Decision analysis in cardiac surgery: a scoping review and methodological primer.

OBJECTIVES: Randomized controlled trials are the gold standard for evidence generation in medicine but are limited by their real-world generalizability, resource needs, shorter follow-up durations and inability to be conducted for all clinical questions. Decision analysis (DA) models may simulate trials and observational studies by using existing data and evidence- and expert-informed assumptions and extend analyses over longer time horizons, different study populations and specific scenarios, helping to translate population outcomes to patient-specific clinical and economic outcomes. Here, we present a scoping review and methodological primer on DA for cardiac surgery research. METHODS: A scoping review was performed using the PubMed/MEDLINE, EMBASE and Web of Science databases for cardiac surgery DA studies published until December 2021. Articles were summarized descriptively to quantify trends and ascertain methodological consistency. RESULTS: A total of 184 articles were identified, among which Markov models (N = 92, 50.0%) were the most commonly used models. The most common outcomes were costs (N = 107, 58.2%), quality-adjusted life-years (N = 96, 52.2%) and incremental cost-effectiveness ratios (N = 89, 48.4%). Most (N = 165, 89.7%) articles applied sensitivity analyses, most frequently in the form of deterministic sensitivity analyses (N = 128, 69.6%). Reporting of guidelines to inform the model development and/or reporting was present in 22.3% of articles. CONCLUSION: DA methods are increasing but remain limited and highly variable in cardiac surgery. A methodological primer is presented and may provide researchers with the foundation to start with or improve DA, as well as provide readers and reviewers with the fundamental concepts to review DA studies.

It's not the arrow, it's the archer: the role of the surgeon leader in a safety driven-era.

BACKGROUND: In an era where team communication and patient safety are paramount, standardized tools have been deemed critical to safe, efficient practice. In some cases-perhaps most notably in the surgical safety checklist (SSC)-these tools have been elevated as the key to safe patient care. However, effects of the SSC on patient safety in practice remain mixed. We explore the role and impact of the surgeon leader in the use of structured communication tools to understand how surgeon engagement impacts intraoperative teamwork. METHODS: Using a constructivist grounded theory approach, OR staff members (surgeons, anesthetists, nurses and perfusionists) were recruited to participate in a one-on-one semi-structured interview. The interview explored participant experiences working in the OR, focusing on the role and impact of the surgeon as leader. RESULTS: Engaged use of the surgical safety checklist by the attending surgeon had the potential to improve teamwork in the operating room. Surgeons who used the checklist to engage with their team and facilitate group discussion were able to avoid tensions later in the operation typically arising from lack of situation awareness and familiarity with team member experience levels. Surgeons who engaged with the SSC as more than a memory aid were able to foster a better team environment. CONCLUSIONS: Surgeons can harness their role as leader in the operating room by engaging with structured communication tools such as the SSC to foster improved teamwork.

Contextualizing the tone of the operating room in practice: drawing on the literature to connect the dots.

The study of teamwork in the operating room has made significant strides in uncovering key constructs which shape safe and effective intraoperative care. However, in recent years, there have been calls to understand teamwork in the operating room more fully by embracing the complexity of the intraoperative environment. We propose the construct of tone as a useful lens through which to understand intraoperative teamwork. In this article, we review the literature on culture, shared mental models, and psychological safety, linking each to the construct of tone. By identifying tone as a theoretical orientation to demonstrate the overlap between these concepts, we aim to provide a starting point for new ways to understand intraoperative team dynamics.

Predictors of premature termination and completion of randomized controlled trials.

Randomized clinical trials (RCTs) have a key role in progressing biomedical research and guiding clinical decision making, but premature termination remains high (up to 30%), raising concerns regarding funding expenditure and resource allocation. This brief report sought to identify variables associated with RCTs' premature termination and completion.

Engaging medical students in cardiac surgery: a focus on equity, diversity, and inclusion.

PURPOSE OF REVIEW: The Coronavirus Disease 2019 pandemic prohibited Canadian medical students from in-person observerships. This may be particularly detrimental to under-represented groups that may consider surgical subspecialties. To address the unprecedented need for alternative surgical career exploration and diversity within the profession, The University of Toronto Cardiac Surgery Interest Group and Division of Cardiac Surgery collaborated on virtual experiential programming. RECENT FINDINGS: Medical students were invited to virtual (1) observerships of a cardiac bypass case, (2) mentorship sessions with surgeons, (3) resident teaching sessions, (4) multidisciplinary case-based Heart Team discussions to further their understanding of the scope of Cardiac surgery, and (5) a virtual coronary anastomosis training program. Additionally, a comprehensive virtual program was spearheaded to increase interest in Cardiac surgery among low-income Black high school students. SUMMARY: Trainee response to the virtual education, mentorship, and skill acquisition was positive. Trainees reported high levels of interest in the profession, particularly among females and under-represented minorities, supporting the principles of equity diversity, and inclusion in Cardiac surgery.

Coronary artery bypass with single versus multiple arterial grafts in women: A meta-analysis.

OBJECTIVE: The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting. METHODS: A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome. RESULTS: A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P = .007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P = .003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P = .91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality. CONCLUSIONS: The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.

Angiographic Patency of Coronary Artery Bypass Conduits: An Updated Network Meta-Analysis of Randomized Trials.

INTRODUCTION: The second best conduit for coronary artery bypass grafting is uncertain. The objective of this study is to determine the second best conduit according to graft patency results from randomized controlled trials using a network meta-analysis. METHODS: A systematic literature search was conducted for randomized controlled trials comparing the angiographic patency rate of the no-touch saphenous vein (NT-SV), the radial artery (RA), the right internal thoracic artery (RITA), and the gastroepiploic artery (GEA) in reference to the conventionally harvested saphenous vein (CON-SV). The primary outcome was graft occlusion, and the secondary outcome was all-cause mortality. RESULTS: A total of 859 studies were retrieved, of which 18 were included. A total of 6,543 patients and 8,272 grafts were analyzed. The weighted mean angiographic follow-up time was 3.5 years. Compared with CON-SV, RA (incidence rate ratio [IRR] 0.56; 95% confidence interval [CI], 0.43-0.74) and NT-SV (IRR 0.56; 95% CI, 0.44-0.70) demonstrated lower graft occlusion. NT-SV and RA were ranked as the best conduits (rank score for NT-SV 0.88 vs. 0.87 for RA, 0.29 for GEA, 0.27 for CON-SV, and 0.20 for RITA). There was no significant difference in late mortality between different conduit types. CONCLUSION: RA and NT-SV are associated with significantly lower graft occlusion rates and are comparably ranked as the best conduit for patency.

Sweet victory: Optimizing glycemic control after coronary artery bypass grafting.

Poor glycemic control, regardless of patients' diabetic status, is associated with worse outcomes after coronary artery bypass grafting. As a result, in the perioperative and postoperative setting, the use of insulin is recommended to maintain glucose levels below 180 mg/dl (10.0 mmol/L). However, challenges exist and errors may occur that can prohibit adequate glucose management. In this commentary, we highlight a real-world example of an educational intervention to empower health workers in managing patients' glucose levels after coronary artery bypass grafting in order to improve postoperative outcomes. We discuss the current evidence and guidelines on peri- and postoperative glycemic control for patients undergoing cardiac surgery and present further quality improvement opportunities that may be introduced.

Impact of the COVID-19 Pandemic on Non-COVID-19 Clinical Trials.

Randomized controlled trials (RCT) were impacted by the COVID-19 pandemic, but no systematic analysis has evaluated the overall impact of COVID-19 on non-COVID-19-related RCTs. The ClinicalTrials.gov database was queried in February 2020. Eligible studies included all randomized trials with a start date after 1 January 2010 and were active during the period from 1 January 2015 to 31 December 2020. The effect of the pandemic period on non-COVID-19 trials was determined by piece-wise regression models using 11 March 2020 as the start of the pandemic and by time series analysis (models fitted using 2015-2018 data and forecasted for 2019-2020). The study endpoints were early trial stoppage, normal trial completion, and trial activation. There were 161,377 non-COVID-19 trials analyzed. The number of active trials increased annually through 2019 but decreased in 2020. According to the piece-wise regression models, trial completion was not affected by the pandemic (p = 0.56) whereas trial stoppage increased (p = 0.001). There was a pronounced decrease in trial activation early during the pandemic (p < 0.001) which then recovered. The findings from the time series models were consistent comparing forecasted and observed results (trial completion p = 0.22; trial stoppage p < 0.01; trial activation, p = 0.01). During the pandemic, there was an increase in non-COVID-19 RCTs stoppage without changes in RCT completion. There was a sharp decline in new RCTs at the beginning of the pandemic, which later recovered.

Angiographic Patency of Coronary Artery Bypass Conduits: An Updated Network Meta-Analysis of Randomized Trials

ABSTRACT Introduction: The second best conduit for coronary artery bypass grafting is uncertain. The objective of this study is to determine the second best conduit according to graft patency results from randomized controlled trials using a network meta-analysis. Methods: A systematic literature search was conducted for randomized controlled trials comparing the angiographic patency rate of the no-touch saphenous vein (NT-SV), the radial artery (RA), the right internal thoracic artery (RITA), and the gastroepiploic artery (GEA) in reference to the conventionally harvested saphenous vein (CON-SV). The primary outcome was graft occlusion, and the secondary outcome was all-cause mortality. Results: A total of 859 studies were retrieved, of which 18 were included. A total of 6,543 patients and 8,272 grafts were analyzed. The weighted mean angiographic follow-up time was 3.5 years. Compared with CON-SV, RA (incidence rate ratio [IRR] 0.56; 95% confidence interval [CI], 0.43-0.74) and NT-SV (IRR 0.56; 95% CI, 0.44-0.70) demonstrated lower graft occlusion. NT-SV and RA were ranked as the best conduits (rank score for NT-SV 0.88 vs. 0.87 for RA, 0.29 for GEA, 0.27 for CON-SV, and 0.20 for RITA). There was no significant difference in late mortality between different conduit types. Conclusion: RA and NT-SV are associated with significantly lower graft occlusion rates and are comparably ranked as the best conduit for patency.

Optimizing resource utilization during proficiency-based training of suturing skills in medical students: a randomized controlled trial of faculty-led, peer tutor-led, and holography-augmented methods of teaching.

BACKGROUND: Suturing is a fundamental skill in undergraduate medical education. It can be taught by faculty-led, peer tutor-led, and holography-augmented methods; however, the most educationally effective and cost-efficient method for proficiency-based teaching of suturing is yet to be determined. METHODS: We conducted a randomized controlled trial comparing faculty-led, peer tutor-led, and holography-augmented proficiency-based suturing training in pre-clerkship medical students. Holography-augmented training provided holographic, voice-controlled instructional material. Technical skill was assessed using hand motion analysis every ten sutures and used to construct learning curves. Proficiency was defined by one standard deviation within average faculty surgeon performance. Intervention arms were compared using one-way ANOVA of the number of sutures placed, full-length sutures used, time to proficiency, and incremental costs incurred. Surveys were used to evaluate participant preferences. RESULTS: Forty-four students were randomized to the faculty-led (n = 16), peer tutor-led (n = 14), and holography-augmented (n = 14) intervention arms. At proficiency, there were no differences between groups in the number of sutures placed, full-length sutures used, and time to achieve proficiency. The incremental costs of the holography-augmented method were greater than faculty-led and peer tutor-led instruction ($247.00 ± $12.05, p < 0.001) due to the high cost of the equipment. Faculty-led teaching was the most preferred method (78.0%), while holography-augmented was the least preferred (0%). 90.6% of students reported high confidence in performing simple interrupted sutures, which did not differ between intervention arms (faculty-led 100.0%, peer tutor-led 90.0%, holography-augmented 83.3%, p = 0.409). 93.8% of students felt the program should be offered in the future. CONCLUSION: Faculty-led and peer tutor-led instructional methods of proficiency-based suturing teaching were superior to holography-augmented method with respect to costs and participants' preferences despite being educationally equivalent.

Machine learning methods for automated technical skills assessment with instructional feedback in ultrasound-guided interventions.

OBJECTIVE: Currently, there is a worldwide shift toward competency-based medical education. This necessitates the use of automated skills assessment methods during self-guided interventions training. Making assessment methods that are transparent and configurable will allow assessment to be interpreted into instructional feedback. The purpose of this work is to develop and validate skills assessment methods in ultrasound-guided interventions that are transparent and configurable. METHODS: We implemented a method based upon decision trees and a method based upon fuzzy inference systems for technical skills assessment. Subsequently, we validated these methods for their ability to predict scores of operators on a 25-point global rating scale in ultrasound-guided needle insertions and their ability to provide useful feedback for training. RESULTS: Decision tree and fuzzy rule-based assessment performed comparably to state-of-the-art assessment methods. They produced median errors (on a 25-point scale) of 1.7 and 1.8 for in-plane insertions and 1.5 and 3.0 for out-of-plane insertions, respectively. In addition, these methods provided feedback that was useful for trainee learning. Decision tree assessment produced feedback with median usefulness 7 out of 7; fuzzy rule-based assessment produced feedback with median usefulness 6 out of 7. CONCLUSION: Transparent and configurable assessment methods are comparable to the state of the art and, in addition, can provide useful feedback. This demonstrates their value in self-guided interventions training curricula.