Determining the factors impacting the quality of life among the general population in coastal communities in central Vietnam.

People living in coastal areas are frequently affected by natural disasters, such as floods and storms. This study aimed to assess the quality of life (QoL) of people living in disadvantaged coastal communes (subdivision of Vietnam) and identify their associated factors by using the World Health Organization's quality of life instrument (WHOQOL-BREF). To achieve this, a cross-sectional descriptive study was conducted on 595 individuals aged 18 years and above living in the coastal communes in Thua Thien Hue province, Vietnam, from October 2022 to February 2023. The results showed that the mean overall QoL (mean ± SD) was 61.1 ± 10.8. Among the four domains of QoL, the physical health (57.2 ± 12.3) domain had a lower score than the psychological health (61.9 ± 13.0), social relations (63.4 ± 13.4), and environment (61.9 ± 13.3) domains. The QoL score of the domains for participants affected by flooding was significantly lower than that of those not affected, except for social relations. Multivariable logistic regression showed that subjects with not good QoL had the educational background with no formal education (Odds ratio (OR) = 2.63, 95% CI 1.19-5.83), fairly poor/poor households (OR = 2.75, 95% CI 1.48-5.12), suffered Musculoskeletal diseases (OR = 1.61, 95% CI 1.02-2.56), unsatisfaction with health status (OR = 5.27, 95% CI 2.44-11.37), family conflicts (OR = 4.51, 95%CI 2.10-9.69), and low levels of social support (OR = 2.62; 95% CI 1.14-6.02). The analysis also revealed that workers (OR = 0.17, 95% CI 0.04-0.66) had a better QoL than farmer-fisherman. QoL in disadvantaged coastal communes was low, with the lowest scores in the physical health domain. Based on the socioeconomic factors associated with not good QoL identified here, it is recommended that local authorities take more appropriate and practical measures to increase support, including measures for all aspects of physical health, psychological health, social relations, and the living environment, especially for people affected by floods.

Apply MIKE 11 model to study impacts of climate change on water resources and develop adaptation plan in the Mekong Delta, Vietnam: a case of Can Tho city.

Can Tho city in the Mekong Delta is in the top ten areas affected by climate change. Therefore, assessing climate change impacts, social and economic activities require proposed solutions to respond to climate change. This study aims to (i) apply the MIKE 11 model (Hydrodynamic module and Advection-Dispersion module) to simulate the impacts of climate change scenarios on water resources in Can Tho city; (ii) calculate water balance in Can Tho city; and (iii) suggest climate change adaptation plan for sustainable social-economic activities of the city. The results show that when the rainfall changes due to climate change, the flow rate tends to decrease at high tide and increase at low tide. When the sea level rises due to climate change, the flow rate tends to increase at high tide and decrease at low tide. For 2030, the flow will decrease up to 15.6% and 14.3% at the low tide period for RCP 2.6 and RCP 8.5 compared to the present, respectively. The flow will increase up to 63.5% and 58.9% at the high tide period for RCP 2.6 and RCP 8.5 compared to the present, respectively. The water demand evaluation shows that the water resource reserve in Can Tho city meets water demands in current and future scenarios under climate change. While rainwater and groundwater can provide enough water in the rainy season, the city has to use surface water during the dry season due to a lack of rainwater. Of these, agriculture contributes the most water demands (85%). Eight adaptation measures to climate change for Can Tho city are developed from 2021 to 2050.

Susceptibility and perceptions of excessive internet use impact on health among Vietnamese youths.

Studies performed worldwide show excessive Internet use could have a negative impact on health. However, Internet use studies in Vietnam are limited. In this study, we reported a high prevalence of frequent Internet usage among Vietnamese youth between 16 and 30 years old. Of 1200 participants, almost 65% reported using the Internet daily. Moreover, 34.3% of the participants reported feeling anxious or uncomfortable after not using the Internet for one day irrespective of their gender, and 40% believed using the Internet frequently did not affect their health. Of those, there was a higher proportion of women than men that held this belief (42.1% vs. 35.9%, respectively, p = .03). In this cohort, undergraduate students were more likely than blue-collar workers to believe that frequent Internet use could affect health. Yet, undergraduate [OR = 1.50, 95%CI = (1.08, 2.09), p < .05)] and high school students (OR = 1.54, 95%CI = 1.00, 2.37), p < .1) were more likely than blue collar workers to feel anxious or uncomfortable after a day without the Internet. Participants in urban areas were more than twice as likely than those from rural areas to believe the Internet did not affect their health [(OR = 0.60, 95%CI = (0.41,0.89), p < .01)]. Lastly, participants between 16 and 18 years old were less likely to believe in the negative impact of the Internet on health than older participants. A better understanding of factors underlying high Internet usage and low perception of its health effects among Vietnamese youth might help develop better intervention strategies for Internet Use Disorder and other Technology Related Use Disorders.

An ensemble boosting model for predicting transfer to the pediatric intensive care unit.

BACKGROUND: Early deterioration indicators have the potential to alert hospital care staff in advance of adverse events, such as patients requiring an increased level of care, or the need for rapid response teams to be called. Our work focuses on the problem of predicting the transfer of pediatric patients from the general ward of a hospital to the pediatric intensive care unit. OBJECTIVES: The development of a data-driven pediatric early deterioration indicator for use by clinicians with the purpose of predicting encounters where transfer from the general ward to the PICU is likely. METHODS: Using data collected over 5.5 years from the electronic health records of two medical facilities, we develop machine learning classifiers based on adaptive boosting and gradient tree boosting. We further combine these learned classifiers into an ensemble model and compare its performance to a modified pediatric early warning score (PEWS) baseline that relies on expert defined guidelines. To gauge model generalizability, we perform an inter-facility evaluation where we train our algorithm on data from one facility and perform evaluation on a hidden test dataset from a separate facility. RESULTS: We show that improvements are witnessed over the modified PEWS baseline in accuracy (0.77 vs. 0.69), sensitivity (0.80 vs. 0.68), specificity (0.74 vs. 0.70) and AUROC (0.85 vs. 0.73). CONCLUSIONS: Data-driven, machine learning algorithms can improve PICU transfer prediction accuracy compared to expertly defined systems, such as a modified PEWS, but care must be taken in the training of such approaches to avoid inadvertently introducing bias into the outcomes of these systems.

Role of Robotics in Children: A brave New World!

CONTEXT: The key in the evolution towards minimally invasive surgery is the availability of appropriate equipment, especially when procedures involve children. While robotic procedures in adults continue to struggle to prove measurable advantages compared with open or classical laparoscopic ones, the use of the robotic platform (RP) in pediatric urology is steadily increasing. OBJECTIVE: To review the contemporary literature regarding the use of robotic-assisted (RA) urologic interventions in children. EVIDENCE ACQUISITION: A nonsystematic review of the literature was conducted through PubMed database between 2002 and 2017, with an emphasis on large series. EVIDENCE SYNTHESIS: A few major challenges must be considered before using the RP in children: anesthesia, placement of trocars, and technical difficulties related to small space. To date, only the robot-assisted pyeloplasty is recognized as safe and efficient with an equivalent outcome compared to the open or classical laparoscopy; this was supported by large multicentric studies, which are not available for most of the other procedures. CONCLUSIONS: RA procedure in children has been proven safe and effective. Still in its infancy, further data over time is likely to prove different RA procedures to be equivalent to open or laparoscopy in terms of outcome. PATIENT SUMMARY: The advent of the robotic platform means an evolution towards minimizing surgical trauma for the child. Currently, the available platforms designed for adults are adapted to work in children. However, it might be expected in the future that new technologies will improve the technical possibilities to improve the robotic platform for minimally invasive surgery in children. To date, a few applications are considered safe and efficient (in experienced hands), considering that the team has to be aware of some challenges to overcome regarding anesthesia, material, and technique adaptation to the patient. The most accepted robotic applications in children comprises of the robot-assisted pyeloplasty, hemi-nephrectomy, and ureteric reimplantation.

Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) Therapy Adherence for Patients with Type 2 Diabetes in a Medicare Population.

INTRODUCTION: Anti-diabetes medication regimen adherence is a clinical challenge in elderly patients with type 2 diabetes (T2D) and other comorbidities associated with aging. Glucagon-like peptide-1 receptor agonists (GLP-1RA) therapies such as exenatide once weekly (QW), exenatide twice daily (BID), and liraglutide once daily (QD) are an increasingly used class of drugs with proven efficacy and tolerability. Real-world evidence on adherence to GLP-1RAs in elderly or disabled patients is limited. To further the understanding of this drug class, the current study examined medication adherence in Medicare patients aged ≥65 years with T2D initiating a GLP-1RA. METHODS: This retrospective cohort study used medical and pharmacy claims between 2010 and 2013 for Medicare members in a United States health plan diagnosed with T2D who were new initiators of either exenatide QW (n = 537), exenatide BID (n = 923), or liraglutide QD (n = 3,673). Included patients were between the ages of 65 and 89 and were continuously enrolled for 6 months pre- and post-index. Medication adherence was examined during the post-index period using proportion of days covered (PDC) ≥80% and ≥90%. RESULTS: A significantly higher percentage of patients receiving exenatide QW had a PDC ≥80% (43.2%) versus exenatide BID (39.0%, P < 0.01) and liraglutide QD (35.0%, P < 0.001). The patients receiving exenatide QW were significantly more likely to reach a PDC of ≥90% (37.2%, P < 0.001) than those initiating exenatide BID (20.6%) or liraglutide QD (23.3%). CONCLUSIONS: While results from this retrospective study suggest room for improvement in adherence to GLP-1RAs, medication adherence rates for patients initiating therapy with exenatide QW were higher than patients initiating therapy with exenatide BID or liraglutide QD. Further research is needed to validate these findings in other T2D patient populations. FUNDING: AstraZeneca Pharmaceuticals.

The Patient Passport Program: An Intervention to Improve Patient-Provider Communication for Hospitalized Minority Children and Their Families.

OBJECTIVE: Effective patient-provider communication is essential to improve health care delivery and satisfaction and to minimize disparities in care for minorities. The objective of our study was to evaluate the impact of a patient-provider communication program, the Patient Passport Program, to improve communication and satisfaction for hospitalized minority children. METHODS: This was a qualitative evaluation of a communication project for families with hospitalized children. Families were assigned to either the Patient Passport Program or to usual care. The Passport Program consisted of a personalized Passport book and additional medical rounds with medical providers. Semistructured interviews at the time of patient discharge were conducted with all participants to measure communication quality and patient/family satisfaction. Inductive qualitative methods were used to identify common themes. RESULTS: Of the 40 children enrolled in the Passport Program, 60% were boys; the mean age was 9.7 years (range, 0.16-19 years). The most common themes in the qualitative analysis of the interviews were: 1) organization of medical care; 2) emotional expressions about the hospitalization experience; and 3) overall understanding of the process of care. Spanish- and English-speaking families had similar patient satisfaction experiences, but the Passport families reported improved quality of communication with the medical care team. CONCLUSIONS: The Patient Passport Program enhanced the quality of communication among minority families of hospitalized children with some common themes around the medical care expressed in the Passport book.

Assessment of Dosing and Patient Factors on the Efficacy of Warfarin Following Total Joint Replacement.

The purpose of this study was to determine the percentage of patients discharged with a subtherapeutic INR <1.8 using our institutions inpatient warfarin dosing nomogram following total joint arthroplasty (TJA). We examined predisposing risk factors for a subtherapeutic discharge (INR <1.8), including increased body weight, age, gender, end stage renal disease (ESRD), smoking, and peri-operative transfusion. Chart review identified 249 patients for study inclusion. Logistic regression (LR) was used to identify associated risk factors for a subtherapeutic INR (<1.8) on day of discharge. The majority of patients (58.6%, 146 of 249) following TJA surgery were found to have a subtherapeutic INR level (INR<1.8) at discharge (mean length of stay 2.6 days). Multivariate LR analysis found that weight greater than 180 lbs. (OR 2.08, CI 1.09, 3.98, P=0.027) was found to increase the odds of a subtherapeutic INR on day of discharge. Our results were not significant for weight 20% beyond ideal body weight, age (>65y), gender, peri-operative transfusion, smoking, ESRD or autoimmune disease. A patient's body weight influences response to warfarin following TJA. An inpatient warfarin dosing nomogram that takes into account a patient's weight should be used to reduce the risk of subtherapeutic INR levels in obese TJA patients.

The short-term cost-effectiveness of once-daily liraglutide versus once-weekly exenatide for the treatment of type 2 diabetes mellitus in the United States.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease with substantial morbidity, mortality, and economic impacts. Glucagon-like peptide-1 (GLP-1) receptor agonists, such as once-daily (QD) liraglutide and once-weekly (QW) exenatide, are FDA-approved treatment for T2DM. Head-to-head trials and meta-analyses comparing these agents have reported clinically meaningful improvements but small differences in glycemic control between both agents. In this study, we calculate and compare the cost-effectiveness implications of these alternative effectiveness outcomes. METHODS: We developed a decision model to evaluate the short-term cost-effectiveness of exenatide QW 2 mg versus liraglutide QD 1.8 mg in T2DM patients, with effectiveness measured as reduction in glycated hemoglobin (HbA1c). In the base case, the model tracks change in HbA1c and direct medical expenditure over a 6-month time horizon. We calculated and compared the cost per 1% reduction in HbA1c of models populated with clinical data from a head-to-head randomized, controlled trial (DURATION-6) and a network meta-analysis. Expenditure inputs were derived from wholesale acquisition costs and published sources. RESULTS: In the base case, 6-month expenditure for the liraglutide and exenatide strategies were $3,509 and $2,618, respectively. Using clinical data from DURATION-6 and the network meta-analysis, the liraglutide strategy had an incremental cost per 1% reduction in HbA1c of $4,773 and $27,179, respectively. The most influential model parameters were drug costs, magnitude of HbA1c reduction in patients on treatment for >1 month, and liraglutide gastrointestinal adverse event rate. In probabilistic sensitivity analyses (PSA) using DURATION-6 data, the exenatide strategy was optimal at willingness-to-pay levels below $4,800 per 1% reduction in HbA1c. In a PSA using meta-analysis data, the exenatide strategy was dominant. CONCLUSIONS: Our modeled results demonstrate that the effectiveness and cost-effectiveness of liraglutide QD 1.8 mg relative to exenatide QW 2 mg depend largely on the chosen source of the clinical data.

Retrospective study comparing healthcare costs and utilization between commercially insured patients with type 2 diabetes mellitus who are newly initiating exenatide once weekly or liraglutide in the United States.

OBJECTIVE: To compare healthcare costs and utilization between commercially insured patients with type 2 diabetes mellitus (T2DM) in the United States newly initiating exenatide once weekly (QW) or liraglutide. METHODS: This retrospective cohort study used US administrative claims data to study patients with T2DM initiating exenatide QW or liraglutide (initiated therapy = index therapy). Patients were included if they had T2DM, were glucagon-like peptide-1 receptor agonist (GLP-1RA) naïve, initiated exenatide QW or liraglutide from 1 February 2012 to 1 October 2012 (date of initiation = index), were ≥18 years at index, and had continuous enrollment for 12 months before (baseline) to 6 months after index (follow-up). Study outcomes were overall and diabetes-specific healthcare utilization and costs. Multivariable regressions compared the study outcomes between exenatide QW and liraglutide, adjusting for potential confounders. Sensitivity analyses were performed to assess liraglutide by dose (1.2 mg/1.8 mg). RESULTS: The study sample included 9106 liraglutide (4188, 1.2 mg; 4918, 1.8 mg) patients and 2445 exenatide QW patients. In multivariable-adjusted analyses, compared with liraglutide patients, exenatide QW patients had statistically significantly lower odds of overall inpatient admissions (odds ratio [OR] = 0.80, p = 0.046) and diabetes-specific (OR = 0.83, p = 0.026) inpatient admissions, similar overall total costs ($7833 exenatide QW, $8296 liraglutide, p = 0.069) and diabetes-specific total costs ($3610 exenatide QW, $3736 liraglutide, p = 0.298), and statistically significantly lower overall medical costs ($3939 exenatide QW, $4652 liraglutide, p = 0.008) and diabetes-specific medical costs ($1161 exenatide QW, $1469 liraglutide, p = 0.007). Sensitivity analyses assessing liraglutide by dose were directionally consistent. Unadjusted exploratory analyses showed that exenatide QW patients obtained a greater median number of days supplied for their GLP-1RA during follow-up (141 days) than liraglutide patients (124 days). CONCLUSIONS: In this 6 month follow-up study, patients receiving exenatide QW had similar total healthcare costs but lower odds of inpatient admission and lower medical costs compared with patients receiving liraglutide.

Validation of the pediatric surgical risk assessment scoring system.

BACKGROUND: Within the adult population, there exist numerous validated risk stratification tools aimed at predicting postoperative outcomes using preoperative and intraoperative parameters. However, similar tools for the pediatric population are scarce. We previously developed and reported on a scoring system to predict postoperative complications in children undergoing surgery at Boston Children's Hospital. The objective of this study was to validate our scoring system to determine its effectiveness in identifying children at risk for major complications or death within 30 days following surgery. STUDY DESIGN: A computer program randomly selected 2015 out of 11,734 patients who underwent surgery at our institution in 2009. The severity of the complications was graded based on the Clavien classification system, with major complications being a grade III or higher. The Preoperative Complication Score (PCS) and the Overall Complication Score (OCS) were calculated for all patients, and Receiver Operating Characteristic (ROC) curves were generated for each scoring system. RESULTS: The overall incidence of major complications was 3.9% (79 patients). Proportionally, cardiac surgery had the highest percentage of major complications (20% of the performed surgeries). Both PCS and OCS demonstrated excellent correlation with postoperative outcomes with c-statistic values of 0.740 (CI 0.682-0.800, p < 0.001) and 0.767 (CI 0.712-0.822, p < 0.001) respectively. CONCLUSIONS: We determined that both the PCS and OCS are effective in identifying children at risk for major complications and death following surgery. Further studies will be needed to determine if these scoring systems are applicable to children undergoing surgery at other institutions and if the use of the scoring systems would result in improved clinical outcomes and reduced costs.

A systematic review to assess comparative effectiveness studies in epidural steroid injections for lumbar spinal stenosis and to estimate reimbursement amounts.

OBJECTIVE: To systematically appraise published comparative effectiveness evidence (clinical and economic) of epidural steroid injections (ESI) for lumbar spinal stenosis and to estimate Medicare reimbursement amounts for ESI procedures. TYPE: Systematic review. LITERATURE SURVEY: PubMed, Embase, and CINAHL were searched through August 2012 for key words that pertain to low back pain, spinal stenosis or sciatica, and epidural steroid injection. We used institutional and Medicare reimbursement amounts for our cost estimation. Articles published in English that assessed ESIs for adults with lumbar spinal stenosis versus a comparison intervention were included. Our search identified 146 unique articles, and 138 were excluded due to noncomparative study design, not having a study population with lumbar spinal stenosis, not having an appropriate outcome, or not being in English. We fully summarized 6 randomized controlled trials and 2 large observational studies. METHODOLOGY: Randomized controlled trial articles were reviewed, and the study population, sample size, treatment groups, ESI dosage, ESI approaches, concomitant interventions, outcomes, and follow-up time were reported. Descriptive resource use estimates for ESIs were calculated with use of data from our institution during 2010 and Medicare-based reimbursement amounts. SYNTHESIS: ESIs or anesthetic injections alone resulted in better short-term improvement in walking distance compared with control injections. However, there were no longer-term differences. No differences between ESIs versus anesthetic in self-reported improvement in pain were reported. Transforaminal approaches had better improvement in pain scores (≤4 months) compared with interlaminar injections. Two observational studies indicated increased rates of lumbar ESI in Medicare beneficiaries. Our sample included 279 patients who received at least 1 ESI during 2010, with an estimated mean total outpatient reimbursement for one ESI procedure "event" to be $637, based on 2010 Medicare reimbursement amounts ($505 technical and $132 professional payments). CONCLUSION: This systematic review of ESI for treating lumbar spinal stenosis found a limited amount of data that suggest that ESI is effective in some patients for improving select short-term outcomes, but results differed depending on study design, outcome measures used, and comparison groups evaluated. Overall, there are relatively few comparative clinical or economic studies for ESI procedures for lumbar spinal stenosis in adults, which indicated a need for additional evidence.

Medical costs and hospitalizations among patients with depression treated with adjunctive atypical antipsychotic therapy: an analysis of health insurance claims data.

BACKGROUND: Depression is frequently debilitating. The American Psychiatric Association recommends adjunctive atypical antipsychotics as a treatment option when response to antidepressants is inadequate. OBJECTIVE: To compare medical costs and hospitalizations among patients with depression treated with adjunctive aripiprazole, olanzapine, or quetiapine. METHODS: This retrospective analysis used medical and pharmacy claims data and enrollment information from a large US health plan. Patients were adult members of a commercial health plan who were diagnosed with depression (ie, ICD-9-CM 296.2x, 296.3x, or 311) and who received an antidepressant with adjunctive atypical antipsychotic therapy (aripiprazole, olanzapine, or quetiapine) between January 1, 2004, and January 31, 2010. Patients were continuously enrolled for 6-month pre- and 12-month postaugmentation periods. Those with schizophrenia or bipolar disorder were excluded. Postaugmentation outcomes were total and mental health-related medical costs and hospitalizations. Costs and hospitalizations were modeled with generalized linear models (ie, gamma distribution, log link) and logistic regression, respectively. Regressions controlled for dose, demographics, and general and medical health-related health status. RESULTS: A total of 10,292 patients were identified across atypical antipsychotic cohorts: 3849 used aripiprazole, 1033 used olanzapine, and 5410 used quetiapine. Mean (SD) age was 44.1 (11.6) years and 70.3% were female. Compared with patients in the aripiprazole cohort, those in the olanzapine cohort had higher total medical costs (cost ratio [CR] 1.22, 95% CI 1.07-1.39) and higher mental health-related medical costs (CR 1.33, 95% CI 1.11-1.59), as well as higher odds of any (total) hospitalization (OR 1.58, 95% CI 1.30-1.92) and any mental health-related hospitalization (OR 1.81, 95% CI 1.38-2.38). Similarly, the quetiapine cohort had higher total medical costs (CR 1.27, 95% CI 1.16-1.39) and higher mental health-related medical costs (CR 1.23, 95% CI 1.09-1.39), as well as higher odds of any (total) hospitalization (OR 1.65, 95% CI 1.44-1.90) and any mental health-related hospitalizations (OR 1.78, 95% CI 1.45-2.18), compared with the aripiprazole cohort. CONCLUSIONS: Compared with adjunctive olanzapine or quetiapine, adjunctive aripiprazole was associated with lower mean total and mental health-related medical costs and with lower odds of total and mental health-related hospitalizations in patients with depression.

Current controversies in pediatric urologic robotic surgery.

PURPOSE OF REVIEW: Minimally invasive surgeries such as conventional laparoscopic surgery and robotic assisted laparoscopic surgery (RALS) have significant advantages over the traditional open surgical approach including lower pain medication requirements and decreased length of hospitalization. However, open surgery has demonstrated better success rates and shorter surgery time when compared to the other modalities. Currently, it is unclear which approach has better long-term clinical outcomes, greater benefits and less cost. RECENT FINDINGS: There are limited studies in the literature comparing these three different surgical approaches. In this review, we will evaluate the advantages and disadvantages of RALS compared to conventional laparoscopic surgery and open surgery for commonly performed pediatric urological procedures such as pyeloplasty, ureteral reimplantation, complete and partial nephrectomy, bladder augmentation and creation of continent catheterizable channels. SUMMARY: Although it is not yet possible to demonstrate the superiority of one single surgical modality over another, RALS has been shown to be feasible, well tolerated and advantageous in reconstructive urological procedures. With experience, the outcomes of RALS are improving, justifying its usage. However, cost remains a significant issue, limiting the accessibility of RALS, which in the future may improve with market competition and device innovation.

A comparative direct cost analysis of pediatric urologic robot-assisted laparoscopic surgery versus open surgery: could robot-assisted surgery be less expensive?

BACKGROUND AND PURPOSE: Cost in healthcare is an increasing and justifiable concern that impacts decisions about the introduction of new devices such as the da Vinci(®) surgical robot. Because equipment expenses represent only a portion of overall medical costs, we set out to make more specific cost comparisons between open and robot-assisted laparoscopic surgery. MATERIALS AND METHODS: We performed a retrospective, observational, matched cohort study of 146 pediatric patients undergoing either open or robot-assisted laparoscopic urologic surgery from October 2004 to September 2009 at a single institution. Patients were matched based on surgery type, age, and fiscal year. Direct internal costs from the institution were used to compare the two surgery types across several procedures. RESULTS: Robot-assisted surgery direct costs were 11.9% (P=0.03) lower than open surgery. This cost difference was primarily because of the difference in hospital length of stay between patients undergoing open vs robot-assisted surgery (3.8 vs 1.6 days, P<0.001). Maintenance fees and equipment expenses were the primary contributors to robotic surgery costs, while open surgery costs were affected most by room and board expenses. When estimates of the indirect costs of robot purchase and maintenance were included, open surgery had a lower total cost. There were no differences in follow-up times or complication rates. CONCLUSIONS: Direct costs for robot-assisted surgery were significantly lower than equivalent open surgery. Factors reducing robot-assisted surgery costs included: A consistent and trained robotic surgery team, an extensive history of performing urologic robotic surgery, selection of patients for robotic surgery who otherwise would have had longer hospital stays after open surgery, and selection of procedures without a laparoscopic alternative. The high indirect costs of robot purchase and maintenance remain major factors, but could be overcome by high surgical volume and reduced prices as competitors enter the market.

Objective measures for longitudinal assessment of robotic surgery training.

OBJECTIVES: Current robotic training approaches lack the criteria for automatically assessing and tracking (over time) technical skills separately from clinical proficiency. We describe the development and validation of a novel automated and objective framework for the assessment of training. METHODS: We are able to record all system variables (stereo instrument video, hand and instrument motion, buttons and pedal events) from the da Vinci surgical systems using a portable archival system integrated with the robotic surgical system. Data can be collected unsupervised, and the archival system does not change system operations in any way. Our open-ended multicenter protocol is collecting surgical skill benchmarking data from 24 trainees to surgical proficiency, subject only to their continued availability. Two independent experts performed structured (objective structured assessment of technical skills) assessments on longitudinal data from 8 novice and 4 expert surgeons to generate baseline data for training and to validate our computerized statistical analysis methods in identifying the ranges of operational and clinical skill measures. RESULTS: Objective differences in operational and technical skill between known experts and other subjects were quantified. The longitudinal learning curves and statistical analysis for trainee performance measures are reported. Graphic representations of the skills developed for feedback to the trainees are also included. CONCLUSIONS: We describe an open-ended longitudinal study and automated motion recognition system capable of objectively differentiating between clinical and technical operational skills in robotic surgery. Our results have demonstrated a convergence of trainee skill parameters toward those derived from expert robotic surgeons during the course of our training protocol.

Factors influencing residents' pursuit of urology fellowships.

OBJECTIVE: To assess the predictors of residents' pursuit of fellowship training by surveying current urology residents and recent graduates. Postgraduate fellowship training of urologists could be an important source of urologic physician-scientists and continued innovation in urologic care. METHODS: A Web-based survey was electronically mailed to urology residents and recent graduates of urologic residency. Variables concerning sex, marital status, debt load, research and clinical exposure, publications, and postgraduate careers were recorded. RESULTS: Of the 71 respondents, 46 (65%) were married and 45% had children/dependents. Of the 69% who applied for fellowship, the "most important" factors influencing the pursuit of fellowship were intellectual appeal (82%), mentors (79%), the desire for an additional point of view for surgical training (58%), and the desire to pursue a career in academics (52%). Forty of those completing a fellowship (87%) versus two of those completing residency alone (13%) would pursue a career in academics. Residents with a mentor were 20 times more likely to pursue a urology fellowship. A shorter residency (5 years), encouragement by a program director, and manuscript publication during residency were also independent predictors. CONCLUSION: Mentorship, a shorter residency, and manuscript publication during residency were independent predictors of pursuing fellowship training. Debt load, age, marital status, and a desire to pursue a career in academic medicine were not significant factors.

Perioperative risk factors for major complications in pediatric surgery: a study in surgical risk assessment for children.

BACKGROUND: There are numerous studies in the adult literature correlating comorbidities and pre- and intraoperative parameters with postoperative outcomes. However, there is a paucity of similar data in the pediatric population. Our goal was to elucidate which pre- and intraoperative patient characteristics in children undergoing surgery are associated with an increased risk of major complication within 30 days. STUDY DESIGN: We identified 108 children who underwent surgery at our institution between June 2005 and May 2007 and had major complication or death within 30 days of surgery. Forty-two preoperative patient characteristics and 22 intraoperative variables were evaluated. The severity of the complications was graded based on the Clavien classification system, with major complications grade III or greater. We randomly selected 723 controls who had undergone surgery within a 3-month date range of the original cohort, but did not develop complications. Statistical significance was assessed by univariate and multivariate analyses. RESULTS: Most complications were cardiovascular, occurred 1 to 3 days after surgery, and were classified as grade IIIB. We identified 5 independent risk factors on multivariate analysis: ≤36 weeks of gestation, American Society of Anesthesiologists score >3, undergoing a cardiovascular or neurosurgical procedure, and receiving an intraoperative albumin transfusion. Three scoring systems (overall, preoperative, and intraoperative complication score) were developed to provide objective risk stratification. CONCLUSIONS: We found 5 patient-specific parameters that were independent risk factors for major complications or death after pediatric surgery. Future prospective studies will help to fully stratify risk and guide interventions to improve postoperative outcomes.

Assessment of parental satisfaction in children undergoing voiding cystourethrography without sedation.

PURPOSE: Approximately 50,000 children undergo voiding cystourethrography annually. There is a recent trend toward using sedation or delaying voiding cystourethrography due to the anticipated distress to the patient. We hypothesized that with adequate preparation and proper techniques to minimize anxiety, voiding cystourethrography can be performed without sedation. We assessed parental satisfaction associated with patient and parent experience of voiding cystourethrography without sedation. MATERIALS AND METHODS: We used a 33-question survey to evaluate parental satisfaction with patient and parent experience of voiding cystourethrography without sedation. Children were divided into 3 groups according to toilet training status. Statistical analysis was performed using Stata®. RESULTS: A total of 200 surveys were completed. Of the children 54% were not toilet trained. Of the parents 90% reported adequate preparation. More than half of parents classified the experience of voiding cystourethrography as equivalent to or better than a physical examination, immunization, ultrasound and prior catheterization. Most parents were satisfied with the ability of the child to tolerate the procedure and considered the experience better than expected. Children in the process of toilet training had the most difficulty with the procedure, correlating with lower levels of parental satisfaction. CONCLUSIONS: Voiding cystourethrography performed with adequate preparation and support can be tolerated without sedation. Children in the process of toilet training and females tolerate the procedure least.

Perioperative risk factors for surgical complications in pediatric urology: a pilot study in preoperative risk assessment in children.

OBJECTIVES: To elucidate which perioperative patient characteristics are associated with an increased risk of complications in pediatric urological surgery. There are numerous published studies that have correlated comorbidities, preoperative, and intraoperative parameters with postoperative outcomes in adults. However, there is a paucity of similar data in the pediatric population. METHODS: Between July 2003 and September 2006, a total of 93 children had an adverse or unexpected event within 35 days of urologic surgery. Thirty-eight preoperative patient characteristics and 20 perioperative parameters were evaluated. The severity of the complications was graded based on the Clavien classification. A total of 163 controls were randomly selected. Statistical significance was assessed by univariate and multivariate analysis. RESULTS: The overall complication rate was 1.1%. Most complications were technical in nature, occurred within 3 days after surgery, and classified as Clavien's grade 3 B. On multivariate analysis, weight less than fifth percentile, pulmonary or hematologic comorbidity, surgery duration >2 hours, first operation, low intraoperative heart rate, and the use of intravenous anesthesia were determined to be independent risk factors, whereas "other" medication was the only independent protective factor. CONCLUSIONS: We observed that some of the parameters conventionally thought to be risk factors for surgical complications such as multiple medical comorbidities, repeat operation, and American Society of Anesthesiologists' Classification of Physical Status score were not significant predictors of postoperative complications, whereas others were unexpectedly significant. Future prospective studies will be needed to fully stratify risk and guide risk interventions to improve postoperative outcomes.