14.20 Improving Trauma and Emergency Care in China: Results from an International Training Collaborative

Posted on December 22, 2014

A. Chaturvedi1, Y. V. Pei2, A. Mohammed3, D. Clapp1, D. M. Allin4, C. Orner5, M. Narayan1  1University Of Maryland,R Adams Cowley Shock Trauma Center,Baltimore, MD, USA 2University Of Maryland,Department Of Emergency Medicine,Baltimore, MD, USA 3Calderdale Royal Hospital,Department Of Emergency Medicine,Halifax, WEST YORKSHIRE, United Kingdom 4University Of Kansas,Department Of Medicine,Lawrence, KS, USA 5Heart To Heart International,Olathe, KS, USA 6China 120,Trauma And Emergency Responce Center,Chengdu, SICHUAN, China

Introduction:
The practice of emergency medicine in China officially began only 28 years ago. However, due to a lack of standardized formal training for emergency medical practitioners, the practice of trauma and emergency care in China is still in early development. Pre-hospital providers in China are typically physicians and nurses who undergo fragmented training at sites that hold variable certification requirements. International speakers are often invited to participate in the instruction of medical professionals. The purpose of this study is to evaluate the impact of an English-based trauma and emergency medicine training module on participants’ confidence in knowledge and skills.

Methods:

An English-based training module was established in conjunction with several international institutions and the Chengdu 120 Center, Chengdu, China. 4 days of structured training in English with consecutive Chinese translation consisted of didactic presentations and practical skills stations targeting nurses and physicians. Participants completed surveys assessing pre and post confidence in knowledge and skills using a semantic differential scale.

Results:
A total of 101 surveys were collected from 63 doctors and 38 nurses from Chengdu. 48% of participants were male. 71% of all participants were between the ages of 20 and 39. Education ranged from high school to master’s level of training. 66% of participants reported having received formal training in trauma within the last 2 years and 56% reported having received formal training in disaster management. Of the 101 surveys, 86 (55 doctors and 31 nurses) were complete for statistical analysis. Student’s t test revealed a statistically significant increase in perceived confidence level in all of the 14 topics of instruction (p<.0001). An increase in confidence was reported in both physicians and nurses, regardless of the participant’s years of experience in his or her respective occupation. Improvement was also significant irrespective of the participant’s previous training experience within the last 2 years.

Conclusion:
Trauma and emergency medical services have limited capacity in most areas of China. Foreign instructors are often invited to participate in health provider instruction.  Potential barriers to the success of such a program include language and teaching style.  A structured educational program based in English with consecutive Chinese translation positively impacted confidence levels of first responders in Chengdu, China. Participants felt more competent in all areas of topics and skills of instruction, which may ultimately improve provider skills in pre-hospital management of trauma and emergencies. These responses were seen in physicians and nurses across all experience levels. The collaboration between local Chinese and international medical professionals may help improve current Chinese emergency medical practices.
 

15.01 Geographic Variation in Use of Video-Assisted Thoracoscopic Surgery (VATS) for Lung Cancer Resection

Posted on December 22, 2014

T. R. Grenda1, J. R. Thumma1, J. B. Dimick1  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction:  A growing body of evidence has emerged supporting the use of video-assisted thoracoscopic surgery (VATS) in lung cancer resection. While trends towards increased utilization of this approach have been observed, wide variations in use remain. The extent to which geography and hospital factors contribute to this variation remains poorly understood.   

Methods:  We used national Medicare data (2008-2012) to examine geographic variations in use of VATS for patients undergoing lung cancer resection. We identified patients undergoing open or VATS approach for lung cancer resection and assigned them to hospital referral regions (HRRs) corresponding to where they received treatment.  Rates of VATS utilization were calculated for each HRR and quartiles of HRR use were created according to HRR utilization rate. We then evaluated rates of VATS utilization across hospital characteristics and trends in time. 

 

Results:  A total of 49,077 patients underwent lung resection across 1,852 hospitals during the study period, with 23,911 (48.7%) resections performed using a VATS approach. Rates of VATS utilization varied dramatically from 0% in the lowest use HRR to 90.6% in the highest use HRR across 306 HRRs. Overall utilization rates increased over time from 32% in 2008 to 50% in 2012 (p<0.001). Mean VATS utilization rates were greater in hospitals with the highest total lung cancer resection volume compared to the lowest volume centers (58% vs 32%, p<0.001).  Non-critical access hospitals had a significantly higher utilization rate than critical access hospitals (38% vs. 19%, p=0.04). There was no significant difference in utilization between high-technology and non-technology hospitals (38% vs. 39%, respectively, p=0.51). 

Conclusion: Wide geographic variations in the utilization of VATS exist, which may limit a patient’s options for surgical approach based on where they live.  Further efforts are needed to understand the main drivers underlying these variations in order to broaden patient access to this technology. 
 

15.02 Do Hospital Compare Metrics Predict Changes in Functional Status After Surgery?

Posted on December 22, 2014

L. H. Nicholas1,2, L. H. Nicholas1,2  1Johns Hopkins School Of Public Health,Health Policy & Management,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: Public and private payers increasingly rely on measures of process compliance and patient satisfaction to determine hospital payments and to steer patients to hospitals where they will have better outcomes.  However, these measures do not correlate with risk-adjusted mortality, raising questions about their usefulness for patients and payers.  Given the low mortality rates associated with most elective surgical procedures, however, it is important to understand whether quality metrics correlate with changes in patient health and functional status. 

Methods: Medicare claims from 6,761 surgical admissions between July 2005 and December 2010 were linked to pre-and post admission survey measures of self-rated health and functional status collected as part of the nationally representative Health and Retirement Study.  Hospitals were classified by their terciles of performance on a composite process score reflecting compliance with Surgical Care Improvement Program (SCIP) measures and the proportion of patients who would recommend their hospital from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) during the period of each admission.  Multivariate regression was used to assess the relationship between risk-adjusted measures of patient self-rated health and counts of activities of daily living (ADL) limitations with the hospital's HCAHPS and SCIP scores.

Results: Compliance with SCIP measures averaged 76.5% in low-performing hospitals, 88.6% in medium-performing, and 94.1% in high-performing hospitals.  57.8% of patients recommended hospitals in the lowest HCAHPS tertile, 68.9% in the middle, and 78.2% in the highest.  Compared to patients treated in hospitals with the lowest SCIP and HCAHPS rankings, patients in higher-scoring hospitals had better self-rated health, fewer depressive symptoms, and fewer ADL limitations.  However, these differences largely reflect healther patients selecting hospitals with higher SCIP compliance and patient satisfaction.  After we controlled for patient health prior to hospitalization, there was no relationship between either SCIP compliance or HCAHPS score and patient health or functional status after admission. 

Conclusion: Hospitals with higher levels of SCIP compliance and higher patient satisfaction scores attract patients who are healthier than those choosing low-performing hospitals.  However, neither SCIP compliance nor HCAHPS rankings consistently correlate with changes in patient self-rated health and functional status with inpatient surgery.  Additional outcomes data collection may be needed to distinguish between high and low-quality hospitals. 

 

15.03 Transitional Care Needs Following Complex Surgery: A Population-Level Analysis

Posted on December 22, 2014

C. Balentine1,2,3, F. G. Bakaeen1,2, P. Kougias1,2, A. Naik2, P. J. Richardson2, D. H. Berger1,2, D. A. Anaya1,2  1Baylor College Of Medicine,Michael E DeBakey Department Of Surgery,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:
Recovery from major surgery is a complex process that frequently requires ongoing care as patients transition from acute care hospitals to home.  This transitional care (TC) can involve time in rehabilitation hospitals, skilled nursing facilities or long term care hospitals designed to help regain functional independence.  While there is considerable information on the need for TC following medical conditions such as heart failure and chronic lung disease, there is little data on the need for TC after surgery.  The purpose of this study is to determine the overall need for TC following complex general, cardiac and vascular surgery.

Methods:
A retrospective cohort study using VA administrative data from 2006-2010 evaluating all patients undergoing colorectal resection, pancreaticoduodenectomy, liver resection, coronary artery bypass, and abdominal aortic aneurysm repair. was performed.  Patients were categorized as needing TC if their discharge destination was being other than a home discharge.  Chi-square was used to compare rates of TC use.

Results:
We found that TC needs were common among all of the operations assessed.  Pancreaticoduodenectomy had the greatest overall proportion of TC utilization as 119 of 1,064 patients (11%) needed TC after discharge.  TC use was higher during 2006-2008 (11.6-15.5%) compared to the final two study years (8-8.4%) though this difference was not statistically significant.  Colorectal (1,850 patients out of 20,449, 9%) and coronary bypass (2,047 patients out of 23,658, 8.7%) operations required TC at similar rates and there was minimal variation in TC usage during the study period.  A total of 54 out of 761 individuals having liver resections needed TC at discharge and this rate steadily declined from 12% in 2006 to 4% in 2010 (p<0.07).  Finally, open and endovascular aneurysm repair had the lowest rates of TC as only 325 of 7,409 patients (4.4%) required TC, and these rates did not fluctuate significantly during the study period.

Conclusion:
Following complex surgery, a significant proportion of patients will require additional assistance in the form of TC as they attempt to recover their preoperative functional status.  While the rate of TC utilization for liver resections seems to be declining over time, the other complex operations studied showed remarkably consistent rates of TC use from year to year.  Further studies are needed to identify underlying reasons for TC use.
 

15.04 Post-discharge Care Fragmentation: Readmission, Distance of Travel, and Postoperative Mortality

Posted on December 22, 2014

T. C. Tsai1,2, E. J. Orav3,4, A. K. Jha2,3  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Harvard School Of Public Health,Health Policy And Management,Boston, MA, USA 3Brigham And Women’s Hospital,Medicine,Boston, MA, USA 4Harvard School Of Public Health,Biostatistics,Boston, MA, USA

Introduction:  Despite policies aimed incentivizing clinical integration, little data exist on whether fragmentation of care is associated with worse outcomes for elderly patients undergoing major surgery. We assessed the state-level variation in post-discharge surgical care fragmentation; whether post-discharge surgical care fragmentation was associated with worse outcomes; and whether accounting for distances between hospitals may explain differences in outcomes for those who are readmitted to a different hospital than the original hospital where the index procedure was performed.  

Methods:  We used the 100% inpatient file for Medicare claims from 2009 through 2011.  Data on hospital structural features including zip code of location were obtained from the 2011 American Hospital Association Annual Survey.  We identified patients who underwent coronary artery bypass graft, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement.  

Results: There were 93,062 patients that underwent the surgical procedures of interest who were subsequently readmitted within 30-days of discharge; 23,278 of these patients (25%) were readmitted to a hospital other than the one where their procedure was performed.  Patients who were readmitted to a different hospital generally lived farther from the index hospital than those who were readmitted to the index hospital (20.7 miles vs. 7.4 miles, p<0.001).  We found large state-level variations in the proportion of surgical patients who were readmitted elsewhere.  Patients readmitted to a different hospital that was the same distance from their home as the index hospital had 48% higher odds of mortality (OR 1.48, 95% CI 1.24-1.78, p<0.001) than patients who were admitted to the index hospital.  

Conclusion: 1 in 4 older Americans undergoing major surgery are readmitted to a hospital different than the one where the initial operation was performed. Even taking distance traveled into account, post-surgical care fragmentation is associated with a substantially higher risk of death.  Focusing on clinical integration may improve outcomes for older Americans undergoing complex surgery. 

15.05 Disruptive and Incremental Innovation: A Snapshot of Surgical Literature

Posted on December 22, 2014

L. E. Grimmer1, M. C. Nally1, J. C. Kubasiak1, M. Luu1, J. Myers1  1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction: "Disruptive innovations" are defined as novel solutions to existing problems which are cheaper, simpler and more convenient than the current solution.  Examples of disruptive innovations include coronary angioplasty rivaling CABG, or TIPS replacing spleno-renal shunts. This is in contrast to "incremental innovations" which modify and improve on the current solution through increased complexity and cost, such as single incision surgery improving upon traditional laparoscopy. Despite widespread application of this innovation framework in other professional fields, classification of surgical innovations as disruptive or incremental has not been previously studied. We hypothesized that a standardized inventory of items related to disruptive and incremental innovations can be applied to surgical literature.

Methods:  Each article in the most recent issues of ten high impact surgical journals was included; editorials and guidelines reviews were excluded. Of 200 articles, 51 lacked an identifiable innovation, and 149 were scored on the following items: cost of implementation, overall healthcare cost, level of infrastructure required, level of care needed during procedure, level of training, level of difficulty, number of operative/non-operative procedures performed, extent of tissue excised or dissected, invasiveness and incision size.

Results: Compared to the current solutions, the innovations proposed in the literature had higher initial cost (55% increased v 8% decreased cost) and overall system cost (21% inc v 11% dec).  Innovations also required more resources (40% inc v 5% dec), more training (38% inc v 3% dec) and were more difficult to perform (37% inc v 5% dec). Innovations tended toward more tissue excised/dissected (26% inc v 13% dec), but offered smaller incisions (18% smaller incision v 11% larger) and less invasive procedures (22% less v 19% more).

Conclusion: Surgical literature is dominated by resource-intense, interval improvements to existing solutions, characteristic of incremental innovations, with a relative dearth of disruptive innovations. 
 

15.06 Who Gets It? A Survey of Physician Attitudes Regarding Disaster Resource Allocation

Posted on December 22, 2014

W. Jacoby1, S. Agarwal1, H. Jung1, A. E. Liepert1, P. J. Mercier1, A. P. O’Rourke1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
Resource allocation during disasters poses clinical, administrative and ethical challenges–overwhelming available healthcare resources and obviating the standard of care.  The lack of  evidence-based standards or consensus-based goals for health care resource allocation in a disaster setting leads to uncertainly for providers being asked to distribute resources. To this end, limited research has been conducted to ascertain the opinions of the health care professionals who will actually be providing care if a disaster strikes.

Methods:
Data was obtained from a brief IRB-approved survey conducted at a quaternary care, academic institution. Personal experiences with disaster planning and awareness, opinions of main goal of crisis care, understanding of possible important disaster resource allocation factors (age, life expectancy, DNR status),and knowledge of triggers for declaring crisis care were ascertained.  The anonymous survey was electronically distributed to a random sample of faculty physicians and residents. Analysis of descriptive characteristics and for possible relationships between baseline awareness and patterns of allocation was performed.

Results:
Analysis of physician responses demonstrated a 39% response rate (yield from 1233 surveys distributed).   Mean years in practice was 12 years. Thirty-five percent of physicians stated they had been involved in disaster planning, but only 21% knew the institutional disaster plan or where to find these plans. Eighteen percent felt they had received adequate training to receive a large surplus of patients. The majority of physicians said that scope of practice (89%) and legal standards (65%) change during disaster scenarios, and just over half (52%) said ethical norms changed. A minority (24%) of physicians had experience with disasters or resource allocation, and most (82%) do not feel they have received adequate training in this area.

Conclusion:
The majority of physicians at a large academic hospital are ill prepared to deal with resource allocation in disasters. This early single institution analysis provides the first reported insights into baseline physician attitudes and can be a basis for targeting institutional education initiatives and future surveys in disaster planning and management.
 

15.07 Hospital Quality and Variations in Episode-Based Spending for Surgical Care

Posted on December 22, 2014

T. C. Tsai1,2, F. Greaves2, E. J. Orav3,4, M. Zinner1, A. Jha2,3  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Harvard School Of Public Health,Health Policy And Management,Boston, MA, USA 3Brigham And Women’s Hospital,Medicine,Boston, MA, USA 4Harvard School Of Public Health,Biostatistics,Boston, MA, USA

Introduction:  The rise of new payment models, such as bundled payments after major surgical procedures, has led policymakers and clinical leaders to increase their focus on episodes of care.  Despite interest in this area, we know little about how much longer-term costs vary after major procedures and whether high quality surgical hospitals, those with high performance on process measures or patient experience, have lower long-term costs after procedures.  Therefore, we examined variations in long-term costs after major procedures, the relationship between key structural factors and Medicare costs, and assessed if higher quality hospitals had higher costs. 

Methods:  Using 2011 national Medicare 20% claims files, we calculated episodes of care associated with an index admission and 30 and 90 of post-discharge care for patients undergoing coronary artery bypass graft, pulmonary lobectomy, abdominal aortic aneurysm repair, colectomy, and hip replacement.  All Medicare payments were standardized to national fee-schedules to allow for national comparisons.  Our main predictors of quality were hospital patient satisfaction as measured by the HCAHPS survey and hospital perioperative mortality. We used bivariate and multivariate models adjusting for case-mix to assess the relationship between hospital characteristics, quality, and long-term costs.  

Results: We identified 51,249 patients.  Average 30-day spending was $32,514.  While spending on the index admission was the largest component of the episode, spending on post-acute care had the largest variation, varying from $2,998 for endovascular abdominal aortic aneurysm repair to $9,667 for hip replacement. Patients who went to hospitals with low satisfaction resulted in $2,626 more in spending than patients who went to hospitals with high satisfaction ($36,637 vs. $34,011, p<0.001). Similarly, patients receiving care at hospitals with high mortality resulted in $1,890 more in spending than patients who went to hospitals with low mortality ($38,952 vs. $34,062, p<0.001).  Patterns were consistent for 90 days.  Spending on post-acute care accounted for the largest variation in spending between high and low quality hospitals (59%).

Conclusion: Elderly patients receiving surgical care at low-quality hospitals result in higher spending than patients receiving care at high quality hospitals, and these patterns persisted out to 90-days.  Post-acute care accounted for the largest variation in spending between high and low-quality hospitals.  Because low-quality surgical care represents a serious cost to Medicare over the course of an episode, policies such as bundled payments may serve as an important step to aligning cost and quality for surgical care.

 

15.08 Risk evaluation of organ donation from donors with primary malignant gliomas

Posted on December 22, 2014

S. Amaefuna1, J. D. Mezrich2, J. S. Kuo1  1University Of Wisconsin,Neurological Surgery,Madison, WI, USA 2University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  Progress in organ transplantation to treat end-stage organ disease has resulted in organ demand greatly outpacing supply. The escalating organ shortage and rising mortality rates for the estimated 123,000 patients on the U.S. organ wait-list motivated our reevaluation of common practices related to organ donation from individuals with primary central nervous system (CNS) tumors. Malignancy is generally considered a contraindication to organ donation, with rare exceptions including non-metastatic primary brain tumors (PBT). Glioblastoma multiforme (GBM) is a WHO grade IV glioma that accounts for over 45.2% of malignant PBTs in the U.S. Therefore, less than 0.5% of 13,000 U.S. patients dying from malignant gliomas annually serve as organ donors. Although a hallmark feature of GBM is infiltration into surrounding brain, metastatic capacity outside the CNS is poorly documented.

Methods:  Using literature review of all available papers reporting on GBM and extra-neural metastasis, we evaluated and assessed the implications of available data on the rarity of extra-neural metastasis (ENM) of GBM regarding the risk of donor-derived transmission (DDT) of cancer to organ recipients. We evaluated and present recent reports on DDT rates among recipients of cadaveric organs from GBM patients. 

Results: Careful screening of papers for only pathologically confirmed metastatic events were considered high quality, reliable data. Literature review revealed only clinical case reports suggesting a maximum incidence of metastasis that is likely significantly lower than 2%, and highlights that such rare GBM metastatic events preferentially target pulmonary, lymph, hepatic and bone tissues. 

Conclusion: These findings imply that kidneys from donors with GBM may be considered for transplantation, and the morbidity and possible mortality of wait-listed renal allograft recipients may outweigh the apparent small risk of DDT from donors with GBM. Further studies are required to validate this implication before implementing any changes in donor evaluation policy. Furthermore, re-evaluation of policies regarding other lower grade primary brain tumors are being considered for study in order to support the goal of increasing donor organs.

 

15.09 Health care revisits following ambulatory surgery

Posted on December 22, 2014

G. D. Sacks1,2, M. M. Gibbons1, S. O. Raetzman4, M. L. Barrett5, P. L. Owens3, C. A. Steiner3  1University Of California – Los Angeles,Surgery,Los Angeles, CA, USA 2Robert Wood Johnson Clinical Scholars Program, UCLA,Los Angeles, CA, USA 3Agency For Healthcare Research And Quality (AHRQ),Center For Delivery, Organization And Markets (CDOM),Rockville, MD, USA 4Truven Health Analytics,Bethesda, MD, USA 5ML Barrett, Inc,Del Mar, CA, USA

Introduction:
Revisits to health care settings following inpatient hospitalization, particularly those resulting in hospital readmission, have emerged as an indicator of health care quality. The prevalence and etiology of revisits following ambulatory surgery, however, remain unknown.

Methods:
We performed a retrospective analysis using the 2010-2011 Healthcare Cost and Utilization Project State Ambulatory Surgery, Inpatient, and Emergency Department Databases for 7 geographically dispersed states (California, Florida, Georgia, Missouri, Nebraska, New York, and Tennessee) of index operations representing a broad range of specialties: laparoscopic cholecystectomy (LC), abdominal hernia repair (AHR), anterior cruciate ligament repair (ACLR), spine surgery (SS), hysterectomy (HYST), and transurethral retrograde prostatectomy (TURP) in low surgical risk adults (defined as no acute care visit in previous 30 days, length of stay less than 2 days, no other surgery on the same day, no infection coded and discharged home the same day). We identified cases resulting in a revisit within 30 days of an operation to the emergency department (ED), hospital-owned ambulatory surgery setting (AS), or inpatient (IP) setting. Rates, site, and reason for revisit were analyzed.

Results:
Of the 482,034 index operations, revisits occurred after 45,760 surgeries (9.5%). The majority of revisits were to the ED (n=28,302, 61.8%), followed by IP readmissions (n=13,027, 28.5%). Few revisits were to an AS (n=4,431, 9.7%). Revisits were most common following TURP (14.5%) and AHR (10.9%) and least common for ACLR (5.1%). Across all operations, medical complications of surgery accounted for 42.1% of revisits, surgical complications for 26.6%, and 31.3% were for clinical issues unrelated to the index operation. The distribution of each revisit type varied by operation. Medical complications were the most common reason for revisit following LC (50.3%), AHR (39.6%), and HYST (43.3%), while surgical complications were most common for ACLR (35.5%), SS (36.6%), and TURP (56.6%). Unrelated readmissions ranged from 23.1% for TURP to 39.6% for AHR. Similarly, the distribution of revisit setting varied by operation.

Conclusion:
Health care revisits following ambulatory surgery in low risk patients occur with significant frequency across a wide variety of operations.  Most revisits were either surgically or medically related to the operation, although one-third of revisits were for clinical issues unrelated to the index operation. Considering the burden associated with revisits, these findings highlight the importance of expanding the focus of health policy interventions and local quality improvement efforts targeting revisits to include ambulatory surgery patients.
 

15.10 Robotic-Assisted Surgery: A Primer on Best Practices for Privileging and Credentialing

Posted on December 22, 2014

A. M. Al-Ayoubi1, C. M. Forleiter3, M. Barsky1, A. Bogis1, S. Rehmani1, S. Belsley3, R. Flores2, F. Y. Bhora1  1Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital/Department Of Thoracic Surgery,New York, NY, USA 2Mount Sinai School Of Medicine,Mount Sinai Hospital/Department Of Thoracic Surgery,New York, NY, USA 3Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital/Department Of Surgery,New York, NY, USA

Introduction: The recent surge of robotic-assisted surgery necessitates effective guidelines to ensure safe outcomes. We provide a stepwise algorithm for granting privileges and credentials in robotic-assisted surgery. This algorithm reflects increasing level of responsibility and complexity of the surgical procedures performed. Furthermore, it takes into account volume, outcomes, surgeon's proficiency and appropriateness of robotic usage.

Methods: We performed a literature review for available strategies to grant privileges and credentials for robotic usage. The following terms were queried: robot, robotic, surgery and credentialing. We provide this algorithm based on review of the literature, our institutional experience, as well as the experience of other medical centers around the US.

Results:

46 manuscripts were identified in the published English language literature through August 2014. Two pathways for robotic training exist: residency- and non-residency-trained. In the US, JCAHO requires hospitals to credential and privilege physicians on their medical staff. Table 1 shows our algorithm for granting robotic privileges in a graduated fashion. A credentialing designee (CD) oversees and reviews all requests. Residency trained surgeons must fulfill 20 cases with program directors’ attestation to obtain Full privileges. Non-residency trained surgeons are required to fulfill the following: simulation, didactics including online modules, wet labs (cadaver or animal) and observation of at least 2 cases for Provisional privileges.

To serve as a proctor, a surgeon with Full privileges must complete 25 cases in the same specialty with good outcomes and be approved by the CD and the chair. A minimum number of cases (10) is required to maintain privileges. Cases are monitored via departmental QA/QI committee review. Investigational uses of the robot require IRB approval. Complex operations may require additional proctoring and QA/QI review.

Conclusion: Safety concerns with the introduction of novel and complex technologies such as robotic-assisted surgery must be paramount. Our algorithm takes into consideration appropriate utilization, restraint of trade and state reporting ramifications. Furthermore, it serves as a basic guideline for institutions that wish to implement a robotic-assisted surgery program.
 

15.11 The “Weekend Effect" in Urgent General Surgical Procedures

Posted on December 22, 2014

M. A. Zapf1, A. Kothari1, T. Markossian2, G. Gupta1, P. Wai1, J. Driver1, P. Kuo1  1Loyola University Chicago Stritch School Of Medicine,Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Public Health Sciences,Maywood, IL, USA

Introduction: There is growing concern that the quality of inpatient care may differ on weekends vs. weekdays.  We aimed to assess the “weekend effect” in common urgent general surgical procedures.

Methods: The Healthcare Cost and Utilization Project Florida State Inpatient Database (2007-2010) was queried to identify inpatient stays with admission from the ER or urgent care center followed by surgery on the same day.  Included were patients undergoing appendectomy, cholecystectomy for acute cholecystitis, and inguinal, femoral, ventral, incisional or umbilical hernia repair with diagnosis of obstructed or gangrenous hernia.  Outcomes included length of stay (LOS), inpatient mortality, hospital-adjusted charges and complications not present on admission.  We assessed patient outcomes using univariate analysis and with multilevel mixed-effects regression modeling that was used to examine the association between patients’ outcomes and admissions day (weekend vs. weekday), controlling for hospital characteristics, patients’ demographic and clinical characteristics, and type of surgery.

Results:A total of 80,861 same day surgeries were identified, of which 19,078 (23.6%) occurred during the weekend.  Patient characteristics were similar between groups.  Patients operated on during the weekend had greater LOS (3.05 ± 0.033 v 2.98 ± 0.016 p<0.05) and an increase in charges by $185 (p<0.05), both of which were also significant in the multiple regression modeling.  Inpatient mortality was similar between groups, however patients undergoing weekend surgeries were more likely to develop wound complications (OR 1.28, 95% CI 1.08-1.52 p<0.05) and pneumonia (OR 1.29, 95% CI 1.10-1.52 p<0.05). When procedures were considered in isolation (table), weekend procedures were associated with distinctive subgroups of inferior outcomes.

Conclusion:Patients undergoing weekend surgery for common urgent general surgical operations are at risk for significantly increased postoperative complications, length of stay and hospital charges.  In an age of quality improvement, health systems should consider processes that bolster weekend perioperative care.  As the cause of the “weekend effect” is still unknown, future studies should focus on elucidating the institutional characteristics that may overcome this disparity.

Table 1. Shaded boxes: p<0.05 in weekend vs. weekday
 

15.12 Is a Colectomy Always Just a Colectomy? Examining the Effect of Concurrent Procedures on Outcomes

Posted on December 22, 2014

K. D. Simmons1, R. L. Hoffman1, L. E. Kuo1, E. K. Bartlett1, D. N. Holena1, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction:
Studies of surgical outcomes can be confounded by operative complexity, one aspect of which is the performance of concurrent procedures.  Complexity is difficult to assess from claims data due to the absence of established measures.  However, surgical databases often include information on concurrent procedures.  Thus, we hypothesized that the presence or absence of same-day procedures would be useful as a step toward including operative complexity in risk adjustment.  Toward this end, we compared the association between concurrent procedures and surgical outcomes to examine the possible role for this information in risk adjustment and prediction.

Methods:

All records in which colon resection was performed at some point during inpatient admission were pulled from three state databases (California, Florida, and New York) between 2007 and 2012.  Our primary outcome was in-hospital mortality; secondary outcomes were post-operative complications.  For each outcome, we developed multivariate logistic regression model based on patient demographic, hospital, and admission characteristics; indications for colectomy; and the presence or absence of other procedures performed on the same day.  Likelihood ratio tests were done to assess the effects of removing individual covariates on model fit.

Results:

We analyzed 209,508 colectomies, of which 40,787 (19.5%) were not performed on the same day as any other procedures.  Overall mortality was 6.3%.  Mortality was higher among patients with another procedure performed on the same day as colectomy (7.3%) than among patients for whom no other procedures were performed on the same day (2.2%, p<.001).  In multivariate regression, having another same-day procedure was significantly associated with mortality (odds ratio 2.62, p<.001).  Moreover, including this measure of complexity significantly improved the fit of the model (chi-squared = 895.98, p<.0001). The only covariates with greater contributions to adjusted mortality were age, number of comorbidities, colon cancer, and emergency admission.  Similarly, same-day procedures were associated with higher complication rates, as shown in the table.

Conclusion:
The risk of complications and mortality following colon resection is increased among patients who have at least one other procedure on the same day.  This measure may be underutilized as a source of variation in outcomes and may provide a window into operative complexity.

15.13 Early vs Late Hospital Readmission after Pancreaticoduodenectomy in Patients with Private Insurance

Posted on December 22, 2014

E. Schneider1, J. Canner1, F. Gani1, C. Wolfgang1, M. Makary1, M. Weiss1, G. Spolverato1, Y. Kim1, A. Ejaz1, T. Pawlik1  1Johns Hopkins University School Of Medicine,Surgical Oncology,Baltimore, MD, USA

Introduction:  Most studies on readmission report only data on the initial readmission to the index hospital within 30-days of surgery.  These data may underestimate the actual impact of readmission, as patients who undergo complex procedures may be readmitted beyond 30-days and/or at other hospitals.  We therefore sought to define the incidence of early versus late readmission of patients undergoing pancreaticoduodenectomy (PD) requiring re-hospitalization at any hospital.

Methods:  Patients discharged after PD (ICD-9-CM procedure code 52.7) between 2010-2012 were identified from the Truven Health Market Scan database, which is a large convenience sample of individuals covered by employer-provided healthcare.  Determinants of early (≤ 30 days) or late (31-90 days) readmission were identified and analyzed. 

Results: A total of 2,243 eligible patients underwent PD during the study period.  Mean (SD) patient age was 54.8 (8.4), 51.6% of the patients were male, and 85.0% had a Charlson Comorbidity Index of 2 or greater. The mean (SD) length-of-stay was 12.7 (11.6) days; 89.2% of patients were discharged home, 5.0% were transferred to another facility, and 1.6% died in hospital. Among 2,209 patients discharged alive, 450 (20.4%) had an early readmission while 165 (9.4%) had a late readmission.  Among patients who were readmitted, fewer than 11 patients (<1.8%) had multiple readmissions.  Common causes of readmission were similar among patients experiencing an early versus late readmission (post-op infection: 22.0% vs. 5.5%, P<0.001; dehydration: 5.6% vs. 4.9%, P=0.73).   Median length-of-stay was longer for early vs. late readmission (5 vs. 3 days, respectively, P=0.002) and no in-hospital mortality occurred among patients readmitted either early or late.   While early readmissions were more likely to occur at the index hospital (index hospital: 94.4% vs. non-index hospital: 5.6%), patients who had a late readmission tended to be re-admitted more often to a different hospital than where the PD had been performed (index hospital: 90.3% vs. non-index hospital: 9.7%)(P=0.06). 

Conclusion: One-in-three readmissions occurred beyond 30-days, with 10% of late readmissions occurring at non-index hospitals among patients undergoing PD.  Assessment of only 30-day same hospital readmissions may underestimate the true incidence of re-hospitalization following PD. 

 

15.14 Evaluation of a New Hospital Requirement to Report Participation in a Registry for General Surgery

Posted on December 22, 2014

C. V. Kinnier1,2, A. R. Dahlke1, J. W. Chung1, A. D. Yang1, M. H. Ju1, M. McHugh3,4, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center, Department Of Surgery And Center For Healthcare Studies,Chicago, IL, USA 2Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 3Northwestern University,The Center For Healthcare Studies,Chicago, IL, USA 4Northwestern University,Department Of Emergency Medicine,Chicago, IL, USA

Introduction: The Centers for Medicare and Medicaid Services (CMS) is attempting to encourage participation in clinical registries to spur quality improvement. CMS now includes reporting of participation in a Systematic Clinical Database Registry (SCDR) for General Surgery as part of the Inpatient Quality Reporting Program (IQRP), and policy makers are considering tying registry participation to reimbursement. However, clinical registry participation is resource intensive and often costs upward of $100,000 annually. It is therefore unknown how many and what types of hospitals participate in an SCDR. Our objective was to examine the proportion and characteristics of hospitals participating in a General Surgery SCDR.

Methods: Hospitals performing inpatient surgery were identified from the CMS 2013 Inpatient Prospective Payment System (IPPS) Final Rule Impact File. SCDR-participating hospitals were identified through participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the Michigan Surgical Quality Improvement Collaborative (MSQC), or the Surgical Clinical Outcomes Assessment Program (SCOAP). Structural characteristics were identified using the 2012 American Hospital Association Annual Survey. To measure hospital financial health, the 2011 and 2012 Healthcare Cost Report Information System was used to calculate hospital operating margin [(Total Operating Revenue – Total Operating Expenses)/Total Operating Revenue]. Baseline hospital quality was approximated with the CMS Value-Based Purchasing score. Multivariable hierarchical logistic regression models with state-level random intercepts were developed to examine hospital characteristics associated with SCDR participation.

Results: Of 2,998 hospitals, 429 (14.3%) participate in an SCDR. SCDR-participating hospitals accounted for 7,535,597 (31.4%) of all operations, 2,974,330 (34.0%) of inpatient operations, and 4,561,267 (30.0%) of outpatient operations. After adjustment, hospitals were more likely to participate in an SCDR if they were a teaching hospital (OR 5.14, 95%CI 3.88-6.80), were non-profit and non-government owned (OR 2.11, 95%CI 1.53-2.91), accredited by the Joint Commission (OR 1.71, 95%CI 1.11-2.63), were a large urban or other-urban facility (large urban: OR 2.71, 95%CI 1.80-4.07; other urban: OR 2.35, 95%CI 1.57-3.51), or had a greater financial operating margin (OR 1.47, 95%CI 1.02-2.13).

Conclusion: Only 14% of inpatient hospitals currently participate in a General Surgery SCDR. Large, teaching, urban, and financially-healthy hospitals are more likely to participate in registries. To further promote successful quality improvement endeavors, CMS may need to tie SCDR participation to payment incentives or provide grants to reduce the cost of SCDR participation to encourage the remaining 85% of US hospitals to participate in a Systematic Clinical Database Registry.

 

14.06 Variability of Surgical Mortality in Low and Middle Income Countries: Meta-Review of Published Data

Posted on December 22, 2014

T. Uribe-Leitz1, L. R. Maurer2, J. D. Jaramillo2, R. Fu3, M. M. Esquivel4, T. G. Weiser1,2  1Stanford University,Department Of Surgery, Section Of Trauma & Critical Care,STANFORD, CA, USA 2Stanford University,School Of Medicine,STANFORD, CA, USA 3Stanford University,School Of Engineering,STANFORD, CA, USA 4Stanford University,School Of Medicine/Division Of General Surgery,STANFORD, CA, USA

Introduction: WHO estimates that low income countries accounting for nearly 35% of the global population receive only 3.5% of all operations. Increased attention has focused on scaling up surgical services, yet post-operative mortality in these settings is unknown but likely to be high. Quantifying postoperative mortality is important to assess challenges in scaling up surgical services and improving care.

Methods: We performed a systematic literature review using Embase, Web of Science, Medline, SCOPUS and Google Scholar to identify articles reporting on mortality following cesarean section, appendectomy and groin hernia repair in low and middle income countries (LMICs) as defined by the World Bank. We included articles published since 2000 that reported mortality following one of these interventions, regardless of preoperative status, indication for intervention, or cause of death. We discarded duplicate analysis of the same data, reports on less than 10 operations, and laparoscopic-only studies. We aggregated studies by country to create larger data samples for analysis. 

Results: Our initial literature search identified 1255 citations. After exclusion criteria, 203 required full-text review and 129 contained data for extraction. Forty two out of 116 LMIC published data on at least one of the predefined operations. We calculated crude post-operative case fatality rates (CFR) per country for each intervention. CFR ranged from 0 to 51.7 (mean=11.4) per 1000 operations for cesarean section, 0 to 88.6 (mean=13.5), per 1000 operations for appendectomy, and 0 to 411.8 (mean=39.9) per 1000 operations for hernia repair. This represents a 20, 5 and 15 fold increase in mean postoperative mortality when compared to Netherlands, a country with historically low CFR (cesarean section 0.58, appendectomy 3.03, and hernia repair 2.78 per 1000 operations). 

Conclusion: Although these estimates do not control for comorbidities, demographics, or facility factors, our findings suggest tremendous variability in mortality following surgical intervention in LMIC. The excessive high death rates following essential surgical interventions indicate safety concerns that demand prompt attention. 
 

12.10 Predictors of Wound Hypergranulation in Pediatric Burns

Posted on December 22, 2014

K. B. Savoie1, M. Bachier-Rodriguez1, R. B. Interiano1, A. Rotenberry2, L. S. Herring2, J. W. Eubanks1,2, R. F. Williams1,2  1University Of Tennessee Health Science Center,General Surgery,Memphis, TN, USA 2Le Bonheur Children’s Hospital,Pediatric Surgery And Trauma,Memphis, TN, USA

Introduction:
The shift in treatment of pediatric burns with silver-impregnated dressings has led to an increase in outpatient therapy.  During these clinic visits, hypergranulation has been identified as a source of poor wound healing leading to increased clinic visits and the need for subsequent skin grafts.  Therefore, we examined all pediatric burn patients treated with silver-impregnated dressings to determine factors associated with severe hypergranulation.

Methods:
A review of all pediatric burn patients from an urban pediatric hospital was performed from 2011 to 2013. Our primary outcome was severe hypergranulation of the burn, defined as significant granulation tissue resulting in the need for treatment with silver nitrate.  Severe burns were classified as those requiring surgical consultation in the emergency room, admission, enteral nutrition, or central line placement.  A Chi-Square test was used to compare categorical variables and a Mann-Whitney U test was employed for continuous variables. Backwards elimination was used to build a model for multivariable analysis. 

Results:
A total of 597 patients were identified. The majority of patients were male, black, and had public insurance. Scald burns were the most common type of burn (59%). Thirty-two patients developed severe hypergranulation (5.4%). On bivariate analysis, thermal and chemical burns, lower extremity burns, and severe burns were associated with severe hypergranulation. In multivariable analysis, thermal and chemical burns and lower extremity burns remained significant predictors of severe hypergranulation (see table). Lower extremity burns remained significant when assessing for effect modification with total body surface area of the burns.

Conclusion:
In pediatric burn patients, thermal and chemical burns, as well as lower extremity burns, result in an increase likelihood of hypergranulation, which may lead to changes in therapy or additional surgical intervention.  These patients may require different initial therapy to decrease the rate of granulation tissue and thus increase burn wound healing.
 

12.11 Pediatric Papillary Thyroid Carcinoma: Outcomes and Survival Predictors in 2,566 Patients

Posted on December 22, 2014

S. Golpanian1, J. Tashiro1, J. I. Lew2, H. L. Neville1, J. E. Sola1, E. A. Perez1, A. R. Hogan1  1University Of Miami,Division Of Pediatric Surgery,Miami, FL, USA 2University Of Miami,Division Of Endocrine Surgery,Miami, FL, USA

Objective:   To evaluate and update outcomes and predictors of survival of pediatric thyroid carcinoma, specifically examining pediatric patients with papillary thyroid carcinoma.

Methods:   Surveillance, Epidemiology, and End Results database was searched for pediatric cases (<20 yrs old) of papillary thyroid carcinoma diagnosed between 1973 and 2011.  Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods.  All papillary types, including follicular variant were included in the data set.

Results: A total of 2,566 cases were identified.  Overall incidence was 0.483/100,000 persons per year with a significant annual percent change (APC) of 2.07% (p<0.05).  Mean age at diagnosis was 16 yrs old and highest incidence was found in white, female patients 15-19 yrs old.  Patients whose tumor sizes were ≤1cm were more likely to receive lobectomies and/or isthmectomy versus subtotal/total thyroidectomies (OR=3.03 [2.12, 4.32]; p<0.001).  When analyzed by propensity score matching by procedure, patients with larger tumors (≥1cm; p<0.001) and lymph node positive statuses (OR=99.0 [12.5, 783]; p<0.001) more likely underwent subtotal/total thyroidectomy compared to lobectomy and/or isthmetctomy.  Mortality did not differ between procedures. When matched by tumor size, larger tumors (≥1cm) tended to be lymph node positive (OR=39.4 [16.6, 93.7]; p<0.001). Subtotal/total thyroidectomy patients were more likely to have distant disease, lymph node sampling (>10), and radiation treatment compared to those who underwent lobectomies and/or isthmectomies (p<0.001).  Overall mean survival was 448 months and survival was highest in white females with regional disease.  Overall 30-yr survival ranged from 89%-100%, regardless of tumor size or procedure type.  Disease specific survival was highest in patients who received surgery, regardless of procedure type.  Lymph node sampling did not affect overall or disease-specific survival.  Multivariate analysis demonstrated that male gender was an independent predictor of poor prognosis (HR 8.074; p<0.0001). 

Conclusions:  The incidence of pediatric papillary thyroid cancer is increasing.  Females have a higher incidence but also a better prognosis with improved survival than males.  Tumors ≥1cm were highly likely to be lymph-node positive, but lymphadenectomy did not alter survival. Although larger tumors (≥1cm) were more likely to be resected by subtotal/total thyroidectomy, survival was high and did not differ based on procedure type.   

12.12 Epidural versus Patient-Controlled Analgesia for Pain Control after Pediatric Thoracotomy

Posted on December 22, 2014

K. W. Gonzalez1, B. G. Dalton1, P. Thomas1, S. W. Sharp1, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:

Optimizing postoperative pain control in patients undergoing thoracotomy can be challenging and utilize substantial resources.  The use of thoracic epidural is standard in adult patients who undergo thoracotomy to facilitate earlier mobilization, deep breathing and minimize narcotic effects.  However, a recent randomized trial in pediatric patients who undergo repair of pectus excavatum suggests patient controlled analgesia (PCA) produces a similar post-operative course as epidural but is less costly, less time consuming and non-invasive.  Given thoracotomy is typically less painful than pectus bar placement, we compared the outcomes of epidural to PCA for pain management after pediatric thoracotomy.

Methods:

A retrospective review was conducted in patients who underwent thoracotomy at a children’s hospital between 2004 and 2013.  Data points included operative details, epidural or PCA use, urinary catheterization, days to regular diet, days to oral pain regimen, pain scores in the postoperative care unit and during admission, length of stay, and anesthesia charges.  Patients were excluded if they did not have epidural or PCA following thoracotomy.   Comparative analysis was performed utilizing 2-tailed Student t-tests.

Results:

There were 17 patients who underwent thoracotomy, of which 6 were treated with an epidural and 11 with a PCA.  Of the patients who received an epidural, 3 were opiate naïve, compared to 2 with a PCA.  The most common indication for thoracotomy was metastatic osteosarcoma (n=13).  When comparing epidural versus PCA, there was no significant difference in time to removal of foley catheter, days to regular diet, days to oral pain control, length of stay, or total operating room time.  Pain scores obtained in the postoperative care unit and during admission were also comparable.  The mean anesthesia charges were significantly higher in patients with an epidural versus PCA (Table 1).

Conclusion:

Epidural catheter and PCA provide comparable pain relief and objective recovery course in children who undergo thoracotomy, however, epidural catheter placement is associated with increased anesthesia charges suggesting PCA is a noninvasive, cost effective alternative.   

 

12.13 Long Term Outcome and State of Health After Fundoplication: Impact of Requiring a Redo Operation

Posted on December 22, 2014

E. Perrone1, J. Baerg1, R. Vannix1, D. Thorpe1, A. Gasior2, S. St Peter2  1Loma Linda University And Children’s Hospital,Pediatric Surgery,Loma Linda, CA, USA 2Children’s Mercy Hospital,Pediatric Surgery,Kansas City, MO, USA

Introduction:  To compare outcome and quality of life variables in children with one Nissen fundoplication to those with redo Nissen fundoplications  for gastroesophageal reflux disease (GERD).  

Methods:

After IRB approval (#5100277), children younger than 18 years, from two children’s hospitals, with Nissen fundoplications or redo fundoplications performed between January 1995 and March 2011 were retrospectively reviewed. 

Follow-up data were collected to December 2012. Phone calls were made to assess the current state of health for patients. Variables recorded included: hospital admissions for pneumonia, acute life threatening events (ALTEs), vomiting, retching, paraesophageal hernia on upper gastrointestinal (UGI) contrast study, need for esophageal dilations, operations for adhesive bowel obstruction, placement of gastro-jejunal (G-J) feeding tubes and administration of anti-GERD medications.

BMI z-scores at fundoplication, at one year after fundoplication, and at final follow-up evaluation were recorded.  Children with one fundoplication were compared to those with redos using t-tests for continuous and chi-square tests for categorical variables.   Means were expressed +/- standard deviation.  A p-value <0.05 was considered significant.

Results:

The families of 212 children were contacted, which included 53.8% males, and 181 had one fundoplication (85.4%) and 31 had redos (14.6%).  The median follow-up for the cohort was 3.4 years (range:  0.5-16 years) (mean: 4.1 +/- 2.9 years).  The median time to first redo was 17 months (range:  1-108 months) (mean:  31.5 +/- 34.4 months).  The median time to second redo after the 1st redo for 3/31(9.7%) was 32.5 months (range:  23-69 months) (mean:  41.5 +/- 24.3 months).  One had a third redo 5 years after the second redo complicated by incarceration of small bowel in a para-esophageal hernia.

Comparison of Variables- see table

 

Conclusion:

Children with redo fundoplications have significant difficulties compared to children with one fundoplication on follow-up evaluation.  They have significantly more admissions for pneumonia, vomiting, retching, paraesophageal hernias, and gastro-jejunal feeding tubes. 

 

« Previous Page
Next Page »