Hospitals with greater diversities of physiologically complex procedures do not achieve greater surgical growth in a market with stable numbers of such procedures.

STUDY OBJECTIVE: Although having a large diversity of types of procedures has a substantial operational impact on the surgical suites of hospitals, the strategic importance is unknown. In the current study, we used longitudinal data for all hospitals and patient ages in the State of Florida to evaluate whether hospitals with greater diversity of types of physiologically complex major therapeutic procedures (PCMTP) also had greater rates of surgical growth. DESIGN: Observational cohort study. SETTING: 1479 combinations of hospitals in the State of Florida and fiscal years, 2008-2015. MEASUREMENTS: The types of International Classification of Diseases, Ninth revision, Clinical Modification (ICD-9-CM) procedures studied were PCMT, defined as: a) major therapeutic procedure; b) >7 American Society of Anesthesiologists base units; and c) performed during a hospitalization with a Diagnosis Related Group with a mean length of stay ≥4.0days. The number of procedures of each type of PCMTP commonly performed at each hospital was calculated by taking 1/Herfindahl index (i.e., sum of the squares of the proportions of all procedures of each type of PCMTP). MAIN RESULTS: Over the 8 successive years studied, there was no change in the number of PCMTP being performed (Kendall's τb=-0.014±0.017 [standard error], P=0.44; N=1479 hospital×years). Busier and larger hospitals commonly performed more types of PCMTP, respectively categorized based on performed PCMTP (τ=0.606±0.017, P<0.0001) or hospital beds (τ=0.524±0.017, P<0.0001). There was no association between greater diversity of types of PCMTP commonly performed and greater annual growth in numbers of PCMTP (τ=0.002±0.019, P=0.91; N=1295 hospital×years). Conclusions were the same with multiple sensitivity analyses. Post hoc, it was recognized that hospitals performing a greater diversity of PCMTP were more similar to the aggregate of other hospitals within the same health district (τ=0.550±0.017, P<0.0001). CONCLUSIONS: During a period with no overall growth in PCMTP, hospitals with greater diversities of types of PCMTP had growth that was, at most, minimally larger than that of the smaller hospitals, and vice-versa. Diversity is important operationally. From the perspective of delivering surgical care within a market, the unique contributions of each large teaching hospital performing many different types of PCMTP needs to be considered relative to the combined capabilities of other hospitals in its region.

Increased trends in the use of treatment-limiting decisions in a regional neurosurgical unit.

INTRODUCTION: Treatment-limiting decisions (TLDs) are employed to actively withhold treatment from patients whom clinicians feel would derive no benefit or suffer detrimental effects from further intervention. The use of such decisions has been heavily discussed in the media and clinicians in the past have been reluctant to institute them, even though it is in the best interests of the patients. Their use is influenced by several ethical, religious and social factors all of which have changed significantly over time. This study reports the trends in use of TLDs in a regional neurosurgical unit over 23 years. METHODS: Patient archives were reviewed to identify the number of admissions and procedures performed at the Institute of Neurological Sciences, Glasgow, in the years 1988, 1997 and 2011. Death certificate records were used to identify mortality in the unit in the year 2011. Patient records were used to obtain details of diagnosis, time from admission to death, and the presence and timing of a TLD. RESULTS: The results show an increase in the use of TLDs, with decisions made for 89% of those who died in 2011, compared to 68% in 1997 and 51% in 1988. The number of admissions has increased substantially since 1988 as has the percentage of patients undergoing surgery (46, 67 and 72% in 1988, 1997 and 2011, respectively). CONCLUSION: There is a trending increase in the number of patients who have a TLD in our regional neurosurgical unit. This demonstrates an increased willingness of clinicians to recognise poor prognosis and to withdraw or withhold treatment in these cases. Continued appropriate use of the TLD is recommended but it is to only ever reflect the best interests of the patient.

Ambulatory surgery centers and outpatient procedure use among Medicare beneficiaries.

BACKGROUND: There has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization. OBJECTIVE: To assess the impact of ASC opening on rates of outpatient surgery. DESIGN: This was a retrospective cohort study of Medicare beneficiaries undergoing outpatient surgery between 2001 and 2010. We compared population-based rates of outpatient surgery in Hospital Service Areas (HSAs) with freestanding ASCs to those without. After adjusting for differences using multiple propensity score methods, we assessed the impact of ASC opening in an HSA previously without one on rates of outpatient surgery. SUBJECTS: Patients included were Medicare beneficiaries with Part B eligibility. MAIN OUTCOME MEASURE: Adjusted HSA-level rates of outpatient surgery. RESULTS: Adjusted outpatient surgery rates increased from 2806 to 3940 per 10,000 and the number of ASC operating rooms grew from 7036 to 11,223 (both P<0.001 for trend). By the fourth year after opening, rates of outpatient surgery increased by 10.9% (from 3338 to 3701 per 10,000) in HSAs adding an ASC for the first time. In contrast, outpatient surgery rates grew by only 2.4% and 0.6% in HSAs where an ASC was always or never present, respectively (P<0.001 for test between 3 slopes). CONCLUSIONS: Rather than redistributing patients from one setting to another, the opening of ASCs increases outpatient surgery use. However, the 10.9% increase is more modest than previously suggested by state-level data.

Surgical services: shaping future directions.

BACKGROUND: Advances in surgical techniques and anaesthetic practise have facilitated a significant change in the way surgery is currently delivered. In particular, short stay surgery including ambulatory surgery has become the norm for the majority of surgical conditions. However, the planning of surgical services has not always kept pace with nor capitalised on these clinical advances. Like many major urban centres in Australia, the Greater Sydney region is changing, in terms of population growth and configuration of clinical and operational networks. In conjunction with NSW Department of Health, the ministerially appointed Surgical Services Taskforce was tasked with determining the shape and direction of surgery in Greater Sydney over the next 5 to 10 years. METHODS: Over 400 clinicians either attended hospitals forums or were contacted by the Surgery Futures project team. RESULTS: From the consultations, three models of service delivery were strongly advocated. These were the development of high volume short stay surgery centres, the establishment of specialty centres and the expansion of the streaming of planned and emergency surgery. CONCLUSION: These three major recommendations will require a significant reorganisation of surgical services in NSW. However, they are also relevant to surgical services planning elsewhere in Australia. It is imperative that these recommendations are incorporated into long term surgical planning in order to improve the efficiency and sustainability of surgical service delivery.

Barriers to accessing surgical care in Pakistan: healthcare barrier model and quantitative systematic review.

Inadequate access to surgical services results in increased morbidity and mortality from a spectrum of conditions in Pakistan. We employed a modification of Andersen's model of health services utilization and developed a 'Healthcare Barrier Model,' to characterize the barriers to accessing health care in developing countries, using surgical care in Pakistan as a case study. We performed a literature search from MEDLINE, EMBASE, CINAHL, SCOPUS, Global Health Database, and Cochrane Central Register of Controlled Trials, and selected 64 of 3113 references for analysis. Patient-related variables included age (elderly), gender (female), preferential use of alternative health providers (Hakeem, traditional healers, others), personal perceptions regarding disease and potential for treatment, poverty, personal expenses for healthcare, lack of social support, geographic constraints to accessing a health facility, and compromised general health status as it relates to the development of surgical disease. Environmental barriers include deficiencies in governance, the burden of displaced or refugee populations, and aspects of the medicolegal system, which impact treatment and referral. Barriers relating to the health system include deficiencies in capacity (infrastructure, physical resources, human resources) and organization, and inadequate monitoring. Provider-related barriers include deficiencies in knowledge and skills (and ongoing educational opportunities), delays in referral, deficient communication, and deficient numbers of female health providers for female patients. The Healthcare Barrier model addresses this broad spectrum of barriers and is designed to help formulate a framework of healthcare barriers. To overcome these barriers will require a multidisciplinary, multisectoral effort aimed at strengthening the health system.

[Current state of laparoscopic hepatic surgery: results of a survey of DGAV-members]. / Stand der laparoskopischen Leberchirurgie: Ergebnisse einer Umfrage der DGAV-Mitglieder.

BACKGROUND: To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008. MATERIALS AND METHODS: A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously. RESULTS: A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551). CONCLUSION: Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.

Neurosurgical center in Astana, capital of Kazakhstan.

Formation of the Republican Scientific Center of Neurosurgery (RSCN) in Astana, the new capital of Kazakhstan, has allowed improvements in neurosurgery in this country on a qualitatively new level. The latest achievements in neuro-oncologic, spine, pediatric, and vascular neurosurgery are available in the RSCN. The center has come into being as a result of dynamic economic development in Kazakhstan. The RSCN is ready to become a leading neurosurgical center in the central Asia region.

Strategic faculty recruitment increases research productivity within an academic university division.

BACKGROUND: Research is an important mandate for academic surgical divisions. However, there is widespread concern that the current health care climate is leading to a decline in research activity. A University of British Columbia (UBC) academic surgical division attempted to address this concern by strategically recruiting PhD research scientists to prioritize research and develop collaborative research programs. The objective of our study was to determine whether this strategy resulted in increased research productivity. METHODS: We reviewed the UBC Department of Surgery database to assess research funding obtained by the Division of General Surgery for the years 1994-2004. We searched MEDLINE for peer-reviewed publications by faculty members during this period. RESULTS: Research funding increased from a mean of Can$417,292 per year in the 5 years (1994/95-1998/99) before the recruitment of dedicated PhD scientists to a mean of Can$1.3 million per year in the 5 years following the recruitment strategy (1999/2000-2003/04; p = 0.012). Funding for the initial 5 years was Can$2.1 million, including 1 Canadian Institutes of Health Research (CIHR) grant. Funding increased to Can$6.8 million, including 22 CIHR grants over the subsequent 5 years (p < 0.001). Collaborative research led to the awarding of multidisciplinary grants exceeding Can$4 million with divisional members as principle or coprinciple investigators. From 1994/05 to 1998/99, the total number of peer-reviewed publications was 116 (mean 23.2, standard deviation [SD] 7 per year), increasing to 144 from 1999/2000 to 2003/04 (mean 28.8, SD 13 per year). The trend was for publications in journals with higher impact factors in the latter 5-year period. CONCLUSION: Strategic recruitment resulted in increased and sustained research productivity. Interactions between research scientists and clinicians resulted in successful program grant funding support. These results have implications for sustaining the research mission within academic departments of surgery.

Trends in emergency surgical admissions in a tertiary health centre in Nigeria.

BACKGROUND: In the past, elective surgery was the predominant in-patient workload of consultant surgeons. Recently, emergency cases are forming an increasing part of the in-patient workload. OBJECTIVE: The aim of this study was to appraise the rising incidence of emergency surgical admissions (EMA) as well as the factors associated with the change. METHODS: A retrospective review of surgical admissions in the Department of Surgery Ahmadu Bello University Teaching Hospital Zaria, Nigeria. Every third year from 1970 to 2000 was selected giving a total of 10 years for review. Details of all surgical admissions were analysed including age and sex of the patients, incidence of the most common primary diagnoses, proportion of patients having operation during their emergency admission, duration of hospital stay and mortality. RESULTS: Overall, 19,436 emergency and 19,528 elective surgical admissions (ELA) were made. The ratio of EMA to ELA per 100,000 catchment's area population rose from 1:1.6 in 1973 to 1.4:1 in 2000. Between 1995 and 2000, the rise in EMA was 8.0% per year compared to 1.5% rise in ELA. About 30% of ELA were cancelled due to factors related to EMA. Rising incidence of appendicitis, acute infections and trauma accounted for most of the increase in EMA. Operations during EMA increased from 35.3% in 1973 to 45.0% in 2000. Postoperative mortality remained at about 6.0% CONCLUSION: Emergency surgical admissions have increased and now exceed elective admissions. This has placed considerable strain on our limited resources and our ability to cope with increasing demand of elective surgery.

Hospital discharges in New Zealand 1991-2005: changes over time and variation between districts.

AIM: This paper describes changes in the rate of hospital discharges in New Zealand between 1991 and 2006, and assesses variation across districts; it contributes to the discussion of the adequacy of the health system. METHODOLOGY: Data on public hospital discharges were obtained from the NZ Health Information Service. Diagnostic Related Groups were used to group and weight cases; domiciliary codes were used to assign cases to districts and as an indication of patients' socioeconomic status. The Intervention Ratio was used as a relative measure of national hospital throughput from 1991 to 2005, and of district service volume. The Coefficient of Variation was used as a measure of overall system variation. RESULTS: There has been an increase of 50.5% in weighted discharges from public hospitals between 1991/2 and 2005/6; adjusted for population change the increase is 17.9%. There has been a modest fall in the degree of variation between districts, but in medicine and surgery 24% of district departments appear to have levels of discharge significantly above or below the national average. CONCLUSIONS: The intensity of public hospital care to the New Zealand public has increased. Where services are provided at a level above or below the national average, local explanations should be sought and corrective action undertaken if warranted.

Endovascular technology, hospital volume, and mortality with abdominal aortic aneurysm surgery.

OBJECTIVE: To determine whether the introduction of endovascular technology changed the relationship of hospital volume to mortality with abdominal aortic aneurysm repair. METHODS: Data from all hospitals in the United States that performed abdominal aortic aneurysm surgery on Medicare patients from 2001 to 2003 were obtained from the national Medicare database. The primary outcome variable was death

Status of trauma and acute care surgery in the United States.

Acute Care Surgery (ACS) is an evolving specialty. The components, as defined by the American Association for the Surgery of Trauma are trauma, surgical critical care and emergency surgery. As documented by the recent reports from the Institute of Medicine, the shortage of surgical specialists who make themselves available for emergency care in the United States, the overcrowding of emergency departments and lack of surge capacity are reaching crisis conditions. The Institute of Medicine has recommended the development of regional centers of surgical specialists, analogous to trauma systems. The training of surgeons in ACS will address the manpower issue to some degree.

Current status and future options for trauma and emergency surgery in Europe.

Currently, there is great variation in the way trauma and non-trauma emergency surgery is organized in Europe. Trauma system development based on orthopedic trauma surgery seems to be more advanced in the central European countries and less developed in Scandinavia, The Baltic States, United Kingdom and the Mediterranean countries. Specific training for trauma surgery correlates with higher level of trauma system development. Multiple common features in the management of a surgical emergency, whether caused by injury or acute disease process, would favor the integration of these two disciplines into a single organizational and educational entity based on regionalization of emergency surgical services and general surgery-based education aiming for multidisciplinary team leadership and decision making skills, and surgical competence in acute life- and limb-saving surgery.

Current status and future options for trauma and emergency surgery in Turkey.

The number of trauma victims in Turkey is expected to increase as a consequence of the increasing vehicular traffic, potential for earthquakes, and risk of terrorist attacks. The Turkish Association for Trauma and Emergency Surgery monitors trauma cases, publishes a quarterly journal, organizes trauma courses and seminars for various health personnel nationwide. It is also extending efforts to improve in-hospital care by establishing trauma and emergency surgery fellowships and trauma and emergency surgery centers nationwide, which is run by General Surgeons currently. Turkey faces the same dilemma as the rest of the developed world regarding the future of trauma surgeons in the current era of nonoperative trauma management. We suggest that the field of trauma and emergency surgery be redefined to include emergency general surgery and cavitary trauma.

Free-standing ambulatory surgery centers and hospital surgery volume.

This paper examines the association of free-standing ambulatory surgery centers (ASCs) with hospital surgery volume, using data from the 2002 Medicare Online Survey Certification and Reporting System and the American Hospital Association Annual Surveys of Hospitals. From 1993 to 2001, the number of ASCs per 100,000 population in metropolitan statistical areas (MSAs) increased by 150%. During the same period, hospital outpatient surgeries increased 28%, while inpatient surgeries decreased by 4.5%. MSA and year fixed-effects regression analyses suggest that an increase of one ASC per 100,000 people was associated with a 4.3% reduction in hospital outpatient surgical volume, but was not associated with inpatient surgical volume.