J Ciesla
- Department of Surgery, University of South Florida College of Medicine and Tampa General Hospital, Tampa, FL, USA.
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