The Impact of the COVID-19 Pandemic on Surgical Management of Breast Cancer: Global Trends and Future Perspectives.

INTRODUCTION: The rapid spread of COVID-19 across the globe is forcing surgical oncologists to change their daily practice. We sought to evaluate how breast surgeons are adapting their surgical activity to limit viral spread and spare hospital resources. METHODS: A panel of 12 breast surgeons from the most affected regions of the world convened a virtual meeting on April 7, 2020, to discuss the changes in their local surgical practice during the COVID-19 pandemic. Similarly, a Web-based poll based was created to evaluate changes in surgical practice among breast surgeons from several countries. RESULTS: The virtual meeting showed that distinct countries and regions were experiencing different phases of the pandemic. Surgical priority was given to patients with aggressive disease not candidate for primary systemic therapy, those with progressive disease under neoadjuvant systemic therapy, and patients who have finished neoadjuvant therapy. One hundred breast surgeons filled out the poll. The trend showed reductions in operating room schedules, indications for surgery, and consultations, with an increasingly restrictive approach to elective surgery with worsening of the pandemic. CONCLUSION: The COVID-19 emergency should not compromise treatment of a potentially lethal disease such as breast cancer. Our results reveal that physicians are instinctively reluctant to abandon conventional standards of care when possible. However, as the situation deteriorates, alternative strategies of de-escalation are being adopted. IMPLICATIONS FOR PRACTICE: This study aimed to characterize how the COVID-19 pandemic is affecting breast cancer surgery and which strategies are being adopted to cope with the situation.

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons.

OBJECTIVE: The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice. SUMMARY BACKGROUND DATA: In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied. METHODS: We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors. RESULTS: Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049]. CONCLUSIONS: Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

Challenges and practices in promoting (ageing) employees working career in the health care sector - case studies from Germany, Finland and the UK.

BACKGROUND: The health and social care sector (HCS) is currently facing multiple challenges across Europe: against the background of ageing societies, more people are in need of care. Simultaneously, several countries report a lack of skilled personnel. Due to its structural characteristics, including a high share of part-time workers, an ageing workforce, and challenging working conditions, the HCS requires measures and strategies to deal with these challenges. METHODS: This qualitative study analyses if and how organisations in three countries (Germany, Finland, and the UK) report similar challenges and how they support longer working careers in the HCS. Therefore, we conducted multiple case studies in care organisations. Altogether 54 semi-structured interviews with employees and representatives of management were carried out and analysed thematically. RESULTS: Analysis of the interviews revealed that there are similar challenges reported across the countries. Multiple organisational measures and strategies to improve the work ability and working life participation of (ageing) workers were identified. We identified similar challenges across our cases but different strategies in responding to them. With respect to the organisational measures, our results showed that the studied organisations did not implement any age-specific management strategies but realised different reactive and proactive human relation measures aiming at maintaining and improving employees' work ability (i.e., health, competence and motivation) and longer working careers. CONCLUSIONS: Organisations within the HCS tend to focus on the recruitment of younger workers and/or migrant workers to address the current lack of skilled personnel. The idea of explicitly focusing on ageing workers and the concept of age management as a possible solution seems to lack awareness and/or popularity among organisations in the sector. The concept of age management offers a broad range of measures, which could be beneficial for both, employees and employers/organisations. Employees could benefit from a better occupational well-being and more meaningful careers, while employers could benefit from more committed employees with enhanced productivity, work ability and possibly a longer career.

Care practices and neonatal survival in 52 neonatal intensive care units in Telangana and Andhra Pradesh, India: A cross-sectional study.

BACKGROUND: The Indian government supports both public- and private-sector provision of hospital care for neonates: neonatal intensive care is offered in public facilities alongside a rising number of private-for-profit providers. However, there are few published reports about mortality levels and care practices in these facilities. We aimed to assess care practices, causes of admission, and outcomes from neonatal intensive care units (NICUs) in public secondary and private tertiary hospitals and both public and private medical colleges enrolled in a quality improvement collaborative in Telangana and Andhra Pradesh-2 Indian states with a respective population of 35 and 50 million. METHODS AND FINDINGS: We conducted a cross-sectional study between 30 May and 26 August 2016 as part of a baseline evaluation in 52 consenting hospitals (26 public secondary hospitals, 5 public medical colleges, 15 private tertiary hospitals, and 6 private medical colleges) offering neonatal intensive care. We assessed the availability of staff and services, adherence to evidence-based practices at admission, and case fatality after admission to the NICU using a range of tools, including facility assessment, observations of admission, and abstraction of registers and telephone interviews after discharge. Our analysis is adjusted for clustering and weighted for caseload at the hospital level and presents findings stratified by type and ownership of hospitals. In total, the NICUs included just over 3,000 admissions per month. Staffing and infrastructure provision were largely according to government guidelines, except that only a mean of 1 but not the recommended 4 paediatricians were working in public secondary NICUs per 10 beds. On admission, all neonates admitted to private hospitals had auscultation (100%, 19 of 19 observations) but only 42% (95% confidence interval [CI] 25%-62%, p-value for difference is 0.361) in public secondary hospitals. The most common single cause of admission was preterm birth (25%) followed by jaundice (23%). Case-fatality rates at age 28 days after admission to a NICU were 4% (95% CI 2%-8%), 15% (9%-24%), 4% (2%-8%) and 2% (1%-5%) (Chi-squared p = 0.001) in public secondary hospitals, public medical colleges, private tertiary hospitals, and private medical colleges, respectively, according to facility registers. Case fatality according to postdischarge telephone interviews found rates of 12% (95% CI 7%-18%) for public secondary hospitals. Roughly 6% of admitted neonates were referred to another facility. Outcome data were missing for 27% and 8% of admissions to private tertiary hospitals and private medical colleges. Our study faced the limitation of missing data due to incomplete documentation. Further generalizability was limited due to the small sample size among private facilities. CONCLUSIONS: Our findings suggest differences in quality of neonatal intensive care and 28-day survival between the different types of hospitals, although comparison of outcomes is complicated by differences in the case mix and referral practices between hospitals. Uniform reporting of outcomes and risk factors across the private and public sectors is required to assess the benefits for the population of mixed-care provision.

Regional Training Needs Assessment: A First Look at High-Priority Training Needs Across the United States by Region.

CONTEXT: Although core scientific skills remain a priority to public health, preventing and responding to today's leading causes of death require the workforce to build additional strategic skills to impact the social, community-based, and economic determinants of health. The 2017 Public Health Workforce Interests and Needs Survey allows novel regional analysis of training needs, both individually and across 8 strategic skill domains. OBJECTIVE: The purpose of this article is to describe the training needs of public health staff nationally, across the 10 Department of Health and Human Services Regions. DESIGN: The Public Health Workforce Interests and Needs Survey was a Web-based survey fielded to 100 000 staff nationwide across 2 major frames: state health agency-central office and local health department. State-based respondents were fielded on a census approach, with locals participating in a more complex sampling design. Balanced repeated replication weights were used to address nonresponse and sampling. SETTING: State and local health departments. PARTICIPANTS: Respondents from state and local health departments. MAIN OUTCOME MEASURES: This article draws from the training needs portion of Public Health Workforce Interests and Needs Survey. Descriptive statistics are generated, showing training needs gaps. Inferential analyses pertain to gaps across Region and supervisory status, using Pearson χ test and Rao-Scott design-adjusted χ test. RESULTS: Training needs varied across regions and work setting. Certain strategic skills tended to see larger, consistent gaps regardless of Region or setting, including Budgeting & Finance, Change Management, Systems Thinking, and Developing a Vision for a Healthy Community. CONCLUSIONS: Overall, the data suggest substantial interregional variation in training needs. Until now, this picture has been incomplete; disparate assessments across health departments, Regions, and disciplines could not be combined into a national picture. Regionally focused training centers are well situated to address Region-specific needs while supporting the broader building of capacity in strategic skills nationwide.

Association between 12-hr shifts and nursing resource use in an acute hospital: Longitudinal study.

AIM: To evaluate whether ≥12-hr shifts are associated with a decrease in resource use, in terms of care hours per patient day and staffing costs per patient day. BACKGROUND: Nurses working long shifts may become less productive and no research has investigated whether potential cost savings are realized. METHOD: A retrospective longitudinal study using routinely collected data from 32 wards within an English hospital across 3 years (1 April 2012-31 March 2015). There were 24,005 ward-days. Hierarchical linear mixed models measured the association between the proportion of ≥12-hr shifts worked on a ward-day, care hours per patient day and staffing costs per patient day. RESULTS: Compared with days with no ≥12-hr shifts, days with between 50% and 75% ≥12-hr shifts had more care hours per patient day and higher costs (estimate for care hours per patient day: 0.32; 95% CI: 0.28-0.36; estimate for staffing costs per patient day: £8.86; 95% CI: 7.59-10.12). CONCLUSIONS: We did not find reductions in total care hours and costs associated with the use of ≥12-hr shifts. The reason why mixed shift patterns are associated with increased cost needs further exploration. IMPLICATIONS FOR NURSING MANAGEMENT: Increases in resource use could result in additional costs or loss of productivity for hospitals. Implementation of long shifts should be questioned.

Acuity-based Scheduling in Primary Care.

OBJECTIVES: Triage algorithms are ubiquitous in emergency care settings, but the extent of their use in primary care is unknown. This study asks whether primary care practices prioritize patients with more acute service needs. METHODS: We used an audit study in which simulated patients were randomized to 2 clinical scenarios-a new patient seeking a routine check-up or a new patient seeking treatment for newly diagnosed hypertension-and attempted to schedule appointments with thousands of randomly selected primary care physicians across 10 states. We estimated the difference in appointment availability by clinical scenario. For scheduled appointments, we also estimated the difference in wait times by clinical scenario. RESULTS: While there was no difference in appointment availability, the mean wait time for simulated patients seeking a routine check-up was nearly 5 days longer than the mean wait time for simulated patients with hypertension. CONCLUSIONS: As demand for primary care increases while the supply remains stable, it will be important for practices to identify and prioritize patients with more acute service needs. Our results show that primary care physicians are already adopting such practices.

Extended operating times are more efficient, save money and maintain a high staff and patient satisfaction.

Current public sector austerity measures necessitate efficiency savings throughout the NHS. Performance targets have resulted in activity being performed in the private sector, waiting list initiative lists and requests for staff to work overtime. This has resulted in staff fatigue and additional agency costs. Adoption of extended operating theatre times (0800-1800 hours) may improve productivity and efficiency, with potentially significant financial savings; however, implementation may adversely affect staff morale and patient compliance. A pilot period of four months of extended operating times (4.5 hour sessions) was completed and included all theatre surgical specialties. Outcome measures included: the number of cases completed, late starts, early finishes, cancelled operations, theatre overruns, preoperative assessment and 18-week targets. The outcomes were then compared to pre-existing normal working day operating lists (0900-1700). Theatre staff, patient and surgical trainee satisfaction with the system were also considered by use of an anonymous questionnaire. The study showed that in-session utilisation time was unchanged by extended operating hours 88.7% (vs 89.2%). The service was rated as 'good' or 'excellent' by 87.5% of patients. Over £345,000 was saved by reducing premium payments. Savings of £225,000 were made by reducing privately outsourced operation and a further £63,000 by reviewing staff hours. Day case procedures increased from 2.8 to 3.2 cases/day with extended operating. There was no significant increase in late starts (5.1% vs 6.8%) or cancellation rates (0.75% vs 1.02%). Theatre over-runs reduced from 5% to 3.4%. The 18 weeks target for surgery was achieved in 93.7% of cases (vs 88.3%). The number of elective procedures increased from 4.1 to 4.89 cases/day. Only 13.33% of trainees (n = 33) surveyed felt that extended operating had a negative impact on training. The study concludes that extended operating increased productivity from 2.8 patients per session to 3.2 patients per session with potential savings of just over £2.4 million per financial year. Extrapolating this to the other 155 trusts in England could be a potential saving of £372 million per year. Staff, trainee and patient satisfaction was unaffected. An improved 18 weeks target position was achieved with a significant reduction in private sector work. However, some staff had difficulty with arranging childcare and taking public transport and this may prevent full implementation.

2015 American College of Rheumatology Workforce Study: Supply and Demand Projections of Adult Rheumatology Workforce, 2015-2030.

OBJECTIVE: To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015-2030. METHODS: The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data-driven estimations regarding the proportion and clinical full-time equivalent (FTE) of academic versus nonacademic practitioners. RESULTS: The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%). CONCLUSION: The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby-boomer retirements, a millennial predominance, and an increase of female and part-time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients.

Diversity and Similarity of Anesthesia Procedures in the United States During and Among Regular Work Hours, Evenings, and Weekends.

BACKGROUND: Anesthesiologists providing care during off hours (ie, weekends or holidays, or cases started during the evening or late afternoon) are more likely to care for patients at greater risk of sustaining major adverse events than when they work during regular hours (eg, Monday through Friday, from 7:00 AM to 2:59 PM). We consider the logical inconsistency of using subspecialty teams during regular hours but not during weekends or evenings. METHODS: We analyzed data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry (NACOR). Among the hospitals in the United States, we estimated the average number of common types of anesthesia procedures (ie, diversity measured as inverse of Herfindahl index), and the average difference in the number of common procedures between 2 off-hours periods (regular hours versus weekends, and regular hours versus evenings). We also used NACOR data to estimate the average similarity in the distributions of procedures between regular hours and weekends and between regular hours and evenings in US facilities. Results are reported as mean ± standard error of the mean among 399 facilities nationwide with weekend cases. RESULTS: The distributions of common procedures were moderately similar (ie, not large, <.8) between regular hours and evenings (similarity index .59 ± .01) and between regular hours and weekends (similarity index, .55 ± .02). For most facilities, the number of common procedures differed by <5 procedures between regular hours and evenings (74.4% of facilities, P < .0001) and between regular hours and weekends (64.7% of facilities, P < .0001). The average number of common procedures was 13.59 ± .12 for regular hours, 13.12 ± .13 for evenings, and 9.43 ± .13 for weekends. The pairwise differences by facility were .13 ± .07 procedures (P = .090) between regular hours and evenings and 3.37 ± .12 procedures (P < .0001) between regular hours and weekends. In contrast, the differences were -5.18 ± .12 and 7.59 ± .13, respectively, when calculated using nationally pooled data. This was because the numbers of common procedures were 32.23 ± .05, 37.41 ± .11, and 24.64 ± .12 for regular hours, evenings, and weekends, respectively (ie, >2x the number of common procedures calculated by facility). CONCLUSIONS: The numbers of procedures commonly performed at most facilities are fewer in number than those that are commonly performed nationally. Thus, decisions on anesthesia specialization should be based on quantitative analysis of local data rather than national recommendations using pooled data. By facility, the number of different procedures that take place during regular hours and off hours (diversity) is essentially the same, but there is only moderate similarity in the procedures performed. Thus, at many facilities, anesthesiologists who work principally within a single specialty during regular work hours will likely not have substantial contemporary experience with many procedures performed during off hours.

Women's Work Pathways Across the Life Course.

Despite numerous changes in women's employment in the latter half of the twentieth century, women's employment continues to be uneven and stalled. Drawing from data on women's weekly work hours in the National Longitudinal Survey of Youth (NLSY79), we identify significant inequality in women's labor force experiences across adulthood. We find two pathways of stable full-time work for women, three pathways of part-time employment, and a pathway of unpaid labor. A majority of women follow one of the two full-time work pathways, while fewer than 10% follow a pathway of unpaid labor. Our findings provide evidence of the lasting influence of work-family conflict and early socioeconomic advantages and disadvantages on women's work pathways. Indeed, race, poverty, educational attainment, and early family characteristics significantly shaped women's work careers. Work-family opportunities and constraints also were related to women's work hours, as were a woman's gendered beliefs and expectations. We conclude that women's employment pathways are a product of both their resources and changing social environment as well as individual agency. Significantly, we point to social stratification, gender ideologies, and work-family constraints, all working in concert, as key explanations for how women are "tracked" onto work pathways from an early age.

[Work schedules in the Hungarian health care system and the sleep quality of nurses]. / Munkarendek a hazai egészségügyi rendszerben, és az ápolók alvásminosége.

INTRODUCTION: One way of ensuring the continuity of health care is the shift work, which is burdensome and it can lead to sleep disturbances. AIM: The aim of the study was to measure the typical Hungarian nursing shift systems in hospitals, to analyse the causes of irregular work schedules, and to compare the sleep quality of nurses in different work schedules. METHOD: 236 head nurses filled out the national online survey, and 217 nurses in clinics of the University of Pécs filled the Hungarian version of Bergen Shift Work Sleep Questionnaire. RESULTS: The head nurses provided data of 8697 nurses's schedules. 51.89% of nurses work in flexible shift system. 1944 employees work in regular shift system, most of them in the following order: 12-hour day shift and 12-hour night shift, followed by a one- or two-day rest. Where there is no system of shifts, the most frequent causes are the needs of nurses and the nurse shortage. Nurses who are working in irregular shift system had worse sleep quality than nurses who are working in flexible and regular shift system (p = 0.044). CONCLUSIONS: It would be helpful if the least burdensome shift system could be established.

Work on Safe Staffing Guidelines Halted in the United Kingdom.

Establishing safe nurse staffing levels is no easier abroad than in the United States.

Predicting nurse staffing needs for a labor and birth unit in a large-volume perinatal service.

This project was designed to test a nurse staffing model for its ability to accurately determine staffing needs for a large-volume labor and birth unit based on a staffing gap analysis using the nurse staffing guidelines from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The staffing model and the AWHONN staffing guidelines were found to be reliable methods to predict staffing needs for a large-volume labor and birth unit.