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Vervoort D, Afzal AM, Ruiz GZL, Mutema C, Wijeysundera HC, Ouzounian M, Fremes SE. Barriers to Access to Cardiac Surgery: Canadian Situation and Global Context. Can J Cardiol 2024; 40:1110-1122. [PMID: 37977275 DOI: 10.1016/j.cjca.2023.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023] Open
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Cardiovascular care spans primary, secondary, and tertiary prevention and care, whereby tertiary care is particularly prone to disparities in care. Challenges in access to care especially affect low- and middle-income countries (LMICs), however, multiple barriers also exist and persist across high-income countries. Canada is lauded for its universal health coverage but is faced with health care system challenges and substantial geographic barriers. Canada possesses 203 active cardiac surgeons, or 5.02 per million population, ranging from 3.70 per million in Newfoundland and Labrador to 7.48 in Nova Scotia. As such, Canada possesses fewer cardiac surgeons per million population than the average among high-income countries (7.15 per million), albeit more than the global average (1.64 per million) and far higher than the low-income country average (0.04 per million). In Canada, adult cardiac surgeons are active across 32 cardiac centres, representing 0.79 cardiac centres per million population, which is just above the global average (0.73 per million). In addition to centre and workforce variations, barriers to care exist in the form of waiting times, sociodemographic characteristics, insufficient virtual care infrastructure and electronic health record interoperability, and health care governance fragmentation. Meanwhile, Canada has highly favourable surgical outcomes, well established postacute cardiac care infrastructure, considerable spending on health, robust health administrative data, and effective health technology assessment agencies, which provides a foundation for continued improvements in care. In this narrative review, we describe successes and challenges surrounding access to cardiac surgery in Canada and globally.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Abdul Muqtader Afzal
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Gabriela Zamunaro Lopes Ruiz
- Division of Cardiovascular Surgery, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Chileshe Mutema
- Division of Cardiothoracic Surgery, National Heart Hospital, Lusaka, Zambia
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Silva HVC, Lunardi AC, Pinto ACPN, de Macedo JRFF, dos Santos EDC. Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis. Braz J Cardiovasc Surg 2024; 39:e20220319. [PMID: 38629953 PMCID: PMC11020284 DOI: 10.21470/1678-9741-2022-0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/16/2023] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Cardiac surgery is a frequent surgical procedure and may present a high risk of complications. Among the prophylactic strategies studied to decrease the rates of negative outcomes, respiratory care seems to reduce pulmonary complications. Incentive spirometry (IS) is a low-cost, respiratory exercise technique, used for the prevention and treatment of postoperative pulmonary complications (PPC). The aim of this review was to evaluate whether IS is superior to respiratory care, mobilization exercises, and noninvasive ventilation on PPC, and clinical outcomes. METHODS Systematic review. Medical Literature Analysis and Retrieval System Online (or MEDLINE®), Embase®, Cochrane Central Register of Controlled Trials (or CENTRAL), Physiotherapy Evidence Database (or PEDro), Cumulative Index of Nursing and Allied Health (or CINAHL®), Latin American and Caribbean Health Sciences Literature (or LILACS), Scientific Electronic Library Online (or SciELO), Allied, Scopus®, and OpenGrey databases, clinical trial registration sites, conferences, congresses, and symposiums were searched. RESULTS Twenty-one randomized trials and one quasi-randomized trial (1,677 participants) were included. For partial pressure of oxygen (PaO2), IS was inferior to respiratory care (mean difference [MD] -4.48; 95% confidence interval [CI] -8.32 to -0.63). Flow-oriented IS was inferior to respiratory care on PaO2 (MD -4.53; 95% CI -8.88 to -0.18). However, compared to respiratory care, flow-oriented IS was superior on recovery vital capacity. CONCLUSIONS This meta-analysis revealed that IS was not superior to standard respiratory care for PPCs and clinical outcomes, therefore its use should not be widely recommended until further studies with high quality be performed to ensure this clinical guidance.
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Affiliation(s)
| | - Adriana Claudia Lunardi
- Programa de Pós-Graduação Stricto Sensu em
Fisioterapia, Universidade Cidade de São Paulo, São Paulo, São
Paulo, Brazil
- Department of Physical Therapy, Escola de Medicina, Universidade de
São Paulo, São Paulo, São Paulo, Brazil
| | - Ana Carolina Pereira Nunes Pinto
- Department of Biological and Health Sciences, Universidade Federal
do Amapá, Macapá, Amapá, Brazil
- Department of Physical Therapy, University of Pittsburgh,
Pennsylvania, United States of America
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Hamzat I, Fenton D, Saunders M, Daramola T, Balkhy H, Dorsey C. Workforce diversity in cardiothoracic surgery: An examination of recent demographic changes and the training pathway. J Thorac Cardiovasc Surg 2024; 167:765-774. [PMID: 37330207 DOI: 10.1016/j.jtcvs.2023.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/19/2023] [Accepted: 04/30/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION The purpose of our study was to examine changes in the demographic makeup of resident physicians in integrated 6-year cardiothoracic surgery and traditional thoracic surgery residency programs from 2013 to 2022 compared with other surgical subspecialties and determine potential leaks in the training pathway. METHODS Data from US Graduate Medical Education reports from 2013 to 2022 and medical student enrollment data from the Association of American Medical Colleges were obtained. Average percentages of women and underrepresented minorities were calculated in 2 5-year intervals: 2013 to 2017 and 2018 to 2022. Average percentages of women, Black, and Hispanic medical students and residents were calculated for the 2019 to 2022 period. Pearson χ2 tests were conducted to determine significant differences in proportions of women, Black/African American, and Hispanic trainees across time (α = 0.05). RESULTS Thoracic surgery and I6 residents saw a significant increase in the proportion of women trainees across the 2 time periods (19.9% (210 out of 1055) to 24.6% (287 out of 1169) (P < .01) and 24.1% (143 out of 592) to 28.9% (330 out of 1142) (P < .05)), respectively. There was no significant change in the proportion of Black and Hispanic trainees in thoracic surgery fellowship or integrated 6-year cardiothoracic residency programs. Hispanic trainees were the only group whose proportion of cardiothoracic surgery trainees was not significantly lower than their medical school proportion. Women and Black trainees had significantly lower proportions of thoracic surgery residents and integrated 6-year cardiothoracic residency program residents than their proportions in medical school (P < .01). CONCLUSIONS Cardiothoracic surgery has not significantly increased the number of Black and Hispanic trainees during the past decade. The lower proportion of Blacks and women in thoracic surgery residency and fellowship programs compared with their proportion in medical schools is concerning and is an opportunity for intervention.
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Affiliation(s)
- Ibraheem Hamzat
- Pritzker School of Medicine, University of Chicago, Chicago, Ill.
| | - David Fenton
- Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | - Milda Saunders
- Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | | | - Husam Balkhy
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Ill
| | - Chelsea Dorsey
- Section of Vascular Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Ill
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Xiao MZX, Khan JS, Dana E, Rao V, Djaiani G, Richebé P, Katz J, Wong D, Clarke H. Prevalence and Risk Factors for Chronic Postsurgical Pain after Cardiac Surgery: A Single-center Prospective Cohort Study. Anesthesiology 2023; 139:309-320. [PMID: 37192204 DOI: 10.1097/aln.0000000000004621] [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: 05/18/2023]
Abstract
BACKGROUND Chronic postsurgical pain is a common complication of surgery. The role of psychologic risk factors like depression and anxiety is substantially understudied in cardiac surgery. This study sought to identify perioperative factors associated with chronic pain at 3, 6, and 12 months after cardiac surgery. The authors hypothesize that baseline psychologic vulnerabilities have a negative influence on chronic postsurgical pain. METHODS The authors prospectively collected demographic, psychologic, and perioperative factors in a cohort of 1,059 patients undergoing cardiac surgery at the Toronto General Hospital between 2012 and 2020. Patients were followed and completed chronic pain questionnaires at 3, 6, and 12 months after surgery. RESULTS The study included 767 patients who completed at least one follow-up questionnaire. The incidence of postsurgical pain (more than 0 out of 10) at 3, 6, and 12 months after surgery was 191 of 663 (29%), 118 of 625 (19%), and 89 of 605 (15%), respectively. Notably, among patients reporting any pain, the incidence of pain compatible with a neuropathic phenotype increased from 56 of 166 (34%) at 3 months to 38 of 97 (39%) at 6 months and 43 of 67 (64%) at 12 months. Factors associated with postsurgical pain scores at 3 months include female sex, pre-existing chronic pain, previous cardiac surgery, preoperative depression, baseline pain catastrophizing scores, and moderate-to-severe acute pain (4 or more out of 10) within 5 postoperative days. CONCLUSIONS Nearly one in three patients undergoing cardiac surgery reported pain at 3 months of follow-up, with approximately 15% reporting persistent pain at 1 yr. Female sex, pre-existing chronic pain, and baseline depression were associated with postsurgical pain scores across all three time periods. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Maggie Z X Xiao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - James S Khan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Elad Dana
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Anesthesia, Intensive Care and Pain Medicine, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vivek Rao
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Canada
| | - George Djaiani
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Research Center of the Integrated University Health and Social Services Center of the East-Island of Montreal, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Canada
| | - Joel Katz
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Psychology, York University, Toronto, Canada; Transitional Pain Service, Toronto General Hospital, Toronto, Canada
| | - Dorothy Wong
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Transitional Pain Service, Toronto General Hospital, Toronto, Canada
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Alghamdi FK, Khouqeer FA, Alayadhi WA. The need for cardiac surgeons in Saudi Arabia in 2030. Surg Open Sci 2022. [DOI: 10.1016/j.sopen.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Balachandran M, Banneheke P, Pakavakis A, Al-Bassam W, Sarode V, Rowland M, Shehabi Y. Postoperative 20% albumin vs standard care and acute kidney injury after high-risk cardiac surgery (ALBICS): study protocol for a randomised trial. Trials 2021; 22:558. [PMID: 34419128 PMCID: PMC8380013 DOI: 10.1186/s13063-021-05519-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common complication of cardiac surgery. Factors such as cardiopulmonary bypass, aortic cross-clamping and surgical stress may precipitate renal hypoperfusion and ischaemia, inflammation and oxidative stress are associated with development of AKI. Albumin’s pharmacological properties and widespread availability have the potential to mitigate these factors. However, the effect of albumin on cardiac surgery-associated AKI is unknown. Objective To evaluate the impact of postoperative 20% albumin infusion on kidney function after high-risk cardiac surgery. Methods We designed an open-label, multicentre, randomised controlled trial—the ALBICS study (ALBumin Infusion and acute kidney injury following Cardiac Surgery). A total of 590 patients undergoing high-risk cardiac surgery (combined procedure or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) will be enrolled into the study and randomly allocated to receive a postoperative 20% albumin infusion or standard care in a 1:1 ratio, stratified by centre and baseline renal function. The study fluid will be administered upon arrival in intensive care for 15 h. Patients will be followed up until 28 days after surgery or until discharge from the hospital. The primary outcome is the proportion of patients who develop AKI in both groups. Secondary outcomes to be measured are proportions of AKI stage II and III, 28-day mortality, mechanical ventilation time and length of stay in intensive care and hospital. Conclusion This trial aims to determine if a postoperative infusion of concentrated albumin reduces the risk of AKI following high-risk cardiac surgery. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12619001355167. Registered on 03 October 2019—retrospectively registered. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378383.
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Affiliation(s)
- Mayurathan Balachandran
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
| | - Piyusha Banneheke
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Adrian Pakavakis
- Intensive Care Services, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Wisam Al-Bassam
- Intensive Care Services, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Vineet Sarode
- Intensive Care Services, Cabrini Health, Malvern, Victoria, Australia.,Cabrini Monash University Department of Medicine, Monash University, Malvern, Victoria, Australia
| | - Michael Rowland
- Department of Cardiothoracic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Yahya Shehabi
- Intensive Care Services, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,University of New South Wales, Prince of Wales Clinical School of Medicine, Randwick, New South Wales, Australia
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Perera SK, Jacob S, Wilson BE, Ferlay J, Bray F, Sullivan R, Barton M. Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study. Lancet Oncol 2021; 22:182-189. [PMID: 33485458 DOI: 10.1016/s1470-2045(20)30675-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/14/2020] [Accepted: 10/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The growing demand for cancer surgery has placed a global strain on health systems. In-depth analyses of the global demand for cancer surgery and optimal workforce requirements are needed to plan service provision. We estimated the global demand for cancer surgery and the requirements for an optimal surgical and anaesthesia workforce, using benchmarks based on clinical guidelines. METHODS Using models of benchmark surgical use based on clinical guidelines, we estimated the proportion of cancer cases with an indication for surgery across 183 countries, stratified by income group. These proportions were multiplied by age-adjusted national estimates of new cancer cases using GLOBOCAN 2018 data and then aggregated to obtain the estimated number of surgical procedures required globally. The numbers of cancer surgical procedures in 44 high-income countries were divided by the actual number of surgeons and anaesthetists in the respective countries to calculate cancer procedures per surgeon and anaesthetist ratios. Using the median (IQR) of these ratios as benchmarks, we developed a three-tiered optimal surgical and anaesthesia workforce matrix, and the predictions were extrapolated up to 2040. FINDINGS Our model estimates that the number of cancer cases globally with an indication for surgery will increase by 5 million procedures (52%) between 2018 (9 065 000) and 2040 (13 821 000). The greatest relative increase in surgical demand will occur in 34 low-income countries, where we also observed the largest gaps in workforce requirements. To match the median benchmark for high-income countries, the surgical workforce in these countries would need to increase by almost four times and the anaesthesia workforce by nearly 5·5 times. The greatest increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries (from 28 000 surgeons to 58 000 surgeons; 107% increase), followed by lower-middle-income countries (from 166 000 surgeons to 277 000 surgeons; 67% increase). INTERPRETATION The global demand for cancer surgery and the optimal workforce are predicted to increase over the next two decades and disproportionately affect low-income countries. These estimates provide an appropriate framework for planning the provision of surgical services for cancer worldwide. FUNDING University of New South Wales Scientia Scholarship and UK Research and Innovation Global Challenges Research Fund.
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Affiliation(s)
- Sathira Kasun Perera
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
| | - Susannah Jacob
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Brooke E Wilson
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia; Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Jacques Ferlay
- Section of Cancer Surveillance, International Agency for Research on Cancer, World Health Organization, Geneva, Switzerland
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, World Health Organization, Geneva, Switzerland
| | - Richard Sullivan
- Institute of Cancer Policy, School of Cancer Sciences, Kings College, London, UK
| | - Michael Barton
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia
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Perera SK, Jacob S, Sullivan R, Barton M. Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis. Lancet Oncol 2021; 22:173-181. [PMID: 33485459 DOI: 10.1016/s1470-2045(20)30589-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/31/2020] [Accepted: 09/21/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model. METHODS We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006-12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations. FINDINGS Surgical treatment was indicated in 58% (95% CI 57-59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17-27) for prostate cancer to 99% (96-99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (-14%). INTERPRETATION The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences. FUNDING University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.
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Affiliation(s)
- Sathira Kasun Perera
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
| | - Susannah Jacob
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Richard Sullivan
- Institute of Cancer Policy, School of Cancer Sciences, Kings College London, London, UK
| | - Michael Barton
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia
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Lowres N, Mulcahy G, Jin K, Gallagher R, Neubeck L, Freedman B. Incidence of postoperative atrial fibrillation recurrence in patients discharged in sinus rhythm after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2019; 26:504-511. [PMID: 29161419 DOI: 10.1093/icvts/ivx348] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/25/2017] [Indexed: 11/13/2022] Open
Abstract
Postoperative atrial fibrillation (POAF) is associated with increased stroke risk and mortality post-discharge. POAF is often considered transient; however, recurrence is likely under-recognized as symptoms are an unreliable guide. Surveillance post-discharge may identify asymptomatic POAF recurrences in patients discharged in sinus rhythm. Therefore, we performed a systematic review and meta-analysis of studies investigating POAF recurrence post-discharge, in patients with new-onset POAF following cardiac surgery who reverted to sinus rhythm prior to discharge. Two independent reviewers searched medical databases, clinical trial registries, reference lists and the Internet. After screening from 6525 studies, 8 studies were identified (n = 1157 participants, mean age 66 ± 10 years and 73% men). Monitoring methods included the following: telemetry during twice-daily exercise sessions (n = 2), continuous telemetry for 3 weeks (n = 1), daily 20-s electrocardiography (ECG) using wearable event recorder (n = 1), 30-s single-lead ECG, 4 times/day (n = 1) and implanted continuous monitoring (n = 2). The incidence rate of POAF recurrence identified through non-invasive monitoring in the first 4 weeks post-discharge was 28.3% [confidence interval (CI) 23.0-33.6%]; recurring 12 ± 5 days (mean ± SD) post-surgery. The incidence rate identified through implanted continuous monitoring was 61-100% within 2 years. Between 40% and 93% of episodes were asymptomatic. In one small study reporting stroke risk, 8 of 10 patients with recurrence were guideline-indicated (CHA2DS2-VASc score ≥2) for oral anticoagulation for stroke prevention. Monitoring for POAF recurrence post-hospital discharge identifies significant numbers of early asymptomatic recurrences in patients at high risk of stroke who may benefit from anticoagulation for stroke prevention. More intense monitoring is more likely to identify POAF recurrence. Future research is required to investigate the prognostic significance of POAF recurrence, especially stroke and mortality risk.
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Affiliation(s)
- Nicole Lowres
- Heart Research Institute, Sydney, NSW, Australia.,Charles Perkins Centre, University of Sydney, Sydney, Australia
| | | | - Kai Jin
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Robyn Gallagher
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Lis Neubeck
- Sydney Nursing School, University of Sydney, Sydney, Australia.,School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK.,School of Nursing and Midwifery, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Adelaide, Australia
| | - Ben Freedman
- Heart Research Institute, Sydney, NSW, Australia.,Charles Perkins Centre, University of Sydney, Sydney, Australia
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Spratt B, Kozan E, Sinnott M. Analysis of uncertainty in the surgical department: durations, requests and cancellations. AUST HEALTH REV 2018; 43:706-711. [PMID: 30185353 DOI: 10.1071/ah18082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/12/2018] [Indexed: 11/23/2022]
Abstract
Objective Analytical techniques are being implemented with increasing frequency to improve the management of surgical departments and to ensure that decisions are well informed. Often these analytical techniques rely on the validity of underlying statistical assumptions, including those around choice of distribution when modelling uncertainty. The aim of the present study was to determine a set of suitable statistical distributions and provide recommendations to assist hospital planning staff, based on three full years of historical data. Methods Statistical analysis was performed to determine the most appropriate distributions and models in a variety of surgical contexts. Data from 2013 to 2015 were collected from the surgical department at a large Australian public hospital. Results A log-normal distribution approximation of the total duration of surgeries in an operating room is appropriate when considering probability of overtime. Surgical requests can be modelled as a Poisson process with rate dependent on urgency and day of the week. Individual cancellations could be modelled as Bernoulli trials, with the probability of patient-, staff- and resource-based cancellations provided herein. Conclusions The analysis presented herein can be used to ensure that assumptions surrounding planning and scheduling in the surgical department are valid. Understanding the stochasticity in the surgical department may result in the implementation of more realistic decision models. What is known about the topic? Many surgical departments rely on crude estimates and general intuition to predict surgical duration, surgical requests (both elective and non-elective) and cancellations. What does this paper add? This paper describes how statistical analysis can be performed to validate common assumptions surrounding surgical uncertainty. The paper also provides a set of recommended distributions and associated parameters that can be used to model uncertainty in a large public hospital's surgical department. What are the implications for practitioners? The insights on surgical uncertainty provided here will prove valuable for administrative staff who want to incorporate uncertainty in their surgical planning and scheduling decisions.
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Affiliation(s)
- Belinda Spratt
- Queensland University of Technology (QUT), 2 George St, Brisbane, Qld 4000, Australia. Email
| | - Erhan Kozan
- Queensland University of Technology (QUT), 2 George St, Brisbane, Qld 4000, Australia. Email
| | - Michael Sinnott
- Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, Qld 4102, Australia. Email
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11
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Park CS, Park NH, Sim SB, Yun SC, Ahn HM, Kim M, Choi JS, Kim MJ, Kim H, Chee HK, Oh S, Kang S, Lee SG, Shin JH, Kim K, Lee KS. Development of Models for Regional Cardiac Surgery Centers. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:S28-S36. [PMID: 28035295 PMCID: PMC5173331 DOI: 10.5090/kjtcs.2016.49.s1.s28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 11/16/2022]
Abstract
Background This study aimed to develop the models for regional cardiac surgery centers, which take regional characteristics into consideration, as a policy measure that could alleviate the concentration of cardiac surgery in the metropolitan area and enhance the accessibility for patients who reside in the regions. Methods To develop the models and set standards for the necessary personnel and facilities for the initial management plan, we held workshops, debates, and conference meetings with various experts. Results After partitioning the plan into two parts (the operational autonomy and the functional comprehensiveness), three models were developed: the ‘independent regional cardiac surgery center’ model, the ‘satellite cardiac surgery center within hospitals’ model, and the ‘extended cardiac surgery department within hospitals’ model. Proposals on personnel and facility management for each of the models were also presented. A regional cardiac surgery center model that could be applied to each treatment area was proposed, which was developed based on the anticipated demand for cardiac surgery. The independent model or the satellite model was proposed for Chungcheong, Jeolla, North Gyeongsang, and South Gyeongsang area, where more than 500 cardiac surgeries are performed annually. The extended model was proposed as most effective for the Gangwon and Jeju area, where more than 200 cardiac surgeries are performed annually. Conclusion The operation of regional cardiac surgery centers with high caliber professionals and quality resources such as optimal equipment and facility size, should enhance regional healthcare accessibility and the quality of cardiac surgery in South Korea.
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Affiliation(s)
- Choon Seon Park
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service
| | - Nam Hee Park
- Department of Thoracic and Cardiovascular Surgery, Keimyung University School of Medicine
| | - Sung Bo Sim
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea College of Medicine
| | | | - Hye Mi Ahn
- Department of Preventive Medicine, Konkuk University School of Medicine
| | - Myunghwa Kim
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service
| | - Ji Suk Choi
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service
| | - Myo Jeong Kim
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service
| | - Hyunsu Kim
- Caleb & Company, Konkuk University School of Medicine
| | - Hyun Keun Chee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine
| | - Sanggi Oh
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital
| | - Shinkwang Kang
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital
| | - Sok-Goo Lee
- Department of Preventive Medicine and Public Health, Chungnam National University School of Medicine
| | - Jun Ho Shin
- Department of Preventive Medicine, Chonnam National University Medical School
| | - Keonyeop Kim
- Department of Preventive Medicine, Kyungpook National University School of Medicine
| | - Kun Sei Lee
- Department of Preventive Medicine, Konkuk University School of Medicine
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