Surgical Health Care Research Articles

EP403 - Departmental Engagement in NELA AUDIT and Royal College Standards of Risk Assessment

Abstract Aims A review of Theatre cases to assess compliance with the ‘National Emergency Laparotomy Audit’ (NELA) and associated guidelines. This study aims to review and ensure eligible NELA patients are being recognised. Further objectives are to verify if NELA scores are calculated and documented by an ST3+ and, in addition, if frailty is assessed as per Royal College and NELA Standards. Methods Data was retrospectively collected. Using ‘Epic’ EPR, all theatres from 01/05/23 - 01/12/23 were filtered for Emergency Laparotomy. These cases were manually reviewed for eligibility in NELA. 101 eligible cases were investigated to assess: documentation of NELA / Ppossum, grade of documenting Doctor, and frailty assessments / referrals. Results 39.6% of the sample had a NELA Score documented. While even fewer at 24.8% had NELA score documented correctly by an ST3+. While 61.4% of cases had a Ppossum Score documented, only 32.7% had both NELA & Ppossum Documented. As per NELA and National Guidelines, only 38.6% of patients 65+ received appropriate assessments of frailty. Conclusion National Targets for the identification of NELA patients, risk assessments and frailty assessments when appropriate are not being met. Ultimately, this presents with increased risks to patients while also reducing the data set size from which national governing bodies can produce future improvements in surgical health care. Moreover, poor engagement with National Guidelines has negative implications for departmental funding. There is a large space for improvement through education and procedural change across multiple sites with subsequent follow up reaudit.

Concept Recognition and Characterization of Patients Undergoing Resection of Vestibular Schwannoma Using Natural Language Processing

Abstract Background Natural language processing (NLP), a subset of artificial intelligence (AI), aims to decipher unstructured human language. This study showcases NLP's application in surgical health care, focusing on vestibular schwannoma (VS). By employing an NLP platform, we identify prevalent text concepts in VS patients' electronic health care records (EHRs), creating concept panels covering symptomatology, comorbidities, and management. Through a case study, we illustrate NLP's potential in predicting postoperative cerebrospinal fluid (CSF) leaks. Methods An NLP model analyzed EHRs of surgically managed VS patients from 2008 to 2018 in a single center. The model underwent unsupervised (trained on one million documents from EHR) and supervised (300 documents annotated in duplicate) learning phases, extracting text concepts and generating concept panels related to symptoms, comorbidities, and management. Statistical analysis correlated concept occurrences with postoperative complications, notably CSF leaks. Results Analysis included 292 patients' records, yielding 6,901 unique concepts and 360,929 occurrences. Concept panels highlighted key associations with postoperative CSF leaks, including “antibiotics,” “sepsis,” and “intensive care unit admission.” The NLP model demonstrated high accuracy (precision 0.92, recall 0.96, macro F1 0.93). Conclusion Our NLP model effectively extracted concepts from VS patients' EHRs, facilitating personalized concept panels with diverse applications. NLP shows promise in surgical settings, aiding in early diagnosis, complication prediction, and patient care. Further validation of NLP's predictive capabilities is warranted.

Mother Capacity for Pain Care Model in a Surgical Pediatric Health Care Setting in Saudi Arabia

Mother Capacity for Pain Care Model in a Surgical Pediatric Health Care Setting in Saudi Arabia

Surgeon Sex and Health Care Costs for Patients Undergoing Common Surgical Procedures

Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex. To examine the association between surgeon sex and health care costs among patients undergoing surgery. This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023. Surgeon sex. The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates. Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202). This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

Financial Implications of the Merit-Based Incentive Payment System for Surgical Health Care Professionals

This study describes financial implications of the merit-based incentive payment system for surgical health care professionals.

The influence of the COVID-19 pandemic on total hip and knee arthroplasty in Ontario: a population-level analysis.

The effects of the COVID-19 pandemic on elective orthopedic surgery have yet to be reported at the population level in Canada. We sought to detail the effect of the pandemic on patients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA), and on surgeons with respect to surgical volume, wait times and health care quality. We compared patient length of hospital stay, revisions, readmissions and emergency department presentations between pre-pandemic (April 2019 to February 2020) and postpandemic (April 2020 to February 2021) cohorts of patients who underwent inpatient THAs or TKAs. Wait times for THA and TKA in Ontario were similarly collected. Case volumes for THA and TKA decreased by 30% during the pandemic. There were significantly fewer medically complex cases during this time period (p < 0.001). Length of hospital stay was reduced from 2.2 to 1.8 days (p < 0.001). Patients were less likely to visit the emergency department within 30 days of surgery (p < 0.001). Patients who underwent TKA were also more likely to be discharged directly home (p = 0.025). There was no difference in rate of revision surgery or readmission within 30 days. The proportion of patients meeting the standard benchmark wait time in Ontario was significantly lower (p < 0.001). The corresponding wait time to treatment increased significantly (p < 0.001). The effects of the COVID-19 pandemic on elective THA and TKA case volumes and wait times was significant. Patients having surgery during the pandemic were less medically complex, had shorter length of hospital stays and had significantly less health care utilization.

Risk factors contributing to early implant failure following sinus augmentation: A study of a challenging cohort.

Sinus augmentation has become a more predictable and successful procedure as the knowledge of its indications and complications increased. However, knowledge of risk factors leading to early implant failure (EIF) among challenging systemic and local conditions is insufficient. The present study aims to assess risk factors for EIF following sinus augmentation in a challenging cohort. A retrospective cohort study conducted during a period of 8 years in a tertiary referral centre providing surgical and dental health care. Implant and patient variables including age, ASA (American Society of Anesthesiology) physical status classification, smoking, residual alveolar bone, type of anaesthesia and EIF were collected. Cohort was comprised of 751 implants placed in 271 individuals. EIF rates at the implant and patient level were 6.3% and 12.5%, respectively. EIF was found to be higher among smokers (patient level: χ2 (1) = 8.74, p = .003), ASA 2 physical classification patients (patient level: χ2 (2) = 6.75, p = .03), sinuses augmented under general anaesthesia (patient level: χ2 (1)=8.97, p = .003), higher bone gain (implant level: W = 12 350, p = .004), lower residual alveolar bone height (implant level: W = 13 837, p = .001) and multiple implantations (patient level: W = 3016.5, p = 0.01). However, other variables such as age, gender, collagen membrane and implant's dimensions did not reach significance. Within the limits of the study, we can conclude that smoking, ASA 2 physical status classification, general anaesthesia, low residual alveolar bone height and numerous implants are risk factors for EIF following sinus augmentation in challenging cohorts.

It is time to revisit and re-evaluate Africa’s sub-par emergency surgical delivery

It is time to revisit and re-evaluate Africa’s sub-par emergency surgical delivery

A Financing Strategy to Expand Surgical Health Care.

Despite an evolving need to provide surgical health care globally, few health systems, particularly in low-income and middle-income countries (LMICs), can sufficiently provide such care. The vast majority of the world's people-an estimated 5 billion-are unable to access safe and affordable surgical health care when they need it. This is a significant concern for global public health because the demand for these services is rising with the epidemiological and demographic transitions occurring worldwide. A principal driver of weak surgical health care services is a lack of adequate health system financing for surgical health care. This article examines the financing of surgical health care by analyzing global trends in health system financing, approaches to expand fiscal space for health, and empirical perspectives on the design, introduction, and scale-up of policies to improve surgical systems. We describe a surgical health care financing strategy, together with broader political and economic considerations, to provide policy recommendations to fund the expansion of surgical health care and an essential surgical package as part of universal health coverage in LMICs.

Spotlight in Plastic Surgery: April 2023.

Spotlight in Plastic Surgery: April 2023.

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&lt;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&lt;0.001). MVA for predictors for 30 day major complications demonstrated RN (OR=0.913 p&lt;0.001). Cochran-Armitage trend analysis indicated that both MU and NMU had significant increases in PN between 2003 and 2021 (p&lt;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 Program of All-Inclusive Care for the Elderly (PACE) in Improving Medical Surgical and Mental Health Care: a Literature Review

Models of care services for the elderly in terms of medical surgical care and mental health need to be improved. Elderly with disabilities are at high risk of adverse health outcomes, and the best model of care has yet to be determined. A good holistic care model to empower every individual in society to improve the quality of care needs to be recommended. For example, comprehensive health care programs such as the Program of All-Inclusive Care for the Elderly (PACE) for adults and the elderly. The research objective was to determine the effectiveness of PACE in improving medical-surgical care and mental health. The search strategy for English-language studies relevant to the topic was carried out using the ScienceDirect database, limited from 2011 to 2021. The keywords used were “PACE”, “Medical Surgical Treatment”, “Mental Health”, “elderly”. Article full text reviewed to select studies that fit the criteria. The inclusion criteria in this review are: the nursing service program model, namely PACE. The search used the keywords above with the ScienceDirect database that matched the inclusion criteria for only 7 articles. The PACE service model improves services in Medical Surgical and Mental Health care, and implement a collaborative care model using a comprehensive interdisciplinary team.

Patient Safety and organizational Safety Culture in Surgery: A Need of an Hour in the developing countries

Every year, more than 200 million surgeries are performed around the world, and recent statistics show that adverse event rates for surgical pathologies remain unacceptably high, despite several national and global patient safety initiatives over the last decade. Patient safety is diverse and highly complicated in nature, with several critical components. Although concern for patient safety is fundamental in health care practice, its transition into knowledge is comparatively recent, and hence patient safety may be deemed a "new" field. Current surgical safety guidelines and checklists are generic and not adapted to specific patient concerns and risk factors in surgical subspecialties. All surgical practitioners and health care organizations must therefore become better aware of the fundamental context of patient safety, actively participate in endeavors to integrate patient safety measures in daily practice, and foster a patient safety culture. The purpose of this review article is to outline patient safety in surgical techniques that should be adopted and implemented.

The Transmogrification of Surgical Telehealth: a PRISMA Review

Telehealth has been used to care for patients at a distance in specific clinical and demographic situations, but the demand for physical isolation during the COVID-19 pandemic has expanded its application to the broader community. This systematic literature review, of very recent publications, elucidates the new ways telehealth has been implemented, confirms it’s acceptability, accessibility and safety by collating reviews, trial and cohort studies from peer reviewed journals meeting defined risk of bias criteria. Five literature reviews, three qualitative studies and 22 quantitative studies were included, which confirmed that telehealth is a safe medium for delivery of surgical health care, is accessible and efficient for the majority of patients and clinicians across the age and socioeconomic spectrum. It is time and resource efficient for providers and recipients and improves the delivery of patient-centred care. Many providers have published innovative solutions to the difficulties of telehealth, such as conducting a physical examination or technological limitations at the remote site. Health care can now be delivered directly to the home or the workplace. Routine in-person postoperative review of patients should be replaced by patient-led telehealth unless there is a specific reason for face-to-face review. Assessment and management of new cases could be managed more efficiently if a carefully planned digital referral process is developed and adopted.

Health System Structure: An Opportunity to Address Structural Racism and Discrimination.

To examine the role of hub-and-spoke systems as a factor in structural racism and discrimination. Health systems are often organized in a "hub-and-spoke" manner to centralize complex surgical care to 1 high-volume hospital. Although the surgical health care disparities are well described across health care systems, it is not known how they seem across a single system's hospitals. Adult patients who underwent 1 of 10 general surgery operations in 12 geographically diverse states (2016-2018) were identified using the Healthcare Cost and Utilization Project's State Inpatient Databases. System status was assigned using the American Hospital Association dataset. Hub designation was assigned in 2 ways: (1) the hospital performing the most complex operations (general hub) or (2) the hospital performing the most of each specific operation (procedure-specific hub). Independent multivariable logistic regression was used to evaluate the risk-adjusted odds of treatment at hubs by race and ethnicity. We identified 122,236 patients across 133 hospitals in 43 systems. Most patients were White (73.4%), 14.2% were Black, and 12.4% Hispanic. A smaller proportion of Black and Hispanic patient underwent operations at general hubs compared with White patients (B: 59.6% H: 52.0% W: 62.0%, P <0.001). After adjustment, Black and Hispanic patients were less likely to receive care at hub hospitals relative to White patients for common and complex operations (general hub B: odds ratio: 0.88 CI, 0.85, 0.91 H: OR: 0.82 CI, 0.79, 0.85). When White, Black, and Hispanic patients seek care at hospital systems, Black and Hispanic patients are less likely to receive treatment at hub hospitals. Given the published advantages of high-volume care, this new finding may highlight an opportunity in the pursuit of health equity.

Patient Satisfaction Towards Outdoor Medical And Surgical Services Provided in a Public Sector Tertiary Care Teaching Hospital of an Industrial City of Pakistan: A Cross-Sectional Study

Background &amp; Objectives: Patient satisfaction is a multidimensional concept that consists of client's perceived needs, their expectations and experience of a health care system. There is no data available on patient satisfaction with outdoor (OPD) medical and surgical health care services in public sector tertiary care hospital of an industrial city of Punjab, Pakistan. This study aimed at measuring patients' satisfaction towards health care facilities provided in OPD of a public sector tertiary care level hospital of Sialkot, Pakistan Methods: This descriptive, cross-sectional study was undertaken during the month of April-June, 2020 in the medical and surgical OPDs of Allama Iqbal Memorial teaching hospital, Sialkot. Overall, 180 adult patients visiting OPD were randomly selected and interviewed in-person in OPD settings using modified O-PAHC questionnaire. Analysis was based on descriptive characterization of participants, estimating patient's satisfaction score and assessing relationship of socio-demographic factors in relation to summary satisfaction score using multiple linear regression technique. Results: Of 180 participants, 93 clients were from medical and 87 were from surgical OPD. Most clients were aged 40 years or above, with females constituted 60% of sample. Two-third participants had no formal education. More than fifty percent clients were not satisfied with OPD timings, waiting time for examination, cleanliness in toilets, and surgeons not listening their health issues attentively. Mean satisfaction score was 59% ± 6 (range: 41% -70%). No statistically significant difference was found for mean satisfaction score as regards to age, sex, education status, and frequency of visit. Conclusion: On average, 59% of the OPD Clients attending medical and surgical departments of this teaching hospital were satisfied from its working. Hospital administration needs to devise strategy to reduce waiting time for consultation, extend OPD timings, with more efforts required to improve physical ambience.

Surgical Residents' Awareness of the Costs of Common Operating Room Supplies.

The Accreditation Council for Graduate Medical Education mandates that residency programs incorporate cost awareness into patient care. This presents a challenge for surgical residents because they must understand operating room costs in addition to other expenses. Trainees' understanding of operating room supply costs is not well understood. A survey was distributed to surgical residents (N = 73) at an urban, university-based residency program. Residents estimated the costs of 21 single-use operating room items. Descriptive statistics and a regression analysis were calculated. The response rate was 62%. Respondents accurately estimated costs for a median of 7/21 items, with error ranging from 26% to 5438%. They substantially underestimated the three highest-cost items. Increasing post-graduate year did not improve estimation accuracy (β = .233, P = .138). Residents have a poor understanding of single-use item costs, and this does not improve with post-graduate training, suggesting inefficiencies. There is opportunity to educate residents and ultimately decrease surgical health care costs.

Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization

Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations. To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations. This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021. The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation. Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation. Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.

Predicting Post-Operative Complications with Wearables

Post-operative complications and hospital readmission are of great concern to surgical patients and health care providers. Wearable devices such as Fitbit wristbands enable long-term and non-intrusive monitoring of patients outside clinical environments. To build accurate predictive models based on wearable data, however, requires effective feature engineering to extract high-level features from time series data collected by the wearable sensors. This paper presents a pipeline for developing clinical predictive models based on wearable sensors. The core of the pipeline is a multi-level feature engineering framework for extracting high-level features from fine-grained time series data. The framework integrates a set of techniques tailored for noisy and incomplete wearable data collected in real-world clinical studies: (1) singular spectrum analysis for extracting high-level features from daily features over the course of the study; (2) a set of daily features that are resilient to missing data in wearable time series data; (3) a K-Nearest Neighbors (KNN) method for imputing short missing heart rate segments; (4) the integration of patients' clinical characteristics and wearable features. We evaluated the feature engineering approach and machine learning models in a clinical study involving 61 patients undergoing pancreatic surgery. Linear support vector machine (SVM) with integrated feature engineering achieved an AUROC of 0.8802 for predicting post-operative readmission or severe complications, which significantly outperformed the existing rule-based model used in clinical practice and other state-of-the-art feature engineering approaches.

Impact of cancer surgery slowdowns on patient survival during the COVID-19 pandemic: a microsimulation modelling study.

Background:With the declaration of the global pandemic, surgical slowdowns were instituted to conserve health care resources for anticipated surges in patients with COVID-19. The long-term implications on survival of these slowdowns for patients with cancer in Canada is unknown.Methods:We constructed a microsimulation model based on real-world population data on cancer care from Ontario, Canada, from 2019 and 2020. Our model estimated wait times for cancer surgery over a 6-month period during the pandemic by simulating a slowdown in operating room capacity (60% operating room resources in month 1, 70% in month 2, 85% in months 3–6), as compared with simulated prepandemic conditions with 100% resources. We used incremental differences in simulated wait times to model survival using per-day hazard ratios for risk of death. Primary outcomes included life-years lost per patient and per cancer population. We conducted scenario analyses to evaluate alternative, hypothetical scenarios of different levels of surgical slowdowns on risk of death.Results:The simulated model population comprised 22 799 patients waiting for cancer surgery before the pandemic and 20 177 patients during the pandemic. Mean wait time to surgery prepandemic was 25 days and during the pandemic was 32 days. Excess wait time led to 0.01–0.07 life-years lost per patient across cancer sites, translating to 843 (95% credible interval 646–950) life-years lost among patients with cancer in Ontario.Interpretation:Pandemic-related slowdowns of cancer surgeries were projected to result in decreased long-term survival for many patients with cancer. Measures to preserve surgical resources and health care capacity for affected patients are critical to mitigate unintended consequences.