Types Of Elective Surgery Research Articles

Demographics and Trends for Inbound Medical Tourism in Germany for Orthopedic Patients before and during the COVID-19 Pandemic.

Medical tourism is a rapidly growing sector of economic growth and diversification. However, data on the demographics and characteristics of the traveling patients are sparse. In this study, we analyzed the common demographic properties and characteristics of the inbound medical tourists seeking orthopedic medical care in Germany for the years 2010 to 2019 compared to a domestic group. At the same time, we examined how the COVID-19 pandemic outbreak of 2020 changed the field of medical tourism in Germany. Calculations were performed using administrative hospital data provided by the Federal Statistical Department of Germany. Data were analyzed from the years 2010 to 2020. A total of six elective orthopedic surgery codes (bone biopsy, knee arthroplasty, foot surgery, osteotomy, hardware removal, and arthrodesis) were identified as key service indicators for medical tourism and further analyzed. Factors including residence, sex, year, and type of elective surgery were modeled using linear regression analysis. Age and sex distributions were compared between patients living inside Germany (DE) or outside Germany (non-DE). Between 2010 and 2020, 6,261,801 orthopedic procedures were coded for the DE group and 27,420 key procedures were identified for the non-DE group. Medical tourists were predominantly male and significantly younger than the domestic population. The linear regression analysis of the OPS codes over the past years showed a significantly different slope between the DE and non-DE groups only for the OPS code "hardware removal". With the COVID-19 pandemic, an overall decline in performed orthopedic procedures was observed for the non-DE and the DE group. A significant reduction below the 95% prediction bands for the year 2020 could be shown for hardware removal and foot surgery (for DE), and for hardware removal, knee arthroplasty, foot surgery, and osteotomy (for non-DE). This study is the first to quantify inbound medical tourism in elective orthopedic surgery in Germany. The COVID-19 pandemic negatively affected many-but not all-areas of orthopedic surgery. It has to be seen how this negative trend will develop in the future.

1706 Is A “COVID-19-Free” Hospital the Answer to Resuming Elective Surgery During the Current Pandemic? Results from The First Available Prospective Study

Abstract Background Resumption of elective surgery during the current coronavirus disease 2019 (COVID-19) pandemic crisis has been debated widely and largely discouraged. This prospective cohort study aimed to assess the feasibility of resuming elective operations during the current and possible future peaks of COVID-19 pandemic. Method Data were collected during the peak of the first pandemic in the United Kingdom on adult patients who underwent elective surgery in a “COVID-19-free” hospital from April 8 to May 29, 2020. The study included patients from various surgical specialities. Non-elective and pediatric cases were excluded. The primary outcome was 30-day mortality postoperatively. Secondary outcomes were the rate of COVID-19 infections, new onset of pulmonary symptoms after hospitalization and requirement for admission to the intensive care unit. Results 309 consecutive adult patients were included in this study. No patients died nor required intensive care unit admission. Operations graded “Intermediate” were the most performed procedures. One patient was diagnosed with COVID-19 infection after being transferred to the nearest local emergency hospital for management of postoperative pain and was successfully treated conservatively on the ward. No patient developed pulmonary complications. Three patients were admitted for greater than 23 hours. Twenty-seven patients (8.7%) developed complications. Complications graded as 2 and 3 according to the Clavien-Dindo classification occurred in 14 and 2 patients, respectively. Conclusions This prospective study shows that, despite the severity and high transmissibility of novel coronavirus 2 diseases, “COVID-19-free” hospitals can represent a safe setting to resume many types of elective surgery during the peak of a pandemic.

Current trends in management of hyperglycaemia in surgical patients with diabetes mellitus: a review

A large amount of clinical evidences demonstrates a clear association between long-term and/or stress-related hyperglycaemia, and development of complications after surgery. The incidences of perioperative hyperglycaemia are demonstrated in 20–80 % of all cases depending on the type of elective surgery, with the highest rate registered in cardiac surgery. The most studied pathophysiological complications of long-term hyperglycaemia in Diabetes Mellitus (DM) patients are; activation of the polyol pathway, diacylglycerol/protein kinase C and hexosamine pathways, advanced glycation product formation, and oxidative stress. The uncontrolled stress-related hyperglycaemia during and after surgery instigates: osmotic diuresis with further fluid and electrolyte imbalance, increased gluconeogenesis and glucogenolysis, breakdown of fats into free fatty acid and glycerol, proteins into amino acids, and increases generation of pro-inflammatory cytokines. All these changes may lead to development of diabetic ketoacidosis, immune deregulation and insulin resistance. Some clinical investigations seems to indicate that anaesthesia with propofol may have some advantages in keeping stable blood sugar over inhalational agents. Two clinical trials comparing the influence of different anaesthetic agents on perioperative glycaemic status in diabetic patients are currently underway. For better management of perioperative hyperglycaemia in diabetic patients under surgery we have proposed several important practical principles.
 

What has changed during the state of emergency due to COVID-19 on an Academic Urology Department of a Tertiary Hospital in Portugal

ObjectiveTo compare the activity the Urology Department of a Portuguese Academic Hospital during the state of emergency and the equivalent period at the previous year. We compared the number of elective consultations and diagnostic urologic examinations, number and type of elective surgeries, as well as patients’ demographic characteristics and main causes of presentation to Urology Emergency Department (ED) during the two mentioned periods. Materials and methodsData from 691 patients coming to emergency department were collected from institutional clinical software from March 18th 2020 to May 2nd 2020—and from the same period the previous year. Data collected were age, sex, day of the presentation to Emergency Department, referral from other hospitals, triage color, reason of admission, diagnosis of discharge, and the need for emergency surgery or hospitalization. In order to identify associations between demographic and clinical variables with having been submitted to an emergency surgery (outcome), logistic regression models were applied. ResultsMultivariable analysis showed an association of sex with being submitted to surgery, 65.6% decrease in the odds for the male gender. The period (COVID versus non-COVID) did not show a significant association with surgery. ConclusionOur department experienced an noticeable activity reduction. We also observe a reduction in urgent causes to attend the ED considered less serious. The percentage of cases requiring emergency surgery and hospitalization was higher during COVID-period.

Los cambios producidos durante el estado de alarma debido a la COVID-19 en un Servicio de Urología de un Hospital Universitario Terciario en Portugal

ObjectiveTo compare the activity the Urology Department of a Portuguese Academic Hospital during the state of emergency and the equivalent period at the previous year. We compared the number of elective consultations and diagnostic urologic examinations, number and type of elective surgeries, as well as patients’ demographic characteristics and main causes of presentation to Urology Emergency Department (ED) during the two mentioned periods Materials and methodsData from 691 patients coming to emergency department were collected from institutional clinical software from March 18 th 2020 to May 2 nd 2020 - and from the same period the previous year. Data collected were age, sex, day of the presentation to Emergency Department, referral from other hospitals, triage color, reason of admission, diagnosis of discharge, and the need for emergency surgery or hospitalization. In order to identify associations between demographic and clinical variables with having been submitted to an emergency surgery (outcome), logistic regression models were applied. ResultsMultivariable analysis showed an association of sex with being submitted to surgery, 65.6% decrease in the odds for the male gender. The period (COVID versus non-COVID) did not show a significant association with surgery. ConclusionOur department experienced a noticeable activity reduction. We also observe a reduction in urgent causes to attend the ED considered less serious. The percentage of cases requiring emergency surgery and hospitalization was higher during COVID-period.

Is a “COVID-19-free” hospital the answer to resuming elective surgery during the current pandemic? Results from the first available prospective study

BackgroundResumption of elective surgery during the current coronavirus disease 2019 pandemic crisis has been debated widely and largely discouraged. The aim of this prospective cohort study was to assess the feasibility of resuming elective operations during the current and possible future peaks of this coronavirus disease 2019 pandemic. MethodsWe collected data during the peak of the current pandemic in the United Kingdom on adult patients who underwent elective surgery in a “COVID-19-free” hospital from April 8 to May 29, 2020. The study included patients from various surgical specialties. Nonelective and pediatric cases were excluded. The primary outcome was 30-day mortality postoperatively. Secondary outcomes were the rate of coronavirus disease 2019 infections, new onset of pulmonary symptoms after hospitalization, and requirement for admission to the intensive care unit. ResultsA total of 309 consecutive adult patients were included in this study. No patients died nor required intensive care unit admission. Operations graded “Intermediate” were the most performed procedure representing 91% of the total number. One patient was diagnosed with a coronavirus disease 2019 infection after being transferred to the nearest local emergency hospital for management of postoperative pain secondary to common bile duct stone and was successfully treated conservatively on the ward. No patient developed pulmonary complications. Three patients were admitted for greater than 23 hours. Twenty-seven patients (8.7%) developed complications. Complications graded as 2 and 3 according to the Clavien-Dindo classification occurred in 14 and 2 patients, respectively. ConclusionThis prospective study shows that, despite the severity and high transmissibility of novel coronavirus 2 disease, COVID-19-free hospitals can represent a safe setting to resume many types of elective surgery during the peak of a pandemic.

A Qualitative Study Exploring Singaporean Parents' Perceptions on PreParing their Child for Surgery

PurposeTo explore the perceptions of parents regarding the preparation of their children for surgery. Design and methodsA qualitative descriptive study was conducted. Sixteen parents of children who were undergoing various types of elective surgery in a public tertiary hospital in Singapore were recruited. Data were collected through face-to-face interviews and analyzed using thematic analysis. ResultsFive themes were derived: (1) assumed roles of the parents; (2) communication, decision-making, and emotional challenges; (3) factors facilitating the preparation of children for surgery; (4) surgery-related and financial concerns; and (5) the desire for more information and better management. While preparing their children for surgery, parents undertook several roles to ensure readiness and to provide support. Parents faced challenges while communicating with their children regarding their surgeries, experiencing negative emotions and dilemmas in making decisions for surgery. Factors such as previous experiences, children's positive mentality, and access to information helped to facilitate their preparation. Parents expressed surgery-related concerns such as anesthesia and a successful outcome of the surgery, the timing of the surgery, and postoperative care. Parents expressed a desire for easier to understand information through the use of visual materials, and improvements in current practices and management. ConclusionThis study provides a greater understanding of parents' perceptions of their roles, challenges, influencing factors, concerns, and needs when preparing their children for surgery. Practice implicationsThe study findings provide insightful aspects for improving current healthcare practices and informing future research studies in exploring better surgery preparation programs for both parents and children.

Frailty in perioperative patients in three South African academic hospitals.

Frailty is a state characterised by diminished physiological reserve that leaves an individual vulnerable to external stressors and delays recovery. Frailty assessments are proving to be more valuable in predicting poor perioperative outcomes than other well-known perioperative risk assessment tools. Very few studies using validated frailty assessment tools have been done to assess the prevalence of frailty in South Africa (SA), and none have assessed the intraoperative implications of frailty in a surgical population. To determine the demographics and frailty levels of patients presenting for surgery at three academic hospitals in Johannesburg, compare intraoperative complications between the frail and non-frail patients, and compare the association between frailty scores and American Society of Anesthesiologists Physical Status (ASA-PS) scores. We prospectively enrolled 299 patients aged 18 - 90 years undergoing various types of elective surgery between mid-November 2016 and mid-March 2017 in three SA academic hospitals. Frailty was assessed using the nine-point Clinical Frailty Scale (CFS) and defined as a score of ≥5. The CFS and demographic and clinical data were documented by the anaesthetists assigned to the respective elective lists. The primary outcome measure was intraoperative complications (hypotension, desaturation, and need for vasopressors and blood transfusion). We also compared associations between the patients' comorbidities and frailty and those between the CFS and ASA-PS scores. Of a total of 299 patients included in the study (mean age (standard deviation) 50.6 (15.8) years), 156 (52%) were women and 67 (22%) were classified as frail. Compared with patients who were not classified as frail, the frail group had significantly higher incidences of hypotension (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.083 - 3.259; p=0.02) and desaturation (OR 3.79, 95% CI 1.367 - 10.54; p=0.01), and were more likely to need vasopressors (OR 2.81, 95% CI 1.607 - 4.912; p=0.00) and blood transfusion (OR 3.26, 95% CI 1.138 - 9.368; p=0.02). On multivariable logistic regression analysis, adjusting for factors related to frailty such as age, gender and comorbidities, desaturation was significantly associated with frailty (adjusted OR (aOR) 4.21, 95% CI 1.31 - 13.53; p=0.01), and the frail were more likely to require blood transfusion (aOR 5.36, 95% CI 1.50 - 19.16; p=0.01) and were older and had more comorbidities. Higher ASA-PS scores were also strongly associated with frailty. The prevalence of frailty was high among surgical patients. Consistent with other studies, frailty was associated with older age and multiple comorbidities. The association between frailty and intraoperative complications found in this study may indicate and help inform areas of further research.

POSTOPERATIVE OUTCOMES IN CHRONIC DIALYSIS PATIENTS: A META‐ANALYSIS OF 42 STUDIES AND 78,805 PATIENTS

Background: Chronic kidney disease is an independent risk factor for postoperative mortality, with an effect similar to that of diabetes mellitus or ischemic heart disease. However, the prognostic significance of dialysis‐dependence chronic kidney disease on perioperative outcomes, and its interaction with comorbid conditions is unclear. Aim: The aim of this study was to estimate the excess risk of postoperative mortality in patients receiving chronic dialysis undergoing elective non‐transplant surgery compared to those with normal kidney function, and to examine the influence on comorbidities on mortality risk. Methods: Two authors independently performed a systematic review of studies published up to 2018 was conducted using MEDLINE, EMBASE, DARE, CDSR, NICE, NIHR HTA databases. Eligible studies reported postoperative outcomes in patients on chronic dialysis and patients with normal kidney function undergoing major non‐transplant surgery. Non‐dialysis chronic kidney disease patients were excluded. Risk of bias was assessed using the Newcastle‐Ottawa Scale. Mortality risk estimates over all studies and according to surgical discipline were obtained using random effects meta‐analysis Meta‐regression analysis was performed to explore heterogeneity and assess associations of mortality with age, and comorbidities including ischemic heart disease and diabetes mellitus. (PROSPERO CRD42017076565) Results: Forty‐two studies involving 78,805 chronic dialysis and 9,984,469 non‐dialysis patients undergoing orthopaedic, vascular, cardiothoracic, general and urological procedures were included. Cohort selection and outcome ascertainment were of good quality, but comparability was poor. Absolute mortality rate varied from 0%‐8·9% in chronic dialysis patients and 0%‐3·9% in patients with normal kidney function across surgical disciplines. Patients on dialysis had a greatly increased postoperative mortality risk compared to patients with normal kidney function following all types of elective surgery (odds ratio [OR] 5·70, 95% CI 4·63 – 7·01). Adjustment for age and comorbidity attenuated this risk (OR 3·13, 95% CI 2·91 ‐ 3·34 I 290%). There was an inverse linear relationship between excess mortality risk and study‐level mean age (slope ‐0·06; P = 0·001), diabetes prevalence (slope ‐0·02; p = 0·001) and ischemic heart disease (slope ‐0·01; p = 0·049). Conclusions: Patients on chronic dialysis have a greatly increased postoperative mortality risk following elective surgery across all surgical disciplines, with the highest excess risk observed in those without other comorbidities. A comprehensive perioperative risk assessment and risk mitigation is required in patients on chronic dialysis.

PHP17 - Cost Saving Analysis of Encephalogram Bispectral Index Monitoring (Bis) During Ten Different Types of Elective Surgeries in Colombia

PHP17 - Cost Saving Analysis of Encephalogram Bispectral Index Monitoring (Bis) During Ten Different Types of Elective Surgeries in Colombia

Assessing surgical patients' expectations and subsequent perceptions of pain in the context of exploring the effects of preparatory information: raising issues of gender and status.

The present study explored both patients' expectations and experiences of pain in the context of utilizing an established research procedure, which previously reported a significant effect of instructional information on post-surgical recovery. No research to date has systematically attempted to identify pre-operative expectations of post-operative pain, nor has it compared pre- and post-operative ratings. A further variable scrutinized during the study was patient gender.Thirty-two males and 31 females undergoing two types of elective surgery were randomly allocated into experimental and control conditions by a third party. Patients in the experimental group received additional instruction information pre-operatively from the anaesthetist and the control group received the routine pre-operative visit. Using a numerical pain scale, all participants provided ratings of expected pain levels and subsequently rated their pain following surgery.Results obtained were contrary to expectations with respect to the effects observed by the established study as instructional information had no significant effect on recovery variables. However, the study did suggest that pre- and post-operative pain ratings were broadly equivalent. A significant gender difference was also found with male patients expecting less pain than they perceived and an opposite pattern for females. Measuring both pain expectations and perceptions is considered a useful technique to inform pain management and is worthy of further investigation. The inconsistent effect of instructional information and the gendered rating patterns are considered in relation to gender and status differentials between health providers and have important implications for future research. Copyright 1999 European Federation of Chapters of the International Association for the Study of Pain.

The effect of financial incentives on gatekeeping doctors: Evidence from a natural experiment

In many health care systems generalist physicians act as gatekeepers to secondary care. Under the English fundholding scheme from 1991/1992 to 1998/1999 general practices could elect to be given a budget to meet the costs of certain types of elective surgery (chargeable electives) for their patients and could retain any surplus. They did not pay for non-chargeable electives or for emergency admissions. Non-fundholding practices did not bear the cost of any type of hospital admissions. Fundholding is to be reintroduced from April 2005. We estimate the effect of fundholding using a differences in differences methodology on a large 4-year panel of English general practices before and after the abolition of fundholding. The abolition of fundholding increased ex-fundholders’ admission rates for chargeable elective admissions by between 3.5 and 5.1%. The effect on the early wave fundholders was greater (around 8%) than on later wave fundholders. We also use differences in differences for two types of admissions (non-chargeable electives, emergencies) not covered by fundholding as additional controls for unobserved temporal factors. These differences in differences in differences estimates suggest that the abolition of fundholding increased ex-fundholders’ chargeable elective admissions by 4.9% (using the non-chargeables DID) and by 3.5% (using the emergencies DID).

Assessing surgical patients' expectations and subsequent perceptions of pain in the context of exploring the effects of preparatory information: raising issues of gender and status

The present study explored both patients' expectations and experiences of pain in the context of utilizing an established research procedure, which previously reported a significant effect of instructional information on post-surgical recovery. No research to date has systematically attempted to identify pre-operative expectations of post-operative pain, nor has it compared pre- and post-operative ratings. A further variable scrutinized during the study was patient gender. Thirty-two males and 31 females undergoing two types of elective surgery were randomly allocated into experimental and control conditions by a third party. Patients in the experimental group received additional instruction information pre-operatively from the anaesthetist and the control group received the routine preoperative visit. Using a numerical pain scale, all participants provided ratings of expected pain levels and subsequently rated their pain following surgery. Results obtained were contrary to expectations with respect to the effects observed by the established study as instructional information had no significant effect on recovery variables. However, the study did suggest that pre- and post-operative pain ratings were broadly equivalent. A significant gender difference was also found with male patients expecting less pain than they perceived and an opposite pattern for females. Measuring both pain expectations and perceptions is considered a useful technique to inform pain management and is worthy of further investigation. The inconsistent effect of instructional information and the gendered rating patterns are considered in relation to gender and status differentials between health providers and have important implications for future research.

The influence of surgical sites on early postoperative hypoxemia in adults undergoing elective surgery.

To determine the influence of the surgical sites on early postoperative hypoxemia, we studied postoperative hypoxemia in 994 patients, ASA physical status I or II, aged 18-68 yr, scheduled for various types of elective surgery. Patients were divided into three groups on the basis of the surgical sites: Group 1 = elective superficial plastic surgery (n = 288); Group 2 = upper abdominal surgery (n = 452); and Group 3 = thoracoabdominal surgery (n = 254). Anesthesia was maintained with 1%-2% enflurane and 67% nitrous oxide in oxygen; thiopental or fentanyl was given IV as required. SpO2 levels were recorded while patients breathed room air shortly after arrival in the recovery room (0 min) and 5, 10, 15, 20, 30, 40, 50, 60, 120, and 180 min thereafter. The results showed that during the early postoperative period, the degree of arterial desaturation and the incidences of hypoxemia (SpO2 86%-90%) and severe hypoxemia (SpO2 85%) were closely related to the operative sites and were greatest for thoracoabdominal operations, less for the upper abdominal operation, and least for the peripheral surgery. The incidence of hypoxemia and severe hypoxemia in the recovery room was 7% and 0.7%, respectively, in Group 1, 38% and 3% in Group 2, and 52% and 20% in Group 3. Mild airway obstruction and hypothermia in the postanesthesia recovery unit (PAR) were the predictive factors of early postoperative hypoxemia. We conclude that during the early postoperative period, there were significant differences in SpO2 levels and incidences of hypoxemia and severe hypoxemia among the three groups. We found that the severity of arterial desaturation and the incidence of hypoxemia during the early postoperative period are closely related to the surgical sites and are strongest for thoracoabdominal surgery, less for upper abdominal surgery, and least for peripheral surgery.

Hospital Costs and Severity of Illness in Three Types of Elective Surgery

MACARIO, ALEX; VITEZ, TERRY S.; DUNN, BRIAN; MCDONALD, TOM; BROWN, BYRON; Diaz, James H. M.D., Dr.P.H. Author Information

Hospital costs and severity of illness in three types of elective surgery.

If patients who are more severely ill have greater hospital costs for surgery, then health-care reimbursements need to be adjusted appropriately so that providers caring for more seriously ill patients are not penalized for incurring higher costs. The authors' goal for this study was to determine if severity of illness, as measured by either the American Society of Anesthesiologists Physical Status (ASA PS) or the comorbidity index developed by Charlson, can predict anesthesia costs, operating room costs, total hospital costs, or length of stay for elective surgery. The authors randomly selected 224 inpatients (60% sampling fraction) having either colectomy (n = 30), total knee replacement (n = 100), or laparoscopic cholecystectomy (n = 94) from September 1993 to September 1994. For each surgical procedure, backward-elimination multiple regression was used to build models to predict (1) total hospital costs, (2) operating room costs, (3) anesthesia costs, and (4) length of stay. Explanatory candidate variables included patient age (years), sex, ASA PS, Charlson comorbidity index (which weighs the number and seriousness of coexisting diseases), and type of insurance (Medicare/Medicaid, managed care, or indemnity). These analyses were repeated for the pooled data of all 224 patients. Costs (not patient charges) were obtained from the hospital cost accounting software. Mean total hospital costs were $3,778 (95% confidence interval +/- 299) for laparoscopic cholecystectomy, $13,614 (95% CI +/- 3,019) for colectomy, and $18,788 (95% CI +/- 573) for knee replacement. The correlation (r) between ASA PS and Charlson comorbidity scores equaled 0.34 (P < .001). No consistent relation was found between hospital costs and either of the two severity-of-illness indices. The Charlson comorbidity index (but not the ASA PS) predicted hospital costs only for knee replacement (P = .003). The ASA PS, but not the Charlson index, predicted operating room and anesthesia costs only for colectomy (P < .03). Severity of illness, as categorized by ASA PS categories 1-3 or by the Charlson comorbidity index, was not a consistent predictor of hospital costs and lengths of stay for three types of elective surgery. Hospital resources for these lower-risk elective procedures may be expended primarily to manage the consequences of the surgical disease, rather than to manage the patient's coexisting diseases.