Impact of COVID-19 Restrictions on Demographics and Outcomes of Patients Undergoing Medically Necessary Non-Emergent Surgeries During the Pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in large-scale healthcare restrictions to control viral spread, reducing operating room censuses to include only medically necessary surgeries. The impact of restrictions on which patients undergo surgical procedures and their perioperative outcomes is less understood. METHODS: Adult patients who underwent medically necessary surgical procedures at our institution during a restricted operative period due to the COVID-19 pandemic (March 23-April 24, 2020) were compared to patients undergoing procedures during a similar time period in the pre-COVID-19 era (March 25-April 26, 2019). Cardinal matching and differences in means were utilized to analyze perioperative outcomes. RESULTS: 857 patients had surgery in 2019 (pre-COVID-19) and 212 patients had surgery in 2020 (COVID-19). The COVID-19 era cohort had a higher proportion of patients who were male (61.3% vs. 44.5%, P < 0.0001), were White (83.5% vs. 68.7%, P < 0.001), had private insurance (62.7% vs. 54.3%, p 0.05), were ASA classification 4 (10.9% vs. 3%, P < 0.0001), and underwent oncologic procedures (69.3% vs. 42.7%, P < 0.0001). Following 1:1 cardinal matching, COVID-19 era patients (N = 157) had a decreased likelihood of discharge to a nursing facility (risk difference-8.3, P < 0.0001) and shorter median length of stay (risk difference-0.6, p 0.04) compared to pre-COVID-19 era patients. There was no difference between the two patient cohorts in overall morbidity and 30-day readmission. CONCLUSIONS: COVID-19 restrictions on surgical operations were associated with a change in the racial and insurance demographics in patients undergoing medically necessary surgical procedures but were not associated with worse postoperative morbidity. Further study is necessary to better identify the causes for patient demographic differences.

Nationwide Analysis of 30-Day Readmissions After Esophagectomy: Causes, Costs, and Risk Factors.

BACKGROUND: Postsurgical readmissions are an increasingly scrutinized marker of health care quality. We sought to estimate the rate, risk factors, causes, and costs associated with readmissions after esophagectomy in a large, nationally representative cohort. METHODS: We studied patients from the Nationwide Readmissions Database undergoing esophagectomy from 2010 to 2014. Data were collected on the prevalence and indications for readmission within 30 days as well as the hospital-, procedure-, and patient-level risk factors as determined by multivariable logistic regression. RESULTS: Among 13,282 cases, the rate of 30-day readmission was 19.4%, with the most common indications for readmission being pulmonary (20.6%) and gastrointestinal complications (20%). Median cost of readmission was $9660 (interquartile range, $5392 to $20,447), and pulmonary complications accounted for the greatest total cost burden at 25.8% of all readmission-related costs. Independent risk factors for readmission on multivariable analysis included perioperative blood transfusion (adjusted odds ratio [AOR] 1.33; 95% confidence interval [CI], 1.08 to 1.65; P = .008), discharge to a nursing facility (AOR 1.83; 95% CI, 1.41 to 2.39; P < .001), high illness severity based on All Patients Refined Diagnosis-Related Groups scoring (AOR 1.49; 95% CI, 1.21 to 1.84; P < .001), chronic renal failure (AOR 1.61; 95% CI, 1.13 to 2.29; P = .009), and comorbid drug abuse (AOR 2.19; 95% CI, 1.08 to 4.41; P = .029). CONCLUSIONS: Nearly 1 in 5 patients undergoing esophagectomy are readmitted within 30 days of discharge, at a median cost of $9660 per readmission. Pulmonary complications account for the greatest number of readmissions and the greatest total cost burden. Targeting the causes of readmission, especially pulmonary causes, may help significantly reduce the total morbidity and health care costs associated with esophagectomy.

Resource Usage Implementing the Surgical Resident Prep Curriculum at a Single Institution.

OBJECTIVE: The Resident Prep Curriculum (RPC), published in 2014 and developed as a collaboration of the American College of Surgeons, Association of Program Directors in Surgery, and the Association for Surgical Education, was designed to improve the quality and consistency of medical student preparation for surgical residency. We aim to assess the feasibility of and resource usage for implementation of this curriculum at our institution. DESIGN: Our institution expanded upon a pre-existing 2-week surgical preparatory course, adding modules designed to meet the goals and objectives of the RPC. We performed an evaluation of the resources required for these additions, namely time, logistics and incremental cost. SETTING: The course took place at the Perelman School of Medicine, which is a large, academic medical center affiliated with the Hospital of the University of Pennsylvania. RESULTS: Our course satisfied each of the six domains outlined in the RPC. In 2015, 22 students were enrolled in the course. It was run over a consecutive 4-week period in the spring of 2015, with 9 full and 9 half days. To meet the needs of the Curriculum, approximately 33 hours (38%) were spent in the classroom, 34 hours (39%) in a simulation center, and 20 hours (23%) in the anatomical laboratory. Seventy faculty-hours (from 5 disciplines) and 73 resident-hours (double-counting for cotaught modules) were required to support the course. Besides room availability, funding was required for certain aspects of the course such as cadavers, dedicated anatomy teaching, and the costs of supplies in the simulation center. There is also a cost associated with the use of the Penn Medicine Simulation Center. Taking these into account, the total cost of implementing the curriculum amounted to $30,627.10. CONCLUSION: The implementation of the RPC was feasible but relied heavily upon faculty/resident time. As a result of the success of this initiative, our medical school seeks to expand the idea across multiple specialties.

Implementation of a systematic culturing program to monitor the efficacy of endoscope reprocessing: outcomes and costs.

BACKGROUND AND AIMS: In 2015, the U.S. Food and Drug Administration and Centers for Disease Control and Prevention (CDC) issued guidance for duodenoscope culturing and reprocessing in response to outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) duodenoscope-related infections. Based on this guidance, we implemented best practices for reprocessing and developed a systematic process for culturing endoscopes with elevator levers. The aim of this study is to report the outcomes and direct costs of this program. METHODS: First, clinical microbiology data from 2011 to 2014 were reviewed retrospectively to assess for possible elevator lever-equipped endoscope-related CRE infections. Second, a program to systematically culture elevator lever-equipped endoscopes was implemented. Each week, about 25% of the inventory of elevator lever-equipped endoscopes is cultured based on the CDC guidelines. If any cultures return bacterial growth, the endoscope is quarantined pending repeat culturing. The costs of the program, including staff time and supplies, have been calculated. RESULTS: From 2011 to 2014, none of 17 patients with documented CRE infection had undergone ERCP or endoscopic ultrasound in the previous 36 months. From June 2015 to September 2016, 285 cultures were performed. Three (1.1%) had bacterial growth, 2 with skin contaminants and 1 with an oral contaminant. The associated endoscopes were quarantined and reprocessed, and repeat cultures were negative. The total estimated cost of our program for an inventory of 20 elevator lever-equipped endoscopes was $30,429.60 per year ($1521.48 per endoscope). CONCLUSIONS: This 16-month evaluation of a systematic endoscope culturing program identified a low rate of positive cultures after elevator lever endoscope reprocessing. All positive cultures were with non-enteric microorganisms. The program was of modest cost and identified reprocessing procedures that may have led to a low rate of positive cultures.

Laparoscopic transhiatal esophagectomy improves hospital outcomes and reduces cost: a single-institution analysis of laparoscopic-assisted and open techniques.

BACKGROUND: Several case series have demonstrated that laparoscopic transhiatal esophagectomy (LTHE) is associated with favorable perioperative outcomes compared to historical data for open transhiatal esophagectomy (OTHE). Contemporaneous evaluation of open and laparoscopic THE is rare, limiting meaningful comparison of techniques. METHODS: All patients who underwent OTHE (n = 32) and LTHE (n = 41) during the introduction of the latter procedure at our institution (1/2012-4/2014) were identified, and patient charts were retrospectively reviewed. RESULTS: Indications for operation included 69 patients with esophageal malignancy (adenocarcinoma: 64; squamous cell carcinoma: 4; melanoma: 1) and 4 patients with benign disease. There were no significant differences in clinicopathologic variables between OTHE and LTHE cohorts, except for an increased rate of cardiovascular disease in the LTHE cohort (p = 0.04). There was no significant difference in median operative time or operative complications, yet LTHE was associated with a lower incidence of intraoperative blood transfusion (p < 0.01). There were no 30-day mortalities. LTHE was associated with a reduced time to reach 24-h tube feeding goals (p = 0.02), shorter length of hospital stay (p = 0.01), and 6 % reduced median direct cost (p = 0.04). There were no significant differences in rates of major perioperative morbidities. Patients were followed for a median of 11.0 months during which there were no significant differences between cohorts in disease-free survival or overall survival. CONCLUSION: When compared to OTHE, LTHE improves surgical outcomes and decreases hospital costs; short-term oncologic outcomes are similar. LTHE is preferable to OTHE in patients requiring transhiatal esophagectomy.

Resident education in robotic-assisted vertical sleeve gastrectomy: outcomes and cost-analysis of 411 consecutive cases.

BACKGROUND: Robotic technology is increasingly prevalent in bariatric surgery, yet there are national deficiencies in exposure of surgical residents to robotic techniques. OBJECTIVES: The purpose of this study is to accurately characterize the perioperative outcomes of a resident teaching model using the robotic-assisted sleeve gastrectomy. SETTING: University Hospital. METHODS: We identified 411 consecutive patients who underwent robotic sleeve gastrectomy at our institution from a prospectively maintained administrative database. Perioperative morbidity, operative time, and supply cost of the procedure were analyzed. RESULTS: Mean operative time was 96.4±24.9 minutes; mean robot usage time was 63.9 minutes (range 30.0-122.0 min). Ninety-day morbidities included reoperation (0.72%), major bleeding complications (0.48%), staple line leak (0.24%), stricture (0.97%), need for blood transfusion (3.86%), surgical site infection (1.69%), deep vein thrombosis (0.48%), and pulmonary embolism (0.48%). Mortality was nil. The resident cohort achieved operative time plateaus after five consecutive cases. Subset analysis for fiscal year 2014 demonstrated significantly increased supply cost for robotic sleeve gastrectomy compared with its laparoscopic equivalent. CONCLUSION: Robotic-assisted sleeve gastrectomy can be instituted as a model for resident robotic education with rates of morbidity and operative times equivalent to historical laparoscopic controls. The robot's enhanced ergonomics and its opportunity for resident education must be weighed against its increased supply cost.

A cost-effective approach to establishing a surgical skills laboratory.

BACKGROUND: Recent studies comparing inexpensive low-fidelity box trainers to expensive computer-based virtual reality systems demonstrate similar acquisition of surgical skills and transferability to the clinical setting. With new mandates emerging that all surgical residency programs have access to a surgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced open and laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models. METHODS: Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) and laparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, advanced in vivo skills) are constructed using a combination of materials found in our surgical research laboratories, retail stores, or donated by industry. Expired surgical materials are obtained from our hospital operating room and animal organs from food-processing plants. In vivo models are performed in an approved research facility. Operation, maintenance, and administration of the surgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility of all surgical faculty from our institution. RESULTS: Overall, the cost analyses of our initial startup costs and operational expenditures over a 3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 2003-2004, $1,049; and 2004-2005, $982). CONCLUSIONS: Our approach to surgical skills education can serve as a template for any surgery program with limited financial resources.