Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Using local rather than general anesthesia for inguinal hernia repair may significantly reduce complications for frail Veterans.

BACKGROUND: Frailty predisposes patients to poor postoperative outcomes. We evaluated whether using local rather than general anesthesia for hernia repair could mitigate effects of frailty. METHODS: We used the Risk Analysis Index (RAI) to identify 8,038 frail patients in the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database who underwent elective, open unilateral inguinal hernia repair under local or general anesthesia. Our outcome of interest was the incidence of postoperative complications. RESULTS: In total, 5,188 (65%) patients received general anesthesia and 2,850 (35%) received local. Local anesthesia was associated with a 48% reduction in complications (OR 0.52, 95%CI 0.38-0.72). Among the frailest patients (RAI≥70), predicted probability of a postoperative complication ranged from 22 to 33% with general anesthesia, compared to 13-21% with local. CONCLUSIONS: Local anesthesia was associated with a ∼50% reduction in postoperative complications in frail Veterans. Given the paucity of interventions for frail patients, there is an urgent need for a randomized trial comparing effects of anesthesia modality on postoperative complications in this vulnerable population.

Surgical Re-entry Strategy Following COVID-19 Pandemic: A Tiered and Balanced Approach.

Following the Presidential declaration of a national emergency, many health care organizations adhered to recommendations from the Centers for Medicare and Medicaid (CMS) as well as the American College of Surgeons (ACS) to postpone elective surgical cases. The transition to only emergent and essential urgent surgical cases raises the question, how and when will hospitals and surgery centers resume elective cases? As a large health care system providing multispecialty tertiary/quaternary care with across the Southeast United States, a collaborative approach to resuming elective surgery is critical. Numerous surgical societies have outlined a tiered approach to resuming elective surgery. The majority of these guidelines are suggestions which place the responsibility of making decisions about re-entry strategy on individual health care systems and practitioners, taking into account the local case burden, projected case surge, and availability of resources and personnel. This paper reviews challenges and solutions related to the resumption of elective surgeries and returning to the pre-COVID-19 surgical volume within an integrated health care system that actively manages 18 facilities, 111 operating rooms, and an annual operative volume exceeding 123,000 cases. We define the impact of COVID-19 across our surgical departments and outline the staged re-entry approach that is being taken to resume surgery within the health care system.

Otolaryngology in the Time of Corona: Assessing Operative Impact and Risk During the COVID-19 Crisis.

OBJECTIVE: Limited research exists on the coronavirus disease 2019 (COVID-19) pandemic pertaining to otolaryngology-head and neck surgery (OHNS). The present study seeks to understand the response of OHNS workflows in the context of policy changes and to contribute to developing preparatory guidelines for perioperative management in OHNS. STUDY DESIGN: Retrospective cohort study. SETTING: Pediatric and general adult academic medical centers and a Comprehensive Cancer Center (CCC). SUBJECTS AND METHODS: OHNS cases from March 18 to April 8, 2020-the 3 weeks immediately following the Ohio state-mandated suspension of all elective surgery on March 18, 2020-were compared with a 2019 control data set. RESULTS: During this time, OHNS at the general adult and pediatric medical centers and CCC experienced 87.8%, 77.1%, and 32% decreases in surgical procedures as compared with 2019, respectively. Aerosol-generating procedures accounted for 86.8% of general adult cases, 92.4% of pediatric cases, and 62.0% of CCC cases. Preoperative COVID-19 testing occurred in 7.1% of general adult, 9% of pediatric, and 6.9% of CCC cases. The majority of procedures were tiers 3a and 3b per the Centers for Medicare & Medicaid Services. Aerosol-protective personal protective equipment (PPE) was worn in 28.6% of general adult, 90% of pediatric, and 15.5% of CCC cases. CONCLUSION: For OHNS, the majority of essential surgical cases remained high-risk aerosol-generating procedures. Preoperative COVID-19 testing and intraoperative PPE usage were initially inconsistent; systemwide guidelines were developed rapidly but lagged behind recommendations of the OHNS department and its academy. OHNS best practice standards are needed for preoperative COVID-19 status screening and PPE usage as we begin national reopening.

Recommendations for the organization of electrophysiology and cardiac pacing services during the COVID-19 pandemic : Latin American Heart Rhythm Society (LAHRS) in collaboration with: Colombian College Of Electrophysiology, Argentinian Society of Cardiac Electrophysiology (SADEC), Brazilian Society Of Cardiac Arrhythmias (SOBRAC), Mexican Society Of Cardiac Electrophysiology (SOMEEC).

COVID-19 is a rapidly evolving public health emergency that has largely impacted the provision of healthcare services around the world. The challenge for electrophysiology teams is double; on one side preventing disease spread by limiting all nonessential face-to-face interactions, but at the same time ensuring continued care for patients who need it. These guidelines contain recommendations regarding triaging in order to define what procedures, device checks and clinic visits can be postponed during the pandemic. We also discuss best practices to protect patients and healthcare workers and provide guidance for the management of COVID-19 patients with arrhythmic conditions.

Validation of algorithms to identify elective percutaneous coronary interventions in administrative databases.

BACKGROUND: Elective percutaneous coronary interventions (PCI) are difficult to discriminate from non-elective PCI in administrative data due to non-specific encounter codes, limiting the ability to track outcomes, ensure appropriate medical management, and/or perform research on patients who undergo elective PCI. The objective of this study was to assess the abilities of several algorithms to identify elective PCI procedures using administrative data containing diagnostic, utilization, and/or procedural codes. METHODS AND RESULTS: For this retrospective study, administrative databases in an integrated healthcare delivery system were queried between 1/1/2015 and 6/31/2016 to identify patients who had an encounter for a PCI. Using clinical criteria, each encounter was classified via chart review as a valid PCI, then as elective or non-elective. Cases were tested against nine pre-determined algorithms. Performance statistics (sensitivity, specificity, positive predictive value, and negative predictive value) and associated 95% confidence intervals (CI) were calculated. Of 521 PCI encounters reviewed, 497 were valid PCI, 93 of which were elective. An algorithm that excluded emergency room visit events had the highest sensitivity (97.9%, 95%CI 92.5%-99.7%) while an algorithm that included events occurring within 90 days of a cardiologist visit and coronary angiogram or stress test had the highest positive predictive value (62.2%, 95%CI 50.8%-72.7%). CONCLUSIONS: Without an encounter code specific for elective PCI, an algorithm excluding procedures associated with an emergency room visit had the highest sensitivity to identify elective PCI. This offers a reasonable approach to identify elective PCI from administrative data.

Complementary medicines use amongst elective surgery patients at a public tertiary hospital: A prospective observational cohort study in Australia.

BACKGROUND: and purpose. Complementary medicines (CM) use may result in untoward effects perioperatively. The study purpose is to identify CM pattern of use amongst elective surgery patients, and improve effectiveness of information collection relating to CM use. MATERIALS AND METHODS: This is a prospective observational cohort study. CM questionnaire was administered alongside standard hospital forms at pre-admission clinic over eight weeks. RESULTS: 992 patients attended pre-admission clinic; 317 patients were included in analysis. Introduction of CM questionnaire increased disclosure rate by 11.7% giving a total prevalence of 44.2%. CM use was significantly higher in females and in older patients. Top CM reported were vitamin D (12%) and omega-3 (12%). Majority of patients did not plan to withhold CM before surgery, and were not concerned about perioperative risks. CONCLUSION: Pre-admission clinics need to encourage CM disclosure. Patient education of potential risks and greater engagement of clinicians in patient assessment is required.

[Skin-to-skin during caesarean section: Assessment of professional practices]. / Le peau à peau du nouveau-né en cours de césarienne : une étude d'évaluation des pratiques professionnelles.

BACKGROUND: Considering its benefits, immediate skin-to-skin should be applied irrespective of the way of delivery. While it is increasingly applied in case of vaginal delivery, it remains difficult to implement in case of caesarean section. OBJECTIVE: To estimate the degree of implementation of skin-to-skin in case of caesarean section. METHODS: Survey in immediate postpartum with a continuous series of patients having given birth by caesarean - whether scheduled or not - in a level 3 hospital systematically realizing skin-to-skin in case of vaginal delivery. The patients were included if the caesarean section had been realized between 16/11/17 and 28/11/17. RESULTS: Thirty-five women gave birth by caesarean section during the period of study, among which 26 were planned (74%). The emergency levels were varied: 18 had a green code (51%), 12 an orange code (34%) and 5 a red code (14%). Forty-six percent of the newborn children were placed skin-to-skin. The frequency of skin-to-skin was closely linked to the planned character of the caesarean section (89 vs. 31%, P=0.005), as well as its color code (green 72%, orange 25%, red 0%). In case of impossibility to realize skin-to-skin in the course of the caesarean, the reasons were mainly related to the maternal state (63%) (malaise, bleeding, pain). In this situation, skin-to-skin was proposed to the spouse in 83% of cases and realized in recovery room with the mother in 82% of the cases. CONCLUSION: Skin-to-skin is feasible during caesarean section, regardless of the color code of the procedure.

A simple care bundle to reduce unplanned admission rate for day case pediatric circumcision.

BACKGROUND: An electronic review of unplanned day case admission rates in our hospital demonstrated an average annual rate for pediatric circumcision of 2%-3% in recent years with high levels of perioperative strong opiate use. This lay above target unplanned admission rates (<2%) set out by the Royal College of Anaesthetists for day case surgery. A targeted quality improvement initiative was undertaken to improve patient flow through the pediatric day case surgery unit for elective circumcision. Among the reasons for unplanned admission, factors modifiable by the anesthetist (pain, postoperative nausea and vomiting, somnolence) are significant contributors. METHODS: A prospective audit was undertaken over a 3-month period. Our practice was compared with evidence-based analgesic and antiemetic interventions in accordance the Association of Paediatric Anaesthetists of Great Britain and Ireland. Perioperative strong opiate administration rates occurred in 44% of cases. Four strategic interventions were selected based on quality of evidence, ease of implementation, and low cost: selection of higher concentration local anesthetic use for penile blocks, intravenous dexamethasone, and preoperative paracetamol combined with maximum dose nonsteroidal anti-inflammatory. RESULTS: The audit was duplicated a year later demonstrating a significant increase in application of these interventions with a parallel fall in strong opiate use from 44% to 9% and an unprecedented zero unplanned admission rate in our unit for 10 months in a row after implementation. CONCLUSION: Regular scrutiny of patient electronic data helps identify high impact areas for audit and intervention. Unplanned admission in pediatric day case surgery is an area amenable to such targeted intervention.

Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy: a propensity-score-matched case-control analysis.

BACKGROUND: Liver resection may be associated with substantial blood loss, and cell saver use has been recommended for patients at high risk. We performed a study to compare the allogenic erythrocyte transfusion rate after liver resection between patients who had intraoperative cell salvage with a cell saver device versus patients who did not. Our hypothesis was that cell salvage with autologous transfusion would reduce the allogenic blood transfusion rate. METHODS: Cell salvage was used selectively in patients at high risk for intraoperative blood loss based on preoperatively known predictors: right and repeat hepatectomy. Patients who underwent elective right or repeat hepatectomy between Nov. 9, 2007, and Jan. 27, 2016 were considered for the study. Data were retrieved from a liver resection database and were analyzed retrospectively. Patients with cell saver use (since January 2013) constituted the experimental group, and those without cell salvage (2007-2012), the control group. To reduce selection bias, we matched propensity scores. The primary outcome was the allogenic blood transfusion rate within 90 days postoperatively. Secondary outcomes were the number of transfused erythrocyte units, and rates of overall and infectious complications. RESULTS: Ninety-six patients were included in the study, 41 in the cell saver group and 55 in the control group. Of the 96, 64 (67%) could be matched, 32 in either group. The 2 groups were balanced for demographic and clinical variables. The allogenic blood transfusion rate was 28% (95% confidence interval [CI] 12.5%-43.7%) in the cell saver group versus 72% (95% CI 56.3%-87.5%) in the control group (p < 0.001). The overall and infectious complication rates were not significantly different between the 2 groups. CONCLUSION: Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy reduced the allogenic blood transfusion rate.

CONTEXTE: La résection hépatique peut s'accompagner de pertes sanguines importantes et l'utilisation d'un système de récupération de sang autologue est recommandée chez les patients à risque élevé. Nous avons procédé à une étude pour comparer le taux de transfusion de sang allogénique après la résection hépatique selon que les patients avaient ou non été soumis à une intervention de récupération de sang autologue. Notre hypothèse est que la récupération de sang autologue peropératoire pourrait réduire le taux de transfusion de sang allogénique. MÉTHODES: La récupération de sang autologue a été utilisée sélectivement chez des patients exposés à un risque élevé à l'égard de pertes sanguines peropératoires, en fonction de facteurs prédictifs préopératoires connus : hépatectomie droite et reprise de l'hépatectomie. Les patients ayant subi une intervention chirurgicale non urgente pour hépatectomie droite ou reprise d'hépatectomie entre le 9 novembre 2007 et le 27 janvier 2016 ont été considérés comme admissibles à l'étude. Les données ont été récupérées à partir d'une base de données sur la résection hépatique et analysées de manière rétrospective. Les patients soumis à la récupération de sang autologue (à partir de janvier 2013) ont constitué le groupe expérimental, et les autres (2007-2012) ont constitué le groupe témoin. Pour réduire le risque de biais de sélection, nous avons apparié les scores de propension. Le paramètre principal était le taux de transfusion de sang allogénique dans les 90 jours suivant l'opération. Les paramètres secondaires étaient le nombre d'unités transfusées, le taux de complications infectieuses et le taux global de complications. RÉSULTATS: Quatre-vingt-seize patients ont pris part à l'étude, 41 dans le groupe soumis à la récupération de sang autologue et 55 dans le groupe témoin. Parmi les 96 patients de l'étude, 64 (67 %) ont pu être assortis, 32 dans chaque groupe. Les 2 groupes étaient équilibrés aux plans des variables démographiques et cliniques. Le taux d'allotransfusions a été de 28 % (intervalle de confiance [IC] de 95 % 12,5 %-43,7 %) dans le groupe soumis à la récupération de sang autologue, contre 72 % (IC de 95 % 56,3 %-87,5 %) dans le groupe témoin (p < 0,001). Le taux de complications infectieuses et le taux global de complications n'ont pas été significativement différents entre les 2 groupes. CONCLUSION: La récupération de sang autologue peropératoire dans les cas d'hépatectomie droite ou d'hépatectomie répétée a réduit le taux de transfusion de sang allogénique.

Evaluation of psychosocial and biological parameters in women seeking for a caesarean section and women who are aiming for vaginal delivery: a cross-sectional study.

PURPOSE: To investigate psychosocial and biological parameters that may influence decision-making concerning the mode of delivery in women with caesarean section on maternal request (CSMR). METHODS: Two hundred and two women were enrolled prospectively. The study sample (n = 93) consisted of women who aimed for CSMR, the control sample were women who seeked for vaginal delivery (n = 109). Parturients of both samples were enrolled during the pre-birth counselling at the delivery room at the University Medical Centre Mannheim, University Heidelberg, Germany. Women completed standardised questionnaires regarding psychosocial burden (SCL-R 90), fear of childbirth (W-DEQ) and anxiety (STAI), personality structure (HEXACO-Pi-R), and ambiguity tolerance (PFI, PNS, and NFC), social support (F-SozU) as well as one questionnaire assessing demographic parameters and further factors potentially influencing their choice of the mode of delivery. Hair cortisol concentration as a marker for chronic psychological stress and pressure pain threshold with a pressure algometer was assessed. RESULTS: Women in the CSMR sample had less social support (F-SozU: 2.99 ± 0.52 vs. 3.12 ± 0.32; p = 0.043) and were less educated (high school or university degree: 37 vs. 71%, p = 0.001) compared to parturients of the control sample. Women who underwent CSMR were less open-minded (HEXACO-Pi-R: 3.08 ± 0.57 vs. 3.26 ± 0.50; p = 0.016) and less extroverted (HEXACO-Pi-R: 3.34 ± 0.36 vs. 3.46 ± 0.41; p = 0.041). The control collective showed higher scores in negative appraisal of the birth ('W-DEQ-negative appraisal': 2.5 ± 0.8 vs. 2.2 ± 0.9; p = 0.006), whereas "lack of positive anticipation" was higher in the study collective ('W-DEQ-lack of positive anticipation': 3.2 ± 1.2 vs. 2.8 ± 0.8; p = 0.015). The study collective had higher pressure pain threshold values (5.07 ± 2.06 vs. 4.35 ± 1.38; p = 0.007), while no significant differences were observed in hair cortisol concentration comparing both groups (5.0 ± 11.4 vs. 4.9 ± 8.3; p = 0.426). The majority of the control collective (80%) had chosen the vaginal route as their mode of delivery before pregnancy, whereas only 21% of the women in the study collective decided to undergo CSMR before conception. The advice of social sources including both medical and non-medical aspects was rated less important in the study sample, with significant differences indicating a lower relevance of counsel from friends (p = 0.002) and midwives (p < 0.001). CONCLUSION: Women who inquired a CSMR had lower social support, were less educated, more anxious, and had a lower sensitivity for physical pain compared to women seeking for spontaneous delivery. This should be considered when counselling women requiring CSMR and could be leverage points to intervene to reduce the continuously increasing CSMR rate.

Promoting normal birth and reducing caesarean section rates: An evaluation of the Rapid Improvement Programme.

This paper evaluates the impact of the 2008 Rapid Improvement Programme that aimed at promoting normal birth and reducing caesarean section rates in the English National Health Service. Using Hospital Episode Statistics maternity records for the period 2001-2013, a panel data analysis was performed to determine whether the implementation of the programme reduced caesarean sections rates in participating hospitals. The results obtained using either the unadjusted sample of hospitals or a trimmed sample determined by a propensity score matching approach indicate that the impact of the programme was small. More specifically there were 2.3 to 3.4 fewer caesarean deliveries in participating hospitals, on average, during the postprogramme period offering a limited scope for cost reduction. This result mainly comes from the reduction in the number of emergency caesareans as no significant effect was uncovered for planned caesarean deliveries.

Wait times in Canada.

A significant barrier to accessing healthcare in Canada is long waiting lists, which can be linked to the way that Medicare was structured. After significant pressure, provincial governments began to address wait times. An example of a successful strategy to reduce wait times for elective surgery is the Saskatchewan Surgical Initiative, which saw wait times in the province change from being among the longest in Canada to the shortest.

Clinical Value of Contrast Enema Prior to Ileostomy Closure.

Purpose To determine the value of routine contrast enema of loop ileostomy before elective ileostomy closure regarding the influence on the clinical decision-making. Materials and Methods Retrospective analysis of contrast enemas at a tertiary care center between 2005 und 2011. Patients were divided into two groups: Group I with ileostomy reversal, group II without ileostomy closure. Patient-related parameters (underlying disease, operation method) and parameters based on the findings (stenosis, leakage of anastomosis, incontinence) were evaluated. Results Analyzing a total of 252 patients in 89 % (group I, n = 225) ileostomy closure was performed. In 15 % the radiologic report was the only diagnostic modality needed for therapy decision; in 36 % the contrast enema and one or more other diagnostic methods were decisive. In 36 % the radiological report of the contrast imaging was not relevant for decision at all. In 11 % (group II, n = 27) no ileostomy closure was performed. In this group in 11 % the radiological report of the contrast enema was the only decision factor for not performing the ileostomy reversal. In 26 % one or more examination was necessary. In 26 % the result of the contrast examination was not relevant. Conclusion The radiologic contrast imaging of loop ileostomy solely plays a minor role in complex surgical decision-making before planned reversal, but is important as first imaging method in detecting complications and often leads to additional examinations. Key points · Contrast enema of loop ileostomy before planned ileostomy closure is a frequently performed examination.. · There exist no general guidelines that give further recommendations on decision-making planning ileostomy closure.. · The radiologic contrast imaging of loop ileostomy solely plays a minor role in decision-making before planned reversal, but is important as first imaging method.. Citation Format · Goetz A, da Silva NP, Moser C et al. Clinical Value of Contrast Enema Prior to Ileostomy Closure. Fortschr Röntgenstr 2017; 189: 855 - 863.

Anesthesia for Ambulatory Pediatric Surgery in Sub-Saharan Africa: A Pilot Study in Burkina Faso.

BACKGROUND: Long surgical wait times and limited hospital capacity are common obstacles to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery might contribute to a solution to these problems. The purpose of this study was to evaluate the safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA. METHODS: This is a cross-sectional descriptive study that took place over 6 months. It includes all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1 year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of bleeding, lasting <90 minutes, and with an expectation of mild to moderate postoperative pain. The family had to live within 1 hour of the hospital and be available by telephone. RESULTS: During the study period, a total of 1250 patients underwent surgery, of whom 515 were elective cases; 115 of these met the criteria for ambulatory surgery; 103 patients, with an average age of 59.74 ± 41.57 months, actually underwent surgery. The principal indications for surgery were inguinal (62) and umbilical (47) hernias. All patients had general anesthesia with halothane. Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or nerve block in 20.77%. The average duration of surgery was 33 ± 17.47 minutes. No intraoperative complications were noted. All the patients received acetaminophen and a nonsteroidal anti-inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery, principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital. CONCLUSIONS: No serious complications were associated with ambulatory surgery. Its introduction could possibly be a solution to improving pediatric surgical access in low-income countries.

Experience With Opportunistic Salpingectomy in a Large, Community-Based Health System in the United States.

OBJECTIVE: To evaluate the trend in uptake of salpingectomy at the time of hysterectomy and assess physicians' attitudes toward the practice. METHODS: This was a retrospective cohort study using the electronic medical record to identify women 18 years of age or older undergoing hysterectomy from June 2011 to May 2014 in a large integrated health care delivery system. The primary outcome was the change in rate of opportunistic salpingectomy over time and after a systemwide practice recommendation was issued in May 2013. Secondary outcomes included data on blood loss, operating time, and length of stay. RESULTS: Of the 12,143 hysterectomies performed over the 3-year study period, 7,498 were performed without oophorectomy. There was a statistically significant rise in rate of salpingectomy over time from 14.7% for June 2011 to May 2012 to 44.6% from June 2012 to May 2013 and to 72.7% from June 2013 to May 2014 (P<.001). Sixty-one percent of laparoscopic hysterectomies were performed with salpingectomy, whereas only 25% of abdominal and 17% of vaginal hysterectomies had salpingectomies. Median estimated blood loss was lower in the salpingectomy group, 100 compared with 150 mL (P<.01). There was a significantly shorter median operating time (147 compared with 154 minutes, P=.002) for laparoscopic hysterectomy with bilateral salpingectomy compared with laparoscopic hysterectomy alone. CONCLUSION: Rates of salpingectomy increased significantly over time, consistent with the high reported acceptance rate reported by health care providers and highlighting the importance of physician education to improve compliance with risk-reducing clinical strategies.

Success of elective cholecystectomy treatment plans after emergency department visit.

BACKGROUND: Differentiation between patients with acute cholecystitis and patients with severe biliary colic can be challenging. Patients with undiagnosed acute cholecystitis can incur repeat emergency department (ED) visits, which is resource intensive. METHODS: Billing records from 2000-2013 of all adults who visited the ED in the 30 d preceding their cholecystectomy were analyzed. Patients who were discharged from the ED and underwent elective cholecystectomy were compared with those who were discharged and returned to the ED within 30 d. T-tests, chi-square tests, and multivariable analysis were used as appropriate. RESULTS: From 2000-2013, 3138 patients (34%) presented to the ED within 30 d before surgery, 63% were women, mean age 51 y, and of those 1625 were directly admitted from the ED for cholecystectomy, whereas 1513 patients left the ED to return for an elective cholecystectomy. Patients who were discharged were younger (mean age 49 versus 54 y, P < 0.001) and had shorter ED stays (5.9 versus 7.2 h, P < 0.001) than the patients admitted immediately. Of the discharged patients, 303 (20%) returned to the ED within 30 d to undergo urgent cholecystectomy. Compared with patients with successful elective cholecystectomy after the ED visit, those who failed the pathway were more likely to have an American Society of Anesthesiologists score ≥3 and were <40 or ≥60 compared with the successful group. CONCLUSIONS: One in five patients failed the elective cholecystectomy pathway after ED discharge, leading to additional patient distress and use of resources. Further risk factor assessment may help design efficient care pathways.