1
|
Development of a disease-based hospital-level diagnostic intensity index. Diagnosis (Berl) 2024; 0:dx-2023-0184. [PMID: 38643385 DOI: 10.1515/dx-2023-0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/01/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES Low-value care is associated with increased healthcare costs and direct harm to patients. We sought to develop and validate a simple diagnostic intensity index (DII) to quantify hospital-level diagnostic intensity, defined by the prevalence of advanced imaging among patients with selected clinical diagnoses that may not require imaging, and to describe hospital characteristics associated with high diagnostic intensity. METHODS We utilized State Inpatient Database data for inpatient hospitalizations with one or more pre-defined discharge diagnoses at acute care hospitals. We measured receipt of advanced imaging for an associated diagnosis. Candidate metrics were defined by the proportion of inpatients at a hospital with a given diagnosis who underwent associated imaging. Candidate metrics exhibiting temporal stability and internal consistency were included in the final DII. Hospitals were stratified according to the DII, and the relationship between hospital characteristics and DII score was described. Multilevel regression was used to externally validate the index using pre-specified Medicare county-level cost measures, a Dartmouth Atlas measure, and a previously developed hospital-level utilization index. RESULTS This novel DII, comprised of eight metrics, correlated in a dose-dependent fashion with four of these five measures. The strongest relationship was with imaging costs (odds ratio of 3.41 of being in a higher DII tertile when comparing tertiles three and one of imaging costs (95 % CI 2.02-5.75)). CONCLUSIONS A small set of medical conditions and related imaging can be used to draw meaningful inferences more broadly on hospital diagnostic intensity. This could be used to better understand hospital characteristics associated with low-value care.
Collapse
|
2
|
The impact of bowel dysfunction on health-related quality of life after rectal cancer surgery: a systematic review. Tech Coloproctol 2022; 26:515-527. [PMID: 35239096 DOI: 10.1007/s10151-022-02594-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Symptoms of bowel dysfunction after sphincter-preserving rectal cancer surgery have an important impact on health-related quality of life (HRQOL), but that relationship is complex. A better understanding of this relationship allows for better informed shared decision-making about surgery. Our objective was to perform a systematic review to determine which HRQOL domains are most affected by postoperative bowel dysfunction. METHODS A systematic review of the CINAHL, Cochrane Library, Embase, Medline, PsycInfo, PubMed, Web of Science, and Scopus databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included studies that evaluated bowel function after sphincter-preserving rectal cancer surgery and assessed HRQOL using a validated instrument. The quality of HRQOL analysis was assessed using an 11-item checklist. The main outcome was the impact bowel dysfunction had on global and domain specific quality-of-life indices. The impact was evaluated for clinical relevance using the Minimum Clinical Important Difference (MCID) for each specific HRQOL instrument. RESULTS Out of 952 unique citations, 103 studies were full-text reviews. Eighteen studies met the inclusion criteria (4 prospective cohorts and 9 cross-sectional studies). Of the 15 studies with long-term follow-up, the time to assessment after surgery ranged from 1.2 to 14.6 years. The low anterior resection syndrome score and European Organization for Research and Treatment core quality-of-life questionnaire (EORTC QLQ-C30) were the most commonly used instruments. Medium and large magnitudes in MCID were seen for global health, social functioning, emotional functioning, fatigue, diarrhea, and financial difficulties. Among included studies, the most consistently reported functional domains affected by bowel function were social functioning and emotional functioning. CONCLUSIONS Following sphincter-preserving rectal cancer surgery, poor bowel function mainly affects the social and emotional functional domains of HRQOL, which in turn impact global scores. This finding can help inform patients about expected changes in HRQOL after rectal cancer surgery and facilitate individualized treatment decisions.
Collapse
|
3
|
Empowering nurses and residents to improve telemetry stewardship in the academic care setting. J Eval Clin Pract 2021; 27:1154-1158. [PMID: 32949195 DOI: 10.1111/jep.13470] [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: 04/21/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource with limited success. Clinical-effectiveness studies have thus far not included care settings in which resident-physicians are the primary caregivers. METHODS We implemented two interventions on general internal medicine units of an academic hospital. The first intervention, or nurse-discontinuation protocol, allowed nurses to trigger the discontinuation of telemetry once the appropriate duration had passed according to practice standards. The second intervention, or physician-discontinuation protocol, instituted a best-practice advisory that notified the resident-physician via the electronic medical record when the appropriate telemetry duration for each patient had elapsed and suggested termination of telemetry. Data collection spanned 8 months following the implementation of the nurse-discontinuation protocol and 12 months following the physician-discontinuation protocol. RESULTS During the control period, the average time spent on telemetry was 86.29 hours/patient/month. During the nurse-discontinuation protocol, patients spent, on average, 70.86 hours/patient/month on telemetry. During the physician-discontinuation protocol, patients spent, on average, 81.6 hours/patient/month on telemetry. During the nurse-discontinuation protocol, there was no significant change in the likelihood that a patient was placed on telemetry throughout their admission when compared with the control period. During the physician-discontinuation protocol, there was a significant decrease of 56.1% in the likelihood that a patient would be put on telemetry when compared with the control time period. CONCLUSIONS These findings expand our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers. Furthermore, these findings represent an important addition to the telemetry and patient monitoring literature by demonstrating the impact that nurse-managed protocols can have on telemetry use and by highlighting effective strategies to improve telemetry use by physicians in training.
Collapse
|
4
|
Emergency department utilization by children with general surgical conditions during the COVID-19 pandemic. Br J Surg 2021; 108:e105-e106. [PMID: 33793715 PMCID: PMC7929116 DOI: 10.1093/bjs/znaa096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 11/22/2022]
|
5
|
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), an entity in children initially characterized by milder case presentations and better prognoses as compared with adults. Recent reports, however, raise concern for a new hyperinflammatory entity in a subset of pediatric COVID-19 patients. METHODS We report a fatal case of confirmed COVID-19 with hyperinflammatory features concerning for both multi-inflammatory syndrome in children (MIS-C) and primary COVID-19. RESULTS This case highlights the ambiguity in distinguishing between these two entities in a subset of pediatric patients with COVID-19-related disease and the rapid decompensation these patients may experience. CONCLUSIONS Appropriate clinical suspicion is necessary for both acute disease and MIS-C. SARS-CoV-2 serologic tests obtained early in the diagnostic process may help to narrow down the differential but does not distinguish between acute COVID-19 and MIS-C. Better understanding of the hyperinflammatory changes associated with MIS-C and acute COVID-19 in children will help delineate the roles for therapies, particularly if there is a hybrid phenotype occurring in adolescents.
Collapse
|
6
|
Choosing Wisely in the COVID-19 Era: Preventing Harm to Healthcare Workers. J Hosp Med 2020; 15:360-362. [PMID: 32490804 PMCID: PMC7289510 DOI: 10.12788/jhm.3457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/04/2020] [Indexed: 01/16/2023]
|
7
|
Contemporary Rates of Preoperative Cardiac Testing Prior to Inpatient Hip Fracture Surgery. J Hosp Med 2019; 14:224-228. [PMID: 30933673 DOI: 10.12788/jhm.3142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 12/02/2018] [Indexed: 11/20/2022]
Abstract
Hip fracture is a common reason for urgent inpatient surgery. In the past few years, several professional societies have identified preoperative echocardiography and stress testing for noncardiac surgeries as low-value diagnostics. We utilized data on hospitalizations with a primary diagnosis of hip fracture surgery between 2011 and 2015 from the State Inpatient Databases (SID) of Maryland, New Jersey, and Washington, combined with data on hospital characteristics from the American Hospital Association (AHA). We found that the rate of preoperative ischemic testing is surprisingly but encouragingly low (stress tests 1.1% and cardiac catheterizations 0.5%), which is consistent with studies evaluating the outpatient utilization of these tests for low-and intermediate-risk surgeries. The rate of echocardiograms was 12.6%, which was higher than other published reports. Our findings emphasize the importance of ensuring that quality improvement efforts are directed toward areas where quality improvement is, in fact, needed.
Collapse
|
8
|
From preoperative risk assessment and prediction to risk attenuation: a case for prehabilitation. Br J Anaesth 2018; 122:11-13. [PMID: 30579388 DOI: 10.1016/j.bja.2018.10.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 11/17/2022] Open
|
9
|
There's a Lot More to Being a Physician: Insights From an Intensive Clinical Shadowing Experience in Internal Medicine. TEACHING AND LEARNING IN MEDICINE 2018; 30:266-273. [PMID: 29377731 DOI: 10.1080/10401334.2017.1415148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Phenomenon: Although most premedical students shadow physicians prior to starting medical school, there is no set of guidelines or expectations to facilitate effective experiences for students and physicians, nor is there data on the value of shadowing medical trainees as a way to learn about the training environment. We sought to understand premedical student perspectives on an intensive resident shadowing experience. APPROACH This was a qualitative study using anonymous data from focus groups conducted with premedical student participants in a month-long time motion analysis of internal medicine interns at two large academic medical centers. The authors convened, professionally transcribed verbatim, and analyzed data using step-by-step thematic analysis from 3 focus groups in 2012. Focus group questions included goals of participants, shadowing experiences, patient safety experiences, and thoughts on physician training. FINDINGS Twenty of the 22 students who were involved in the time motion study participated in the focus groups (91%). Three major themes were generated from the transcripts: qualities of a good physician, the inefficiencies of the healthcare system and the hospital, and the realities of graduate medical education. Insights: The intensive shadowing experience exposed premedical students to the hospital environment and many of the challenges they will face as future residents. Observing patient care firsthand, students considered the qualities of good intern physicians and appreciated the teamwork and collaboration essential to patient care in an academic medical center. Students witnessed some of the fundamental challenges of graduate medical training, including time pressures, documentation requirements, and the medical hierarchy. They also observed the difficulties of providing quality care in the current healthcare system, including hospital inefficiencies, interprofessional tensions, and financial barriers to care. Intensive shadowing of residents can begin the process of socialization to the culture of medicine by giving premedical students a realistic perspective of both positive and negative aspects of medical training and inpatient care.
Collapse
|
10
|
Provider Perceptions of the Organization's Cultural Competence Climate and Their Skills and Behaviors Targeting Patient-Centered Care for Socially At-Risk Populations. J Health Care Poor Underserved 2018; 29:481-496. [PMID: 29503313 DOI: 10.1353/hpu.2018.0032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
As part of a cultural competence needs assessment study at a large academic health care system, we conducted a survey among 1,220 practicing physicians to assess their perceptions of the organization's cultural competence climate and their skills and behaviors targeting patient-centered care for culturally and socially diverse patients. Less than half of providers reported engaging in behaviors to address cultural and social barriers more than 75% of the time. In multivariable logistic regression models, providers who reported moderate or major structural problems were more likely to report low skillfulness in identifying patient mistrust (aOR: 2.01; 95% CI: 1.23-3.28, p<0.01), how well patients read and write English (aOR: 1.63; 95% CI: 1.03-2.57, p=0.03), and socioeconomic barriers (aOR: 2.14; 95% CI: 1.14-4.01, p=0.01), than providers who reported only small or no structural problems. Improved structural support for socially and culturally complex medical encounters is needed to enhance care for socially at-risk patients.
Collapse
|
11
|
A Department of Medicine Infrastructure for Patient Safety and Clinical Quality Improvement. Am J Med Qual 2017; 33:413-419. [PMID: 29183149 DOI: 10.1177/1062860617743324] [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] [Indexed: 11/17/2022]
Abstract
Payers, providers, and patients increasingly recognize the importance of quality and safety in health care. Academic Departments of Medicine can advance quality and safety given the large populations they serve and the broad spectrum of diseases they treat. However, there are only few detailed examples of how quality and safety can be organized. This article describes a practical model at The Johns Hopkins Hospital Department of Medicine and details its structure and operation within a large academic health system. It is based on a fractal model that integrates multiple smaller units similar in structure (composition of faculty/staff), process (use of similar tools), and approach (using a common framework to address issues). This organization stresses local, multidisciplinary leadership, facilitates horizontal connections for peer learning, and maintains vertical connections for broader accountability.
Collapse
|
12
|
|
13
|
Physicians' Perceptions of Radiation Dose Quantity Depend on the Language in Which It Is Expressed. J Am Coll Radiol 2016; 13:909-13. [PMID: 27292371 DOI: 10.1016/j.jacr.2016.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE Radiation dose information is increasingly requested by nonradiology providers, but there are no standard methods for communicating dose. The aim of this study was to compare physicians' perceptions of the amount of radiation associated with similar dose quantities expressed using different dose terms to evaluate the impact of word choice on physicians' understanding of radiation dose. METHODS Internal medicine and pediatric residents were surveyed online for 42 days. After obtaining demographics and training levels, respondents were asked to rank five different radiation dose quantities, each corresponding to one of the five ACR relative radiation levels (RRLs) expressed using different dose terms. Respondents ranked the choices from least to greatest (ie, from 1 to 5) or indicated if all five were equal. For the final question, the same dose quantity was expressed five different ways. RESULTS Fifty-one medicine and 45 pediatric residents responded (a 44% response rate). Mean differences in rankings were as follows: for chest x-rays, 0.109 (95% confidence interval [CI], -0.018 to 0.236); for cross-country flights, 0.462 (95% CI, 0.338 to 0.585); for natural background radiation, -0.672 (95% CI, -0.793 to -0.551); for cancer risk, -0.294 (95% CI, -0.409 to -0.178); and for ACR RRL, 0.239 (95% CI, 0.148 to 0.329). Statistically significant differences were found in the distributions of rankings (P < .001) and percentage of correct rankings across each radiation dose term (P < .001), with the ACR RRL having the highest percentage of correct rankings (61.2%). CONCLUSIONS Adult and pediatric physicians consistently over- or underestimated radiation dose quantities using different terms to express radiation dose. These results suggest that radiation dose information should be communicated using standard terminology such as the ACR RRL scale to foster consistency and improve the accuracy of physicians' radiation risk perceptions.
Collapse
|
14
|
Avoiding contrast-enhanced computed tomography scans in patients with shellfish allergies. J Hosp Med 2016; 11:435-7. [PMID: 27253586 DOI: 10.1002/jhm.2509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/05/2015] [Accepted: 10/07/2015] [Indexed: 11/10/2022]
|
15
|
Carotid artery ultrasound for syncope. J Hosp Med 2016; 11:117-9. [PMID: 26818390 DOI: 10.1002/jhm.2428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/01/2015] [Accepted: 06/27/2015] [Indexed: 11/08/2022]
|
16
|
Serum and red blood cell folate testing on hospitalized patients. J Hosp Med 2015; 10:753-5. [PMID: 26463111 DOI: 10.1002/jhm.2385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/29/2015] [Accepted: 03/03/2015] [Indexed: 11/10/2022]
|
17
|
|
18
|
The outcomes of the elderly in acute care general surgery. Eur J Trauma Emerg Surg 2015; 42:107-13. [PMID: 26038035 DOI: 10.1007/s00068-015-0517-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/11/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Elderly patients form a growing subset of the acute care surgery (ACS) population. Older age may be associated with poorer outcomes for some elective procedures, but there are few studies focusing on outcomes for the elderly ACS population. Our objective is to characterize differences in mortality and morbidity for acute care surgery patients >80 years old. METHODS A retrospective review of all ACS admissions at a large teaching hospital over 1 year was conducted. Patients were classified into non-elderly (<80 years old) and elderly (≥80 years old). In addition to demographic differences, outcomes including care efficiency, mortality, postoperative complications, and length of stay were studied. Data analysis was completed with the Student's t test for continuous variables and Fisher's exact test for categorical variables using STATA 12 (College Station, TX, USA). RESULTS We identified 467 non-elderly and 60 elderly patients with a mean age-adjusted Charlson score of 3.2 and 7.2, respectively (p < 0.001) and a mortality risk of 1.9 and 11.7 %, respectively (p < 0.001). The elderly were at risk of longer duration (>4 days) hospital stay (p = 0.05), increased postoperative complications (p = 0.002), admission to the ICU (p = 0.002), and were more likely to receive a non-operative procedure (p = 0.003). No difference was found (p = NS) for patient flow factors such as time to consult general surgery, time to see consult by general surgery, and time to operative management and disposition. CONCLUSIONS Compared to younger patients admitted to an acute care surgery service, patients over 80 years old have a higher risk of complications, are more likely to require ICU admission, and stay longer in the hospital.
Collapse
|
19
|
Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery. Br J Surg 2015; 102:577-89. [DOI: 10.1002/bjs.9747] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/16/2014] [Accepted: 11/13/2014] [Indexed: 02/04/2023]
Abstract
Abstract
Background
Intraoperative goal-directed therapy (GDT) was introduced to titrate intravenous fluids, with or without inotropic drugs, based on objective measures of hypovolaemia and cardiac output measurements to improve organ perfusion. This meta-analysis aimed to determine the effect of GDT on the recovery of bowel function after abdominal surgery.
Methods
MEDLINE, Embase, the Cochrane Library and PubMed databases were searched for randomized clinical trials and cohort studies, from January 1989 to June 2013, that compared patients who did, or did not, receive intraoperative GDT, and reported outcomes on the recovery of bowel function. Time to first flatus and first bowel motion, time to tolerate oral diet, postoperative nausea and vomiting, and primary postoperative ileus were included.
Results
Thirteen trials with 1399 patients were included in the analysis. GDT shortened the time to the first bowel motion (weighted mean difference (WMD −0·67, 95 per cent c.i. −1·23 to −0·11; P = 0·020) and time to tolerate oral intake (WMD −0·95, −1·81 to −0·10; P = 0·030), and reduced postoperative nausea and vomiting (risk difference −0·15, −0·26 to −0·03; P = 0·010). When only high-quality studies were included, GDT reduced only the time to tolerate oral intake (WMD −1·18, −2·03 to −0·33; P = 0·006). GDT was more effective outside enhanced recovery programmes and in patients undergoing colorectal surgery.
Conclusion
GDT facilitated the recovery of bowel function, particularly in patients not treated within enhanced recovery programmes and in those undergoing colorectal operations.
Collapse
|
20
|
Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 2014; 101:159-70. [PMID: 24469616 DOI: 10.1002/bjs.9324] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies. METHODS A systematic search of MEDLINE, Embase and Cochrane databases was conducted. Prospective studies evaluating ERPs compared with traditional care in abdominal surgery published between 2000 and 2013 were included. All reported outcomes were classified into categories: biological and physiological variables, symptom status, functional status, general health perceptions and quality of life (QoL). The phase of recovery measured was defined as baseline, intermediate (in hospital) and late (following discharge). RESULTS A total of 38 studies were included based on the systematic review criteria. Biological or physiological variables other than postoperative complications were reported in 30 studies, and included return of gastrointestinal function (25 studies), pulmonary function (5) and physical strength (3). Patient-reported symptoms, including pain (16 studies) and fatigue (9), were reported less commonly. Reporting of functional status outcomes, including mobilization (16 studies) and ability to perform activities of daily living (4), was similarly uncommon. Health aspects of QoL were reported in only seven studies. Length of follow-up was generally short, with 24 studies reporting outcomes within 30 days or less. All studies documented in-hospital outcomes (intermediate phase), but only 17 reported postdischarge outcomes (late phase) other than complications or readmission. CONCLUSION Patient-reported outcomes, particularly postdischarge functional status, were not commonly reported. Future studies of the effectiveness of ERPs should include validated, patient-reported outcomes to estimate better their impact on recovery, particularly after discharge from hospital.
Collapse
|
21
|
Abstract
Abstract
Background
With advances in operative technique and perioperative care, traditional endpoints such as morbidity and mortality provide an incomplete description of surgical outcomes. There is increasing emphasis on the need for patient-reported outcomes (PROs) to evaluate fully the effectiveness and quality of surgical interventions. The objective of this study was to identify the outcomes reported in clinical studies published in high-impact surgical journals and the frequency with which PROs are used.
Methods
Electronic versions of material published between 2008 and 2012 in the four highest-impact non-subspecialty surgical journals (Annals of Surgery, British Journal of Surgery (BJS), Journal of the American College of Surgeons (JACS), Journal of the American Medical Association (JAMA) Surgery) were hand-searched. Clinical studies of adult patients undergoing planned abdominal, thoracic or vascular surgery were included. Reported outcomes were classified into five categories using Wilson and Cleary's conceptual model.
Results
A total of 893 articles were assessed, of which 770 were included in the analysis. Some 91·6 per cent of studies reported biological and physiological outcomes, 36·0 per cent symptoms, 13·4 per cent direct indicators of functional status, 10·6 per cent general health perception and 14·8 per cent overall quality of life (QoL). The proportion of studies with at least one PRO was 38·7 per cent overall and 73·4 per cent in BJS (P < 0·001). The proportion of studies using a formal measure of health-related QoL ranged from 8·9 per cent (JAMA Surgery) to 33·8 per cent (BJS).
Conclusion
The predominant reporting of clinical endpoints and the inconsistent use of PROs underscore the need for further research and education to enhance the applicability of these measures in specific surgical settings.
Collapse
|
22
|
Economic impact of an enhanced recovery pathway for oesophagectomy. Br J Surg 2013; 100:1326-34. [PMID: 23939844 DOI: 10.1002/bjs.9224] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Data are lacking to support the cost-effectiveness of enhanced recovery pathways (ERP) for oesophagectomy. The aim of this study was to investigate the impact of an ERP on medical costs for oesophagectomy. METHODS This study investigated all patients undergoing elective oesophagectomy between June 2009 and December 2011 at a single high-volume university hospital. From June 2010, all patients were enrolled in an ERP. Clinical outcomes were recorded for up to 30 days. Deviation-based cost modelling was used to compare costs between the traditional care and ERP groups. RESULTS A total of 106 patients were included (47 traditional care, 59 ERP). There were no differences in patient, pathological and operative characteristics between the groups. Median length of hospital stay (LOS) was lower in the ERP group (8 (interquartile range 7-18) days versus 10 (9-18) days with traditional care; P = 0·019). There was no difference in 30-day complication rates (59 per cent with ERP versus 62 per cent with traditional care; P = 0·803), and the 30-day or in-hospital mortality rate was low (3·8 per cent, 4 of 106). Costs in the on-course and minor-deviation groups were significantly lower after implementation of the ERP. The pathway-dependent cost saving per patient was €1055 and the overall cost saving per patient was €2013. One-way sensitivity analysis demonstrated that the ERP was cost-neutral or more costly only at extreme values of ward, operating and intensive care costs. CONCLUSION A multidisciplinary ERP for oesophagectomy was associated with cost savings, with no increase in morbidity or mortality.
Collapse
|
23
|
Abstract
IMPORTANCE Inpatient care providers often order laboratory tests without any appreciation for the costs of the tests. OBJECTIVE To determine whether we could decrease the number of laboratory tests ordered by presenting providers with test fees at the time of order entry in a tertiary care hospital, without adding extra steps to the ordering process. DESIGN Controlled clinical trial. SETTING Tertiary care hospital. PARTICIPANTS All providers, including physicians and nonphysicians, who ordered laboratory tests through the computerized provider order entry system at The Johns Hopkins Hospital. INTERVENTION We randomly assigned 61 diagnostic laboratory tests to an "active" arm (fee displayed) or to a control arm (fee not displayed). During a 6-month baseline period (November 10, 2008, through May 9, 2009), we did not display any fee data. During a 6-month intervention period 1 year later (November 10, 2009, through May 9, 2010), we displayed fees, based on the Medicare allowable fee, for active tests only. MAIN OUTCOME MEASURES We examined changes in the total number of orders placed, the frequency of ordered tests (per patient-day), and total charges associated with the orders according to the time period (baseline vs intervention period) and by study group (active test vs control). RESULTS For the active arm tests, rates of test ordering were reduced from 3.72 tests per patient-day in the baseline period to 3.40 tests per patient-day in the intervention period (8.59% decrease; 95% CI, -8.99% to -8.19%). For control arm tests, ordering increased from 1.15 to 1.22 tests per patient-day from the baseline period to the intervention period (5.64% increase; 95% CI, 4.90% to 6.39%) (P < .001 for difference over time between active and control tests). CONCLUSIONS AND RELEVANCE Presenting fee data to providers at the time of order entry resulted in a modest decrease in test ordering. Adoption of this intervention may reduce the number of inappropriately ordered diagnostic tests.
Collapse
|
24
|
Potential role of coronary computed tomography-angiography for guiding perioperative cardiac management for non-cardiac surgery. Heart Int 2013; 8:e1. [PMID: 24179635 PMCID: PMC3805165 DOI: 10.4081/hi.2013.e1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 11/28/2012] [Indexed: 11/22/2022] Open
Abstract
Perioperative cardiac events can be a major consequence of surgery. The American College of Cardiology Foundation/American Heart Association has set out guidelines to aid physicians in identifying patients at the highest risk for these events. The guidelines do recommend for some patients to undergo non-invasive cardiac stress testing for further risk stratification, but their sensitivity and specificity for predicting cardiac events is not optimal. With more data emerging of the superior performance of computed coronary tomography angiography (CCTA) compared to non-invasive stress testing, CCTA could be more useful in risk stratification for these patients.
Collapse
|
25
|
Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med 2012; 7:396-401. [PMID: 22371379 DOI: 10.1002/jhm.1921] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 12/24/2011] [Accepted: 01/08/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND Medication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs. METHODS Nurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview. If a patient was not able to provide a written HML or recall medications, the nurses reviewed the electronic record along with other sources. The nurses then compared the HML to the patient's active inpatient medications and judged whether the discrepancies were intentional or potentially unintentional. This was repeated at discharge as well. If the prescriber changed the order when contacted about a potential unintentional discrepancy, it was categorized as unintentional and rated on a 1-3 potential harm scale. RESULTS The study included 563 patients. HML information gathering averaged 29 minutes. Two hundred twenty-five patients (40%; 95% confidence interval [CI], 36%-44%) had at least 1 unintended discrepancy on admission or discharge. One hundred sixty-two of the 225 patients had an unintended discrepancy ranked 2 or 3 on the harm scale. It cost $113.64 to find 1 potentially harmful discrepancy. Based on the 2008 cost of an ADE, preventing 1 discrepancy in every 290 patient encounters would offset the intervention costs. We potentially averted 81 ADEs for every 290 patients. CONCLUSION Potentially harmful medication discrepancies occurred frequently at both admission and discharge. A nurse-pharmacist collaboration allowed many discrepancies to be reconciled before causing harm. The collaboration was efficient and cost-effective, and the process potentially improves patient safety.
Collapse
|
26
|
Canadian Surgery Forum. Can J Surg 2010; 53:S51-S104. [PMID: 35488396 PMCID: PMC2912011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
|
27
|
Exotic origin, familiar culprit. Am J Med 2010; 123:220-2. [PMID: 20193827 DOI: 10.1016/j.amjmed.2009.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 11/20/2009] [Accepted: 11/20/2009] [Indexed: 11/29/2022]
|
28
|
Abstracts of presentations to the Annual Meetings of the Canadian Association of General Surgeons Canadian Association of Thoracic Surgeons Canadian Hepato-Pancreato-Biliary Society Canadian Society of Surgical Oncology Canadian Society of Colon and Rectal Surgeons: Victoria, BC Sept. 10-13, 2009. Can J Surg 2009; 52:S1-S48. [PMID: 35488397 PMCID: PMC2726442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
|
29
|
Abstract
An 89-year-old woman was admitted to Johns Hopkins Hospital with a small bowel obstruction and symptoms of urinary retention. She had been started on solifenacin for bladder overactivity 10 days prior to her presentation. Withdrawal of the solifenacin resulted in a full recovery, which has persisted for greater than 6 months without surgical intervention. This is the first reported case report of small bowel pseudo-obstruction due to solifenacin.
Collapse
|
30
|
Abstract
CONTEXT Accreditation requirements mandate teaching quality improvement (QI) concepts to medical trainees, yet little is known about the effectiveness of teaching QI. OBJECTIVES To perform a systematic review of the effectiveness of published QI curricula for clinicians and to determine whether teaching methods influence the effectiveness of such curricula. DATA SOURCES The electronic literature databases of MEDLINE, EMBASE, CINAHL, and ERIC were searched for English-language articles published between January 1, 1980, and April 30, 2007. Experts in the field of QI were queried about relevant studies. STUDY SELECTION Two independent reviewers selected studies for inclusion if the curriculum taught QI principles to clinicians and the evaluation used a comparative study design. DATA EXTRACTION Information about the features of each curriculum, its use of 9 principles of adult learning, and the type of educational and clinical outcomes were extracted. The relationship between the outcomes and the number of educational principles used was assessed. RESULTS Of 39 studies that met eligibility criteria, 31 described team-based projects; 37 combined didactic instruction with experiential learning. The median number of adult learning principles used was 7 (range, 2-8). Evaluations included 22 controlled trials (8 randomized and 14 nonrandomized) and 17 pre/post or time series studies. Fourteen studies described educational outcomes (attitudes, knowledge, or skills or behaviors) and 28 studies described clinical process or patient outcomes. Nine of the 10 studies that evaluated knowledge reported only positive effects but only 2 of these described a validated assessment tool. The 6 assessments of attitudes found mixed results. Four of the 6 studies on skill or behavior outcomes reported only positive effects. Eight of the 28 studies of clinical outcomes reported only beneficial effects. Controlled studies were more likely than other studies to report mixed or null effects. Only 4 studies evaluated both educational and clinical outcomes, providing limited evidence that educational outcomes influence the clinical effectiveness of the interventions. CONCLUSIONS Most published QI curricula apply sound adult learning principles and demonstrate improvement in learners' knowledge or confidence to perform QI. Additional studies are needed to determine whether educational methods have meaningful clinical benefits.
Collapse
|
31
|
Experienced surgeons can do more than one thing at a time: effect of distraction on performance of a simple laparoscopic and cognitive task by experienced and novice surgeons. Surg Endosc 2007; 22:196-201. [PMID: 17705087 DOI: 10.1007/s00464-007-9452-0] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND While operating, surgeons are required to make cognitive decisions and often are interrupted to attend to questions from other members of the health care team. Technical automatization may be achieved by experienced surgeons such that these distractions have little effect on performance of either the surgical or the cognitive task. This study assessed the effect of adding a distracting cognitive task on performance of a basic laparoscopic skill by novice and experienced surgeons. METHODS In this study, 31 novice (medical students in postgraduate years [PGYs] 1-2) and 9 experienced (fellows/attendants and PGYs 4-5) laparoscopic surgeons practiced the Fundamentals of Laparoscopic Surgery (FLS) laparoscopic peg transfer task until their scores stabilized. The mean normalized score after five repetitions then was recorded. The subjects also were tested on the number of mathematical addition questions they could answer in 1 min. This was repeated five times, with the mean number of questions attempted and the accuracy (% correct) recorded. The laparoscopic and addition tasks then were performed concurrently five times. Data, presented as mean +/- standard deviation, were analyzed using Student's t-test. A p value less than 0.05 was considered statistically significant. RESULTS After practice to stable peg transfer performance, the baseline peg transfer score was higher in the experienced group (98 +/- 6 vs 87 +/- 12; p < 0.01). There were no baseline differences between the groups in the number of math questions attempted in 1 min (10 +/- 2 vs 9 +/- 2; p = 0.55) or the number of correct answers (9 +/- 3 vs 8 +/- 3; p = 0.36). The comparison of baseline performance and dual-task performance showed that the experienced surgeons had no decline in peg transfer score (98 +/- 6 vs 97 +/- 6; p = 0.48), number of questions attempted in 1 min (10 +/- 2 vs 9 +/- 3; p = 0.32), or number of correct answers (9 +/- 3 vs 8 +/- 3; p = 0.46). In contrast, dual-tasking among the novices was associated with a decrease in the number of questions attempted (9 +/- 2 vs 8 +/- 2; p < 0.01) and the number of correct answers (8 +/- 3 vs 7 +/- 2; p = 0.02), and with no change in the peg transfer score (87 +/- 12 vs 88 +/- 8; p = 0.38) compared with baseline. CONCLUSIONS Distraction significantly decreased a novice's ability to process cognitively based math problems, whereas there was no effect on experienced subjects. This occurred despite the fact that the novice group had practiced to high-level peg transfer scores at baseline. This suggests that the experienced surgeons had achieved automatization of the peg transfer basic surgical skill to a level that cognitive distraction did not affect performance of either task. The experienced surgeons were able to attend equally to both tasks, whereas the novices attended to the surgical task at the expense of some aspects of cognitive task performance.
Collapse
|
32
|
Abstracts of presentations to the Annual Meetings of the Canadian Society of Colon and Rectal Surgeons Canadian Association of General Surgeons Canadian Association of Thoracic Surgeons: Canadian Surgery Forum, Toronto, Ont., September 6-9, 2007. Can J Surg 2007; 50:1-32. [PMID: 37353894 PMCID: PMC10390043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023] Open
|
33
|
Abstract
INTRODUCTION Simulators are being used more and more for teaching and testing laparoscopic skills. However, it has yet to be firmly established that simulator performance reflects operative laparoscopic skill. The study reported here was designed to test the hypothesis that laparoscopic simulator performance predicts intraoperative laparoscopic skill. METHODS A review of our prospectively maintained database identified 40 subjects who underwent Fundamentals of Lapraoscopic Surgery (FLS) skills testing and objective intraoperative assessments within the same 6-month period. Subjects consisted of 22 novice (postgraduate year [PGY] 1-2), 10 intermediate (PGY 3-4), and 8 experienced (PGY 5, fellows, and attendings) laparoscopic surgeons. Laparoscopic performance was objectively assessed in the operating room using the previously validated Global Operative Assessment of Laparoscopic Skill (GOALS). Analysis of variance (ANOVA) was used to compare mean FLS scores and mean GOALS scores across experience levels. The relationship between individual FLS scores and GOALS scores was assessed with linear regression analysis. A multivariate analysis evaluated FLS score and surgeon experience as predictors of intraoperative GOALS score. A receiver-operator curve (ROC) was constructed in order to define an FLS cutoff score that predicts intraoperative performance at or above the level of experienced surgeons. Significance was defined as p < 0.05. RESULTS Mean FLS scores and mean GOALS scores increased with increasing experience. Individual FLS scores correlated significantly with intraoperative GOALS scores (0.77, p < 0.001). Multivariate analysis confirmed that FLS score is an independent predictor of intraoperative GOALS scores. The ROC identified an FLS cutoff score of 70 with optimal sensitivity (91%) and specificity (86%) for predicting a GOALS score at or above the level of experienced surgeons. CONCLUSIONS In this study sample, FLS simulator scores were independently predictive of intraoperative laparoscopic performance as measured by GOALS. More precisely, an FLS cutoff score of 70 optimized sensitivity and specificity for expert intraoperative performance. A larger prospective study is justified to validate these findings.
Collapse
|
34
|
Validation of esophageal Doppler for noninvasive hemodynamic monitoring under pneumoperitoneum. Surg Endosc 2007; 21:1349-53. [PMID: 17235722 DOI: 10.1007/s00464-006-9106-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Accepted: 10/16/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Commonly used perioperative measurements of hemodynamics, such as Swan-Ganz catheter assessment, are invasive and may not be reliable under pneumoperitoneum. The purpose of this study was to validate the use of esophageal Doppler for noninvasive hemodynamic monitoring under pneumoperitoneum in an experimental pig model. METHODS Eight female pigs were submitted to two 30-min study periods, one each for the baseline (no interventions) and pneumoperitoneum (12-mmHg carbon dioxide pneumoperitoneum) conditions. One pig was excluded because of tachycardia (>140 at baseline). A Swan-Ganz pulmonary artery catheter was used to measure cardiac output (CO-SG) and pulmonary capillary wedge pressure (PCWP). An esophageal Doppler probe was inserted to record cardiac output (CO-ED) and corrected flow time (FTc), an index of preload. Transthoracic echocardiography was used to measure left ventricular end-diastolic diameter (LVEDD) and cardiac output (CO-TTE). Pearson correlation was used to assess individual associations between the measured hemodynamic parameters. RESULTS There was good correlation between CO-ED and CO-SG (r = 0.577; p < 0.001) and excellent correlation between CO-ED and CO-TTE (r = 0.815; p < 0.001). There was no correlation between FTc and LVEDD or PCWP. These relationships were consistent when analyzed separately at baseline and during pneumoperitoneum. CONCLUSION Esophageal Doppler monitoring is a valid noninvasive method of estimating cardiac output at baseline and during pneumoperitoneum in a porcine model. Corrected flow time did not correlate with other estimates of preload at baseline or during pneumoperitoneum.
Collapse
|
35
|
|
36
|
The MISTELS program to measure technical skill in laparoscopic surgery : evidence for reliability. Surg Endosc 2006; 20:744-7. [PMID: 16508817 DOI: 10.1007/s00464-005-3008-y] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Accepted: 07/17/2005] [Indexed: 11/24/2022]
Abstract
BACKGROUND The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) is a series of five tasks with an objective scoring system. The purpose of this study was to estimate the interrater and test-retest reliability of the MISTELS metrics and to assess their internal consistency. METHODS To determine interrater reliability, two trained observers scored 10 subjects, either live or on tape. Test-retest reliability was assessed by having 12 subjects perform two tests, the second immediately following the first. Interrater and test-retest reliability were assessed using intraclass correlation coefficients. Internal consistency between tasks was estimated using Cronbach's alpha. RESULTS The interrater and test-retest reliabilities for the total scores were both excellent at 0.998 [95% confidence interval (CI), 0.985-1.00] and 0.892 (95% CI, 0.665-0.968), respectively. Cronbach's alpha for the first assessment of the test-retest was 0.86. CONCLUSIONS The MISTELS metrics have excellent reliability, which exceeds the threshold level of 0.8 required for high-stakes evaluations. These findings support the use of MISTELS for evaluation in many different settings, including residency training programs.
Collapse
|
37
|
Does aggressive hydration reverse the effects of pneumoperitoneum on renal perfusion? Surg Endosc 2005; 20:274-80. [PMID: 16362475 DOI: 10.1007/s00464-005-0244-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 09/18/2005] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although pneumoperitoneum (PP) decreases renal blood flow, it remains unclear whether this impacts renal function. Our aim was to characterize the effects of PP on renal perfusion and function using two fluid strategies for intravenous fluid administration. METHODS Twelve 30-kg pigs were randomized into two groups: maintenance (3 cc/kg/h of normal saline (NS)) and bolus (15 cc/kg/h + 20 cc/kg NaCl bolus prior to induction of PP). Pigs were studied in a blinded fashion for 30 min prior, 60 min during, and 30 min after release of 15 mmHg CO(2) PP. Cardiac output (CO) and stroke volume (SV) were measured using an esophageal Doppler probe, renal cortical perfusion (RCP) was measured with a laser Doppler probe on the right kidney, and renal function was measured using the fractional excretion of sodium (FeNa) and urine output. Statistical analysis was performed with area-under-the-curve (AUC) analysis and analysis of variance RESULTS AUC analysis revealed moderate effect size for CO (0.416) and small effect size for SV (0.366) and RCP (0.363), with decreases seen in the control group but not the bolus group. During PP, urine output increased in the bolus group (p = 0.04) but not in the control group; there was no difference in FeNa in either group. CONCLUSION Aggressive fluid hydration during CO(2) PP of 15 mmHg preserves CO, SV, and RCP while increasing urine output. No effect on renal function as measured by FeNa was observed in either group.
Collapse
|
38
|
Relationship between subjective and objective outcome measures after Heller myotomy and Dor fundoplication for achalasia. Surg Endosc 2005; 20:214-9. [PMID: 16333549 DOI: 10.1007/s00464-005-0213-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2005] [Accepted: 09/07/2005] [Indexed: 01/17/2023]
Abstract
BACKGROUND The purpose of this study is to assess how subjective evaluation (heartburn, dysphagia, quality of life, and satisfaction) correlates with objective data after Heller myotomy and Dor fundoplication for achalasia. METHODS A total of 53 consecutive patients with achalasia undergoing laparoscopic Heller myotomy and Dor fundoplication were studied prospectively. Subjective evaluation was done preop and postop using the Gastroesophageal Reflux Disease Health-Related Quality of Life instrument (GERD-HRQL; 0 = best, 45 = worse), 4-point dysphagia and heartburn scales (0 = best, 3 = worst), patient satisfaction scale (0 = very satisfied, 5 = incapacitated), and the SF-12 general health-related quality-of-life score. At 3 months postop, patients were asked to undergo objective evaluation with 24-h pH testing, manometry, and endoscopy. Data are expressed as median (interquartile range) and analyzed by Wilcoxon signed rank test or Mann-Whitney U test. RESULTS Forty-nine patients were more than 3 months postsurgery. Comparing preop to postop, improvements were found in dysphagia [3 (2-3) to 0 (0-1)], heartburn [1 (0-2) to 0 (0-1)], GERD-HRQL [13.5 (6.3-22.5) to 2 (0-5)], satisfaction [3 (3-4) to 1 (0-1)], and SF-12 mental component summary [46 (37-56) to 58 (50-59)] and physical component summary [46 (36-53) to 55 (48-56)] scores (p < 0.0001 for all). Thirty-eight patients (78%) agreed to undergo objective testing, and complete data were available for 32 (65%). Four of 32 patients (12.5%) had evidence of reflux based on 24-h pH testing. Of nine patients with GERD-HRQL >5, only two had positive pH test (22%). Of 23 patients with GERD-HRQL <5, two had positive pH test (7%). Of four tested patients with moderate to severe heartburn, two had an abnormal pH test. There was no significant relationship between GERD-HRQL score and pH test results. Lower esophageal sphincter pressure (LESP) decreased from 24 (16-35) to 13 mmHg (11-17) (p < 0.001). There was no relationship between dysphagia score and postop absolute LESP or a decrease in LESP after operation. CONCLUSIONS Laparoscopic Heller myotomy and Dor fundoplication is an effective treatment for achalasia. Subjective evaluation can document patient satisfaction and health-related quality of life but does not accurately reflect postop reflux. Twenty-four-hour pH study is required to accurately assess reflux disease.
Collapse
|
39
|
Characterizing the learning curve for a basic laparoscopic drill. Surg Endosc 2005; 19:1572-8. [PMID: 16235127 DOI: 10.1007/s00464-005-0150-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Accepted: 08/16/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND The psychomotor challenges inherent in laparoscopic surgery are evident by the steep procedural "learning curves" documented throughout the literature. Few methods have been described to evaluate learning curves. The cumulative summation (CUSUM) method is a criterion-based evaluation of the learning process. The purpose of this study is to describe the CUSUM learning curves for a simple task for individuals and for a group of novice laparoscopists. METHODS Sixteen medical students undertook four weekly sessions of 10 laparoscopic pegboard transfers in the MISTELS system. Their performance was scored and recorded for each trial. CUSUM learning curves were constructed based on the goal of achieving mean scores for senior, intermediate, or junior laparoscopists >or=95% of the time. RESULTS Based on senior criteria, one student achieved the goal by the 40th peg transfer trial. Based on intermediate criteria, three students achieved the goal by their 40th trial (trials 21 and 36), and for junior criteria, 10 students achieved the acceptable success rate by their 40th trial (range, 26-40). CONCLUSION CUSUM analysis suggests criterion-based practice is useful for novice laparoscopists. It allows educators to track the progress of an individual toward target criteria for each MISTELS task, to more logically allocate time for training and set attainable goals, to objectively evaluate trainee acquisition of basic laparoscopic skills, and to identify trainees who need remediation.
Collapse
|
40
|
Assessing the learning curve for the acquisition of laparoscopic skills on a virtual reality simulator. Surg Endosc 2005; 19:678-82. [PMID: 15776208 DOI: 10.1007/s00464-004-8943-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Accepted: 11/16/2004] [Indexed: 01/22/2023]
Abstract
BACKGROUND The aim of this study was to develop summary metrics and assess the construct validity for a virtual reality laparoscopic simulator (LapSim) by comparing the learning curves of three groups with different levels of laparoscopic expertise. METHODS Three groups of subjects ('expert', 'junior', and 'naïve') underwent repeated trials on three LapSim tasks. Formulas were developed to calculate scores for efficiency ('time-error') and economy of 'motion' ('motion') using metrics generated by the software after each drill. Data (mean +/- SD) were evaluated by analysis of variance (ANOVA). Significance was set at p < 0.05. RESULTS All three groups improved significantly from baseline to final for both 'time-error' and 'motion' scores. There were significant differences between groups in time error performances at baseline and final, due to higher scores in the 'expert' group. A significant difference in 'motion' scores was seen only at baseline. CONCLUSION We have developed summary metrics for the LapSim that differentiate among levels of laparoscopic experience. This study also provides evidence of construct validity for the LapSim.
Collapse
|
41
|
Between a rock and a sad place. J Palliat Med 2005; 3:325-30. [PMID: 15859674 DOI: 10.1089/jpm.2000.3.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
42
|
Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach? Surg Endosc 2004; 19:4-8. [PMID: 15531968 DOI: 10.1007/s00464-004-8903-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2004] [Accepted: 07/27/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The most appropriate approach to the repair of large paraesophageal hernias remains controversial. Despite early results of excellent outcomes after laparoscopic repair, recent reports of high recurrence require that this approach be reevaluated. METHODS For this study, 60 primary paraesophageal hernias consecutively repaired at one institution from 1990 to 2002 were reviewed. These 25 open transabdominal and 35 laparoscopic repairs were compared for operative, short-, and long-term outcomes on the basis of quality-of -life questionnaires and radiographs. RESULTS No difference in patient characteristics was detected. Laparoscopic repair resulted in lower blood loss, fewer intraoperative complications, and a shorter length of hospital stay. No difference in general or disease-specific quality-of-life was documented. Radiographic follow-up was available for 78% open and 91% laparoscopic repairs, showing anatomic recurrence rates of 44% and 23%, respectively (p = 0.11). CONCLUSIONS Laparoscopic repair should remain in the forefront for the management of paraesophageal hernias. However, there is considerable room for improvement in reducing the incidence of recurrence.
Collapse
|
43
|
Intraoperative fluid management in laparoscopic live-donor nephrectomy: Challenging the dogma. Surg Endosc 2004; 18:1625-30. [PMID: 15931475 DOI: 10.1007/s00464-004-8811-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2004] [Accepted: 06/10/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients undergoing laparoscopic live donor nephrectomy (LLDN) commonly receive large amounts of fluid intraoperatively to counter the negative effects of pneumoperitoneum on renal function. Our aim is to demonstrate that a low-volume fluid management strategy does not adversely affect donor or recipient outcomes. METHODS Fifty-two patients underwent LLDN between December 2000 and January 2004. Data were collected in prospective databases, and augmented with retrospective medical record review. Donors were divided into two groups: the fluid-load group (n = 24) received > 10 ml/kg/h of intravenous crystalloids intraoperatively, while the fluid-restriction group (n = 28) received < 10 m/kg/h. RESULTS Donors in the fluid-restriction group had a lower intraoperative urine output. There were no differences in postoperative creatinine levels (117.5 micromol/L vs 121.5 micromol/L, p = 0.8) or complications (4.2% vs 7.1%, p = 0.9). In the recipients, there were no differences in postoperative creatinine levels up to 12 months, incidence of delayed graft function (18% vs 10%, p = 0.7) or acute rejection (9% vs 5%, p = 1.0) between groups. CONCLUSION Lower volume fluid management strategies in LLDN do not appear to worsen recipient outcomes nor are they detrimental to the donors.
Collapse
|
44
|
Optimization of cardiac preload during laparoscopic donor nephrectomy: a preliminary study of central venous pressure versus esophageal Doppler monitoring. Surg Endosc 2004; 18:412-6. [PMID: 14716541 DOI: 10.1007/s00464-003-8907-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2003] [Accepted: 06/17/2003] [Indexed: 12/25/2022]
Abstract
BACKGROUND While the popularity of laparoscopic donor nephrectomy (LDN) has increased, concern persists about the potential deleterious effects of pneumoperitoneum on renal function. Thus, preload optimization with vigorous intravenous hydration has been recommended. The purpose of this study was to compare central venous pressure (CVP) monitoring with a noninvasive measure of cardiac preload (esophageal Doppler) during LDN. METHODS Thirteen patients were studied. Following induction of general anesthesia, a Doppler probe was inserted in the lower third of the esophagus to measure flow time corrected for heart rate (FTc), which is an index of preload. In 10 patients, a catheter was placed in the right internal jugular vein and CVP measured. CVP and FTc were measured at baseline in the supine and right lateral decubitus positions, then 15 and 60 min after the establishment of CO(2) pneumoperitoneum (12-15 mmHg). IV fluids were increased if the FTc fell below 300 msec. Results are expressed as means (+/-SD). Data were analyzed using repeated measures ANOVA. RESULTS Lateral positioning and pneumoperitoneum significantly increased CVP from baseline ( p < 0.01), while the FTc did not change ( p = 0.57). After 60 min of pneumoperitoneum, the FTc was <300 msec in only one patient. CONCLUSION CVP is not an accurate guide for administration of IV fluids during LDN. Esophageal Doppler monitoring can be used to noninvasively follow changes in preload during LDN and is worthy of further study.
Collapse
|
45
|
Evaluating laparoscopic skills: setting the pass/fail score for the MISTELS system. Surg Endosc 2003; 17:964-7. [PMID: 12658417 DOI: 10.1007/s00464-002-8828-4] [Citation(s) in RCA: 257] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2002] [Accepted: 11/21/2002] [Indexed: 11/29/2022]
Abstract
BACKGROUND The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) was developed to assess laparoscopic skills and to score them objectively. This system has been described previously. The purpose of the current study was to determine a pass/fail threshold. METHODS In this study, 165 individuals were tested and grouped according to their clinical competency in laparoscopic surgery. The noncompetent group consisted of medical students and surgical residents in their first 2 years of training (n = 83). The competent group consisted of chief general surgical residents in their last year of training, laparoscopy fellows, and practicing laparoscopic surgeons (n = 82). The Mann-Whitney U test was used to evaluate differences in task performance between the two groups. RESULTS There was a significant difference in total scores and individual MISTELS task scores between the noncompetent and competent laparoscopic surgeons (189 vs 372.5; p <0.0001). By setting specific pass/fail total score thresholds (cutoff scores), competent surgeons can be discriminated from noncompetent surgeons. CONCLUSION An objective pass/fail evaluation can be given to individuals tested with the MISTELS system.
Collapse
|
46
|
Does a special interest in laparoscopy affect the treatment of acute cholecystitis? Surg Endosc 2002; 16:1697-703. [PMID: 12098035 DOI: 10.1007/s00464-002-8514-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2002] [Accepted: 05/15/2002] [Indexed: 10/27/2022]
Abstract
BACKGROUND We tested the hypothesis that the treatment of patients with acute cholecystitis (AC) would be improved under the care of laparoscopic specialists. METHODS The records of patients undergoing cholecystectomy for AC from 1 January 1996 to 31 December 1998 were reviewed retrospectively. Of 170 patients, 48 were cared for by three laparoscopic specialists (LS group), whereas 122 were treated by nine general surgeons who perform only laparoscopic cholecystectomy (LC) (GS group). The rates of successful LC, complications, and length of hospital stay were compared. Multivariate analysis was used to control for baseline differences. RESULTS The patients in the GS group were older (median age, 63 vs 53 years; p = 0.01). In all, 31 LS patients (65%), as compared with 44 GS patients (36%), had successful laparoscopic treatment (p = 0.001). The operating time was the same (median, 70 min). The proportion of patients with postoperative complications was similar in the two groups (37% in the GS vs 31% in the LS group; p = 0.6). The median postoperative hospital stay (3 vs 5 days; p <0.01) was shorter in the LS group. On logistic regression analysis, significant predictors of a successful laparoscopic operation included LS group (p <0.01) and age (p = 0). Predictors of prolonged length of hospital stay were age (p <0.01) and comorbidity score (p <0.01), with LS group status not a significant factor (p = 0.21). CONCLUSIONS Patients with AC are more likely to undergo successful LC if cared for by a surgeon with an interest in laparoscopy. However, length of hospital stay is influenced more by patient factors in a multivariate model.
Collapse
|
47
|
Abstracts of presentations to the Annual Meetings of the Canadian Society of Colon and Rectal Surgeons Canadian Association of General Surgeons Canadian Association of Thoracic Surgeons: Canadian Surgery Forum, London, Ont., Sept. 19 to 22, 2002. Can J Surg 2002; 45:3-26. [PMID: 37381180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
|
48
|
Operative management of "hockey groin syndrome": 12 years of experience in National Hockey League players. Surgery 2001; 130:759-64; discussion 764-6. [PMID: 11602909 DOI: 10.1067/msy.2001.118093] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND At the elite level of hockey, groin injuries can threaten a player's career. The aim of this review is to describe the clinical presentation and evaluate our operative approach to "hockey groin syndrome" in National Hockey League (NHL) players. METHODS Between November 1989 and June 2000, 22 NHL players with debilitating groin pain underwent operative exploration. A repair, including ablation of the ilioinguinal nerve and reinforcement of the external oblique aponeurosis with a Goretex (W.L. Gore & Associates, Inc, Flagstaff, Ariz) mesh, was performed. Medical records were reviewed, and the players or their trainers were contacted by telephone after a mean follow-up period of 31.2 months to assess function, symptoms, and overall satisfaction. RESULTS All patients had tearing of the external oblique aponeurosis, with branches of the ilioinguinal nerve emerging from the torn areas. At follow-up, 18 players (82%) had no pain, whereas 4 (18%) reported mild, intermittent pain. All 22 patients returned to playing hockey, with 19 (85%) able to continue their careers in the NHL. CONCLUSIONS The "hockey groin syndrome," marked by tearing of the external oblique aponeurosis and entrapment of the ilioinguinal nerve, is a cause of groin pain in professional hockey players. Ilioinguinal nerve ablation and reinforcement of the external oblique aponeurosis successfully treats this incapacitating entity.
Collapse
|
49
|
Laparoscopic fundoplication: a model for assessing new technology in surgical procedures. Surgery 2001; 130:686-93; discussion 693-5. [PMID: 11602900 DOI: 10.1067/msy.2001.118092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgical success has traditionally been judged from the surgeon's perspective. A more complete evaluation of outcome incorporates the patient's, surgeon's, and payor's perspectives. Because gastroesophageal reflux disease (GERD) is primarily a quality-of-life (QOL) problem, the evaluation of laparoscopic fundoplication (LF) is a useful model for evaluating outcomes from these 3 perspectives. METHODS Between 1995 and 2000, 74 patients underwent primary LF for GERD. In addition to undergoing physiologic testing, 63 patients (85%) were evaluated with use of a disease-specific health-related QOL scale (GERD-HRQL), scored from 0 (no symptoms) to 45 (incapacitating symptoms). Thirty-three patients also completed a generic QOL questionnaire (SF-12), in which patient satisfaction was scored from 1 (very satisfied) to 5 (very dissatisfied). Preoperative and postoperative data were compared with use of the Wilcoxon signed rank test or the paired t test. RESULTS The median GERD-HRQL score improved from 18 to 0 at 2 years postoperation (P <.01). The median satisfaction score improved from 5 to 1 (P <.01). The SF-12 summary scores also improved after 6 weeks postoperatively (P <.05). The mean +/- SD lower esophageal sphincter pressure rose from 7.3 +/- 4 mm Hg preoperatively to 17.5 +/- 6 postoperatively (P <.01), and the mean percentage of time that the esophagus was exposed to a pH of less than 4 declined from 14.7% +/- 12% to 1.1% +/- 2% (P <.01). The median operative time was 110 minutes, which declined with experience with the procedure (P <.01). Median postoperative stay was 2 days. CONCLUSIONS In evaluating the outcomes of a new procedure, 3 overlapping points of view were addressed: the patient's (QOL, satisfaction), the surgeon's (physiologic changes), and the payor's (operating room time, hospital stay). With use of this framework, we found that LF for GERD improves QOL, corrects the physiologic abnormalities, and is associated with short hospitalization and operating time that declines with experience with the procedure.
Collapse
|
50
|
Abstract
UNLABELLED Ascorbic acid can be important in sickle cell anemia (SCA) because significant oxidative stress occurs in the disease. Ascorbate could contribute to reduction of the increased oxygen free radicals generated in sickle red blood cells (SRBC) and to the recycling of vitamin E in the cells, while renal loss could contribute to the low plasma levels. Evaluation of red blood cell (RBC) and urine ascorbate in SCA has not been reported. Results showed (1) ascorbate levels in SRBC were similar to those in normals; (2) urine ascorbate excretion was increased in 36% of patients; (3) plasma levels of ascorbate were decreased. CONCLUSIONS (1) Ascorbate is present in SRBC, most likely due to ascorbate recycling, despite increased free-radical generation. (2) The increase in renal excretion may contribute to the low plasma levels of ascorbate. (3) The presence of ample ascorbate in SRBC and decreased plasma ascorbate suggests that ascorbate movement across the SRBC membrane may differ from normal RBC.
Collapse
|