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1.
Am J Manag Care ; 27(10): e355-e360, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34668678

RESUMO

OBJECTIVES: To compare the use of top-ranked cancer hospitals for complex cancer surgery between Medicare Advantage (MA) and traditional Medicare fee-for-service (FFS) enrollees. STUDY DESIGN: Cross-sectional analysis of Medicare claims and enrollment data. METHODS: The study used Medicare Provider Analysis and Review files to compare differences in use of top-ranked cancer hospitals for complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and the Whipple procedure [pancreaticoduodenectomy]) between MA and FFS enrollees 65 years and older who underwent the surgery in 2015 to 2017. RESULTS: After adjusting for demographic characteristics and county fixed effects, MA enrollees were less likely to use top-ranked cancer hospitals than FFS enrollees by 6.0 percentage points (95% CI, 4.7-7.2) overall; the difference varied from 3.5 percentage points (95% CI, 2.5-4.6) for colectomy to 14.3 percentage points (95% CI, 10.9-17.8) for the Whipple procedure. The difference in cancer surgery rate at a top-ranked cancer hospital between MA and FFS enrollees was larger for MA plans without out-of-network (OON) benefits (-7.5 percentage points; 95% CI, -9.1 to -5.9) than for MA plans with OON benefits (-2.3 percentage points; 95% CI, -2.9 to -1.7). CONCLUSIONS: MA enrollees were less likely to use top-ranked cancer hospitals for complex cancer surgery than FFS enrollees. This difference was larger for MA plans with more restrictive OON policies. These findings suggest that MA enrollees, particularly those with lower OON benefits, may have restricted access to top-ranked hospitals for cancer care compared with FFS enrollees.


Assuntos
Medicare Part C , Neoplasias , Idoso , Institutos de Câncer , Estudos Transversais , Planos de Pagamento por Serviço Prestado , Hospitais , Humanos , Neoplasias/cirurgia , Estados Unidos
2.
Ann Surg ; 274(4): e315-e319, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34506325

RESUMO

OBJECTIVE: To determine how Medicare Advantage (MA) health plan networks impact access to high-volume hospitals for cancer surgery. BACKGROUND: Cancer surgery at high-volume hospitals is associated with better short- and long-term outcomes. In the United States, health insurance is a major detriment to seeking care at high-volume hospitals. A third of older (>65 years) Americans are enrolled in privatized MA health plans. The impact of MA plan networks on access to high-volume surgery hospitals is unknown. METHODS: We analyzed in-network hospitals for MA plans offered in Los Angeles county during open enrollment of 2015. For the purposes of this analysis, MA network data from provider directories were linked to hospital volume data from California Office of Statewide Health Planning and Development. Volume thresholds were based on published literature. RESULTS: A total of 34 MA plans enrolled 554,754 beneficiaries in Los Angeles county during 2014 open enrollment for coverage starting in 2015 (MA penetration ∼43%). The proportion of MA plans that included high-volume cancer surgery hospital varied by the type of cancer surgery. While most plans (>71%) included at least one high-volume hospital for colon, rectum, lung, and stomach; 59% to 82% of MA plans did not include any high-volume hospitals for liver, esophagus, or pancreatic surgery. A significant proportion of beneficiaries in MA plans did not have access to high-volume hospitals for esophagus (93%), stomach (44%), liver (39%), or pancreas (70%) surgery. In contrast, nearly all MA beneficiaries had access to at least one high-volume hospital for lung (93%), colon (100%), or rectal (100%) surgery. Overall, Centers for Medicare & Medicaid Services plan rating or plan popularity were not correlated with access to high-volume hospital (P > 0.05). CONCLUSIONS: The study identifies lack of high-volume hospital coverage in MA health plans as a major detriment in regionalization of cancer surgery impacting at least a third of older Americans.


Assuntos
Acesso aos Serviços de Saúde/organização & administração , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Medicare Part C/organização & administração , Neoplasias/cirurgia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Utilização de Instalações e Serviços , Feminino , Humanos , Masculino , Neoplasias/epidemiologia , Neoplasias/patologia , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Estados Unidos
3.
Medicine (Baltimore) ; 100(35): e26752, 2021 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-34477115

RESUMO

ABSTRACT: To describe the outcomes of elective cancer surgeries and adverse consequences on the patients and medical staff due to the surgical interventions in children during the Coronavirus Disease 2019 (COVID-19) pandemic.The study included children younger than 15 years who underwent elective cancer surgeries from March 4, 2020 and December 3, 2020.A total of 121 patients (62% male; median age, 3 years) underwent surgery. The surgical procedures included nephrectomies (n = 18), neuroblastoma (n = 26) and soft tissue tumor resections (n = 24) and complex surgical procedures like extended liver resections (n = 2), intra-atrial thrombectomy under cardiopulmonary bypass (n = 2), pancreatoduodenectomy (n = 1), and free microvascular flaps (n = 7). Clavien-Dindo Grade III complications were 5% (n = 6), and there were no postoperative deaths. Preoperative COVID-19 testing was performed in 82% of children, and only 2% showed severe acute respiratory syndrome coronavirus 2 positivity. Postoperatively, 26 children were tested because of specific symptoms and, 6 tested positive for severe acute respiratory syndrome coronavirus 2. Except for a median delay of 23 days in treatment, none of the patients with COVID-19 required critical hospital management. None of the surgical residents or faculty acquired COVID-19, while 4 each medical and support staff were tested positive in the study period.COVID-19 was not a deterrent for continued cancer care, and surgeries could be safely performed adopting universal preventive measures without any added morbidity from COVID-19. Caregivers and centers dealing with childhood cancers can be encouraged to sustain or seek early healthcare.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Neoplasias/cirurgia , Adolescente , COVID-19/diagnóstico , COVID-19/epidemiologia , Criança , Pré-Escolar , Feminino , Humanos , Índia/epidemiologia , Lactente , Masculino , Pandemias , Estudos Retrospectivos , SARS-CoV-2 , Centros de Atenção Terciária/estatística & dados numéricos
4.
Ann Surg Oncol ; 28(12): 7566-7574, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33895902

RESUMO

INTRODUCTION: While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined. OBJECTIVE: The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery. METHODS: The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon's integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined. RESULTS: Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p < 0.001]. On multivariable analysis, patients residing in low integration areas had higher odds of complications [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.11], extended LOS (OR 1.13, 95% CI 1.09-1.18), and 90-day mortality (OR 1.29, 95% CI 1.22-1.38) and, in turn, lower odds of achieving a TO (OR 0.87, 95% CI 0.84-0.90) versus patients from highly integrated communities. CONCLUSION: Patients who resided in counties with a lower integration index were less likely to have an optimal TO following resection of cancer compared with patients who resided in more integrated counties. The data highlight the importance of increasing residential racial diversity and integration as a means to improve patient outcomes.


Assuntos
Medicare , Neoplasias , Idoso , Humanos , Tempo de Internação , Neoplasias/cirurgia , Pancreatectomia , Período Pós-Operatório , Estados Unidos/epidemiologia
7.
Ann Surg Oncol ; 28(11): 6525-6534, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33748892

RESUMO

BACKGROUND: The impact of depression on utilization of post-discharge care and overall episode of care expenditures remains poorly defined. We sought to define the impact of depression on postoperative outcomes, including discharge disposition, as well as overall expenditures associated with the global episode of surgical care. METHOD: The Medicare 100% Standard Analytic Files were used to identify patients undergoing resection for esophageal, colon, rectal, pancreatic, and liver cancer between 2013 and 2017. The impact of depression on inpatient outcomes, as well as home health care and skilled nursing facilities utilization and expenditures, was analyzed. RESULTS: Among 113,263 patients, 14,618 (12.9%) individuals had depression. Patients with depression were more likely to experience postoperative complications (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.31-1.42), extended length of stay (LOS) (OR 1.41, 95% CI 1.36-1.47), readmission within 90 days (OR 1.20, 95% CI 1.14-1.25), as well as 90-day mortality (OR 1.35, 95% CI 1.27-1.42) (all p < 0.05). In turn, the proportion of patients who achieved a textbook outcome following cancer surgery was lower among patients with depression (no depression: 53.3% vs. depression: 45.3%; OR 0.70, 95% CI 0.68-0.73). Patients with a preexisting diagnosis of depression had higher odds of additional post-discharge expenditures compared with individuals without a diagnosis of depression (OR 1.42; 95% CI 1.35-1.50); patients with a preexisting diagnosis of depression ($10,500, IQR $3,200-$22,500) had higher median post-discharge expenditures versus patients without depression ($6600, IQR $2100-$17,400) (p < 0.001). On multivariable analysis, after controlling for other factors, depression remained associated with a 19.0% (95% confidence interval [CI] 15.7-22.3%) increase in post-discharge expenditures. CONCLUSIONS: Patients with depression undergoing resection for cancer had worse in-patient outcomes and were less likely to achieve a TO. Patients with depression were more likely to require post-discharge care and had higher post-discharge expenditures.


Assuntos
Assistência ao Convalescente , Neoplasias , Idoso , Depressão/etiologia , Gastos em Saúde , Humanos , Medicare , Neoplasias/complicações , Neoplasias/cirurgia , Alta do Paciente , Readmissão do Paciente , Estudos Retrospectivos , Estados Unidos/epidemiologia
8.
Int J Cancer ; 149(3): 635-645, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33739453

RESUMO

Inadequate margins continue to occur frequently in patients who undergo surgical resection of a tumor, suggesting that current intraoperative methods are not sufficiently reliable in determining the margin status. This clinical demand has inspired the development of many novel imaging techniques that could help surgeons with intraoperative margin assessment. This systematic review provides an overview of novel imaging techniques for intraoperative margin assessment in surgical oncology, and reports on their technical properties, feasibility in clinical practice and diagnostic accuracy. PubMed, Embase, Web of Science and the Cochrane library were systematically searched (2013-2018) for studies reporting on imaging techniques for intraoperative margin assessment. Patient and study characteristics, technical properties, feasibility characteristics and diagnostic accuracy were extracted. This systematic review identified 134 studies that investigated and developed 16 groups of techniques for intraoperative margin assessment: fluorescence, advanced microscopy, ultrasound, specimen radiography, optical coherence tomography, magnetic resonance imaging, elastic scattering spectroscopy, bio-impedance, X-ray computed tomography, mass spectrometry, Raman spectroscopy, nuclear medicine imaging, terahertz imaging, photoacoustic imaging, hyperspectral imaging and pH measurement. Most studies were in early developmental stages (IDEAL 1 or 2a, n = 98); high-quality stage 2b and 3 studies were rare. None of the techniques was found to be clearly superior in demonstrating high feasibility as well as high diagnostic accuracy. In conclusion, the field of imaging techniques for intraoperative margin assessment is highly evolving. This review provides a unique overview of the opportunities and limitations of the currently available imaging techniques.


Assuntos
Imageamento por Ressonância Magnética/métodos , Margens de Excisão , Neoplasias/patologia , Neoplasias/cirurgia , Oncologia Cirúrgica , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodos , Humanos , Neoplasias/diagnóstico por imagem , Prognóstico
9.
World Neurosurg ; 151: e28-e36, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33722718

RESUMO

OBJECTIVE: The Council of State Neurosurgical Societies surveyed neurosurgeons applying for oral board certification in 2008 to assess their preparedness to practice. This survey was repeated in 2013 for a subsequent group of board applicants to evaluate the quality of neurosurgery training and identify opportunities for improvement. METHODS: Applicants for the American Board of Neurological Surgeons oral examination from 2008 to 2013 were provided an anonymous survey focused on clinical and socioeconomic skills. Survey responses were compared with the published results of a similar survey using an inferential statistical analysis. RESULTS: In total, 110 of 655 neurosurgeons responded (response rate 16.8%). Significantly more respondents from the 2013 survey felt prepared to perform the following techniques: angiography, endoscopic surgery, anterior lumbar interbody fusion, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion, kyphoplasty, and deep brain stimulation. Significantly more respondents in 2013 attested to receiving appropriate education on Health Insurance Portability and Accountability Act and pay-for-performance practice models of health care. However, significantly fewer respondents in 2013 felt prepared in open vascular neurosurgery techniques. In both surveys, fewer than 35% of respondents felt adequately prepared in endovascular neurosurgery techniques, medical coding, negotiating an employment contract, and issues regarding practice management and the economics of neurosurgery. CONCLUSIONS: The 2013 survey suggests that candidates for board certification in neurosurgery perceive themselves to be adequately prepared to independently perform nearly all neurosurgical procedures. However, additional work is required to optimize neurosurgery training in endovascular procedures and the socioeconomic aspects of neurosurgery practice.


Assuntos
Economia Médica , Internato e Residência , Neurocirurgia/educação , Certificação , Competência Clínica , Epilepsia/cirurgia , Humanos , Neoplasias/cirurgia , Neurocirurgiões/educação , Procedimentos Neurocirúrgicos , Pediatria/educação , Coluna Vertebral/cirurgia , Inquéritos e Questionários , Estados Unidos , Procedimentos Cirúrgicos Vasculares
10.
JCO Glob Oncol ; 7: 435-442, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33788595

RESUMO

PURPOSE: Limited access to adequate cancer surgery training is one of the driving forces behind global inequities in surgical cancer care. Affordable virtual reality (VR) surgical training could enhance surgical skills in low- and middle-income settings, but most VR and augmented reality systems are too expensive and do not teach open surgical techniques commonly practiced in these contexts. New low-cost VR can offer skill development simulations relevant to these settings, but little is known about how knowledge is gained and applied by surgeons training and working in specific resource-constrained settings. This study addresses this gap, exploring gynecologic oncology trainee learning and user experience using a low-cost VR simulator to learn to perform an open radical abdominal hysterectomy in Lusaka, Zambia. METHODS: Eleven surgical trainees rotating through the gynecologic oncology service were sequentially recruited from the University Teaching Hospital in Lusaka to participate in a study evaluating a VR radical abdominal hysterectomy training designed to replicate the experience in a Zambian hospital. Six participated in semi-structured interviews following the training. Interviews were analyzed using open and axial coding, informed by grounded theory. RESULTS: Simulator participation increased participants' perception of their surgical knowledge, confidence, and skills. Participants believed their skills transferred to other related surgical procedures. Having clear goals and motivation to improve were described as factors that influenced success. CONCLUSION: For cancer surgery trainees in lower-resourced settings learning medical and surgical skills, even for those with limited VR experience, low-cost VR simulators may enhance anatomical knowledge and confidence. The VR simulator reinforced anatomical and clinical knowledge acquired through other modalities. VR-enhanced learning may be particularly valuable when mentored learning opportunities are limited.


Assuntos
Neoplasias , Realidade Virtual , Competência Clínica , Simulação por Computador , Feminino , Humanos , Aprendizagem , Neoplasias/cirurgia , Zâmbia
11.
JCO Glob Oncol ; 7: 311-323, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33617304

RESUMO

PURPOSE: There has been noteworthy concern about the impact of COVID-19 pandemic on health services including the management of cancer. In addition to being considered at higher risk for worse outcomes from COVID-19, people with cancer may also experience disruptions or delays in health services. This systematic review aimed to identify the delays and disruptions to cancer services globally. METHODS: This is a systematic review with a comprehensive search including specific and general databases. We considered any observational longitudinal and cross-sectional study design. The selection, data extraction, and methodological assessment were performed by two independent reviewers. The methodological quality of the studies was assessed by specific tools. The delays and disruptions identified were categorized, and their frequency was presented. RESULTS: Among the 62 studies identified, none exhibited high methodological quality. The most frequent determinants for disruptions were provider- or system-related, mainly because of the reduction in service availability. The studies identified 38 different categories of delays and disruptions with impact on treatment, diagnosis, or general health service. Delays or disruptions most investigated included reduction in routine activity of cancer services and number of cancer surgeries; delay in radiotherapy; and delay, reschedule, or cancellation of outpatient visits. Interruptions and disruptions largely affected facilities (up to 77.5%), supply chain (up to 79%), and personnel availability (up to 60%). CONCLUSION: The remarkable frequency of delays and disruptions in health care mostly related to the reduction of the COVID-19 burden unintentionally posed a major risk on cancer care worldwide. Strategies can be proposed not only to mitigate the main delays and disruptions but also to standardize their measurement and reporting. As a high number of publications continuously are being published, it is critical to harmonize the upcoming reports and constantly update this review.


Assuntos
COVID-19 , Atenção à Saúde/métodos , Neoplasias/terapia , Assistência Ambulatorial , Estudos Transversais , Atenção à Saúde/organização & administração , Atenção à Saúde/estatística & dados numéricos , Humanos , Neoplasias/radioterapia , Neoplasias/cirurgia
12.
Ann R Coll Surg Engl ; 103(3): 173-179, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33557703

RESUMO

INTRODUCTION: With the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic. MATERIALS AND METHODS: A protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 'clean' site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff. RESULTS: A total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive. CONCLUSION: This study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.


Assuntos
Procedimentos Cirúrgicos Eletivos/métodos , Neoplasias/cirurgia , Procedimentos Cirúrgicos Operatórios/métodos , Tempo para o Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/métodos , Derivação Arteriovenosa Cirúrgica , COVID-19 , Teste de Ácido Nucleico para COVID-19 , Cateterismo Cardíaco , Atenção à Saúde/organização & administração , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Histerectomia , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , SARS-CoV-2 , Reino Unido/epidemiologia , Procedimentos Cirúrgicos Urológicos , Adulto Jovem
13.
In Vivo ; 35(2): 1065-1071, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33622903

RESUMO

BACKGROUND/AIM: Postoperative complications have a tremendous impact on in-hospital costs. The novel Comprehensive Complication Index® (CCI®) summarizes all complications together and is more sensitive than existing morbidity endpoints. The purpose of this study was to assess the correlation of CCI® with in-hospital costs and externally validate a novel cost prediction calculator. PATIENTS AND METHODS: This was a prospective study including consecutive patients undergoing elective major hepatopancreaticobiliary (HPB) surgery for malignancy at a London tertiary referral hospital. A priori sample size and post-hoc power calculations were performed. RESULTS: Thirty patients were included in the analysis, 14 were female, and the median age was 67 [interquartile range (IQR)=54-74] years. The median Charlson Comorbidity Index was 6 (IQR=5-8). Eighteen patients underwent liver, 9 pancreatic surgery and three a palliative bypass; 11 patients had a major complication (≥grade 3a) according to the Clavien-Dindo classification. The median CCI® was 30.2 (IQR=12.18-39.5). The mean cost per case was 13,908 (SD=4,600) GBP. There was no correlation between the Charlson Comorbidity Index or age with actual cost. However, there was very good correlation of actual cost with the CCI® (r=0.77, 95% confidence interval=0.57-0.89, p<0.001) as well as with the predicted cost (Clavien Cost Prediction Calculator) (r=0.70, 95% confidence interval=0.44-0.85, p<0.001). CONCLUSION: These findings support the hypothesis that complications are the most important predictor of overall cost in the setting of elective major HPB surgery for malignancy. Furthermore, CCI® and the novel Cost Prediction Calculator can be used in this setting to accurately predict costs using no additional resources.


Assuntos
Efeitos Psicossociais da Doença , Neoplasias , Idoso , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos
14.
J Am Coll Surg ; 232(4): 351-359, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33508426

RESUMO

BACKGROUND: The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer. METHODS: Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression. RESULTS: Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05). CONCLUSIONS: Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.


Assuntos
Medicare/estatística & dados numéricos , Grupos Minoritários/estatística & dados numéricos , Neoplasias/cirurgia , Complicações Pós-Operatórias/epidemiologia , Populações Vulneráveis/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Humanos , Incidência , Masculino , Neoplasias/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos/epidemiologia
15.
Lancet Oncol ; 22(2): 182-189, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33485458

RESUMO

BACKGROUND: The growing demand for cancer surgery has placed a global strain on health systems. In-depth analyses of the global demand for cancer surgery and optimal workforce requirements are needed to plan service provision. We estimated the global demand for cancer surgery and the requirements for an optimal surgical and anaesthesia workforce, using benchmarks based on clinical guidelines. METHODS: Using models of benchmark surgical use based on clinical guidelines, we estimated the proportion of cancer cases with an indication for surgery across 183 countries, stratified by income group. These proportions were multiplied by age-adjusted national estimates of new cancer cases using GLOBOCAN 2018 data and then aggregated to obtain the estimated number of surgical procedures required globally. The numbers of cancer surgical procedures in 44 high-income countries were divided by the actual number of surgeons and anaesthetists in the respective countries to calculate cancer procedures per surgeon and anaesthetist ratios. Using the median (IQR) of these ratios as benchmarks, we developed a three-tiered optimal surgical and anaesthesia workforce matrix, and the predictions were extrapolated up to 2040. FINDINGS: Our model estimates that the number of cancer cases globally with an indication for surgery will increase by 5 million procedures (52%) between 2018 (9 065 000) and 2040 (13 821 000). The greatest relative increase in surgical demand will occur in 34 low-income countries, where we also observed the largest gaps in workforce requirements. To match the median benchmark for high-income countries, the surgical workforce in these countries would need to increase by almost four times and the anaesthesia workforce by nearly 5·5 times. The greatest increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries (from 28 000 surgeons to 58 000 surgeons; 107% increase), followed by lower-middle-income countries (from 166 000 surgeons to 277 000 surgeons; 67% increase). INTERPRETATION: The global demand for cancer surgery and the optimal workforce are predicted to increase over the next two decades and disproportionately affect low-income countries. These estimates provide an appropriate framework for planning the provision of surgical services for cancer worldwide. FUNDING: University of New South Wales Scientia Scholarship and UK Research and Innovation Global Challenges Research Fund.


Assuntos
Anestesia/tendências , Planos de Sistemas de Saúde/tendências , Mão de Obra em Saúde/tendências , Neoplasias/cirurgia , Anestesia/economia , Atenção à Saúde/economia , Atenção à Saúde/tendências , Saúde Global/economia , Planos de Sistemas de Saúde/economia , Mão de Obra em Saúde/economia , Humanos , Renda , Neoplasias/economia , Neoplasias/epidemiologia , Cirurgiões/economia
16.
Lancet Oncol ; 22(2): 173-181, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33485459

RESUMO

BACKGROUND: Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model. METHODS: We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006-12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations. FINDINGS: Surgical treatment was indicated in 58% (95% CI 57-59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17-27) for prostate cancer to 99% (96-99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (-14%). INTERPRETATION: The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences. FUNDING: University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.


Assuntos
Países Desenvolvidos/economia , Neoplasias Embrionárias de Células Germinativas/economia , Neoplasias/economia , Neoplasias Testiculares/economia , Austrália/epidemiologia , Benchmarking/economia , Canadá/epidemiologia , Gerenciamento de Dados , Guias como Assunto/normas , Humanos , Neoplasias/epidemiologia , Neoplasias/cirurgia , Neoplasias Embrionárias de Células Germinativas/epidemiologia , Neoplasias Testiculares/epidemiologia , Reino Unido/epidemiologia
17.
Eur J Surg Oncol ; 47(4): 896-901, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33036830

RESUMO

BACKGROUND: We aimed to evaluate the potential utility of the Robinson Frailty Score (RFS), the Edmonton Frail Scale (EFS), and the G8 tool for predicting postoperative adverse events (AEs) in older adults with cancer. METHODS: We included consecutive older adults evaluated at geriatric oncology service before undergoing oncologic surgery between September 2018 and December 2019. The RFS measures cognition, function, falls, comorbidity, albumin, and hematocrit. The EFS evaluates cognition, function, incontinence, self-perceived health, mood, nutrition, polypharmacy, and social support. These scales classify patients into three frailty categories (fit, pre-frail, or frail). The G8 score was dichotomized at a cut-off value of 14. The primary outcome was composite AEs including 30-day postoperative complications (≥Clavien-Dindo grade II) and discharge to an institutional care facility. The severity of surgery was assessed using the Operative Stress Score (OSS). RESULTS: Among 114 patients (median age 80 years, range 72-96 years), the main surgery types were gastrointestinal (62%), and head and neck (20%). Using the OSS, surgical procedures were classified as very low to low-stress (9%), moderate-stress (31%), high-stress (46%), and very high-stress (15%). Forty-five patients (40%) experienced postoperative AEs. After adjusting for the OSS, preoperative RFS was significantly associated with AEs (fit: 25%, pre-frail: 49%, frail: 77%; p < 0.01). However, the EFS (fit: 30%, pre-frail: 37%, frail: 60%; p = 0.14) and the G8 tool (score >14: 17%, score ≤14: 41%; p = 0.07) were not significantly associated with the risk of AEs. CONCLUSION: The RFS is predictive of postoperative AEs in older adults undergoing elective surgery for cancer.


Assuntos
Fragilidade/complicações , Fragilidade/diagnóstico , Avaliação Geriátrica/métodos , Neoplasias/cirurgia , Complicações Pós-Operatórias/etiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Indicadores Básicos de Saúde , Humanos , Masculino , Neoplasias/complicações , Alta do Paciente , Período Pré-Operatório , Procedimentos Cirúrgicos Operatórios/efeitos adversos
18.
Ann Surg Oncol ; 28(3): 1298-1310, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32789531

RESUMO

BACKGROUND: Functional outcomes are central to decision-making by older adults (OA), but long-term risks after cancer surgery have not been described beyond 1 year for this population. This study aimed to evaluate long-term health care support needs by examining homecare use after cancer surgery for OA. METHODS: This population-based study investigated adults 70 years of age or older with a new cancer diagnosis between 2007 and 2017 who underwent resection. The outcomes were receipt and intensity of homecare from postoperative discharge to 5 years after surgery. Time-to-event analysis with competing events was used. RESULTS: Among 82,037 patients, homecare use was highest (43.7% of eligible patients) in postoperative month 1. The need for homecare subsequently decreased to stabilize between year 1 (13.9%) and year 5 (12.6%). Of the patients not receiving preoperative homecare, 10.9% became long-term users at year 5 after surgery. Advancing age, female sex, frailty, high-intensity surgery, more recent period of surgery, and receipt of preoperative homecare were associated with increased hazards of postoperative homecare. Intensity of homecare went from 10.3 to 10.1 days per patient-month between month 1 and year 1, reaching 12 days per patient-month at year 5. The type of homecare services changed from predominantly nursing care in year 1 (51.9%) to increasing personal support services from year 2 (69.6%) to year 5 (77.5%). CONCLUSION: Receipt of homecare increased long-term after cancer surgery for OA, peaking in the first 6 months and plateauing thereafter at a new baseline. One tenth of the patients without preoperative homecare became long-term homecare users postoperatively, indicating changing health care needs focused on personal support services from year 2 to year 5.


Assuntos
Serviços de Assistência Domiciliar , Neoplasias , Fatores Etários , Idoso , Atenção à Saúde , Feminino , Humanos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Neoplasias/cirurgia , Cuidados Paliativos , Alta do Paciente , Cuidados Pós-Operatórios
19.
Eur J Surg Oncol ; 47(3 Pt A): 519-523, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32753116

RESUMO

Physiological and mental reserve decreases with age and the ability to mount a response to a stress like surgery can represent a burden to the frail and sarcopenic patient. It is necessary to evaluate the cardiorespiratory capacity and muscle strength before surgery in the older persons and prepare adequately to the same extent the marathon runner prepares before a full marathon. Assessment and stratification of risk are necessary for decision-making, but also for planning interventions aimed at improving the functional and emotional status in anticipation of surgery. Prehabilitation can improve the physiological reserve by optimizing cardiorespiratory capacity, muscle strength, and mental resiliency. Patients with low reserve and chronic medical conditions at high risk can benefit.


Assuntos
Idoso Fragilizado , Avaliação Geriátrica , Neoplasias/cirurgia , Cuidados Pré-Operatórios , Exercício Pré-Operatório , Atividades Cotidianas , Idoso , Transtornos Cognitivos , Comorbidade , Humanos , Estado Nutricional , Polimedicação , Complicações Pós-Operatórias/prevenção & controle , Medição de Risco
20.
Surgery ; 169(3): 573-579, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33189365

RESUMO

BACKGROUND: We sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer. METHODS: Standard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition. RESULTS: Among 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio = 0.83, 95% confidence interval: 0.76-0.89), prolonged duration of stay (odds ratio = 0.89, 95% confidence interval: 0.82-0.97), and higher odds of experiencing textbook outcome (odds ratio = 1.12, 95% confidence interval: 1.06-1.19). Patients undergoing surgery for lung (odds ratio = 1.19, 95% confidence interval: 1.10-1.30) and pancreatic cancer (odds ratio = 1.37, 95% confidence interval: 1.21-1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio = 1.16, 95% confidence interval: 0.90-1.48) or rectal cancer (odds ratio = 1.11, 95% confidence interval: 0.98-1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes. CONCLUSION: Quality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.


Assuntos
Cirurgia Geral , Hospitais/normas , Benefícios do Seguro/estatística & dados numéricos , Medicare/estatística & dados numéricos , Neoplasias/epidemiologia , Idoso , Feminino , Pesquisas sobre Serviços de Saúde , Ambiente de Instituições de Saúde , Humanos , Masculino , Oncologia , Pessoa de Meia-Idade , Neoplasias/cirurgia , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Padrões de Prática Médica , Estados Unidos
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