Delivery Of Surgical Care Research Articles

Scoping Review of Ethical Discourse in Global Cleft Surgery Literature.

The ethical discourse regarding the delivery of global surgical care has increased in the 21st century. The aims of this manuscript are to explore the differences in ethical domains in the global cleft surgical literature discussed by authors from high-income countries versus lower-middle-income countries and to elucidate changes in ethical discussions over the last decade. A thematic coding analysis was completed using NVivo 12 qualitative data analysis software. Articles were analyzed and coded for discussion of 24 distinct subdomains in the global cleft surgical literature from 1992 to 2022. The domains with the most significant discourse in the global cleft surgery literature found were (1) clinical care and delivery and (2) engagement in collaborations and partnerships. Furthermore, when manuscripts are first authored by low- and middle-income country (LMIC) authors, the subdomains of (1) level of visiting trainee supervision, (2) relevance of educational activities, and (3) patient/procedure/location selection increase in relative discourse. The impact of visiting trainees on local educational programs is the ethical subdomain that has the largest increase in the last decade. There are barriers to publication as evidenced by the exclusion of abstracts which included LMIC authors but did not result in publications in peer-reviewed journals. A critical finding of this study is that the distribution of discussed ethical domains differs when LMIC authors are included as authors, in particular when primary authorship is from an LMIC author. To the authors' knowledge, there is no other study to date which has attempted this form of analysis.

The Role of Telemedicine in Enhancing Surgical Care Delivery in Africa: A Literature Review.

In Africa, telemedicine holds great potential to revolutionize surgical care delivery, especially in areas where access to quality treatment is scarce. Data about the use of these services in African countries is, however, limited. To outline the present issues in surgical care delivery, as well as the significant role of telemedicine in advancing surgical care delivery in Africa. This review will also discuss the challenges behind telemedicine utilization in Africa, and recommend targeted measures to address those barriers while promoting the enhanced integration of telemedicine into surgical care delivery. A comprehensive online literature search was conducted using several search engines, including PubMed, ScienceDirect, and Google Scholar to assess the potential advantages of telemedicine over traditional surgical practices in Africa, as well as to identify the challenges hindering its implementation. The literature review examined the role of nongovernmental organizations in promoting telemedicine adoption across various African countries. Literature search terms include "countries of Africa," "impact of telesurgery and telemedicine in Africa," and "current situation of telemedicine in intervention." Only articles written in English were considered, and inclusion criteria included relevance to our research objectives and countries in Africa. The potential for telesurgery in Saharan and sub-Saharan countries is still a milestone to be unlocked, but already telemedicine implementation has shown great results. Although hindrances like trust, lack of infrastructure, and lack of trained personnel in the field of telecommunication have been issues. There is a rise in the use of telemedicine in areas of interest like postsurgical care, doctor-patient consultation, and tele-monitoring. Various schemes and plans implemented by public organizations have also peaked since the pandemic. A telemedicine establishment requires multifactorial development occurring in a step-by-step manner. Although complexity in development and barriers faced in countries in Africa are concerns, the outcomes of using telemedicine are considerably better. The rising population and lack of medical specialists have led to a gap in access to approachable surgical care, and telemedicine has shown promising potential to overcome it. Telemedicine implementation has changed the method of intervention in clinics all over the world. Implementation of parts of telemedicine like telesurgery and tele-monitoring has the potential to overcome the concern of a rising population, but there is still a long way to go.

Current state of surgery and trauma in Mauritania: a Scoping Review

Introduction: Nearly one-third of the global burden of disease can be addressed through surgical care. Trauma forms a significant part of this burden, resulting in higher mortality than HIV, tuberculosis, and malaria combined. Mauritania, one of the largest countries in West Africa, lags significantly behind the sustainable development goals set by the World Health Organization (WHO). In this study, we reviewed the available literature on surgery and trauma in Mauritania. Methods: We conducted a literature review using the Embase database (from 1974) and Medline (from 1946) up to June 2024. All studies related to surgery and trauma in Mauritania were included. Studies focused solely on obstetrics, gynaecology and anaesthesia were excluded. Articles were screened for eligibility using Rayyan software. Results: The search strategy returned 449 abstracts. After manual de-duplication, 25 were removed. Following further screening, 411 articles were excluded. The final analysis included nine eligible full length articles and 2 conference abstracts. The 9 full length articles articles addressed a range of topics: emergency general surgery – ileal perforations (1), endocrine surgery specific to the thyroid gland (1), surgical expenditures (1), surgical availability (1), a surgical experience account in Mauritania (1), youth violence (1), causes of mortality and the burden of trauma (2), and an analysis of terrorist attacks (1). Both conference abstracts were related to emergency general surgery, covering the management of cholecystitis and malignant large bowel obstruction. Conclusion: The literature on surgery and trauma in Mauritania is extremely limited. More epidemiological data, as well as studies on interventions, are necessary to better inform the delivery of global surgical care in this country of approximately 5 million people.

Obstacles in "Time to Spine": Challenges for the Timely Delivery of Acute Surgical Care for Patients with Traumatic and Non-Traumatic Spinal Cord Injury.

Over the past three decades, advancements in our understanding of the pathophysiology of spinal cord injury (SCI) have underscored the critical importance of early treatment for both traumatic and non-traumatic cases. Early surgical intervention significantly improves outcomes by limiting the extent of secondary damage. Despite numerous studies highlighting the superior outcomes associated with early decompression surgery for patients with SCIs, hospital reviews reveal that less than 60% of patients undergo surgical decompression within 24 h of injury. This occurs despite consensus among physicians regarding the benefits of early surgery. Therefore, it is important to highlight the multifactorial causes of this knowledge to action discordance. This review aims to elucidate the administrative, logistical, and technical challenges that hinder timely access to surgery for SCIs.

Piloting an Assessment Tool to Organize Surgical Care in Armed Conflicts: Findings From Cameroon

IntroductionArmed conflict is increasing globally and is dramatically disrupting surgical care more than ever before. To address this, the PIPESS (Personnel, Infrastructure, Procedures, Equipment, Supplies, and Standard) tool was designed to facilitate assessment of hospital capacity. It assesses 6 key categories at 3 timepoints: preconflict, during conflict, and postconflict. This tool was piloted to assess the impact of conflict and COVID-19 on surgical care delivery at the Buea Regional Hospital in Cameroon. MethodsThis was a cross-sectional, qualitative study combining in-depth interviews and on-site observations of the surgical care unit. The data collected during the interviews were then applied to the modified PIPESS tool to calculate a preconflict score based on recall and a during conflict score to quantify differences before and during conflict. ResultsWe interviewed 12 key informants: 6 patients, 3 doctors, and 3 other staff. The themes extracted from the preconflict period highlight major barriers including rudimentary prehospital care and referral limitations from remote areas, lack of funding and training, and a demand exceeding the supply of care. COVID-19 resulted in an influx of resources into the region and did not disrupt care to the extent of the conflict. Quantitatively, the PIPESS score for preconflict was 110, and the PIPESS score during conflict was 115, showing an increase in resources, specifically in personnel and infrastructure during conflict. ConclusionsThe conflict increased the burden on existing health centers and strained resources for trauma care. Paradoxically, surgical resources increased during the conflict likely because of increased international support along with local displacement of staff toward the hospital. Further data should be collected during the postconflict setting.

Differences in Surgical Cancer Care Delivery and Outcomes Between Safety-Net and Non-Safety-Net Hospitals in the United States: A Comprehensive Systematic Review.

Studies evaluating the association of safety-net hospitals (SNHs) with outcomes of surgical care in cancer patients have demonstrated mixed results. We sought to systematically investigate the association of SNH status with measures of surgical cancer care delivery and outcomes. A comprehensive review of the literature identified from the MEDLINE/PubMed, Embase, Web of Science, and Cochrane databases was performed according to the PRISMA guidelines. Risk of bias assessment was conducted using the Joanna Briggs Institute's tool. The findings were synthesized qualitatively. Of the 1749 records identified, 33 retrospective studies were included, 79% of which investigated national databases. Risk of bias assessment revealed average score of 78%. Among studies assessing each outcome, lower likelihood of receiving appropriate surgical interventions in SNH patients was reported by 85%; longer intervals to surgery by 100%; and prolonged hospital stays by 73%. Most studies reported no differences in survival (65%) or readmission (67%). Results were mixed regarding complications and mortality. Patient characteristics and shortage of resources and interdisciplinary teams were frequently proposed factors for observed disparities. Cancer patients at SNHs may be less likely to undergo some surgical treatments and experience longer intervals to treatment but achieve largely comparable short- and long-term outcomes to non-SNH patients.

Organization of abdominal emergency surgical care across healthcare services in Senegal: a cross-sectional nationwide survey

IntroductionStudying surgical services and the workforce in sub-Saharan Africa is crucial for enhancing access to quality surgical care in the region. Despite many recommendations to produce evidence based on reliable data on this subject to guide policymakers, there is still a knowledge gap on this topic. The aim of this nationwide survey was to describe the organization of abdominal emergency surgical care across healthcare services in Senegal.MethodologyThis was a cross-sectional nationwide survey. The study period was between October 1st, 2023, and January 20th, 2024. The target population included all registered healthcare facilities in Senegal offering emergency surgical services. A structured questionnaire was designed to gather infrastructure-related data, surgical activities, and human resources.ResultsAll 33 identified healthcare facilities responded to the survey (100%). Emergency abdominal surgery services were available for 96.7% of the surveyed structures. The teams were mainly composed of surgeons and residents (45.2%) or surgeons and medical trainees (48.8%). The average bed capacity of the services was 21.9, with a standard deviation of 13.9. The absence of a dedicated hospitalization section for patients requiring special monitoring was found in 69.6% of the facilities. Operating rooms dedicated to emergency abdominal digestive surgery were present in 54.6% of the services. On average, the services performed 17.6 scheduled surgical interventions with a standard deviation of 11.5 and 29.7 emergency surgical interventions with a standard deviation of 16.8 per month. Morbidity and mortality conferences were not routinely held in the majority of departments (only 27.3%). Professional development programmes were present only in 24.2% of departments. Most of the departments did not have adequate human resources (69.6%). A total of 70 surgeons were identified, resulting in a national ratio of 0.39 general surgeons per 100,000 inhabitants. The strategies employed to address staff shortages included additional working hour by staff (54.5%), temporary workers (30.3%) or the use of trainee doctors or nurses (12.1%).ConclusionThis research shows that significant deficiencies are present in the essential physical and human resources needed to conduct fundamental life-saving surgical procedures. These findings suggest potential areas for improvement in the delivery of emergency surgical care in the region.

Using Systems Engineering and Implementation Science to Design an Implementation Package for Preoperative Comprehensive Geriatric Assessment Among Older Adults Having Major Abdominal Surgery: Protocol for a 3-Phase Study.

Older Americans, a growing segment of the population, have an increasing need for surgical services, and they experience a disproportionate burden of postoperative complications compared to their younger counterparts. A preoperative comprehensive geriatric assessment (pCGA) is recommended to reduce risk and improve surgical care delivery for this population, which has been identified as vulnerable. The pCGA optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social and environmental support. The pCGA has been shown to decrease postoperative morbidity, mortality, and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of the pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic medical centers. By applying implementation science and human factors engineering methods, this study will provide the necessary evidence to optimize the implementation of the pCGA in a variety of health care settings. The purpose of this paper is to describe the study protocol to design an adaptable, user-centered pCGA implementation package for use among older adults before major abdominal surgery. This protocol uses systems engineering methods to develop, tailor, and pilot-test a user-centered pCGA implementation package, which can be adapted to community-based hospitals in preparation for a multisite implementation trial. The protocol is based upon the National Institutes of Health Stage Model for Behavioral Intervention Development and aligns with the goal to develop behavioral interventions with an eye to real-world implementation. In phase 1, we will use observation and interviews to map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery. In phase 2, we will apply user-centered design methods, engaging health care providers, patients, and caregivers to co-design a pCGA implementation package. This package will be applicable to a diverse population of older patients undergoing major abdominal surgery at a large academic hospital and an affiliate community site. In phase 3, we will pilot-test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. We anticipate that this study will take approximately 60 months (April 2023-March 2028). This study protocol will generate (1) a detailed process map of the pCGA; (2) an adaptable, user-centered pCGA implementation package ready for feasibility testing in a pilot trial; and (3) preliminary pilot data on the implementation and effectiveness of the package. We anticipate that these data will serve as the basis for future multisite hybrid implementation-effectiveness clinical trials of the pCGA in older adults undergoing major abdominal surgery. The expected results of this study will contribute to improving perioperative care processes for older adults before major abdominal surgery. DERR1-10.2196/59428.

Challenges and Opportunities in Accessing Surgery for Glioblastoma in Low-Middle Income Countries: A Narrative Review.

Glioblastoma: a highly aggressive brain tumor, presents substantial challenges in treatment and management, with surgical intervention playing a pivotal role in improving patient outcomes. Disparities in access to brain tumor surgery arise from a multitude of factors, including socioeconomic status, geographical location, and healthcare resource allocation. Low- and middle-income countries (LMICs) often face significant barriers to accessing surgical services, such as shortages of specialized neurosurgical expertise, limited healthcare infrastructure, and financial constraints. Consequently, glioblastoma patients in LMICs experience delays in diagnosis, suboptimal treatment, and poorer clinical outcomes compared to patients in high-income countries (HICs). The clinical impact of these disparities is profound. Patients in LMICs are more likely to be diagnosed at advanced disease stages, receive less effective treatment, and have lower survival rates than their counterparts in HICs. Additionally, disparities in access to surgical care exacerbate economic and societal burdens, emphasizing the urgent need for targeted interventions and health policy reforms to address healthcare inequities. This review highlights the importance of addressing global disparities in access to brain tumor surgery for glioblastoma through collaborative efforts, policy advocacy, and resource allocation, aiming to improve outcomes and promote equity in surgical care delivery for all glioblastoma patients worldwide.

Can Operating Room Design Make Orthopedic Surgeries Shorter, Safer, and More Efficient?: A Quasi-Experimental Study.

The study aimed to fill the knowledge gap about how operating room (OR) design could reduce orthopedic surgery duration and contribute to surgical care safety and efficiency. Long surgery duration may lead to delays and cancellations of surgeries, deteriorated patient experiences, postoperative complications, and waste of healthcare resources. The OR physical environment may contribute to the reduction of surgery duration by minimizing workflow disruptions and personnel movements during surgeries. Unobtrusive observations were conducted of 70 unilateral total knee or hip replacement surgeries in two differently designed ORs at a community hospital in the United States. A set of computer-based forms adapted from recent research was used to measure the surgery duration, environment-related disruptions, and ambulatory movements involving circulators. Potential confounding factors like surgery type were controlled in statistical analyses. Significantly shorter surgery durations were recorded in the larger OR with more clearances on both sides of the operating table, a wider door located on the sidewall, more cabinets, and more clearance between the circulator workstation and the sterile field (p =.019). The better-designed OR was also associated with less frequent disruptions and fewer movements per case (p < .001). Significant correlations existed between surgery duration, the number of disruptions, and the number of movements (rs = .576-.700, ps < .001). The study demonstrated the important role of OR physical environment in supporting the safe and efficient delivery of surgical care, which should be further enhanced through research and design innovations.

Digitizing operating theater data in resource-limited settings: Understanding surgical care delivery post-implementation at Tanzanian referral hospital.

Digitizing surgical data infrastructure is critical for policymakers to make informed decisions. The implementation of the first web-based operating theater (OT) recordings at Muhimbili Orthopedic Institute (MOI) represents significant advancements in data management for Tanzania. This study aims to share post-platform implementation outcomes, challenges, and insights gained offering guidance to settings facing similar data repository challenges. In July 2023, after training clinicians, the platform was deployed at MOI operating theaters (OTs) to facilitate prospective data entry following procedures, ensuring timely updates of perioperative outcomes. Semi-structured interviews were conducted with key stakeholders to gather insights into the platform's functionality and efficient data management systems. We presented data from August 2023 to February 2024 along with platform insights. Over 4449 procedures were conducted, comprising 1321 emergencies and 3128 electives, with orthopedics/trauma accounting for the majority (3606). Trauma-related emergencies (921) predominate among interventions. General anesthesia was prevalent; 60.56% in emergencies and 44.51% in electives. Orthopedics/trauma utilized 90.91% of assigned operating days in electives, while neurosurgery utilized 93.39% (p<0.011). The cancellation rate was 7.5%, primarily due to emergency interferences (32%). Of procedures, 96.76% were discharged, while 2.81% died. Challenges encountered during platform implementation included securing local support, integrating technology, and navigating administrative adjustments. Lessons learned emphasized continuous communication for stakeholder buy-in and training for platform familiarity. The web-based OT recordings at MOI succeeded with local support and showed promise for wider scalability. To ensure sustainability, ongoing follow-up, monitoring of platform functionality, local funding establishment, and strengthening global partnerships are recommended.

The safety and efficacy of ambulatory urologic surgery A paradigm shift towards optimizing resource use in outpatient settings.

Amid substantial surgical wait lists, novel methods are needed to improve the delivery of surgical care in Canada. One strategy involves shifting select surgeries from hospitals into community ambulatory centers, which expedite procedures and allow hospitals to prioritize critical and complex patients. We sought to evaluate surgical outcomes at a novel, Canadian urologic clinic and surgical center. A retrospective study was conducted at a novel, accredited surgical facility and outpatient ambulatory clinic from August 2022 to August 2023. Procedures ranged from scrotal and transurethral surgeries to inflatable penile prosthesis insertion. Traditional outpatient procedures, including vasectomy and cystoscopy, were excluded. All patients were discharged the same day and seen 4-6 weeks post-procedure. Variables of interest included surgery type, anesthesia administered, additional clinic appointments, unplanned family physician appointments, visits to the emergency department (ED), and hospital admissions. In a 12-month period, 519 surgeries were performed. The mean patient age was 49.6±17.3 years, with most classified as American Society of Anesthesiologists (ASA) 1-2 (88.8%). Most (95.8%, n=497) patients did not require medical care outside the clinic before their scheduled followup; 2.5% (n=13) visited the ED presenting for wound concerns, postoperative pain, query infection, or catheter-related concerns. Only 1.7% (n=9) required an unscheduled appointment with their family physician, with concerns being inadequate postoperative pain management (n=4) or suspected infection (n=4). No patient required hospital admission. Many urologic surgeries classically performed in hospital operating rooms can be safely performed in a non-hospital, outpatient surgical facility with preservation of good outcomes. This strategy can potentially improve the efficiency of urologic healthcare delivery in select patients.

The Sustained Impact of the COVID-19 Pandemic on Vascular Surgical Care Delivery

The COVID-19 pandemic necessitated postponement of vascular surgery procedures nationally. Whether procedure volumes have since recovered remains undefined. Therefore, our objective was to quantify changes in procedure volumes and determine whether surgical volume has returned to its prepandemic baseline. This study was a retrospective cross-sectional study between 2018 and 2023 using the US Fee-for-Service Medicare 5% National Sample as part of the VA Disrupted Care National Project. We studied patients who underwent 1 of 3 procedures: abdominal aortic aneurysm (AAA) repair for intact aneurysms, carotid endarterectomy (CEA), and major lower extremity amputation (LEA). The case volume of each quarter of 2020-2023 was compared to its corresponding prepandemic quarter in 2019. We then performed a subanalysis of these trends by sex, age, and race. We identified 21,031 procedures: 4,411 AAA repair, 8,361 CEA, and 8,259 LEA. The average percent change during the baseline prepandemic period from 2018 to 2019 was -4.3% for AAA repair, -8.5% for CEA, and -2.6% for LEA. Compared to Q2 of 2019, Q2 of 2020 demonstrated that AAA repair procedures decreased by 47%, CEA by 40%, and LEA by 14%. While procedures initially rebounded in Q3 of 2020, volumes did not return to their prepandemic baseline, demonstrating a persistent volume reduction (-16% AAA, -22% CEA, and -11% LEA). Thereafter, procedure counts again declined in Q1 of 2022 (-25% AAA, -34% CEA, and -25% LEA). Despite a perception that vascular surgical care was singularly disrupted at the outset of the pandemic, there has been a sustained reduction in vascular surgical volume since 2019. Not only have procedure volumes not returned to prepandemic baseline but it also appears that there has been a cumulative incremental impact on overall procedure volume. The impact of these findings on long-term population health remains uncertain and necessitates a better understanding of postpandemic care delivery.

Overcoming Geographic Barriers: Surgical Care in Rural Populations

AbstractThis chapter examines the challenges rural Americans face in accessing surgical care, which is characterized by geographical barriers, a decreasing surgical workforce, and unique patient factors. The widening health care disparity between rural and urban residents highlights the need for comprehensive strategies to improve surgical care delivery to rural areas. Focusing on colorectal care delivery, encompassing the spectrum of common and complex care, exemplifies opportunities to optimize care delivery for rural populations. Here, we discuss the complex and unique interplay of challenges within rural hospital infrastructure, workforce shortages, and patient factors emphasizing financial strain, closure of rural hospitals, and limited access to specialty providers and resources. Current evidence focuses on volume–outcome relationships, the safety of common surgical care at rural hospitals, and the impact of rural hospitals joining larger health systems. Strategies to optimize care delivery include site-of-care optimization, improved care coordination, dissemination of specialty expertise, and policy programs to support the rural workforce. Recent federal policies, including the rural emergency hospital program, underscore the delicate balance between sustaining essential local health care services and the financial realities of rural health care delivery. We then conclude with evidence-based strategies to bridge the urban-rural health care gap, ensuring equitable access to high-quality surgical care regardless of geographic location.

An analysis of virtual reality in abdominal surgery-A scoping review.

The integration of virtual reality (VR) in surgery has gained prominence as VR applications have increased in popularity. A scoping review was undertaken, gathering the most relevant sources, utilising a detailed literature search of medical and academic databases including EMBASE, PubMed, Cochrane, IEEE, Google Scholar, and the Google search engine. Of the 18 articles included, 7 focused on VR in colon surgery, 5 addressed VR in pancreas surgery, and the remaining 6 concentrated on VR in liver surgery. All the articles concluded that VR has a promising future in abdominal surgery by facilitating precision, visualisation, and surgeon training. Adopting VR technology in abdominal surgery has the potential to improve preoperative planning, decrease perioperative anxiety among patients, and facilitate the training of surgeons, residents, and medical students. Additional supporting studies are necessary before VR can be widely implemented in surgical care delivery.

Consensus on topical issues of multidisciplinary management of elderly patients with frailty in planned surgical care delivery

The number of elderly and senile patients who are in need of surgical care delivery is growing steadily year over year. This category of patients is characterized by comorbidity, polypragmasy and high prevalence of geriatric syndromes including loss of autonomy, malnutrition and cognitive impairments that increase the risk of developing perioperative complications. Management of these patients at all stages requires a comprehensive multidisciplinary approach. Nevertheless, there is no uniform understanding of solution of this problem at present. Determination of consensus on certain issues using the Delphi method will allow to gather and unite expert opinions. In this regard, the working group formulated the main points of management of elderly and senile patients before, during and after surgical treatment and conducted a cross-sectional analysis of experts' opinions.

Clinical and economic justification of icg-cholangiography in «difficult» laparoscopic cholecystectomy

To prove from a clinical and economic point of view the expediency of using ICG cholangiography in patients with «difficult» laparoscopic cholecystectomy for the prevention of damage to the bile ducts. The results of treatment of 173 patients with cholelithiasis at various levels of health care providing were analyzed with regard to assessment of indicators of surgery complexity, developed complications and economic costs. The effectiveness of the original scale of «difficult» laparoscopic cholecystectomy has been proved. The financial and economic costs of treatment of patients with damage of biliary ducts and patients with cholelithiasis without development of complications have been analyzed and evaluated. A comparative description of financial costs for patients with «difficult» laparoscopic cholecystectomy with the use of ICG-cholangiography has been given. A program on care delivery for patients suffering from cholelithiasis in the conditions of region with regard to safety and economic effectiveness has been developed. The implementation of this program provides the minimization of postoperative complications and fatality at all levels of surgical care delivery. It has been established that a rational approach to reducing the number of biliary ducts damages is their prevention by prediction of «difficult» laparoscopic cholecystectomy and performance of such interventions in medical organizations of III level with the possibility of modern technologies use.

Unsupervised clustering analysis of trauma/non-trauma centers using hospital features including surgical care.

Injuries are a leading cause of death in the United States. Trauma systems aim to ensure all injured patients receive appropriate care. Hospitals that participate in a trauma system, trauma centers (TCs), are designated with different levels according to guidelines that dictate access to medical and research resources but not specific surgical care. This study aimed to identify patterns of injury care that distinguish different TCs and hospitals without trauma designation, non-trauma centers (non-TCs). We extracted hospital-level features from the state inpatient hospital discharge data in Washington state, including all TCs and non-TCs, in 2016. We provided summary statistics and tested the differences of each feature across the TC/non-TC levels. We then conducted 3 sets of unsupervised clustering analyses using the Partition Around Medoids method to determine which hospitals had similar features. Set 1 and 2 included hospital surgical care (volume or distribution) features and other features (e.g., the average age of patients, payer mix, etc.). Set 3 explored surgical care without additional features. The clusters only partially aligned with the TC designations. Set 1 found the volume and variation of surgical care distinguished the hospitals, while in Set 2 orthopedic procedures and other features such as age, social vulnerability indices, and payer types drove the clusters. Set 3 results showed that procedure volume rather than the relative proportions of procedures aligned more, though not completely, with TC designation. Unsupervised machine learning identified surgical care delivery patterns that explained variation beyond level designation. This research provides insights into how systems leaders could optimize the level allocation for TCs/non-TCs in a mature trauma system by better understanding the distribution of care in the system.

Association of Medicaid Expansion with Reduction in Racial Disparities in the Timely Delivery of up-front Surgical Care for Patients with Early-Stage Breast Cancer.

We evaluated the association between Medicaid expansion and time to surgery among patients with early-stage breast cancer (BC). Delays in surgery are associated to adverse outcomes. It is known that underrepresented minorities are more likely to experience treatment delays. Understanding the impact of Medicaid expansion on reducing racial and ethnic disparities in healthcare delivery is critical. This was a population-based study including women ages 40-64 with stage I-II BC who underwent upfront surgery identified in the National Cancer Database (2010-2017) residing in states that expanded Medicaid on January 1, 2014. Difference-in-difference (DID) analysis compared rates of delayed surgery (>90d from pathological diagnosis) according to time period (pre-expansion [2010-2013] and post-expansion [2014-2017]) and race/ethnicity (White vs. racial and ethnic minority), stratified by insurance type (private vs. Medicaid/uninsured). Secondary analyses included logistic and Cox proportional hazards regression. All analyses were conducted among a cohort of patients in the non-expansion states as a falsification analysis. Finally, a triple-differences approach compared pre-expansion with the post-expansion trend between expansion and non-expansion states. Among Medicaid expansion states, 104,569 patients were included (50,048 pre- and 54,521 post-expansion). In the Medicaid/uninsured subgroup, Medicaid expansion was associated with a -1.8% point (95% CI -3.5% to -0.1, P =0.04) reduction of racial disparity in delayed surgery. Cox regression models demonstrated similar findings (adjusted DID hazard ratio 1.12 [95% CI 1.05-1.21]). The falsification analysis showed significant racial disparity reduction among expansion states but not among non-expansion states, resulting in a triple-difference estimate of -2.5% points (95% CI -4.9% to -0.1%, P =0.04) in this subgroup. As continued efforts are being made to increase access to healthcare, our study demonstrates a positive association between Medicaid expansion and a reduction in the delivery of upfront surgical care, reducing racial disparities among patients with early-stage BC.

Delivery and Prioritization of Surgical Care in Canada During COVID-19: An Environmental Scan.

During COVID-19 healthcare systems had to make concessions to make room for the surge of COVID-19 patients requiring hospital and intensive care. Postponing surgeries was a common strategy; however, it is unclear how surgical care was delivered during this time of constraint. The objective of this study was to understand how surgical care was delivered and prioritized during the COVID-19 pandemic response. This was an environmental scan following the Canadian Agency for Drugs and Technologies in Health methodology. This study was conducted in Canada; a universal, publicly funded healthcare system. Evidence sources on policies pertaining to the provision of surgical care between January 2020 and October 2022 were obtained from ministries of health, health services agencies and publicly funded hospitals across all 10 provinces and three territories. We synthesized the evidence sources using framework analysis. We identified 205 evidence sources that described six themes about the provision of surgical care during the COVID-19 pandemic: the cycle of postponement and resumption; guidelines for triaging and prioritizing surgical cases; Infection Prevention and Control (IPAC), and safety measures for surgical care during COVID-19, patient-centred care, and looking forward (recovery planning, leadership, and decision-making). This study provides a comprehensive understanding of how surgical care was disrupted and innovated during COVID-19 which can inform future strategies for providing effective and efficient surgical care during times of healthcare constraint.