Effect of neurosurgical residency programs on neurosurgical patient outcomes in a single health care system: a cohort study.

BACKGROUND: The evidence on the benefits and drawbacks of involving neurosurgical residents in the care of patients who undergo neurosurgical procedures is heterogeneous. We assessed the effect of neurosurgical residency programs on the outcomes of such patients in a large single-payer public health care system. METHODS: Ten population-based cohorts of adult patients in Ontario who received neurosurgical care from 2013 to 2017 were identified on the basis of procedural codes, and the cohorts were followed in administrative health data sources. Patient outcomes by the status of the treating hospital (with or without a neurosurgical residency program) within each cohort were compared with models adjusted for a priori confounders and with adjusted multilevel models (MLMs) to also account for hospital-level factors. RESULTS: A total of 46 608 neurosurgical procedures were included. Operative time was 8%-30% longer in hospitals with neurosurgical residency programs in 9 out of 10 cohorts. Thirty-day mortality was lower in hospitals with neurosurgical residency programs for aneurysm repair (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.20-0.44), cerebrospinal fluid shunting (OR 0.52, 95% CI 0.34-0.79), intracerebral hemorrhage evacuation (OR 0.66, 95% CI 0.52-0.84), and posterior lumbar decompression (OR 0.32, 95% CI 0.15-0.65) in adjusted models. The mortality rates remained significantly different only for aneurysm repair (OR 0.19, 95% CI 0.05-0.69) and cerebrospinal shunting (OR 0.42, 95% CI 0.21-0.85) in MLMs. Length of stay was mostly shorter in hospitals with neurosurgical residents, but this finding did not persist in MLMs. Thirty-day reoperation rates did not differ between hospital types in MLMs. For 30-day readmission rates, only extracerebral hematoma decompression was significant in MLMs (OR 1.41, 95% CI 1.07-1.87). CONCLUSION: Hospitals with neurosurgical residents had longer operative times with similar to better outcomes. Most, but not all, of the differences between hospitals with and without residency programs were explained by hospital-level variables rather than direct effects of residents.

Sex-based differences in referral of heart failure patients to outpatient clinics: a scoping review.

BACKGROUND: Guidelines recommend that hospitalized patients newly diagnosed with HF be referred to an outpatient HF clinic (HFC) within 2 weeks of discharge. Our study aims were (i) to assess the current literary landscape on the impact of patient sex on HFC referral and outcomes and (ii) to provide a qualitative overview of possible considerations for the impact of sex on referral patterns and HF characteristics including aetiology, symptom severity, investigations undertaken and pharmacologic therapy. METHODS AND RESULTS: We conducted a scoping review using the Arksey and O'Malley framework and searched Medline, EMBASE, PsychINFO, Cochrane Library, Ageline databases and grey literature. Eligible articles included index HF hospitalizations or presentations to the Emergency Department (ED), a description of the HFC referral of patients not previously followed by an HF specialist and sex-specific analysis. Of the 11 372 potential studies, 8 met the inclusion criteria. These studies reported on a total of 11 484 participants, with sample sizes ranging between 168 and 3909 (25.6%-50.7% female). The included studies were divided into two groups: (i) those outlining the referral process to an HFC and (ii) studies which include patients newly enrolled in an HFC. Of the studies in Group 1, males (51%-82.4%) were more frequently referred to an HFC compared with females (29%-78.1%). Studies in Group 2 enrolled a higher proportion of males (62%-74% vs. 26%-38%). One study identified independent predictors of HFC referral which included male sex, younger age, and the presence of systolic dysfunction, the latter two more often found in males. Two studies, one from each group reported a higher mortality amongst males compared with females, whereas another study from Group 2 reported a higher hospitalization rate amongst females following HFC assessment. CONCLUSIONS: Males were more likely than females to be referred to HFCs after hospitalization and visits to the Emergency Department, however heterogeneity across studies precluded a robust assessment of sex-based differences in outcomes. This highlights the need for more comprehensive longitudinal data on HF patients discharged from the acute care setting to better understand the role of sex on patient outcomes.

Derivation of Patient-Defined Adverse Cardiovascular and Noncardiovascular Events Through a Modified Delphi Process.

Importance: There is little evidence to support patient-centered outcomes in patients with cardiovascular disease. Objective: To derive patient-defined adverse cardiovascular and noncardiovascular events (PACE) through a consensus-based process. Design, Setting, and Participants: This pan-Canadian, consensus-based, qualitative study used an iterative Delphi method to achieve consensus within a 35-member panel consisting of patients with cardiovascular diseases and their caregivers and clinicians. The process included 4 rounds of online questionnaires, followed by an in-person final consensus meeting. Data analysis was performed in September 2019. Main Outcomes and Measures: Defining PACE as a 5-item composite outcome. Results: Thirty-five potential panelists consented to participate, including 11 clinicians (8 men [73%]) and 24 patients and caregivers (13 men [54%]). Twenty-nine (83%), 28 (80%), 26 (74%), and 23 (66%) of the panelists participated in each of respective the online rounds. A shortlist of 11 patient-defined items was further refined at the in-person meeting, which 20 of the panelists attended. The PACE definition that was decided through the consensus process was a composite of severe stroke necessitating hospitalization for 14 days or longer or inpatient rehabilitation, ventilator dependence, new onset or worsening heart failure, nursing home admission, or new onset dialysis. Conclusions and Relevance: This study defined PACE as a versatile, patient-centered outcome through a consensus process with input from patients, caregivers, and clinicians. Given the paucity of patient-centered outcomes in cardiovascular research, PACE may be considered as a potential outcome after methodological evaluation of its reliability.