Predictors and outcomes of same day discharge after minimally invasive hysterectomy in gynecologic oncology within the National Surgical Quality Improvement Program database

OBJECTIVE

To assess trends over time of same day discharge after minimally invasive hysterectomy in oncology, identify perioperative factors influencing same day discharge, and evaluate 30 day postoperative morbidity.

METHODS

A retrospective cohort of elective minimally invasive hysterectomies performed for gynecologic oncologic indications between January 2013 and December 2021 was identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Clinical and surgical characteristics, length of stay, and 30 day postoperative complications were captured. Clinical and surgical factors affecting same day discharge rate and impact of same day discharge on postoperative outcomes were evaluated using χ2 tests and logistic regression.

RESULTS

Patients undergoing minimally invasive hysterectomy (n=32 823) had a same day discharge rate of 34.5% over the 9 year period, increasing from 15.5% in 2013 to 55.1% in 2021. The rate of patients discharged on postoperative day 1 decreased from 76.4% to 41.4% over this period. On multivariable analysis, same day discharge decreased with: age 70-79 years (odds ratio (OR) 0.80) and ≥80 years (OR 0.42); body mass index 40-49.9 kg/m2 (OR 0.89) and ≥50 kg/m2 (OR 0.67); patient comorbidities, including hypertension (OR 0.85), chronic steroid use (OR 0.74), bleeding disorder (OR 0.54), anemia (OR 0.89), and hypoalbuminemia (OR 0.76); and surgical time >90th percentile (OR 0.40) (all p<0.05). Lymphadenectomy did not impact the same day discharge rate (unadjusted OR 1.03, p=0.22). Same day discharge had no effect on 30 day postoperative composite morbidity (OR 0.91, p=0.20), and was associated with fewer readmissions (OR 0.75, p=0.005). Age 70-79 years (OR 1.07, p=0.435) and age ≥80 years (OR 1.11, p=0.504) did not increase postoperative morbidity. However, body mass index categories 40-49.9 kg/m2 (OR 1.28, 95% CI 1.08 to 1.51) and ≥50 kg/m2 (OR 1.60, 95% CI 1.27 to 2.01) were associated with greater 30 day composite morbidity.

CONCLUSION

In this study, same day discharge following minimally invasive hysterectomy for oncologic indications was safe, and rates are rising among all age and body mass index categories. Quality improvement initiatives are needed at oncology centers to promote early discharge after minimally invasive gynecologic oncology surgery.

Navigating Tensions of Efficiency and Caring in Clerkship: A Qualitative Study

Phenomenon: Clerkship is a challenging transition during which medical students must learn to navigate the responsibilities of medical school and clinical medicine. We explored how clerks understand their roles as both medical learners and developing professionals and some of the tensionss that arise therein. Understanding how the clinical learning environment shapes the clerkship role can help educators foster compassionate care. Approach: We conducted 5 focus groups and 1 interview with 3rd-year medical students (n = 14) at University of Toronto between January and June 2016 regarding the perceived role of the clerk, compassionate care, assessment and feedback. Data were analyzed thematically. Findings: In addition to transitioning to a new learning environment, clerkship students assume different roles in response to complex and often competing expectations from preceptors. We identified three main themes: learning to impress preceptors with varying expectations, providing compassionate care-sometimes supported by preceptors, other times being secondary to efficiency-and passing assessments that required a different skill set than simply being a "good clerk." Insights: Clerks perceive their role as providing compassionate care to patients and balance this with fulfilling the (sometimes) competing roles of being a student and developing medical professional. In a system where efficiency is often prioritized, medical students are afforded an opportunity to help satisfy the demand for greater compassion in patient-centered care.

Clinical inertia in the pharmacological management of hypertension: A systematic review and meta-analysis

BACKGROUND

Clinical Inertia is defined as "failure of health care providers to initiate or intensify therapy according to current guidelines". This phenomenon is gaining increasing attention as a major cause of clinicians' failure to adequately manage hypertension, thus leading to an increased incidence of cardiovascular events. We performed a systematic review and meta-analysis of randomized controlled trials to determine whether interventions aimed at reducing clinical inertia in the pharmacological treatment of hypertension improve blood pressure (BP) control.

METHODS

MEDLINE, Embase, and Cochrane Database of Systematic Reviews were searched from the start of their database until October 3, 2017 for the MESH terms "Hypertension" or "Blood Pressure", their subheadings, and the keywords "Therapeutic Inertia" or "Clinical Inertia". Studies were included if they addressed pharmacologic hypertension management, clinical inertia, were randomized controlled trials, reported an outcome describing prescriber behavior, and were available in English. Data for the included studies was extracted by two independent observers. Quality of studies was analyzed using the Cochrane Risk of Bias Assessment. Data was pooled for statistical analysis using both fixed- and random-effects models. The primary study outcome was the percentage of patients achieving blood pressure control as defined by the Joint National Committee guidelines or study authors.

RESULTS

Of 474 citations identified, ten met inclusion criteria comprising a total of 26,871 patients, and eight were selected for meta-analysis. Interventions included Physician Education, Physician Reminders, Patient Education, Patient Reminders, Ambulatory BP Monitoring, Digital Medication Offerings, Physician Peer Visits, and Pharmacist-led Counselling. Pooled event rates revealed more patients with controlled BP in the intervention group versus control (55%, 95% CI 46-63% versus 45%, 95% CI 37-53%) and interventions significantly improved the odds of BP control (OR = 1.19, 95% CI = 1.12-1.27, P < .001). Heterogeneity in the quantitative analysis was moderate.

CONCLUSIONS & RELEVANCE

Addressing clinical inertia through physician reminders, ambulatory BP monitoring, and educational interventions for primary care providers was associated with an improvement in blood pressure control. Our findings encourage further research to investigate strategies at reducing clinical inertia in the management of hypertension.