Surgical Health Care Research Articles

High-Risk Surgery

Surgical morbidity is a significant public health issue worldwide. It is estimated that >230 million surgical procedures are performed each year, with an estimated mortality of at least 0.4% and morbidity of between 3% and 17%. Furthermore, there are potentially far-reaching consequences of a complicated perioperative course, because perioperative morbidity is associated with reduced long-term survival. In this review, we examine the factors that are associated with surgical outcomes. Issues related to the delivery of health care, such as structure, process, and resource utilization, have been shown to vary within and between institutions, leading to differences in both morbidity and mortality after surgery. Patient-related factors, in particular comorbid illness, functional capacity, and cardiovascular health, are also related to perioperative risk, and may be assessed using risk stratification models, exercise testing, and biomarker assays. The strengths and weaknesses of each of these techniques are discussed. We also review the strengths and limitations of the measures used to assess outcome after surgery, including patient-centered variables such as mortality and morbidity scores, and patient-related outcome measures. Finally, we suggest the direction of future work, which should be aimed at improving the precision of tools for describing perioperative risk, and of the measures used to assess the outcomes and quality of surgical health care. These tools are the building blocks of high-quality clinical trials, epidemiological studies, and quality improvement programs.

Determinants of good adherence to hand hygiene among surgical health care workers

Background: Hand hygiene is the main pillar on standard precautions (hospital infection prevention), and of increasing concern. Nevertheless few is known about cognitive, attitude, perception and motivational determinants of hand hygiene’s health care workers in a surgical arena where they have never been exposed to amultimodal hand hygiene campaign. Methods: Cross-sectional study in a 900-bed university teaching hospital in Barcelona (Spain). A confidential self-administered and validated questionnaire survey was conducted in a sample of 176 surgical units’ healthcare workers (medical and nursing) before a multimodal Hand hygiene (HH) campaign started. Results: A total of 172 questionnaires were returned (response rate 97.7%), 54 (30.7%) were physicians, 75 (42.6%) were nurses and 47 (26.7%) nursing assistants. The median years of institution experience was 13.00 years (IQR 20.0), 68.8% were women, 21% were from the General Surgery ward, 21.6% were from the Urology, 39.8% from the Orthopedics and 17.6% from the Vascular Surgery ward. The self HH compliance estimated was 77.47(DE17.74), being in 107 participants (63.7%) higher than 80%. Knowledge determinants were poorly ranked as determinants of hand hygiene (OR 1.08, CI95% 1,02—1.15), while motivation to improve the hand hygiene compliance (OR 0.59, CI95% 0,39—0.88) and medical staff (OR 0.11, CI95% 0.02—0.55) or nurses (OR 0.15, CI95% 0.04—0.66) versus nursing assitants were higly ranked as determinants, independently of positive perception about hand hygiene, gender, attitude toward HH and years of institutional experience. Conclusion: In a setting of absent exposure to hand hygiene campaign, knowledge about hand hygiene, motivation and profesional status are strongly in favor of hand hygiene, rather than behavioral beliefs, independently of gender, more than 10 years of institution experience, and professional category. These results are quite different from that observed in an extensive exposure to hand hygiene campaigns where behavioral beliefs and the perception of high self-efficacy are related to hand hygiene compliance rather than reasoning. This additional insight should be considered in settings that have never been exposed to promotion activities about standard precautions.

National and Surgical Health Care Expenditures, 2005–2025

Health care expenditures for 2005 in the United States were $1.9733 trillion and 15.9% of the gross domestic product (GDP). Twenty-nine percent of those expenditures were secondary to surgical revenues. Health care expenditures are increasing 2(1/2) times the rate of the general US economy and are being fed by new technologies, new medications, the aging population, more services provided per patient, defensive medicine and little tort reform, the insurance system, and the free rider problem, ie, patients are cared for as emergencies regardless of insurance coverage and legality, which all have contributed to rising health care and surgical expenditures over the last 50 years. The purpose of this study was to project aggregate national health care expenditures, aggregate surgical health care expenditures, and the United States GDP for the years 2005-2025. Model building and existing state and national data were used. Aggregate surgical health care expenditures were computed as 29% of aggregate health care expenditures using a unique model developed by the late Dr. Francis D. Moore. The model of Dr. Moore which used 1981 federal data was verified/tested using data from UMDNJ-University Hospital, and New Jersey and national data from 2005. From 1965 to 2005 mean health care expenditures increased at 4.9% per year, and US GDP increased at a mean of 2.1% per year. Aggregate surgical expenditures are expected to grow from $572 billion in 2005 (4.6% of US GDP) to $912 billion (2005 dollars) in the year 2025 (7.3% of US GDP). Aggregate health care expenditures are projected to increase from $5572 per capita (15.9% of GDP) in 2005 to $8832 per capita (2005 dollars) in 2025 (25.2% of US GDP). Both surgery and national health care expenditures are expected to expand by almost 60% during the period 2005-2025. Thus, surgical health care expenditures by 2025 are likely to be 1/14 of the US economy, and health care expenditures will be (1/4) of the US economy. Real per capita GDP growth is relatively flat in the United States. Rising surgical health care expenditures and national health care expenditures are a significant issue for the US population. Unfortunately, programs at the state and federal level as well as private programs, for the last 50 years have not been able to slow the growth in health care expenditures. These trends are likely to continue and the effects will be: * A change in the US standard of living as surgical and health care expenditures become a larger part of the earned dollar per American especially with the current volatility of the US economy, * A rise in the cost of products made in the United States to pay the rising health care bill with a concomitant change in our national and international standard of living, and * An increasing debt and increases in federal and state taxes which will be required to maintain the current health care system, ie, Medicare, Medicaid, and the private health care insurance payment scheme, which has not changed substantially over the past 40 to 50 years. Surgeons must look at the incremental benefit of new technologies and procedures and determine which to choose if we are to slow the growth of surgical health care expenditures.

Addressing the Millennium Development Goals From a Surgical Perspective

Surgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs. Survey. District-level health facilities in multiple LMICs A standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons. Data from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of São Tomé and Príncipe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus. Enormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

Current concepts and future perspectives on surgical optical imaging in cancer

There are vibrant developments of optical imaging systems and contrast-enhancing methods that are geared to enhancing surgical vision and the outcome of surgical procedures. Such optical technologies designed for intraoperative use can offer high integration in the operating room compared to conventional radiological modalities adapted to intraoperative applications. Simple fluorescence epi-illumination imaging, in particular, appears attractive but may lead to inaccurate observations due to the complex nature of photon-tissue interaction. Of importance therefore are emerging methods that account for the background optical property variation in tissues and can offer accurate, quantitative imaging that eliminates the appearance of false negatives or positives. In parallel, other nonfluorescent optical imaging methods are summarized and overall progress in surgical optical imaging applications is outlined. Key future directions that have the potential to shift the paradigm of surgical health care are also discussed.

SE13P OPEN DISCLOSURE PROGRAM: SHOULD ALL TRAINEE SURGEONS BE EDUCATED?

Open disclosure is the open discussion of incidents or errors that results in harm to a patient while receiving health care. Disclosing medical errors respects patient autonomy, and truth‐telling is desired by patients and their surrogates and is endorsed by ethicists and many professional organisations. Despite this, recent research would suggest that, the full disclosure of errors to patients by physicians especially by trainee doctors is very low (i.e. 24%). The question remains how can one change this culture?A two day open disclosure consultant training program introduced by Queensland Health was attended with the sole purpose being to establish a working group of senior clinicians to lead institutional open disclosure. To our knowledge no such programme exists for trainee doctors. Introducing open disclosure education during the early part of training may alleviate concerns of the trainees in terms of support the institution would provide should medical errors occur. The implementation of such programmes may also encourage junior doctors to report errors more openly without fear of repercussion. The knock on effect would be a more ‘open disclosure’ orientated culture which fosters greater trust from patients and their surrogates.We strongly believe that training in open disclosure should be an integral part of the surgical training program and health care institutions and organisations should strengthen their support for these programs. This we hope will improve the clinical incident management and will facilitate more consistent and effective communication following an adverse event.

The University of Cincinnati College of Medicine Department of Surgery

The University of Cincinnati College of Medicine Department of Surgery has a legacy of discovery, transformation, and education that began more than 200 years ago. Through collaborations with related disciplines at the University of Cincinnati, industry, the government and military, as well as our partners in the community, we look forward to new innovations to continue the legacy and our ongoing mission to provide the best possible surgical care, research, and education of our future surgeon leaders. Our mission remains: 1) To provide comprehensive surgical services for Cincinnati and the surrounding region; 2) To train the next generation of surgeon leaders; 3) To advance the state-of-the-art and scientific basis of the discipline of surgery; and 4) To provide leadership in ensuring surgical health care for all members of the Cincinnati community. These principles have always been part of our legacy and ongoing challenges as an academic department of surgery. It is a proud tradition that we embrace and will carry into the future.

Latex allergy: new insights to explain different sensitization profiles in different risk groups

Differences in latex allergen sensitization profiles have been described between children subjected to repetitive surgical interventions and health care workers (HCW). 'Major' allergens for patients with spina bifida are Hev b 1, 3 and 7, while for HCW, 'major' allergens are Hev b 2, 5, 6.01 and 13. The reason for these differential sensitization profiles is currently unknown. To investigate latex allergen profiles on internal and external surfaces of natural rubber latex gloves. Eighty-two samples of commonly used surgical gloves (41 glove brands) were used for analysis. Specific allergen levels of Hev b 1, 3, 5 and 6.02 on both surfaces of the gloves were quantified using an enzyme immunometric assay, a FITkit (FIT Biotech, Tampere, Finland). Differences in allergen levels were observed between internal and external surfaces of all glove types. Concentrations of Hev b 1 and Hev b 3 were significantly higher on external surfaces, while internal surfaces had higher allergen levels of Hev b 5 and Hev b 6.02. Analysis of surgical and examination gloves, powdered and nonpowdered gloves also showed that the content of Hev b 5 and Hev b 6.02 was significantly higher on internal surfaces while that of Hev b 1 and Hev b 3 was higher on external surfaces. Our study showed different allergen profiles on internal and external surfaces of natural rubber latex gloves. These results may suggest a relationship between latex allergen localization and sensitization routes in different risk groups.

Knowledge Transfer in Surgery: Skills, Process and Evaluation

Knowledge transfer is an essential element in the management of surgical health care. In a routine clinical practice, surgeons need to make changes to the health care they provide as new clinical evidence emerges. The information was derived from the authors' experience and research in evidence-based practice, searching of the literature, teaching and organisation of various national and international workshops on evidence-based medicine. This manuscript discusses principles of knowledge transfer in surgery including evaluation of recommended changes that can improve quality of health care in routine surgical practice. Skills, process and evaluation are carefully described. Continuous information delivery is required to enable surgeons to improve knowledge transfer and to keep up to date their knowledge.

Prospects of Developing Medical Tourism in India

Medical tourism is one of the recently developed and rapid growing tourism activities of the World, especially in India. "Medical Tourism can be generally defined as the movement of people for the purpose of getting cost effective personal health care in association with the tourism industry for patients needing surgical health care and other forms of dedicated treatment." Recent days several Indian state governments have realized the potential of medical tourism and have been actively promoting it Visitors, especially from the West and the Middle East find Indian hospitals a very affordable and viable option to grdppling with insurance and National medical systems in their native lands and combine their treatments with a visit to the 'exotic east' with their families.Quality medical treatment at low cost, coupled with great traveling experience is possibly the perfect way to recover from any medical ailment. An inexpensive vacation package combined with a low cost medical treatment has led to the evolution of a new but rapidly growing industry called medical tourism. This process is being facilitated by M1 the corporate sector concerned in heath care as well as the tourism industry including tour operators, hospital administrators, travel agents, airlines, hotels and government tourism organizations. Medical or health treatment package tourism has become a persistent form of engaging the vacation in a different way by inculcating leisure with treatment and covers a broad range of health, medical and dental services. Medical tourism is organized in such a manner that leisure time inculcate with enjoyment and recreation together with wellness and health care packages in a country other than the place of residence. Health and Medical Tourism is perceived as one of the fastest growing segments in marketing 'Destination India' today. The Ministry of Tourism, airlines, tour operators, insurance companies, tourism sector and healthcare providers can make India as a dream destination for medical Tourism through an orchestrated effort. Government and private organizations that are playing a vital role in the development of tourism in India should orchestrate their developmental efforts to take advantage of the enormous potential of Medical and Dental tourism through ensuring international standard treatment to the patients and envisage a coordinated marketing and promotional strategies enough to overcome the Asian competitors.

Placing the future in safe hands: legacy funds at the College

As a registered charity independent of the NHS, the College is heavily reliant on voluntary income. Legacies, in particular, have always played a vital role in the College's funding and have in the past enabled us to purchase equipment and to support projects: often in areas of surgical health care that were of special interest or concern to the legator. In reviewing the activities of the College over the past year, for the first time we have taken the opportunity in the annual report to thank this very important group of donors who wish to push forward the boundaries of surgery through leaving a legacy to the College in their will.

Health Surveillance for Rural Volunteer Firefighters and Emergency Medical Services Personnel

The purpose of this study was to assess the effectiveness of coronary heart disease risk screening as a primary prevention tool. Screening included a lipid screening and American College of Cardiology Framingham cardiac risk profile for volunteers 45 years and older desiring A (interior) or B (exterior) classifications. Health surveillance records from 1998 to 2003 were reviewed for all firefighters and emergency medical services personnel in a rural New York county. Of the 1,458 volunteers evaluated, 1,166 were men and 292 were women. Three hundred fifteen individuals were screened for coronary heart disease risk; 52 had scores indicative of substantially increased risk. Subsequently, a health care provider or cardiologist saw 39 of these individuals, 26 (67%) of whom received pharmacologic, surgical, or other health care intervention. Coronary heart disease risk screening is an effective intervention in this population, and provides volunteers and their primary care providers with added motivation to actively reduce the risk of coronary heart disease via early intervention.

An International Perspective on Surgical Health Care and Education

An International Perspective on Surgical Health Care and Education

Nature of human error: implications for surgical practice.

As the attitude to adverse events has changed from the defensive "blame and shame culture" to an open and transparent healthcare delivery system, it is timely to examine the nature of human errors and their impact on the quality of surgical health care. The approach of the review is generic rather than specific, and the account is based on the published psychologic and medical literature on the subject. Rather than detailing the various "surgical errors," the concept of error categories within the surgical setting committed by surgeons as front-line operators is discussed. The important components of safe surgical practice identified include organizational structure with strategic control of healthcare delivery, teamwork and leadership, evidence-based practice, proficiency, continued professional development of all staff, availability of wireless health information technology, and well-embedded incident reporting and adverse events disclosure systems. In our quest for the safest possible surgical health care, there is a need for prospective observational multidisciplinary (surgeons and human factors specialists) studies as distinct for retrospective reports of adverse events. There is also need for research to establish the ideal system architecture for anonymous reporting of near miss and no harm events in surgical practice.

Differential expression of allergens on the internal and external surfaces of latex surgical gloves

Background Differences in latex allergen sensitization profiles have been described between children undergoing repeated surgical interventions and health care workers. The purpose of this study was to determine whether such sensitization profiles are associated with differences in the expression of latex allergen between the internal and external surfaces of surgical gloves. Methods Extracts were obtained from whole surgical gloves as well as from their external and internal surfaces. The extracts were centrifuged, filtered, concentrated, dialyzed and lyophilized. The protein profile of the extracts was analyzed using hydrophobic interaction chromatography (HIC) and sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Immunoblotting was performed using era from two patients with confirmed latex allergy. Latex recombinant allergen-specific IgE in these two patients was determined using a fluorescence enzyme immunoassay (FEIA) method. Latex allergen quantification was determined on both glove surfaces using an ELISA method. Results HIC and SDS-PAGE showed qualitative and quantitative differences in proteins between the internal and external glove surfaces, with the former being much richer in proteins. Immunoblotting of glove extracts using sera from two latex-allergic health workers showed differences between glove surface extracts. ELISA quantification of latex allergens demonstrated that the internal glove surface had high amounts of Hev b 5 and Hev b 6.02 whereas the external surface showed Hev b 1, Hev b 3, and Hev b 6.02. Conclusions Our results reveal substantial differences in the composition of latex allergen profiles between the internal and external surfaces of surgical latex gloves, which may suggest a relationship between latex allergen localization and sensitization routes in different risk groups.

Evidence-based medicine—from best research evidence to a better surgical practice and health care

The use of the terms evidence-based medicine (EBM) and healthcare (EBHC) has become commonplace in the medical as well as in the surgical literature. Using the best available evidence, however, is not yet a working routine among surgeons because of the large amount and complexity of published research and the lack of user-friendly tools and necessary skills for the use of research results. This article encourages to formulate surgically relevant questions and to answer them on the basis of high-quality research, preferably by using systematic reviews which are based on the quality criteria of the Cochrane Collaboration. As currently only 77 Cochrane reviews address surgical procedures; much work remains to be done to enlarge the number of high-quality and relevant reviews. Similarly, the number and quality of randomized controlled trials need to be increased in all surgical specialties.

Socioeconomic status and the utilization of diagnostic imaging in an urban setting

In publicly funded health care systems, the utilization of health care services should be equitable, irrespective of socioeconomic status (SES). Although the association between SES and health care utilization has been examined in Canada relative to surgical, cardiac and preventive health care services, no published studies have specifically explored the association between SES and diagnostic imaging. We examined over 300,000 diagnostic imaging claims made in the Winnipeg Regional Health Authority between Apr. 1, 2001, and Mar. 31, 2002. Using patient postal codes, we assigned SES on the basis of average household incomes in Canada's 1996 census. Using multiple regression, we examined the association between income quintile, patient age group (< or =16, 17-64, > or = 65 years), patient morbidity level according to the Johns Hopkins University Adjusted Clinical Group method (high, moderate, low), and imaging modality (general radiology, vascular, computed tomography, magnetic resonance, and general and obstetric ultrasound). Relative rates (RR) of diagnostic imaging utilization (highest v. lowest income quintile) were significantly increased in pediatric and adult patient groups at all morbidity levels receiving general radiology (highest RR 2.47, 95% confidence interval [CI] 2.07-2.93); pediatric and adult patient groups at high and low morbidity levels and elderly patient groups at low morbidity levels receiving general ultrasound (highest RR 2.26, 95% CI 1.20-4.26); pediatric and adult patient groups at all morbidity levels and elderly patients at high and moderate morbidity levels receiving magnetic resonance imaging (highest RR 2.51, 95% CI 1.78- 3.52); and adult patient groups at all morbidity levels receiving computed tomography (highest RR 1.46, 95% CI 1.35- 1.59). A lower RR of diagnostic imaging utilization in the highest income quintile was found only among patients receiving obstetric ultrasound (RR 0.80, 95% CI 0.73-0.87). No significant associations were found among elderly patients receiving general radiology or computed tomography or adult patients receiving vascular imaging. We found a pattern of increased diagnostic imaging utilization in patient groups with a higher SES. Further research is needed to better understand the nature of this finding and how it contributes to health outcomes.

Inequality of Access to Surgical Specialty Health Care: Why Children With Government-Funded Insurance Have Less Access Than Those With Private Insurance in Southern California

More than 25 million children in the United States are dependent on federal and state medical insurance programs for their health care needs. In California, 3.25 million children depend on Medi-Cal for their health insurance. In Southern California alone, the figure is as high as 1.81 million. However, 9.30 million children nationally and 1.55 million in California have no health insurance. Various public policies that would increase enrollment in these programs are being discussed to address this problem. However, before their implementation, it is important to understand what impact such policies would have on the actual delivery of health care to this patient population. In California, 2 predominant health care delivery models exist for Medi-Cal: a fee-for-service (so-called regular or straight Medi-Cal) and a managed care plan. One third of the children in Medi-Cal in the state are enrolled in the fee-for-service plan with the remainder in the managed care plan, whereas in Southern California, this figure is slightly lower at 28% in the fee-for-service plan. The objective of this study was to determine the number of otolaryngologists in Southern California who would offer a new patient appointment for an evaluation for tonsillectomy for a child with commercial insurance versus government-funded (Medi-Cal) insurance through direct contact with the physician and to determine whether the surgeon would offer to perform the procedure or refer the patient to another institution and to identify the specific reason(s) for any disparity in access to health care. A written questionnaire was sent via regular mail to 303 otolaryngologists in the Southern California area in 2003. A total of 100 fully completed questionnaires were received. Ninety-seven surgeons would offer an office appointment to a child with commercial insurance as compared with only 27 for a child with Medi-Cal. Of those 27 surgeons, 8 would then refer the child to another physician to perform the surgery, and only 19 would actually offer to perform surgery, if indicated. Reasons provided for not offering an office appointment or surgery for the child with Medi-Cal include excessive paperwork and/or administrative burdens (96%), low monetary reimbursement for the surgery (92%), and low monetary reimbursement for the office visit (87%). There is a tremendous inequality of access to surgical specialty health care for children with government-funded insurance when compared with those with commercial insurance in Southern California. Physicians indicate that this disparity is related to excessive administrative burdens and low monetary reimbursement. The implications of our findings on public health care policies are discussed.

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.

Methodological challenges in the study of psychological recovery from modern surgery

Most cases of elective surgery in the UK are now undertaken in day-case facilities, and the trend is set to increase. Surgical and anaesthetic health care is changing rapidly. Traditional pre- and post-operative nursing intervention, once commonly taught and practised, must now be re-evaluated as a result of such transformations. However, undertaking research in order to investigate the fresh challenges facing nursing in the modern surgical environment may present many difficulties. Methodological issues, such as the application of research approaches, time for adequate data collection, and the utilisation of patients as participants undergoing modern surgery, will present numerous barriers. In this article, Mark Mitchell identifies and discusses three problematic methodological issues that currently challenge the effective study of psychological recovery from modern surgery in the UK.