Association between anaesthesia-surgery team sex diversity and major morbidity.

BACKGROUND: Team diversity is recognized not only as an equity issue but also a catalyst for improved performance through diversity in knowledge and practices. However, team diversity data in healthcare are limited and it is not known whether it may affect outcomes in surgery. This study examined the association between anaesthesia-surgery team sex diversity and postoperative outcomes. METHODS: This was a population-based retrospective cohort study of adults undergoing major inpatient procedures between 2009 and 2019. The exposure was the hospital percentage of female anaesthetists and surgeons in the year of surgery. The outcome was 90-day major morbidity. Restricted cubic splines were used to identify a clinically meaningful dichotomization of team sex diversity, with over 35% female anaesthetists and surgeons representing higher diversity. The association with outcomes was examined using multivariable logistic regression. RESULTS: Of 709 899 index operations performed at 88 hospitals, 90-day major morbidity occurred in 14.4%. The median proportion of female anaesthetists and surgeons was 28 (interquartile range 25-31)% per hospital per year. Care in hospitals with higher sex diversity (over 35% female) was associated with reduced odds of 90-day major morbidity (OR 0.97, 95% c.i. 0.95 to 0.99; P = 0.02) after adjustment. The magnitude of this association was greater for patients treated by female anaesthetists (OR 0.92, 0.88 to 0.97; P = 0.002) and female surgeons (OR 0.83, 0.76 to 0.90; P < 0.001). CONCLUSION: Care in hospitals with greater anaesthesia-surgery team sex diversity was associated with better postoperative outcomes. Care in a hospital reaching a critical mass with over 35% female anaesthetists and surgeons, representing higher team sex-diversity, was associated with a 3% lower odds of 90-day major morbidity.

Association of chronic poststernotomy pain and health-related quality of life: a prospective cohort study.

PURPOSE: Chronic poststernotomy pain (CPSP) after cardiac surgery is multifactorial and impacts patient recovery. We aimed to evaluate the association between CPSP severity and health-related quality of life at six months after cardiac surgery. METHODS: This was a single-centre prospective cohort study of patients who underwent cardiac surgery with median sternotomy between September 2020 and March 2021. Telephone interviews were conducted at six and 12 months postoperatively using the Short Form McGill Pain Questionnaire and the EQ-5D-5L. Strength of correlation was described using Spearman's correlation coefficient. Multivariable regression analysis was used to account for confounding variables. RESULTS: A total of 252 patients responded to the six-month interview (response rate, 65%). The mean (standard deviation) age of respondents was 65 (13) yr. Twenty-nine percent of respondents (72/252) reported CPSP at six months, and 14% (41/252) reported more than mild pain (score ≥ 2/5). At 12 months, of the 89% (64/72) patients who responded, 47% (30/64) still reported pain. The strength of the correlation between pain scores and EQ-5D-5L was weak (Spearman's correlation coefficient, -0.3). Risk factors for CPSP at six months included higher pain score on postoperative day 1, history of chronic pain prior to surgery, and history of depression. Intraoperative infusion of dexmedetomidine or ketamine was associated with a reduced risk of CPSP at six months. CONCLUSION: Chronic poststernotomy pain still affects patient recovery at six and 12 months after cardiac surgery. The severity of that pain is poorly correlated with patients' quality of life. STUDY REGISTRATION: www.osf.io ( https://osf.io/52rsw ); registered 14 May 2022.

RéSUMé: OBJECTIF: La douleur chronique post-sternotomie (DCPS) après une chirurgie cardiaque est multifactorielle et a un impact sur le rétablissement des patient·es. Nous avons cherché à évaluer l'association entre la sévérité de la DCPS et la qualité de vie liée à la santé six mois après la chirurgie cardiaque. MéTHODE: Il s'agissait d'une étude de cohorte prospective monocentrique portant sur des patient·es ayant bénéficié d'une chirurgie cardiaque avec sternotomie médiane entre septembre 2020 et mars 2021. Des entrevues téléphoniques ont été menées à six et 12 mois après l'opération en se servant du questionnaire abrégé de McGill sur la douleur et de l'EQ-5D-5L. La force de corrélation a été décrite à l'aide du coefficient de corrélation de Spearman. Une analyse de régression multivariée a été utilisée pour tenir compte des variables confondantes. RéSULTATS: Au total, 252 patient·es ont répondu à l'entrevue à six mois (taux de réponse de 65 %). L'âge moyen (écart type) des répondant·es était de 65 (13) ans. Vingt-neuf pour cent des personnes répondantes (72/252) ont déclaré avoir été atteintes de DCPS à six mois, et 14 % (41/252) ont signalé une douleur plus que légère (score ≥ 2/5). À 12 mois, sur les 89 % (64/72) personnes ayant répondu, 47 % (30/64) signalaient encore de la douleur. La force de la corrélation entre les scores de douleur et l'EQ-5D-5L était faible (coefficient de corrélation de Spearman, −0,3). Les facteurs de risque de DCPS à six mois comprenaient un score de douleur plus élevé au jour 1 postopératoire, des antécédents de douleur chronique avant la chirurgie et des antécédents de dépression. Une perfusion peropératoire de dexmédétomidine ou de kétamine a été associée à une réduction du risque de DCPS à six mois. CONCLUSION: La douleur chronique post-sternotomie affecte toujours le rétablissement des patient·es six et 12 mois après la chirurgie cardiaque. La sévérité de cette douleur est faiblement corrélée à la qualité de vie des patient·es. ENREGISTREMENT DE L'éTUDE: www.osf.io ( https://osf.io/52rsw ); enregistrée le 14 mai 2022.

Frailty: Implications for Neuroanesthesia.

Frailty is increasingly prevalent in the aging neurosurgical population and is an important component of perioperative risk stratification and optimization to reduce complications. Frailty is measured using the phenotypic or deficit accumulation models, with simplified tools most commonly used in studies of neurosurgical patients. There are a limited number of frailty measurement tools that have been validated for individuals with neurological disease, and those that exist are mainly focused on spine pathology. Increasing frailty consistently predicts worse outcomes for patients across a range of neurosurgical procedures, including early complications, disability, non-home discharge, and mortality. Evidence for interventions to improve outcomes for frail neurosurgical patients is limited, and the role of bundled care pathways, prehabilitation, and multidisciplinary involvement requires further investigation. Surgery itself may be an intervention to improve frailty in selected patients, and future research should focus on identifying effective interventions to improve both short-term complications and long-term outcomes.

Association Between Anesthesiologist Sex and Patients' Postoperative Outcomes: A Population-based Cohort Study.

OBJECTIVE: To examine the association of anesthesiologist sex on postoperative outcomes. BACKGROUND: Differences in patient postoperative outcomes exist, depending on whether the primary surgeon is male or female, with better outcomes seen among patients treated by female surgeons. Whether the intraoperative anesthesiologist's sex is associated with differential postoperative patient outcomes is unknown. METHODS: We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007 to 2019 in Ontario, Canada. We assessed the association between the sex of the intraoperative anesthesiologist and the primary end point of the adverse postoperative outcome, defined as death, readmission, or complication within 30 days after surgery, using generalized estimating equations. RESULTS: Among 1,165,711 patients treated by 3006 surgeons and 1477 anesthesiologists, 311,822 (26.7%) received care from a female anesthesiologist and 853,889 (73.3%) from a male anesthesiologist. Overall, 10.8% of patients experienced one or more adverse postoperative outcomes, of whom 1.1% died. Multivariable adjusted rates of the composite primary end point were higher among patients treated by male anesthesiologists (10.6%) compared with female anesthesiologists (10.4%; adjusted odds ratio 1.02, 95% CI: 1.00-1.05, P =0.048). CONCLUSIONS: We demonstrated a significant association between sex of the intraoperative anesthesiologist and patient short-term outcomes after surgery in a large cohort study. This study supports the growing literature of improved patient outcomes among female practitioners. The underlying mechanisms of why outcomes differ between male and female physicians remain elusive and require further in-depth study.

Perioperative cortical hand stroke syndrome mimicking peripheral neuropathy: a case report.

PURPOSE: Timely diagnosis of perioperative stroke is challenging, and therapeutic interventions are infrequently offered. The cortical hand syndrome is a rare stroke presentation that results from infarction of the precentral gyrus leading to variable neurologic deficits mimicking peripheral nerve injuries, with no prior reports in the perioperative setting. To raise awareness of this complication among anesthesiologists, we present a case of cortical hand syndrome in a surgical patient initially suspected to have a peripheral neuropathy. CLINICAL FEATURES: A 68-yr-old male with multiple stroke risk factors underwent a nephroureterectomy under general anesthesia and thoracic epidural analgesia for urothelial carcinoma. The patient noted right-hand numbness and weakness to digits 3-5 immediately after surgery and notified his bedside nurse the following day. His symptoms were initially presumed to be a peripheral neuropathy secondary to surgical positioning. Computed tomography of the head the following day revealed an acute cortical infarct in the precentral gyrus consistent with cortical hand stroke syndrome. Subsequent neurologic consultation revealed additional subtle right-sided weakness. Further workup revealed moderate (60-80%) stenosis of the left carotid artery and he underwent a successful carotid endarterectomy one week later. His symptoms had mostly resolved six weeks later. CONCLUSION: Cortical hand stroke syndrome is a rare presentation of perioperative stroke that may be misdiagnosed as a peripheral neuropathy. Our case presentation highlights that perioperative stroke should be considered for patients presenting with neurologic deficits of the hand, particularly those with deficits in multiple peripheral nerve territories and stroke risk factors.

RéSUMé: OBJECTIF: Le diagnostic rapide de l'accident vasculaire cérébral (AVC) périopératoire est difficile, et les interventions thérapeutiques sont rarement proposées. Le syndrome de la main corticale est une présentation rare de l'AVC qui résulte d'un infarctus du gyrus précentral entraînant des déficits neurologiques variables imitant les lésions nerveuses périphériques, sans avoir été préalablement rapporté dans le cadre périopératoire. Afin de sensibiliser les anesthésiologistes à cette complication, nous présentons un cas de syndrome de la main corticale chez un patient chirurgical chez lequel une neuropathie périphérique était initialement suspectée. CARACTéRISTIQUES CLINIQUES: Un homme de 68 ans présentant de multiples facteurs de risque d'AVC a subi une néphro-urétérectomie sous anesthésie générale et une analgésie péridurale thoracique pour un carcinome urothélial. Le patient a remarqué un engourdissement et une faiblesse de la main droite du majeur à l'auriculaire immédiatement après la chirurgie et a avisé le personnel infirmier à son chevet le lendemain. On a d'abord présumé que ses symptômes indiquaient une neuropathie périphérique secondaire au positionnement chirurgical. La tomodensitométrie de la tête réalisée le lendemain a révélé un infarctus cortical aigu dans le gyrus précentral, compatible avec un syndrome d'AVC de la main corticale. Une consultation neurologique ultérieure a révélé une faiblesse subtile supplémentaire du côté droit. Un examen plus approfondi a révélé une sténose modérée (60 à 80 %) de l'artère carotide gauche et le patient a bénéficié d' une endartériectomie carotidienne réussie une semaine plus tard. Ses symptômes avaient pour la plupart disparu six semaines plus tard. CONCLUSION: Le syndrome de l'AVC de la main corticale est une présentation rare d'AVC périopératoire qui peut être diagnostiqué à tort comme une neuropathie périphérique. Notre présentation de cas souligne que l'AVC périopératoire devrait être envisagé chez les patient·es présentant des déficits neurologiques de la main, en particulier chez les personnes présentant des déficits dans plusieurs territoires nerveux périphériques et des facteurs de risque d'AVC.

Healthcare delivery gaps in pain management within the first 3 months after discharge from inpatient noncardiac surgeries: a scoping review.

BACKGROUND: Poor pain control during the postoperative period has negative implications for recovery, and is a critical risk factor for development of persistent postsurgical pain. The aim of this scoping review is to identify gaps in healthcare delivery that patients undergoing inpatient noncardiac surgeries experience in pain management while recovering at home. METHODS: Searches were conducted by a medical librarian in PubMed, MEDLINE, EMBASE, EBSCO CINAHL, Web of Science, and Cochrane Database of Systematic Reviews for articles published between 2016 and 2022. Inclusion criteria were adults (≥18 yr), English language, inpatient noncardiac surgery, and included at least one gap in care for acute and/or persistent pain management after surgery within the first 3 months of recovery at home. Two reviewers independently screened articles for inclusion and extracted data. Quotations from each article related to gaps in care were synthesised using thematic analysis. RESULTS: There were 4794 results from databases and grey literature, of which 38 articles met inclusion criteria. From these, 23 gaps were extracted, encompassing all six domains of healthcare delivery (capacity, organisational structure, finances, patients, care processes and infrastructure, and culture). Identified gaps were synthesised into five overarching themes: education (22 studies), provision of continuity of care (21 studies), individualised management (10 studies), support for specific populations (11 studies), and research and knowledge translation (10 studies). CONCLUSIONS: This scoping review identified health delivery gaps during a critical period in postoperative pain management. These gaps represent potential targets for quality improvement and future research to improve perioperative care and longer-term patient-centred outcomes. SCOPING REVIEW PROTOCOL: Open Science Framework (https://osf.io/cq5m6/).

Innovating for Value-Based Surgical Care in Canada: A Post-Pandemic Necessity.

Providing high-quality, efficient and cost-effective surgical care to Canadians has become increasingly challenging since the pandemic, resulting in long waitlists due to limited staff and resources. The pandemic has facilitated some areas of innovation in surgical care, notably in virtual care and expedited discharge, although many challenges remain. Key policy recommendations for reform include investing in infrastructure to collect and report on value-based metrics beyond volume, devising strategies to improve health equity, enhancing out-of-hospital support for surgical patients by using remote monitoring and digital technology, increasing patient segmentation into low- and high-complexity pathways, centralizing surgical triage and initiating careful financial incentivization of integrated groups of clinicians.

Outcomes of COVID-19 manuscripts submitted to the Canadian Journal of Anesthesia: a retrospective audit of author gender and person of colour status.

PURPOSE: We aimed to evaluate the representation of women and persons of colour (POC) authors of COVID-19 manuscripts submitted to, accepted in, and rejected from the Journal and to evaluate trends in their representation during the pandemic. METHODS: All COVID-19 manuscripts submitted to the Journal between 1 February 2020 and 30 April 2021 were included. Manuscript data were retrieved from Editorial Manager, and gender and POC status were obtained through: 1) e-mail communication with corresponding authors; 2) e-mail queries to other coauthors; 3) NamSor software, and 4) Internet searches. The data were described using percentages and summary statistics. A two-sample test of proportions was used for comparisons and trends were analyzed with linear regression. RESULTS: We identified 314 manuscripts (1,555 authors), 95 (461 authors) of which were accepted for publication. Of all authors, 515 (33%) were women, and women were the lead and senior authors of 101 (32%) and 69 (23%) manuscripts, respectively. There were no differences in women's representation as authors between accepted and rejected manuscripts. Overall, 923/1,555 (59%) authors were identified as POC, with a significantly lower proportion of POC authors among accepted vs rejected manuscripts (41%, 188/461 vs 67%, 735/1,094; difference, -26%; 95% CI, -32 to -21; P < 0.001). We did not observe significant trends in the proportion of women and POC authors over the study period. CONCLUSION: The proportion of women authors of COVID-19 manuscripts was lower than men's representation. Further research is required to determine the factors that account for the higher proportion of POC authors across rejected manuscripts.

RéSUMé: OBJECTIF: Nous avions pour objectif d'évaluer la représentation des femmes et des personnes de couleur ayant rédigé des manuscrits portant sur la COVID-19 soumis, acceptés et rejetés au Journal et d'évaluer les tendances concernant leur représentation pendant la pandémie. MéTHODE: Tous les manuscrits portant sur la COVID-19 soumis au Journal entre le 1er février 2020 et le 30 avril 2021 ont été inclus. Les données des manuscrits ont été extraites de la plateforme de gestion des manuscrits Editorial Manager, et le sexe et le statut de personne de couleur ont été obtenus par : 1) la communication par courrier électronique avec les auteurs et autrices correspondant·es; 2) des requêtes par courrier électronique envoyées à d'autres coautrices et coauteurs; 3) le logiciel NamSor, et 4) des recherches sur Internet. Les données ont été décrites à l'aide de pourcentages et de statistiques sommaires. Un test de proportions à deux échantillons a été utilisé pour les comparaisons et les tendances ont été analysées par régression linéaire. RéSULTATS: Nous avons identifié 314 manuscrits (1555 auteurs et autrices), dont 95 (461 autrices et auteurs) ont été acceptés pour publication. Parmi tou·tes les auteurs/autrices, 515 (33 %) étaient des femmes, et les femmes étaient les autrices principales et senior de 101 (32 %) et 69 (23 %) manuscrits, respectivement. Il n'y avait aucune différence dans la représentation des femmes en tant qu'autrices entre les manuscrits acceptés et rejetés. Dans l'ensemble, 923/1555 (59 %) auteurs et autrices ont été identifié·es comme étant des personnes de couleur, avec une proportion significativement plus faible d'autrices et d'auteurs de couleur parmi les manuscrits acceptés vs rejetés (41 %, 188/461 vs 67 %, 735/1094; différence, -26 %; IC 95 %, -32 à -21; P < 0,001). Nous n'avons pas observé de tendances significatives dans la proportion d'auteurs et d'autrices femmes et de couleur au cours de la période à l'étude. CONCLUSION: La proportion de femmes autrices de manuscrits sur la COVID-19 était inférieure à celle des hommes. D'autres recherches sont nécessaires pour déterminer les facteurs qui expliquent la plus grande proportion d'autrices et d'auteurs de couleur parmi les manuscrits rejetés.

Associations between perceptions of shared decision making and health among hysterectomy patients: A prospective observational study.

OBJECTIVE: To investigate patient and clinical factors that are associated with perceptions of shared decision making between hysterectomy patients and surgeons and to evaluate associations between shared decision making and postoperative health. METHODS: This study is based on a prospective cohort scheduled for hysterectomy for benign conditions in Vancouver, Canada. Validated patient-reported outcomes assessed shared decision making, pelvic health, depression, and pain. Regression analyses measured the association between perceptions of shared decision making with patient and clinical factors. Then, associations between shared decision making with postoperative pelvic health, pain and depression were evaluated using regression analysis and adjusted for patient and clinical factors. RESULTS: In this study, 308 participants completed preoperative measures, and a subset of 146 participants also completed the postoperative measures. More than 50% of participants reported less than optimal shared decision making scores. No significant associations were identified between patients' perceptions of shared decision making with patients' age, comorbidities, socioeconomic factors, indication for surgery, or preoperative depression and pain. Regression analyses found that higher/better self-reported shared decision making scores were associated with fewer postoperative pelvic organ symptoms (P = 0.01). CONCLUSION: Many patients' reporting lower than optimal scores on the shared decision making instrument highlight the opportunity to improve surgeon-patient communication in this surgical cohort. Strengthening shared decision making between surgeons and their patients may be associated with improved self-reported postoperative health.

The Role of Frailty and Sarcopenia in Predicting Major Adverse Events, Length of Stay and Reoperation Following En Bloc Resection of Primary Tumours of the Spine.

STUDY DESIGN: Retrospective observational cohort study. OBJECTIVE: En bloc resection for primary tumours of the spine is associated with a high rate of adverse events (AEs). The objective was to explore the relationship between frailty/sarcopenia and major perioperative AEs, length of stay (LOS), and unplanned reoperation following en bloc resection of primary spinal tumours. METHODS: This is a unicentre study consisting of adult patients undergoing en bloc resection for a primary spine tumor. Frailty was calculated with the modified frailty index (mFI) and spine tumour frailty index (STFI). Sarcopenia was quantified with the total psoas area/vertebral body area ratio (TPA/VB) at L3 and L4. Univariable regression analysis was used to quantify the association between frailty/sarcopenia and major perioperative AEs, LOS and unplanned reoperation. RESULTS: 95 patients met the inclusion criteria. The mFI and STFI identified a frailty prevalence of 3% and 18%. Mean CT TPA/VB ratios were 1.47 (SD ± .05) and 1.83 (SD ± .06) at L3 and L4. Inter-observer reliability was .93 and .99 for CT and MRI L3 and L4 TPA/VB ratios. Unadjusted analysis demonstrated sarcopenia and mFI did not predict perioperative AEs, LOS or unplanned reoperation. Frailty defined by an STFI score ≥2 predicted unplanned reoperation for surgical site infection (SSI) (P < .05). CONCLUSIONS: The STFI was only associated with unplanned reoperation for SSI on unadjusted analysis, while the mFI and sarcopenia were not predictive of any outcome. Further studies are needed to investigate the relationship between frailty, sarcopenia and perioperative outcomes following en bloc resection of primary spinal tumors.

Variation in Anesthesiology Provider-Volume for Complex Gastrointestinal Cancer Surgery: A Population-Based Study.

OBJECTIVE: Examine between-hospital and between-anesthesiologist variation in anesthesiology provider-volume (PV) and delivery of high-volume anesthesiology care. BACKGROUND: Better outcomes for anesthesiologists with higher PV of complex gastrointestinal cancer surgery have been reported. The factors linking anesthesiology practice and organization to volume are unknown. METHODS: We identified patients undergoing elective esophagectomy, hepatectomy, and pancreatectomy using linked administrative health data sets (2007-2018). Anesthesiology PV was the annual number of procedures done by the primary anesthesiologist in the 2 years before the index surgery. High-volume anesthesiology was PV>6 procedures/year. Funnel plots to described variation in anesthesiology PV and delivery of high-volume care. Hierarchical regression models examined between-anesthesiologist and between-hospital variation in delivery of high-volume care use with variance partition coefficients (VPCs) and median odds ratios (MORs). RESULTS: Among 7893 patients cared for at 17 hospitals, funnel plots showed variation in anesthesiology PV (median ranging from 1.5, interquartile range: 1-2 to 11.5, interquartile range: 8-16) and delivery of HV care (ranging from 0% to 87%) across hospitals. After adjustment, 32% (VPC 0.32) and 16% (VPC: 0.16) of the variation were attributable to between-anesthesiologist and between-hospital differences, respectively. This translated to an anesthesiologist MOR of 4.81 (95% CI, 3.27-10.3) and hospital MOR of 3.04 (95% CI, 2.14-7.77). CONCLUSIONS: Substantial variation in anesthesiology PV and delivery of high-volume anesthesiology care existed across hospitals. The anesthesiologist and the hospital were key determinants of the variation in high-volume anesthesiology care delivery. This suggests that targeting anesthesiology structures of care could reduce variation and improve delivery of high-volume anesthesiology care.

Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery.

Importance: The surgeon-anesthesiologist teamwork and relationship is crucial to good patient outcomes. Familiarity among work team members is associated with enhanced success in multiple fields but rarely studied in the operating room. Objective: To examine the association between surgeon-anesthesiologist dyad familiarity-as the number of times working together-with short-term postoperative outcomes for complex gastrointestinal cancer surgery. Design, Setting, and Participants: This population-based retrospective cohort study based in Ontario, Canada, included adults undergoing esophagectomy, pancreatectomy, and hepatectomy for cancer from 2007 through 2018. The data were analyzed January 1, 2007, through December 21, 2018. Exposures: Dyad familiarity captured as the annual volume of procedures of interest done by the surgeon-anesthesiologist dyad in the 4 years before the index surgery. Main Outcomes and Measures: Ninety-day major morbidity (any Clavien-Dindo grade 3 to 5). The association between exposure and outcome was examined using multivariable logistic regression. Results: Seven thousand eight hundred ninety-three patients with a median age of 65 years (66.3% men) were included. They were cared for by 737 anesthesiologists and 163 surgeons who were also included. The median surgeon-anesthesiologist dyad volume was 1 (range, 0-12.2) procedures per year. Ninety-day major morbidity occurred in 43.0% of patients. There was a linear association between dyad volume and 90-day major morbidity. After adjustment, the annual dyad volume was independently associated with lower odds of 90-day major morbidity, with an odds ratio of 0.95 (95% CI, 0.92-0.98; P = .01) for each incremental procedure per year, per dyad. The results did not change when examining 30-day major morbidity. Conclusions and Relevance: Among adults undergoing complex gastrointestinal cancer surgery, increasing familiarity of the surgeon-anesthesiologist dyad was associated with improved short-term patient outcomes. For each additional time that a unique surgeon-anesthesiologist dyad worked together, the odds of 90-day major morbidity decreased by 5%. These findings support organizing perioperative care to increase the familiarity of surgeon-anesthesiologist dyads.

The Association Between Hospital High-volume Anesthesiology Care and Patient Outcomes for Complex Gastrointestinal Cancer Surgery: A Population-based Study.

OBJECTIVE: To examine the association of between hospital rates of high-volume anesthesiology care and of postoperative major morbidity. BACKGROUND: Individual anesthesiology volume has been associated with individual patient outcomes for complex gastrointestinal cancer surgery. However, whether hospital-level anesthesiology care, where changes can be made, influences the outcomes of patients cared at this hospital is unknown. METHODS: We conducted a population-based retrospective cohort study of adults undergoing esophagectomy, pancreatectomy, or hepatectomy for cancer from 2007 to 2018. The exposure was hospital-level adjusted rate of high-volume anesthesiology care. The outcome was hospital-level adjusted rate of 90-day major morbidity (Clavien-Dindo grade 3-5). Scatterplots visualized the relationship between each hospital's adjusted rates of high-volume anesthesiology and major morbidity. Analyses at the hospital-year level examined the association with multivariable Poisson regression. RESULTS: For 7893 patients at 17 hospitals, the rates of high-volume anesthesiology varied from 0% to 87.6%, and of major morbidity from 38.2% to 45.4%. The scatter plot revealed a weak inverse relationship between hospital rates of high-volume anesthesiology and of major morbidity (Pearson: -0.23). The adjusted hospital rate of high-volume anesthesiology was independently associated with the adjusted hospital rate of major morbidity (rate ratio: 0.96; 95% CI, 0.95-0.98; P <0.001 for each 10% increase in the high-volume rate). CONCLUSIONS: Hospitals that provided high-volume anesthesiology care to a higher proportion of patients were associated with lower rates of 90-day major morbidity. For each additional 10% patients receiving care by a high-volume anesthesiologist at a given hospital, there was an associated reduction of 4% in that hospital's rate of major morbidity.

A comparison of patient-reported outcomes among Canadian women having hysterectomies.

PURPOSE: Many indications for hysterectomy can negatively affect patients' quality of life. This study uses patient-reported outcomes to measure changes in self-reported health among hysterectomy patients. METHOD: A prospective cohort of 294 hysterectomy patients completed patient-reported outcomes preoperatively and six months postoperatively in Vancouver, Canada. Patient-reported outcomes measured pelvic health, sexual function, pain, and depression. Changes in health were compared with paired t-tests, and multi-variable regression analysis measured associations between patient and clinical factors with postoperative outcomes RESULTS: Many patients reported improvements in health. Unadjusted analysis found that 65% of participants reported less pelvic distress, 55% reported less pain, and 47% reported less depression symptoms postoperatively. Multivariable regression analysis found that poorer preoperative health was associated with poorer postoperative outcomes in all domains of health measured (p-value < 0.01). Postoperative pain scores were lower (less pain) by 0.78 among residents of the most affluent neighborhoods (p-value = 0.02) compared to those in less affluent neighborhoods. Postoperative depression scores were 1.58 points worse among participants with endometriosis (p-value = 0.03) and 1.02 points worse among participants having abdominal surgery (p-value = 0.02). CONCLUSION: Many participants reported improvements in pelvic symptoms, pain, and depression after hysterectomy. Lower socioeconomic status patients may be at risk for reporting higher pain after surgery, and endometriosis patients may report higher depression. Further investigation is needed to determine effective interventions for the higher postoperative pain observed in this study for residents of less affluent neighborhoods.

Current Recommendations for Perioperative Brain Health: A Scoping Review.

Perioperative complications such as stroke, delirium, and neurocognitive dysfunction are common and responsible for increased morbidity and mortality. Our objective was to characterize and synthesize the contemporary guidelines on perioperative brain health for noncardiac, non-neurologic surgery in a scoping review. We performed a structured search for articles providing recommendations on brain health published between 2016 and 2021 and included the following complications: perioperative stroke and perioperative neurocognitive disorders, the latter of which encompasses postoperative delirium and a spectrum of postoperative cognitive dysfunction. We categorized recommendations by subtopic (stroke, postoperative delirium, postoperative cognitive dysfunction), type (disclosure/ethics/policies, prevention, risk stratification, screening/diagnosis, and management), and pharmacological versus nonpharmacological strategies. We noted country of origin, specialty of the authors, evidence grade (if available), and concordance/discordance between recommendations. Eight publications provided 129 recommendations, originating from the United States (n=5), Europe (n=1), United Kingdom (n=1), and China (n=1). Three publications (37%) applied grading of evidence as follows: Grading of Recommendations, Assessment, Development, and Evaluations (GRADE): A, 30%; B, 36%; C, 30%; D, 4%. We identified 42 instances of concordant recommendations (≥2 publications) on 15 themes, including risk factor identification, risk disclosure, baseline neurocognitive testing, nonpharmacological perioperative neurocognitive disorder prevention, intraoperative monitoring to prevent perioperative neurocognitive disorders, avoidance of benzodiazepines, delaying elective surgery after stroke, and emergency imaging and rapid restoration of cerebral perfusion after perioperative stroke. We identified 19 instances of discordant recommendations on 7 themes, including the use of regional anesthesia and monitoring for perioperative stroke prevention, pharmacological perioperative neurocognitive disorder management, and postoperative stroke screening. We synthesized recommendations for clinical practice and highlighted areas where high-quality evidence is required to inform best practices in perioperative brain health.

Value-based Care and Quality Improvement in Perioperative Neuroscience.

Value-based care and quality improvement are related concepts used to measure and improve clinical care. Value-based care represents the relationship between the incremental gain in outcome for patients and cost efficiency. It is achieved by identifying outcomes that are important to patients, codesigning solutions using multidisciplinary teams, measuring both outcomes and costs to drive further improvements, and developing partnerships across the health system. Quality improvement is focused on process improvement and compliance with best practice, and often uses "Plan-Do-Study-Act" cycles to identify, test, and implement change. Validated, standardized core outcome sets for perioperative neuroscience are currently lacking, but neuroanesthesiologists can consider using traditional clinical indicators, patient-reported outcomes measures, and perioperative core outcome measures. Several examples of bundled care solutions have been successfully implemented in perioperative neuroscience to increase value; for example, enhanced recovery for spine surgery, delirium reduction pathways, and same-day discharge craniotomy. This review proposes potential individual- and system-based solutions to address barriers to value-based care and quality improvement in perioperative neuroscience.

Association of anaesthesia technique with 30-day primary graft patency after open lower limb revascularization: retrospective cohort study.

BACKGROUND: The relationship between anaesthetic technique and graft patency after open lower limb revascularization is unclear. The aim of this study was to evaluate the association between 30-day graft patency after elective infrainguinal bypass and anaesthetic technique (regional anaesthesia (RA, i.e. neuraxial and/or peripheral nerve blockade) compared with general anaesthesia (GA)). METHODS: Patients who underwent elective infrainguinal bypass in the 2014-2019 National Surgical Quality Improvement Program Vascular Procedure Targeted Lower Extremity Open data set were included. Excluded patients were those under 18 years old, those who did not receive RA or GA, and/or had an international normalized ratio of 1.5 of greater, a partial thromboplastin time more than 35 s, or a platelet count less than 80 × 109/L. The primary outcome was primary graft patency without reintervention. The relationship between anaesthetic technique and patency was analysed with multivariable logistic regression. RESULTS: Included were 8893 patients with a mean(s.d.) age of 68(11) years and 31.5 per cent female. Within the cohort, 7.7 per cent (n = 688) patients received RA only, 90.4 per cent (n = 8039) GA only, and 1.9 per cent (n = 166) both GA and RA. In the RA-only group, 91.7 per cent (631 of 688) received neuraxial anaesthesia. The primary patency rate was 93.2 per cent (573 of 615) for RA only, and 91.5 per cent (6390 of 6983) for GA only (standardized mean difference, 0.063). RA was not associated with a higher rate of patency compared with GA (adjusted OR, 1.16; 95 per cent c.i., 0.83 to 1.63; P = 0.378). CONCLUSION: There was no association between anaesthetic technique and 30-day graft patency after elective infrainguinal bypass surgery. Further prospective studies would be useful to study the impact of anaesthesia technique on important patient-centred outcomes such as long-term patency and non-home discharge.