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1.
J Surg Res ; 257: A1-A11, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32768197

RESUMO

The issue of burnout among surgical trainees became evident during our work on the FIRST Trial. In studying the issue, we found that burnout symptoms occurred in a relatively large proportion of surgical trainees, and burnout was associated with significant risks of having thoughts of leaving the residency program or having suicidal thoughts. The SECOND Trial seeks to reduce trainee wellbeing and mistreatment by leveraging approaches used in healthcare quality performance improvement (e.g., comparative reports, toolkits, collaboration). Importantly, the epidemic of surgical trainee wellbeing issues have worsened (i.e., fanning the burnout fire) given our misconceptions about generational differences, our delayed adaptations to shifts in healthcare, and even some of our good intentions. However, there are several things we can do to improve the situation: (1) embrace the change that comes with each generation; (2) appreciate, respect, and enjoy our trainees; (3) teach residents constructively, leaving yelling and bullying behind; (4) embrace the concept of wellness for ourselves and each other; (5) provide meaningful feedback and mentorship; and (6) give each other the benefit of the doubt (e.g., principle of charity). Despite these issues, academic surgery remains the best job in the world, and the strength of our profession, leaders, and colleagues will see us through these challenges. The Association for Academic Surgery will help lead the way on these important issues.


Assuntos
Esgotamento Profissional/epidemiologia , Cirurgiões/educação , Cirurgiões/psicologia , Esgotamento Profissional/etiologia , Esgotamento Profissional/prevenção & controle , Cirurgia Geral/educação , Humanos , Internato e Residência/métodos , Internato e Residência/tendências , Sociedades Médicas , Cirurgiões/tendências , Ensino/psicologia , Ensino/tendências
3.
Surgery ; 168(3): 355-362, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32741622

RESUMO

BACKGROUND: To interview extraordinary women who have made recent significant contributions to the field of colorectal surgery. DESIGN: The authors asked some of the many extraordinary women who have made significant contributions to the field of colorectal surgery to answer several questions. These women were selected from many potential candidates based upon their extraordinary recent contributions to the field of colorectal surgery. These thought leaders were asked about their contributions to colorectal surgery, their mentors, whether they had any women as role models, and, lastly, what they would tell their younger selves. The study was structured to recognize these women for their remarkable recent contributions to colorectal surgery, and we wished to encourage women to pursue leadership in colorectal surgery including the allied fields of colorectal pathology and colorectal imaging. Furthermore, the authors hoped to inspire male colorectal surgeons to actively mentor and help the career development of women colorectal surgeons. The potential limitations of the study include the fact that there are many more well-deserving women who could have been included in the sample survey but, because of space constraints, were not invited. CONCLUSION: Women in colorectal surgery and in the allied specialties of colorectal pathology and colorectal radiology have made many recent major significant contributions to colorectal surgery. The expectation is that the volume and frequency of such contributions as well as the number of women making these contributions should further significantly increase with time.


Assuntos
Cirurgia Colorretal/organização & administração , Liderança , Mentores , Médicas/psicologia , Cirurgiões/psicologia , Escolha da Profissão , Cirurgia Colorretal/estatística & dados numéricos , Cirurgia Colorretal/tendências , Feminino , Humanos , Masculino , Médicas/estatística & dados numéricos , Médicas/tendências , Cirurgiões/estatística & dados numéricos , Cirurgiões/tendências
5.
J Vasc Interv Radiol ; 31(6): 961-966, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32376176

RESUMO

PURPOSE: To evaluate utilization trends in percutaneous embolization among radiologists and nonradiologist providers. MATERIALS AND METHODS: The nationwide Medicare Part B fee-for-service databases for 2005-2016 were used to evaluate percutaneous embolization codes. Six codes describing embolization procedures were reviewed. Physician providers were grouped as radiologists, vascular surgeons, cardiologists, nephrologists, other surgeons, and all others. RESULTS: The total volume of Medicare percutaneous embolization procedures increased from 20,262 in 2005 to 45,478 in 2016 (+125%). Radiologists performed 13,872 procedures in 2005 (68% of total volume) and 33,254 in 2016 (73% of total volume), a 140% increase in volume. While other specialists also increased the number of cases performed from 2005 to 2016, radiologists strongly predominated, performing 87% of arterial and 30% of venous procedures in 2016, more than any other single specialty. In 2014 and 2015, a sharp increase in venous embolization cases performed by nonradiologists preceded a sharp decrease in 2016, likely the result of complicated billing codes for venous procedures. Radiologists maintained a steady upward trend in the number of cases they performed during those years. CONCLUSIONS: The volume of percutaneous embolization procedures performed in the Medicare population increased from 2005 to 2016, reflecting a trend toward minimally invasive intervention. In 2016, radiologists performed nearly 10 times more arterial embolization procedures than the second highest specialty and more venous embolization procedures than any other single specialty.


Assuntos
Embolização Terapêutica/tendências , Neoplasias/terapia , Padrões de Prática Médica/tendências , Radiologistas/tendências , Especialização/tendências , Idoso , Idoso de 80 Anos ou mais , Cardiologistas/tendências , Bases de Dados Factuais , Feminino , Humanos , Masculino , Medicare Part B/tendências , Nefrologistas/tendências , Cirurgiões/tendências , Fatores de Tempo , Estados Unidos
9.
J Vasc Interv Radiol ; 31(4): 614-621.e2, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32127322

RESUMO

PURPOSE: To describe national trends in peripheral endovascular interventions by physician specialty, anatomic segment of disease, and clinical location of service. MATERIALS AND METHODS: Current Procedural Terminology codes were used to identify claims for peripheral vascular interventions (PVIs) in 2011-2017 Physician Supplier Procedure Summary master files, which contain 100% Part B Medicare billing. Market share was defined as enrollment-adjusted proportion of billed PVI services for each specialty. Annual volume of billed services was additionally evaluated by clinical location (inpatient, outpatient, office-based laboratories) and anatomic segment of disease (iliac, femoral/popliteal, infrapopliteal). RESULTS: Aggregate PVI claims increased 31.3%, from 227,091 in 2011 to 298,127 in 2017. Annual market share remained relatively stable for all specialties: surgery, 48.3%-49.6%; cardiology, 37.2%-35.1%; radiology, 12.8%-13.3%. Accounting for Medicare enrollment, the volume of iliac interventions decreased by 18% over the study period, while femoral/popliteal interventions increased modestly (+7.5%) and infrapopliteal interventions increased (+46%). The greatest proportional increase in infrapopliteal claims occurred among radiologists (surgeons +40.4%, cardiologists +32.1%, radiologists +106.6%). Adjusting for enrollment, claims from office-based laboratories increased substantially (+305.7%), while hospital-based billing decreased (inpatient -25.7%, outpatient -12.9%). Office-based laboratory utilization increased dramatically with all specialties (surgery +331.8%, cardiology +256.0%, radiology +475.7%). CONCLUSIONS: Utilization of PVIs continues to increase, while specialty market shares have stabilized since 2011, leaving surgeons and cardiologists as the major providers of endovascular peripheral artery disease care. The greatest relative increases are occurring in infrapopliteal interventions and office-based laboratory procedures, where radiologist involvement has increased dramatically.


Assuntos
Procedimentos Endovasculares/tendências , Extremidade Inferior/irrigação sanguínea , Medicare/tendências , Doença Arterial Periférica/terapia , Padrões de Prática Médica/tendências , Especialização/tendências , Demandas Administrativas em Assistência à Saúde , Assistência Ambulatorial/tendências , Procedimentos Cirúrgicos Ambulatórios/tendências , Cardiologistas/tendências , Bases de Dados Factuais , Hospitalização/tendências , Humanos , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Radiologistas/tendências , Cirurgiões/tendências , Fatores de Tempo , Estados Unidos
10.
Ann Vasc Surg ; 66: 282-288, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32027989

RESUMO

BACKGROUND: Concern regarding the adequacy of the vascular surgery workforce persists. We aimed to predict future vascular surgery workforce size and capacity using contemporary data on the US population and number, productivity, and practice patterns of vascular surgeons. METHODS: The workforce size needed to maintain current levels of access was estimated to be 1.4 vascular surgeons/100,000 population. Updated population estimates were obtained from the US Census Bureau. We calculated future vascular surgery workforce needs based on the estimated population for every 10 years from 2020 to 2050. American Medical Association Physician Masterfile data from 1997 to 2017 were used to establish the existing vascular surgery workforce size and predict future workforce size, accounting for annual rates of new certificates (increased to an average of 133/year since 2013), retirement (17%/year), and the effects of burnout, reduced work hours, transitions to nonclinical jobs, or early retirement. Based on Medical Group Management Association data that estimate median vascular surgeon productivity to be 8,481 work relative value units (wRVUs)/year, excess/deficits in wRVU capacity were calculated based on the number of anticipated practicing vascular surgeons. RESULTS: Our model predicts declining shortages of vascular surgeons through 2040, with workforce size meeting demand by 2050. In 2030, each surgeon would need to increase yearly wRVU production by 22%, and in 2040 by 8%, to accommodate the workload volume. CONCLUSIONS: Our model predicts a shortage of vascular surgeons in the coming decades, with workforce size meeting demand by 2050. Congruence between workforce and demand for services in 2050 may be related to increases in the number of trainees from integrated residencies combined with decreases in population estimates. Until then, vascular surgeons will be required to work harder to accommodate the workload. Burnout, changing practice patterns, geographic maldistribution, and expansion of health care coverage and utilization may adversely affect the ability of the future workforce to accommodate population needs.


Assuntos
Necessidades e Demandas de Serviços de Saúde/tendências , Mão de Obra em Saúde/tendências , Determinação de Necessidades de Cuidados de Saúde/tendências , Cirurgiões/provisão & distribução , Cirurgiões/tendências , Procedimentos Cirúrgicos Vasculares/tendências , Censos , Previsões , Humanos , Modelos Teóricos , Fatores de Tempo , Estados Unidos , Carga de Trabalho
11.
J Vasc Surg ; 72(1): 298-303, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32037082

RESUMO

OBJECTIVE: The purpose of this study was to examine trends in application submission, rank lists, and applicant quality for vascular surgery integrated residency. METHODS: The National Resident Matching Program Results and Data reports and the Electronic Residency Application Service Statistics from 2007 to 2017 were compiled and mined for trends in terms of application submission and the number of applicants a program needed to rank to fill all residency positions. Applicant pool depth and percentage of programs applied to were calculated. Outcome data from the National Resident Matching Program were reviewed for 2014 and 2016 for United States Medical Licensing Examination Step scores and experiences. RESULTS: During the last 10 years, the number of vascular surgery integrated residency spots rose from 9 to 60 per year. Most programs offer one spot per year; none offer more than two. The average number of applications received by programs rose from 17 applications in 2008 to 63.8 in 2017. The average rank list depth needed by programs to fill the spots has not increased (range, 2.5-5.1; standard deviation, 0.73). The proportional depth of the applicant pool decreased from 4.6 U.S. and Canadian applicants for every one residency spot in 2008 to 1.7 applicants for every one residency spot in 2017. Applicant quality metrics were available for 2 years (2014 and 2016). Step 1 scores (237/239), Step 2 scores (250/250), research experiences (3.7/4.2), and volunteer experiences (5.9/5.5) remained nearly unchanged. The number of contiguous ranks for matched applicants remained stable (12.3/12.8). CONCLUSIONS: The current system promotes multiple inefficiencies, resulting in application glut. Fewer applicants are flooding programs with an increasing number of applications. More money is being spent on Electronic Residency Application Service applications without changes in the number needed to rank by applicants or programs to achieve a match. There is no improvement in the quality of the applicant. Should these trends continue, they represent an unsustainable model for resident selection.


Assuntos
Educação de Pós-Graduação em Medicina/tendências , Internato e Residência/tendências , Seleção de Pessoal/tendências , Cirurgiões/educação , Cirurgiões/tendências , Procedimentos Cirúrgicos Vasculares/educação , Procedimentos Cirúrgicos Vasculares/tendências , Currículo/tendências , Eficiência Organizacional/tendências , Humanos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Fatores de Tempo
12.
J Clin Neurosci ; 73: 51-56, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32019726

RESUMO

Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.


Assuntos
Estenose das Carótidas/cirurgia , Bases de Dados Factuais/normas , Endarterectomia das Carótidas/normas , Cuidados Pré-Operatórios/normas , Melhoria de Qualidade/normas , Cirurgiões/normas , Idoso , Estenose das Carótidas/epidemiologia , Bases de Dados Factuais/tendências , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/tendências , Melhoria de Qualidade/tendências , Estudos Retrospectivos , Fatores de Risco , Cirurgiões/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
Plast Reconstr Surg ; 145(3): 844-852, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32097336

RESUMO

BACKGROUND: The year 2017 marked the first year women comprised a majority of U.S. medical school matriculants. While more women are pursuing surgical training, within plastic surgery, there is a steady attrition of women advancing in leadership roles. The authors report the current status of women in academic plastic surgery, from trainees to chairwomen and national leadership positions. METHODS: The Electronic Residency Applications Service, San Francisco Match, National Resident Matching Program, Association of American Medical Colleges, American Council of Academic Plastic Surgeons, Plastic Surgery Education Network, and professional websites for journals and national societies were accessed for demographic information from 2007 to 2017. RESULTS: The number of female integrated pathway applicants remained stable (30 percent), with an increased proportion of female residents from 30 percent to 40 percent. There was an increase in female faculty members from 14.6 percent to 22.0 percent, an increase of less than 1 percent per year. Twelve percent of program directors and 8.7 percent of department heads were women. Nationally, major professional societies and administrative boards demonstrated a proportion of female members ranging from 19 percent to 55 percent (average, 27.7 percent). The proportion of female committee leaders ranged from 0 percent to 50 percent (average, 21.5 percent). Only six societies have had female presidents. No major journal had had a female editor-in-chief. The proportion of female editorial board members ranged from 1 percent to 33 percent (average, 16.1 percent). CONCLUSIONS: The authors' study shows a leak in the pipeline at all levels, from trainees to faculty to leadership on the national stage. This report serves as a starting point for investigating reasons for the underrepresentation of talented women in plastic surgery leadership.


Assuntos
Liderança , Sexismo/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Cirurgia Plástica/estatística & dados numéricos , Docentes de Medicina/organização & administração , Docentes de Medicina/estatística & dados numéricos , Docentes de Medicina/tendências , Feminino , Humanos , Internato e Residência/organização & administração , Internato e Residência/estatística & dados numéricos , Internato e Residência/tendências , Masculino , Faculdades de Medicina/organização & administração , Faculdades de Medicina/estatística & dados numéricos , Faculdades de Medicina/tendências , Sexismo/prevenção & controle , Sexismo/tendências , Sociedades Médicas/organização & administração , Sociedades Médicas/estatística & dados numéricos , Sociedades Médicas/tendências , Cirurgiões/organização & administração , Cirurgiões/tendências , Cirurgia Plástica/organização & administração , Cirurgia Plástica/tendências , Estados Unidos
14.
Ann R Coll Surg Engl ; 102(4): 271-276, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31918560

RESUMO

INTRODUCTION: There has been regular dialogue regarding the importance of developing clinical networks to compensate for the steady decline in general paediatric surgery performed by adult surgeons. Despite this dialogue, there are no contemporary published data to quantify the issue. This report documents patterns in delivery of general paediatric surgery in England and shows what is being performed where and by whom. MATERIALS AND METHODS: Using the Surgical Workload Outcome Database, we compared hospital-level data between 2009 and 2017. Inclusion criteria were children under 18 years admitted to NHS hospitals in England for elective general paediatric surgery. Data were analysed with an online statistical package performing paired t-tests. RESULTS: There was no real change in the overall number of elective general paediatric surgical marker cases, but the type mix has changed. The number of marker cases performed by adult surgeons fell by 34% (4699 vs 3090 p < 0.05). The number of marker cases performed by specialist paediatric surgeons increased by 21% (8184 vs 9862 p < 0.05). This increase in workload occurred in both tertiary (21% increase) and peripheral (18% increase) centres. When analysing data by operation type it was apparent that 78% of the increased workload was attributable to an increase in orchidopexy rate. CONCLUSION: Best practice is to treat children close to home by staff with the right skills. This study shows significant shifts in the general paediatric surgical workload. It is important to monitor these trends for successful succession planning as well as configuration of services.


Assuntos
Procedimentos Cirúrgicos Eletivos/tendências , Hospitais Gerais/tendências , Hospitais Pediátricos/tendências , Centro Cirúrgico Hospitalar/tendências , Carga de Trabalho/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Bases de Dados Factuais/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Inglaterra , Feminino , Planejamento Hospitalar/organização & administração , Hospitais Gerais/estatística & dados numéricos , Hospitais Pediátricos/organização & administração , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Especialização/estatística & dados numéricos , Especialização/tendências , Medicina Estatal/organização & administração , Medicina Estatal/estatística & dados numéricos , Medicina Estatal/tendências , Cirurgiões/estatística & dados numéricos , Cirurgiões/tendências , Centro Cirúrgico Hospitalar/estatística & dados numéricos
15.
J Thorac Cardiovasc Surg ; 159(3): 1040-1048, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31924357

RESUMO

OBJECTIVES: We present the evolution of Norwood operation outcomes and practice pattern changes over 15 years from a single institution in Saudi Arabia. We intended to identify time trends in patient selection, procedural details, and outcome predictors over time. METHODS: Patients who underwent a Norwood operation (n = 145) between 2003 and 2018 with the use of a Blalock-Taussig shunt (BT group; n = 72), right ventricle to pulmonary artery shunt (Sano group; n = 66), or a primary cavopulmonary shunt (CPS group; n = 7) were included. The study outcomes were operative mortality, long-term survival, and multistate transition to CPS, Fontan, and death. RESULTS: Median age was 29 days. Predictors of operative mortality were lower weight (P = .026), and longer bypass time (P = .014), whereas age, and type of shunt were not. Predictors of improved long-term survival were greater weight at operation (P = .0016), later era (P = .006), and shorter bypass time (P = .001). The multistate model revealed that patients with lower weight were more likely to undergo Sano versus BT (P < .001), and if BT was chosen in such patients, they were more likely to die (P = .027). The likelihood of receiving Sano shunt was 3-fold greater in the recent era (P = .003). CONCLUSIONS: Improved outcomes of the Norwood operation are evident in the recent era and with Sano shunt, especially in patients of smaller weight. Late presentation or older age is not a contraindication to Norwood operation. The incorporation of a primary CPS at stage one operation is feasible in selected patients.


Assuntos
Cardiopatias Congênitas/cirurgia , Procedimentos de Norwood/tendências , Padrões de Prática Médica/tendências , Cirurgiões/tendências , Fatores Etários , Bases de Dados Factuais , Feminino , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Procedimentos de Norwood/efeitos adversos , Procedimentos de Norwood/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Arábia Saudita/epidemiologia , Fatores de Tempo , Resultado do Tratamento
17.
J Thorac Cardiovasc Surg ; 159(3): 987-996.e6, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31128897

RESUMO

OBJECTIVE: Cardiovascular disease is the leading cause of death worldwide, responsible for 17.5 million deaths every year, of which 80% occur in low- and middle-income countries. Some 75% of the world does not have access to cardiac surgery when needed because of lack of infrastructure, human resources, and financial coverage. This study aims to map access to cardiac surgery around the world. METHODS: A scoping review was done on access to cardiac surgery for an undifferentiated population. Workforce data were collected from the Cardiothoracic Surgery Network database and used to calculate numbers and ratios of adult and pediatric cardiac surgeons to population. RESULTS: A total of 12,180 adult cardiac surgeons and 3858 pediatric cardiac surgeons were listed in the Cardiothoracic Surgery Network in August 2017, equaling 1.64 (0-181.82) adult cardiac surgeons and 0.52 (0-25.97) pediatric cardiac surgeons per million population globally. Large disparities existed between regions, ranging from 0.12 adult cardiac surgeons and 0.08 pediatric cardiac surgeons per million population (sub-Saharan Africa) to 11.12 adult cardiac surgeons and 2.08 pediatric cardiac surgeons (North America). Low-income countries possessed 0.04 adult cardiac surgeons and 0.03 pediatric cardiac surgeons per million population, compared with 7.15 adult cardiac surgeons and 1.67 pediatric cardiac surgeons in high-income countries. CONCLUSIONS: This study maps the current global state of access to cardiac surgery. Disparities exist between and within world regions, with a positive correlation between a nation's economic status and access to cardiac surgery. Low early mortality rates in low-resource settings suggest the possibility of high-quality cardiac surgery in low- and middle-income countries. There is the need to increase human and physical resources, while focusing on safety, quality, and efficiency to improve access to cardiac surgery for the 4.5 billion people without.


Assuntos
Procedimentos Cirúrgicos Cardíacos/tendências , Saúde Global/tendências , Acesso aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/economia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Países em Desenvolvimento , Saúde Global/economia , Custos de Cuidados de Saúde/tendências , Acesso aos Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/economia , Humanos , Determinação de Necessidades de Cuidados de Saúde/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Especialização/tendências , Cirurgiões/tendências
18.
J Vasc Access ; 21(5): 582-588, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31556350

RESUMO

This article described the current state of vascular access management for patients with end-stage renal disease in Singapore. Over the past 10 years, there has been a change in the demographics of end-stage renal disease patients. Aging population and the increase in prevalence of diabetes mellitus has led to the acceleration of chronic kidney disease and increase in incidence and prevalence of end-stage renal disease. Vascular access care has, therefore, been more complicated, with the physical, psychological, and social challenges that occur with increased frequency in elderly patients and patients with multiple co-morbidities. Arteriovenous fistula and arteriovenous graft are created by vascular surgeons, while maintenance of patency of vascular access through endovascular intervention has been a shared responsibility between surgeons, interventional radiologists, and interventional nephrologists. Pre-emptive access creation among end-stage renal disease patients has been low, with up to 80% of new end-stage renal disease patients being commenced on hemodialysis via a dialysis catheter. Access creation is exclusively performed by a dedicated vascular surgeon with arteriovenous fistula success rate up to 78%. The primary and cumulative patency rates of arteriovenous fistula and arteriovenous graft were consistent with the results from many international centers. Vascular access surveillance is not universally practiced in all dialysis centers due to its controversies, in addition to the cost and the limited availability of equipment for surveillance. Timely permanent access placement, with reduced dependence on dialysis catheters, and improved vascular access surveillance are the main areas for potential intervention to improve vascular access management.


Assuntos
Derivação Arteriovenosa Cirúrgica/tendências , Falência Renal Crônica/terapia , Padrões de Prática Médica/tendências , Diálise Renal/tendências , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Custos de Cuidados de Saúde/tendências , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/epidemiologia , Nefrologistas/tendências , Padrões de Prática Médica/economia , Prevalência , Radiologistas/tendências , Diálise Renal/efeitos adversos , Diálise Renal/economia , Fatores de Risco , Singapura/epidemiologia , Cirurgiões/tendências , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
19.
J Thorac Cardiovasc Surg ; 159(6): 2326-2335.e3, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31604638

RESUMO

OBJECTIVE: To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands. METHODS: Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER). Total grant funding, publications, and type was collected. Academic rank, secondary degrees, and fellowship information was collected from faculty pages. Grant productivity was calculated using a validated grant impact metric. RESULTS: A total of 818 academic cardiac surgeons were identified, of whom 144 obtained 293 NIH grants totaling $458 million and resulting in 6694 publications. We identified strong associations between an institution's overall NIH funding rank and the number of cardiac surgeons, NIH grants to cardiac surgeons, and amount of NIH funding to cardiac surgeons (P < .0001 for all). The majority of NIH funding to cardiac surgeons is concentrated in the top quartile of institutions. Cardiac surgeons had a high conversion rates from K awards (mentored development awards) to R01s (6 of 14; 42.9%). Finally, we demonstrate that the rate of all NIH grants awarded to cardiac surgeons has increased, driven primarily by P and U (collaborative project) grants. CONCLUSIONS: NIH-funded cardiac surgical research has had a significant impact over the last 3 decades. Aspiring cardiac surgeon-scientists may be more successful at top quartile institutions owing to better infrastructure and mentorship.


Assuntos
Centros Médicos Acadêmicos/economia , Pesquisa Biomédica/economia , Cardiologistas/economia , National Institutes of Health (U.S.)/economia , Apoio à Pesquisa como Assunto/economia , Cirurgiões/economia , Centros Médicos Acadêmicos/tendências , Pesquisa Biomédica/tendências , Cardiologistas/tendências , Feminino , Humanos , Masculino , Mentores , National Institutes of Health (U.S.)/tendências , Padrões de Prática Médica/economia , Padrões de Prática Médica/tendências , Apoio à Pesquisa como Assunto/tendências , Cirurgiões/tendências , Fatores de Tempo , Estados Unidos , Carga de Trabalho/economia
20.
Neurosurgery ; 86(2): 241-249, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30873551

RESUMO

BACKGROUND: The "Volume Pledge" aims to centralize carotid artery stenting (CAS) to hospitals and surgeons performing ≥10 and ≥5 procedures annually, respectively. OBJECTIVE: To compare outcomes after CAS between hospitals and surgeons meeting or not meeting the Volume Pledge thresholds. METHODS: We queried the Nationwide Inpatient Sample for CAS admissions. Hospitals and surgeons were categorized as low volume and high volume (HV) based on the Volume Pledge. Multivariable hierarchical regression models were used to examine the impact of hospital volume (2005-2011) and surgeon volume (2005-2009) on perioperative outcomes. RESULTS: Between 2005 and 2011, 22 215 patients were identified. Most patients underwent CAS by HV hospitals (86.4%). No differences in poor outcome (composite endpoint of in-hospital mortality, postoperative neurological or cardiac complications) were observed by hospital volume but HV hospitals did decrease the likelihood of other complications, nonroutine discharge, and prolonged hospitalization. From 2005 to 2009, 9454 CAS admissions were associated with physician identifiers. Most patients received CAS by HV surgeons (79.2%). On multivariable analysis, hospital volume was not associated with improved outcomes but HV surgeons decreased odds of poor outcome (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.97; P = .028), complications (OR 0.56, 95% CI 0.46-0.71, P < .001), nonroutine discharge (OR 0.70, 95% CI 0.57-0.87; P = .001), and prolonged hospitalization (OR 0.52, 95% 0.44-0.61, P < .001). CONCLUSION: Most patients receive CAS by hospitals and providers meeting the Volume Pledge threshold for CAS. Surgeons but not hospitals who met the policy's volume standards were associated with superior outcomes across all measured outcomes.


Assuntos
Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Stents/tendências , Cirurgiões/tendências , Idoso , Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/epidemiologia , Endarterectomia das Carótidas/efeitos adversos , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents/efeitos adversos , Cirurgiões/normas
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