Pub Date : 2024-05-13DOI: 10.1097/as9.0000000000000410
Sarah Jung, Ting Sun
{"title":"Competence and Assessment: Meeting the Needs of Accuracy and Fairness","authors":"Sarah Jung, Ting Sun","doi":"10.1097/as9.0000000000000410","DOIUrl":"https://doi.org/10.1097/as9.0000000000000410","url":null,"abstract":"","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"28 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140984082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-06DOI: 10.1097/as9.0000000000000431
Frank F. Yang, Elina Serrano, Kyle S. Bilodeau, Michael Weykamp, Caitlin J. Silvestri, Ashleigh C. M. Bull, Brenda Lin, Sara L. Schaefer, Colette Galet, Luis J. Garcia, Baraka Gitonga, D. T. Kolodziej, Samantha Esposito, Molly Parker-Brigham, Rohan Luhar, Avinash Mamgain, Kendrick C. Brown, S. Dewdney, T. Price, N. Siparsky, Sarah Knerr, Pauline K. Park, Sabrina Sanchez, D. Skeete, K. Fischkoff, D. Flum
To describe rates of dexamethasone use in the nonoperative management of malignant small bowel obstruction (mSBO) and their outcomes. mSBO is common in patients with advanced abdominal-pelvic cancers. Management includes prioritizing quality of life and avoiding surgical intervention when possible. The use of dexamethasone to restore bowel function is recommended in the National Comprehensive Cancer Network guidelines for mSBO. Yet, it is unknown how often dexamethasone is used for mSBO and whether results from nonresearch settings support its use. This is a multicenter retrospective cohort study including unique admissions for mSBO from January 1, 2019 to December 31, 2021. Dexamethasone use and management outcomes were summarized with descriptive statistics and multiple logistic regression. Among 571 admissions (68% female, mean age 63 years, 85% history of abdominal surgery) that were eligible and initially nonoperative, 26% [95% confidence interval (CI) = 23%–30%] received dexamethasone treatment (69% female, mean age 62 years, 87% history of abdominal surgery). Dexamethasone use by site ranged from 13% to 52%. Among dexamethasone recipients, 13% (95% CI = 9%–20%) subsequently required nonelective surgery during the same admission and 4 dexamethasone-related safety-events were reported. Amongst 421 eligible admissions where dexamethasone was not used, 17% (95% CI = 14%–21%) required nonelective surgery. Overall, the unadjusted odds ratio (OR) for nonelective surgery with dexamethasone use compared to without its use was 0.7 (95% CI = 0.4–1.3). Using multiple logistic regression, OR after adjusting for site, age, sex, history of abdominal surgery, nasogastric tube, and Gastrografin use was 0.6 (95% CI = 0.3–1.1). Dexamethasone was used in about 1 in 4 eligible mSBO admissions with high variability of use between tertiary academic centers. This multicenter retrospective cohort study suggested an association between dexamethasone use and lower rates of nonelective surgery, representing a potential opportunity for quality improvement.
{"title":"Use and Outcomes of Dexamethasone in the Management of Malignant Small Bowel Obstruction","authors":"Frank F. Yang, Elina Serrano, Kyle S. Bilodeau, Michael Weykamp, Caitlin J. Silvestri, Ashleigh C. M. Bull, Brenda Lin, Sara L. Schaefer, Colette Galet, Luis J. Garcia, Baraka Gitonga, D. T. Kolodziej, Samantha Esposito, Molly Parker-Brigham, Rohan Luhar, Avinash Mamgain, Kendrick C. Brown, S. Dewdney, T. Price, N. Siparsky, Sarah Knerr, Pauline K. Park, Sabrina Sanchez, D. Skeete, K. Fischkoff, D. Flum","doi":"10.1097/as9.0000000000000431","DOIUrl":"https://doi.org/10.1097/as9.0000000000000431","url":null,"abstract":"\u0000 \u0000 To describe rates of dexamethasone use in the nonoperative management of malignant small bowel obstruction (mSBO) and their outcomes.\u0000 \u0000 \u0000 \u0000 mSBO is common in patients with advanced abdominal-pelvic cancers. Management includes prioritizing quality of life and avoiding surgical intervention when possible. The use of dexamethasone to restore bowel function is recommended in the National Comprehensive Cancer Network guidelines for mSBO. Yet, it is unknown how often dexamethasone is used for mSBO and whether results from nonresearch settings support its use.\u0000 \u0000 \u0000 \u0000 This is a multicenter retrospective cohort study including unique admissions for mSBO from January 1, 2019 to December 31, 2021. Dexamethasone use and management outcomes were summarized with descriptive statistics and multiple logistic regression.\u0000 \u0000 \u0000 \u0000 Among 571 admissions (68% female, mean age 63 years, 85% history of abdominal surgery) that were eligible and initially nonoperative, 26% [95% confidence interval (CI) = 23%–30%] received dexamethasone treatment (69% female, mean age 62 years, 87% history of abdominal surgery). Dexamethasone use by site ranged from 13% to 52%. Among dexamethasone recipients, 13% (95% CI = 9%–20%) subsequently required nonelective surgery during the same admission and 4 dexamethasone-related safety-events were reported. Amongst 421 eligible admissions where dexamethasone was not used, 17% (95% CI = 14%–21%) required nonelective surgery. Overall, the unadjusted odds ratio (OR) for nonelective surgery with dexamethasone use compared to without its use was 0.7 (95% CI = 0.4–1.3). Using multiple logistic regression, OR after adjusting for site, age, sex, history of abdominal surgery, nasogastric tube, and Gastrografin use was 0.6 (95% CI = 0.3–1.1).\u0000 \u0000 \u0000 \u0000 Dexamethasone was used in about 1 in 4 eligible mSBO admissions with high variability of use between tertiary academic centers. This multicenter retrospective cohort study suggested an association between dexamethasone use and lower rates of nonelective surgery, representing a potential opportunity for quality improvement.\u0000","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"13 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141009578","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-06DOI: 10.1097/as9.0000000000000430
Arielle C. Thomas, R. Royan, A. Nathens, Brendan T. Campbell, Susheel Reddy, Sarabeth Spitzer, D. Hamad, Angie Jang, Anne M. Stey
To quantify the association between insurance and hospital admission following minor isolated extremity firearm injury. The association between insurance and injury admission has not been examined. This was an observational retrospective cohort study of minor isolated extremity firearm injury captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases in 6 states (New York, Arkansas, Wisconsin, Massachusetts, Florida, and Maryland) from 2016 to 2017 among patients aged 16 years or older. The primary exposure was insurance. Admitted patients were propensity score matched to nonadmitted patients on age, extremity Abbreviated Injury Score, and Elixhauser Comorbidity Index with exact matching within hospital to adjust for selection bias. A general estimating equation logistic regression estimated the association between insurance and odds of admission in the matched cohort while controlling for sex, race, injury intent, injury type, hospital profit type, and trauma center designation with observations clustered by propensity score-matched pairs within hospital. A total of 8151 patients presented to hospital with a minor isolated extremity firearm injury between 2016 and 2017 in 6 states. Patients were 88.0% male, 56.6% Black, and 71.7% aged 16 to 36 years old, and 22.1% were admitted. A total of 2090 patients were matched on propensity for admission. Privately insured matched patients had 1.70 higher adjusted odds of admission and 95% confidence interval of 1.30 to 2.22, compared with uninsured after adjusting for patient and hospital characteristics. Insurance was associated with hospital admission for minor isolated extremity firearm injury.
{"title":"Patient and Hospital Characteristics Associated with Admission Among Patients With Minor Isolated Extremity Firearm Injuries: A Propensity-Matched Analysis","authors":"Arielle C. Thomas, R. Royan, A. Nathens, Brendan T. Campbell, Susheel Reddy, Sarabeth Spitzer, D. Hamad, Angie Jang, Anne M. Stey","doi":"10.1097/as9.0000000000000430","DOIUrl":"https://doi.org/10.1097/as9.0000000000000430","url":null,"abstract":"\u0000 \u0000 To quantify the association between insurance and hospital admission following minor isolated extremity firearm injury.\u0000 \u0000 \u0000 \u0000 The association between insurance and injury admission has not been examined.\u0000 \u0000 \u0000 \u0000 This was an observational retrospective cohort study of minor isolated extremity firearm injury captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases in 6 states (New York, Arkansas, Wisconsin, Massachusetts, Florida, and Maryland) from 2016 to 2017 among patients aged 16 years or older. The primary exposure was insurance. Admitted patients were propensity score matched to nonadmitted patients on age, extremity Abbreviated Injury Score, and Elixhauser Comorbidity Index with exact matching within hospital to adjust for selection bias. A general estimating equation logistic regression estimated the association between insurance and odds of admission in the matched cohort while controlling for sex, race, injury intent, injury type, hospital profit type, and trauma center designation with observations clustered by propensity score-matched pairs within hospital.\u0000 \u0000 \u0000 \u0000 A total of 8151 patients presented to hospital with a minor isolated extremity firearm injury between 2016 and 2017 in 6 states. Patients were 88.0% male, 56.6% Black, and 71.7% aged 16 to 36 years old, and 22.1% were admitted. A total of 2090 patients were matched on propensity for admission. Privately insured matched patients had 1.70 higher adjusted odds of admission and 95% confidence interval of 1.30 to 2.22, compared with uninsured after adjusting for patient and hospital characteristics.\u0000 \u0000 \u0000 \u0000 Insurance was associated with hospital admission for minor isolated extremity firearm injury.\u0000","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"65 6","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141007675","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-02DOI: 10.1097/as9.0000000000000419
John M. Harris
Western armies have relied on surgical field manuals to help physicians deal with unfamiliar combat medical conditions from the Napoleonic wars to the present day, but there has been little discussion of whether these handbooks have been used or improved outcomes. Recent research shows that the Union Army’s American Civil War (1861–1865) surgical case fatality rates improved as the war progressed, much like the US Army’s experience in later wars, and were generally superior to comparable European results. These positive Civil War outcomes have been attributed to field experience, adoption of best practices, and enhanced communication, without consideration of New York surgeon Stephen Smith’s widely-used Hand-Book of Surgical Operations. The Army of the Potomac added Smith’s pocket-sized Hand-Book to its supply table in 1862. Northern medical journals applauded it, and Smith’s contemporaries documented its wide use. Smith’s handbook explained and demonstrated surgical techniques that were adopted as the war progressed, such as the use of general anesthesia and limb-sparing resection (debridement) of gunshot wounds. It offered pithy, well-documented advice from recognized experts along with numerous illustrations, which allowed untrained physicians to visualize anatomical relationships and see contemporary best practices in a way that no other wartime publication provided, making it an exemplar of a mass-media surgical improvement change agent.
{"title":"The Union Army’s Surgical Handbook and the Positive Story of Civil War Surgery","authors":"John M. Harris","doi":"10.1097/as9.0000000000000419","DOIUrl":"https://doi.org/10.1097/as9.0000000000000419","url":null,"abstract":"Western armies have relied on surgical field manuals to help physicians deal with unfamiliar combat medical conditions from the Napoleonic wars to the present day, but there has been little discussion of whether these handbooks have been used or improved outcomes. Recent research shows that the Union Army’s American Civil War (1861–1865) surgical case fatality rates improved as the war progressed, much like the US Army’s experience in later wars, and were generally superior to comparable European results. These positive Civil War outcomes have been attributed to field experience, adoption of best practices, and enhanced communication, without consideration of New York surgeon Stephen Smith’s widely-used Hand-Book of Surgical Operations. The Army of the Potomac added Smith’s pocket-sized Hand-Book to its supply table in 1862. Northern medical journals applauded it, and Smith’s contemporaries documented its wide use. Smith’s handbook explained and demonstrated surgical techniques that were adopted as the war progressed, such as the use of general anesthesia and limb-sparing resection (debridement) of gunshot wounds. It offered pithy, well-documented advice from recognized experts along with numerous illustrations, which allowed untrained physicians to visualize anatomical relationships and see contemporary best practices in a way that no other wartime publication provided, making it an exemplar of a mass-media surgical improvement change agent.","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"10 9","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141021471","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-02DOI: 10.1097/as9.0000000000000434
Totadri Dhimal, Paula Cupertino, Aqsa Ghaffar, Yue Li, Xueya Cai, Cristopher Soto, Megha Ramaswamy, Bruce W. Herdman, Fergal J. Fleming, A. Loria
This study, examining literature up to December 2023, aims to comprehensively assess surgical care for incarcerated individuals, identifying crucial knowledge gaps for informing future health services research and interventions. The US prison system detains around 2 million individuals, mainly young, indigent males from ethnic and racial minorities. The constitutional right to healthcare does not protect this population from unique health challenges and disparities. The scarcity of literature on surgical care necessitates a systematic review to stimulate research, improve care quality, and address health issues within this marginalized community. A systematic review, pre-registered with the International Prospective Register of Systematic Reviews (CRD42023454782), involved searches in PubMed, Embase, and Web of Science. Original research on surgical care for incarcerated individuals was included, excluding case reports/series (<10 patients), abstracts, and studies involving prisoners of war, plastic surgeries for recidivism reduction, transplants using organs from incarcerated individuals, and nonconsensual surgical sterilization. Out of 8209 studies screened, 118 met inclusion criteria, with 17 studies from 16 distinct cohorts reporting on surgical care. Predominantly focusing on orthopedic surgeries, supplemented by studies in emergency general, burns, ophthalmology, and kidney transplantation, the review identified delayed hospital presentations, a high incidence of complex cases, and low postoperative follow-up rates. Notable complications, such as nonfusion and postarthroplasty infections, were more prevalent in incarcerated individuals compared with nonincarcerated individuals. Trauma-related mortality rates were similar, despite lower intraabdominal injuries following penetrating abdominal injuries in incarcerated patients. While some evidence suggests inferior surgical care in incarcerated patients, the limited quality of available studies underscores the urgency of addressing knowledge gaps through future research. This is crucial for patients, clinicians, and policymakers aiming to enhance care quality for a population at risk of surgical complications during incarceration and postrelease.
{"title":"Systematic Review of Surgical Care in the Incarcerated Population: Identifying Knowledge Gaps for Future Research","authors":"Totadri Dhimal, Paula Cupertino, Aqsa Ghaffar, Yue Li, Xueya Cai, Cristopher Soto, Megha Ramaswamy, Bruce W. Herdman, Fergal J. Fleming, A. Loria","doi":"10.1097/as9.0000000000000434","DOIUrl":"https://doi.org/10.1097/as9.0000000000000434","url":null,"abstract":"\u0000 \u0000 This study, examining literature up to December 2023, aims to comprehensively assess surgical care for incarcerated individuals, identifying crucial knowledge gaps for informing future health services research and interventions.\u0000 \u0000 \u0000 \u0000 The US prison system detains around 2 million individuals, mainly young, indigent males from ethnic and racial minorities. The constitutional right to healthcare does not protect this population from unique health challenges and disparities. The scarcity of literature on surgical care necessitates a systematic review to stimulate research, improve care quality, and address health issues within this marginalized community.\u0000 \u0000 \u0000 \u0000 A systematic review, pre-registered with the International Prospective Register of Systematic Reviews (CRD42023454782), involved searches in PubMed, Embase, and Web of Science. Original research on surgical care for incarcerated individuals was included, excluding case reports/series (<10 patients), abstracts, and studies involving prisoners of war, plastic surgeries for recidivism reduction, transplants using organs from incarcerated individuals, and nonconsensual surgical sterilization.\u0000 \u0000 \u0000 \u0000 Out of 8209 studies screened, 118 met inclusion criteria, with 17 studies from 16 distinct cohorts reporting on surgical care. Predominantly focusing on orthopedic surgeries, supplemented by studies in emergency general, burns, ophthalmology, and kidney transplantation, the review identified delayed hospital presentations, a high incidence of complex cases, and low postoperative follow-up rates. Notable complications, such as nonfusion and postarthroplasty infections, were more prevalent in incarcerated individuals compared with nonincarcerated individuals. Trauma-related mortality rates were similar, despite lower intraabdominal injuries following penetrating abdominal injuries in incarcerated patients.\u0000 \u0000 \u0000 \u0000 While some evidence suggests inferior surgical care in incarcerated patients, the limited quality of available studies underscores the urgency of addressing knowledge gaps through future research. This is crucial for patients, clinicians, and policymakers aiming to enhance care quality for a population at risk of surgical complications during incarceration and postrelease.\u0000","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"75 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141018013","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1097/as9.0000000000000429
Tyler J. Loftus, M. Ruppert, B. Shickel, T. Ozrazgat-Baslanti, Jeremy A. Balch, Kenneth L. Abbott, Die Hu, Adnan Javed, Firas G Madbak, F. Guirgis, David Skarupa, P. Efron, P. Tighe, William R. Hogan, Parisa Rashidi, Gilbert R. Upchurch, A. Bihorac
To determine whether certain patients are vulnerable to errant triage decisions immediately after major surgery and whether there are unique sociodemographic phenotypes within overtriaged and undertriaged cohorts. In a fair system, overtriage of low-acuity patients to intensive care units (ICUs) and undertriage of high-acuity patients to general wards would affect all sociodemographic subgroups equally. This multicenter, longitudinal cohort study of hospital admissions immediately after major surgery compared hospital mortality and value of care (risk-adjusted mortality/total costs) across 4 cohorts: overtriage (N = 660), risk-matched overtriage controls admitted to general wards (N = 3077), undertriage (N = 2335), and risk-matched undertriage controls admitted to ICUs (N = 4774). K-means clustering identified sociodemographic phenotypes within overtriage and undertriage cohorts. Compared with controls, overtriaged admissions had a predominance of male patients (56.2% vs 43.1%, P < 0.001) and commercial insurance (6.4% vs 2.5%, P < 0.001); undertriaged admissions had a predominance of Black patients (28.4% vs 24.4%, P < 0.001) and greater socioeconomic deprivation. Overtriage was associated with increased total direct costs [$16.2K ($11.4K–$23.5K) vs $14.1K ($9.1K–$20.7K), P < 0.001] and low value of care; undertriage was associated with increased hospital mortality (1.5% vs 0.7%, P = 0.002) and hospice care (2.2% vs 0.6%, P < 0.001) and low value of care. Unique sociodemographic phenotypes within both overtriage and undertriage cohorts had similar outcomes and value of care, suggesting that triage decisions, rather than patient characteristics, drive outcomes and value of care. Postoperative triage decisions should ensure equality across sociodemographic groups by anchoring triage decisions to objective patient acuity assessments, circumventing cognitive shortcuts and mitigating bias.
目的是确定某些病人是否容易在大手术后立即受到错误分流决定的影响，以及在过度分流和分流不足的人群中是否存在独特的社会人口表型。 在一个公平的系统中，将低急症患者过度分流到重症监护室（ICU）和将高急症患者分流到普通病房会对所有社会人口亚群产生同等影响。 这项针对大手术后立即入院的多中心纵向队列研究比较了 4 个队列的住院死亡率和护理价值（风险调整后死亡率/总成本），这 4 个队列分别是：过度分流（660 人）、风险匹配的普通病房过度分流对照组（3077 人）、过度分流（2335 人）和风险匹配的重症监护病房过度分流对照组（4774 人）。K-均值聚类确定了过度接种和低度接种队列中的社会人口表型。 与对照组相比，过度分流的入院患者中男性患者居多（56.2% vs 43.1%，P < 0.001），且有商业保险（6.4% vs 2.5%，P < 0.001）；分流不足的入院患者中黑人患者居多（28.4% vs 24.4%，P < 0.001），且社会经济贫困程度更高。过度接诊与直接总成本增加[1.62万美元（11.4-23.5万美元）vs 1.41万美元（9.1-20.7万美元），P < 0.001]和护理价值低有关；不足接诊与住院死亡率增加（1.5% vs 0.7%，P = 0.002）和临终关怀（2.2% vs 0.6%，P < 0.001）和护理价值低有关。过度分流和过度分流队列中的独特社会人口表型具有相似的治疗效果和护理价值，这表明分流决策而非患者特征决定了治疗效果和护理价值。 术后分流决策应确保不同社会人口群体之间的平等，将分流决策与客观的患者严重程度评估挂钩，避免认知上的捷径并减少偏见。
{"title":"Association of Sociodemographic Factors With Overtriage, Undertriage, and Value of Care After Major Surgery","authors":"Tyler J. Loftus, M. Ruppert, B. Shickel, T. Ozrazgat-Baslanti, Jeremy A. Balch, Kenneth L. Abbott, Die Hu, Adnan Javed, Firas G Madbak, F. Guirgis, David Skarupa, P. Efron, P. Tighe, William R. Hogan, Parisa Rashidi, Gilbert R. Upchurch, A. Bihorac","doi":"10.1097/as9.0000000000000429","DOIUrl":"https://doi.org/10.1097/as9.0000000000000429","url":null,"abstract":"\u0000 \u0000 To determine whether certain patients are vulnerable to errant triage decisions immediately after major surgery and whether there are unique sociodemographic phenotypes within overtriaged and undertriaged cohorts.\u0000 \u0000 \u0000 \u0000 In a fair system, overtriage of low-acuity patients to intensive care units (ICUs) and undertriage of high-acuity patients to general wards would affect all sociodemographic subgroups equally.\u0000 \u0000 \u0000 \u0000 This multicenter, longitudinal cohort study of hospital admissions immediately after major surgery compared hospital mortality and value of care (risk-adjusted mortality/total costs) across 4 cohorts: overtriage (N = 660), risk-matched overtriage controls admitted to general wards (N = 3077), undertriage (N = 2335), and risk-matched undertriage controls admitted to ICUs (N = 4774). K-means clustering identified sociodemographic phenotypes within overtriage and undertriage cohorts.\u0000 \u0000 \u0000 \u0000 Compared with controls, overtriaged admissions had a predominance of male patients (56.2% vs 43.1%, P < 0.001) and commercial insurance (6.4% vs 2.5%, P < 0.001); undertriaged admissions had a predominance of Black patients (28.4% vs 24.4%, P < 0.001) and greater socioeconomic deprivation. Overtriage was associated with increased total direct costs [$16.2K ($11.4K–$23.5K) vs $14.1K ($9.1K–$20.7K), P < 0.001] and low value of care; undertriage was associated with increased hospital mortality (1.5% vs 0.7%, P = 0.002) and hospice care (2.2% vs 0.6%, P < 0.001) and low value of care. Unique sociodemographic phenotypes within both overtriage and undertriage cohorts had similar outcomes and value of care, suggesting that triage decisions, rather than patient characteristics, drive outcomes and value of care.\u0000 \u0000 \u0000 \u0000 Postoperative triage decisions should ensure equality across sociodemographic groups by anchoring triage decisions to objective patient acuity assessments, circumventing cognitive shortcuts and mitigating bias.\u0000","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"54 2","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141042413","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-23DOI: 10.1097/as9.0000000000000425
Said Maldonado, N. Lyons, Jonathan S. Lall, J. S. Zimmerle, Brendan Rosamond, Ashlynn Mills, Yoolim Alex Seo, Angelica Calderon Rodriguez, Rainna Coelho, Natalia Cavagnaro, Zuhair Ali, M. K. Liang
We aimed to evaluate the prevalence of highly detailed ventral hernia repair (VHR) operative reports and associations between operative report detail and postoperative outcomes in a medico-legal dataset. VHR are one of the most common surgical procedures performed in the United States. Previous work has shown that VHR operative reports are poorly detailed, however, the relationship between operative report detail and patient outcomes is unknown. This is a retrospective cross-sectional observational study. Operative reports describing VHR were obtained from a medical-legal database. Medical records were screened and data was extracted including clinical outcomes, such as surgical site infection (SSI), hernia recurrence, and reoperation and the presence of key details in each report. Highly detailed operative reports were defined as having 70% of recommended details. The primary outcome was the prevalence of highly detailed VHR operative reports. A total of 1011 VHR operative reports dictated by 693 surgeons across 517 facilities in 50 states were included. Median duration of follow-up was 4.6 years after initial surgery. Only 35.7% of operative reports were highly detailed. More recent operative reports, cases with resident involvement, and contaminated procedures were more likely to be highly detailed (all P < 0.05). Compared to poorly detailed operative reports, cases with highly detailed reports had fewer SSIs (13.2% vs 7.5%, P = 0.006), hernia recurrence (65.8% vs 55.4%, P = 0.002), and reoperation (78.9% vs 62.6%, P = 0.001). In this medico-legal dataset, most VHR operative reports are poorly detailed while highly detailed operative reports were associated with lower rates of complications. Future studies should examine a nationally representative dataset to validate our findings.
{"title":"Adequate Reporting Among Ventral Hernia Repair Operative Reports: A Cross-Sectional Study of Prevalence of Details and Association With Clinical Outcomes","authors":"Said Maldonado, N. Lyons, Jonathan S. Lall, J. S. Zimmerle, Brendan Rosamond, Ashlynn Mills, Yoolim Alex Seo, Angelica Calderon Rodriguez, Rainna Coelho, Natalia Cavagnaro, Zuhair Ali, M. K. Liang","doi":"10.1097/as9.0000000000000425","DOIUrl":"https://doi.org/10.1097/as9.0000000000000425","url":null,"abstract":"\u0000 \u0000 We aimed to evaluate the prevalence of highly detailed ventral hernia repair (VHR) operative reports and associations between operative report detail and postoperative outcomes in a medico-legal dataset.\u0000 \u0000 \u0000 \u0000 VHR are one of the most common surgical procedures performed in the United States. Previous work has shown that VHR operative reports are poorly detailed, however, the relationship between operative report detail and patient outcomes is unknown.\u0000 \u0000 \u0000 \u0000 This is a retrospective cross-sectional observational study. Operative reports describing VHR were obtained from a medical-legal database. Medical records were screened and data was extracted including clinical outcomes, such as surgical site infection (SSI), hernia recurrence, and reoperation and the presence of key details in each report. Highly detailed operative reports were defined as having 70% of recommended details. The primary outcome was the prevalence of highly detailed VHR operative reports.\u0000 \u0000 \u0000 \u0000 A total of 1011 VHR operative reports dictated by 693 surgeons across 517 facilities in 50 states were included. Median duration of follow-up was 4.6 years after initial surgery. Only 35.7% of operative reports were highly detailed. More recent operative reports, cases with resident involvement, and contaminated procedures were more likely to be highly detailed (all P < 0.05). Compared to poorly detailed operative reports, cases with highly detailed reports had fewer SSIs (13.2% vs 7.5%, P = 0.006), hernia recurrence (65.8% vs 55.4%, P = 0.002), and reoperation (78.9% vs 62.6%, P = 0.001).\u0000 \u0000 \u0000 \u0000 In this medico-legal dataset, most VHR operative reports are poorly detailed while highly detailed operative reports were associated with lower rates of complications. Future studies should examine a nationally representative dataset to validate our findings.\u0000","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"113 9","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140669551","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-22DOI: 10.1097/as9.0000000000000413
T. Schouten, A. C. Henry, F. Smits, L. Daamen, I. Molenaar, H. V. van Santvoort
{"title":"Response to: Comment on “Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort”","authors":"T. Schouten, A. C. Henry, F. Smits, L. Daamen, I. Molenaar, H. V. van Santvoort","doi":"10.1097/as9.0000000000000413","DOIUrl":"https://doi.org/10.1097/as9.0000000000000413","url":null,"abstract":"","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"10 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140673695","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-18DOI: 10.1097/as9.0000000000000423
N. Mateussi, Michael P. Rogers, Emily A. Grimsley, M. Read, Rajavi Parikh, Ricardo Pietrobon, Paul C. Kuo
This review introduces interpretable predictive machine learning approaches, natural language processing, image recognition, and reinforcement learning methodologies to familiarize end users. As machine learning, artificial intelligence, and generative artificial intelligence become increasingly utilized in clinical medicine, it is imperative that end users understand the underlying methodologies. This review describes publicly available datasets that can be used with interpretable predictive approaches, natural language processing, image recognition, and reinforcement learning models, outlines result interpretation, and provides references for in-depth information about each analytical framework. This review introduces interpretable predictive machine learning models, natural language processing, image recognition, and reinforcement learning methodologies. Interpretable predictive machine learning models, natural language processing, image recognition, and reinforcement learning are core machine learning methodologies that underlie many of the artificial intelligence methodologies that will drive the future of clinical medicine and surgery. End users must be well versed in the strengths and weaknesses of these tools as they are applied to patient care now and in the future.
{"title":"Clinical Applications of Machine Learning","authors":"N. Mateussi, Michael P. Rogers, Emily A. Grimsley, M. Read, Rajavi Parikh, Ricardo Pietrobon, Paul C. Kuo","doi":"10.1097/as9.0000000000000423","DOIUrl":"https://doi.org/10.1097/as9.0000000000000423","url":null,"abstract":"\u0000 \u0000 This review introduces interpretable predictive machine learning approaches, natural language processing, image recognition, and reinforcement learning methodologies to familiarize end users.\u0000 \u0000 \u0000 \u0000 As machine learning, artificial intelligence, and generative artificial intelligence become increasingly utilized in clinical medicine, it is imperative that end users understand the underlying methodologies.\u0000 \u0000 \u0000 \u0000 This review describes publicly available datasets that can be used with interpretable predictive approaches, natural language processing, image recognition, and reinforcement learning models, outlines result interpretation, and provides references for in-depth information about each analytical framework.\u0000 \u0000 \u0000 \u0000 This review introduces interpretable predictive machine learning models, natural language processing, image recognition, and reinforcement learning methodologies.\u0000 \u0000 \u0000 \u0000 Interpretable predictive machine learning models, natural language processing, image recognition, and reinforcement learning are core machine learning methodologies that underlie many of the artificial intelligence methodologies that will drive the future of clinical medicine and surgery. End users must be well versed in the strengths and weaknesses of these tools as they are applied to patient care now and in the future.\u0000","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":" 13","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140686477","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-15DOI: 10.1097/as9.0000000000000415
R. Amiri, Maurice J. Zwart, Leia R. Jones, M. Abu Hilal, H. Beerlage, M. I. van Berge Henegouwen, W. Laméris, W. A. Bemelman, M. Besselink
To assess the added value of 3-dimensional (3D) vision, including high definition (HD) technology, in laparoscopic surgery in terms of surgeon preference and clinical outcome. The use of 3D vision in laparoscopic surgery has been suggested to improve surgical performance. However, the added value of 3D vision remains unclear as a systematic review of randomized controlled trials (RCTs) comparing 3D vision including HD technology in laparoscopic surgery is currently lacking. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines with a literature search up to May 2023 using PubMed and Embase (PROSPERO, CRD42021290426). We included RCTs comparing 3D versus 2-dimensional (2D) vision in laparoscopic surgery. The primary outcome was operative time. Meta-analyses were performed using the random effects model to estimate the pooled effect size expressed in standard mean difference (SMD) with corresponding 95% confidence intervals (CIs). The level of evidence and quality was assessed according to the Cochrane risk of bias tool. Overall, 25 RCTs with 3003 patients were included. Operative time was reduced by 3D vision (−8.0%; SMD, −0.22; 95% CI, −0.37 to −0.06; P = 0.007; n = 3003; 24 studies; I 2 = 75%) compared to 2D vision. This benefit was mostly seen in bariatric surgery (−16.3%; 95% CI, −1.28 to −0.21; P = 0.006; 2 studies; n = 58; I 2 = 0%) and general surgery (−6.7%; 95% CI, −0.34 to −0.01; P = 0.036; 9 studies; n = 1056; I 2 = 41%). Blood loss was nonsignificantly reduced by 3D vision (SMD, −0.33; 95% CI, −0.68 to 0.017; P = 0.060; n = 1830; I 2 = 92%). No differences in the rates of morbidity (14.9% vs 13.5%, P = 0.644), mortality (0% vs 0%), conversion (0.8% vs 0.9%, P = 0.898), and hospital stay (9.6 vs 10.5 days, P = 0.078) were found between 3D and 2D vision. In 15 RCTs that reported on surgeon preference, 13 (87%) reported that the majority of surgeons favored 3D vision. Across 25 RCTs, this systematic review and meta-analysis demonstrated shorter operative time with 3D vision in laparoscopic surgery, without differences in other outcomes. The majority of surgeons participating in the RCTs reported in favor of 3D vision.
{"title":"Surgeon Preference and Clinical Outcome of 3D Vision Compared to 2D Vision in Laparoscopic Surgery: Systematic Review and Meta-Analysis of Randomized Trials","authors":"R. Amiri, Maurice J. Zwart, Leia R. Jones, M. Abu Hilal, H. Beerlage, M. I. van Berge Henegouwen, W. Laméris, W. A. Bemelman, M. Besselink","doi":"10.1097/as9.0000000000000415","DOIUrl":"https://doi.org/10.1097/as9.0000000000000415","url":null,"abstract":"\u0000 \u0000 To assess the added value of 3-dimensional (3D) vision, including high definition (HD) technology, in laparoscopic surgery in terms of surgeon preference and clinical outcome.\u0000 \u0000 \u0000 \u0000 The use of 3D vision in laparoscopic surgery has been suggested to improve surgical performance. However, the added value of 3D vision remains unclear as a systematic review of randomized controlled trials (RCTs) comparing 3D vision including HD technology in laparoscopic surgery is currently lacking.\u0000 \u0000 \u0000 \u0000 A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines with a literature search up to May 2023 using PubMed and Embase (PROSPERO, CRD42021290426). We included RCTs comparing 3D versus 2-dimensional (2D) vision in laparoscopic surgery. The primary outcome was operative time. Meta-analyses were performed using the random effects model to estimate the pooled effect size expressed in standard mean difference (SMD) with corresponding 95% confidence intervals (CIs). The level of evidence and quality was assessed according to the Cochrane risk of bias tool.\u0000 \u0000 \u0000 \u0000 Overall, 25 RCTs with 3003 patients were included. Operative time was reduced by 3D vision (−8.0%; SMD, −0.22; 95% CI, −0.37 to −0.06; P = 0.007; n = 3003; 24 studies; I\u0000 2 = 75%) compared to 2D vision. This benefit was mostly seen in bariatric surgery (−16.3%; 95% CI, −1.28 to −0.21; P = 0.006; 2 studies; n = 58; I\u0000 2 = 0%) and general surgery (−6.7%; 95% CI, −0.34 to −0.01; P = 0.036; 9 studies; n = 1056; I\u0000 2 = 41%). Blood loss was nonsignificantly reduced by 3D vision (SMD, −0.33; 95% CI, −0.68 to 0.017; P = 0.060; n = 1830; I\u0000 2 = 92%). No differences in the rates of morbidity (14.9% vs 13.5%, P = 0.644), mortality (0% vs 0%), conversion (0.8% vs 0.9%, P = 0.898), and hospital stay (9.6 vs 10.5 days, P = 0.078) were found between 3D and 2D vision. In 15 RCTs that reported on surgeon preference, 13 (87%) reported that the majority of surgeons favored 3D vision.\u0000 \u0000 \u0000 \u0000 Across 25 RCTs, this systematic review and meta-analysis demonstrated shorter operative time with 3D vision in laparoscopic surgery, without differences in other outcomes. The majority of surgeons participating in the RCTs reported in favor of 3D vision.\u0000","PeriodicalId":503165,"journal":{"name":"Annals of Surgery Open","volume":"15 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140703281","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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