A Mixed-Methods Evaluation of Patient Education Materials for Colorectal Cancer.

BACKGROUND: Patient education materials are created by professional organizations to inform patients about their disease and its treatment. However, it remains unclear if these materials are appropriate for patients. OBJECTIVE: This study aims to broadly evaluate the education materials for patients with colorectal cancer. DESIGN: Patient education materials from the National Comprehensive Cancer Network, the National Cancer Institute, and the American Society of Colon and Rectal Surgeons were assessed quantitatively by using 1) the Flesch-Kincaid readability formula and 2) the Patient Education Material Assessment Tool. The Patient Education Material Assessment Tool scores materials in 2 domains: understandability and actionability. These materials were further evaluated qualitatively via an exploratory focus group with patients and their caregivers (n = 5) and semi-structured interviews with board-certified/eligible colorectal surgeons (n = 10). SETTING: This study was conducted at academic centers and a regional professional society meeting. PARTICIPANTS: The mean patient age was 63. Most surgeons (8/10) practiced in an academic setting, and 4/10 were female. MAIN OUTCOME MEASURES: The primary outcomes measured were reading grade level and domain scores for the Patient Education Material Assessment Tool. Qualitative data were recorded, transcribed, and coded. Themes were generated through data interpretation and data reduction. RESULTS: Materials ranged from 7th to 11th grade reading level. National Comprehensive Cancer Network materials scored highest for understandability (92.2% ± 6.1%, mean ± SD), followed by National Cancer Institute (84.0% ± 6.6%) and American Society of Colon and Rectal Surgeons (82.2% ± 6.3%) materials. Actionability scores varied; the National Comprehensive Cancer Network materials scored 82.5% ± 1.7%, whereas the National Cancer Institute and American Society of Colon and Rectal Surgeons materials scored 23.3% ± 6.7% and 50.0% ± 8.2%. Critical gaps were identified in the content of these materials. Patients wanted more information about self-care, both emotional and physical. Specifically, patients sought details about postoperative bowel function. Whereas surgeons wanted information about the typical hospital course and recovery, all wanted materials to be customizable. LIMITATIONS: A limited number of materials were reviewed, and patient focus groups were exploratory. CONCLUSIONS: Commonly available printed education materials for colorectal cancer are written at a high reading grade level, vary in their usability, and neglect important details about postoperative recovery. See Video Abstract at http://links.lww.com/DCR/B535. EVALUACIN DE MTODOS MIXTOS DE MATERIALES EDUCATIVOS PARA PACIENTES SOBRE CNCER COLORECTAL: ANTECEDENTES:Los materiales educativos para pacientes son creados por organizaciones profesionales para informar a los pacientes sobre su enfermedad y su tratamiento. Sin embargo, no está claro si estos materiales son apropiados para los pacientes.OBJETIVO:Evaluar ampliamente los materiales para el cáncer colorrectal.DISEÑO:Los materiales educativos para pacientes de la Red Nacional Integral del Cáncer (NCCN), el Instituto Nacional del Cáncer (NCI) y la Sociedad Americana de Cirujanos de Colon y Recto (ASCRS) se evaluaron cuantitativamente utilizando (1) la fórmula de legibilidad de Flesch-Kincaid y (2) la herramienta de evaluación de material educativo para pacientes. La Herramienta de evaluación de materiales educativos para pacientes califica los materiales en dos dominios: comprensibilidad y viabilidad. Estos materiales fueron evaluados cualitativamente a través de un grupo de enfoque exploratorio con pacientes y sus cuidadores (n = 5) y entrevistas semiestructuradas con cirujanos colorrectales certificados o elegibles para certificación por el consejo (n = 10).ESCENARIO:Centros académicos y un encuentro regional de una sociedad profesional.PACIENTES:La edad media de los pacientes fue de 63 años. La mayoría de los cirujanos (8/10) practicaban en un entorno académico, y 4/10 eran mujeres.PRINCIPALES MEDIDAS DE RESULTADO:Nivel de grado de lectura y puntajes de dominios para la Herramienta de evaluación de materiales educativos para pacientes. Los datos cualitativos se registraron, transcribieron y codificaron. Los temas se generaron mediante la interpretación y la reducción de datos.RESULTADOS:Los materiales variaron desde el nivel de lectura del 7° al 11° grado. Los materiales de la NCCN obtuvieron la puntuación más alta en comprensibilidad (92.2 ± 6.1%, media ± DE), seguidos por los materiales de NCI (84.0 ± 6.6%) y ASCRS (82.2 ± 6.3%). Los puntajes de viabilidad variaron; Los materiales de NCCN obtuvieron una puntuación de 82.5 ± 1.7%, mientras que los materiales de NCI y ASCRS obtuvieron una puntuación de 23.3 ± 6.7% y 50.0 ± 8.2%, respectivamente. Se identificaron lagunas críticas en el contenido de estos materiales. Los pacientes querían más información sobre el autocuidado, tanto emocional como físico. Específicamente, los pacientes buscaron detalles sobre la función intestinal posoperatoria. Mientras que los cirujanos querían información sobre el curso hospitalario típico y la recuperación, y todos querían que los materiales fueran personalizables.LIMITACIONES:Se revisó una cantidad limitada de materiales y los grupos de enfoque de pacientes fueron exploratorios.CONCLUSIONES:Los materiales educativos impresos comúnmente disponibles para el cáncer colorrectal están escritos a un alto nivel de grado de lectura, varían en su usabilidad y omiten detalles importantes sobre la recuperación postoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B535.

Analysis of Pediatric Surgery Using the National Healthcare Insurance Service Database in Korea: How Many Pediatric Surgeons Do We Need in Korea?

BACKGROUND: In the past, general surgeons (GSs) without a pediatric surgical subspecialty often performed surgery on children and, even now, GSs are performing many pediatric surgeries. We aimed to investigate the involvement of pediatric surgeons (PSs) and GSs in pediatric surgery, compare the outcomes of surgery in the neonatal intensive care unit (NICU), and estimate the appropriate PS workforce in Korea. METHODS: We used surgical data from the National Health Insurance Service database that was collected from patients under the age of 19 years in hospitals nationwide from January 2002 to December 2017. In this database, we found 37 hospitals where PSs worked by using the index operation (congenital diaphragmatic hernia, esophageal atresia, hypertrophic pyloric stenosis, Hirschsprung's disease, abdominal wall defect, jejunoileal atresia, malrotation, anorectal malformation, and biliary atresia). It was assumed that the surgery in the 37 hospitals was performed by PS and that the surgery in other hospitals was performed by GS. Mortality was analyzed to compare the outcomes of acute abdominal surgery in the NICU. We estimated the number of PS currently needed in Korea for each situation under the assumption that PS would perform all operations for the index operation, main pediatric diseases (index operation + gastroesophageal reflux disease, choledochal cyst, inguinal hernia, and appendicitis), acute abdominal surgery in the NICU, and all pediatric surgeries. Additionally, we estimated the appropriate number of PS required for more advanced pediatric surgery in the future. RESULTS: The number of pediatric surgeries from 2002 to 2017 increased by 124%. Approximately 10.25% of the total pediatric surgeries were performed by PSs, and the percentage of the surgery performed by PSs increased from 8.32% in 2002 to 15.92% in 2017. The percentage of index operations performed by PSs annually was 62.44% in average. It was only 47.81% in 2002, and increased to 88.79% in 2017. During the last 5 years of the study period, the average annual number of surgeries for main pediatric diseases was approximately 33,228. The ratio of the number of surgeries performed by PS vs. GS steadily increased in main pediatric diseases, however, the ratio of the number of surgery performed by PS for inguinal hernia and appendicitis remained low in the most recent years. The percentage of the number of acute abdominal surgery performed by PS in the NICU was 44% in 2002, but it had recently risen to 89.7%. After 30 days of birth, mortality was significantly lower in all groups that were operated on by PS, rather than GS, during the last 5 years. In 2019, 49 PSs who were under the age of 65 years were actively working in Korea. Assuming that all pediatric surgeries of the patients under the age of 19 years should be performed by PS, the minimum number of PS currently required was about 63 if they perform all of the index operations, the main pediatric surgery was about 209, the NICU operation was about 63, and the all pediatric surgeries was about 366. Additionally, it was determined that approximately 165 to 206 PS will be appropriate for Korea to implement more advanced pediatric surgery in the future. CONCLUSION: The proportion of the pediatric surgery performed by PS rather than GS is increasing in Korea, but it is still widely performed by GS. PSs have better operative outcomes for acute abdominal surgery in the NICU than GSs. We believe that at least the index operation or the NICU operation should be performed by PS for better outcome, and that a minimum of 63 PSs are needed in Korea to do so. In addition, approximately 200 PSs will be required in Korea in order to manage main pediatric diseases and to achieve more advanced pediatric surgery in the future.

The use of intravenous iron in pregnancy: for whom and when? A survey of Australian and New Zealand obstetricians.

BACKGROUND: Iron deficiency anaemia in pregnancy (IDAP) affects 11-18% of Australian pregnancies and is associated with adverse perinatal outcomes. National prescribing data suggests the use of intravenous iron in pregnancy is increasingly common. This study aimed to: 1) Establish the current patterns of intravenous iron use by Fellows of the Royal Australian and New Zealand College of Obstetricians (FRANZCOG) when treating iron deficiency and IDAP including immediately postpartum and; 2) Assess FRANZCOG opinions regarding potential trial of intravenous iron for first-line treatment of IDAP. METHODS: An online survey of RANZCOG Fellows practicing obstetrics was distributed in September 2018. Results were analysed descriptively and responses compared by clinician demographics using Chi-squared testing. RESULTS: Of 484 respondents (21% of FRANZCOG), 457 were currently practicing obstetrics. Most prescribed intravenous iron in pregnancy (96%) and/or postpartum (85%). Most intravenous iron was prescribed for IDAP (98%) rather than iron deficiency without anaemia (53%), and for IDAP most commonly second-line to failed oral iron supplementation and first-line in special circumstances (59%). Intravenous iron prescribing was associated with shorter time since FRANZCOG completion (p = 0.01), public hospital practice (p = 0.008) and higher hospital birth numbers (p = 0.01). Most respondents (90%) would consider a randomised controlled trial of first-line intravenous iron for IDAP, although views on appropriate thresholds differed. CONCLUSIONS: Almost all respondents prescribed intravenous iron for IDAP, and while mostly used for second-line treatment over half sometimes used it first-line. With accelerating intravenous iron use, further research is required into its optimal use in pregnancy, recognizing important clinical outcomes and cost effectiveness.

Adherence to the National Comprehensive Cancer Network Criteria of Complete Circumferential Peripheral and Deep Margin Assessment in Treatment of High-Risk Basal and Squamous Cell Carcinoma.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) has established guidelines for the treatment of keratinocyte carcinomas (KCs). Complete circumferential peripheral and deep margin assessment (CCPDMA) is recommended for "high-risk" tumors that cannot be closed primarily. If flap or grafts are needed and CCPDMA was not used, it is recommended that reconstruction be delayed until achieving clear margins. OBJECTIVE: To measure provider utilization rates of the NCCN guidelines for high-risk KCs and assess barriers that are limiting adherence. MATERIALS AND METHODS: A ten-item questionnaire was distributed to NCCN nonmelanoma skin cancer panel members and physicians participating in KC treatment at academic institutions. RESULTS: Response rate was 49% (57/116). Responses were categorized by practice area: Mohs surgery, pathology, and other specialties: General Dermatology, Otolaryngology, Plastic Surgery, Surgical Oncology, Radiation Oncology, and Oral and Maxillofacial Surgery. Mohs surgeons were most likely to use CCPDMA for tumors meeting NCCN criteria with 14/15 using this technique in a majority of their cases, versus 2/6 pathologists and 10/16 specialists from other fields. Reasons cited for not using CCPDMA included deference to pathologists to determine the appropriate method for margin assessment and logistical difficulty. CONCLUSION: Further efforts are needed to increase adherence to NCCN's guidelines regarding CCPDMA in KCs.

A global survey of surgeons' preferences and practice with regard to laxative use after elective colorectal surgery.

PURPOSE: The role of laxatives after elective colorectal surgery is unclear, resulting in heterogenous guidelines and variability in clinical practice. This study aimed to gauge surgeons' preferences and practice with regard to laxative use following elective colorectal surgery. METHODS: A short one-minute anonymous web-based questionnaire designed in English and Chinese (Mandarin) using the Research Electronic Data Capture application (REDCap) was distributed to member surgeons of every identifiable international colorectal specialist society via email communication, physical newsletters and social media channels. Frequency of laxative use after elective colorectal surgery, type of laxative used, and, if not used, the reasons for not using laxatives were collected. RESULTS: A total of 852 surgeons, representing 28 surgical societies completed the survey: 80% were colorectal surgeons and 20% were general surgeons with colorectal interest. Twenty-seven percent of the respondents routinely prescribed laxatives after colorectal surgery. There was wide variation in the type of laxatives used, with magnesium-based laxatives (42%), macrogol (Movicol, 36%) and lactulose (Duphalac, 22%) being the most common. Geographical location was correlated with choice of laxative. Those not routinely using laxatives stated the reasons as being no evidence for benefit (48%), potential of adverse events (24%), more than one reason (21%) and other (7%). The majority (93%) non-users would consider using laxatives if better evidence was available. CONCLUSION: Most surgeons do not routinely prescribe laxatives after elective colorectal surgery due to lack of evidence. Amongst those surgeons who do use them, there is wide variability in the type of laxatives used.

Pre-/postprocedure measures for laser/energy treatments: A survey.

BACKGROUND: Laser and energy-based devices may be used for many cutaneous indications, including facial resurfacing, improving skin conditions, and reducing signs of photoaging. Currently, no consensus papers or guidelines exist concerning peri-operative agents and specifically their use for laser skin resurfacing and their potential/possible role in prevention or treatment of side effects. AIM: To explore current practice using laser and energy devices, a survey was developed to identify the trends in pre- and postprocedural treatment measures. METHODS: The survey was sent out digitally to 300 randomly selected US dermatologist and plastic surgeon physicians practicing medical esthetics using laser and other energy devices treatment for facial rejuvenation. The survey gathered information on demographics, types of devices used in the clinic and pre-/postprocedural measures for facial laser, and other energy-based devices treatment. RESULTS: The survey was active from June 15, to July 15, 2018, and fifty-eight dermatologists and plastic surgeons completed the survey (19.3% response rate, 58/300). The results showed inconsistency in skin preparation strategies and postprocedure wound care. The majority of survey participants (55/58 [96%]) reported prophylactic oral antiviral use pre- and post-treatment; however, there was inconsistency about when to start and when to stop the use. A similar inconsistency existed in the recommended period of post-treatment sun protection before and after treatment. CONCLUSION: The results of the survey confirmed the lack of consistency in the types and duration of pre- and postprocedural measures-emphasizing the need for evidence-based recommendations to optimize outcomes, prevent infection, enhance comfort, and reduce downtime.

So you need a surgeon? Need for surgeon presence as an alternative metric to predict outcomes and assess triage in the pediatric trauma population.

BACKGROUND: Injury Severity Score (ISS) is the primary metric by which triage has been evaluated in trauma activations. We compared ISS to a previously described set of criteria defined as Need for Surgical Presence (NSP). We hypothesize that NSP may serve as a way to augment ISS in predicting mortality and assessing triage in pediatric trauma patients. METHODS: A total of 19,139 pediatric trauma patients in the 2016 National Trauma Quality Improvement Program Database (excluding transfers) had complete data for mortality, mode of transport, age, injury type, ISS, and NSP factors. NSP was defined as having one or more of the following: intubation, transfusion, operation for hemorrhage control/craniotomy, vasopressors, interventional radiology, spinal cord Injury, tube thoracostomy, emergency thoracotomy, intracranial pressure monitor, or pericardiocentesis. RESULTS: Overall mortality was 1.3% and 96% of all patients suffered blunt injury. A total of 2787 (14.6%) patients had an NSP indicator compared to 2036 (10.8%) with an ISS ≥16. NSP was noninferior to ISS in predicting mortality with the AUC of 0.91 (95% CI 0.89-0.92) and 0.90 (95% CI 0.88-0.92) respectively. CONCLUSION: NSP predicts mortality in pediatric trauma patients as well as ISS, and may compliment ISS. NSP status can be assigned shortly after patient arrival. Proper assessment of over and undertriage allows for optimal resource utilization by the medical facility and ultimately benefits the hospital, physician and patient. STUDY TYPE: Retrospective national dataset study. LEVEL OF EVIDENCE: Level II.

Perioperative Practices Concerning Sleeve Gastrectomy - a Survey of 863 Surgeons with a Cumulative Experience of 520,230 Procedures.

BACKGROUND: Sleeve Gastrectomy (SG) is the most commonly performed bariatric procedure worldwide. There is currently no scientific study aimed at understanding variations in practices concerning this procedure. The aim of this study was to study the global variations in perioperative practices concerning SG. METHODS: A 37-item questionnaire-based survey was conducted to capture the perioperative practices of the global community of bariatric surgeons. Data were analyzed using descriptive statistics. RESULTS: Response of 863 bariatric surgeons from 67 countries with a cumulative experience of 520,230 SGs were recorded. A total of 689 (80%) and 764 (89%) surgeons listed 13 absolute and relative contraindications, respectively. 65% (n = 559) surgeons perform routine preoperative endoscopy and 97% (n = 835) routinely use intraoperative orogastric tube for sizing the resection. A wide variation is observed in the diameter of the tube used. 73% (n = 627) surgeons start dividing the stomach at a distance of 3-5 cm from the pylorus, and 54% (n = 467) routinely use staple line reinforcement. Majority (65%, n = 565) of surgeons perform routine intraoperative leak test at the end of the procedure, while 25% (n = 218) surgeons perform a routine contrast study in the early postoperative period. Lifelong multivitamin/mineral, iron, vitamin D, calcium, and vitamin B12 supplementation is advocated by 66%, 29%, 40%, 38% and 44% surgeons, respectively. CONCLUSION: There is a considerable variation in the perioperative practices concerning SG. Data can help in identifying areas for future consensus building and more focussed studies.

Keratinocyte cancer excisions in Australia: Who performs them and associated costs.

BACKGROUND/OBJECTIVE: To describe the clinical settings in which keratinocyte cancers are excised in Queensland and describe the types of practitioners who excise them; to examine costs; and to identify predictors of hospital admission. METHODS: We used linked data for participants from the QSkin study (n = 43 794), including Medicare claims and Queensland hospital admissions relating to treatment episodes for incident keratinocyte cancers from July 2011 to June 2015. We used multinomial logistic regression to measure associations between demographic and clinical characteristics and treatment setting. The median costs of Medicare claims (AU$) were calculated. RESULTS: During 4 years of follow-up, there were 18 479 skin cancer excision episodes among 8613 people. Most excisions took place in private clinical rooms (89.7%), the remainder in hospitals (7.9% private; 2.4% public). Compared with other anatomical sites, skin cancers on the nose, eyelid, ear, lip, finger or genitalia were more likely to be treated in hospitals than in private clinical rooms (public hospital OR 5.7; 95%CI 4.5-7.2; private hospital OR 8.3; 95%CI 7.3-9.4). Primary care practitioners excised 83% of keratinocyte cancers, followed by plastic surgeons (9%) and dermatologists (6%). The median Medicare benefit paid was $253 in private clinical rooms and $334 in private hospitals. Out-of-pocket payments by patients treated in private hospitals were fourfold higher than those in private clinical rooms ($351 vs $80). CONCLUSIONS: Most keratinocyte cancers are excised in primary care, although more than 10% of excisions occur in hospital settings.

Management of Hirschsprung disease in Australia and New Zealand: a survey of the Australian and New Zealand Association of Paediatric Surgeons (ANZAPS).

PURPOSE: To define the practice of management for Hirschsprung disease (HD) in Australia and New Zealand. METHODS: Online survey of Australian and New Zealand Association of Paediatric Surgeons (ANZAPS) members. RESULTS: 56/80 (70%) members from 17 centres responded. DIAGNOSIS: 100% perform suction rectal biopsies; 40% perform a contrast enema. HISTOPATHOLOGICAL STAINING: H&E (94%), ACHE (70%) and calretinin (75%). SURGERY: Primary pull-through (PT) is performed by 88% (100% by < 6/12 months). The Soave-Boley PT is the preferred approach (85%), with laparoscopic assistance (77%) and muscle cuff division (93%). Routine post-operative dilatations are performed by 63% of respondents. If symptoms persist following PT, majority adopt a conservative approach (enemas/laxatives 90%; Botox 74%). If a long-segment is identified at PT, 60% fashion a stoma and delay definitive surgery. If total colonic aganglionosis is identified at PT, 76% fashion a stoma and delay definitive surgery. A dedicated bowel management program is available in 45% of centres with transition to adult services in 29%. CONCLUSIONS: A laparoscopic-assisted Soave-Boley PT is the most common technique for recto-sigmoid HD. Differences are noted in both the management of long-segment/total aganglionosis HD and post-operative management/follow-up.

Emergency general surgery in the United Kingdom: A lot of general, not many emergencies, and not much surgery.

BACKGROUND: The provision of emergency general surgery services is a global issue, with important implications for patients and workforce. The aim of this study was to analyze the characteristics of emergency general surgical patients in the United Kingdom, with reference to diagnostic case mix, operative workload, comorbidity, discharge destination, and outcomes, to facilitate comparisons and future service development. METHODS: This is a cross-sectional population-based study based in the National Health Service in Scotland, one of the home nations of the United Kingdom. All patients aged 16 or older admitted under the care of a general surgeon, as an emergency, to a National Health Service hospital in Scotland, in 2016, were included. RESULTS: There were 81,446 emergency general surgery admissions by 66,498 patients. Median episode age was 53 years. There were more female patients than male (55% vs 45%, p < 0.0001). The most common diagnoses were nonspecific abdominal pain (20.2%), cholecystitis (7.2%), constipation (3.4%), pancreatitis (3.1%), diverticular disease (3.1%), and appendicitis (3.1%). Only 25% of patients had operations (n = 20,292). The most frequent procedures were appendicectomy (13.1%), endoscopy (11.3%), and drainage of skin lesions (9.7%). Diagnoses and operations differed with age. Overall median length of stay was 1 day. With a 6-month follow-up, patients older than 75 years had a 19.8% mortality rate. CONCLUSIONS: Emergency general surgery in the United Kingdom is a high-volume, diagnostically diverse, and low-operative volume specialty with high short-term mortality rate in elderly patients. Consideration should be given to alternative service delivery models, which make better use of surgeons' skills while also ensuring optimal care for patients who are increasingly elderly and have complex chronic health problems. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Current practices of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal surface malignancies: an international survey of oncologic surgeons.

BACKGROUND: The goal of the study was to investigate the current clinical practices among oncologic surgeons regarding cytoreductive surgery (CRS) with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: From September to October 2016, an online questionnaire surveyed the oncologic surgeons by email. The questionnaire included 20 multiple-choice questions of the following: eligibility for the CRS with HIPEC procedure, perioperative staging and surgery skill, assessment of residual tumors, and method used for intraperitoneal HIPEC. RESULTS: The response rate was 16% (34/217). The majority of respondents (68%) worked at a university hospital. All respondents indicated that mesenteric invasion is the most crucial factor affecting treatment decision. Most surgeons (79%) used the Sugarbaker's staging system to intraoperatively measure the extent of peritoneal invasion. The methods used to measure the extent of miliary pattern of residual tumor spread, and the amount of residual tumor after electrocauterization varied among the surgeons. Most responders (65%) used the closed system of HIPEC. CONCLUSIONS: Despite the fact that CRS HIPEC is the standard treatment for PSM, the clinical practices are very different according to each clinical situation. Nevertheless, mesenteric invasion was found to be the most important factor impacting the treatment decision-making by the majority of responders.

Current management of small bowel obstruction in the UK: results from the National Audit of Small Bowel Obstruction clinical practice survey.

AIM: Small bowel obstruction (SBO) is associated with high rates of morbidity and mortality. The National Audit of Small Bowel Obstruction (NASBO) is a collaboration between trainees and specialty associations to improve the care of patients with SBO through national clinical audit. The aim of this study was to define current consultant practice preferences in the management of SBO in the UK. METHOD: A survey was designed to assess practice preferences of consultant surgeons. The anonymous survey captured demographics, indications for surgery or conservative management, use of investigations including water-soluble contrast agents (WSCA), use of laparoscopy and nutritional support strategies. The questionnaire underwent two pilot rounds prior to dissemination via the NASBO network. RESULTS: A total of 384 responses were received from 131 NASBO participating units (overall response rate 29.2%). Abdominal CT and serum urea and electrolytes were considered essential initial investigations by more than 80% of consultants. Consensus was demonstrated on indications for early surgery and conservative management. Three hundred and thirty-eight (88%) respondents would consider use of WSCA; of these, 328 (97.1%) would use it in adhesive SBO. Two hundred (52.1%) consultants considered a laparoscopic approach when operating for SBO. Oral nutritional supplements were favoured in operatively managed patients by 259 (67.4%) respondents compared with conservatively managed patients (186 respondents, 48.4%). CONCLUSION: This survey demonstrates consensus on imaging requirements and indications for early surgery in the management of SBO. Significant variation exists around awareness of the need for nutritional support in patients with SBO, and on strategies to achieve this support.

The Road to Improving Access to Surgical Specialist Consultations: Ontario's Experience with Wait 1 Wait Time Data.

In 2009, the Ontario Ministry of Health and Long-Term Care engaged Cancer Care Ontario to expand the Wait Time Information System to capture surgical consultation data (Wait 1). Over the years, an increasing number of patient and provider reports have shown that Wait 1 wait times account for a significant portion of the total wait time for surgery. With data published online by the ministry in late summer 2017, patients were given access to consultation wait time information for over 200 types of procedures at 92 surgical facilities in Ontario. This article explains how a highly focused data strategy, strong stakeholder and clinical expert support and a comprehensive communications strategy were critical to driving change for a large-scale provincial initiative, which is helping to drive better access for patients and improve transparency and accountability.

A minimum 20-year outcome of 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon.

BACKGROUND:: Ceramic-on-ceramic (CoC) is currently a viable bearing combination in primary total hip arthroplasty (THA) and, due to its mechanical properties, it can be used in young patients requiring a long-lasting implant. The aim of this study is to report the results of a series of CoC THAs at a minimum 20 years follow-up. METHODS:: A retrospective study was conducted on the 1st 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon on 51 females and 40 males with an average age of 60.7 years. The mean preoperative Harris Hip Score was 35. The press-fit cup consisted of a pure titanium core with a titanium alloy mesh. Both the inlay and the head were made of dense polycrystalline surgical-grade alumina. The 32-mm femoral head was anchored on 3 different femoral components. RESULTS:: 19 patients with 22 THAs were died or lost, 2 anatomic cementless stems were revised due to sinking, 1 THA was revised for periprosthetic infection. 2 patients sustained a Vancouver B1 periprosthetic femoral fracture. None of the 78 THAs eligible for this study were revised for wear, breakage, noise of the ceramic components. None of the cups, none of the cemented stems, none of the cementless straight stems failed. HHS raised up to a mean value of 95. CONCLUSIONS:: The present report demonstrates that CoC coupling offers minimal wear at a long-term follow-up. Further studies are needed to evaluate whether the modern ceramic composites will confirm such excellent results in total hip replacement.

Perioperative Practices Concerning One Anastomosis (Mini) Gastric Bypass: A Survey of 210 Surgeons.

BACKGROUND: There is currently little evidence available on the perioperative practices concerning one anastomosis/mini gastric bypass (OAGB/MGB) and no published consensus amongst experts. Even the published papers are not clear on these aspects. The purpose of this study was to understand various perioperative practices concerning OAGB/MGB. METHODS: Bariatric surgeons from around the world were invited to participate in a questionnaire-based survey. Only surgeons performing this procedure were included. RESULTS: Two hundred and ten surgeons from 39 countries with a cumulative experience of 68,442 procedures took the survey. Surgeons described a large number of absolute (n = 55) and relative contraindications (n = 59) to this procedure in their practice. Approximately 71.0% (n = 148/208), 70.0% (n = 147/208) and 65.0% (n = 137/209), respectively, routinely perform a preoperative endoscopy, screening for Helicobacter pylori and ultrasound scan of the abdomen. A minority (35.0%, n = 74/208) of the surgeons used a constant bilio-pancreatic limb (BPL) length for all the patients with remaining preferring to tailor the limb length to the patient and approximately half (49.0%, n = 101/206) routinely approximate diaphragmatic crura in patients with hiatus hernia. Some 48.5% (n = 101/208) and 40.0% (n = 53/205) surgeons, respectively, do not recommend routine iron and calcium supplementation. CONCLUSION: This survey is the first attempt to understand a range of perioperative practices with OAGB/MGB. The findings will help in identifying areas for future research and allow consensus building amongst experts with preparation of guidelines for future practice.

Effect of Surgeon Age on Bariatric Surgery Outcomes.

OBJECTIVE: This study sought to explore the relationship of bariatric surgeon age and patient outcomes. BACKGROUND: Regulators, policy makers, and patient advocacy groups have recently been pushing to establish clear guidelines for physician retirement in the United States. Although it is often assumed that increasing physician age leads to worse patient outcomes, the relationship is lacking robust evidence, and is still unclear. METHODS: We conducted a study analyzing all bariatric surgeons in Michigan who participated in a statewide collaborative quality improvement program (n = 71) who performed primary laparoscopic Roux-en-Y Gastric Bypass, or sleeve gastrectomy operations, and data on their patients (n = 60430) over the past 10 years. Our primary outcomes were 30-day postoperative complications. Odds ratios for overall complications and serious complications were calculated for each age group, and surgery type. RESULTS: Late career surgeons had more bariatric surgery experience and had a higher average annual case volume than early career surgeons. Considering all cases in the past 10 years, older surgeons performed more Roux-en-Y Gastric Bypass (40%) and less sleeve gastrectomy (38.8%) than younger surgeons (34.7% and 51.5%). When adjusting for patient and surgeon characteristics, there were no statistically significant differences in overall or serious complication rates for either procedure among surgeon age groups. CONCLUSIONS: When evaluating bariatric surgeons in the State of Michigan, we found no statistically significant association between surgeon age and patient outcomes. Our findings do not provide evidence for age-specific retirement cut-offs, but support the development of guidelines which are holistic, and focus on evaluating and improving physician outcomes at all career levels.

Surgeon Participation in Early Accountable Care Organizations.

OBJECTIVE: We aimed to characterize the landscape of surgeon participation in early accountable care organizations (ACOs) and to identify specialty-, organization-, and market-specific factors associated with ACO participation. BACKGROUND: Despite rapid deployment of alternative payment models (APMs), little is known about the prevalence of surgeon participation, and key drivers behind surgeon participation in APMs. METHODS: Using data from SK&A, a research firm, we evaluated the near universe of US practices to characterize ACO participation among 125,425 US surgeons in 2015. We fit multivariable logistic regression models to characterize key drivers of ACO participation, and more specifically, the interaction between ACO affiliation and organizational structure. RESULTS: Of 125,425 US surgeons, 27,956 (22.3%) participated in at least 1 ACO program in 2015. We observed heterogeneity in participation by subspecialty, with trauma and transplant reporting the highest rate of ACO enrollment (36% for both) and plastic surgeons reporting the lowest (12.9%) followed by ophthalmology (16.0%) and hand (18.6%). Surgeons in group practices and integrated systems were more likely to participate relative to those practicing independently (aOR 1.57, 95% CI 1.50, 1.64; aOR 4.87, 95% CI 4.68, 5.07, respectively). We observed a statistically significant interaction (P <0.001) between surgical specialty and practice organization. Model-derived predicted probabilities revealed that, within each specialty, surgeons in integrated health systems had the highest predicted probabilities of ACO and those practicing independently generally had the lowest. CONCLUSIONS: We observed considerable variation in ACO enrollment among US surgeons, mediated at least in part by differences in practice organization. These data underscore the need for development of frameworks to characterize the strategic advantages and disadvantages associated with APM participation.

Resource utilization for non-operative cervical radiculopathy: Management by surgeons versus non-surgeons.

OBJECTIVES: To compare the estimated resource utilization for non-operative treatment of cervical radiculopathy if managed by surgeons versus non-surgeons. PATIENTS AND METHODS: A Cervical Spine Research Society-sponsored survey was administered at a national spine surgery conference to surgeons and non-surgeons, as classified above. The survey asked questions regarding resource utilization and perceived costs for the "average patient" with cervical radiculopathy managed non-operatively. Resource utilization and perceived costs were compared between surgeon and non-surgeon participants, and between private practice and academic and/or hybrid groups that combine academic and private practices. RESULTS: In total, 101 of the 125 conference attendees participated in the survey (return rate 80.8%, of which 60% were surgeons). Surgeon and non-surgeon estimates for duration of non-operative care did not differ (3.3 versus 4.2 months, p=0.071). Estimates also did not differ for estimated number of physical therapy visits (10.5 versus 10.5, p=0.983), cervical injections (1.4 versus 1.7, p=0.272), chiropractic visits (3.1 versus 3.7, p=0.583), or perceived days off from work (14.9 versus 16.3, p=0.816). The only difference identified was that surgeon estimates of the number of physician visits while providing non-operative care were lower than non-surgeon estimates (3.2 versus 4.0, p=0.018). In terms of estimated costs, surgeon and non-surgeon were mostly similar (only difference being that surgeon estimates for the total cost of physician visits per patient were lower than non-surgeon estimates ($382 versus $579, p=0.007). Surgeon estimates for the percent of their patients that go on to receive surgery within 6 months were higher than non-surgeon estimates (28.6% versus 18.8%, p=0.018). Similarly, surgeon estimates for the percent of their patients to go on to receive surgery within 2 years were higher than non-surgeon estimates (37.8% versus 24.8%, p=0.013). Academic/hybrid and private practice group resource utilization estimates and costs were also compared, and no significant differences were found in any comparisons. Additionally, no significant differences were found in these groups for duration of non-operative care, or the estimates of the percent of patients who go on to receive surgery within 6 months or two years. CONCLUSION: These data suggest that patients with cervical radiculopathy managed by surgeons and those by non-surgeons have overall similar resource utilization during a non-operative trial. This suggests that relatively similar care is provided regardless of whom initiates the non-operative trial (surgeon or non-surgeon). Although surgeons thought their patients more likely to undergo surgery following a non-operative trial, this may be a bias due to patient referral-specifically, surgeons may be more likely than non-surgeons to manage patients with more severe or longer-standing radiculopathy.