Case Mix Research Articles

Wavy Marangoni effect and strategic slip-pattern-driven species transport in micro-confined sandwiched liquid films

In microfluidic systems, analyte/reagent mixing is essential to achieve rapid chemical/biochemical reactions. The low Reynolds number (Re) flow, however, makes passive mixing difficult and necessitates the use of some external stimulus to cause disturbance in the system. Here, we report how a periodic thermocapillary effect may interact with strategically patterned wall wettability and boost the mixing dynamics in a micro-confined ternary-liquid film system. Approximate, yet without compromise on the physics involved, analytical solutions to the energy and Navier–Stokes equations under creeping flow conditions are obtained to comprehend the thermal and hydrodynamic characteristics of the thermo-capillarity. In the binary fluid limit, our model is validated with the findings of Pendse & Esmaeeli (Intl J. Therm. Sci., vol. 49, 2010, pp. 1147–1155), and good agreement is found. The flow characteristics in the ternary-liquid system due to discrete wall temperatures is also demonstrated via finite-element-based numerical simulations, and agreement with the semi-analytical solution is noted. The qualitative study of the flow pattern reveals that enhanced mixing is obtained as a result of vortical motion created by the interplay of the periodic thermo-capillarity-driven interfacial flow and wall slip. The observation is further consolidated from the numerical simulation of the species transport equation. The species distribution so obtained is compared with fully developed laminar flow for the same inlet concentration. Our study further investigates the effects of the fluids’ relative thermal conductivity, wall slip length, relative film thickness and thermal (or slip) phase differences on the mixing efficiency of the proposed arrangement. While wall slip, relative film thickness and relative thermal conductivity regulate mixing in the top and bottom layers, phase difference determines how well the middle fluid layer mixes. Slip at the walls creates vortex distortions to get a strong churning effect. The lower thermal conductivity of the top and bottom fluids weakens the thermocapillary flow; however, the dominance of the patterned slip improves mixing in such cases.

Haitian State Hospital Orthopedic Grand Rounds Series: A Virtual Curriculum to Address Global Surgery Needs.

Orthopedic Relief Services International (ORSI), in partnership with the Foundation for Orthopedic Trauma and the department of Orthopedic Surgery of La Paix University Hospital in Haiti, has developed a year-round Orthopedic Grand Round series. This series is moderated by Haitian faculty, features presentations by American orthopedic surgeons, and is broadcast to major state hospitals in Haiti for residents and attendings. To introduce clinical concepts and increase knowledge in an area that is medically underserved, especially in the field of orthopedics, through lectures that tailor to the educational needs of Haiti. Topics for lecture series are requested by Haitian attending orthopedic surgeons and residents in collaboration with American orthopedic surgeons to meet the educational needs of the residents in Haiti. These lectures reflect the case mix typically seen at state hospitals in Haiti and consider the infrastructural capacity of participating centers. Grand rounds are held an average of twice per month for an hour each, encompassing an educational lesson followed by an open forum for questions and case discussion. Feedback is taken from Haitian residents to ensure the sessions are beneficial to their learning. To date 95 sessions hosted by 32 lecturers have been completed over Zoom between the US and Haiti. The fourth year of the lecture series is currently ongoing with an expansion of topics. In an underserved medical area such as Haiti, programs that educate local surgeons are crucial to continuing the growth and development of the medical community. Programs like this have the potential to contribute to the educational infrastructure of countries in need, regardless of the specialty. The model of this program can be used to produce similar curricula in various specialties and areas around the world.

Construction and application of a nursing human resource allocation model based on the case mix index

BackgroundThe case mix index (CMI) may reflect the severity of disease and the difficulty of care objectively, and is expected to be an ideal indicator for assessing the nursing workload. The purpose of this study was to explore the quantitative relationship between daily nursing worktime (DNW) and CMI to provide a method for the rational allocation of nursing human resources.MethodsTwo hundred and seventy-one inpatients and 36 nurses of the department of hepatobiliary surgery were prospectively included consecutively from August to September 2022. The DNW of each patient were accurately measured, and the CMI data of each patient were extracted. Among 10 curve estimations, the optimal quantitative model was selected for constructing the nursing human resource allocation model. Finally, the applicability of the allocation model was preliminarily assessed by analyzing the relationship between the relative gap in nursing human resources and patient satisfaction, as well as the incidence of adverse events in 17 clinical departments.ResultsThe median (P25, P75) CMI of the 271 inpatients was 2.62 (0.92, 4.07), which varied by disease type (F = 3028.456, P < 0.001), but not by patient gender (F = 0.481, P = 0.488), age (F = 2.922, P = 0.089), or level of care (F = 0.096, P = 0.757). The median (P25, P75) direct and indirect DNW were 76.07 (57.98, 98.85) min and 43.42 (39.42, 46.72) min, respectively. Among the 10 bivariate models, the quadratic model established the optimal quantitative relationship between CMI and DNW; DNW = 92.3 + 4.8*CMI + 2.4*CMI2 (R2 = 0.627, F = 225.1, p < 0.001). The relative gap between theoretical and actual nurse staffing in the 17 clinical departments were linearly associated with both patient satisfaction (r = 0.653, P = 0.006) and incidence of adverse events (r = − 0.567, P = 0.021). However, after adjusting for other factors, it was partially correlated only with patient satisfaction (rpartial = 0.636, P = 0.026).ConclusionThe DNW derived from CMI can be used to allocate nursing human resources in a rational and convenient way, improving patient satisfaction while ensuring quality and safety.

Quality of Surgical Care Within the Criminal Justice Health Care System

Individuals who are incarcerated represent a vulnerable group due to concerns about their ability to provide voluntary and informed consent, and there are considerable legal protections regarding their participation in medical research. Little is known about the quality of surgical care received by this population. To evaluate perioperative surgical care provided to patients who are incarcerated within the Texas Department of Criminal Justice (TDCJ) and compare their outcomes with that of the general nonincarcerated population. This cohort study analyzed data from patients who were incarcerated within the TDCJ and underwent general or vascular surgery at the University of Texas Medical Branch (UTMB) from 2012 to 2021. Case-specific outcomes for a subset of these patients and for patients in the general academic medical center population were obtained from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) and compared. Additional quality metrics (mortality index, length of stay index, and excess hospital days) from the Vizient Clinical Data Base were analyzed for patients in the incarcerated and nonincarcerated groups who underwent surgery at UTMB in 2020 and 2021 to provide additional recent data. Patient-specific demographics, including age, sex, and comorbidities were not available for analysis within this data set. Perioperative outcomes (30-day morbidity, mortality, and readmission rates) were compared between the incarcerated and nonincarcerated groups using the Fisher exact test. The sample included data from 6675 patients who were incarcerated and underwent general or vascular surgery at UTMB from 2012 to 2021. The ACS-NSQIP included data (2012-2021) for 2304 patients who were incarcerated and 602 patients who were not and showed that outcomes were comparable between the TDCJ population and that of the general population treated at the academic medical center with regard to 30-day readmission (6.60% vs 5.65%) and mortality (0.91% vs 1.16%). However, 30-day morbidity was significantly higher in the TDCJ population (8.25% vs 5.48%, P = .01). The 2020 and 2021 data from the Vizient Clinical Data Base included 629 patients who were incarcerated and 2614 who were not and showed that the incarcerated and nonincarcerated populations did not differ with regard to 30-day readmission (12.52% vs 11.30%) or morbidity (1.91% vs 2.60%). Although the unadjusted mortality rate was significantly lower in the TDCJ population (1.27% vs 2.68%, P = .04), mortality indexes, which account for case mix index, were similar between the 2 populations (1.17 vs 1.12). Findings of this cohort study suggest that patients who are incarcerated have equivalent rates of mortality and readmission compared with a general academic medical center population. Future studies that focus on elucidating the potential factors associated with perioperative morbidity and exploring long-term surgical outcomes in the incarcerated population are warranted.

Natural Experiment Outcomes Studies in Rotor Wing Air Medical Transport: Systematic Review and Meta-Analysis of Before-and-After and Helicopter-Unavailable Publications From 1970 to 2022

ObjectiveHelicopter emergency medical services (HEMS) is widely used for prehospital and interfacility transport, but there is a paucity of HEMS outcomes data from studies using randomized controlled trial designs. In the absence of robust randomized controlled trial evidence, judgments regarding HEMS potential benefit must be informed by observational data. Within the study design set of observational analyses, the natural experiment (NE) is notable for its high potential methodologic quality; NE designs are occasionally denoted “quasi-experimental.” The aim of this study is to examine all NE outcomes studies in the HEMS literature and to discern what lessons can be learned from these potentially high-quality observational data. MethodsHEMS NE studies were identified during the development of a new HEMS Outcomes Assessment Research Database (HOARD). HOARD was constructed using a broad-ranging search of published and gray literature resources (eg, PubMed, Embase, and Google Scholar) that used variations of the terms “helicopter EMS,” “air ambulance,” and “air medical transport.” Among the 221 studies ultimately included in HOARD, 16 NE publications describing 13 sets of observational data comprising myriad diagnostic groups were identified. Of these 16 HEMS NEs, 4 HEMS NE studies assessing trauma outcomes were used in a meta-analysis. A meta-analysis was also performed of 4 HEMS NE studies. ResultsAlthough the disparity of studies (in terms of both case mix and end points) precluded the generation of a pooled effect estimate of an adjusted mortality benefit of HEMs versus ground emergency medical services, HEMS was found to be associated with outcomes improvement in 8 of the 13 cohorts. ConclusionThe weight of the NE evidence supports a conclusion of some form of HEMS-mediated outcomes improvement in a variety of patient types. Meta-analysis of 4 HEMS NE studies assessing trauma outcomes generated a model with acceptable heterogeneity (I2 = 43%, Q test: P = .16), which significantly (P < .01) favored HEMS use with a pooled HEMS survival odd ratio estimate of 1.66 (95% confidence interval, 1.23-2.22).

Genetic heterogeneity of Alzheimer’s disease: Evidence for disease‐relevant and disease‐specific clustering

AbstractBackgroundAlzheimer’s disease (AD) demonstrates heterogeneity across domains of cognitive impairment, atrophy, and pathological accumulation. This has led to speculations that AD may comprise several disease subtypes. AD is under substantial genetic influence, thus searching for genetic clustering may provide insight towards the origins of this phenotypic variability.MethodGenotyping data from 2,739 AD cases and 5,478 age and sex‐matched controls from the UK Biobank were used as the discovery data. A principal components analysis (PCA) was applied to AD‐associated variants (p&lt;0.05 in the IGAPS2 GWAS of AD) to assess disease‐relevant structure. A novel biclustering algorithm was then applied to find disease‐specific genetic signatures of AD. This algorithm searches for subsets of subjects and variants that are present in cases, but importantly, not in controls. Pathway analysis was used to characterize the biological pathways implicated by disease‐relevant and specific clustering. Data from 476 AD cases and 591 controls from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) were used to test replication of clusters.ResultPCA revealed 3 distinct clusters. Each cluster contained a mix of cases and controls but these clusters only became apparent when restricting to AD‐associated variants, suggesting disease‐relevant structure. Examining clusters separately, we found 2 significant disease‐specific biclusters comprising sets of variants found more frequently in a subset of AD cases than in controls. When projecting ADNI data on UK Biobank principal components, there was almost perfect overlap of disease‐relevant clusters. Disease‐specific biclusters significantly replicated (p&lt;0.05) across a range of parameter choices.ConclusionThese findings demonstrate a hierarchy of heterogeneity for AD genetic risk. At the first level, the three disease‐relevant clusters may indicate that different pathways are more vulnerable for different groups of individuals, but additional risk factors or insults are required to substantially increase risk for AD. At the next level, individuals assigned to the biclusters may represent subtypes of AD with different genetic signatures that significantly increase risk for AD. Replication in ADNI demonstrates that this hierarchical structure is a generalizable aspect of AD genetic risk. More broadly, this study illustrates an approach that can be extended to investigate genetic heterogeneity of other complex diseases.

The impact of hospital experience in bariatric surgery on short-term outcomes after minimally invasive esophagectomy: a nationwide analysis.

Minimally invasive esophagectomy (MIE) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIE. Data on esophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case mix. Of 3371 patients undergoing esophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIE. Bariatric hospitals (N = 6) accounted for 1057 (43.1%) MIE. Annual volume of bariatric procedures was median 523 and esophagectomies 42. In non-bariatric hospitals, volume of esophagectomies was median 52 (P = 0.145). Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P < 0.001). Bariatric hospitals were associated with a reduced risk of overall complications (aOR 0.76 [95% CI 0.62-0.92]), length of hospital (aOR 0.79 [95% CI 0.65-0.95]), and ICU stay (aOR 0.81 [95% CI 0.67-0.98]) after MIE. Surgical radicality (R0) did not differ. Lymph node yield (≥ 15) was lower in bariatric hospitals (90.0% vs. 94.7%, P < 0.001). Over the years, several short-term outcomes improved in bariatric hospitals compared to non-bariatric hospitals. In this nationwide analysis, there was an association between bariatric hospitals and improved short-term outcomes after MIE. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify.

Positive Surgical Margins After Anterior Robot-assisted Radical Prostatectomy: Assessing the Learning Curve in a Multi-institutional Collaboration

BackgroundThe learning curve for robot-assisted radical prostatectomy (RARP) remains controversial, with prior studies showing that, in contrast with evidence on open and laparoscopic radical prostatectomy, biochemical recurrence rates of experienced versus inexperienced surgeons did not differ. ObjectiveTo characterize the learning curve for positive surgical margins (PSMs) after RARP. Design, setting, and participantsWe analyzed the data of 13 090 patients with prostate cancer undergoing RARP by one of 74 surgeons from ten institutions in Europe and North America between 2003 and 2022. Outcome measurements and statistical analysisMultivariable models were used to assess the association between surgeon experience at the time of each patient’s operation and PSMs after surgery, with adjustment for preoperative prostate-specific antigen level, grade, stage, and year of surgery. Surgeon experience was coded as the number of robotic radical prostatectomies done by the surgeon before the index patient’s operation. Results and limitationsOverall, 2838 (22%) men had PSMs on final pathology. After adjusting for case mix, we found a significant, nonlinear association between surgical experience and probability of PSMs after surgery, with a lower risk of PSMs for greater surgeon experience (p < 0.0001). The probabilities of PSMs for a patient treated by a surgeon with ten, 250, 500, and 2000 prior robotic procedures were 26%, 21%, 18%, and 14%, respectively (absolute risk difference between ten and 2000 procedures: 11%; 95% confidence interval: 9%, 14%). Similar results were found after stratifying patients according to extracapsular extension at final pathology. Results were also unaltered after excluding surgeons who had moved between institutions. ConclusionsWhile we characterized the learning curve for PSMs after RARP, the relative contribution of surgical learning to the achievement of optimal outcomes remains controversial. Future investigations should focus on what experienced surgeons do to avoid positive margins and should explore the relationship between learning, margin rate, and biochemical recurrence. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors may shed light on where to focus future efforts in surgical education. Patient summaryIn patients receiving robotic radical prostatectomy for prostate cancer, we characterized the learning curve for positive margins. The risk of surgical margins decreased progressively with increasing experience, and plateaued around the 500th procedure. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors has implications for surgeons and patients, and it may shed light on where to focus future efforts in surgical education.

Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study

ObjectiveInterhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA. MethodsThis was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions. Nonfederal referring hospitals located in the home state of the associated critical care transport medicine program and within 100 miles of the primary receiving facility in the region were included if complete data were available. We fit a Poisson principal component regression model incorporating geographic distance, the number of emergency department visits, the number of hospital discharges, case mix index, the number of intensive care unit beds, and the number of general beds and tested the association of the variables with helicopter emergency medical services utilization. ResultsA total of 106 referring hospitals were analyzed, 21 of which were hospitals identified as having a consistent request pattern. Using the hospitals with a consistent referral pattern, geographic distance had a significant positive association with flight request volume. Other variables, including emergency department visit volume, were not associated. Overall, the included variables offered poor explanatory power for the observed variation between referring facilities in the use of IHTA (r2 = 0.09). Predicted flights based on the principal component regression model for all referring hospitals suggested the majority of referring hospitals used multiple flight programs. ConclusionGeographic distance is associated with the use of IHTA. Unexpectedly, most basic hospital characteristics are not associated with the use of IHTA, and the degree of variation between referring facilities that is explained by patient volume is limited. The evaluation of nonhospital factors, such as the density and availability of critical care or advanced life support ground emergency medical services resources, is needed.

HPB P58 Laparoscopic cholecystectomy as a training case in the post-Covid world

Abstract Background Laparoscopic cholecystectomy is an index procedure for all higher surgical trainees, regardless of sub-specialty. Minimum numbers and evidenced ‘Level 4’ competency are necessary for successful completion of training. The Covid-19 pandemic led to falls in training opportunities, during the acute phase itself and in the current drive to reduce elective waiting lists. More cases are outsourced and those cases that are being performed in the NHS may be more complex due to longer waiting times. These twin pressures have led to concerns that training opportunities for laparoscopic cholecystectomy are being limited. This study evaluated the training opportunities for laparoscopic cholecystectomy. Methods All patients who had laparoscopic cholecystectomy over a four-month period, from January 2023 to April 2023 were identified from a prospectively maintained database of operations. Electronic patient records were interrogated to gather pre-operative data (symptomology, co-morbidities, acuity of presentation, pre-operative investigations), intra-operative findings and progress (grade of primary surgeon, nature of operation) and post-operative outcomes and complications. Factors which were associated with the case being performed by a trainee were assessed, as well as differences in outcomes between consultant and registrar procedures. Results There were 150 laparoscopic cholecystectomies performed during the study period. 79 (53%) of these cases were performed acutely ('hot' gallbladders). Registrars performed 36 elective laparoscopic cholecystectomies (51%) and 42 acute cases (53%). Operating time was comparable between registrars and consultants (median operating time [registrar vs. consultant], 72 vs. 78 minutes). There were no particular pre-operative factors that predicted a case being performed by a trainee. There were no differences in post-operative outcome or complication between grade of primary surgeon; there were no bile duct injuries. There were three patients who had a return-to-theatre (2 registrar, 1 consultant case). Conclusions The current case mix in our hospital has meant that just over half the laparoscopic cholecystectomies performed were completed by a trainee. Not a single case was performed by an 'SHO' level surgeon, suggesting that this operation is now the preserve of higher surgical trainees. Without a high-functioning acute gallbladder service, training opportunities for this operation would be severely limited. It is safe to train laparoscopic cholecystectomy, even in the acute setting, and more should be done to identify factors which could improve training opportunities.

Forecasting The Impact of the 2023 Current Procedural Terminology Coding Changes On Ventral Hernia Work Relative Value Units. A Cross-Sectional Study

BackgroundIn January 2023, significant changes were implemented to ventral hernia repair Current Procedural Terminology codes, with new codes replacing previous codes. The new codes were assigned a 0-day global period. The impact of these changes on clinical productivity remains unclear. Our objective was to forecast the impact of Current Procedural Terminology changes on ventral hernia-related work relative value units using historical data. MethodsVentral hernia repairs performed between March 2021 and December 2022 on adults by a single surgeon with available 90-day follow-up were retrospectively retrieved from the Abdominal Core Health Quality Collaborative. Demographic, hernia, and operative and postoperative data were collected. The ventral hernia repairs were coded twice using the previous and new Current Procedural Terminology codes, and work relative value units were calculated using both systems. The median work relative value units per case were compared using the Wilcoxon signed-rank test. ResultsA total of 143 ventral hernia repairs were included. The median age was 59 years, and 50% of patients were male. Median hernia width and length were 3.5 and 5.0 cm, respectively. The most common ventral hernia types were incisional 57% and umbilical 33%. Twenty percent of hernias were recurrent, and 99% were elective repairs. 49% of the procedures were open, 30% robotic, and 21% laparoscopic. Component separation was performed in 16%. The median length of stay was 0.0, and the median number of 90-day outpatient postoperative visits was 1.0. The new Current Procedural Terminology coding system was associated with a higher median 90-day work relative value units per case (14.1) than the previous system (13.8) (P = .002). Subset analysis identified statistically higher median 90-day work relative value units per case using the new versus previous Current Procedural Terminology codes for hernias with the largest defect dimension >10 cm (23.3 vs 18.8), umbilical/epigastric/Spigelian hernias (9.2 vs 7.1), recurrent hernias (20.1 vs 17.3) and open ventral hernia repairs (9.8 vs 7.1), all P < .05. Median 90-day work relative value units per case were statistically lower using the new versus previous codes for non-recurrent (11.6 vs 13.8) and incarcerated/strangulated (14.8 vs 14.9) hernias, all P < .05. In the new coding system, postoperative care within 90-days contributed to a median of 1.3 work relative value units per case (9% of total 90-day work relative value units). ConclusionWe forecast that in our practice, the 2023 ventral hernia repair Current Procedural Terminology changes will result in a modest impact on clinical productivity. The impact of these changes on a particular practice depends on surgical practice patterns and ventral hernia case mix.

Abstract 18981: Regional Variation in Inpatient Hospital Resources Utilized in Cardiac Surgery Performed in Children

Introduction: Care for congenital heart disease is highly resource-intensive due to its complexity, and due to patients’ need for surgery and other inpatient care. Understanding regional variation in resource utilization for cardiac surgical care can promote collaborative learning opportunities that could help optimize resources for patient-centered care. Methods: This cross-sectional analysis used the nationally representative 2012 Kids’ Inpatient Database, managed by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Based on International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes, we identified hospital discharges of cardiac surgery patients under 18 years of age. We excluded patients undergoing cardiac transplantation and newborns under 31 days of age who only underwent ligation of isolated patent ductus arteriosus. Included cases were aggregated based on the nine US geographic divisions used by the US Census Bureau. Regional variation in observed inpatient billed charges, estimated hospital costs based on cost-to-charge ratios and inpatient length of stay (LOS) were analyzed. The log transformed outcomes were compared unadjusted, and after adjusting for RACHS-1 inpatient surgical mortality risk, admission type, expected primary payer and coded complications (as appropriate). Results: Among 15,350 analyzed discharges, the mean nationwide adjusted in-hospital mortality was 3%. It was highest in East South Central (5%). However, the differences among divisions were not significant for all RACHS-1 categories. Mean adjusted complications frequencies ranged from 21 to 32%.LOS showed only minor variations across divisions. Median billed hospital charges ranged from $93,869 to $226,061. For all RACHS-1 categories, New England (lowest) and East North Central had significantly lower charges than did the Mid-Atlantic division. Estimated costs were significantly lower than charges, ranging from $44,402 to $66,726 across all divisions. Costs were lowest in the Mid-Atlantic division. Conclusions: There is regional variation in resource utilization in cardiac surgical care for CHD with no observed correlation with LOS, case mix or complications.

Abstract 16570: Benchmarking Risk-Adjusted Outcomes in Congenital Heart Surgery

Background: Robust models exist to predict risk-adjusted mortality following congenital heart surgery. It is known that underlying diagnosis modifies predicted risk of operations, and institution-level outcomes vary based on their unique case mix. We therefore evaluated risk-adjusted outcomes for a subset of diagnosis-procedure (D-P) combinations within the Society of Thoracic Surgeons' (STS) congenital heart surgery database (CHSD). Methods: A clinician panel identified the most frequently encountered D-P combinations in CHSD between 07/2017 and 06/2021. Candidate modeling techniques were compared in a random 80% development cohort. Model performance was assessed using internal and cross-validation calibration, discrimination plots and optimism adjusted C-statistics. The final selected model was evaluated in the 20% validation sample. Results: The chosen subset of D-P combinations represented 45,384 of 87,589 (52%) unique episodes of surgical care in CHSD during this time-period. The development cohort (36,350 episodes) had 1.8% mortality (667 deaths). All candidate models had excellent discrimination with C-statistics ranging from 0.862 to 0.876. The model with the best combination of discrimination, calibration, and clinical face validity was a modified version of the current STS mortality risk model. This version included all current risk model variables with the addition of indicator variables for D-P combinations. In the 20% validation sample (9,034 episodes), this model was well calibrated (Figure) and had excellent discrimination (C = 0.879). Conclusion: We describe a cohort of D-P combinations widely encountered in the STS CHSD. Further, we refined the existing STS CHSD risk model for application to these D-P dyads to derive empirical risk-adjusted benchmark outcomes. This approach will benefit quality improvement efforts at an institutional level and may have implications for publicly reporting congenital heart surgery outcomes.

Impacts of an Acute Care Telenursing Program on Discharge, Patient Experience, and Nursing Experience: Retrospective Cohort Comparison Study.

Despite widespread growth of televisits and telemedicine, it is unclear how telenursing could be applied to augment nurse labor and support nursing. This study evaluated a large-scale acute care telenurse (ACTN) program to support web-based admission and discharge processes for hospitalized patients. A retrospective, observational cohort comparison was performed in a large academic hospital system (approximately 2100 beds) in Houston, Texas, comparing patients in our pilot units for the ACTN program (telenursing cohort) between June 15, 2022, and December 31, 2022, with patients who did not participate (nontelenursing cohort) in the same units and timeframe. We used a case mix index analysis to confirm comparable patient cases between groups. The outcomes investigated were patient experience, measured using the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHCPS) survey; nursing experience, measured by a web-based questionnaire with quantitative multiple-choice and qualitative open-ended questions; time of discharge during the day (from electronic health record data); and duration of discharge education processes. Case mix index analysis found no significant case differences between cohorts (P=.75). For the first 4 units that rolled out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHCPS domains. Scores for "communication with doctors" and "would recommend hospital" were improved significantly (P=.03 and P=.04, respectively) in 1 unit in phase 1. The impact of telenursing in phases 2 and 3 was mixed. However, "communication with doctors" was significantly improved in 2 units (P=.049 and P=.002), and the overall rating of the hospital and the "would recommend hospital" scores were significantly improved in 1 unit (P=.02 and P=04, respectively). Of 289 nurses who were invited to participate in the survey, 106 completed the nursing experience survey (response rate 106/289, 36.7%). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program was very helpful or somewhat helpful to them as bedside nurses. The only noticeable difference between the telenursing and nontelenursing cohorts for the time of day discharge was a shift in the volume of patients discharged before 2 PM compared to those discharged after 2 PM at a hospital-wide level. The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and 29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was 13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice (nontelenursing cohort) of a bedside nurse engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation time study. This study shows that ACTN programs are feasible and associated with improved outcomes for patient and nursing experience and reducing time allocated to admission and discharge education.

Bariatric surgery provision in response to the COVID-19 pandemic: retrospective cohort study of a national registry.

When surgery resumed following the outbreak of the COVID-19 pandemic, guidelines recommended the prioritization of patients with greater obesity-related co-morbidities and/or higher body mass index. The aim of this study was to record the effect of the pandemic on total number, patient demographics, and perioperative outcomes of elective bariatric surgery patients in the United Kingdom. The United Kingdom National Bariatric Surgical Registry was used to identify patients who underwent elective bariatric surgery during the pandemic (1 yr from April 1, 2020). Characteristics of this group were compared with those of a pre-pandemic cohort. Primary outcomes were case volume, case mix, and providers. National Health Service cases were analyzed for baseline health status and perioperative outcomes. Fisher exact, χ2, and Student t tests were used as appropriate. The total number of cases decreased to one third of pre-pandemic volume (8615 to 2930). The decrease in operating volume varied, with 36 hospitals (45%) experiencing a 75%-100% reduction. Cases performed in the National Health Service fell from 74% to 53% (P < .0001). There was no change in baseline body mass index (45.2 ± 8.3 kg/m2 from 45.5 ± 8.3 kg/m2; P = .23) or prevalence of type 2 diabetes (26% from 26%; P = .99). Length of stay (median 2 d) and surgical complication rate (1.4% from 2.0%; relative risk = .71; 95% CI .45-1.12; P = .13) were unchanged. In the context of a dramatic reduction in elective bariatric surgery due to the COVID-19 pandemic, patients with more severe co-morbidities were not prioritized for surgery. These findings should inform preparation for future crises.

Towards compartmentalized micelles: Mixed perfluorinated and hydrogenated ionic surfactants in aqueous solution

HypothesisAqueous solutions of mixtures of hydrogenated and perfluorinated ionic surfactants are known to display anomalous aggregation behavior due to the mutual phobicity between hydrogenated and perfluorinated chains. Despite all efforts, different experimental limitations prevented so far a definite interpretation of the existing experimental results: both intermicellar and intramicellar segregation remain acceptable possibilities. MethodThe potential for segregation of mixtures of fluorinated and hydrogenated ionic surfactants in water was assessed using atomistic molecular dynamics simulations. Aqueous mixtures of hydrogenated and perfluorinated ionic surfactants were studied: mixtures of anionic surfactants (sodium dodecylsulfate (SDS) + sodium perfluoro-octanoate (SPFO)) and catanionic surfactants (decyltrimethylammonium bromide (DeTAB) + SPFO) were simulated. FindingsThe mixture of anionic surfactants, SDS + SPFO, exhibits clear intramicellar segregation between fluorinated and hydrogenated chains, displaying hydrogenous-rich and fluorous-rich regions. Compartmentalized micelles are thus clearly formed. The simulation results also suggest the possibility of intermicellar segregation. Conversely, catanionic mixtures of DeTAB and SPFO in water solution assemble into a large oblate structure, containing all available molecules in the simulation box, resembling a double layer membrane or a vesicle wall. In this case mixing between fluorinated and hydrogenated surfactants is dictated by charge alternation.

Long-term Prostate Cancer–specific Mortality After Prostatectomy, Brachytherapy, External Beam Radiation Therapy, Hormonal Therapy, or Monitoring for Localized Prostate Cancer

BackgroundThe optimal treatment of localized prostate cancer (PCa) remains controversial. ObjectiveTo compare long-term survival among men who underwent radical prostatectomy (RP), brachytherapy (BT), external beam radiation therapy (EBRT), primary androgen deprivation therapy (PADT), or monitoring (active surveillance [AS]/watchful waiting [WW]) for PCa. Design, setting, and participantsThis is a cohort study with long-term follow-up from the multicenter, prospective, largely community-based Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry. Men with biopsy-proven, clinical T1–3aN0M0, localized PCa were consecutively accrued within 6 mo of diagnosis and had clinical risk data and at least 12 mo of follow-up after diagnosis available. Outcome measurements and statistical analysisPCa risk was assessed, and multivariable analyses were performed to compare PCa-specific mortality (PCSM) and all-cause mortality by primary treatment, with extensive adjustment for age and case mix using the Cancer of the Prostate Risk Assessment (CAPRA) score and a well-validated nomogram. Results and limitationsAmong 11 864 men, 6227 (53%) underwent RP, 1645 (14%) received BT, 1462 (12%) received EBRT, 1510 (13%) received PADT, and 1020 (9%) were managed with AS/WW. At a median of 9.4 yr (interquartile range 5.8–13.7) after treatment, 764 men had died from PCa. After adjusting for CAPRA score, the hazard ratios for PCSM with RP as the reference were 1.57 (95% confidence interval [CI] 1.24–1.98; p < 0.001) for BT, 1.55 (95% CI 1.26–1.91; p < 0.001) for EBRT, 2.36 (95% CI 1.94–2.87; p < 0.001) for PADT, and 1.76 (95% CI 1.30–2.40; p < 0.001) for AS/WW. In models for long-term outcomes, PCSM differences were negligible for low-risk disease and increased progressively with risk. Limitations include the evolution of diagnostic and therapeutic strategies for PCa over time. In this nonrandomized study, the possibility of residual confounding remains salient. ConclusionsIn a large, prospective cohort of men with localized PCa, after adjustment for age and comorbidity, PCSM was lower after local therapy for those with higher-risk disease, and in particular after RP. Confirmation of these results via long-term follow-up of ongoing trials is awaited. Patient summaryWe evaluated different treatment options for localized prostate cancer in a large group of patients who were treated mostly in nonacademic medical centers. Results from nonrandomized trials should be interpret with caution, but even after careful risk adjustment, survival rates for men with higher-risk cancer appeared to be highest for patients whose first treatment was surgery rather than radiotherapy, hormones, or monitoring.

Describing the monthly variability of hospital-onset Clostridioides difficile during early coronavirus disease 2019 (COVID-19) using electronic health record data.

To assess the relative risk of hospital-onset Clostridioides difficile (HO-CDI) during each month of the early coronavirus disease 2019 (COVID-19) pandemic and to compare it with historical expectation based on patient characteristics. This study used a retrospective cohort design. We collected secondary data from the institution's electronic health record (EHR). The Ohio State University Wexner Medical Center, Ohio, a large tertiary healthcare system in the Midwest. All adult patients admitted to the inpatient setting between January 2018 and May 2021 were eligible for the study. Prisoners, children, individuals presenting with Clostridioides difficile on admission, and patients with <4 days of inpatient stay were excluded from the study. After controlling for patient characteristics, the observed numbers of HO-CDI cases were not significantly different than expected. However, during 3 months of the pandemic period, the observed numbers of cases were significantly different from what would be expected based on patient characteristics. Of these 3 months, 2 months had more cases than expected and 1 month had fewer. Variations in HO-CDI incidence seemed to trend with COVID-19 incidence but were not fully explained by our case mix. Other factors contributing to the variability in HO-CDI incidence beyond listed patient characteristics need to be explored.

Measuring efficiency of public hospitals under the impact of Covid-19: the case of Türkiye

The Covid-19 pandemic has had serious medical, administrative and financial effects on the health system and hospitals around the world. In Türkiye, compared to 2019 realizations, in 2020 and 2021 respectively there were 39% and 21% decrease in the number of outpatient services and 29% and 17% decline in total inpatient services of public hospitals. The main subject of this research is how the pandemic period affects the Turkish public hospitals’ efficiency. We have measured the technical efficiency of outpatient and inpatient care services of Turkish public hospitals using Stochastic Frontier Analysis (SFA). The dataset includes 563 hospitals for the years 2015 through 2021. Inputs of number of physicians, nurses and other medical staff, and number of beds and their interactions with each other are introduced to the SFA models of outputs of outpatient visits and inpatient discharges adjusted with case mix index are derived. Firstly, we found that the years associated with Covid-19 have a significant negative impact on the inpatient service efficiency. Training and Research and City Hospitals have low efficiency scores in outpatient services but high efficiency scores in inpatient services. In addition, the regions with high population rates have positive impact in outpatient efficiency and negative impact in inpatient efficiency. During the pandemic, city hospitals, have received large investments, gained a key role by increasing both the patient load and their efficiency. Future reforms can be guided by taking advantage of the efficiency differences of hospitals in different environmental factors.

The efficacy of utility functions for multicriteria hospital case‐mix planning

AbstractA new approach to perform hospital case‐mix planning (CMP) is introduced in this article. Our multicriteria approach utilizes utility functions (UF) to articulate the preferences and standpoint of independent decision makers regarding outputs. The primary aim of this article is to test whether a utility functions method (UFM) based on the scalarization of aforesaid UF is an appropriate quantitative technique to (i) distribute hospital resources to different operating units and (ii) provide a better capacity allocation and case mix. Our approach is motivated by the need to provide a method able to evaluate the trade‐off between different stakeholders and objectives of hospitals. To the best of our knowledge, no such approach has been considered before in the literature. As we will later show, this idea addresses various technical limitations, weaknesses, and flaws in current CMP. The efficacy of the aforesaid approach is tested on a case study of a large tertiary hospital. Currently UF are not used by hospital managers, and real functions are unavailable, hence, 14 rational options are tested. Our exploratory analysis has provided important guidelines for the application of these UF. It indicates that these UF provide a valuable starting point for planners, managers, and executives of hospitals to impose their goals and aspirations. In conclusion, our approach may be better at identifying case mix that users want to treat and seems more capable of modeling the varying importance of different levels of output. Apart from finding desirable case mixes to consider, the approach can provide important insights via a sensitivity analysis of the parameters of each UF.