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Bertoni S, M M K Magema JP, Van Geluwe B, Abbes Orabi N, Bislenghi G, D'Hoore A, Wolthuis A. Digital postoperative follow-up after colorectal resection: a multi-center preliminary qualitative study on a patient reporting and monitoring application. Updates Surg 2024; 76:139-146. [PMID: 37943493 DOI: 10.1007/s13304-023-01671-9] [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: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 11/10/2023]
Abstract
The development of minimally invasive colorectal surgery in the last decades led to a decrease in length of hospital stay. However, readmission and postoperative complications were still observed. Several studies have shown that close postoperative follow-up is required to decrease postoperative morbidity through patient education and by detecting early signs of complications. To help in this task, multiple monitoring programs have been set up to follow patients at home, allowing detection of several complications at an early stage. To evaluate acceptance, satisfaction, usability, compliance and safety of a mobile application following postoperative colorectal patients during the first 15 days post-discharge from hospital. A mobile application enabling the communication between the patient and medical staff during the recovery phase was developed and tested in four hospitals. Patients who underwent a colorectal resection were included in this prospective qualitative study. Questionnaires to assess satisfaction and usability were handed out to patients at the end of the test period. Overall, 118 patients (52% females, median age 52.5 years) were included. Median adherence-rate during 15 days was 89.6%. Satisfaction-rate for the application was 76% and usability was high. Overall, 1220 notifications were collected, of which 722 were orange, 466 red and 32 purple, colours used to rate the severeness of complaints. We analyzed the most common notifications, showing trends in different subgroups of the study with higher risks of complications (pain (409 notifications), abnormal stools (196 notifications), and wound problems (118 notifications)). A mobile application could be used to follow patients at home after colorectal resection. Future studies should evaluate whether these applications can detect complications and prevent readmission.
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Affiliation(s)
- Sébastien Bertoni
- General and Digestive Surgery Unit, CHU-UCL Namur, Site Dinant, 5500, Dinant, Belgium
| | | | - Bart Van Geluwe
- Abdominal Surgery Unit, AZ Groeninge, 8500, Kortrijk, Belgium
| | - Nora Abbes Orabi
- General and Digestive Surgery Unit, CHR Mons-Hainaut, 7022, Mons, Belgium
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, UZ Leuven Campus Gasthuisberg, Herestraat 49, 3000, Louvain, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, UZ Leuven Campus Gasthuisberg, Herestraat 49, 3000, Louvain, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, UZ Leuven Campus Gasthuisberg, Herestraat 49, 3000, Louvain, Belgium.
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2
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D’Souza J, Richards S, Eglinton T, Frizelle F. Incidence and risk factors for unplanned readmission after colorectal surgery: A meta-analysis. PLoS One 2023; 18:e0293806. [PMID: 37972100 PMCID: PMC10653493 DOI: 10.1371/journal.pone.0293806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Unplanned readmissions (URs) after colorectal surgery (CRS) are common, expensive, and result from failure to progress in postoperative recovery. These are considered preventable, although the true extent is yet to be defined. In addition, their successful prediction remains elusive due to significant heterogeneity in this field of research. This systematic review and meta-analysis of observational studies aimed to identify the clinically relevant predictors of UR after colorectal surgery. METHODS A systematic review was conducted using indexed sources (The Cochrane Database of Systematic Reviews, MEDLINE, and Embase) to search for published studies in English between 1996 and 2022. The search strategy returned 625 studies for screening of which, 150 were duplicates, and 305 were excluded for irrelevance. An additional 150 studies were excluded based on methodology and definition criteria. Twenty studies met the inclusion criteria and for the meta-analysis. Independent meta-extraction was conducted by multiple reviewers (JD & SR) in accordance with PRISMA guidelines. The primary outcome was defined as UR within 30 days of index discharge after colorectal surgery. Data were pooled using a random-effects model. Risk of bias was assessed using the Quality in Prognosis Studies tool. RESULTS The reported 30-day UR rate ranged from 6% to 22.8%. Increased comorbidity was the strongest preoperative risk factor for UR (OR 1.39, 95% CI 1.28-1.51). Stoma formation was the strongest operative risk factor (OR 1.54, 95% CI 1.38-1.72). The occurrence of postoperative complications was the strongest postoperative and overall risk factor for UR (OR 3.03, 95% CI 1.21-7.61). CONCLUSIONS Increased comorbidity, stoma formation, and postoperative complications are clinically relevant predictors of UR after CRS. These risk factors are readily identifiable before discharge and serve as clinically relevant targets for readmission risk-reducing strategies. Successful readmission prediction may facilitate the efficient allocation of healthcare resources.
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Affiliation(s)
- Joel D’Souza
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Simon Richards
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Timothy Eglinton
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
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3
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Leenen JPL, Ardesch V, Patijn G. Remote Home Monitoring of Continuous Vital Sign Measurements by Wearables in Patients Discharged After Colorectal Surgery: Observational Feasibility Study. JMIR Perioper Med 2023; 6:e45113. [PMID: 37145849 DOI: 10.2196/45113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/01/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Hospital stays after colorectal surgery are increasingly being reduced by enhanced recovery and early discharge protocols. As a result, postoperative complications may frequently manifest after discharge in the home setting, potentially leading to emergency room presentations and readmissions. Virtual care interventions after hospital discharge may capture clinical deterioration at an early stage and hold promise for the prevention of readmissions and overall better outcomes. Recent technological advances have enabled continuous vital sign monitoring by wearable wireless sensor devices. However, the potential of these devices for virtual care interventions for patients discharged after colorectal surgery is currently unknown. OBJECTIVE We aimed to determine the feasibility of a virtual care intervention consisting of continuous vital sign monitoring with wearable wireless sensors and teleconsultations for patients discharged after colorectal surgery. METHODS In a single-center observational cohort study, patients were monitored at home for 5 consecutive days after discharge. Daily vital sign trend assessments and telephone consultations were performed by a remote patient-monitoring department. Intervention performance was evaluated by analyzing vital sign trend assessments and telephone consultation reports. Outcomes were categorized as "no concern," "slight concern," or "serious concern." Serious concern prompted contact with the surgeon on call. In addition, the quality of the vital sign data was determined, and the patient experience was evaluated. RESULTS Among 21 patients who participated in this study, 104 of 105 (99%) measurements of vital sign trends were successful. Of these 104 vital sign trend assessments, 68% (n=71) did not raise any concern, 16% (n=17) were unable to be assessed because of data loss, and none led to contacting the surgeon. Of 62 of 63 (98%) successfully performed telephone consultations, 53 (86%) did not raise any concerns and only 1 resulted in contacting the surgeon. A 68% agreement was found between vital sign trend assessments and telephone consultations. Overall completeness of the 2347 hours of vital sign trend data was 46.3% (range 5%-100%). Patient satisfaction score was 8 (IQR 7-9) of 10. CONCLUSIONS A home monitoring intervention of patients discharged after colorectal surgery was found to be feasible, given its high performance and high patient acceptability. However, the intervention design needs further optimization before the true value of remote monitoring for early discharge protocols, prevention of readmissions, and overall patient outcomes can be adequately determined.
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Affiliation(s)
- Jobbe P L Leenen
- Connected Care Center, Isala, Zwolle, Netherlands
- Department of Surgery, Isala, Zwolle, Netherlands
- Isala Academy, Isala, Zwolle, Netherlands
| | - Vera Ardesch
- Connected Care Center, Isala, Zwolle, Netherlands
- Flexpool General Wards, Department of Care Support, Isala, Zwolle, Netherlands
| | - Gijsbert Patijn
- Connected Care Center, Isala, Zwolle, Netherlands
- Department of Surgery, Isala, Zwolle, Netherlands
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Pooni A, Brar MS, Anpalagan T, Schmocker S, Rashid S, Goldstein R, Goriawala A, Easson A, Kennedy ED. Home to Stay: A Randomized Controlled Trial Evaluating the Effect of a Postdischarge Mobile App to Reduce 30-Day Readmission Following Elective Colorectal Surgery. Ann Surg 2023; 277:e1056-e1062. [PMID: 35815882 DOI: 10.1097/sla.0000000000005527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A randomized controlled trial was conducted to evaluate the effect of a postdischarge app on 30-day readmissions and patient-reported outcomes following colorectal surgery. BACKGROUND Patients undergoing colorectal surgery are particularly vulnerable during their transition from hospital-to-home. There has been increasing interest in e-health to provide cost-effective transitional care. An integrated discharge monitoring program using a mobile app platform was developed to support patients after surgery. METHODS A 2 arm, superiority randomized control trial was conducted at an academic tertiary care center with patients undergoing elective colorectal surgery. The intervention group received usual postoperative care and postdischarge monitoring with the app. The primary outcome was 30-day readmissions following hospital discharge. RESULTS Two hundred eighty-two participants were randomized. The majority were young, had inflammatory bowel disease and underwent laparoscopic surgery. Intention to treat analysis showed no difference between groups for 30-day readmission (14.8% vs 17.6%, P =0.55), ER visits (25.0% vs 28.8%, P =0.49), primary care visits (12.5% vs 8.8%, P =0.34) or unplanned healthcare visits (34.4% vs 35.2%, P =0.89). All patient reported outcomes were significantly improved with median scores higher with the app for satisfaction [9, interquartile range (IQR): 8-10 vs 8, IQR: 7-9, P =0.001], well-being (7, IQR: 6-8 vs 6, IQR: 5-7, P =0.001) and significantly lower for anxiety (3, IQR: 2-5 vs 5, IQR: 3-6, P =0.001). CONCLUSIONS Although the app did not show a significant reduction in 30-day readmission or ER visits, it did lead to significant improvements in patient-reported outcomes. The app may be an important tool to support patients following colorectal surgery.
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Affiliation(s)
- Aman Pooni
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Mantaj S Brar
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Tharani Anpalagan
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Saira Rashid
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Rachel Goldstein
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Alexandra Easson
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Erin D Kennedy
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
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Wyse R, Smith S, Zucca A, Fakes K, Mansfield E, Johnston SA, Robinson S, Oldmeadow C, Reeves P, Carey ML, Norton G, Sanson-Fisher RW. Effectiveness and cost-effectiveness of a digital health intervention to support patients with colorectal cancer prepare for and recover from surgery: study protocol of the RecoverEsupport randomised controlled trial. BMJ Open 2023; 13:e067150. [PMID: 36878662 PMCID: PMC9990701 DOI: 10.1136/bmjopen-2022-067150] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Surgery is the most common treatment for colorectal cancer (CRC) and can cause relative long average length of stay (LOS) and high risks of unplanned readmissions and complications. Enhanced Recovery After Surgery (ERAS) pathways can reduce the LOS and postsurgical complications. Digital health interventions provide a flexible and low-cost way of supporting patients to achieve this. This protocol describes a trial aiming to evaluate the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention in decreasing the hospital LOS in patients undergoing CRC surgery. METHODS AND ANALYSIS The two-arm randomised controlled trial will assess the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention compared with usual care (control) in patients with CRC. The intervention consists of a website and a series of automatic prompts and alerts to support patients to adhere to the patient-led ERAS recommendations. The primary trial outcome is the length of hospital stay. Secondary outcomes include days alive and out of hospital; emergency department presentations; quality of life; patient knowledge and behaviours related to the ERAS recommendations; health service utilisation; and intervention acceptability and use. ETHICS AND DISSEMINATION The trial has been approved by the Hunter New England Research Ethics Committee (2019/ETH00869) and the University of Newcastle Ethics Committee (H-2015-0364). Trial findings will be disseminated via peer-reviewed publications and conference presentations. If the intervention is effective, the research team will facilitate its adoption within the Local Health District for widespread adaptation and implementation. TRIAL REGISTRATION NUMBER ACTRN12621001533886.
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Affiliation(s)
- Rebecca Wyse
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Stephen Smith
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Alison Zucca
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Kristy Fakes
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Elise Mansfield
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Sally-Ann Johnston
- Department of Surgery, Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | - Sancha Robinson
- Department of Surgery, Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
- Department of Anaesthetics, John Hunter Hospital, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Christopher Oldmeadow
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Penny Reeves
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Mariko L Carey
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Grace Norton
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Rob W Sanson-Fisher
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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6
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Anpalagan T, Schmocker S, Raval M, Baxter NN, Brar MS, Easson A, Feldman LS, Lee L, Liberman AS, Scales DC, Kennedy ED. Home to Stay: A randomized controlled trial protocol to assess use of a mobile app to reduce readmissions following colorectal surgery. Colorectal Dis 2022; 24:1616-1621. [PMID: 36004553 DOI: 10.1111/codi.16312] [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: 08/08/2022] [Accepted: 08/14/2022] [Indexed: 01/07/2023]
Abstract
AIM Patients undergoing colorectal surgery face high rates of emergency room visits and readmission to hospital. These unplanned hospital visits lead to both increased patient anxiety and health care costs. The aim of this study is to evaluate the use of mobile application to support patients undergoing colorectal surgery following discharge from hospital. METHOD This study is a randomized controlled trial in which the control group will receive standard follow-up care following discharge after surgery and the intervention group will receive standard follow-up care in addition to the mobile application. The primary outcome is the proportion of patients with unplanned hospital visits within 30 days of discharge. The secondary outcomes are patient-reported outcomes on validated scales evaluating their quality of recovery following discharge. A sample size of 670 subjects is planned. For the primary outcome, the control and intervention groups will be compared using a generalized linear model to account for clustering of patients within centres. For the secondary outcomes, the overall scores on the Quality of Recovery 15 and Patient Activation Measure will be analysed using a linear regression model. RESULTS It is expected that the results of this study will show that the mobile app will lead to significant improvements in unplanned hospital visits as well as improved quality of recovery for patients. CONCLUSION If the trial is successful, the mobile app can be easily adopted more widely into clinical practice to support patients at home following surgery.
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Affiliation(s)
- Tharani Anpalagan
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Manoj Raval
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nancy N Baxter
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Department of Medicine, St Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
| | - Mantaj S Brar
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alexandra Easson
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexander S Liberman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Erin D Kennedy
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
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Plonkowski A, Allison C, Philipson P, Brady RRW. Risk factors associated with readmission within 30 days following stoma surgery: Development of a 'traffic light' prediction model. Colorectal Dis 2022; 25:747-756. [PMID: 36411954 DOI: 10.1111/codi.16423] [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: 02/09/2022] [Revised: 10/30/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
AIM Patients undergoing stoma surgery have a higher risk for early readmission. Some patients may benefit from closer postdischarge surveillance to provide early detection of complications and timely intervention. However, there is a paucity of validated tools to identify those at higher risk of readmission. Here, we aim to determine the independent risk factors associated with readmission within 30 days of discharge following stoma surgery, attempt to validate previous predictive models and develop a novel prediction tool. METHOD A retrospective review of 423 patients who underwent ileostomy or colostomy stoma formation at a UK tertiary colorectal centre between 2019 and 2021. Univariate, multivariate and logistic regression analyses were used to analyse a large number of demographics and risk factors and the association with readmission. RESULTS This study cohort included 220 ileostomy and 203 colostomy patients. Of these, 87 (20.6%) were readmitted within 30 days of discharge following index surgery. A large number of demographics were evaluated for association with readmission. Readmission was associated with chronic heart failure (p < 0.05), postoperative stoma-specific complications (bleeding, p = 0.02; high-output stoma, p = 0.01) and those with a loop ileostomy (34.0% vs. 18.6%; p = 0.01). A previous predictive model was ineffective in this cohort, therefore a simplified 'traffic light' risk scoring system was developed and found to have improved discrimination. CONCLUSION Readmission following stoma formation is associated with key variables that could provide the means to triage, risk score and potentially predict readmissions. We found that a novel and simplified scoring system may provide improved prediction.
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Affiliation(s)
- Alexander Plonkowski
- Newcastle Centre for Bowel Disease Research Group, Royal Victoria Infirmary, Newcastle Hospitals, Newcastle upon Tyne, UK
| | - Callum Allison
- Newcastle Centre for Bowel Disease Research Group, Royal Victoria Infirmary, Newcastle Hospitals, Newcastle upon Tyne, UK
| | - Pete Philipson
- School of Mathematics, Statistics and Physics, Newcastle University, Newcastle upon Tyne, UK
| | - Richard R W Brady
- Newcastle Centre for Bowel Disease Research Group, Royal Victoria Infirmary, Newcastle Hospitals, Newcastle upon Tyne, UK
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8
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Sosa MP, McNicholas DG, Bebla AB, Needham KA, Starker PM. All-cause 30- and 90-day inpatient readmission costs associated with four minimally invasive colon surgery approaches: A propensity-matched analysis using Medicare and commercial claims data. Surg Open Sci 2022; 10:158-164. [PMID: 36237948 PMCID: PMC9552086 DOI: 10.1016/j.sopen.2022.09.007] [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: 08/09/2022] [Accepted: 09/19/2022] [Indexed: 11/25/2022] Open
Abstract
Background The purpose of this study is to assess which minimally invasive colon surgery approach may be associated with the least 30- and 90-day inpatient readmission costs from a payer perspective. Methods This retrospective claims analysis included adult Medicare and commercially insured beneficiaries who underwent minimally invasive sigmoid, left, or right colon surgery between January 2016 and December 2019. Two cohorts were created based on the use of near-infrared fluorescence (NIF) and were propensity-score matched 1 NIF:5 NoNIF. Four subgroups were then created based on the presence of robotics (R): NIF-NoR, NIF-R, NoNIF-R, and NoNIF-NoR. Results A total of 50,148 patients were identified, of which 165 (0.3%) indicated the use of NIF and 49,983 (99.7%) did not. After propensity score matching, 990 patients were included (NIF cohort: 165; NoNIF cohort: 825). Of the 165 NIF patients, 87 were robotic-assisted and 78 were conventional laparoscopy. Of the 825 NoNIF patients, 136 were robotic-assisted and 689 were conventional laparoscopy. Postindex inpatient readmission costs were significantly different between the NIF and NoNIF cohorts with the NIF cohort having the lowest 30- and 90-day postindex readmission costs. Postindex readmission costs were also significantly different across the 4 subgroups at 30 and 90 days, with the NIF-NoR group having the lowest postindex readmission costs (all P < .05). Conclusion Using NIF without the robot during minimally invasive colon surgery is associated with the least 30- and 90-day inpatient readmission costs compared to the other 3 approaches. Hospitals may want to consider these potential cost savings when evaluating technologies for laparoscopic colon surgery. Key Message Near-infrared fluorescence (NIF) imaging without the robot during minimally invasive colon surgery may significantly save hospitals 30- and 90-day inpatient readmission costs compared to NIF with the robot, NoNIF with the robot, and NoNIF without the robot. This is important as hospitals may want to consider these cost findings in addition to capital equipment and disposable costs when evaluating technologies for laparoscopic colon surgery.
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9
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Pollak YL, Lee JY, Khalid SI, Aquina CT, Hayden DM, Becerra AZ. Social determinants of health Z-codes and postoperative outcomes after colorectal surgery: A national population-based study. Am J Surg 2022; 224:1301-1307. [DOI: 10.1016/j.amjsurg.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/10/2022] [Accepted: 06/20/2022] [Indexed: 11/01/2022]
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10
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The impact of surgical trainee involvement in total hip arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1365-1409. [PMID: 35662374 DOI: 10.1007/s00590-022-03290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Concerns persist that trainee participation in surgical procedures may compromise patient care and potentiate adverse events and costs. We aimed to analyse the potential impact and consequences of surgical trainee involvement in total hip arthroplasty (THA) procedures in terms of surgical efficacy, patient safety, and functional outcomes. METHODS We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in October 2021. Eligible studies reported a direct comparison between THA cases performed with and without trainee involvement. RESULTS Eighteen publications met our eligibility criteria and were included in our study. The included studies reported on 142,450 THAs completed on 142,417 patients. Specifically, 48,155 and 94,295 surgeries were completed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 5,662) and without (n = 14,763) trainee involvement were 106.20 and 91.41 min, respectively. Mean overall complication rates were 6.43% and 5.93% for THAs performed with (n = 4842) and without (n = 12,731) trainees. Lastly, the mean Harris Hip Scores (HHS) for THAs performed with (n = 442) and without (n = 750) trainee participation were 89.61 and 86.97, respectively. CONCLUSION Our systematic review confirmed previous studies' reports of increased operative time for THA cases with trainee involvement. However, based on the overall similar complication rates and functional hip scores obtained, patients should be reassured concerning the relative safety of trainee involvement in THA. Future prospective studies with higher levels of evidence are still needed to reinforce the existing evidence.
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11
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Zou X, Yang YC, Wang Y, Pei W, Han JG, Lu Y, Zhang MS, Tu JF, Lin LL, Wang LQ, Shi G, Yan SY, Yang JW, Liu CZ. Electroacupuncture versus sham electroacupuncture in the treatment of postoperative ileus after laparoscopic surgery for colorectal cancer: study protocol for a multicentre, randomised, sham-controlled trial. BMJ Open 2022; 12:e050000. [PMID: 35428615 PMCID: PMC9014026 DOI: 10.1136/bmjopen-2021-050000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Postoperative ileus (POI) is an inevitable complication of almost all abdominal surgeries, which results in prolonged hospitalisation and increased healthcare costs. Various treatment strategies have been developed for POI but with limited success. Electroacupuncture (EA) might be a potential therapy for POI. However, evidence from rigorous trials that evaluated the effectiveness of EA for POI is limited. Thus, the aim of this study was to examine whether EA can safely reduce the time to the first defecation after laparoscopic surgery in patients with POI. METHODS AND ANALYSIS This multicentre randomised sham-controlled trial will be conducted in four hospitals in China. A total of 248 eligible participants with colorectal cancer who will undergo laparoscopic surgery will be randomly allocated to an EA group and a sham EA group in a 1:1 ratio. Treatment will be performed starting on postoperative day 1 and continued for four consecutive days, once per day. If the participant is discharged within 4 days after surgery, the treatment will cease on the day of discharge. The primary outcome will be the time to first defecation. The secondary outcome measures will include time to first flatus, tolerability of semiliquid and solid food, length of postoperative hospital stay, postoperative nausea and vomiting, abdominal distension, postoperative pain, postoperative analgesic, time to first ambulation, blinding assessment, credibility and expectancy and readmission rate. ETHICS AND DISSEMINATION Ethics approval was obtained from the Ethics Committee of Beijing University of Chinese Medicine (number 2020BZHYLL0116) and the institutional review board of each hospital. The results will be disseminated through peer-reviewed publications. This study protocol (V.3.0, 6 March 2020) involves human participants and was approved by the ethics committees of Beijing University of Chinese Medicine (number 2020BZHYLL0116), Beijing Friendship Hospital Affiliated to Capital Medical University (number 2020-P2-069-01), Beijing Chao-Yang Hospital Affiliated to Capital Medical University (number 2020-3-11-2), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (number 20/163-2359), and the Affiliated Hospital of Qingdao University (number QYFYKYLL711311920). The participants gave informed consent to participate in the study before taking part. TRIAL REGISTRATION NUMBER ChiCTR2000038444.
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Affiliation(s)
- Xuan Zou
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Ying-Chi Yang
- Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yu Wang
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Wei Pei
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia-Gang Han
- Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yun Lu
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Mao-Shen Zhang
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jian Feng Tu
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Lu Lu Lin
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Li-Qiong Wang
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Guangxia Shi
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Shi-Yan Yan
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Jing-Wen Yang
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Cun-Zhi Liu
- International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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12
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Banchini F, Luzietti E, Conti L, Palmieri G, Capelli P. Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review. Int J Surg Case Rep 2022; 93:106967. [PMID: 35367950 PMCID: PMC8976098 DOI: 10.1016/j.ijscr.2022.106967] [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: 02/21/2022] [Revised: 03/15/2022] [Accepted: 03/24/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Case presentation Discussion Conclusion Complications after colorectal anastomosis, such as septic leakage or anastomotic disruption, remain a problem to deal with for colorectal surgeons. Conversion to terminal colostomy is the most frequent option chosen, but the most of time restoration of bowel continuity is not performed. Delayed coloanal anastomosis with pull-through procedure described by Turnbull-Cutait might be an option to consider in difficult situations, to maintain or to restore intestinal continuity and could be also chosen as a first option for coloanal anastomosis.
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13
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Masum S, Hopgood A, Stefan S, Flashman K, Khan J. Data analytics and artificial intelligence in predicting length of stay, readmission, and mortality: a population-based study of surgical management of colorectal cancer. Discov Oncol 2022; 13:11. [PMID: 35226196 PMCID: PMC8885960 DOI: 10.1007/s12672-022-00472-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/07/2022] [Indexed: 12/24/2022] Open
Abstract
Data analytics and artificial intelligence (AI) have been used to predict patient outcomes after colorectal cancer surgery. A prospectively maintained colorectal cancer database was used, covering 4336 patients who underwent colorectal cancer surgery between 2003 and 2019. The 47 patient parameters included demographics, peri- and post-operative outcomes, surgical approaches, complications, and mortality. Data analytics were used to compare the importance of each variable and AI prediction models were built for length of stay (LOS), readmission, and mortality. Accuracies of at least 80% have been achieved. The significant predictors of LOS were age, ASA grade, operative time, presence or absence of a stoma, robotic or laparoscopic approach to surgery, and complications. The model with support vector regression (SVR) algorithms predicted the LOS with an accuracy of 83% and mean absolute error (MAE) of 9.69 days. The significant predictors of readmission were age, laparoscopic procedure, stoma performed, preoperative nodal (N) stage, operation time, operation mode, previous surgery type, LOS, and the specific procedure. A BI-LSTM model predicted readmission with 87.5% accuracy, 84% sensitivity, and 90% specificity. The significant predictors of mortality were age, ASA grade, BMI, the formation of a stoma, preoperative TNM staging, neoadjuvant chemotherapy, curative resection, and LOS. Classification predictive modelling predicted three different colorectal cancer mortality measures (overall mortality, and 31- and 91-days mortality) with 80-96% accuracy, 84-93% sensitivity, and 75-100% specificity. A model using all variables performed only slightly better than one that used just the most significant ones.
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Affiliation(s)
- Shamsul Masum
- Faculty of Technology, University of Portsmouth, Portland Building, Portland Street, Portsmouth, PO1 3AH UK
| | - Adrian Hopgood
- Faculty of Technology, University of Portsmouth, Portland Building, Portland Street, Portsmouth, PO1 3AH UK
| | - Samuel Stefan
- Colorectal Department, Portsmouth Hospitals University NHS Trust, Southwick Hill Road, Portsmouth, PO6 3LY UK
| | - Karen Flashman
- Colorectal Department, Portsmouth Hospitals University NHS Trust, Southwick Hill Road, Portsmouth, PO6 3LY UK
| | - Jim Khan
- Colorectal Department, Portsmouth Hospitals University NHS Trust, Southwick Hill Road, Portsmouth, PO6 3LY UK
- Faculty of Science & Health, University of Portsmouth, St Michael’s Building, White Swan Road, Portsmouth, PO1 2DT UK
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14
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Quintana JM, Anton-Ladislao A, Lázaro S, Gonzalez N, Bare M, Fernandez-de-Larrea N, Redondo M, Escobar A, Sarasqueta C, Garcia-Gutierrez S, Aguirre U. Effect of comorbidities on long-term outcomes of colorectal cancer patients. Eur J Cancer Care (Engl) 2022; 31:e13561. [PMID: 35174571 DOI: 10.1111/ecc.13561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 09/09/2021] [Accepted: 01/26/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The objective of this work is to evaluate the association of comorbidities with various outcomes in patients diagnosed with colon or rectal cancer. METHODS We conducted a prospective cohort study of patients diagnosed with colon or rectal cancer who underwent surgery. Data were gathered on sociodemographic, clinical characteristics, disease course, and the EuroQol EQ-5D and EORTC QLQ-C30 scores, up to 5 years after surgery. The main outcomes of the study were mortality, complications, readmissions, reoperations, and changes in PROMs up to 5 years. Multivariable multilevel logistic regression models were used in the analyses. RESULTS Mortality at some point during the 5-year follow-up was related to cardiocerebrovascular, hemiplegia and/or stroke, chronic obstructive pulmonary disease (COPD), diabetes, cancer, and dementia. Similarly, complications were related to cardiovascular disease, COPD, diabetes, hepatitis, hepatic or renal pathologies, and dementia; readmissions to cardiovascular disease, COPD, and hepatic pathologies; and reoperations to cerebrovascular and diabetes. Finally, changes in EQ-5D scores at some point during follow-up were related to cardiocerebrovascular disease, COPD, diabetes, pre-existing cancer, hepatic and gastrointestinal pathologies, and changes in EORTC QLQ-C30 scores to cardiovascular disease, COPD, diabetes, and hepatic and gastrointestinal pathologies. CONCLUSIONS Optimising the management of the comorbidities most strongly related to adverse outcomes may help to reduce those events in these patients.
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Affiliation(s)
- José M Quintana
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, 48960, Spain.,Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain
| | - Ane Anton-Ladislao
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, 48960, Spain.,Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain
| | - Santiago Lázaro
- Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain.,Servicio de Cirugía General, Hospital Basurto, Bilbao, Bizkaia, Spain
| | - Nerea Gonzalez
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, 48960, Spain.,Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain
| | - Marisa Bare
- Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain.,Unidad de Epidemiología Clínica, Corporacio Parc Tauli, Barcelona, Spain
| | - Nerea Fernandez-de-Larrea
- Centro Nacional de Epidemiología, ISCIII, Madrid, Spain.,Instituto de Salud Carlos III, CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Maximino Redondo
- Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain.,Unidad de Investigación, Hospital Costa del Sol, Malaga, Spain
| | - Antonio Escobar
- Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain.,Unidad de Investigación, Hospital Basurto, Bilbao, Bizkaia, Spain
| | - Cristina Sarasqueta
- Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain.,Unidad de Investigación, Hospital Donostia/BioDonostia, Donostia, Guipuzkoa, Spain
| | - Susana Garcia-Gutierrez
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, 48960, Spain.,Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain
| | - Urko Aguirre
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, 48960, Spain.,Instituto de Salud Carlos III, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, 48960, Spain
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15
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Lu Y, Fang PP, Yu YQ, Cheng XQ, Feng XM, Wong GTC, Maze M, Liu XS. Effect of Intraoperative Dexmedetomidine on Recovery of Gastrointestinal Function After Abdominal Surgery in Older Adults: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2128886. [PMID: 34648009 PMCID: PMC8517746 DOI: 10.1001/jamanetworkopen.2021.28886] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Postoperative ileus is common after abdominal surgery, and small clinical studies have reported that intraoperative administration of dexmedetomidine may be associated with improvements in postoperative gastrointestinal function. However, findings have been inconsistent and study samples have been small. Further examination of the effects of intraoperative dexmedetomidine on postoperative gastrointestinal function is needed. OBJECTIVE To evaluate the effects of intraoperative intravenous dexmedetomidine vs placebo on postoperative gastrointestinal function among older patients undergoing abdominal surgery. DESIGN, SETTING, AND PARTICIPANTS This multicenter, double-blind, placebo-controlled randomized clinical trial was conducted at the First Affiliated Hospital of Anhui Medical University in Hefei, China (lead site), and 12 other tertiary hospitals in Anhui Province, China. A total of 808 participants aged 60 years or older who were scheduled to receive abdominal surgery with an expected surgical duration of 1 to 6 hours were enrolled. The study was conducted from August 21, 2018, to December 9, 2019. INTERVENTIONS Dexmedetomidine infusion (a loading dose of 0.5 μg/kg over 15 minutes followed by a maintenance dose of 0.2 μg/kg per hour) or placebo infusion (normal saline) during surgery. MAIN OUTCOMES AND MEASURES The primary outcome was time to first flatus. Secondary outcomes were postoperative gastrointestinal function measured by the I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) scoring system, time to first feces, time to first oral feeding, incidence of delirium, pain scores, sleep quality, postoperative nausea and vomiting, hospital costs, and hospital length of stay. RESULTS Among 808 patients enrolled, 404 were randomized to receive intraoperative dexmedetomidine, and 404 were randomized to receive placebo. In total, 133 patients (60 in the dexmedetomidine group and 73 in the placebo group) were excluded because of protocol deviations, and 675 patients (344 in the dexmedetomidine group and 331 in the placebo group; mean [SD] age, 70.2 [6.1] years; 445 men [65.9%]) were included in the per-protocol analysis. The dexmedetomidine group had a significantly shorter time to first flatus (median, 65 hours [IQR, 48-78 hours] vs 78 hours [62-93 hours], respectively; P < .001), time to first feces (median, 85 hours [IQR, 68-115 hours] vs 98 hours [IQR, 74-121 hours]; P = .001), and hospital length of stay (median, 13 days [IQR, 10-17 days] vs 15 days [IQR, 11-18 days]; P = .005) than the control group. Postoperative gastrointestinal function (as measured by the I-FEED score) and delirium incidence were similar in the dexmedetomidine and control groups (eg, 248 patients [72.1%] vs 254 patients [76.7%], respectively, had I-FEED scores indicating normal postoperative gastrointestinal function; 18 patients [5.2%] vs 12 patients [3.6%] had delirium on postoperative day 3). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, the administration of intraoperative dexmedetomidine reduced the time to first flatus, time to first feces, and length of stay after abdominal surgery. These results suggest that this therapy may be a viable strategy to enhance postoperative recovery of gastrointestinal function among older adults. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR1800017232.
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Affiliation(s)
- Yao Lu
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Pan-Pan Fang
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yong-Qi Yu
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xin-Qi Cheng
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiao-Mei Feng
- Department of Anesthesiology, University of Utah, Salt Lake City
| | | | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco
| | - Xue-Sheng Liu
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
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16
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Shim JS, Noh TI, Ku JH, Lee S, Kwon TG, Kim TH, Jeon SH, Lee SH, Nam JK, Kim WS, Jeong BC, Lee JY, Hong SH, Rha KH, Han WK, Ham WS, Lee YG, Lee YS, Park SY, Yoon YE, Kang SG, Oh JJ, Kang SH. Effect of intraoperative fluid volume on postoperative ileus after robot-assisted radical cystectomy. Sci Rep 2021; 11:10522. [PMID: 34006918 PMCID: PMC8131600 DOI: 10.1038/s41598-021-89806-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/29/2021] [Indexed: 01/15/2023] Open
Abstract
This study aimed to investigate the effect of intraoperative fluid volume on the postoperative ileus (POI) recovery period. A retrospective review of the Korean robot-assisted radical cystectomy database identified 718 patients who underwent robot-assisted radical cystectomy (RARC). Regression analyses were performed to identify the associations between the amount of intraoperative fluid administration (crystalloid/colloid/total), POI period (time to flatus/bowel movements), and length of hospital stay (LOS) after adjusting for covariates. In addition, we analyzed the risk factors for gastrointestinal complications and prolonged POI using a logistic regression model. An increasing volume of the administered crystalloid/total fluid was associated with prolonged POI (crystalloid R2 = 0.0725 and P < 0.0001; total amount R2 = 0.0812 and P < 0.0001), and the total fluid volume was positively associated with the LOS (R2 = 0.099 and P < 0.0001). The crystalloid amount was a risk factor for prolonged POI (P < 0.001; odds ratio, 1.361; 95% confidence interval, 1.133–1.641; P < 0.001). In the context of RARC, increased intravenous fluids are associated with prolonged POI and longer LOS.
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Affiliation(s)
- Ji Sung Shim
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Tae Il Noh
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Sangchul Lee
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Gyun Kwon
- Department of Urology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae-Hwan Kim
- Department of Urology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Hyun Jeon
- Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang Hyup Lee
- Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jong Kil Nam
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wan Seok Kim
- Department of Urology, College of Medicine, Busan Paik Hospital, Inje University, Busan, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Youl Lee
- Department of Urology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sung Hoo Hong
- Department of Urology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Koon Ho Rha
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Kyu Han
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Sik Ham
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Goo Lee
- Department of Urology, Hallym University Kangnam Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea
| | - Yong Seong Lee
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sung Yul Park
- Department of Urology, Hanyang University College of Medicine, Seoul, Korea
| | - Young Eun Yoon
- Department of Urology, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Gu Kang
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Jong Jin Oh
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea. .,Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Seok Ho Kang
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea.
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17
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Matula TJ, Wang YN, Khokhlova T, Leotta DF, Kucewicz J, Brayman AA, Bruce M, Maxwell AD, MacConaghy BE, Thomas G, Chernikov VP, Buravkov SV, Khokhlova VA, Richmond K, Chan K, Monsky W. Treating Porcine Abscesses with Histotripsy: A Pilot Study. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:603-619. [PMID: 33250219 PMCID: PMC7855811 DOI: 10.1016/j.ultrasmedbio.2020.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/18/2020] [Accepted: 10/19/2020] [Indexed: 06/12/2023]
Abstract
Infected abscesses are walled-off collections of pus and bacteria. They are a common sequela of complications in the setting of surgery, trauma, systemic infections and other disease states. Current treatment is typically limited to antibiotics with long-term catheter drainage, or surgical washout when inaccessible to percutaneous drainage or unresponsive to initial care efforts. Antibiotic resistance is also a growing concern. Although bacteria can develop drug resistance, they remain susceptible to thermal and mechanical damage. In particular, short pulses of focused ultrasound (i.e., histotripsy) generate mechanical damage through localized cavitation, representing a potential new paradigm for treating abscesses non-invasively, without the need for long-term catheterization and antibiotics. In this pilot study, boiling and cavitation histotripsy treatments were applied to subcutaneous and intramuscular abscesses developed in a novel porcine model. Ultrasound imaging was used to evaluate abscess maturity for treatment monitoring and assessment of post-treatment outcomes. Disinfection was quantified by counting bacteria colonies from samples aspirated before and after treatment. Histopathological evaluation of the abscesses was performed to identify changes resulting from histotripsy treatment and potential collateral damage. Cavitation histotripsy was more successful in reducing the bacterial load while having a smaller treatment volume compared with boiling histotripsy. The results of this pilot study suggest focused ultrasound may lead to a technology for in situ treatment of acoustically accessible abscesses.
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Affiliation(s)
- Thomas J Matula
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA.
| | - Yak-Nam Wang
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Tatiana Khokhlova
- Department of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Daniel F Leotta
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - John Kucewicz
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Andrew A Brayman
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Matthew Bruce
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Adam D Maxwell
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Brian E MacConaghy
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Gilles Thomas
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Valery P Chernikov
- Research Institute of Human Morphology, Laboratory of Cell Pathology, Moscow, Russia
| | - Sergey V Buravkov
- Faculty of Fundamental Medicine, M. V. Lomonosov Moscow State University, Moscow, Russia
| | - Vera A Khokhlova
- Applied Physics Laboratory, University of Washington, Seattle, Washington, USA; Department of Acoustics, Physics Faculty, M. V. Lomonosov Moscow State University, Moscow, Russia
| | | | - Keith Chan
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Wayne Monsky
- Department of Radiology, University of Washington, Seattle, Washington, USA
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18
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Du RY, Shelton G, Ledet CR, Mills WL, Neal-Herman L, Horstman M, Trautner B, Awad S, Berger D, Naik AD. Implementation and Feasibility of the Re-Engineered Discharge for Surgery (RED-S) Intervention: A Pilot Study. J Healthc Qual 2021; 43:92-100. [PMID: 32544139 PMCID: PMC9825132 DOI: 10.1097/jhq.0000000000000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Adapting Project Re-Engineered Discharge (Project RED), an intervention for reducing internal medicine hospital readmissions, is a promising option for reducing colorectal surgery readmissions. METHODS We conducted a pilot study for the adaptation and implementation of Project RED with patients admitted for colectomy at a regional VA tertiary care center between July 2014 and January 2015. Implementation was evaluated using adherence to intervention components and results from the Survey of Healthcare Experiences of Patients. The adapted Project RED for Surgery has five components: surgical wound/ostomy-care education, scheduled follow-up appointments, medication reconciliation, an After Hospital Care Plan, and postdischarge phone calls. RESULTS All (n = 21) participants received postoperative wound care education, and 77% of ostomy patients received education. Follow-up appointments were scheduled for 76% with surgery clinic and 67% with primary care. Half received pharmacist-led medication reconciliation. Seventy-five percent received a postdischarge phone call. Ninety five percent of participants reported positive or satisfactory care transitions versus less than 60% of a comparison group of surgery patients from the same institution. We summarized lessons learned from this intervention study to facilitate future dissemination efforts. CONCLUSION The lessons learned from this pilot can guide quality improvement teams seeking to implement the Re-Engineered Discharge for Surgery intervention within their existing workflows.
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Agnes A, Puccioni C, D'Ugo D, Gasbarrini A, Biondi A, Persiani R. The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review. BMC Surg 2021; 21:83. [PMID: 33579260 PMCID: PMC7881582 DOI: 10.1186/s12893-021-01087-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery. METHODS We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics. RESULTS According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection. CONCLUSIONS The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.
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Affiliation(s)
- Annamaria Agnes
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Caterina Puccioni
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
| | - Domenico D'Ugo
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Alberto Biondi
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy.
| | - Roberto Persiani
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
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Kim JW, Mannalithara A, Sehgal M, Mithal A, Singh G, Ladabaum U. A nationwide analysis of readmission rates after colorectal cancer surgery in the US in the Era of the Affordable Care Act. Am J Surg 2020; 220:1015-1022. [DOI: 10.1016/j.amjsurg.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/22/2020] [Accepted: 04/13/2020] [Indexed: 11/15/2022]
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Rubens M, Ramamoorthy V, Saxena A, Bhatt C, Das S, Veledar E, McGranaghan P, Viamonte-Ros A, Odia Y, Chuong M, Kotecha R, Mehta MP. A risk model for prediction of 30-day readmission rates after surgical treatment for colon cancer. Int J Colorectal Dis 2020; 35:1529-1535. [PMID: 32377912 DOI: 10.1007/s00384-020-03605-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to develop a risk model for the prediction of 30-day unplanned readmission rate after surgery for colon cancer. METHOD This study was a cross-sectional analysis of data from Nationwide Readmissions Database, collected during 2010-2014. Patients ≥ 18 years of age who underwent surgery for colon cancer were included in the study. The primary outcome of the study was 30-day unplanned readmission rate. RESULTS There were 141,231 index hospitalizations for surgical treatment of colon cancers and 16,551 had unplanned readmissions. Age, sex, primary payer, Elixhauser comorbidity index, node positive or metastatic disease, length of stay, hospital bedsize, teaching status, hospital ownership, presence of stoma, surgery types, surgery procedures, infectious complications, surgical complications, mechanical wounds, pulmonary complications, and gastrointestinal complications were selected for the risk analysis during backward regression model. Based on the estimated coefficients of selected variables, risk scores were developed and stratified as low risk (≤ 1.08), moderate risk (> 1.08 to ≤ 1.5), and high risk (> 1.5) for unplanned readmission. Validation analysis (n = 42,269) showed that 7.1% of low-risk individuals, 11.1% of moderate-risk individuals, and 17.1% of high-risk individuals experienced unplanned readmissions (P < 0.001). Pairwise comparisons also showed statistically significant differences between low-risk and moderate-risk participants (P < 0.001), between moderate-risk and high-risk participants (P < 0.001), and between low-risk and high-risk participants (P < 0.001). The area under the ROC curve was 0.622. CONCLUSIONS Our risk model could be helpful for risk-stratifying patients for readmission after surgical treatment for colon cancer. This model needs further validation by incorporating all possible clinical variables.
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Affiliation(s)
- Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA
| | | | | | | | - Sankalp Das
- Baptist Health South Florida, Miami, FL, USA
| | | | - Peter McGranaghan
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA
| | | | - Yazmin Odia
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael Chuong
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA. .,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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Zand A, Nguyen A, Stokes Z, van Deen W, Lightner A, Platt A, Jacobs R, Reardon S, Kane E, Sack J, Hommes D. Patient Experiences and Outcomes of a Telehealth Clinical Care Pathway for Postoperative Inflammatory Bowel Disease Patients. Telemed J E Health 2020; 26:889-897. [DOI: 10.1089/tmj.2019.0102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Aria Zand
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
- Leiden University Medical Center, Department of Digestive Diseases, Leiden, The Netherlands
| | - Audrey Nguyen
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Zack Stokes
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Welmoed van Deen
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amy Lightner
- UCLA Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, California, USA
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anya Platt
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Rutger Jacobs
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Sarah Reardon
- UCLA Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, California, USA
| | - Ellen Kane
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Jonathan Sack
- UCLA Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, California, USA
| | - Daniel Hommes
- UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
- Leiden University Medical Center, Department of Digestive Diseases, Leiden, The Netherlands
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Antiseptic efficacy of an innovative perioperative surgical skin preparation: A confirmatory FDA phase 3 analysis. Infect Control Hosp Epidemiol 2020; 41:653-659. [PMID: 32131912 PMCID: PMC7282856 DOI: 10.1017/ice.2020.27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND An innovative approach to perioperative antiseptic skin preparation is warranted because of potential adverse skin irritation, rare risk of serious allergic reaction, and perceived diminished clinical efficacy of current perioperative antiseptic agents. The results of a confirmatory US Food and Drug Administration (FDA) phase 3 efficacy analysis of a recently approved innovative perioperative surgical skin antiseptic agent are discussed. METHODS The microbial skin flora on abdominal and groin sites in healthy volunteers were microbiologically sampled following randomization to either ZuraGard, a 2% chlorhexidine/70% isopropyl alcohol preparation (Chloraprep), or a control vehicle (alcohol-free ZuraGard). Mean log10 reduction of colony-forming units (CFU) was assessed at 30 seconds, 10 minutes, and 6 hours. RESULTS For combined groin sites (1,721 paired observations) at all time points, the mean log10 CFU reductions were significantly greater in the ZuraGard group than in the Chloraprep group (P < .02). Mean log10 CFU reductions across combined abdominal and groin sites at all time points (3,277 paired observations) were significantly greater in the ZuraGard group than in the Chloraprep group (P < .02). CONCLUSIONS A confirmatory FDA phase 3 efficacy analysis of skin antisepsis in human volunteers documented that ZuraGard was efficacious in significantly reducing the microbial burden on abdominal and groin test sites, exceeding that of Chloraprep. No significant adverse reactions were observed following the application of ZuraGard. TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT02831998 and NCT02831816.
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Metabolomics Analysis of Laparoscopic Surgery Combined with Wuda Granule to Promote Rapid Recovery of Patients with Colorectal Cancer Using UPLC/Q-TOF-MS/MS. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:5068268. [PMID: 32104193 PMCID: PMC7040410 DOI: 10.1155/2020/5068268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/20/2019] [Accepted: 12/21/2019] [Indexed: 12/30/2022]
Abstract
Surgery is the primary curative treatment for patients with nonmetastasized colorectal cancer (CRC). Rate of complications, morbidity, mortality, and overall survival of patients with CRC are factors associated with speed of recovery following surgery. Wuda granule (WD) is a traditional Chinese medicine (TCM) prescription used to promote rapid recovery after surgery. However, the specific mechanism of action of WD has not been characterized. Our study included 60 patients with clear histopathological evidence of colon or rectal cancer who underwent CRC laparoscopic surgery and 30 healthy individuals. Serum biochemistry and clinical evaluation of gastrointestinal function showed that WD could improve the nutritional status and gastrointestinal function and reduce the level of inflammation of patients with CRC following laparoscopic surgery. In addition, we used UPLC/Q-TOF-MS/MS-based metabolomics analysis to determine the mechanism of WD-related rapid recovery following laparoscopic surgery in patients with CRC. Twenty metabolites associated with arachidonic acid, alanine, aspartate and glutamate, α-linolenic acid, pyruvate, histidine, and glycerophospholipids were identified. The results suggested that the therapeutic mechanism of laparoscopic surgery combined with WD may be related to regulation of nutritional status, inflammation, immune function, energy, and gastrointestinal function in patients with CRC. This study also highlighted the ability of TCM compounds to interact with multiple targets to induce synergistic effects. This study may result in further studies of WD as a therapeutic agent to promote recovery following surgical resection of CRC tumors.
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25
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Chung JS, Kwak HD, Ju JK. Thirty-Day Readmission After Elective Colorectal Surgery for Colon Cancer: A Single-Center Cohort Study. Ann Coloproctol 2020; 36:186-191. [PMID: 32054242 PMCID: PMC7392574 DOI: 10.3393/ac.2019.11.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose There is a concern that enhanced recovery after surgery may affect other proposed quality measures, including the rate of readmission due to early discharge. We examine the 30-day readmission rate, risk factors associated with readmission after elective colorectal surgery for colon cancer, causes of readmission, disease-free survival (DFS), and overall survival (OS) in a single institution. Methods We retrospectively investigated 292 patients who underwent elective colorectal surgery for colon cancer between 2010 and 2015. Baseline data including age, sex, body mass index, American Society of Anesthesiologists physical status classification, preoperative comorbidities, previous operation history, TNM stage, surgical approach, operation time, gas passage time, and length of hospital stay were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with 30-day readmission. Results A total of 229 patients who underwent elective colorectal surgery were enrolled. Twenty-four patients were readmitted 30 days after discharge. The most common readmission diagnoses were wound bleeding or surgical site infection. Multivariate analysis indicated that patients who had preoperative hepatic disease were at the highest risk of readmission (odds ratio [OR], 8.98; 95% confidence interval [CI], 7.35–10.61). Survival outcomes were significantly better in the nonreadmitted group (OS, P=0.00; DFS, P=0.04). Conclusion This study identified that preoperative comorbidities including hepatic and pulmonary diseases were associated with higher readmission rates after elective colorectal surgery. Moreover, the most common cause of readmission in patients who underwent elective colorectal surgery was wound bleeding or surgical site infection.
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Affiliation(s)
- Jun Seong Chung
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Han Deok Kwak
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
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Keng CJS, Goriawala A, Rashid S, Goldstein R, Schmocker S, Easson A, Kennedy E. Home to Stay: An Integrated Monitoring System Using a Mobile App to Support Patients at Home Following Colorectal Surgery. J Patient Exp 2020; 7:1241-1246. [PMID: 33457571 PMCID: PMC7786720 DOI: 10.1177/2374373520904194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Patients undergoing colorectal surgery are vulnerable during their transition from hospital to home and require increased support following discharge from hospital. Study objectives were to perform an initial assessment of patient uptake, outcomes, and satisfaction with an integrated discharge monitoring system called Home to Stay. Methods: The intervention was an integrated discharge monitoring system that uses a mobile app platform. Patients downloaded the app prior to discharge from hospital and received a Daily Health Check day #1 to #14, #21, and #30. Patient responses’ were accessed by the health-care team via secure web site, and extreme responses were “flagged” to indicate that a follow-up telephone call was necessary. Primary outcomes were patient uptake, Quality of Recovery scores and satisfaction with the program. Secondary outcomes were 30-day emergency room (ER) visits and readmissions. Results: One hundred and thirty-two patients were invited to participate and 106 accepted. Of these, 93 used the app at least once. The mean overall score on the Quality of Recovery Scale increased significantly from day 1 to day 14. Patient satisfaction with the app was high, with 92% of patients reporting overall satisfaction as good or excellent. The 30-day readmission rate was 6% and was lower than the 30-day readmission rate of 18% reported for the 4 months prior to the start of the study. Conclusions: The Home to Stay Program to support patients at home after colorectal surgery is feasible with high patient uptake and satisfaction. This program has the potential to reduce 30-day readmissions, however further studies are required.
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Affiliation(s)
- Christine J S Keng
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alifiya Goriawala
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Saira Rashid
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Goldstein
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Selina Schmocker
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Easson
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Erin Kennedy, Mount Sinai Hospital, 449-600 University Ave, Toronto, Ontario, Canada M5G 1X5.
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Postoperative Ileus: Old and New Observations on Prevention and Treatment in Adult Spinal Deformity Surgery. World Neurosurg 2019; 132:e618-e622. [DOI: 10.1016/j.wneu.2019.08.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022]
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Sanaiha Y, Xing H, Morchi R, Seo YJ, Rudasill S, Benharash P. National Study of Immediate and Delayed Readmissions After Colostomy Creation. J Surg Res 2019; 246:457-463. [PMID: 31706537 DOI: 10.1016/j.jss.2019.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/17/2019] [Accepted: 09/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy. METHODS The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission. RESULTS Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively. CONCLUSIONS Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Los Angeles, California
| | - Hanning Xing
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Ravi Morchi
- Department of General Surgery, University of California, Irvine, Orange, California
| | - Young Ji Seo
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Los Angeles, California.
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James TA, Kasumova G, Alapati A, Mamtani A. Unplanned readmissions following breast cancer surgery. Am J Surg 2019; 218:988-992. [PMID: 31272676 DOI: 10.1016/j.amjsurg.2019.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Understanding the underlying factors associated with unplanned readmissions is an important first step toward interventions designed to improve quality of care. This study aimed to identify predictors of unplanned 30-day readmission using a national breast surgery cohort. STUDY DESIGN Using the National Cancer Database, we performed a review of patients undergoing surgery for breast cancer from 2006 to 2014. A multivariatble logistic regression model was generated to assess predictors of 30-day unplanned readmission. RESULTS Of 944,092 patients identified, 15,695 (1.7%) had an unplanned readmission within 30 days. Significant predictors of readmission included: increased procedure complexity, high co-morbidity score, Medicaid or lack of insurance, and low annual hospital volume; p < 0.0001. CONCLUSION Unplanned readmission following breast surgery is an uncommon event. However, our results demonstrate risk factors associated with higher rates of readmission following surgery. Understanding the underlying causes for readmission allows for identification of high-risk individuals and the design of targeted intervention programs.
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Affiliation(s)
- Ted A James
- Department of Surgery, Breast Cancer Outcomes Research Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Gyulnara Kasumova
- Department of Surgery, Breast Cancer Outcomes Research Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Amuyla Alapati
- Department of Surgery, Breast Cancer Outcomes Research Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Anita Mamtani
- Department of Surgery, Breast Cancer Outcomes Research Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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30-day unplanned readmission rate in otolaryngology patients: A population-based study in Thuringia, Germany. PLoS One 2019; 14:e0224146. [PMID: 31622434 PMCID: PMC6797198 DOI: 10.1371/journal.pone.0224146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/06/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Analyze associations between patients’ characteristics and treatment factors with 30-day unplanned readmissions in hospitalized otolaryngology patients in the German Diagnosis Related Group (D-DRG) system. Methods A retrospective cohort study was performed on 15.271 otolaryngology admissions of 12.859 patients in 2015 in Thuringia, Germany. The medical records of the 1173 cases (7.6%) with readmission within 30-days were analyzed in detail. Results The 30-day readmission was planned in 747 cases (4.9%) and was unplanned in 422 cases (2.8%). The median interval between primary and next inpatient treatment was 11 days. The principal diagnosis was the same as during the primary index treatment in 72% of the cases. The most frequent reasons for readmission were: Need for non-surgical therapy (31.2%), need for further surgery (26.3%), post-surgical complaints (16.9%), and recurrence of primary complaints (10.7%). The multivariate analysis revealed that discharge due to patient’s request against medical advice was a strong independent factor with high risk for unplanned readmission (Odds Ratio [OR] = 9.62]; confidence interval [CI] = 2.69–34.48). Surgery at index admission (OR = 3.33; CI = 1.86–5.96) was the second important independent risk factor for unplanned readmission. Unplanned readmission had more frequently a non-surgical treatment at readmission than a surgical treatment (OR = 3.92; CI = 2.24–6.84) and needed more frequently further diagnostics (OR = 2.34; CI = 1.34–4.11). The following index International Classification of Diseases (ICD) categories had the highest risk for unplanned readmission: Injury, poisoning and certain other consequences of external causes, ICD: S00-T98 (OR = 66.67; CI = 15.87–333.33), symptoms, signs, abnormal findings, ill-defined causes, not otherwise classified, ICD: R00-R99 (OR = 62.5; CI = 11.76–333.33), blood forming organ diseases, ICD: D50-D90 (OR = 21.276; CI = 3.508–125), and eye/ ear diseases, ICD: H00-H95 (OR = 12.66; CI = 4.29–37.03). Conclusions The causes of unplanned 30-day readmission in German otolaryngology inpatients are multifactorial. Specific patient and treatment characteristics were identified to be targeted with health care interventions to decrease unplanned readmissions.
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Theile DE, Philpot S, Blake M, Harrington J, Youl PH. Outcomes following colorectal cancer surgery: Results from a population-based study in Queensland, Australia, using quality indicators. J Eval Clin Pract 2019; 25:834-842. [PMID: 30575221 DOI: 10.1111/jep.13087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 02/06/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Colorectal cancer (CRC) is one of the most common cancers diagnosed worldwide, and rates are continuing to rise. Surgery is the primary treatment for CRC, and our aim was to examine clinical outcomes following major resection using a series of established quality indicators and to identify factors associated with poor clinical outcomes. METHOD This population-based retrospective study included 4321 patients with diagnosed with CRC in 2012 and 2014 in Queensland, Australia, who underwent a major resection. Primary outcomes included in-hospital mortality, 30-day unplanned readmission, extended hospital stay (>21 days), and 30- and 90-day mortality. Multivariable logistic regression modelling was conducted to establish factors independently associated with each outcome of interest. RESULTS Overall, in-hospital mortality was 1.5%, 3.0% had an unplanned readmission, 8% had an extended hospital stay, and 30- and 90-day postoperative mortality was 1.6% and 3.1%, respectively. After adjustment, we found that factors such as older age, presence of comorbidities, emergency admission, and stoma formation were significantly associated with poorer outcomes with these findings being consistent across each of the outcomes of interest. In addition to these factors, the risk of 90-day mortality was significantly elevated for patients with advanced stage disease (OR = 1.95, CI 1.35-2.82). Sex, primary site, hospital volume, residential location, nor socioeconomic status was found to be associated with any of the outcomes of interest. CONCLUSION Overall, the risk of poorer clinical outcomes for CRC patients in Queensland, Australia, is low. There is however a subgroup of patients at particularly elevated risk of poorer outcomes following CRC. Strategies to reduce the poorer clinical outcomes this group of patients experience should be explored.
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Affiliation(s)
- David E Theile
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Australia
| | - Shoni Philpot
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Australia
| | - Michael Blake
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Australia
| | - John Harrington
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Australia
| | - Philippa H Youl
- Cancer Alliance Queensland, Metro South Hospital and Health Service, Brisbane, Australia
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Predictors of readmission and reoperation in patients with colorectal cancer. Support Care Cancer 2019; 28:2339-2350. [PMID: 31485982 DOI: 10.1007/s00520-019-05050-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/22/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE To assess the impact of readmission and reoperation on colon or rectal cancer patients in clinical and patient-reported outcome measures (PROMs) and to identify predictors of these events up to 1 year after surgery. METHODS Prospective cohort study of patients diagnosed with colon or rectal cancer who underwent surgery at 1 of 22 hospitals. Medical history, clinical parameters, and PROMs were evaluated as possible predictors. Multivariable multilevel logistic regression and survival models were used in the analyses to create the clinical prediction rules. Models were developed in a derivation sample and validated in a different sample. RESULTS Readmission and reoperation were related to clinical outcomes and changes in some PROMs. Predictors of readmission in colon cancer were ASA class (odds ratio (OR) 4.5), TNM (OR for TNM III 3.24, TNM IV 4.55), evidence of residual tumor (R2) (OR 3.96), and medical (OR 1.96) and infectious (OR 2.01) complications within 30 days after surgery, while for rectal cancer, the predictors identified were age (OR 1.03), R2 (OR 6.48), infectious complications within 30 days (OR 2.29), hemoglobin (OR 3.26), lymph node ratio (OR 2.35), and surgical complications within 1 month (OR 3.04). Predictors of reoperation were TNM IV (OR 5.06), surgical complications within 30 days (OR 1.98), and type and site of tumor (OR 1.72) in colon cancer and being male (OR 1.52), age (OR 1.80), stoma (OR 1.87), and surgical complications within 1 month (OR 1.95) in rectal cancer. CONCLUSIONS Our clinical prediction rule models are easy to use and could help to develop and implement interventions to reduce preventable readmissions and reoperations. TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT02488161 Identifier: NCT02488161.
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Liccardo F, Baird DLH, Pellino G, Rasheed S, Kontovounisios C, Tekkis PP. Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:477-484. [PMID: 31250396 PMCID: PMC6686032 DOI: 10.1007/s13304-019-00669-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/22/2019] [Indexed: 11/24/2022]
Abstract
Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists' (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65 years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.
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Affiliation(s)
- Filomena Liccardo
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Daniel L. H. Baird
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
| | - Gianluca Pellino
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Advanced Medical and Surgical Sciences, Universitá della Campania “Luigi Vanvitelli, Naples, Italy
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
- Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Paris P. Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
- Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
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Efficacy and safety of a novel antimicrobial preoperative skin preparation. Infect Control Hosp Epidemiol 2019; 40:1157-1163. [PMID: 31385562 DOI: 10.1017/ice.2019.200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Alternatives to skin preparation with conventional preoperative antiseptics are required because of adverse reactions and the potential emergence of resistance. Here, we present 2 phase 2 studies of ZuraGard (ZG), a novel formulation of isopropyl alcohol and functional excipients developed for preoperative skin antisepsis. METHODS Microbial skin flora on abdominal and inguinal sites in healthy volunteers were quantitatively assessed following application of ZG versus a negative control (ZV) and a chlorhexidine/alcohol preparation, Chloraprep (CP). In trial 1, ZG administered for both recommended and abbreviated application times was compared with CP and ZV via bacterial reductions at 10 minutes, and 6 hours, 12 hours, and 24 hours following application. In trial 2, the 10-minute postapplication responder rates (RRs) for ZG, participants with abdominal ≥2 log10 per cm2, and inguinal ≥3 log10 per cm2 reductions in colony-forming units (CFU) were compared to RRs of participants treated with CP. RESULTS In trial 1, ZG at the recommended application time reduced mean bacterial counts by ~3.18 log10 CFU/cm2 and ~2.98 log10 CFU/cm2 at abdominal and inguinal sites, respectively. Qualitatively similar reductions were observed for the abbreviated ZG application time and all CP applications. Application of ZV was ineffective. In trial 2, 10-minute RRs for ZG and CP exceeded 90% at abdominal sites. At inguinal sites, RRs were 83.3% for ZG and 86.7% for CP. No skin irritation or other adverse events were observed. CONCLUSIONS ZG matched CP efficacy under these experimental conditions with immediate and persistent microbial reductions, including abbreviated application times. Further clinical studies of this novel preoperative antiseptic are merited.
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Garmpis N, Dimitroulis D, Garmpi A, Diamantis E, Spartalis E, Schizas D, Angelou A, Margonis GA, Farmaki P, Antoniou EA, Mantas D, Markatos K, Kontzoglou K, Damaskos C. Enhanced Recovery After Surgery: Is It Time to Change Our Strategy Regarding Laparoscopic Colectomy? In Vivo 2019; 33:669-674. [PMID: 31028183 PMCID: PMC6559898 DOI: 10.21873/invivo.11525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 02/08/2023]
Abstract
Enhanced recovery after surgery or 'fast-track' methods are evidence-based protocols designed to standardize post-operative medical care, improve patient outcomes, promote early recovery, and reduce healthcare expenditure. Fast-track surgery is a multifunctional concept involving pre-, peri- and post-operative measures aiming to reduce the length of hospital stay and morbidity and complication rates, following elective abdominal surgery. Through the optimization of peri-operative care and the recovery process in adherence to these fast-track protocols, improved outcomes are reached, surgical trauma and post-operative stress are reduced, with less surgical pain, reduced complications, and shorter length of hospital stay. Fast-track care requires a multidisciplinary collaboration of all healthcare professionals, as well as a high rate of protocol compliance and a good organizational structure. Despite the existing evidence of the benefits of fast-track protocols in a variety of surgical procedures and the similar outcomes of laparoscopic colonic surgery compared to open surgery, clear evidence of the benefits of fast-track care after laparoscopic colonic surgery is yet to be clearly demonstrated.
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Affiliation(s)
- Nikolaos Garmpis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Garmpi
- Internal Medicine Department, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Eleftherios Spartalis
- N.S. Christeas Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Paraskevi Farmaki
- First Department of Pediatrics, Agia Sofia Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios A Antoniou
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Mantas
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos Kontzoglou
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Damaskos
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Janssen TL, Mosk CA, van Hoof-de Lepper CCHA, Wielders D, Seerden TCJ, Steyerberg EW, van Gammeren AJ, de Lange DC, van Alphen R, van der Zee M, de Bruijn RM, de Vries J, Wijsman JH, Ho GH, Gobardhan PD, van der Laan L. A multicomponent prehabilitation pathway to reduce the incidence of delirium in elderly patients in need of major abdominal surgery: study protocol for a before-and-after study. BMC Geriatr 2019; 19:87. [PMID: 30894131 PMCID: PMC6427885 DOI: 10.1186/s12877-019-1101-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 03/06/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Due to the increase in elderly patients who undergo major abdominal surgery there is a subsequent increase in postoperative complications, prolonged hospital stays, health-care costs and mortality rates. Delirium is a frequent and severe complication in the 'frail' elderly patient. Different preoperative approaches have been suggested to decrease incidence of delirium by improving patients' baseline health. Studies implementing these approaches are often heterogeneous, have a small sample and do not provide high-quality or successful strategies. The aim of this study is to prevent postoperative delirium and other complications by implementing a unique multicomponent and multidisciplinary prehabilitation program. METHODS This is a single-center controlled before-and-after study. Patients aged ≥70 years in need of surgery for colorectal cancer or an abdominal aortic aneurysm are considered eligible. Baseline characteristics (such as factors of frailty, physical condition and nutritional state) are collected prospectively. During 5 weeks prior to surgery, patients will follow a prehabilitation program to optimize overall health, which includes home-based exercises, dietary advice and intravenous iron infusion in case of anaemia. In case of frailty, a geriatrician will perform a comprehensive geriatric assessment and provide additional preoperative interventions when deemed necessary. The primary outcome is incidence of delirium. Secondary outcomes are length of hospital stay, complication rate, institutionalization, 30-day, 6- and 12-month mortality, mental health and quality of life. Results will be compared to a retrospective control group, meeting the same inclusion and exclusion criteria, operated on between January 2013 and October 2015. Inclusion of the prehabilitation cohort started in November 2015; data collection is ongoing. DISCUSSION This is the first study to investigate the effect of prehabilitation on postoperative delirium. The aim is to provide evidence, based on a large sample size, for a standardized multicomponent strategy to improve patients' preoperative physical and nutritional status in order to prevent postoperative delirium and other complications. A multimodal intervention was implemented, combining physical, nutritional, mental and hematinic optimization. This research involves a large cohort, including patients most at risk for postoperative adverse outcomes. TRIAL REGISTRATION The protocol is retrospectively registered at the Netherlands National Trial Register (NTR) number: NTR5932 . Date of registration: 05-04-2016.
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Affiliation(s)
- Ties L Janssen
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands.
| | - Christina A Mosk
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | | | - Daphne Wielders
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical center Rotterdam, Rotterdam, The Netherlands
| | - Adriaan J van Gammeren
- Department of Clinical Chemistry and Hematology, Amphia Hospital, Breda, The Netherlands
| | | | - René van Alphen
- Department of Physical Therapy, Amphia Hospital, Breda, The Netherlands
| | | | - René M de Bruijn
- Medical Manager Surgery, Amphia Hospital, Breda, The Netherlands
| | - Jolanda de Vries
- Department of Medical Psychology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
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Should They Stay or Should They Go? The Utility of C-Reactive Protein in Predicting Readmission and Anastomotic Leak After Colorectal Resection. Dis Colon Rectum 2019; 62:241-247. [PMID: 30640836 DOI: 10.1097/dcr.0000000000001225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hospital readmission and anastomotic leak following colorectal resection have a negative impact on patients, surgeons, and the health care system. Novel markers of patients unlikely to experience these complications are of value in avoiding readmission. OBJECTIVE This study aimed to determine the predictive value of C-reactive protein for readmission and anastomotic leak within 30 days following colorectal resection. DESIGN This is a retrospective review of a prospectively compiled single-institution database. PATIENTS From January 1, 2013, to July 20, 2017, consecutive patients undergoing elective colorectal resection with anastomosis without the presence of proximal intestinal stoma, who had C-reactive protein measured on postoperative day 3, were included. MAIN OUTCOME MEASURES The primary outcome measured was the predictive value of C-reactive protein measured on postoperative day 3 for readmission or anastomotic leak within 30 days after colorectal resection. RESULTS Of the 752 patients examined, 73 (10%) were readmitted within 30 days of surgery and 17 (2%) had an anastomotic leak. Mean C-reactive protein in patients who neither had an anastomotic leak nor were readmitted (127 ± 77 mg/L) was lower than for patients who were readmitted (157 ± 96 mg/L, p = 0.002) and lower than for patients who had an anastomotic leak (228 ± 123 mg/L, p = 0.0000002). The area under the receiver operating characteristic curve for the diagnostic accuracy of C-reactive protein for readmission was 0.59, with a cutoff value of 145 mg/L, generating a 93% negative predictive value. The area under the curve for the diagnostic accuracy of C-reactive protein for anastomotic leak was 0.76, with a cutoff value of 147 mg/L generating a 99% negative predictive value. LIMITATIONS This study was limited by its retrospective design and because all patients were treated at a single center. CONCLUSIONS Patients with a C-reactive protein below 145 mg/L on postoperative day 3 after colorectal resection have a low likelihood of readmission within 30 days, and a very low likelihood of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A761.
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Iqbal A, Sakharuk I, Goldstein L, Tan SA, Qiu P, Li Z, Hughes SJ. Readmission After Elective Ileostomy in Colorectal Surgery Is Predictable. JSLS 2018; 22:JSLS.2018.00008. [PMID: 30275672 PMCID: PMC6158969 DOI: 10.4293/jsls.2018.00008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives: Patients who undergo colorectal surgery have high postoperative morbidity, with ileostomates being the most disadvantaged. Recent studies assessing readmission risk factors do not provide a specific prediction model and, if so, do not focus on patients who have had colorectal surgery; thus, the results of these studies have limited applicability to our specialized practice. We wanted to develop a prediction model for readmission within 30 days of discharge after ileostomy creation. Methods: Patients who underwent elective ileostomy creation from 2013 to 2016 at the University of Florida were included in this retrospective study. Factors significantly associated with readmission within 30 days after discharge were identified by comparing a cohort that was readmitted within 30 days with one that was not. A practical, predictive model that stratified a patient's risk of readmission after the index procedure was developed. Results: A total of 86 iliostomates were included; of those, 22 (26%) were readmitted within 30 days. Factors significantly associated with readmission included preoperative steroid use, history of diabetes, history of depression, lack of a hospital social worker or postoperative ostomy education, and the presence of complications after the index procedure. A model predicting readmission within 30 days of discharge that comprised the first 4 factors was developed, with a sensitivity of 73% and a specificity of 77%. Conclusion: Prediction of readmission in patients who undergo ileostomy creation is possible, suggesting interventions addressing predictive factors that may help decrease the readmission rate. Prospective validation of the model in a larger cohort is needed.
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Affiliation(s)
| | - Ilya Sakharuk
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | | | - Peihua Qiu
- Biostatistics, University of Florida, Gainesville, Florida
| | - Zhaomian Li
- Biostatistics, University of Florida, Gainesville, Florida
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Saadat LV, Fields AC, Lyu H, Urman RD, Whang EE, Goldberg J, Bleday R, Melnitchouk N. National Surgical Quality Improvement Program analysis of unplanned reoperation in patients undergoing low anterior resection or abdominoperineal resection for rectal cancer. Surgery 2018; 165:602-607. [PMID: 30309616 DOI: 10.1016/j.surg.2018.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/29/2018] [Accepted: 08/14/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rate of unplanned reoperation for rectal cancer can provide information about surgical quality. We sought to determine factors associated with unplanned reoperation after low anterior resection and abdominoperineal resection for patients with rectal cancer and outcomes after these reoperations. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to conduct this retrospective study. Patients who underwent elective low anterior resection and abdominoperineal resection for rectal cancer from 2012-2014 were identified. The primary outcomes were 30-day reoperation rates and postoperative complications. RESULTS A total of 454 low anterior resection patients (5.9%) and 289 abdominoperineal resection patients (8.1%) required reoperation within 30 days of their index operation. The most common reasons for reoperation were infection, bleeding, and bowel obstruction. Multivariate analysis revealed that male sex (odds ratio: 1.5, P = .001), poor functional status (odds ratio: 2.2, P = .04), operative time (odds ratio: 1.001, P = .01), low preoperative albumin (odds ratio: 0.79, P = .04), and lack of ostomy (odds ratio, 0.66, P = .005) were independent risk factors for reoperation after low anterior resection. Smoking (odds ratio: 1.7, P = .001), chronic obstructive pulmonary disease (odds ratio: 1.8, P = .03), poor functional status (odds ratio: 2.1, P = .032), operative time (odds ratio: 1.003, P < .001), low preoperative albumin (odds ratio: 0.69, P = .007), and open approach (odds ratio: 1.5, P = .02) were independent risk factors for reoperation after abdominoperineal resection. Postoperative complication rates are high for those undergoing reoperation, often leading to non-home discharge (P < .001) after reoperation. CONCLUSION Reoperation after low anterior resection and abdominoperineal resection for rectal cancer is not uncommon. This study highlights the indications for reoperation, potentially modifiable preoperative risk factors for reoperation, and the morbidity associated with such operations.
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Affiliation(s)
- Lily V Saadat
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Heather Lyu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and; Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joel Goldberg
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Lumpkin ST, Strassle P, Chaumont N. Risk factors for 30-day readmission after colorectal surgery: does transfer status matter? J Surg Res 2018; 231:234-241. [PMID: 30278934 DOI: 10.1016/j.jss.2018.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 04/02/2018] [Accepted: 05/18/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Rates of readmission after colorectal surgery (CRS) range from 9% to 25% and cost the US $300 million annually. The aim of this study was to identify risk factors for 30-d readmission after CRS. Our hypothesis was that transfer from an outside hospital before CRS increases incidence of 30-d readmission. METHODS Using the Healthcare Cost and Utilization Project Nationwide Readmissions Database, a retrospective analysis of surviving adult patients who underwent inpatient colon and/or rectal resection from 2010 to 2014 was performed. Using multivariable logistic regression, we assessed the direct effect of potential risk factors for readmission, including demographics, hospital characteristics, comorbidities, indication for CRS, and transfer status to the index hospital where the CRS was performed. RESULTS A total of 336,792 patients were included, and 13% (n = 43,546) were readmitted within 30 d. Overall, 1% of patients (n = 3652) were transferred from another hospital for surgery, and these patients were more likely to be older, have comorbidities, have public insurance, and have low income. After adjustment, age, insurance type, household income, comorbidities, and primary indication for CRS were all significant predictors of readmission. Transfer status did not meaningfully impact the incidence of readmission after accounting for patient and hospital characteristics (aOR 1.08, 95% CI 1.00, 1.18). Patients with primary indications of trauma (aOR 1.88, 95% CI 1.48, 2.38), inflammatory bowel disease (aOR 1.64, 95% CI 1.1.56, 1.71), and ischemia (aOR 1.77, 95% CI 1.1.59, 1.97) were most likely to be readmitted. Patients treated at a rural nonteaching hospital, compared with those at a urban teaching hospital, were significantly less likely to be readmitted (aOR 0.80, 95% CI 0.76, 0.83). CONCLUSIONS Preoperative factors, such as patient comorbidities and primary indications for CRS, are important risk factors for postoperative readmission. Although transfer status does not independently predict readmission, it serves as a proxy for a high-risk group of patients that could be targeted for future interventions.
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Affiliation(s)
| | - Paula Strassle
- Department of Surgery, University of North Carolina School of Medicine; Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Nicole Chaumont
- Department of Surgery, University of North Carolina School of Medicine
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Rattan R, Parreco J, Lindenmaier LB, Yeh DD, Zakrison TL, Pust GD, Sands LR, Namias N. Underestimation of Unplanned Readmission after Colorectal Surgery: A National Analysis. J Am Coll Surg 2018; 226:382-390. [DOI: 10.1016/j.jamcollsurg.2017.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
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Naik AD, Horstman MJ, Li LT, Paasche-Orlow MK, Campbell B, Mills WL, Herman LI, Anaya DA, Trautner BW, Berger DH. User-centered design of discharge warnings tool for colorectal surgery patients. J Am Med Inform Assoc 2018; 24:975-980. [PMID: 28340218 DOI: 10.1093/jamia/ocx018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 02/18/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives Readmission following colorectal surgery, typically due to surgery-related complications, is common. Patient-centered discharge warnings may guide recognition of early complication signs after colorectal surgery. Materials and Methods User-centered design of a discharge warnings tool consisted of iterative health literacy review and a heuristic evaluation with human factors and clinical experts as well as patient end users to establish content validity and usability. Results Literacy evaluation of the prototype suggested >12th-grade reading level. Subsequent revisions reduced reading level to 8th grade or below. Contents were formatted during heuristic evaluation into 3 action-oriented zones (green, yellow, and red) with relevant warning lexicons. Usability testing demonstrated comprehension of this 3-level lexicon and recognition of appropriate patient actions to take for each level. Discussion We developed a discharge warnings tool for colorectal surgery using staged user-centered design. The lexicon of surgical discharge warnings could structure communication among patients, caregivers, and clinicians to improve post-discharge care.
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Affiliation(s)
- Aanand D Naik
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,VA Quality Scholars Coordinating Center, Michael E. DeBakey VA Medical Center
| | - Molly J Horstman
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,VA Quality Scholars Coordinating Center, Michael E. DeBakey VA Medical Center
| | - Linda T Li
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Bryan Campbell
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Whitney L Mills
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Levi I Herman
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Gastrointestinal Oncology, Section of Hepatobiliary Tumors and Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Daniel A Anaya
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of General Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - David H Berger
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Ready to Go Home? Patients' Experiences of the Discharge Process in an Enhanced Recovery After Surgery (ERAS) Program for Colorectal Surgery. J Gastrointest Surg 2017; 21:1865-1878. [PMID: 28932946 DOI: 10.1007/s11605-017-3573-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/29/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND With the adoption of enhanced recovery after surgery (ERAS) programs, patients are being discharged earlier and require more post-discharge teaching, educational materials, and information. OBJECTIVE The purpose of this study is to assess satisfaction, discharge needs, and follow-up concerns of patients within an ERAS implementation program (iERAS). METHODS Between 2012 and 2015, the iERAS program was undertaken at an academic hospital where 554 patients having elective colorectal surgery were enrolled. After discharge, patients were sent a survey containing multiple choice questions, preference ranking, and open-ended questions. Free-text responses were analyzed through a thematic approach. RESULTS Overall, 496 patients were mailed surveys and 219 (44.2%) completed the survey. Ninety-three percent were satisfied with the discharge information, and 90% felt they were ready for discharge. Eighty-six percent of patients saw their surgeon at 6 weeks, and 88% were satisfied with this follow-up plan. Some patients felt they had inadequate post-operative information, including how to resolve complications while at home and lack of reliable information for common post-operative occurrences. Patients with ostomies wanted more information about what to expect post-discharge and what symptoms were normal. Support from the homecare team and having a surgical nurse available were considered to be essential. CONCLUSIONS Improved post-operative education for surgical patients prior to discharge within iERAS is required to facilitate patient-centered discharge planning. Such interventions may help decrease unplanned hospital visits during the immediate post-discharge period.
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Decreasing readmissions by focusing on complications and underlying reasons. Am J Surg 2017; 215:557-562. [PMID: 28760355 DOI: 10.1016/j.amjsurg.2017.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/06/2017] [Accepted: 07/16/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND To analyze demographics and outcomes of patients focusing on 30-day readmission status and identify procedure-specific risk factors. METHODS Patients undergoing abdominal colorectal surgery (2011-2013) were identified Demographics and outcomes including in-hospital complications were compared based on readmission status. RESULTS A total of 6637 patients were identified with a mean age of 51.2(±17.1) years. Seven hundred and seventy five(11.7%) patients were readmitted at least once within 30-day. The most common index procedures related to readmission were stoma closure (n = 127/775, 16.4%) and total colectomy (n = 105/775, 13.6%). Readmitted patients had longer length of index hospital stay (LOS)(8.2 ± 5.9 vs 7.9 ± 6.9 days,p < 0.001) and operative time(167 ± 104 vs 144 ± 95 min, p < 0.001), higher intraoperative(2% vs 1%,p = 0.04) and in-hospital complication rates(36% vs 28%,p < 0.001). Main reasons for readmissions were gastrointestinal-related causes(n = 222, 29%), small bowel obstruction (n = 133,17%), wound-related complications(n = 108,14%), and dehydration(n = 93,12%). Median readmission LOS was 4(1-71)days and 54%(n = 407) of readmissions occurred within 7 days of discharge. CONCLUSION Increased postoperative complications may be the main preventable underlying reason for increased risk of hospital readmission after colorectal surgery. Preventive measures to decrease complications and actions to identify high risk patients for complications would help to reduce readmissions.
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Moran B, Cunningham C, Singh T, Sagar P, Bradbury J, Geh I, Karandikar S. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Surgical Management. Colorectal Dis 2017. [PMID: 28632309 DOI: 10.1111/codi.13704] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | | | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Pucciarelli S, Zorzi M, Gennaro N, Gagliardi G, Restivo A, Saugo M, Barina A, Rugge M, Zuin M, Maretto I, Nitti D. In-hospital mortality, 30-day readmission, and length of hospital stay after surgery for primary colorectal cancer: A national population-based study. Eur J Surg Oncol 2017; 43:1312-1323. [DOI: 10.1016/j.ejso.2017.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 02/21/2017] [Accepted: 03/06/2017] [Indexed: 01/14/2023] Open
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Alrawashdeh M, Zomak R, Dew MA, Sereika S, Song MK, Pilewski J, DeVito Dabbs A. Pattern and Predictors of Hospital Readmission During the First Year After Lung Transplantation. Am J Transplant 2017; 17:1325-1333. [PMID: 27676226 PMCID: PMC5368039 DOI: 10.1111/ajt.14064] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 09/11/2016] [Accepted: 09/18/2016] [Indexed: 01/25/2023]
Abstract
Hospital readmission after lung transplantation negatively affects quality of life and resource utilization. A secondary analysis of data collected prospectively was conducted to identify the pattern of (incidence, count, cumulative duration), reasons for and predictors of readmission for 201 lung transplant recipients (LTRs) assessed at 2, 6, and 12 mo after discharge. The majority of LTRs (83.6%) were readmitted, and 64.2% had multiple readmissions. The median cumulative readmission duration was 19 days. The main reasons for readmission were other than infection or rejection (55.5%), infection only (25.4%), rejection only (9.9%), and infection and rejection (0.7%). LTRs who required reintubation (odds ratio [OR] 1.92; p = 0.008) or were discharged to care facilities (OR 2.78; p = 0.008) were at higher risk for readmission, with a 95.7% cumulative incidence of readmission at 12 mo. Thirty-day readmission (40.8%) was not significantly predicted by baseline characteristics. Predictors of higher readmission count were lower capacity to engage in self-care (incidence rate ratio [IRR] 0.99; p = 0.03) and discharge to care facilities (IRR 1.45; p = 0.01). Predictors of longer cumulative readmission duration were older age (arithmetic mean ratio [AMR] 1.02; p = 0.009), return to the intensive care unit (AMR 2.00; p = 0.01) and lower capacity to engage in self-care (AMR 0.99; p = 0.03). Identifying LTRs at risk may assist in optimizing predischarge care, discharge planning and long-term follow-up.
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Affiliation(s)
| | - Rachelle Zomak
- Cardiothoracic Transplantation Program, UPMC, Pittsburgh, PA
| | - Mary Amanda Dew
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Susan Sereika
- School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Mi-Kyung Song
- School of Nursing, University of North Carolina, Chapel Hill, NC
| | - Joseph Pilewski
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
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Beckmann K, Moore J, Wattchow D, Young G, Roder D. Short-term outcomes after surgical resection for colorectal cancer in South Australia. J Eval Clin Pract 2017; 23:316-324. [PMID: 27480799 DOI: 10.1111/jep.12612] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVE Short-term outcomes (unplanned readmission, post-surgical complication rates, 30-day and 90-day post-surgical mortality) are often used as indicators of quality of surgical care for colorectal cancer (CRC). Differences in these immediate outcomes can highlight disparities in care across patient subpopulations. This study aimed to document short-term outcomes following major surgery for CRC and to identify whether there were any sociodemographic differences across South Australia (SA). METHODS This population-based study included all CRC resections among SA residents diagnosed with CRC aged 50-79 years in 2003-2008 (n = 3940). Clinical, treatment, comorbidity and outcomes data were compiled through linkage of administrative and surveillance datasets across SA. A retrospective cohort design was used to examine short-term outcomes including post-operative complications, 28-day emergency readmission and 30-day and 90-day mortality. We used multivariable logistic regression to identify factors associated with each outcome. RESULTS Post-operative complications occurred in 28% of cases. Thirty-day and ninety-day mortality were 1.3% and 3%, respectively. Later stage, older age, multiple comorbidities and emergency admissions were associated with poorer short-term outcomes. Risk of complications was lower among patients from higher socio-economic areas (OR = 0.77, 95%CI 0.62-0.98). Risk of 30-day mortality was higher among non-metropolitan patients (OR = 2.33, 95%CI 1.22-4.46). Post-operative complications increased the risk of emergency readmission and short-term mortality. CONCLUSIONS Short-term outcomes following CRC surgery may be improved through strategies to increase earlier detection and reduce emergency admissions. Socioeconomic and regional disparities require further examination of health system factors.
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Affiliation(s)
- Kerri Beckmann
- Centre for Population Health, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - James Moore
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Wattchow
- Department of General and Digestive Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Graeme Young
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia, Australia
| | - David Roder
- Centre for Population Health Research, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Kaplan JA, Finlayson E, Auerbach AD. Impact of Multimodality Pain Regimens on Elective Colorectal Surgery Outcomes. Am Surg 2017. [DOI: 10.1177/000313481708300432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Trials of enhanced recovery programs suggest that multimodality pain regimens improve outcomes after colorectal surgery. We sought to determine whether patients receiving postoperative multimodality pain regimens would have shorter lengths of stay without an associated increase in readmission rate as compared to those receiving opioid-based pain regimens. Retrospective cohort study of adults who underwent elective colorectal surgery between January 1, 2006, and December 31, 2012, in a national hospital network participating in the Premier Perspective database. Patients were grouped into multimodality or opioid-based using postoperative medication charges. Primary outcome measures included length of stay and 30-day readmission rate. Among 91,936 patients, 38 per cent received multimodality pain regimens and 61 per cent received opioid-based regimens. After adjustment for patient and surgical characteristics, there was no difference in length of stay or cost, odds of readmission were 1.2 (95% confidence interval = 1.2–1.3, P < 0.001), and odds of mortality were 0.8 (95% confidence interval = 0.6–0.9, P < 0.001) in the multimodality group compared to nonopioid sparing. Our results were consistent in secondary analyses using propensity matching. Fewer than half of patients undergoing elective colorectal surgery in our cohort received multimodality pain regimens, and receipt of these medications was associated with mixed benefits in terms of length of stay, readmission, and mortality.
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Affiliation(s)
- Jennifer A. Kaplan
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Andrew D. Auerbach
- Division Hospital Medicine, University of California, San Francisco, San Francisco, California
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Horstman MJ, Mills WL, Herman LI, Cai C, Shelton G, Qdaisat T, Berger DH, Naik AD. Patient experience with discharge instructions in postdischarge recovery: a qualitative study. BMJ Open 2017; 7:e014842. [PMID: 28228448 PMCID: PMC5337662 DOI: 10.1136/bmjopen-2016-014842] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/12/2017] [Accepted: 01/16/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES We examined the role of discharge instructions in postoperative recovery for patients undergoing colorectal surgery and report themes related to patient perceptions of discharge instructions and postdischarge experience. DESIGN Semistructured interviews were conducted as part of a formative evaluation of a Project Re-Engineered Discharge intervention adapted for surgical patients. SETTING Michael E. DeBakey VA Medical Center, a tertiary referral centre in Houston, Texas. PARTICIPANTS Twelve patients undergoing elective colorectal surgery. Interviews were conducted at the two-week postoperative appointment. RESULTS Participants demonstrated understanding of the content in the discharge instructions. During the interviews, participants reported several positive roles for discharge instructions in their postdischarge care: a sense of security, a reminder of inhospital education, a living document and a source of empowerment. Despite these positive associations, participants reported that the instructions provided insufficient information to promote access to care that effectively addressed acute issues following discharge. Participants noted difficulty reaching providers after discharge, which resulted in the adoption of workarounds to overcome system barriers. CONCLUSIONS Despite concerted efforts to provide patient-centred instructions, the discharge instructions did not provide enough context to effectively guide postdischarge interactions with the healthcare system. Insufficient information on how to access and communicate with the most appropriate personnel in the healthcare system is an important barrier to patients receiving high-quality postdischarge care. Tools and strategies from team training programmes, such as team strategies and tools to enhance performance and patient safety, could be adapted to include patients and provide them with structured methods for communicating with healthcare providers post discharge.
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Affiliation(s)
- Molly J Horstman
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA Quality Scholars Coordinating Center, IQuESt, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Whitney L Mills
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Levi I Herman
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Jesse H. Jones Graduate School of Business, Rice University, Houston, Texas, USA
| | - Cecilia Cai
- Internal Medicine Residency Program, Baylor College of Medicine, Houston, Texas, USA
| | - George Shelton
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Tareq Qdaisat
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - David H Berger
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA Quality Scholars Coordinating Center, IQuESt, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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