Healthier Patients Research Articles

P-204 Outcomes of geriatric population with resectable colorectal liver metastases cancer: Data from real life

In selected patients with metastatic colorectal cancer (mCRC), resection of liver metastasis (LM) is the only potential curative option. The geriatric population is often underrepresented in clinical trials, leading to extrapolation of data from younger and healthier patients. Age is often considered a risk factor for poorer postoperative outcomes. The aim of this study was to evaluate the outcomes of older patients with resectable LM undergoing liver resection.

Hospitalised patients with breakthrough COVID-19 following vaccination during two distinct waves in Israel, January to August 2021: a multicentre comparative cohort study.

BackgroundChanging patterns of vaccine breakthrough can clarify vaccine effectiveness.AimTo compare breakthrough infections during a SARS-CoV-2 Delta wave vs unvaccinated inpatients, and an earlier Alpha wave.MethodsIn an observational multicentre cohort study in Israel, hospitalised COVID-19 patients were divided into three cohorts: breakthrough infections in Comirnaty-vaccinated patients (VD; Jun–Aug 2021) and unvaccinated cases during the Delta wave (ND) and breakthrough infections during an earlier Alpha wave (VA; Jan–Apr 2021). Primary outcome was death or ventilation.ResultsWe included 343 VD, 162 ND and 172 VA patients. VD were more likely older (OR: 1.06; 95% CI: 1.05–1.08), men (OR: 1.6; 95% CI: 1.0–2.5) and immunosuppressed (OR: 2.5; 95% CI: 1.1–5.5) vs ND. Median time between second vaccine dose and admission was 179 days (IQR: 166–187) in VD vs 41 days (IQR: 28–57.5) in VA. VD patients were less likely to be men (OR: 0.6; 95% CI: 0.4–0.9), immunosuppressed (OR: 0.3; 95% CI: 0.2–0.5) or have congestive heart failure (OR: 0.6; 95% CI: 0.3–0.9) vs VA. The outcome was similar between all cohorts and affected by age and immunosuppression and not by vaccination, variant or time from vaccination.ConclusionsVaccination was protective during the Delta variant wave, as suggested by older age and greater immunosuppression in vaccinated breakthrough vs unvaccinated inpatients. Nevertheless, compared with an earlier post-vaccination period, breakthrough infections 6 months post-vaccination occurred in healthier patients. Thus, waning immunity increased vulnerability during the Delta wave, which suggests boosters as a countermeasure.

Beyond Clinical Trials in Patients With Multiple Myeloma: A Critical Review of Real-World Results.

The current strategies for the treatment of multiple myeloma (MM) have improved, thanks to effective drug classes and combination therapies, for both the upfront and relapsed settings. Clinical trials for newly diagnosed transplant-ineligible patients led to the approval of immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs) in combination with anti-CD38 monoclonal antibodies (mAbs), to be administered during the induction phase before transplantation and during maintenance treatment, with lenalidomide recommended until relapse. In relapsed/refractory patients, the complex treatment scenario currently includes several options, such as triplets with anti-CD38 mAbs plus IMiDs or PIs, and novel targeted molecules. Comparisons among clinical trials and real-world data showed a good degree of reproducibility of some important results, particularly in terms of overall response rate, progression-free survival, and overall survival. This may help clinicians towards a proper selection of the best treatment options, particularly in real-world settings. However, as compared with the management of real-world settings, clinical trials have some pitfalls in terms of outcome and especially in terms of safety and quality of life. In fact, trials include younger and presumably healthier patients, excluding those with worst clinical conditions due to MM features (e.g., renal insufficiency or bone disease, which can impair the performance status) and comorbidities (e.g., cardiac and pulmonary disease), thus resulting in a possible lack of representativeness of data about the patients enrolled. In this review, we analyze comparable and discrepant results from clinical trials vs. real-world settings published in the last 10 years, focusing on different drugs and combinations for the treatment of MM and providing an overview of treatment choices.

Drivers of paediatric inpatient experience: retrospective analysis of casemix factors for the Alberta Paediatric Inpatient Experience Survey in Alberta, Canada

ObjectiveIn Alberta, the Alberta Paediatric Inpatient Experience Survey (APIES) is used as a proxy-reported measure of paediatric experience. To our knowledge, the influence of casemix factors on patient experience as...

Informative presence bias in analyses of electronic health records-derived data: a cautionary note.

Electronic health record (EHR)-derived data are extensively used in health research. However, the pattern of patient interaction with the healthcare system can result in informative presence bias if those who have poorer health have more data recorded than healthier patients. We aimed to determine how informative presence affects bias across multiple scenarios informed by real-world healthcare utilization patterns. We conducted an analysis of EHR data from a pediatric healthcare system as well as simulation studies to characterize conditions under which informative presence bias is likely to occur. This analysis extends prior work by examining a variety of scenarios for the relationship between a biomarker and a health event of interest and the healthcare visit process. Using biomarker values gathered at both informative and noninformative visits when estimating the effect of the biomarker on the event of interest resulted in minimal bias when the biomarker was relatively stable over time but produced substantial bias when the biomarker was more volatile. Adjusting analyses for the number of prior visits within a fixed look-back window was able to reduce but not eliminate this bias. These results suggest that bias may arise frequently in commonly encountered scenarios and may not be eliminated by adjusting for prior visit intensity. Depending on the context, the estimated effect from analyses using data from all visits available may diverge from the true effect. Sensitivity analyses using only visits likely to be informative or noninformative based on visit type may aid in the assessment of the magnitude of potential bias.

Vaginal repair of vesicovaginal fistula: comparison of national practice patterns by surgeon specialty.

There are limited data comparing patient and operative characteristics for vaginal repair of vesicovaginal fistula (VVF) by surgeon specialty. Our objective was to compare national practice patterns by surgeon specialty for vaginal repair of VVF. Using the American College of Surgeons National Surgical Quality Improvement Program database, we conducted a retrospective cohort analysis of women who underwent vaginal repair of VVF from 2010 to 2019. Demographic and perioperative characteristics were compared by surgeon specialty. A total of 252 women were analyzed. Urologists performed 57% of cases (n=144), gynecologists performed 38% (n=96), and general surgeons performed 5% (n=12). There were differences among surgeon specialties in patient characteristics including age (p=0.002), creatinine (p=0.002), hypertension (p=0.02), morbidity probability (p<0.001), hospital stay (p<0.001), inpatient status (p=0.03). Urologists were more likely than gynecologists to use grafts/flaps (p=0.002). There were trending differences among surgeon specialties in patient race (p=0.07) and ethnicity (p=0.06). Urologists and gynecologists were more likely to operate on younger, healthier patients with differences in racial populations. When directly comparing urologists with gynecologists, there were differences in race (p=0.05) and a trending difference in ethnicity (p=0.06), General surgeons were more likely to operate on older white women with worse health status, more concomitant procedures, and longer hospital stay. Urologists, gynecologists, and general surgeons perform vaginal repair of VVF. Among these specialties, there were differences in patient and perioperative characteristics. This information may help referring providers and patients to understand which types of surgical providers most commonly manage VVF.

Transfusion Avoidance in Severely Anemic Total Hip and Total Knee Arthroplasty Patients: An Analysis of Risk.

BackgroundAllogenic blood transfusions increase the risk of multiple complications. We evaluated the influence of restricting transfusions in adults with osteoarthritis that underwent total hip or knee arthroplasty (THA/TKA) with severe postoperative anemia.Material and methodsPatients that underwent THA/TKA for osteoarthritis with postoperative hemoglobin (Hb) ≤ 8 g/dl were retrospectively identified. We evaluated characteristics and adverse postoperative outcomes of patients not transfused and compared them to those of patients who received postoperative transfusion. Adverse outcomes were 90-day readmission, reoperation, infection, and falls, as well as inpatient cardiovascular events and deaths.ResultsOne thousand eighty-seven patients meeting inclusion criteria underwent THA and TKA. The 399 patients (36.7%) who did not undergo transfuion were younger (67.4 vs 69.5 years, P = .008), healthier (American Society of Anesthesiologist ≤ 2: 64.2% vs 56%, P = .006), comprised a lower proportion of cardiovascular disease patients (13.8% vs 24.7%, P < .001), a lower proportion of patients with Medicare/Medicare Managed Care (57.2% vs 65.5%, P = .05), received tranexamic acid more frequently (66.4% vs 52.9%, P < .01), had a shorter procedure time (92.7 vs 103.1, P < .01), a lower postoperative drop in Hb (4.0 vs 4.2 g/dl, P = .022), a later drop in Hb (2.6 vs 2.2 days, P = .003), and a shorter length of stay (3.5 vs 4.8, P < .01). TKA patients underwent transfusion more frequently than THA patients (67.5% vs 59%, P = .004). There were no postoperative deaths. Adverse events were similar between the 2 groups.ConclusionFindings suggest that younger and healthier patients that have lower Hb later during their hospital stay need not undergo transfusion solely based on Hb levels. Routine transfusion triggers can be avoided even in more anemic patients.

Distance traveled to undergo revision shoulder arthroplasty is impacted by patient demographics and exceeds that of primary shoulder arthroplasty

BackgroundPrevious research has highlighted disparities in access to and outcomes following shoulder arthroplasty. The purpose of this study is to compare travel distance for primary vs. revision surgery and to determine the relationships between travel distance to undergo revision shoulder arthroplasty and patient demographics and postoperative adverse outcomes. We hypothesized that older patients, those with increased medical comorbidities, and those with greater financial resources would travel farther for surgery. MethodsThe Healthcare Cost and Utilization Project, American Hospital Association, and UnitedStatesZipCodes.org Enterprise data sets were compiled to collect data on patient demographics, operation performed, and postoperative adverse outcomes. Population-weighted zip code centroid points of patients’ residences as well as hospital coordinates were used to approximate the distance traveled to undergo shoulder arthroplasty. Kruskal-Wallis tests and logistic regression analyses were used to analyze the relationship between travel distance and patients’ demographics and postoperative outcomes. ResultsPatients traveled farther to undergo revision shoulder arthroplasty than to undergo primary shoulder arthroplasty (P = .0001). Among patients who underwent revision operations, older age (P = .0001) and increased medical comorbidities (P = .003) were associated with decreased travel distance. White patients and those with commercial insurance traveled farther to receive care (P = .0001). There were no clinically significant associations between postoperative outcomes following revision surgery and travel distance. ConclusionPatients may travel farther to undergo revision surgery owing to patient preferences or because these complex operations are performed at fewer centers. Younger and healthier patients, white patients, and those with commercial insurance plans traveled farther to receive care. Future work is needed to determine the underlying causes of these disparities and whether it is patient preferences or systemic factors such as hospital density or access to high-quality health insurance that are influencing access to this specialized surgical care.

Association of β-Blocker Use at Time of Radical Prostatectomy With Rate of Treatment for Prostate Cancer Recurrence

The perioperative period has gained attention as a window of opportunity to prevent cancer recurrence. Evidence in support of a role for nonselective β-blockers (nsBBs) in cancer treatment is increasing, and counteracting cancer recurrence associated with perioperative stress and catecholamine is one of the suggested mechanisms of action. To explore whether use of nsBBs at the time of radical prostatectomy is associated with a lower rate of treatment for prostate cancer recurrence. This cohort study analyzed prospectively collected data from the Cancer Registry of Norway, Norwegian Patient Registry, Norwegian Prescription Database, and Norwegian Cause of Death Registry. Of 12 298 eligible patients, this study included 11 117 treatment-naive patients with prostate cancer (ie, no prior hormonal therapy, radiotherapy, or chemotherapy) who underwent radical prostatectomy in Norway from January 1, 2008, to December 31, 2015, with a minimum progression-free follow-up of 6 months. Data analysis was performed from April 20, 2020, to April 30, 2021. Use of nsBBs and selective β-blockers (sBBs) at time of radical prostatectomy. Treatment for cancer recurrence after radical prostatectomy (defined as initiation of hormonal therapy, radiotherapy, or chemotherapy) or, if no treatment was identified, cancer-specific mortality. The study included 11 117 men with prostate cancer (median [IQR] age at radical prostatectomy, 64.8 [60.4-68.3] years). Of these, 1622 (14.6%) later received treatment for cancer recurrence during a median follow-up of 4.3 years (IQR, 2.4-6.3 years). Use of nsBBs at time of surgery among 209 patients was significantly associated with a lower risk of treatment for cancer recurrence (adjusted hazard ratio [aHR], 0.64; 95% CI, 0.42-0.96; P = .03). No such association was observed for use of sBBs (aHR, 0.96; 95% CI, 0.84-1.11; P = .62). Subanalyses with (1) relaxed inclusion criteria allowing for inclusion also of patients with early progression (within 6 months) and (2) only the healthiest patients (Eastern Cooperative Oncology Group performance status of 0) supported the main findings. In this cohort study, use of nsBB but not sBBs at the time of radical prostatectomy was associated with less treatment initiation for cancer recurrence. This finding, together with accumulated preclinical and clinical evidence, provides a foundation for initiation of an interventional study.

Nasopharyngeal cancer: Incidence and prognosis of human papillomavirus and Epstein-Barr virus association at a single North American institution.

The prognostication of Epstein-Barr virus (EBV) and human papillomavirus (HPV) status in nasopharyngeal cancer (NPC) is unclear. This retrospective study analyzed NPC from 2000 to 2019. Seventy-eight patients were included: 43 EBV+ , 12 HPV+ , 23 EBV- /HPV- , and 0 EBV+ /HPV+ . All p16+ tumors were also positive for HPV-CISH. Baseline characteristics were not different between groups except age, N-classification, and Karnofsky Performance Scale (KPS) (p < 0.05). For EBV+ , HPV+ , and EBV- /HPV- respectively, 3-year overall survival (OS) was 89.9%, 69.8%, and 52.5% (p=0.006). EBV- /HPV- status was significantly associated with worse OS but not freedom from progression (FFP) on univariate analysis, and did not remain a significant predictor of OS after adjusting for KPS, age, and group stage. EBV+ NPC tumors were seen in younger, healthier patients than HPV+ and EBV- tumors, and there were no cases of coinfection. The association of viral status with OS was insignificant after adjusting for KPS and age.

Analysis of predictors of mortality after surgical and non-surgical management in proximal humerus fractures

BackgroundProximal humerus fractures are one of the main osteoporotic fractures. Choosing between conservative or surgical treatment is a controversial topic in the literature, as is the functional impact. The main aim of our study was to analyse whether patient comorbidities should influence the final therapeutic decision for these fractures.Material and methodsWe collected data from 638 patients with proximal humerus fractures. The main variable collected was exitus. We also collected the following data: age, gender, type of fracture, laterality, type of treatment, production mechanism, comorbidities and the Charlson comorbidity index (CCI) for each patient. The therapeutic indication used the criteria established by the Upper Limb Unit in our centre. We performed chi-square tests, Fischer’s exact tests and Student’s t-tests to compare the variables. We used the Kaplan–Meier method to analyse both the overall and disease-specific survival rates. We employed the Cox regression model to analyse factors associated with mortality.ResultsPatients with a CCI greater than 5 showed greater mortality (HR = 3.83; p < 0.001) than those with a CCI lower than 5. Within the patients who underwent surgery, those with a CCI higher than 5 had an increased mortality rate (HR = 22.6; p < 0.001) compared with those with a CCI lower than 5. Within the patients who received conservative treatment, those with a CCI over 5 showed greater mortality (HR = 3.64; p < 0.001) than those with a CCI under 5.ConclusionsPatients with proximal humerus fractures and associated comorbidities (CCI > 5) presented higher mortality than healthier patients. This mortality risk was greater in patients with comorbidities if surgical treatment was indicated rather than conservative treatment. Patient’s comorbidities should be a fundamental parameter when planning the therapeutic strategy.Level of evidenceLevel 3.

Outpatient versus inpatient total shoulder arthroplasty: A cost and outcome comparison in a comorbidity matched analysis

BackgroundPrevious studies comparing total and reverse shoulder arthroplasty (TSA/RSA) are subject to surgeon selection bias. This study objective is to compare the outcomes and cost of outpatient TSA/RSA to inpatient TSA/RSA. Methods108,889 elective inpatient and outpatient TSA/RSA from Medicare claims data (2016–2018). 90-day readmission and total 90-day costs were compared following propensity score matching. ResultsYounger and healthier patients are receiving outpatient TSA/RSA. Outpatient TSA/RSA was associated with fewer 90-day readmissions (OR 0.48 CI 0.38–0.59, p < 0.001) and lower 90-day costs (−20.1% CI -19.1%; −21.1%, p < 0.001). ConclusionsOutpatient TSA/RSA surgery offers lower complication rates and total costs. Level of evidenceIII.

Clinical Characteristics, Course, and Outcomes of Vertebral Artery Dissections in the Postpartum Period.

Postpartum vertebral artery dissections (ppVADs) are rare but potentially morbid conditions that occur in otherwise healthy patients. To evaluate clinical characteristics of ppVADs. Demographic, clinical, treatment, and outcome data were collected on ppVADs and are presented in a case series of 12 patients and compared to the general cohort. In total, 12 patients had ppVADs in our cohort of 310 patients with vertebral artery dissections (VADs). They occurred 11.27 days (95% CI, -0.85 to 23.39) postdelivery. Of these, there were 5 (42%) with a hypertensive disorder of pregnancy, and 4 (33%) who had migraines. A total of 3 (25%) had ischemic strokes and 1 (8%) had a subarachnoid hemorrhage. In total, 2 patients (17%) had unfavorable modified Rankin Scale (mRS, 2-6) at discharge from hospital. Patients with ppVADs more often had bilateral VADs (42%vs 17%, P=.03), had pseudoaneurysms (50%vs 18%, P=.0068), were younger (33.83 years vs 44.32 years, P=.018), and had lower Charlson Comorbidity Index (CCI = 0vs 0.99, P=.0038). Anticoagulant treatment was used in a similar percentage of patients. Multivariate analysis revealed 3 factors were predictive of change in mRS: CCI (OR=1.09, 95% CI, 1.02-1.15), stroke (OR=0.78, 95% CI, 0.65-0.95), and mRS at hospital discharge (OR=0.80, 95% CI, 0.74-0.87). There are only 15 isolated ppVADs reported in the literature; this study adds 12 patients with 17 ppVADs. Postpartum VADs occur in younger, healthier patients than in the general cohort, raising questions about mechanism of injury. The majority of ppVADs have good neurological outcomes.

Inpatient Versus Outpatient Acute Venous Thromboembolism Management: Trends and Postacute Healthcare Utilization From 2011 to 2018.

BackgroundAcute outpatient management of venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep vein thrombosis (DVT), is perceived to be as safe as inpatient management in some settings. How widely this strategy is used is not well documented.Methods and ResultsUsing MarketScan administrative claims databases for years 2011 through 2018, we identified patients with International Classification of Diseases (ICD) codes indicating incident VTE and trends in the use of acute outpatient management. We also evaluated healthcare utilization and hospitalized bleeding events in the 6 months following the incident VTE event. A total of 200 346 patients with VTE were included, of whom 50% had evidence of PE. Acute outpatient management was used for 18% of those with PE and 57% of those with DVT only, and for both DVT and PE its use increased from 2011 to 2018. Outpatient management was less prevalent among patients with cancer, higher Charlson comorbidity index scores, and whose primary treatment was warfarin as compared with a direct oral anticoagulant. Healthcare utilization in the 6 months following the incident VTE event was generally lower among patients managed acutely as outpatients, regardless of initial presentation. Acute outpatient management was associated with lower hazard ratios of incident bleeding risk for both patients who initially presented with PE (0.71 [95% CI, 0.61, 0.82]) and DVT only (0.59 [95% CI, 0.54, 0.64]).ConclusionsOutpatient management of VTE is increasing. In the present analysis, it was associated with lower subsequent healthcare utilization and fewer bleeding events. However, this may be because healthier patients were managed on an outpatient basis.

Debate Update: Surgery After 48 Hours of Admission for Geriatric Hip Fracture Patients Is Associated With Increase in Mortality and Complication Rate: A Study of 27,058 Patients Using the National Trauma Data Bank.

To determine the association between surgical timing and short-term morbidity and mortality in elderly patients who sustain hip fractures using a national trauma database (OTA/AO 31A1-3, 31B1-3). Retrospective cohort study. Level I-IV trauma centers in the United States. All patients ≥65 years of age who underwent surgery for hip fracture from 2011 to 2013. Time to surgery of <24, 24-48, and >48 hours from admission. Primary outcome was mortality by hospital discharge. Secondary outcomes were complications of myocardial infarction, cardiac arrest, acute respiratory distress syndrome (ARDS), unplanned reintubation, pneumonia, stroke, severe sepsis, and intensive care unit length of stay. Twenty-seven thousand fifty-eight patients were included in the study. Relative to the <24 hours cohort, patients in the >48 hours cohort were at increased risk for mortality (OR 1.89, 95% CI 1.52-2.33, P < 0.001), ARDS (OR 2.57, 95% CI 1.94-3.39, P < 0.001 for ARDS), myocardial infarction (OR 2.19, 95% CI 1.64-2.94, P < 0.0001), pneumonia (OR 2.04, 95% CI 1.71-2.44, P < 0.001), severe sepsis (OR 2.34, 95% CI 1.52-3.58, P = 0.003), and intensive care unit stay (OR 2.48, 95% CI 2.25-2.74, P < 0.0001). A subgroup analysis showed that healthier patients (modified Charlson Comorbidity Index less than 5) who had surgery >48 hours were not at increased risk of mortality. For elderly patients with hip fractures, delaying surgery for more than 48 hours may be associated with increased short-term morbidity and mortality. This association may be pronounced for patients with more medical comorbidities. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association between livelihood capital and catastrophic health expenditure among patients with critical illness: a cross-sectional study in rural Shandong, China

ObjectiveThe objective of this study is to examine the association between livelihood capital and catastrophic health expenditure (CHE).DesignBetween July and August 2019, a cross-sectional study was conducted in critically ill...

COVID-19 patients age, comorbidity profiles and clinical presentation related to the SARS-CoV-2 UK-variant spread in the Southeast of France

The variant 20I/501Y.V1, associated to a higher risk of transmissibility, emerged in Nice city (Southeast of France, French Riviera) during January 2021. The pandemic has resumed late December 2020 in this area. A high incidence rate together with a fast turn-over of the main circulating variants, provided us the opportunity to analyze modifications in clinical profile and outcome traits. We performed an observational study in the University hospital of Nice from December 2020 to February 2021. We analyzed data of sequencing of SARS-CoV-2 from the sewage collector and PCR screening from all positive samples at the hospital. Then, we described the characteristics of all COVID-19 patients admitted in the emergency department (ED) (n = 1247) and those hospitalized in the infectious diseases ward or ICU (n = 232). The UK-variant was absent in this area in December, then increasingly spread in January representing 59% of the PCR screening performed mid-February. The rate of patients over 65 years admitted to the ED decreased from 63 to 50% (p = 0.001). The mean age of hospitalized patients in the infectious diseases ward decreased from 70.7 to 59.2 (p < 0.001) while the proportion of patients without comorbidity increased from 16 to 42% (p = 0.007). Spread of the UK-variant in the Southeast of France affects younger and healthier patients.

Active Cancer Patients Presenting to the Emergency Department with Acute Venous Thromboembolism: A Retrospective Cohort Study on Risks and Outcomes.

There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.

PD02-06 EFFECT OF RESIDENT INVOLVEMENT IN UROLOGICAL SURGERY ON SHORT-TERM PATIENT OUTCOMES: A META-ANALYSIS AND SYSTEMATIC REVIEW

You have accessJournal of UrologyEducation Research I (PD02)1 Sep 2021PD02-06 EFFECT OF RESIDENT INVOLVEMENT IN UROLOGICAL SURGERY ON SHORT-TERM PATIENT OUTCOMES: A META-ANALYSIS AND SYSTEMATIC REVIEW Nazia Hossain, Hussien Mohamed, and Avi-Chai Robinson Nazia HossainNazia Hossain More articles by this author , Hussien MohamedHussien Mohamed More articles by this author , and Avi-Chai RobinsonAvi-Chai Robinson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001966.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The effect on patient outcomes with and without resident involvement in urological surgery remains controversial. This study aims to systematically determine the effect of resident involvement on patient outcomes in urological surgery. METHODS: This paper followed the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers searched PubMed, Embase, and the Cochrane Library to find studies assessing the impact of resident involvement on patient outcomes in urology cases. Eight patient variables were compared between cohorts to investigate participant similarity. Fifteen outcome variables potentially impacted by resident involvement were compared via meta-analysis. Study quality was assessed using the Newcastle-Ottawa Scale for cohort analysis and given a quality label based on Agency for Healthcare Research and Quality standards. Several papers relied on data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), which reports 30-day patient outcomes. Sensitivity analysis was done to assess for patient overlap between papers that used ACS-NSQIP data. RESULTS: Fifteen studies were included in the meta-analysis, comprising a total of 95,326 patients. The resident-involved group had an overall lower amount of patients with diabetes (odds ratio [OR], 0.84; [95% CI], [0.74, 0.94]), hypertension ([OR], 0.84; [95% CI], [0.82, 0.87]) and smoking ([OR], 0.81; [95% CI], [0.76, 0.86]). Residents were also less involved in operations where patients had a Class 3 or 4 American Society of Anesthesiologists (ASA) scores ([OR], 0.96; [95% CI], [0.93, 1.00]). However, the resident-involved group had more negative post-operative outcomes. The resident-involved surgery group had higher rates of postoperative septic ([OR], 1.37; [95% CI], [1.16, 1.62]) and deep vein thrombosis (DVT) ([OR], 1.36; [95% CI], [1.07, 1.74]). The resident group also had longer operative times when results were reported dichotomously ([OR], 1.78; [95% CI], [1.64, 1.93]). CONCLUSIONS: Based on the results, resident involvement in urological surgery seems to have a negative effect on patient outcomes, specifically increased rates of septic shock, DVT and longer operative time despite resident involvement in cases with healthier patients. However, the data is limited due to the lack of high-quality, propensity-scored studies. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e39-e39 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nazia Hossain More articles by this author Hussien Mohamed More articles by this author Avi-Chai Robinson More articles by this author Expand All Advertisement Loading ...

Assessing Goals-of-Care Documentation during the COVID-19 Patient Surge in an Academic Safety-Net Medical Center.

Context/Objectives: It is paramount that clinicians assess and document patients' priorities to guide goal-concordant interventions, especially during a public health crisis. Design: Retrospective chart review. Setting: Academic safety-net medical center in central Massachusetts, United States. Methods: We examined electronic medical records (EMRs) to discern goals-of-care (GOC) conversations with COVID-19 patients seen at some point by palliative care during their hospitalization, and all clinicians' use of a structured note template during the peak incidence of COVID-19 from March to May 2020. Patients were grouped based on comorbidities and preadmission living situation. GOC discussions were categorized into three types: code status decisions, other treatment decisions, and no treatment decisions. Results: Nearly all (97%) patients had GOC documentation within 48 hours of admission. Forty-four percent of first GOC conversations incorporated the template. Patients with dementia living in nursing facilities had GOC documentation within hours of hospital admission, whereas healthier patients had their first GOC conversation at one week of hospitalization. Decisions about code status predominated in the first (83%) and second (49%) discussions, followed by a focus on other treatment decisions in subsequent discussions (44%-57%). Many did not require a treatment decision (19%-27%) but focused on quality-of-life definitions. Nearly all survivors were discharged to a facility and only four patients returned home. Many survivors died within three months (case fatality rate: 77%). Conclusions: GOC documentation using a structured template combined with easy EMR retrievability and clinician training holds promise for aligning patients' values with real-time medical decisions, during and after the pandemic.