Potential Carbon Savings with Day-case Compared to Inpatient Transurethral Resection of Bladder Tumour Surgery in England: A Retrospective Observational Study Using Administrative Data.

Background: The National Health Service (NHS) in England has set a net-zero target for carbon emissions by 2040. Increasing use of day-case surgery pathways may help in meeting this target. Objective: To investigate the estimated difference in carbon footprint between day-case and inpatient transurethral resection of bladder tumour (TURBT) surgery in England. Design setting and participants: This was a retrospective analysis of administrative data extracted from the Hospital Episode Statistics database for all TURBT procedures conducted in England from April 1, 2013 to March 31, 2022. Outcome measurements and statistical analysis: Day-case and inpatient TURBT procedures were identified and the carbon footprint for key elements of the surgical pathway was estimated using data from Greener NHS and the Sustainable Healthcare Coalition. Results and limitations: Of 209 269 TURBT procedures identified, 41 583 (20%) were classified as day-case surgery. The day-case rate increased from 13% in 2013-2014 to 31% in 2021-2022. The move from inpatient stays to day-case surgery between 2013-2014 and 2021-2022 demonstrates a trend toward a lower-carbon pathway, with an estimated saving of 2.9 million kg CO2 equivalents (equivalent to powering 2716 homes for 1 yr) in comparison to no change in practice. We calculated that potential carbon savings for the financial year 2021-2022 would be 217 599 kg CO2 equivalents (equivalent to powering 198 homes for 1 yr) if all hospitals in England not already in the upper quartile were able to achieve the current upper-quartile day-case rate. Our study is limited in that estimates are based on carbon factors for generic surgical pathways. Conclusions: Our study highlights potential NHS carbon savings that could be achieved by moving from inpatient stays to day-case surgery. Reducing variation in care across the NHS and encouraging all hospitals to adopt day-case surgeries, where clinically appropriate, would lead to further carbon savings. Patient summary: In this study we estimated the potential for carbon savings if patient undergoing bladder tumour surgery were admitted and discharged on the same day. We estimate that increasing use of day-case surgery between 2013-2014 and 2021-2022 has saved 2.9 million kg CO2 equivalents. If all hospitals were to achieve day case-rates comparable to those in the highest quarter of hospitals in England in 2021-2022, then the carbon equivalent to powering 198 homes for 1 year could have been saved.

What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure.

OBJECTIVES: To measure the financial burden associated with accessing surgical care in Sierra Leone. DESIGN: A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed. SETTING: The main tertiary-level hospital in Freetown, Sierra Leone. PARTICIPANTS: 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards. OUTCOME MEASURES: Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived. RESULTS: Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance. CONCLUSION: Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.

Does the use of video improve patient satisfaction in the consent process for local-anaesthetic urological procedures?

PURPOSE: To assess patient satisfaction with the use of portable video media (PVM) for the purpose of taking informed consent for common urological outpatient procedures performed under local anaesthesia. METHODS: Patients undergoing the following procedures were approached for recruitment: flexible cystoscopy with or without biopsy, transrectal ultrasound-guided prostate biopsy or flexible cystoscopy with insertion or removal of a ureteric stent. Audio-visual media were developed for each procedure, with each script translated from English into isiXhosa and Afrikaans. The study involved a cross-over for each patient between standard verbal consent (SVC) and PVM consent, with each patient randomised to start with SVC or PVM consent. Each of these consent arms was assessed via a questionnaire. RESULTS: Sixty patients completed participation, with PVM as the first exposure for 28 patients and 32 patients receiving SVC as their first arm of the study. When comparing the overall satisfaction between SVC and PVM consent (the total scores out of 18 for the questionnaire), patients scored significantly higher for PVM consent (M = 16.3 ± 2.4) compared to SVC (M = 15.4 ± 2.9) (p = 0.002). 92% of the total patient sample preferred PVM consent. CONCLUSION: Portable video media proved superior to SVC in improving satisfaction in the consent process for common outpatient urological procedures performed under local anaesthesia.

Validating the European randomised study for screening of prostate cancer (ERSPC) risk calculator in a contemporary South African cohort.

INTRODUCTION: Numerous prostate cancer predictive tools have been developed to help with decision-making in men needing prostate biopsy. However, they have been modelled and validated almost exclusively in Caucasian cohorts, hence limiting their use in other population groups. The aim of this study was to assess the validity of the ERSPC risk calculator in a South African cohort. METHODS: Patients who have had a transrectal ultrasound (TRUS)-guided prostate biopsy at Groote Schuur Hospital from January 2008 to August 2017 were reviewed. Predictor variables were entered into the ERSPC risk calculator and results were compared with prostate biopsy pathology results. Predictive accuracy of the ERSPC risk calculator for these patients was derived using receiver operator characteristics (ROC) Area under the curve and is expressed as a percentage. RESULTS: 516 prostate biopsy sessions in 475 different men were analysed. The predictive accuracy of the ERSPC risk calculator was better than a PSA/DRE strategy for the presence of cancer-0.738 (95% CI 0.695-0.781) vs 0.686 (95% CI 0.639-0.732), and for significant PCa-0.833 (95% CI 0.789-0.876) vs 0.793 (95% CI 0.741-0.846). This translated into 50 less biopsies when compared to a PSA > 4/abnormal DRE strategy. Use of the ERSPC RC would have missed eight non-significant cancers [Significant cancer being defined as having a tumour stage T2b (> 1/2 lobe involved with prostate cancer) and/or a Gleason Score equal to or greater than 7]. CONCLUSION: Our results confirm the validity of the ERSPC RC in a South African cohort. Application of this calculator to the wider South African population would allow better selection of patients for prostate biopsy and spare a significant number its adverse consequences.

Novel macro-microporous gelatin scaffold fabricated by particulate leaching for soft tissue reconstruction with adipose-derived stem cells.

The restoration of body contours as shaped by adipose tissue remains a clinical challenge specifically in patients who have experienced loss of contour due to trauma, surgical removal of tumours or congenital abnormalities. We have developed a novel macro-microporous biomaterial for use in soft tissue re-bulking and augmentation. Alginate beads provided the pore template for the construct. Incorporation, and subsequent dissolution, of the beads within a 7 % (w/v) gelatin matrix, produced a highly porous scaffold with an average pore size of 2.01 ± 0.08 mm. The ability of this scaffold to support the in vitro growth and differentiation of human adipose-derived stem cells (ADSCs) was then investigated. Histological analysis confirmed that the scaffold itself provided a suitable environment to support the growth of ADSCs on the scaffold walls. When delivered into the macropores in a fibrin hydrogel, ADSCs proliferated and filled the pores. In addition, ADSCs could readily be differentiated along the adipogenic lineage. These results therefore describe a novel scaffold that can support the proliferation and delivery of ADSCs. The scaffold is the first stage in developing a clinical alternative to current treatment methods for soft tissue reconstruction.