Comparison of BioLIFT versus LIFT for the treatment of trans-sphincteric anal fistula: a protocol for systematic review and meta-analysis.

INTRODUCTION: Identifying the optimal treatment for anal fistula has been challenging. Since first reported in 2007, the ligation of the intersphincteric fistula tract (LIFT) procedure has reported healing rates between 40% and 95% and is being increasingly adopted. The BioLIFT is an augmentation of the LIFT with an intersphincteric bioprosthetic mesh and has reported healing rates between 69% and 94%. Despite increased costs and potential complications associated with mesh, the evidence comparing healing rates between BioLIFT and LIFT is unknown. This study details the protocol for a systematic review and meta-analysis of BioLIFT and LIFT to compare outcomes associated with each procedure. METHODS AND ANALYSIS: MEDLINE, EMBASE and the Cochrane Database will be searched from inception using a search strategy designed by an information specialist. Randomised controlled trials, prospective and retrospective cohort studies, consecutive series, cross-sectional studies and case series with more than five patients will be included. Both comparative and single group studies will be included. The eligible population will be adult patients undergoing BioLIFT or LIFT for trans-sphincteric anal fistula. The primary outcome will be primary healing rate. Secondary outcomes will capture secondary healing rate and complications. Abstract, full text and data extraction will be completed independently and in duplicate by two reviewers. Study risk of bias will be assessed using Risk of Bias In Non-randomized Studies - of Interventions and the Risk of Bias (RoB 2.0) tool. Quality of evidence for outcomes will be evaluated using Grading of Recommendations, Assessment, Development and Evaluations criteria. A meta-analysis will be performed using a random-effects inverse variance model. Subgroup and sensitivity analyses will be explored in relation to complex fistula characteristics and patients who have undergone previous LIFT. Heterogeneity will be assessed using the I2 statistic. ETHICS AND DISSEMINATION: This review does not require research ethics board approval. This study will be completed in September 2022. The findings of this study will be disseminated through peer-reviewed international conferences and journals. PROSPERO REGISTRATION NUMBER: CRD42020127996.

Neoadjuvant Chemotherapy, Excision, and Observation for Early Rectal Cancer: The Phase II NEO Trial (CCTG CO.28) Primary End Point Results.

PURPOSE: Organ-sparing therapy for early-stage I/IIA rectal cancer is intended to avoid functional disturbances or a permanent ostomy associated with total mesorectal excision (TME). The objective of this phase II trial was to determine the outcomes and organ-sparing rate of patients with early-stage rectal cancer treated with neoadjuvant chemotherapy followed by transanal excision surgery (TES). METHODS: This phase II trial included patients with clinical T1-T3abN0 low- or mid-rectal adenocarcinoma eligible for endoscopic resection who were treated with 3 months of chemotherapy (modified folinic acid-fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin). Those with evidence of response proceeded to transanal endoscopic surgery 2-6 weeks later. The primary end point was protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1N0/X and who avoided radical surgery. RESULTS: Of 58 patients enrolled, all commenced chemotherapy and 56 proceeded to surgery. A total of 33/58 patients had tumor downstaging to ypT0/1N0/X on the surgery specimen, resulting in an intention-to-treat protocol-specified organ preservation rate of 57% (90% CI, 45 to 68). Of 23 remaining patients recommended for TME surgery on the basis of protocol requirements, 13 declined and elected to proceed directly to observation resulting in 79% (90% CI, 69 to 88) achieving organ preservation. The remaining 10/23 patients proceeded to recommended TME of whom seven had no histopathologic residual disease. The 1-year and 2-year locoregional relapse-free survival was, respectively, 98% (95% CI, 86 to 100) and 90% (95% CI, 58 to 98), and there were no distant recurrences or deaths. Minimal change in quality of life and rectal function scores was observed. CONCLUSION: Three months of induction chemotherapy may successfully downstage a significant proportion of patients with early-stage rectal cancer, allowing well-tolerated organ-preserving surgery.

Outcomes of Patients Undergoing Elective Bowel Resection Before and After Implementation of an Anemia Screening and Treatment Program.

BACKGROUND: Patients with anemia undergoing elective colorectal cancer surgery are known to have significantly higher rates of postoperative complications and worse outcomes. OBJECTIVE: This study aimed to improve rates of anemia screening and treatment in patients undergoing elective colon and rectal resections through a quality improvement initiative. DESIGN: We compared a historical cohort of patients before implementation of our anemia screening and treatment quality improvement program to a prospective cohort after implementation. SETTINGS: This study was conducted at a tertiary care hospital. PATIENTS: This study included all adult patients with a new diagnosis of colon or rectal cancer without evidence of metastatic disease between 2017 and 2019. INTERVENTIONS: The interventions include the anemia screening and treatment quality improvement program. MAIN OUTCOME MEASURES: The primary outcome was hospital cost per admission. RESULTS: This study includes a total of 84 patients who underwent elective colon or rectal resection before implementation of our anemia quality improvement project and 88 patients who underwent surgery after. In the preimplementation cohort 44 of 84 patients (55.9%) were anemic compared to 47 of 99 patients (54.7%) in the postimplementation cohort. Rates of screening (25%-86.4%) and treatment (27.8%- 63.8%) were significantly increased in the postimplementation cohort. Mean total cost per admission was significantly decreased in the postimplementation cohort (mean cost $16,827 vs $25,796; p = 0.004); this significant reduction was observed even after adjusting for relevant confounding factors (ratio of means: 0.74; 95% CI, 0.65-0.85). The mechanistic link between treatment of anemia and reductions in cost remains unknown. No significant difference was found in rates of blood transfusion, complications, or mortality between the groups. LIMITATIONS: The study limitation includes before-after design subjected to selection and temporal biases. CONCLUSIONS: We demonstrate the successful implementation of an anemia screening and treatment program. This program was associated with significantly reduced cost per admission. This work demonstrates possible value and benefits of implementation of an anemia screening and treatment program. See Video Abstract at http://links.lww.com/DCR/C15 .RESULTADOS DE LOS PACIENTES SOMETIDOS A RESECCIÓN INTESTINAL ELECTIVA ANTES Y DESPUÉS DE LA IMPLEMENTACIÓN DE UN PROGRAMA DE DETECCIÓN Y TRATAMIENTO DE ANEMIA. ANTECEDENTES: Se sabe que los pacientes anémicos que se someten a una cirugía electiva de cáncer colorrectal tienen tasas significativamente más altas de complicaciones posoperatorias y peores resultados. OBJETIVO: Mejorar las tasas de detección y tratamiento de la anemia en pacientes sometidos a resecciones electivas de colon y recto a través de una iniciativa de mejora de calidad. DISEO: Comparamos una cohorte histórica de pacientes antes de la implementación de nuestro programa de detección de anemia y mejora de la calidad del tratamiento con una cohorte prospectiva después de la implementación. ENTORNO CLINICO: Hospital de atención terciaria. PACIENTES: Todos los pacientes adultos con un nuevo diagnóstico de cáncer de colon o recto sin evidencia de enfermedad metastásica entre 2017 y 2019. INTERVENCIONES: Detección de anemia y programa de mejora de la calidad del tratamiento. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue el costo hospitalario por ingreso. RESULTADOS: Un total de 84 pacientes se sometieron a resección electiva de colon o recto antes de la implementación de nuestro proyecto de mejora de calidad de la anemia y 88 pacientes se sometieron a cirugía después. En la cohorte previa a la implementación, 44/84 (55,9 %) presentaban anemia en comparación con 47/99 (54,7 %) en la cohorte posterior a la implementación. Las tasas de detección (25 % a 86,4 %) y tratamiento (27,8 % a 63,8 %) aumentaron significativamente en la cohorte posterior a la implementación. El costo total medio por admisión se redujo significativamente en la cohorte posterior a la implementación (costo medio $16 827 vs. $25 796, p = 0,004); esta reducción significativa se observó incluso después de ajustar los factores de confusión relevantes (proporción de medias: 0,74, IC del 95 %: 0,65 a 0,85). El vínculo mecánico entre el tratamiento de la anemia y la reducción de costos sigue siendo desconocido. No hubo diferencias significativas en las tasas de transfusión de sangre, complicaciones o mortalidad entre los grupos. LIMITACIONES: El diseño de antes y después está sujeto a sesgos temporales y de selección. CONCLUSIONES: Demostramos la implementación exitosa de un programa de detección y tratamiento de anemia. Este programa se asoció con un costo por admisión significativamente reducido. Este trabajo demuestra el valor y los beneficios posibles de la implementación de un programa de detección y tratamiento de la anemia. Consulte Video Resumen en http://links.lww.com/DCR/C15 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Video-based interviewing in medicine: a scoping review.

BACKGROUND: The Coronavirus 2019 pandemic necessitated a rapid uptake of video-based interviewing within the personnel selection process in healthcare. While video-based interviews have been evaluated previously, we identified a gap in the literature on the implementation of video-based interviews and how they compare to their face-to-face counterparts. METHODS: A scoping review was conducted to consolidate the available literature on the benefits and limitations of video-based interviews and to understand the perceived barriers associated with transitioning away from face-to-face interviews. A search strategy, developed in concert with an academic health sciences librarian, was run on Ovid MEDLINE, Embase, PsycInfo, and Cochrane Central. The search was performed on March 31, 2020, and updated on February 21, 2021. Studies that implemented and evaluated the impact of video-based interviewing in healthcare were included in our study. Review articles and editorials were excluded. RESULTS: Forty-three studies were included in our scoping review, of which 17 were conference abstracts and 26 were peer-reviewed manuscripts. The risk of bias was moderate or high in most studies, with only four studies having a low risk of bias. Both financial costs and opportunity costs associated with the selection process were reported to be improved with video-based interviewing, while no studies explored the impact on environmental costs. Technical limitations, which were not prevalent, were easily managed during the interview process. Overall, video-based interviews were well received by both applicants and interviewers, although most participants still reported a preference for face-to-face interviews. CONCLUSIONS: While video-based interviewing has become necessary during the Coronavirus 2019 era, there are benefits from a financial, opportunistic, and environmental point of view that argue for its continued use even after the pandemic. Despite its successful implementation with minimal technical issues, a preference still remains for face-to-face interviews. Reasons for this preference are not clear from the available literature. Future studies on the role of nonverbal communication during the video-based interview process are important to better understand how video-based interviewing can be optimized. SYSTEMATIC REVIEW REGISTRATION: This scoping review was registered with Open Science Framework.

Derivation and external validation of a 30-day mortality risk prediction model for older patients having emergency general surgery.

BACKGROUND: Older people (≥65 yr) are at increased risk of morbidity and mortality after emergency general surgery. Risk prediction models are needed to guide decision making in this high-risk population. Existing models have substantial limitations and lack external validation, potentially limiting their applicability in clinical use. We aimed to derive and validate, both internally and externally, a multivariable model to predict 30-day mortality risk in older patients undergoing emergency general surgery. METHODS: After protocol publication, we used the National Surgical Quality Improvement Program (NSQIP) database (2012-6; estimated to contain 90% data from the USA and 10% from Canada) to derive and internally validate a model to predict 30-day mortality for older people having emergency general surgery using logistic regression with elastic net regularisation. Internal validation was done with 10-fold cross-validation. External validation was done using a temporally separate health administrative database exclusively from Ontario, Canada. RESULTS: Overall, 6012 (12.0%) of the 50 221 patients died within 30 days. The model demonstrated strong discrimination (area under the curve [AUC]=0.871) and calibration across the spectrum of observed and predicted risks. Ten-fold internal cross-validation demonstrated minimal optimism (AUC=0.851, optimism 0.019 [standard deviation=0.06]) with excellent calibration. External validation demonstrated lower discrimination (AUC=0.700) and degraded calibration. CONCLUSION: A multivariable mortality risk prediction model was strongly discriminative and well calibrated internally. However, poor external validation suggests the model may not be generalisable to non-NSQIP data and hospitals. The findings highlight the importance of external validation before clinical application of risk models.

Comparison of non-operative versus operative management of resectable colorectal cancer in elderly patients: study protocol for a systematic review.

BACKGROUND: In the 2021 Statistics Canada census, 18.5% of the Canadian population were senior (65 years and older), among those 1.7 million (4.5%) were aged 80 years and older. Colorectal cancer (CRC) is the third most common cancer in both men and women, with its highest incidence rate in septu- and octogenarians. As clinicians encounter a growing number of very elderly patients (80 years and older) with resectable colorectal cancer, justifying major surgery in a comorbid population with limited life expectancy is difficult. Therefore, this study aims to systemically review the available literature to compare non-operative management to surgical resection with respect to overall survival and quality of life. METHOD: We designed and registered a study protocol for a systematic review. We will include all patients above the age of 80 with resectable colorectal cancer. We will search MEDLINE, EMBASE, and the Cochrane Database of Controlled Trials from January 2000 onwards. We will include randomized, non-randomized controlled trials and observational studies comparing non-operative versus operative management of resectable colorectal cancer in elderly patients. The primary outcomes will be overall survival and mortality. Secondary outcomes will include quality of life, and health services/ resources utilization (e.g., treatments, change of level of care…). Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or bias) will be appraised using the ROB-2 and ROBIN-I tools. If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., study design and methodological quality). DISCUSSION: This systematic review will synthesize the existing data on the management of colorectal cancer in the very elderly patients, and identify the gap in the literature for potential future research. More specifically, we aim to streamline non-operative outcome data on resectable colorectal cancers to aid clinicians' decision-making with respect to survival outcomes and quality of life. The results of this study will be of interest to multiple audiences including patients, their families, caregivers, healthcare professionals, and policy makers. Results will be published in a peer-reviewed journal.

Leveraging financial incentives and behavioural economics to engage physicians in achieving quality-improvement process measures.

BACKGROUND: Dedicated quality-improvement (QI) initiatives within health care systems are of clear benefit, and physicians respond to financial incentivization. The Canadian health care system often lacks this lever, and many financially incentivized QI programs rely on traditional economic principles. We describe our evaluation of financial incentivization for the implementation of QI process metrics in a department of surgery at a Canadian academic hospital system and its impact over a 4-year period. METHODS: Quality-improvement processes informed by extant QI incentivization literature and guided by the principles of behavioural economics were implemented within our institution's Department of Surgery. Disbursement of supplemental government funding was modified to be contingent on the ability of divisions within the department to meet predefined QI metrics, including regular multidisciplinary meetings, morbidity and mortality rounds with documented feedback of systemic issues to division members, reviews of adverse events, and implementation of annual patient experience projects. We evaluated the effect of the QI processes from 2015/16 to 2018/19. RESULTS: There was a significant increase in the number of divisions that satisfied all the QI metrics over the study period, from 2 (28%) in 2015/16, to 5 (71%) in 2016/17, to 7 (100.0%) in 2017/18 and 2018/19 (p < 0.01). The application of behavioural economics principles, such as reward versus penalty payoff, loss aversion, payment separation, aligning of values, and relative social ranking, was important to the outcome of the study. CONCLUSION: Incentivizing QI activities in the Canadian health care system is possible and led to improvement in QI processes as a whole in our department. This paper lays out a method of financial reimbursement to facilitate engagement of physicians and establishment of a foundation of important QI processes and measures within a department.

A Mobile App for Wound and Symptom Surveillance After Colorectal Surgery: Protocol for a Feasibility Randomized Controlled Trial.

BACKGROUND: Surgical site infections (SSIs) are the most common nosocomial infection and occur in 16.3% of patients undergoing colorectal surgery at our institution (The Ottawa Hospital), the majority of which are identified after discharge from hospital. Patients who suspect having an SSI generally present to the emergency department or surgery clinic. Both options for in-person interaction are costly to the health care system and patients. A mobile app, how2trak, has proven to be beneficial for patients with complex wounds at our institution by facilitating at-home monitoring and virtual consultations. OBJECTIVE: This study aims to assess the feasibility of a randomized controlled trial to assess if how2trak can improve patients' experience and increase detection of SSIs after colorectal surgery while reducing patients' risk of COVID-19 exposure. METHODS: In this single-center prospective feasibility trial, eligible patients undergoing colorectal surgery will be randomized to either standard care or how2trak postoperative monitoring of their incision, symptoms, and ostomy function. Patient self-assessments will be monitored by a nurse specialized in wound and ostomy care who will follow-up with patients with a suspected SSI. The primary outcome is feasibility as measured by enrollment, randomization, app usability, data extraction, and resource capacity. RESULTS: This study was approved by our institution's ethics board on February 26, 2021, and received support from The Ottawa Hospital Innovation and Care Funding on November 12, 2021. Recruitment started June 3, 2021, and 29 were patients enrolled as of September 2021. We expect to publish results in spring 2022. CONCLUSIONS: This study will determine the feasibility of using a mobile app to monitor patients' wounds and detect SSIs after colorectal surgery. If feasible, we plan to assess if this mobile app facilitates SSI detection, enhances patient experience, and optimizes their care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04869774; https://clinicaltrials.gov/ct2/show/NCT04869774. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26717.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking.

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

Video-based interviewing in medicine: protocol for a scoping review.

BACKGROUND: Careers in healthcare involve an extensive interview process as transitions are made from one level of training to the next. For physicians, interviews mark the gateway from entrance into medical school, acceptance into residency, fellowships, and subsequent job opportunities. Previous literature outlining the costs associated with face-to-face interviews and concerns regarding the climate crisis has triggered an interest in video-based interviews. Barriers to transitioning away from in-person interviews include concerns regarding lack of rapport between applicants and interviewers, and applicants being less able to represent themselves. In a new era ushered in by COVID where many of us have utilized virtual meetings more than any prior time both personally and for work, we wanted to consolidate the current literature on the use of video-based interviews in healthcare and summarize the findings. METHODS: A scoping review will be conducted to explore the benefits and limitations of video-based interviews for both applicants and interviewers within healthcare fields, as well as the perceived barriers associated with transitioning away from face-to-face interviews. The scoping review methodology outlined by Arksey and O'Malley will be implemented. The search strategy developed by the authors in collaboration with an academic health sciences librarian will be conducted across four electronic databases (Embase, MEDLINE, Cochrane Central, and PsycInfo) and supplemented by a review of the grey literature and reference lists of included studies. The study selection process will be documented using the PRISMA flow diagram, and reasons for exclusion following full-text review will be recorded. The extracted data will be analyzed using quantitative and qualitative analysis. DISCUSSION: Despite previous literature on the costs associated with face-to-face interviews, there has been hesitancy with transitioning to video-based interviews due to concerns of lack of rapport between applicants and interviewers, and applicants being less able to represent themselves. While these limitations have been explored in previous studies, a succinct review of the current literature to guide the effective restructuring of the interview process is lacking. With our scoping review, we hope to fill this gap in the literature to better understand barriers to transitioning from face-to-face interviews and directions for future research.

Comparison of Ligation of the Intersphincteric Fistula Tract and BioLIFT for the Treatment of Transsphincteric Anal Fistula: A Retrospective Analysis.

BACKGROUND: Ligation of the intersphincteric fistula tract is a sphincter-preserving technique for the treatment of anal fistulas. The BioLIFT modification involves the placement of a biologic mesh in the intersphincteric plane. Advocates of this modification state improved healing rates, however evidence for this is lacking, and this approach costs significantly more. OBJECTIVE: The purpose of this study was to compare the healing rates of the ligation of the intersphincteric fistula tract with the BioLIFT. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a tertiary care hospital from April 2008 to April 2018. PATIENTS: All adult patients with transsphincteric anal fistulas were included. Patients were excluded if they had IBD, more than 1 fistula tract operated on simultaneously, or a previous attempt at repair. MAIN OUTCOME MEASURES: The primary outcome was primary healing of the fistula tract, and secondary outcomes included overall success, complications, and time to recurrence. RESULTS: There were 119 cases (75 ligation of the intersphincteric fistula tract and 44 BioLIFTs). One surgeon performed 84% of the BioLIFT cases. The primary healing rate was 75.0% versus 58.7% (p = 0.08), and the complication rate was 22.7% versus 17.3% (p = 0.48; BioLIFT vs ligation of intersphincteric fistula tract). After multivariate logistic regression, the BioLIFT had a significantly better healing rate (OR = 2.38 (95% CI, 1.01-5.62); p = 0.048). Median follow-up was 9 versus 29 weeks (BioLIFT vs ligation of intersphincteric fistula tract). Kaplan-Meier analysis demonstrated no difference in the time to recurrence (p = 0.48). LIMITATIONS: This study was limited by the retrospective nature, different lengths of follow-up, and varying case numbers between the surgeons. CONCLUSIONS: The BioLIFT modification is safe and effective for the treatment of anal fistulas but has a higher cost. This modification warrants additional prospective studies to establish its benefits over the ligation of the intersphincteric fistula tract procedure. See Video Abstract at http://links.lww.com/DCR/B139. COMPARACIÓN DE LIFT VERSUS BIOLIFT PARA EL TRATAMIENTO DE LA FÍSTULA ANAL TRANSFINTERÉRICA: UN ANÁLISIS RETROSPECTIVO: Ligadura del tracto de la fístula interesfintérica es una técnica para preservación del esfínter en el tratamiento de las fístulas anales. La modificación BioLIFT implica la colocación de una malla biológica en el plano interesfintérico. Protagonistas de la modificación mejoraron las tasas de curación, sin embargo, carecen evidencias definitivas y la técnica eleva costos significativamente.Comparar las tasas de curación de ligadura del tracto de la fístula interesfintérica con el BioLIFT.Estudio de cohorte retrospectivo.Hospital de atención de tercer nivel desde abril de 2008 hasta abril de 2018.Se incluyeron todos los pacientes adultos con fístulas anales transfinteréricas. Los pacientes fueron excluidos si tenían enfermedad inflamatoria intestinal, más de un tracto fistuloso operado simultáneamente o con un intento previo de reparación.El resultado principal fue la curación primaria del tracto fistuloso y los resultados secundarios incluyeron el éxito en general, las complicaciones y tiempo hasta recurrencia.Se registraron 119 casos (75 ligaduras del tracto de la fístula interesfintérica y 44 BioLIFT). Un cirujano realizó el 84% de los casos de BioLIFT. La tasa de curación primaria fue del 75.0% vs 58.7%, p = 0.08, y la tasa de complicaciones fue del 22.7% vs 17.3%, p = 0.48 comparando BioLIFT vs ligadura del tracto de la fístula interesfintérica. Después de la regresión logística multivariada, el BioLIFT tuvo una tasa de curación significativamente mejor (OR 2.38 [IC 95% 1.01-5.62], p = 0.048). La mediana de seguimiento fue de 9 vs 29 semanas (BioLIFT vs ligadura del tracto de la fístula interesfintérica). El análisis de Kaplan-Meier no demostró diferencias en el tiempo hasta la recurrencia (p = 0,48).Este estudio estuvo limitado por ser retrospectivo, las diferentes duraciones de seguimiento y el número variable de casos entre los cirujanos.La modificación BioLIFT es segura y efectiva para el tratamiento de las fístulas anales pero tiene un costo más alto. Esta modificación amerita más estudios prospectivos para establecer los beneficios sobre ligadura del tracto de la fístula interesfintérica. Consulte Video Resumen en hhttp://links.lww.com/DCR/B139.

Protocol for the derivation and external validation of a 30-day mortality risk prediction model for older patients having emergency general surgery (PAUSE score-Probability of mortality Associated with Urgent/emergent general Surgery in oldEr patients score).

INTRODUCTION: People 65 years and older represent the fastest growing segment of the surgical population. Older age is associated with doubling of risk when undergoing emergency general surgery (EGS) procedures and often coexists with medical complexity and considerations of end-of-life care, creating prognostic and decisional uncertainty. Combined with the time-sensitive nature of EGS, it is challenging to gauge perioperative risk and ensure that clinical decisions are aligned with the patient values. Current preoperative risk prediction models for older EGS patients have major limitations regarding derivation and validation, and do not address the specific risk profile of older patients. Accurate and externally validated models specific to older patients are needed to inform care and decision making. METHODS AND ANALYSIS: We will derive, internally and externally validate a multivariable model to predict 30-day mortality in EGS patients >65 years old. Our derivation sample will be individuals enrolled in the National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2016 having 1 of 7 core EGS procedures. Postulated predictor variables have been identified based on previous research, clinical and epidemiological knowledge. Our model will be derived using logistic regression penalised with elastic net regularisation and ensembled using bootstrap aggregation. The resulting model will be internally validated using k-fold cross-validation and bootstrap validation techniques and externally validated using population-based health administrative data. Discrimination and calibration will be reported at each step. ETHICS AND DISSEMINATION: Ethics for NSQIP data use was obtained from the Ottawa Hospital Research Ethics Board; external validation will use routinely collected anonymised data legally exempt from research ethics review. The final risk score will be published in a peer-reviewed journal. We plan to further disseminate the model as an online calculator or application for clinical use. Future research will be required to test the clinical application of the final model.

Do Diagnostic and Procedure Codes Within Population-Based, Administrative Datasets Accurately Identify Patients with Rectal Cancer?

BACKGROUND: Procedural and diagnostic codes may inaccurately identify specific patient populations within administrative datasets. PURPOSE: Measure the accuracy of previously used coding algorithms using administrative data to identify patients with rectal cancer resections (RCR). METHODS: Using a previously published coding algorithm, we re-created a RCR cohort within administrative databases, limiting the search to a single institution. The accuracy of this cohort was determined against a gold standard reference population. A systematic review of the literature was then performed to identify studies that use similar coding methods to identify RCR cohorts and whether or not they comment on accuracy. RESULTS: Over the course of the study period, there were 664,075 hospitalizations at our institution. Previously used coding algorithms identified 1131 RCRs (administrative data incidence 1.70 per 1000 hospitalizations). The gold standard reference population was 821 RCR over the same period (1.24 per 1000 hospitalizations). Administrative data methods yielded a RCR cohort of moderate accuracy (sensitivity 89.5%, specificity 99.9%) and poor positive predictive value (64.9%). Literature search identified 18 studies that utilized similar coding methods to derive a RCR cohort. Only 1/18 (5.6%) reported on the accuracy of their study cohort. CONCLUSIONS: The use of diagnostic and procedure codes to identify RCR within administrative datasets may be subject to misclassification bias because of low PPV. This underscores the importance of reporting on the accuracy of RCR cohorts derived within population-based datasets.

Impact of group practices on patients, physicians and healthcare systems: protocol for a scoping review.

INTRODUCTION: Group practices have potential benefits for patients, physicians and healthcare systems. Although group practices have been around for many years, research in this area is lacking and generally is centred around the economic benefits that may be realised from group practice. The aim of this scoping review is to identify the impact that group practices have on patients, physicians and healthcare systems to guide further research in this area. METHODS AND ANALYSIS: A scoping review will be performed based on the methodology proposed by Arksey and O'Malley and refined by Levac and colleagues. MEDLINE, EMBASE, Cochrane Central and Cochrane Economic Database will be searched from inception to present day to identify relevant studies that assess the impact of group practices on patient care, satisfaction and outcomes; physician quality of life, satisfaction and income and healthcare systems. Titles and abstracts will be screened by two members and the abstraction results charted and verified. Qualitative and quantitative analyses will be performed to identify key themes. ETHICS AND DISSEMINATION: Research ethics board approval is not required for this scoping review. A consultation phase will be used to discuss the results with key stakeholders followed by dissemination at local and national levels. We will also publish the results in a peer-reviewed journal.

Can Text-Search Methods of Pathology Reports Accurately Identify Patients with Rectal Cancer in Large Administrative Databases?

BACKGROUND: The aim of this study is to derive and to validate a cohort of rectal cancer surgical patients within administrative datasets using text-search analysis of pathology reports. MATERIALS AND METHODS: A text-search algorithm was developed and validated on pathology reports from 694 known rectal cancers, 1000 known colon cancers, and 1000 noncolorectal specimens. The algorithm was applied to all pathology reports available within the Ottawa Hospital Data Warehouse from 1996 to 2010. Identified pathology reports were validated as rectal cancer specimens through manual chart review. Sensitivity, specificity, and positive predictive value (PPV) of the text-search methodology were calculated. RESULTS: In the derivation cohort of pathology reports (n = 2694), the text-search algorithm had a sensitivity and specificity of 100% and 98.6%, respectively. When this algorithm was applied to all pathology reports from 1996 to 2010 (n = 284,032), 5588 pathology reports were identified as consistent with rectal cancer. Medical record review determined that 4550 patients did not have rectal cancer, leaving a final cohort of 1038 rectal cancer patients. Sensitivity and specificity of the text-search algorithm were 100% and 98.4%, respectively. PPV of the algorithm was 18.6%. CONCLUSIONS: Text-search methodology is a feasible way to identify all rectal cancer surgery patients through administrative datasets with high sensitivity and specificity. However, in the presence of a low pretest probability, text-search methods must be combined with a validation method, such as manual chart review, to be a viable approach.

Association between perioperative beta blocker use and cancer survival following surgical resection.

BACKGROUND: Recent studies have demonstrated an association between beta-blocker exposure and improved survival in multiple cancer types. We sought to investigate the effects of beta-blockers at the time of index surgery for breast, lung, and colorectal cancer. MATERIALS AND METHODS: Using linked data from a provincial cancer registry, we conducted a retrospective matched cohort study comparing disease-specific and overall survival between patients over age 64 exposed and not exposed to beta-blockers before and after index surgical resection for breast, lung and colorectal cancer between April 1st, 2002 and December 31st, 2010. A high-dimensional propensity score was used to match patients and Cox proportional hazard models were used to estimate relative risks of the outcomes. RESULTS: 30,020 patients were included in the final matched cohorts. Mean follow up time for breast, lung, and colorectal cancer was 57.6 ± 30.5, 43.1 ± 28.7, and 53.4 ± 31.0 months, respectively. The adjusted hazard ratio for disease-specific mortality for patients exposed to beta-blockers was 1.03 (0.83-1.29) for breast, 1.05 (0.92-1.20) for lung, and 1.10 (0.96-1.25) for the colorectal cancer cohort. CONCLUSIONS: In this large population-based study, no association between perioperative beta-blocker exposure and improved cancer-specific survival for breast, lung, or colorectal cancer was demonstrated.

Laparoscopic Colorectal Surgery in the Emergency Setting: Trends in the Province of Ontario.

BACKGROUND: The purpose of this study was to examine the adoption trends of emergency laparoscopic colorectal surgery in the province of Ontario. STUDY DESIGN: We conducted a retrospective time-series analysis examining rates of emergency colorectal surgery among 10.5 million adults in Ontario, Canada from April 1, 2002 to December 31, 2009. We linked administrative claims databases and the Ontario Cancer Registry to assess procedure rates over time. Procedure trends were assessed using time-series analysis. RESULTS: Over the 8-year period, 29,676 emergency colorectal procedures were identified. A total of 2582 (8.7%) were performed laparoscopically and 27,094 (91.3%) were open. Open and laparoscopic patients were similar with respect age, sex, and Charlson Comorbidity Index. The proportion of surgery for benign (63.8% of open cases vs. 65.6% laparoscopic, standardized difference=0.04) and malignant disease (36.2% open vs. 34.4% laparoscopic, standardized difference=0.04) was equal between groups. The percentage of emergency colorectal surgery performed laparoscopically increased from 5.7% in 2002 to 12.0% in 2009 (P<0.01). The use of laparoscopy increased for both benign and malignant disease. Statistically significant upward trends in laparoscopic surgery were seen for inflammatory bowel disease (P<0.01), obstruction (P<0.01), and colon cancer (P<0.01). From 2002 to 2009, annual procedure rates increased at a greater rate in nonacademic centers (P<0.01). CONCLUSIONS: Laparoscopic emergency colorectal surgery has increased significantly between 2002 and 2009 for both benign and malignant disease and for a wide range of diagnoses. This was driven in part by steadily rising usage of laparoscopy in nonacademic centers.

Plastic freezer bags: a cost-effective method to protect extraction sites in laparoscopic colorectal procedures?

PURPOSE: To review surgical-site infection (SSI) and retrieval-site tumor recurrence rates in laparoscopic colorectal procedures when using a plastic freezer bag as a wound protector. METHODS: Laparoscopic colorectal procedures where a plastic freezer bag used as a wound protector at the extraction site were reviewed between 1991 and 2008 from a prospectively collected database. χ test was used to compare SSI and tumor recurrence rates between groups. Costing data were obtained from the operating room supplies department. RESULTS: A total of 936 cases with 51 (5.45%) surgical-site infections were identified. SSI rates did not differ when comparing groups based on demographic factors, diagnosis, or location of procedure. Retrieval-site tumor recurrence rate was 0.21% (1/474). Cost of plastic freezer bags including sterilization ranged from $0.25 to $3. CONCLUSIONS: Plastic freezer bags as wound protectors in laparoscopic colorectal procedures are cost effective and have SSI and retrieval-site tumor recurrence rates that compare favorably to published data.

The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections.

BACKGROUND: Surgical site infections (SSI) are an important cause of peri-surgical morbidity with risks that vary extensively between patients and surgeries. Quantifying SSI risk would help identify candidates most likely to benefit from interventions to decrease the risk of SSI. METHODS: We randomly divided all surgeries recorded in the National Surgical Quality Improvement Program from 2010 into a derivation and validation population. We used multivariate logistic regression to determine the independent association of patient and surgical covariates with the risk of any SSI (including superficial, deep, and organ space SSI) within 30 days of surgery. To capture factors particular to specific surgeries, we developed a surgical risk score specific to all surgeries having a common first 3 numbers of their CPT code. RESULTS: Derivation (n = 181 894) and validation (n = 181 146) patients were similar for all demographics, past medical history, and surgical factors. Overall SSI risk was 3.9%. The SSI Risk Score (SSIRS) found that risk increased with patient factors (smoking, increased body mass index), certain comorbidities (peripheral vascular disease, metastatic cancer, chronic steroid use, recent sepsis), and operative characteristics (surgical urgency; increased ASA class; longer operation duration; infected wounds; general anaesthesia; performance of more than one procedure; and CPT score). In the validation population, the SSIRS had good discrimination (c-statistic 0.800, 95% CI 0.795-0.805) and calibration. CONCLUSION: SSIRS can be calculated using patient and surgery information to estimate individual risk of SSI for a broad range of surgery types.