Immigration Status and Breast Cancer Surgery Quality of Care Metrics: A Population-Level Analysis.

INTRODUCTION: As immigrant women face challenges accessing health care, we hypothesized that immigration status would be associated with fewer women with breast cancer receiving surgery for curable disease, fewer undergoing breast conserving surgery (BCS), and longer wait time to surgery. METHODS: A population-level retrospective cohort study, including women aged 18-70 years with Stage I-III breast cancer diagnosed between 2010 and 2016 in Ontario was conducted. Multivariable analysis was performed to assess odds of undergoing surgery, receiving BCS and wait time to surgery. RESULTS: A total of 31,755 patients were included [26,253 (82.7%) Canadian-born and 5502 (17.3%) immigrant women]. Immigrant women were younger (mean age 51.6 vs. 56.1 years) and less often presented with Stage I/II disease (87.4% vs. 89.8%) (both p < .001). On multivariable analysis, there was no difference between immigrant women and Canadian-born women in odds of undergoing surgery [Stage I OR 0.93 (95% CI 0.79-1.11), Stage II 1.04 (0.89-1.22), Stage III 1.22 (0.94-1.57)], receiving BCS [Stage I 0.93 (0.82-1.05), Stage II 0.96 (0.86-1.07), Stage III 1.00 (0.83-1.22)], or wait time [Stage I 0.45 (-0.61-1.50), Stage II 0.33 (-0.86-1.52), Stage III 3.03 (-0.05-6.12)]. In exploratory analysis, new immigrants did not have surgery more than established immigrants (12.9% vs. 10.1%), and refugee women had longer wait time compared with economic-class immigrants (39.5 vs. 35.3 days). CONCLUSIONS: We observed differences in measures of socioeconomic disadvantage and disease characteristics between immigrant and Canadian-born women with breast cancer. Upon adjusting for these factors, no differences emerged in rate of surgery, rate of BCS, and time to surgery. The lack of disparity suggests barriers to accessing basic components of breast cancer care may be mitigated by the universal healthcare system in Canada.

Differences in in-hospital outcomes and healthcare utilization for laparoscopic versus open approach for emergency inguinal hernia repair: a nationwide analysis.

PURPOSE: There has been a growing debate of whether laparoscopic or open surgical techniques are superior for inguinal hernia repair. For incarcerated and strangulated inguinal hernias, the laparoscopic approach remains controversial. This study aims to be the first nationwide analysis to compare clinical and healthcare utilization outcomes between laparoscopic and open inguinal hernia repair in an emergency setting. METHODS: A retrospective analysis of the National Inpatient Sample was performed. All patients who underwent laparoscopic inguinal hernia repair (LIHR) and open inguinal hernia repair (OIHR) between October 2015 and December 2019 were included. The primary outcome was mortality, and secondary outcomes include post-operative complications, ICU admission, length of stay (LOS), and total admission cost. Two approaches were compared using univariate and multivariate logistic and linear regression. RESULTS: Between the years 2015 and 2019, 17,205 patients were included. Among these, 213 patients underwent LIHR and 16,992 underwent OIHR. No difference was observed between laparoscopic and open repair for mortality (odds ratio [OR] 0.80, 95% CI [0.25, 2.61], p = 0.714). Additionally, there was no significant difference between groups for post-operative ICU admission (OR 1.11, 95% CI [0.74, 1.67], p = 0.614), post-operative complications (OR 1.09, 95% CI [0.76, 1.56], p = 0.647), LOS (mean difference [MD]: -0.02 days, 95% CI [- 0.56, 0.52], p = 0.934), or total admission cost (MD: $3,028.29, 95% CI [$- 110.94, $6167.53], p = 0.059). CONCLUSION: Laparoscopic inguinal hernia repair is comparable to the open inguinal hernia repair with respect to low rates of morbidity, mortality as well as healthcare resource utilization.

The effect of bariatric surgery on breast cancer incidence and characteristics: A meta-analysis and systematic review.

BACKGROUND: Obesity is a major risk factor for breast cancer. This study examines whether bariatric surgery affects breast cancer incidence in women with obesity compared to BMI-matched controls. METHODS: EMBASE, MEDLINE, Web of Science, and CINAHL were searched. Primary studies on female breast cancer incidence after bariatric surgery were eligible. RESULTS: 11 studies were included (n = 1,106,939). The rate of cancer diagnosis was lower in the surgical group (0.54%) compared to control (0.84%; risk ratio (RR) 0.50, 95%CI 0.37-0.67, I2 = 88%). The results were robust to sensitivity analyses for patient age and study size. Bariatric surgery was associated with increased risk of stage I cancer (RR 1.23, 95%CI 1.06-1.44) and reduced risk of stage III or IV cancer (RR 0.50, 95%CI 0.28-0.88). Hormone receptor characteristics were not affected. CONCLUSIONS: Bariatric surgery is associated with reduced incidence and earlier stage at diagnosis of breast cancer in women with obesity compared to BMI-matched controls.

Geographic and socioeconomic factors affecting delivery of bariatric surgery across high- and low-utilization healthcare systems.

BACKGROUND: In countries with universal health coverage, the delivery of care should be driven by need. However, other factors, such as proximity to local facilities or neighbourhood socioeconomic status, may be more important. The objective of this study was to evaluate which geographic and socioeconomic factors affect the delivery of bariatric care in Canada. METHODS: This was a national retrospective cohort study of all adult patients undergoing bariatric surgery between April 2008 and March 2015 in Canada (excluding Quebec). The main outcome was neighbourhood rate of bariatric surgery per 1000 obese individuals (BMI over 30 kg/m2 ). Geographic cluster analysis and multilevel ordinal logistic regression were used to identify high-use clusters, and to evaluate the effect of geographic and socioeconomic factors on care delivery. RESULTS: Having a bariatric facility within the same public health unit as the neighbourhood was associated with a 6·6 times higher odds of being in a bariatric high-use cluster (odds ratio (OR) 6·60, 95 per cent c.i. 1·90 to 22·88; P = 0·003). This finding was consistent across provinces after adjusting for utilization rates. Neighbourhoods with higher obesity rates were also more likely to be within high-use clusters (OR per 5 per cent increase: 2·95, 1·54 to 5·66; P = 0·001), whereas neighbourhoods closer to bariatric centres were less likely to be (OR per 50 km: 0·91, 0·82 to 1·00; P = 0·048). CONCLUSION: In this study, across provincial healthcare systems with high and low utilization, the delivery of care was driven by the presence of local facilities and neighbourhood obesity rates. Increasing distance to bariatric centres substantially influenced care delivery.

Non-technical skills of surgeons and anaesthetists in simulated operating theatre crises.

BACKGROUND: Deficiencies in non-technical skills (NTS) have been increasingly implicated in avoidable operating theatre errors. Accordingly, this study sought to characterize the impact of surgeon and anaesthetist non-technical skills on time to crisis resolution in a simulated operating theatre. METHODS: Non-technical skills were assessed during 26 simulated crises (haemorrhage and airway emergency) performed by surgical teams. Teams consisted of surgeons, anaesthetists and nurses. Behaviour was assessed by four trained raters using the Non-Technical Skills for Surgeons (NOTSS) and Anaesthetists' Non-Technical Skills (ANTS) rating scales before and during the crisis phase of each scenario. The primary endpoint was time to crisis resolution; secondary endpoints included NTS scores before and during the crisis. A cross-classified linear mixed-effects model was used for the final analysis. RESULTS: Thirteen different surgical teams were assessed. Higher NTS ratings resulted in significantly faster crisis resolution. For anaesthetists, every 1-point increase in ANTS score was associated with a decrease of 53·50 (95 per cent c.i. 31·13 to 75·87) s in time to crisis resolution (P < 0·001). Similarly, for surgeons, every 1-point increase in NOTSS score was associated with a decrease of 64·81 (26·01 to 103·60) s in time to crisis resolution in the haemorrhage scenario (P = 0·001); however, this did not apply to the difficult airway scenario. Non-technical skills scores were lower during the crisis phase of the scenarios than those measured before the crisis for both surgeons and anaesthetists. CONCLUSION: A higher level of NTS of surgeons and anaesthetists led to quicker crisis resolution in a simulated operating theatre environment.