The latest medical research on Head & Neck Surgery
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Request AccessCost-Effectiveness of Nonoperative Management vs Upfront Laparoscopic Appendectomy for Pediatric Uncomplicated Appendicitis Over 1 Year.
American College of SurgeonsNon-operative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared to appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of non-operative versus operative management for pediatric uncomplicated acute appendicitis.
A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional non-randomized controlled trial investigating NOM versus surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges (RCC)-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System (PHIS). Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and one-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay (WTP) threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). Primary outcome measures included total and incremental mean costs, QALY, DALY, and incremental cost-effectiveness ratios (ICERs).
Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791/patient and yielded an average of 0.884 QALYs while NOM cost an average of $8,044/patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating utilities.
NOM is cost-effective compared to laparoscopic appendectomy for pediatric uncomplicated appendicitis over 1 year.
Eliminating Error in Central Line Scheduling and Placement Using Quality Improvement Methods.
American College of SurgeonsThe Joint Commission defines a sentinel event as "surgery or other invasive procedure performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for a patient regardless of the type of procedure or the magnitude of the outcome." At our institution, we observed a low but consistent rate of incorrect surgical line placement for pediatric patients with cancer.
Following quality improvement methodology and using the resources available on a large academic medical campus we designed and implemented a new multi-factorial process to schedule and place surgical central lines for pediatric patients with cancer. Changes included re-defining responsibilities, adding staff, and redesigning the process with workflows supported by modifications to the electronic medical record. Our primary outcome measures were incorrect central line placement or near miss event per quarter and days between these events.
After implementation the rate of incorrect line placement and near miss events was reduced to zero with 1018 days since the last incorrect line placement.
As a result of our multi-factorial quality improvement initiative in the scheduling and placement of central lines, we were able to eliminate surgical line placement sentinel events and improve care for pediatric patients with cancer.
Omitting Radiotherapy after Breast-Conserving Surgery in Luminal A Breast Cancer: The LUMINA Study.
American College of SurgeonsThe modern generation of trials evaluating the role of adjuvant radiation have turned to genomic profiling as a further risk stratification tool. T...
Beyond American College of Surgeons Verification: Quality Metrics Associated with High Performance at Level I and II Trauma Centers.
American College of SurgeonsThe American College of Surgeons (ACS) Committee on Trauma has established a framework for trauma center quality improvement. Despite efforts, recent studies show persistent variation in patient outcomes across national trauma centers. We aimed to investigate whether risk-adjusted mortality varies at the hospital level and if high-performing centers demonstrate better adherence to ACS Verification, Review, and Consultation (VRC) program quality measures.
We analyzed data from the 2018-2021 ACS TQIP Participant Use Files, focusing on adult admissions at ACS-verified Level I or II trauma centers for blunt, penetrating, or isolated traumatic brain injury. We used mixed-effects models to assess center-specific risk-adjusted mortality and identified high-performing centers (HPTC), defined as those with the lowest decile of overall risk-adjusted mortality. We compared patient and hospital characteristics, outcomes, and adherence to ACS-VRC quality measures between HPTC and non-HPTC.
Over the study period, 1,498,602 patients across 442 Level I and II trauma centers met inclusion criteria: 65.3% presenting with blunt injury, 9.3% with penetrating injury, and 25.4% with isolated TBI. Management at HPTC was associated with lower odds of major complications, failure-to-rescue and takeback. Furthermore, HPTC status was associated with increased odds of adherence to several ACS-VRC quality measures, including balanced resuscitation (Odds Ratio [OR] 1.40, 95%Confidence Interval [CI] 1.29-1.51), appropriate pediatric admissions (OR 1.88, 95%CI 1.07-3.68), and substance abuse screening (AOR 1.14, 95%CI 1.12-1.16).
Significant variation in risk-adjusted mortality persists across trauma centers. Given the association between adherence to quality measures and high-performance, multidisciplinary efforts to refine and implement guidelines are warranted.
Surgeon Perception and Attitude Towards the Moral Imperative of Institutionally Addressing Second-Victim Syndrome in Surgery.
American College of SurgeonsSecond victim syndrome (SVS) is described as when health care providers encounter significant moral distress after traumatic patient care events. Although broadly recognized in medicine, this remains underrecognized in surgery and no systemic approaches exist to mitigate potential harms of SVS amongst surgeons. When SVS is left unaddressed, surgeons not only suffer personal psychological harm but their ability to care for future patients can also be compromised. The aim was to examine surgeons' perceptions and attitudes regarding mitigation of SVS.
This study was conducted at a tertiary-care university hospital using a mixed-methods approach coupling quantitative and qualitative assessments including a 13-item survey, follow-up focus group, and semi-structured interviews The Wilcoxon signed-rank test was used for quantitative analysis and content analysis used to report qualitative findings.
Surgeons believe SVS is a universal experience amongst surgeons that healthcare institutions have a moral obligation to address. Surgeons further believe that any effective mitigation strategy must receive legal protection similar to morbidity and mortality (M&M) conferences. The culture, tenor, and tone of review processes after surgical complications can either reduce or exacerbate the burden of SVS. Successful interventions must be easily accessible, voluntary, and culturally acceptable. Furthermore, surgeons may suffer greater SVS compared with non-procedural physicians as adverse events can be inevitable in operation and may potentially be a high frequency outcome depending on patient population.
Surgeons agreed that healthcare organizations have a moral imperative to assist surgeons in navigating the psychosocial impacts of SVS after adverse surgical outcomes. The success of mitigation strategies was viewed as ethically relevant to patients and surgeons and dependent on the culture, tenor, and tone of the process.
Factors Predicting Overnight Admission after Same-Day Mastectomy Protocol and Associated Financial Implications.
American College of SurgeonsSame-day mastectomy (SDM) protocols have been shown to be safe, and their use increased up to four-fold compared to pre-pandemic rates. We sought to identify factors that predict overnight patient admission and evaluate the associated cost of care.
Patients undergoing mastectomy from March 2020 to April 2022 were analyzed. Patients' demographics, tumor characteristics, operative details, perioperative factors, 30-day complications, fixed and variable cost, and contribution margin (CM) were compared between those who underwent SDM vs. those who required overnight admission after mastectomy (OAM).
Of a total of 183 patients with planned SDM, 104 (57%) had SDM and 79 (43%) had OAM. Both groups had similar demographic, tumor, and operative characteristics. OAM patients were more likely to be preoperative opioid users (POU) (p=0.002), have higher American Society of Anesthesiology (ASA) class (p= 0.028), and more likely to have procedure start time (PST) after 12:00 PM (49% vs. 33%, p=0.033). The rates of 30-day unplanned postoperative events were similar between SDM and OAM. POU (OR 3.62 CI 1.56 - 8.40), PACU length of stay greater than one hour (OR 1.17 CI 1.01 - 1.37), and PST after 12:00 PM (OR 2.56 CI 1.19 - 5.51), were independent predictors of OAM on multivariate analysis. Both fixed ($ 5,545 vs $4,909, p=0.03) and variable costs ($6,426 vs $4,909, p=0.03) were higher for OAM compared to SDM. CM, was not significantly different between the two groups (-$431 SDM vs -$734 OAM, p=0.46).
Preoperative opioid use, ASA class, longer PACU length of stay, and PST after noon predict a higher likelihood of admission following planned SDM. OAM translated to higher costs, but not to decreased profit for the hospital.
Comparison of Climate Impact, Clinical Outcome, and Cost-Efficiency of Pediatric Transumbilical Laparoscopic Assisted Appendectomy vs Standard 3-Port Laparoscopic Appendectomy.
American College of SurgeonsHealthcare is responsible for 8.5% of US greenhouse gas emissions. These impacts must be mitigated while maintaining clinical excellence. This study compares clinical outcomes, cost-efficiency, and climate impact of trans-umbilical laparoscopic assisted appendectomy (TULAA) versus 3-port laparoscopic appendectomy (LA).
Institutional Review Board approval was obtained. Appendectomies performed between Jan 1, 2020 and December 31, 2022 at a tertiary children's hospital were reviewed. Data abstracted included clinical characteristics, operative approach and findings, supplies and equipment utilized, and complications. For analysis TULAA was combined with cases converted to LA (TULAA+C). To determine a surgical site infection (SSI) increase of ≤ 2.5%, a minimum sample size of 479 patients per group was needed to achieve a power of 80%. A composite supply list for each approach was determined by averaging supplies from cases reviewed. The composite was used to calculate cost-efficiency and climate impact. Life cycle assessment was used to determine the carbon footprint (according to ISO 14067) of supplies and equipment.
Analysis was performed on 1,611 appendectomies: 497 LA and 1,114 TULAA+C (932 TULAA, 182 converted). Except for BMI, there were no clinically significant differences between groups. SSI did not increase with TULAA+C (n=15, 1.3%) versus LA (n=6, 1.2%), p=0.81. TULAA+C ($369.21/case) was more cost efficient than LA ($879.30/case) and TULAA+C (24.8 kg CO2e) produced fewer emissions than LA (27.4 kg CO2e).
While patient safety and excellent clinical outcomes must remain the top priority in healthcare, the current environmental crisis demands consideration of climate impacts. When clinical non-inferiority can be demonstrated, treatment options with a fewer greenhouse gas emissions should be chosen.
Are We Supporting Surgical Quality Improvement in Training and Beyond? A Qualitative Study of Surgical Trainees and Practicing Surgeons.
American College of SurgeonsWe conducted a qualitative study to describe surgeon and surgical trainee perspectives of quality improvement (QI) in training and practice to elucidate how surgeons and trainees interact with barriers and leverage facilitators to learn and conduct QI.
Surgeons and surgical trainees of the American College of Surgeons were recruited via email and snowball sampling to participate in focus groups. Eligible individuals were English speaking surgical trainees or practicing surgeons. We developed a semi-structured focus group protocol to explore barriers and facilitators of quality training and improvement. An inductive thematic approach was used to identify actionable items.
Thirty-two surgical trainees and surgeons participated in six focus groups. 28% of participants were trainees (8 residents, 1 fellow) and 72% were practicing surgeons, representing practice settings in university, community, and Veterans Affairs hospitals in urban and suburban regions. Thematic analysis revealed the central theme among trainees was that they lacked necessary support to effectively learn and conduct QI. Dominant sub-themes included lack of formal education, insufficient time, inconsistent mentorship, and maximizing self-sufficiency to promotes success. The central theme among surgeons was that effective QI initiatives require adequate resources and institutional support; however, surgeons in this study were ultimately constrained by institutional limitations. Sub-themes included difficulties in data acquisition and interpretation, financial limitations, workforce and staffing challenges, misaligned stakeholder priorities, and institutional culture.
This qualitative evaluation further details gaps in QI demonstrated by previous quantitative studies. There is an opportunity to address these gaps with dedicated QI training and mentorship for surgical trainees and by creating a supportive environment with ample resources for surgeons.
Scheduled Follow-Up and Association with Emergency Department Use and Readmission after Trauma.
American College of SurgeonsAfter traumatic injury, 13-14% of patients utilize the emergency department (ED) and 11% are readmitted within 30 days. Decreasing ED visits and readmission represents a target for quality improvement. This cohort study evaluates risk factors for ED visits and readmission after trauma, focusing on outpatient follow-up.
We conducted a retrospective chart review of adult trauma admissions from 1/1/2018-12/31/2021. Our primary exposure was outpatient follow-up, our primary outcome was ED use, and our secondary outcome was readmission. Multivariable logistic regression evaluated the association between primary exposure and outcomes, adjusting for factors identified on unadjusted analysis.
2,266 patients met inclusion criteria, with an 11.3% ED visit rate and 4.1% readmission rate. Attending follow-up did not have a significant association with ED visits (OR 0.99, 95% CI 0.99-2.01, p=0.05) or readmission rates (OR 1.68, 95% CI 0.95-2.99, p=0.08). Significant associations with ED use included non-white race, depression, anxiety, substance use disorder, discharge disposition, and being discharged with lines or drains. Significant associations with readmission included depression, anxiety, and discharge disposition.
Emphasizing outpatient follow-up in trauma patients is not an effective target to decrease ED use or readmission. Future studies should focus on supporting patients with mental health comorbidities and investigating interventions to optimally engage with trauma patients after hospital discharge.
Collaborative Approach toward Transplant Candidacy for Obese End-Stage Renal Disease Patients.
American College of SurgeonsAn elevated Body Mass Index (BMI) is a major cause of transplant preclusion for patients with End Stage Renal Disease (ESRD). This phenomenon exacerbates existing socioeconomic and racial disparities and increases the economic burden of maintaining patients on dialysis. Metabolic Bariatric Surgery (MBS) in such patients is not widely available. Our center created a collaborative program to undergo weight loss surgery before obtaining a kidney transplant.
We studied the outcomes of these patients post MBS and transplant surgery. One hundred and eighty-three ESRD patients were referred to the bariatric team by the transplant team between Jan 2019 through June 2023. Of these, 36 underwent MBS (20 RYGB, 16 SG), and 10 underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams.
The mean starting BMI for all referrals was 46.4 kg/m2 and was 33.9 kg/m2 at the time of transplant. The average number of hypertension medications decreased from 2.0 (range 2.0 to 4.0) pre-surgery to 1.0 (range 1.0 to 3.0) post-surgery. Similarly, HbA1C levels improved, with pre-operative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 - 1.6) mg/dl (GFR 46 (36.3 - 71.0)).
A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for obese ESRD patients, and potentially alleviates existing healthcare disparities. ESRD patients that undergo MBS have unique complications to be aware of. The improvement in comorbidities may lead to superior post-transplant outcomes.
Barriers to Black Medical Students and Residents Pursuing and Completing Surgical Residency in Canada: A Qualitative Analysis.
American College of SurgeonsThe limited available data suggest that the Canadian surgical workforce does not reflect the racial diversity of the patient population it serves, despite the well-established benefits of patient-provider race concordance. There have been no studies to date that characterize the systemic and individual challenges faced by Black medical students in matching to and successfully finishing training in a surgical specialty within a Canadian context that can explain this underrepresentation.
Using critical qualitative inquiry and purposive sampling to ensure gender, geographical, and student/trainee year heterogeneity, we recruited self-identifying Black medical students and surgical residents across Canada. Online in-depth semi-structured interviews were conducted and transcribed verbatim. Transcripts were analyzed through an inductive reflexive narrative thematic process by four analysts.
27 participants including 18 medical students and 9 residents, were interviewed. The results showed three major themes that characterized their experiences: journey to and through medicine, perceptions of the surgical culture, and recommendations to improve the student experience. Medical students identified lack of mentorship and representation, as well as experiences with racism as the main barriers to pursuing surgical training. Surgical trainees cited systemic racism, lack of representation and insufficient safe spaces as the key deterrents to program completion. The intersection with gender exponentially increased these identified barriers.
Except for a few surgical programs, medical schools across Canada do not offer a safe space for Black students and trainees to access and complete surgical training. An urgent change is needed to provide diverse mentorship that is transparent, acknowledges the real challenges related to systemic racism and biases, and is inclusive of different racial and ethnic backgrounds.
Effect of Behavioral Health Disorders on Surgical Outcomes in Cancer Patients.
American College of SurgeonsBehavioral health disorders (BHD) can often be exacerbated in the setting of cancer. We sought to define the prevalence of BHD among cancer patients and characterize the association of BHD with surgical outcomes.
Patients diagnosed with lung, esophageal, gastric, liver, pancreatic, and colorectal cancer between 2018-2021 were identified within Medicare Standard Analytic Files. Data on BHD defined as substance abuse, eating disorder, or sleep disorder were obtained. Post-operative textbook outcome (TO)(i.e., no complications, prolonged length of stay, 90-day readmission, or 90-day mortality), as well as in-hospital expenditures and overall survival were assessed.
Among 694,836 cancer patients, 46,719 (6.7%) patients had at least one BHD. Patients with BHD were less likely to undergo resection (no BHD: 23.4% vs. BHD: 20.3%; p<0.001). Among surgical patients, individuals with BHD had higher odds of a complication (OR 1.32 [1.26-1.39]), prolonged length of stay (OR 1.36 [1.29-1.43]), and 90-day readmission (OR 1.57 [1.50-1.65]) independent of social vulnerability or hospital volume status, resulting in lower odds to achieve a TO (OR 0.66 [0.63-0.69]). Surgical patients with BHD also had higher in-hospital expenditures (no BHD: $16,159 vs. BHD: $17,432; p<0.001). Of note, patients with BHD had worse long-term post-operative survival (median, no BHD: 46.6 [45.9-46.7] vs. BHD: 37.1 [35.6-38.7] months) even after controlling for other clinical factors (HR 1.26 [1.22-1.31], p<0.001).
BHD was associated with lower likelihood to achieve a postoperative TO, higher expenditures, as well as worse prognosis. Initiatives to target BHD are needed to improve outcomes of cancer patients undergoing surgery.
