Surgical Health Care Delivery Research Articles

Radical nephrectomy in medically underserved patients: Selection bias and disparity in surgical health care delivery.

609 Background: Disparities in outcomes of renal cell carcinoma (RCC) exist with respect to survival outcomes between different ethnic, and socioeconomic groups. We sought to evaluate disparities in delivery of surgical care between medically underserved (MU) and non-medically underserved (NMU) patients. Methods: We conducted a single-center retrospective analysis of consecutive patients presenting with localized renal cortical neoplasms who underwent surgical excision [Radical (RN) or Partial Nephrectomy (PN)] at an academic tertiary-care referral center. The cohort was divided into MU and NMU groups and descriptive analyses were conducted for demographics and clinical disease characteristics, type of surgery, time to surgery, estimated blood loss, and 30-day total and major complications (Clavien-Dindo, ≥3). Cochran-Armitage trend analysis was conducted to evaluate for surgical trends, and logistic regression multivariable analyses (MVA) were conducted for type of surgery and major complications. Results: 1418 patients were analyzed (MU n=334/NMU n=1084). Comparing MU vs. NMU, no differences were noted for age (p=0.612), Charlson Comorbidity Index (p=0.803), tumor size (p=0.236), or time to surgery (p=0.482). Significantly greater proportions of white patients were noted in NMU (60.6% vs. MU=45.5%, p<0.001) and higher proportion of RN in MU (47% vs. NMU=40.4%, p=0.028). Subgroup analyses of PN groups revealed no differences with respect to demographics, tumor size (p=0.33), major complications (p=0.66), or blood loss (p=0.583). Subgroup analysis of RN revealed significantly higher proportion of non-white patients (p=0.019) and patients with diabetes (p=0.019). MVA for predictors for receipt of RN were non-white (OR1.4, p=0.002), MU (OR=1.32, p=0.043), age (OR=1.01, p=0.009) and treatment year (OR=0.913, p<0.001). MVA for predictors for 30 day major complications demonstrated RN (OR=0.913 p<0.001). Cochran-Armitage trend analysis indicated that both MU and NMU had significant increases in PN between 2003 and 2021 (p<0.0001). Conclusions: Despite overall similarities with respect to demographics and clinical disease characteristics and time to surgery, MU status was associated with a significantly higher odds of receiving a RN at a tertiary care referral center, which represents a disparity in care and possible selection bias. Nonetheless, RN was also associated with a decreased risk of complications. While trends have demonstrated an increase in proportion of PN for both NMU and MU groups, comparative underutilization of PN in MU patients may be associated with increased downstream risks to health. Further investigation is requisite.

The study of medical supplies used for the servicemen with battlefield surgical trauma within the context of marketing analysis

Aim. Further improvement of medical supplies system at providing of the optimal level of efficient surgical health care delivery for servicemen with battlefield surgical trauma.Methods. A preliminary list of remedies was made accordingly to the retrospective analysis of hospital charts of servicemen who were treated in military hospitals. The range of medications used at the above-mentioned stage of treatment has been studied by the method of marketing analysis.Results. The main development trends of the national market of studied remedies were examined. The share of both Ukrainian and international remedies was determined. Quantitative characteristic of medications on the market current structure was displayed and applied in normative documents.Conclusion. The necessity of the national remedies range expansion has been proved; recently this question remains relevant at formation of the state defense order

Initiating an Enhanced Recovery Pathway Program: An Anesthesiology Department’s Perspective

Enhanced recovery pathways (ERPs) for surgical patients may reduce variation in care and improve perioperative outcomes. Mainstays of ERPs are standardized perioperative pathways. At The Johns Hopkins Hospital (Baltimore), an integrated ERP was proposed to further reduce the surgical site infection rate and the longer-than-expected hospital length of stay in colorectal surgery patients. To develop the technical components of the anesthesia pathway, evidence on enhanced recovery was reviewed and the limitations of the hospital infrastructure and policies were considered. The goals of the perioperative anesthesiology pathway were achieving superior analgesia, minimizing postoperative nausea and vomiting, facilitating patient recovery, and preserving perioperative immune function. ERP was implemented in phases during a 30-day period, starting with the anesthesiology elements and followed by the pre- and postoperative surgical team processes. The perioperative anesthetic regimen was tailored to meet the goal of preservation of perioperative immune function (in an attempt to decrease surgical site infection and cancer recurrence), in part by minimizing perioperative opioid use. After six months of exposure to all ERP elements, a 45% reduction in length of stay was observed among colorectal surgery patients. In addition, patient satisfaction scores for this cohort of patients improved from the 37th percentile preimplementation to >97th percentile postimplementation. Development of an ERP requires collaboration among surgeons, anesthesiologists, and nurses. Thoughtful, collaborative pathway development and implementation, with recognition of the strengths and weakness of the existing surgical health care delivery system, should lead to realization of early improvement in outcomes.

Surgical Education in the United States: Portents for Change

In Brief The authors describe the areas of surgical health care delivery that are not being fulfilled by current surgical education programs. There are compelling reasons to adapt surgical education programs to increase the appeal of surgery and to fulfill the expectations of patient, surgeon, and academic health care institutions.

Socioeconomic aspects.

Most surgeons conceptualize "surgical advance" as the introduction of a new operative technique or the presentation of a technologic breakthrough. However, the true landmark innovations of the past decade, with regard to effecting surgical health care delivery, have been the impact of economics and sociology in determining the profession's future. In the past, the surgeon's primary interests revolved around the art and science of surgery, and socioeconomic issues were deemed of secondary importance. Consequently, few of the investigations into "surgical socioeconomics" were conducted by surgeons, and the surgical establishment was more than mildly apathetic toward such social science research. All of this has changed, and it is now evident that there is an overwhelming need for surgeons to incorporate an understanding of sociologic and economic conditions into their clinical thinking. Basic tenets of surgical socioeconomics are presented, and their impact on various clinical situations is discussed.

Surgical Health Care Delivery

This recent volume of the Surgical Clinics of North America (August 1982) was devoted to surgical health care delivery. Although this may not be the sort of topic the readership can easily apply to the clinical care of patients, the authors and the Surgical Clinics are to be commended for bringing to the surgical community and to all health planners an excellent and concise symposium dealing with a complex and increasingly important set of issues. We are all aware of sporadic reports in both the surgical literature and the lay press dealing with various topics on the delivery of surgical care in the United States. These range from compendia of often conflicting data, from which it is difficult to draw useful conclusions, to highly editorial essays based on little or no data. Now, for the first time in a single, highly readable, and remarkably concise volume, Ira Rutkow (guest editor)

Surgical Health Care Delivery

After two decades of costly new surgical procedures involving open heart surgery and multiple types of replacement therapies, the editor of this volume writes, "surgeons must become actively involved in research on surgical health care services." Rutkow has assembled a group of public health planners to discuss issues of ethics, morality, cost-effectiveness, and cost benefits of surgery in a decade of limited health care dollars. Dr Rutkow has tackled the issue of a higher rate of surgery in the United States. Is such a high rate a consequence of fee for service, in contrast to the prepaid group practice of health maintenance organizations or to nations with nationalized health care programs? Do prepaid group practices and HMOs encourage less than optimal care by denying or delaying elective surgery? Have the surgical second-opinion programs been cost-effective while promoting higher-quality surgical care? What constitutes the "unnecessary surgical procedure"? The authors have addressed

Cancer of the stomach—consequences of surgical health care delivery in Norway 1968–1975<xref ref-type="fn" rid="fn1"><sup>*</sup></xref>

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Rates of Surgery in the United States: The Decade of the 1970s

Rates of surgery for gynecology, general surgery, otorhinolaryngology, and urology have either decreased or reached a plateau since 1974. Increasing rates are demonstrated for orthopedics, ophthalmology, cardiothoracic surgery, and neurosurgery. These changes are analyzed. Such data can help health care planners to more accurately predict the future of surgical health care delivery.

Cancer of the stomach—consequences of surgical health care delivery in Norway 1968–1975

Cancer of the stomach—consequences of surgical health care delivery in Norway 1968–1975

Delivery of surgical health care in the United States.

In the past, a surgeon's primary interest concerned the art and science of surgery. Socioeconomic issues affecting surgical practice were only of minor importance. Consequently, little of the overall research into the delivery system of surgical health care has been conducted by the surgeon. In addition, since many of these investigations are ultimately published in journals not read by the surgeon it has been difficult if not impossible for the active practitioner to be aware of current thoughts and changing concepts in surgical health-services research. In this report, I discuss the major articles that have begun to analyze issues in this growing and important discipline. It is hoped that such a review will stimulate surgeons to begun taking a more active role in the formulation and conduct of future work into surgical health care delivery.