ANZ Journal of Surgery最新文献

Unnecessary care, where the potential for harm exceeds the potential for benefit, is widespread in medical care. Orthopaedic surgery is no exception. This has significant implications for patient safety and health care expenditure. This narrative review explores unnecessary care in orthopaedic surgery. There is wide geographic variation in orthopaedic surgical practice that cannot be explained by differences in local patient populations. Furthermore, many orthopaedic interventions lack adequate low-bias evidence to support their use. Quantifying the size of the problem is difficult, but the economic burden and morbidity associated with unnecessary care is likely to be significant. An evidence gap, evidence-practice gap, cognitive biases, and health system factors all contribute to unnecessary care in orthopaedic surgery. Unnecessary care is harming patients and incurring high costs. Solutions include increasing awareness of the problem, aligning financial incentives to high value care and away from low value care, and demanding low bias evidence where none exists.

Backgrounds: Streamlined, expedited clinical research is fundamental to rapidly test, translate and implement novel treatments into routine care to improve patient outcomes. The National Mutual Acceptance (NMA) scheme was designed to expedite the ethics approval process, however, growing concerns exist about the fragmented time-consuming governance process needed to actually commence clinical research in Australia. This study reports hurdles and barriers encountered while seeking governance approval for the SCANPatient trial.

Methods: SCANPatient is a nationwide multi-centre trial comparing standard narrative radiological reporting of CT scans for suspected pancreatic ductal adenocarcinoma. with an alternative structured approach. SCANPatient was approved by a national Human Research Ethics Committee under the NMA. The documents, time, costs and platforms required to obtain governance approval and open the trial at 30 participating hospitals were analysed.

Results: Wide variation exists in research governance office (RGO) requirements for local approval, resulting in extra costs (>$117 000), delays of up to 4 months in commencing the trial at some participating sites, unplanned adjustment of the study design, and ultimately the loss of several potential sites. There were inconsistencies among RGOs minimum requirements and processes across jurisdictions and sites, with delays in obtaining approval signatures, time-consuming processes, differing platforms used to submit governance reviews and inflexibility of RGO processes all contributing to delays in progressing the trial and obtaining governance approval.

Conclusion: The current governance process is time- and cost-consuming and undermines the NMA scheme's efforts to streamline the clinical trials review process.

Background: To assess the effect of private versus public insurance on hospital length of stay, discharge destination, and costs in managing Vancouver B periprosthetic femoral fractures (PFF).

Methods: A retrospective cohort study of PFF patients operatively managed at five public trauma centers. The primary outcome was hospital length of stay. Secondary outcomes included discharge destination and costs related to implants and hospital beds.

Results: The study included 195 PFF cases (133 public, 62 private). Private patients had lower ASA scores (2.8 versus 3.1, P = 0.006) and were more likely to come from independent residences (87% versus 74%, P = 0.045). Private patients spent 8 fewer days in the hospital (12 ± 8 versus 20 ± 19 days, P < 0.001) and were more often discharged to rehabilitation (74% versus 48%, P = 0.003). Public hospital costs were higher for public patients ($37 456 versus $25 324, P = 0.005), largely due to longer stays. Implant costs were similar between private and public patients, but patients that underwent revision surgeries increased costs significantly compared to patients that underwent open reduction and internal fixation alone ($6257 versus $3511, P < 0.001).

Conclusion: Private insurance was linked to shorter hospital stays and increased discharge to rehabilitation. Public PPF patients incur an average cost of $37 456 for public hospitals, compared to $25 324 for private patients. Delays in public patient rehabilitation access may prolong hospital stays, suggesting a need for alternative care pathways, such as PPF tailored home-based rehabilitation and support programs.

Introduction: The global standard of care for hip fracture surgery is early weight-bearing, but this has not extended to other lower extremity fractures in the elderly. Patients undergoing fixation of distal femur fractures are often prescribed weight-bearing restrictions, which may lead to deconditioning and other complications. The purpose of this study was to compare the outcomes and complication rates between patients permitted early versus restricted weight-bearing following distal femur fracture fixation.

Methods: Medline, Embase, Cochrane and Web of Science databases were searched for English language articles up to 21 October 2023, identifying 366 studies for screening. Comparative studies evaluating patients undergoing distal femur fracture fixation with early or restricted weight-bearing were included. Native knee and periprosthetic fractures were included.

Results: Ten studies were included for analysis. Two studies provided Level II evidence, while the remaining eight studies provided Level III evidence. Cochrane risk of bias tools were utilized to assess study quality. Revision and complication rates were analyzed and reported as odds ratio. Sub-analysis was undertaken to address the heterogeneity in author definitions of weight-bearing. There was no statistically significant difference in the revision or complication rate between the two groups.

Conclusion: Early weight-bearing following distal femur fracture fixation in a predominantly elderly population does not demonstrate an increased rate of revision or complications compared to restricted weight-bearing. However, there are limitations to the available literature, and the strength of the findings is insufficient to provide strong recommendations for all patients. Future studies should employ standardized definitions and avoid partial or time-based restrictions.

Background: Routine preoperative risk assessment (RPRA) using objective risk prediction tools may improve the perioperative outcomes of emergency major abdominal surgery (EMAS). This project aims to identify whether the introduction of RPRA with the 'National Emergency Laparotomy Audit (NELA) Calculator' as standard-of-care for EMAS at a regional Victorian hospital has improved postoperative outcomes, reduced unplanned postoperative critical care unit (CCU) admission rates, and impacted the 'no-lap' rate.

Methods: An audit was performed including all adult general surgery patients who required EMAS at Bendigo Health between September 2017 and August 2022, including those palliated up-front. Patients requiring surgery for uncomplicated appendicitis, cholecystitis, trauma, and diagnostic laparoscopy were excluded. Patient demographics, preoperative NELA score, CCU admission data and postoperative outcomes were collected and compared between patients undergoing surgery before and after the introduction of RPRA.

Results: Six hundred and ninety-one patients were included in the analysis. Median NELA score was 5 (IQR 1.5-11.75). 2.60% of patients were palliated up-front and did not proceed to surgery. Among the 673 operative patients, 30-day mortality was 5.20%. Following the introduction of RPRA there was a significant reduction in the unplanned CCU admission rate, from 9.14% to 3.48% (P = 0.04). There was no change in postoperative mortality, severe complication rate or planned CCU admission rate.

Conclusion: RPRA reduced rate of unplanned CCU admissions. Postoperative mortality and complication rates did not change following introduction of RPRA. RPRA appears useful in guidance of preoperative palliative decision-making, but further study is required to validate its use in this context.