A Crucial Moment for Reflection on the Importance of Ethical Leadership in Academic Medicine.

The extreme disturbances caused by the COVID -19 pandemic on our academic medical centers compounded by a recurrent surge of violence against people of color have reopened our wounds exposing fragility, inequality, and continued racial disparities in society and health. At the center of this severe institutional disruption, leaders will be compelled to take action to keep their constituents and patients safe and their hospitals and departments afloat during and after a pandemic, all while simultaneously addressing and implementing the cultural changes required to eliminate systemic racism and discrimination. Organizational disruptions of this magnitude will naturally test one's principles, loyalties and responsibilities while challenging the practical burdens of leadership. If the goal of responding to these upheavals is to bring them to resolution and ultimately to bring about organizational change for the better, ethical leadership is critical. Applying ethical principles allows leaders to chart clear paths to solutions both in the short and long term. We review the principles of ethical leadership exemplified by a case illustration and provide a novel resource to help ensure ethical leadership in academic medicine and beyond.

The Art of Surgery: Balancing Compassionate With Virtual Care.

The recent drive to include virtual care in surgical practice has been accelerated due to the COVID-19 pandemic. Many physicians feel that communicating via telehealth is unlike traditional methods of providing health care, and thus guidance on maintaining excellence in communication is necessary, especially as academic literature on virtual care in surgery is nonexistent. Challenges faced in transitioning to virtual care include the inability to utilize body language, barriers to traditional physical examination, exacerbation of existing vulnerabilities and inequities in patient groups, the declining quality of medical education, and the fragmentation of the multidisciplinary health care team. This paper seeks to resolve these challenges by focusing on the pillars of good communication, including preparation, professionalism, empathy, respect, and the virtual physical examination.

Papillary Thyroid Cancers with Focal Tall Cell Change are as Aggressive as Tall Cell Variants and Should Not be Considered as Low-Risk Disease.

BACKGROUND: The tall cell variant of papillary thyroid carcinoma (PTC) is as an aggressive histological variant. The proportion of tall cells needed to influence prognosis is debated. METHODS: Patients with PTC and tall cells, defined as having a height-to-width ratio of ≥ 3:1, seen at a high-volume center between 2001 and 2015, were reviewed. Specimens were classified as (1) focal tall cell change, containing < 30% of tall cells; (2) tall cell variant, ≥ 30% of tall cells; and (3) control cases selected from infiltrative classical PTCs without adverse cytologic features. Univariate, sensitivity, and multivariate analyses were performed with persistent/recurrent disease as the primary outcome. RESULTS: We identified 96 PTCs with focal tall cell change, 35 with the tall cell variant and 104 control cases. Factors associated with poor clinical prognosis were significantly greater in those with focal tall cell change and tall cell variants. Regarding primary outcome, hazard ratios were 2.3 (95% confidence interval [CI] 1.0-5.7) for focal tall cell change, and 3.4 (95% CI 1.2-8.7) for tall cell variants compared with controls. Five-year disease-free survival was higher for the control group (92.7%, CI 87.4-98.0) compared with focal tall cell change (76.3%, CI 66.1-86.5) and the tall cell variant (62.2%, CI 43.2-81.2). When stratified in groups consisting of tall cell proportions (< 10%, 10-19%, 20-29% and ≥ 30%), identification of ≥ 10% tall cell change was associated with worse outcome (p = 0.002). CONCLUSIONS: PTCs with ≥ 10% tall cell change have worse prognosis than those without tall cells. Our data indicate that thyroid cancer management guidelines should consider PTCs with focal tall cell change outside of the low-risk classification.

Characteristics of Adrenal Masses in Familial Adenomatous Polyposis.

BACKGROUND: Adrenal masses are a known extraintestinal manifestation of familial adenomatous polyposis. However, the literature on this association is largely confined to case reports. OBJECTIVE: This study aimed to determine the characteristics of adrenal masses in familial adenomatous polyposis and their clinical significance, as well as to estimate their prevalence. Mutational analysis was conducted to determine if any potential genotype-phenotype correlations exist. DESIGN: This is a retrospective cohort study. SETTING: Analysis included all patients meeting the criteria of classic familial adenomatous polyposis who were registered with the Familial Gastrointestinal Cancer Registry, a national Canadian database. PATIENTS: Appropriate imaging or autopsy reports were available in 311 registry patients. Patients with adrenal metastases were excluded. OUTCOME MEASURES: Data collection included demographic data, mutation genotype, adrenal mass characteristics, surgical interventions and mortality. RESULTS: The prevalence of adrenal masses was 16% (n = 48/311). The median age at diagnosis of adrenal mass was 45 years. The median diameter of adrenal mass at diagnosis was 1.7 cm (interquartile range, 1.4-3.0) with a median maximal diameter of 2.5 cm (interquartile range, 1.7-4.1) with median imaging follow-up of 48 months. The majority of adrenal masses were benign (97%, n = 61/63). Surgery was performed on 7 patients because of concerns for size, malignancy, or hormonal secretion. One adrenal-related death was due to an adrenocortical carcinoma. Mutation analysis did not identify any specific genotype-phenotype correlations. LIMITATIONS: There were incomplete or insufficient endocrinology data available in the registry to allow for the analysis of hormone secretion patterns. CONCLUSIONS: Adrenal masses are approximately twice as prevalent in the familial adenomatous polyposis population as in previous studies of the general population. Nearly all mutations led to truncation of the APC gene; however, there was no genetic signature to help predict those at increased risk. The majority of adrenal lesions identified were of benign etiology; thus, an intensive management or surveillance strategy with imaging screening is likely unwarranted. See Video Abstract at http://links.lww.com/DCR/A507.

Clinical Safety of Renaming Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: Is NIFTP Truly Benign?

BACKGROUND: Renaming encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was recently suggested to prevent the overtreatment, cost and stigma associated with this low-risk entity. The purpose of this study is to document the incidence and further assess the clinical outcomes of reclassifying EFVPTC to NIFTP. METHODS: We searched synoptic pathologic reports from a high-volume academic endocrine surgery hospital from 2004 to 2013. The standard of surgical pathology practice was based on complete submission of malignant thyroid nodules along with the nontumorous thyroid parenchyma. Rigid morphological criteria were used for the diagnosis of noninvasive EFVPTC, currently known as NIFTP. A retrospective chart review was conducted looking for evidence of malignant behavior. RESULTS: One hundred and two patients met the strict inclusion criteria of NIFTP. The incidence of NIFTP in our cohort was 2.1% of papillary thyroid cancer cases during the studied time period. Mean follow-up was 5.7 years (range 0-11). Five patients were identified with nodal metastasis and one patient with distant metastasis. Overall, six patients showed evidence of malignant behavior representing 6% of patients with NIFTP. CONCLUSION: Our study demonstrates that the incidence of NIFTP is significantly lower than previously thought. Furthermore, evidence of malignant behavior was seen in a significant number of NIFTP patients. Although the authors fully support the de-escalation of aggressive treatment for low-risk thyroid cancers, NIFTP behaves as a low-risk thyroid cancer rather than a benign entity and ongoing surveillance is warranted.

Training surgical residents to use a framework to promote shared decision-making for patients with poor prognosis experiencing surgical emergencies.

BACKGROUND: Patients with poor underlying prognosis experiencing surgical emergencies face challenging treatment decisions. The Best Case/Worst Case (BC/WC) framework has improved shared decision-making by surgeons, but it is unclear whether residents can be similarly trained. We evaluated senior general surgical residents' acceptance of the BC/WC tool and their attitudes, confidence and actions before and after training. METHODS: Two-hour training included a didactic session, live demonstration, small-group practice and debriefing. We developed questionnaires to evaluate residents' attitudes, confidence and actions at 3 time points: before the intervention, after the intervention and 6 months after the intervention. We used the Ottawa Decision Support Framework Acceptability questionnaire to evaluate acceptability and a structured observation form to evaluate performance. RESULTS: Eighteen (50%) of 36 invited residents participated. Most residents (83%) felt that a new communication tool would be useful. Almost all (94%) used BC/WC in practice. Residents found the tool acceptable and useful to enhance preference-sensitive communications. They felt that the training was valuable and that role play was its greatest strength but that these situations were challenging to simulate. Barriers to BC/WC use included time constraints and difficulty defining the best and worst cases precisely. Summative attitudes and confidence scores were not different before and after the intervention; however, actions scores were higher after the intervention (p = 0.04). Residents performed a median of 15 (interquartile range 13-17) of the 19 elements on the formative performance evaluation. Commonly missed items were narrating outcomes of palliative approaches, prompting deliberation and providing treatment recommendations. CONCLUSION: Senior residents found the BC/WC tool to be acceptable and useful, and are amenable to training in this type of communication. After training, self-reported actions scores increased, and observed performance was accurate.

CONTEXTE: La prise de décisions relatives au traitement est difficile pour les patients qui ont un pronostic sous-jacent défavorable et qui envisagent une intervention chirurgicale d'urgence. Le cadre d'évaluation de la meilleure et de la pire issue possible (Best Case/Worst Case framework [BC/WC]) a amélioré la prise de décision partagée chez les chirurgiens, mais on ignore si les médecins résidents adopteraient aussi facilement une formation sur un tel cadre. Nous avons évalué à quel point les médecins résidents principaux en chirurgie générale étaient prêts à accepter le cadre BC/WC, ainsi que leur attitude, leur confiance et leurs actions avant et après une formation sur celui-ci. MÉTHODES: La formation de 2 heures comprenait une présentation didactique, une démonstration pratique, une période d'essai en petits groupes et un débreffage. Nous avons créé un questionnaire évaluant l'attitude, la confiance et les actions des médecins résidents à 3 moments : avant la formation, immédiatement après celle-ci et 6 mois plus tard. Nous avons utilisé le questionnaire sur l'admissibilité du Modèle d'aide à la décision d'Ottawa pour évaluer le degré d'acceptation du cadre, et un formulaire d'observation structurée pour évaluer son application au travail. RÉSULTATS: Des 36 médecins résidents invités, 18 (50 %) ont accepté de participer. La plupart d'entre eux (83 %) croyaient qu'un nouvel outil de communication leur serait utile. Presque tous (94 %) ont appliqué le cadre BC/WC dans leur travail. Ils l'ont trouvé acceptable, et considéraient qu'il permettait d'améliorer la communication tenant compte des préférences. Selon eux, la formation était utile, particulièrement les mises en situation, mais la nature des interactions se prêtait mal à la simulation. Interrogés sur les obstacles à l'application du cadre, ils ont cité les contraintes de temps et la difficulté de définir avec précision la meilleure et la pire issue. Les résultats sommatifs pour l'attitude et la confiance étaient similaires avant et après la formation; cependant, la note pour les actions était plus élevée après la formation qu'avant (p = 0,04). Pour l'évaluation formative du travail, la note médiane était de 15 (écart interquartile : 13 à 17), sur un total de 19 éléments. Parmi les éléments couramment oubliés, notons la description des issues des approches palliatives, l'incitation à la discussion et la formulation de recommandations de traitement. CONCLUSION: Les médecins résidents considèrent le cadre BC/WC acceptable et utile, et seraient disposés à suivre une formation sur le type de communication qu'il prône. Après la formation, la note de l'auto-évaluation des actions a augmenté, une tendance aussi constatée à l'observation du travail.

Using Texting for Clinical Communication in Surgery: A Survey of Academic Staff Surgeons.

BACKGROUND: Text messaging has become ubiquitous and is being increasingly used within the health care system. The purpose of this study was to understand texting practices for clinical communication among staff surgeons at a large academic institution. METHODS: Staff surgeons in 4 subspecialties (vascular, plastics, urology, and general surgery) were surveyed electronically. RESULTS: A total of 62 surgeons from general surgery (n = 33), vascular surgery (n = 6), plastic surgery (n = 13), and urology (n = 10) completed the study (response rate 30%). When conveying urgent patient-related information, staff surgeons preferred directly calling other staff surgeons (61.5%) and trainees (58.8%). When discussing routine patient information, staff surgeons used email to reach other staff surgeons (54.9%) but preferred texting (62.7%) for trainees. The majority of participants used texting because it is fast (65.4%), convenient (69.2%) and allows transmitting information to multiple recipients simultaneously (63.5%). Most felt that texting enhances patient care (71.5%); however, only half believed that it enhanced trainees' educational experiences. The majority believed that texting identifiable patient information breaches patient confidentiality. CONCLUSIONS: Our data showed high adoption of text messaging for clinical communication among surgeons, particularly with trainees. The majority of surgeons acknowledge security concerns inherent in texting for patient care. Existing mobile communication platforms fail to meet the needs of academic surgeons. Further research should include guidelines related to texting in clinical practice, educational implications of texting, and technologies to better meet the needs of clinicians working in an academic surgical settings.

Smartphones and Patient Care: Exploring the Use of Text-Based Messaging for Patient-Related Communication.

Background Text messaging (texting) has become a routine medium of communication in society. However, its use among clinicians has not been fully characterized. We explored general surgery residents' practices and views on texting for patient-related communication. Methods An email survey was distributed to all general surgery residents at a large Canadian medical school. Results Overall, 46 (57%) of those surveyed responded. All used texting for patient-related communication. Eleven percent of residents did not have a password on their cell phone and 89% did not have encrypted phones. Texting was the most common way (41%) by which residents communicated routine patient-related information with staff physicians. Most (85%) residents agreed that texting enhances patient care. The majority (66%) did not know if their hospital had a policy on texting and were unaware of legislation surrounding texting in patient care (89%). Conclusions Most general surgery residents use texting for communication of routine patient-related care issues. However, they acknowledge concerns regarding the security of this medium.

How Social Are We? A Cross-Sectional Study of the Website Presence and Social Media Activity of Canadian Plastic Surgeons.

The internet and social media are increasingly being used by patients not only for health-related research, but also for obtaining information on their surgeon. Having an online presence via a website and social media profile is one-way plastic surgeons can meet this patient driven demand. The authors sought to document current website and social media usage of Canadian plastic surgeons and to determine if this usage correlated with years in practice. A Google search was performed using publicly available lists of all plastic surgeons registered with the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Canadian Society for Aesthetic Plastic Surgery (CSAPS). This search found 42% (268/631) of RCPSC plastic surgeons had a website and 85% (536/631) had a profile on social media. Younger RCPSC surgeons (registered for less years) were significantly more likely to have a website (12.8 vs. 21.9 years, P < 0.0001) and an active social media profile (16.2 vs. 23.9 years, P < 0.002). The social media platform most used was RateMDs (81%) followed in decreasing order by: LinkedIn (28%), RealSelf (22%), Facebook (20%), Google+ (17%) and Twitter (16%). Dual RCPSC-CSAPS members were more likely than RCPSC-only members to have a website (56 vs. 36%, P < 0.0001) and an active social media profile (P < 0.05). Overall, current website usage and social media presence by Canadian plastic surgeons is comparable to counterparts in the US and UK. It may be possible to better optimize online presence through education of current search engine technology and becoming active on multiple social media platforms.

Ethics and genomic medicine, how to navigate decisions in surgical oncology.

Using genetic information to make medical decisions and tailor treatments to individuals will likely provide major benefits and become an important part of health care. Surgical oncologists must ethically apply scientific genetic information in a complex and evolving environment to the benefit of their patients. In this review we address ethical issues associated with: indications for genetic testing, informed consent for testing and therapy, confidentiality, targeted therapy, prophylactic surgery, and genetic testing in children.

Tragic knowledge: truth telling and the maintenance of hope in surgery.

Surgeons often are faced with the challenge of balancing truth telling and the maintenance of hope in the setting of a poor prognosis. This ethical dilemma is informed by conflicting appeals to principles of autonomy and nonmaleficence, where a patient's right to be told important medical information must be weighed against the potential harm that may result from the knowledge of an unfavourable diagnosis. Truth telling in surgery raises questions on the nature of truth itself, how much information ought to be shared, what information can be withheld, and how surgeons should share tragic knowledge with patients. This paper will address these questions and provide some insight on how surgeons may navigate the sharing of tragic knowledge.

Successful Deceased Donor Parathyroid Allotransplantation: A Novel Approach in a Patient with Severe Refractory Hypoparathyroidism after Thyroidectomy for Thyroid Cancer.

Background Hypoparathyroidism following thyroid surgery presents significant challenges, often leading to debilitating symptoms and reduced quality of life despite conventional treatment. We describe a patient who had a staged total thyroidectomy for low-risk thyroid cancer and developed severe refractory iatrogenic hypoparathyroidism in whom we performed the first successful fresh normal-tissue deceased donor parathyroid transplant in an immune-naïve recipient. Methods A rigorous protocol for donor selection and transplantation was developed. Donor criteria aimed at minimizing infectious and immunological risks. Surgical techniques involved retrieval and transplantation of healthy parathyroid glands from a deceased donor into the recipient's muscle tissue, followed by immunosuppression. Results Following transplantation, the patient exhibited rapid resolution of symptoms, normalization of calcium levels, and cessation of calcium supplementation. Follow-up-has revealed sustained graft function without the need for additional therapy. Conclusion Deceased donor parathyroid allotransplantation emerges as a promising therapeutic option for severe refractory hypoparathyroidism, underscoring the potential for physiologic cure and improved quality of life in patients with this debilitating complication of thyroid cancer surgery. Further research is warranted to validate the efficacy and safety of this innovative approach.

Primary hyperparathyroidism in adolescents: the same but different.

PURPOSE: Primary hyperparathyroidism has been studied more extensively in adults than in adolescents. The objective of this study is to define the similarities and differences that exist between these groups. METHODS: A retrospective review of 1,000 primary hyperparathyroidism patients undergoing parathyroidectomy at a single tertiary-care university teaching hospital between 1990 and 2004. All patients 20 years of age or younger comprised our study cohort, and were compared to two historical adult groups. RESULTS: Of 1,000 parathyroidectomies, 21 (2.1 %) were 20 years of age or younger (adolescent). The adolescents presented with higher serum calcium levels (p < 0.01) more severe symptoms (p = 0.02), more renal stones (p = 0.048), and a higher incidence of hypercalcemic crisis (p = 0.02), when compared with adults. We found that 67 % suffered from a triad of tiredness, weakness, and depression versus 39 % of adults (p = 0.02). Sestamibi scans were less helpful in the adolescents than in adults. Similar to the adults, 86 % of adolescent patients had single gland disease, and 95 % were cured at the first operation. CONCLUSION: Adolescents with primary hyperparathyroidism typically have more severe disease than adults. Contrary to popular belief, most adolescents have single gland disease and not hyperplasia associated with a genetic disorder.

The Deceased, Public Health, and Research: Proposing Legal Reforms.

There is little guidance concerning biomedical research using tissues from deceased individuals. Unique ethical and legal challenges gained visibility during the coronavirus disease 2019 (COVID-19) pandemic, when important studies using genome sequencing required access to biological materials from deceased individuals. These studies proposed to determine whether specific genomic profiles were associated with important disease outcomes. Such research has previously required consent from next-of-kin or other surrogate decision makers. Ethics waivers for such consent vary within Canada. In Ontario, research ethics boards can grant waivers of consent if the Tri-Council Policy Statement-2 conditions are met. These include that the individual is not harmed, that the materials are essential to the research, and that privacy will be protected. Conversely, in Quebec, Civil Code article 22 imposes an obligation on researchers to seek consent from next-of-kin or another surrogate decision maker with no option for waivers. It became evident to researchers that these standards can sometimes impose an impracticable balance of risks and benefits, especially in public health emergencies. We seek to establish why and when consent requirements should be waived for public health and research involving the tissues of deceased individuals.

Gender Differences in Fears Related to Low-Risk Papillary Thyroid Cancer and Its Treatment.

Importance: Fear is commonly experienced by individuals newly diagnosed with papillary thyroid cancer (PTC). Objective: To explore the association between gender and fears of low-risk PTC disease progression, as well as its potential surgical treatment. Design, Setting, and Participants: This single-center prospective cohort study was conducted at a tertiary care referral hospital in Toronto, Canada, and enrolled patients with untreated small low risk PTC (<2 cm in maximal diameter) that was confined to the thyroid. All patients had a surgical consultation. Study participants were enrolled between May 2016 and February 2021. Data analysis was performed from December 16, 2022, to May 8, 2023. Exposures: Gender was self-reported by patients with low-risk PTC who were offered the choice of thyroidectomy or active surveillance. Baseline data were collected prior to the patient deciding on disease management. Main Outcomes and Measures: Baseline patient questionnaires included the Fear of Progression-Short Form and Surgical Fear (referring to thyroidectomy) questionnaires. The fears of women and men were compared after adjustment for age. Decision-related variables, including Decision Self-Efficacy, and the ultimate treatment decisions were also compared between genders. Results: The study included 153 women (mean [SD] age, 50.7 [15.0] years) and 47 men (mean [SD] age, 56.3 [13.8] years). There were no significant differences in primary tumor size, marital status, education, parental status, or employment status between the women and men. After adjustment for age, there was no significant difference observed in the level of fear of disease progression between men and women. However, women reported greater surgical fear compared with men. There was no meaningful difference observed between women and men with respect to decision self-efficacy or the ultimate treatment choice. Conclusions and Relevance: In this cohort study of patients with low-risk PTC, women reported a higher level of surgical fear but not fear of the disease compared with men (after adjustment for age). Women and men were similarly confident and satisfied with their disease management choice. Furthermore, the decisions of women and men were generally not significantly different. The context of gender may contribute to the emotional experience of being diagnosed with thyroid cancer and its treatment perception.

Ambulatory Parathyroidectomy for Secondary Hyperparathyroidism at a Large Dialysis Program in Toronto: A Program Report.

Purpose of program: Operative wait times for non-oncology-related procedures continue to rise in Canada, and this was further exacerbated by the COVID-19 pandemic. These challenges will remain prevalent beyond the pandemic given the limited number of acute care beds and resources required to care for patients. As a result, the need for innovative approaches to optimize the utilization of health care resources while maintaining equitable and timely access is needed. In this report, we describe the development of a collaborative ambulatory parathyroidectomy program between two centers in Toronto, allowing for more expedient surgical treatment of secondary hyperparathyroidism among patients from a large dialysis program. Sources of information: The need for expanded access to surgical care for secondary hyperparathyroidism was identified through interdepartmental communication between referring nephrologists and surgeons at Sunnybrook Health Sciences Centre and Women's College Hospital, respectively. Methods: A multidisciplinary ambulatory parathyroidectomy planning team was formed that included nephrologists, endocrine surgeons, nurses, and patient care managers to conduct a needs assessment. It was identified that patients had long wait times, and to address that gap in care, a protocol was developed to identify suitable patients requiring treatment. The teams created a plan to coordinate patient care and transfers. A clinical tool and protocol for post-operative management of hypocalcemia was developed using a Delphi model, gathering input from many members of the care team. The Delphi process to finalize the protocol included a series of virtual meetings over a period of about 4 months with various stakeholders and included input from two departmental heads (medicine and surgery), three nephrologists, a nurse practitioner, a patient care manager, and two nurse educators. Meetings involved core members of the Nephrology Quality Improvement and Patient Safety at Sunnybrook Health Sciences Centre and finalized protocol was agreed upon by members of this group at a quarterly meeting. Key findings: In this article, we describe the development, initial deployment, and planned assessment of the ambulatory parathyroidectomy program at the Women's College Hospital and Sunnybrook Health Sciences Centre. The primary aim of the program is to increase accessibility to parathyroidectomy for secondary hyperparathyroidism. A secondary aim was to allow patients to have streamlined care with a team that is well versed with maintenance dialysis needs and optimizing treatment of post operative hypocalcemia through standardized protocols. Limitations: Ambulatory parathyroidectomy relies on effective communication, flow, and availability of acute care beds. It is anticipated that occasionally, unexpected hospital demands, and health care disruptions may occur, which can limit efficiency of the program. We will also need to examine the cost-effectiveness of this program as it may improve access but increase costs related to the procedure. As the program is implemented, useful adaptations and policies to our protocol to help mitigate these limitations will be documented and published in our outcomes report. Implications: Ontario residents with chronic kidney disease with secondary hyperparathyroidism who have failed medical management will have increased and timely access to parathyroidectomy.

Objectif du program: Les temps d'attente pour les interventions non oncologiques continuent d'augmenter au Canada, une situation qui s'est aggravée avec la pandémie de COVID-19. Ce problème persistera au-delà de la pandémie en raison du nombre limité de lits en soins aigus et de ressources pour soigner les patients. Par conséquent, l'adoption d'approches novatrices pour optimiser l'utilisation des ressources en santé, tout en maintenant un accès équitable et opportun, est nécessaire. Dans ce rapport, nous décrivons l'élaboration d'un programme collaboratif de parathyroïdectomie ambulatoire entre deux centres de Toronto, lequel permettra le traitement chirurgical plus rapide de l'hyperparathyroïdie secondaire chez les patients d'un important programme de dialyse. Sources: Le besoin d'élargir l'accès aux soins chirurgicaux pour l'hyperparathyroïdie secondaire a été révélé grâce à la communication interservices entre les néphrologues traitants du Sunnybrook Health Sciences Centre et les chirurgiens de l'Hôpital Women's College. Méthodologie: Une équipe multidisciplinaire de planification de la parathyroïdectomie ambulatoire composée de néphrologues, de chirurgiens-endocrinologues, d'infirmières et de gestionnaires de soins aux patients a été formée pour procéder à une évaluation des besoins. Il a été établi que les patients expérimentaient de longs temps d'attente et, pour combler cette lacune, un protocole a été mis au point pour identifier adéquatement les patients nécessitant un traitement. Les équipes ont créé un plan pour coordonner les soins aux patients et les transferts. Un outil clinique et un protocole de prise en charge postopératoire de l'hypocalcémie ont été mis au point à l'aide d'un modèle Delphi impliquant la participation plusieurs membres de l'équipe soignante. Le processus Delphi de finalisation du protocole a comporté, sur une période de quatre mois, une série de réunions virtuelles avec divers intervenants, ainsi que la participation de deux chefs de service (médecine et chirurgie), de trois néphrologues, d'une infirmière praticienne, d'un gestionnaire des soins aux patients et de deux formateurs en soins infirmiers. Ces rencontres ont réuni les principaux membres du Nephrology Quality Improvement and Patient Safety at Sunnybrook Health Sciences Centre, et ces derniers ont convenu d'un protocole finalisé lors d'une réunion trimestrielle. Principaux resultants: Cet article décrit l'élaboration, le déploiement initial et l'évaluation prévue du programme de parathyroïdectomie ambulatoire du Women's College Hospital et du Sunnybrook Health Sciences Centre. Le principal objectif du programme est d'accroître l'accessibilité à la parathyroïdectomie pour les patients souffrant d'hyperparathyroïdie secondaire. Les autres objectifs étaient de permettre aux patients de bénéficier de soins rationalisés, grâce à une équipe qui connaît parfaitement les besoins en dialyse d'entretien, et d'optimiser le traitement de l'hypocalcémie postopératoire grâce à des protocoles normalisés. Limites: La parathyroïdectomie ambulatoire repose sur l'efficacité du flux et de la communication, et sur la disponibilité des lits en soins aigus. Il est attendu que des demandes hospitalières inattendues et des perturbations se produiront de temps à autre, ce qui pourrait limiter l'efficacité du programme. Nous devrons également examiner la rentabilité du programme, car l'amélioration de l'accès pourrait se traduire par une augmentation des coûts liés à la procédure. Au fur et à mesure de la mise en œuvre du programme, des adaptations et politiques utiles à notre protocole seront documentées et publiées dans notre rapport sur les résultats, afin d'aider à atténuer ces limites. Conclusion: Les résidents de l'Ontario atteints d'insuffisance rénale chronique et d'hyperparathyroïdie secondaire dont la prise en charge médicale a échoué auront un accès accru et opportun à la parathyroïdectomie.

Quality Indicators for the Diagnosis and Management of Primary Hyperparathyroidism.

IMPORTANCE: Primary hyperparathyroidism (pHPT) is a common endocrine disorder with many diagnostic and treatment challenges. Despite high-quality guidelines, care is variable, and there is low adherence to evidence-based treatment pathways. OBJECTIVE: To develop quality indicators (QIs) to evaluate the diagnosis and treatment of pHPT that could measure, improve, and optimize quality of care and outcomes for patients with this disease. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used a guideline-based approach to develop QIs that were ranked by a Canadian 9-member expert panel of 3 endocrinologists, 3 otolaryngologists, and 3 endocrine surgeons. Data were analyzed between September 2020 and May 2021. MAIN OUTCOMES AND MEASURES: Candidate indicators (CIs) were extracted from published primary hyperparathyroidism guidelines and summarized with supporting evidence. The 9-member expert panel rated each CI on the validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND-University of California, Los Angeles appropriateness methodology. All panelists were then asked to rank the top 5 QIs for primary, endocrine, and surgical care. RESULTS: Forty QIs were identified and evaluated by the expert panel. After 2 rounds of evaluations and discussion, a total of 18 QIs were selected as appropriate measures of high-quality care. The top 5 QIs for primary, endocrine, and surgical care were selected following panelist rankings. CONCLUSIONS AND RELEVANCE: This quality improvement study proposes 18 QIs for the diagnosis and management of pHPT. Furthermore, the top 5 QIs applicable to physicians commonly treating pHPT, including general physicians, internists, endocrinologists, otolaryngologists, and surgeons, are included. These QIs not only assess the quality of care to guide the process of improvement, but also can assess the implementation of evidence-based guideline recommendations. Using these indicators in clinical practice and health system registries can improve quality and cost-effectiveness of care for patients with pHPT.

A Population-Based Analysis of Outpatient Thyroidectomy: Safe and Under-Utilized.

OBJECTIVES/HYPOTHESIS: Performance of thyroidectomy on an outpatient basis has gained popularity although many jurisdictions have not shifted their practice despite a strong safety profile. We sought to assess the uptake and safety of outpatient thyroidectomy in Ontario. STUDY DESIGN: Retrospective cohort study. METHODS: This was a population-based retrospecive cohort of adult patients undergoing hemithyroidectomy or total thyroidectomy between 1993 and 2017 in Ontario, Canada. Outpatient surgery was defined as discharge home on the same day of surgery. Outcomes of interest include 30-day all cause death, hematoma, emergency department use, and readmission. To adjust for confounding, propensity scores were calculated. Logistic regression models with inverse probability of treatment weighting (IPTW) were then used to estimate the exposure-outcome relationship. RESULTS: The final cohort consisted of 81,199 patients: 8,442 underwent same day surgery and 72,757 were admitted. The proportion of patients undergoing outpatient thyroidectomy increased overtime (2.3% in 1993-1994 to 17.8% in 2016-2017). Factors associated with higher odds of outpatient thyroidectomy included: younger age, less material deprivation, less comorbidities, and higher surgeon volume. The absolute number of deaths (≤5) and hematomas (64, 0.8%) in the outpatient cohort was low. After IPTW adjustment, patients with outpatient management had lower odds of neck hematoma (OR 0.73[95CI% 0.58-0.93)], but higher odds of emergency department use (OR 1.67[95%CI 1.56-1.79]). CONCLUSIONS: Outpatient thyroidectomy is not associated with an increased mortality risk. Less than one in five patients undergo outpatient thyroidectomy in Ontario, despite a well-established safety profile. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2625-2633, 2021.