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1.
Anesth Analg ; 133(5): 1280-1287, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34673726

RESUMO

BACKGROUND: Perioperative outcomes of children depend on the skill and expertise in managing pediatric patients, as well as integration of surgical, anesthesiology, and medical teams. We compared the types of pediatric patients and inpatient surgical procedures performed in low- versus higher-volume hospitals throughout the United States. METHODS: Retrospective analysis of 323,258 hospitalizations with an operation for children age 0 to 17 years in 2857 hospitals included in the Agency for Healthcare Research and Quality (AHRQ) Kids' Inpatient Database (KID) 2016. Hospitals were categorized by their volume of annual inpatient surgical procedures. Specific surgeries were distinguished with the AHRQ Clinical Classification System. We assessed complex chronic conditions (CCCs) using Feudtner and Colleagues' system. RESULTS: The median annual volume of pediatric inpatient surgeries across US hospitals was 8 (interquartile range [IQR], 3-29). The median volume of inpatient surgeries for children with a CCC was 4 (IQR, 1-13). Low-volume hospitals performed significantly fewer types of surgeries (median 2 vs 131 types of surgeries in hospitals with 1-24 vs ≥2000 volumes). Appendectomy and fixation of bone fracture were among the most common surgeries in low-volume hospitals. As the volume of surgical procedures increased from 1 to 24 to ≥2000, the percentage of older children ages 11 to 17 years decreased (70.9%-32.0% [P < .001]) and the percentage of children with a CCC increased (11.2%-60.0% [P < .001]). CONCLUSIONS: Thousands of US hospitals performed inpatient surgeries on few pediatric patients, including those with CCCs who have the highest risk of perioperative morbidity and mortality. Evaluation of perioperative decision making, workflows, and pediatric clinicians in low- and higher-volume hospitals is warranted.


Assuntos
Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Pacientes Internados , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Pediatria/tendências , Procedimentos Cirúrgicos Operatórios/tendências , Adolescente , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias/mortalidade , Indicadores de Qualidade em Assistência à Saúde/tendências , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
2.
JACC Cardiovasc Interv ; 14(17): 1926-1936, 2021 09 13.
Artigo em Inglês | MEDLINE | ID: mdl-34503743

RESUMO

OBJECTIVES: The aim of this study was to evaluate the interaction between hospital endovascular lower extremity revascularization (eLER) volume and outcomes after eLER for critical limb ischemia (CLI). BACKGROUND: There is a paucity of data on the relationship between hospital procedural volume and outcomes of eLER for CLI. METHODS: The authors queried the Nationwide Readmission Database (2013-2015) for hospitalized patients who underwent eLER for CLI. Hospitals were divided into tertiles according to annual eLER volume: low volume (<100 eLER procedures), moderate volume (100-550 eLER procedures), and high volume (>550 eLER procedures). Stepwise multivariable regression models were used. The main outcomes were in-hospital mortality and 30-day readmission with major adverse limb events, defined as the composite of amputation, acute limb ischemia, or repeat revascularization. RESULTS: Among 145,785 hospitalizations for eLER for CLI, 5,199 (3.6%) were at low-volume eLER hospitals, 27,857 (19.1%) at moderate-volume eLER hospitals, and 112,728 (77.3%) at high-volume eLER hospitals. On multivariable analysis, there was no difference with regard to in-hospital mortality among moderate-volume hospitals (adjusted odds ratio [OR]: 0.78; 95% CI: 0.60-1.01) and high-volume hospitals (adjusted OR: 0.84; 95% CI: 0.64-1.05) compared with low-volume hospitals. There was lower risk of in-hospital major amputation (adjusted OR: 0.82; 95% CI: 0.70-0.96) and minor amputation at high- versus low-volume hospitals. The length of hospital stay was shorter and discharges to nursing facilities were fewer among moderate- and high-volume hospitals compared with low-volume hospitals. Compared with low-volume hospitals, eLER for CLI at high-volume hospitals had a lower risk for 30-day readmission with major adverse limb events (adjusted OR: 0.83; 95% CI: 0.70-0.99), while there was no difference among moderate-volume hospitals (adjusted OR: 0.92; 95% CI: 0.77-1.10). CONCLUSIONS: This nationwide observational analysis suggests that annual eLER volume does not influence in-hospital mortality after eLER for CLI. However, high eLER volume (>550 eLER procedures) was associated with better rates of limb preservation after eLER for CLI.


Assuntos
Procedimentos Endovasculares , Doença Arterial Periférica , Amputação , Estado Terminal , Procedimentos Endovasculares/efeitos adversos , Hospitais com Baixo Volume de Atendimentos , Humanos , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Salvamento de Membro , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
3.
Eur J Vasc Endovasc Surg ; 62(3): 388-398, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34384687

RESUMO

OBJECTIVE: To investigate whether there is a correlation between institutional or surgeon case volume and outcomes in patients with ruptured abdominal aortic aneurysm (rAAA). DATA SOURCES: The Healthcare Database Advanced Search interface developed by the National Institute of Health and Care Excellence was used to search MEDLINE, Embase, CINAHL, and CENTRAL. REVIEW METHODS: The systematic review complied with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines with the protocol registered in PROSPERO (CRD42020213121). Prognostic studies were considered comparing outcomes of patients with rAAA undergoing repair in high and low volume institutions or by high and low volume surgeons. Pooled estimates for peri-operative mortality were calculated using the odds ratio (OR) and 95% confidence intervals (CI), applying the Mantel-Haenszel method. Analysis of adjusted outcome estimates was performed with the generic inverse variance method. RESULTS: Thirteen studies reporting a total of 120 116 patients were included. Patients treated in low volume centres had a statistically significantly higher peri-operative mortality than those treated in high volume centres (OR 1.39; 95% CI 1.22 - 1.59). Subgroup analysis showed a mortality difference in favour of high volume centres for both endovascular aneurysm repair (EVAR; OR 1.61, 95% CI 1.11 - 2.35) and open repair (OR 1.50, 95% CI 1.25 - 1.81). Adjusted analysis showed a benefit of treatment in high volume centres for open repair (OR 1.68, 95% CI 1.21 - 2.33) but not for EVAR (OR 1.42, 95% CI 0.84 - 2.41). Differences in peri-operative mortality between low and high volume surgeons were not statistically significant for either EVAR (OR 1.06, 95% CI 0.59 - 1.89) or open surgical repair (OR 1.18, 95% CI 0.87 - 1.63). CONCLUSION: A high institutional volume may result in a reduction of peri-operative mortality following surgery for rAAA. This peri-operative survival advantage is more pronounced for open surgery than EVAR. Individual surgeon caseload was not found to have a significant impact on outcomes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/mortalidade , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/mortalidade , Implante de Prótese Vascular/métodos , Competência Clínica , Procedimentos Endovasculares/mortalidade , Humanos , Razão de Chances , Resultado do Tratamento
4.
Can J Surg ; 64(4): E371-E376, 2021 07 05.
Artigo em Inglês | MEDLINE | ID: mdl-34222771

RESUMO

Background: Tibial shaft fractures are the most common long-bone injury, with a reported annual incidence of more than 75 000 in the United States. This study aimed to determine whether patients with tibial fractures managed with intramedullary nails experience a lower rate of reoperation if treated at higher-volume hospitals, or by higher-volume or more experienced surgeons. Methods: The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) was a multicentre randomized clinical trial comparing reamed and nonreamed intramedullary nailing on rates of reoperation to promote fracture union, treat infection or preserve the limb in patients with open and closed fractures of the tibial shaft. Using data from SPRINT, we quantified centre and surgeon volumes into quintiles. We performed analyses adjusted for type of fracture (open v. closed), type of injury (isolated v. multitrauma), gender and age for the primary outcome of reoperation using multivariable logistic regression. Results: There were no significant differences in the odds of reoperation between high- and low-volume centres (p = 0.9). Overall, surgeon volume significantly affected the odds of reoperation (p = 0.03). The odds of reoperation among patients treated by moderate-volume surgeons were 50% less than those among patients treated by verylow-volume surgeons (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.28­0.88), and the odds of reoperation among patients treated by high-volume surgeons were 47% less than those among patients treated by very-low-volume surgeons (OR 0.53, 95% CI 0.30­0.93). Conclusion: There appears to be no significant additional patient benefit in treatment by a higher-volume centre for intramedullary fixation of tibial shaft fractures. Additional research on the effects of surgical and clinical site volume in tibial shaft fracture management is needed to confirm this finding. The odds of reoperation were higher in patients treated by very-low-volume surgeons; this finding may be used to optimize the results of tibial shaft fracture management. Clinical trial registration: ClinicalTrials.gov, NCT00038129


Assuntos
Fixação Intramedular de Fraturas , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Reoperação/estatística & dados numéricos , Fraturas da Tíbia/cirurgia , Canadá , Humanos , Países Baixos , Estudos Prospectivos , Cirurgiões , Estados Unidos
5.
Bone Joint J ; 103-B(7): 1261-1269, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34192933

RESUMO

AIMS: Uncemented mobile bearing designs in medial unicompartmental knee arthroplasty (UKA) have seen an increase over the last decade. However, there are a lack of large-scale studies comparing survivorship of these specific designs to commonly used cemented mobile and fixed bearing designs. The aim of this study was to evaluate the survivorship of these designs. METHODS: A total of 21,610 medial UKAs from 2007 to 2018 were selected from the Dutch Arthroplasty Register. Multivariate Cox regression analyses were used to compare uncemented mobile bearings with cemented mobile and fixed bearings. Adjustments were made for patient and surgical factors, with their interactions being considered. Reasons and type of revision in the first two years after surgery were assessed. RESULTS: In hospitals performing less than 100 cases per year, cemented mobile bearings reported comparable adjusted risks of revision as uncemented mobile bearings. However, in hospitals performing more than 100 cases per year, the adjusted risk of revision was higher for cemented mobile bearings compared to uncemented mobile bearings (hazard ratio 1.78 (95% confidence interval 1.34 to 2.35)). The adjusted risk of revision between cemented fixed bearing and uncemented mobile bearing was comparable, independent of annual hospital volume. In addition, 12.3% of uncemented mobile bearing, 20.3% of cemented mobile bearing, and 41.5% of uncemented fixed bearing revisions were for tibial component loosening. The figures for instability were 23.6%, 14.5% and 11.7%, respectively, and for periprosthetic fractures were 10.0%, 2.8%, and 3.5%. Bearing exchange was the type of revision in 40% of uncemented mobile bearing, 24.3% of cemented mobile bearing, and 5.3% cemented fixed bearing revisions. CONCLUSION: The findings of this study demonstrated improved survival with use of uncemented compared to cemented mobile bearings in medial UKA, only in those hospitals performing more than 100 cases per year. Cemented fixed bearings reported comparable survival results as uncemented mobile bearings, regardless of the annual hospital volume. The high rates of instability, periprosthetic fractures, and bearing exchange in uncemented mobile bearings emphasize the need for further research. Cite this article: Bone Joint J 2021;103-B(7):1261-1269.


Assuntos
Artroplastia do Joelho/métodos , Prótese do Joelho , Reoperação/estatística & dados numéricos , Cimentação , Feminino , Seguimentos , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Desenho de Prótese , Falha de Prótese , Sistema de Registros , Fatores de Risco
6.
BMC Pregnancy Childbirth ; 21(1): 531, 2021 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-34315416

RESUMO

BACKGROUND: There is convincing evidence that birth in hospitals with high birth volumes increases the chance of healthy survival in high-risk infants. However, it is unclear whether this is true also for low risk infants. The aim of this systematic review was to analyze effects of hospital's birth volume on mortality, mode of delivery, readmissions, complications and subsequent developmental delays in all births or predefined low risk birth cohorts. The search strategy included EMBASE and Medline supplemented by citing and cited literature of included studies and expert panel highlighting additional literature, published between January/2000 and February/2020. We included studies which were published in English or German language reporting effects of birth volumes on mortality in term or all births in countries with neonatal mortality < 5/1000. We undertook a double-independent title-abstract- and full-text screening and extraction of study characteristics, critical appraisal and outcomes in a qualitative evidence synthesis. RESULTS: 13 retrospective studies with mostly acceptable quality were included. Heterogeneous volume-thresholds, risk adjustments, outcomes and populations hindered a meta-analysis. Qualitatively, four of six studies reported significantly higher perinatal mortality in lower birth volume hospitals. Volume-outcome effects on neonatal mortality (n = 7), stillbirths (n = 3), maternal mortality (n = 1), caesarean sections (n = 2), maternal (n = 1) and neonatal complications (n = 1) were inconclusive. CONCLUSION: Analyzed studies indicate higher rates of perinatal mortality for low risk birth in hospitals with low birth volumes. Due to heterogeneity of studies, data synthesis was complicated and a meta-analysis was not possible. Therefore international core outcome sets should be defined and implemented in perinatal registries. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42018095289.


Assuntos
Salas de Parto , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Resultado da Gravidez/epidemiologia , Gravidez , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Mortalidade Materna , Morbidade , Mortalidade Perinatal
7.
J Am Heart Assoc ; 10(15): e018373, 2021 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-34325522

RESUMO

Background Previous studies of patients with nontraumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume-outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke center certification. Methods and Results Data from 8512 discharges in the National Inpatient Sample (NIS) from 2010 to 2011 were analyzed using logistic regression models to evaluate the association between clinical outcomes (in-hospital mortality and the NIS-SAH Outcome Measure [NIS-SOM]) and measures of hospital annual case volume (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable outcomes with different volume thresholds were performed. During 8512 SAH hospitalizations, 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2% for in-hospital mortality and 38.6% for poor outcome on the NIS-SOM. The mean (range) of SAH, coiling, and clipping annual case volumes were 30.9 (1-195), 8.7 (0-94), and 6.1 (0-69), respectively. Logistic regression demonstrated improved outcomes with increasing annual case volumes of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/year. Analysis of sensitivity and specificity using different volume thresholds confirmed these results. Analysis of previously proposed volume thresholds, including those utilized as minimum standards for comprehensive stroke center certification, showed that hospitals with more than 35 SAH cases annually had consistently superior outcomes compared with hospitals with fewer cases, although some hospitals below this threshold had similar outcomes. The adjusted odds ratio demonstrating lower risk of poor outcomes with SAH annual case volume ≥35 compared with 20 to 34 was 0.82 for the NIS-SOM (95% CI, 0.71-094; P=0.0054) and 0.80 (95% CI, 0.68-0.93; P=0.0055) for in-hospital mortality. Conclusions Outcomes for patients with SAH improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.


Assuntos
Procedimentos Endovasculares/tendências , Hospitalização/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Procedimentos Neurocirúrgicos/tendências , Hemorragia Subaracnóidea/terapia , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Pacientes Internados , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
8.
JACC Cardiovasc Interv ; 14(13): 1423-1430, 2021 07 12.
Artigo em Inglês | MEDLINE | ID: mdl-34147386

RESUMO

OBJECTIVES: The aims of this study were to use a national percutaneous coronary intervention (PCI) registry to study temporal changes in procedure volumes of PCI using rotational atherectomy (ROTA-PCI), the patient and procedural factors associated with differing quartiles of operator ROTA-PCI volume, and the relationship between operator ROTA-PCI volumes and in-hospital patient outcomes. BACKGROUND: Whether higher operator volume is associated with improved outcomes after ROTA-PCI is poorly defined. METHODS: Data from the British Cardiovascular Intervention Society national PCI database were analyzed for all ROTA-PCI procedures performed in the United Kingdom between 2013 and 2016. Individual logistic regressions were performed to quantify the independent association between annual operator ROTA-PCI volume and in-hospital outcomes. RESULTS: In total, 7,740 ROTA-PCI procedures were performed, with a negatively skewed distribution and an annualized operator volume median of 2.5 procedures/year (range 0.25 to 55.25). Higher volume operators undertook more complex procedures in patients with greater comorbid burdens than lower volume operators. A significant inverse association was observed between operator ROTA-PCI volume and in-hospital mortality (odds ratio [OR]: 0.986/case; 95% confidence interval [CI]: 0.975 to 0.996; p = 0.007) and major adverse cardiac and cerebral events (OR: 0.983/case; 95% CI: 0.975 to 0.993; p < 0.001). Additionally, lower rates of emergency cardiac surgery (OR: 0.964/case; 95% CI: 0.939 to 0.991; p = 0.008), arterial complications (OR: 0.975/case; 95% CI: 0.975 to 0.982; p < 0.001) and in-hospital major bleeding (OR: 0.985/case; 95% CI: 0.977 to 0.993; p < 0.001) were associated with higher ROTA-PCI operator volume. Sensitivity analyses in several subgroups demonstrated a consistency of improved outcomes as annual ROTA-PCI volume increased. An annual volume of <4 ROTA-PCI procedures/year was observed to be associated with increased major adverse cardiac and cerebral events, with 239 of 432 operators (55%) not exceeding this threshold. CONCLUSIONS: In-hospital adverse outcomes occurred less frequently as ROTA-PCI operator volume increased. These data suggest that operator volume is an important factor determining outcome after ROTA-PCI.


Assuntos
Aterectomia Coronária , Intervenção Coronária Percutânea , Aterectomia Coronária/efeitos adversos , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Fatores de Risco , Resultado do Tratamento
9.
Medicine (Baltimore) ; 100(23): e26261, 2021 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-34115019

RESUMO

ABSTRACT: The rapid response system (RRS) was introduced for early stage intervention in patients with deteriorating clinical conditions. Responses to unexpected in-hospital patient emergencies varied among hospitals. This study was conducted to understand the prevalence of RRS in smaller hospitals and to identify the need for improvements in the responses to in-hospital emergencies.A questionnaire survey of 971 acute-care hospitals in western Japan was conducted from May to June 2019 on types of in-hospital emergency response for patients in cardiac arrest (e.g., medical emergency teams [METs]), before obvious deterioration (e.g., rapid response teams [RRTs]), and areas for improvement.We received 149 responses, including those from 56 smaller hospitals (≤200 beds), which provided fewer responses than other hospitals. Response systems for cardiac arrest were used for at least a limited number of hours in 129 hospitals (87%). The absence of RRS was significantly more frequent in smaller hospitals than in larger hospitals (13/56, 23% vs 1/60, 2%; P < .01). METs and RRTs operated in 17 (11%) and 15 (10%) hospitals, respectively, and the operation rate for RRTs was significantly lower in smaller hospitals than in larger hospitals (1/56, 2% vs 12/60, 20%; P < .01). Respondents identified the need for education and more medical staff and supervisors; data collection or involvement of the medical safety management sector was ranked low.The prevalence of RRS or predetermined responses before obvious patient deterioration was ≤10% in small hospitals. Specific education and appointment of supervisors could support RRS in small hospitals.


Assuntos
Serviços Médicos de Emergência , Parada Cardíaca , Equipe de Respostas Rápidas de Hospitais , Hospitais com Baixo Volume de Atendimentos , Deterioração Clínica , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Pesquisas sobre Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Equipe de Respostas Rápidas de Hospitais/organização & administração , Equipe de Respostas Rápidas de Hospitais/normas , Equipe de Respostas Rápidas de Hospitais/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/organização & administração , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Japão/epidemiologia , Prevalência , Melhoria de Qualidade , Desenvolvimento de Pessoal
10.
PLoS One ; 16(6): e0253081, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34138904

RESUMO

BACKGROUND AND OBJECTIVE: Few studies have investigated the association between surgical volume and outcome of robot-assisted radical prostatectomy (RARP) in an unselected cohort. We sought to investigate the association between surgical volume with peri-operative and short-term outcomes in a nation-wide, population-based study group. METHODS: 9,810 RARP's registered in the National Prostate Cancer Register of Sweden (2015-2018) were included. Associations between outcome and volume were analyzed with multivariable logistic regression including age, PSA-density, number of positive biopsy cores, cT stage, Gleason score, and extent of lymph node dissection. RESULTS: Surgeons and hospitals in the highest volume group compared to lowest group had shorter operative time; surgeon (OR 9.20, 95% CI 7.11-11.91), hospital (OR 2.16, 95% CI 1.53-3.06), less blood loss; surgeon (OR 2.58. 95% CI 2.07-3.21) hospital (no difference), more often nerve sparing intention; surgeon (OR 2.89, 95% CI 2.34-3.57), hospital (OR 2.02, 95% CI 1.66-2.44), negative margins; surgeon (OR 1.90, 95% CI 1.54-2.35), hospital (OR 1.28, 95% CI 1.07-1.53). There was wide range in outcome between hospitals and surgeons with similar volume that remained after adjustment. CONCLUSIONS: High surgeon and hospital volume were associated with better outcomes. The range in outcome was wide in all volume groups, which indicates that factors besides volume are of importance. Registration of surgical performance is essential for quality control and improvement.


Assuntos
Prostatectomia/instrumentação , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Excisão de Linfonodo , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Gradação de Tumores , Duração da Cirurgia , Período Perioperatório , Neoplasias da Próstata/patologia , Cirurgiões , Suécia , Resultado do Tratamento
11.
J Trauma Acute Care Surg ; 90(6): 996-1002, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34016923

RESUMO

BACKGROUND: Emergency general surgery (EGS) is a high-volume and high-risk surgical service. Interhospital variation in EGS outcomes exists, but there is disagreement in the literature as to whether hospital admission volume affects in-hospital mortality. Scotland collects high-quality data on all admitted patients, whether managed operatively or nonoperatively. Our aim was to determine the relationship between hospital admission volume and in-hospital mortality of EGS patients in Scotland. Second, to investigate whether surgeon admission volume affects mortality. METHODS: This national population-level cohort study included EGS patients aged 16 years and older, who were admitted to a Scottish hospital between 2014 and 2018 (inclusive). A logistic regression model was created, with in-hospital mortality as the dependent variable, and admission volume of hospital per year as a continuous covariate of interest, adjusted for age, sex, comorbidity, deprivation, surgeon admission volume, surgeon operative rate, transfer status, diagnosis, and operation category. RESULTS: There were 376,076 admissions to 25 hospitals, which met our inclusion criteria. The EGS hospital admission rate per year had no effect on in-hospital mortality (odds ratio [OR], 1.000; 95% confidence interval [CI], 1.000-1.000). Higher average surgeon monthly admission volume increased the odds of in-hospital mortality (>35 admissions: OR, 1.139; 95% CI, 1.038-1.250; 25-35 admissions: OR, 1.091; 95% CI, 1.004-1.185; <25 admissions was the referent). CONCLUSION: In Scotland, in contrast to other settings, EGS hospital admission volume did not influence in-hospital mortality. The finding of an association between individual surgeons' case volume and in-hospital mortality warrants further investigation. LEVEL OF EVIDENCE: Care management, Level IV.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/mortalidade , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Carga de Trabalho/estatística & dados numéricos , Adolescente , Adulto , Idoso , Estudos de Coortes , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Escócia/epidemiologia , Cirurgiões/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adulto Jovem
13.
Ann R Coll Surg Engl ; 103(6): 444-451, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34058117

RESUMO

INTRODUCTION: Despite early enthusiasm, minimally invasive cardiac surgery has had a low uptake compared with novel techniques in interventional cardiology. Steep learning curves from high-volume centres have deterred smaller units from engaging, even though low-volume centres undertake a large proportion of surgical interventions worldwide. We sought to identify the safety and experience of learning minimally invasive cardiac surgery after undertaking a structured fellowship at Blackpool Victoria Hospital, a low-volume centre. MATERIALS AND METHODS: A retrospective analysis of outcomes for all consecutive minimally invasive cardiac surgery procedures performed via a right mini-thoracotomy at our institution between 2007 and 2017 was undertaken. Clinical outcomes included death, conversion to sternotomy, stroke, renal failure and other organ support. Cardiopulmonary bypass, aortic cross-clamp times and learning cumulative sum sequential probability method curves were also assessed to determine how safely the procedure was adopted. RESULTS: A total of 316 patients were operated on for mitral, tricuspid, atrial fibrillation, septal defects or other conditions. The mean logistic European System for Cardiac Operative Risk Evaluation score was 7.0 (± 8.5). Conversion to sternotomy occurred in 12 patients (3.8%) and in-hospital mortality was 7 (2.2%). None of the converted patients died. The learning curves showed an accelerated process of adoption, similar to reference figures from a high-volume German centre. DISCUSSION: It is possible for low-volume cardiac surgical centres to undertake minimally invasive surgical programmes with good outcomes and short learning curves. Despite technical complexities, with a team approach, the learning curve can be navigated safely.


Assuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Cardiopatias/cirurgia , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/cirurgia , Ponte Cardiopulmonar , Feminino , Defeitos dos Septos Cardíacos/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Mortalidade Hospitalar , Hospitais com Baixo Volume de Atendimentos/organização & administração , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Duração da Cirurgia , Estudos Retrospectivos , Esternotomia , Toracotomia/métodos , Adulto Jovem
14.
J Stroke Cerebrovasc Dis ; 30(8): 105806, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34058701

RESUMO

BACKGROUND: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on various aspects of thrombectomy systems. AIMS: We conducted a convenience electronic survey with a 21-item questionnaire aimed to identify the changes in stroke admission volumes and thrombectomy treatment practices seen during a specified time period of the COVID-19 pandemic. METHODS: The survey was designed using Qualtrics software and sent to stroke and neuro-interventional physicians around the world who are part of the Global Executive Committee (GEC) of Mission Thrombectomy 2020, a global coalition under the aegis of Society of Vascular and Interventional Neurology, between April 5th and May 15th, 2020. RESULTS: There were 113 responses to the survey across 25 countries with a response rate of 31% among the GEC members. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during the COVID-19 pandemic period until May 15th, 2020 compared to pre-pandemic months. The intubation policy for MT procedures during the pandemic was highly variable across participating centers: 44% preferred intubating all patients, including 25% of centers that changed their policy to preferred-intubation (PI) from preferred non-intubation (PNI). On the other hand, 56% centers preferred not intubating patients undergoing MT, which included 27% centers that changed their policy from PI to PNI. There was no significant difference in rate of COVID-19 infection between PI versus PNI centers (p=0.60) or if intubation policy was changed in either direction (p=1.00). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) were less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers were more likely to report them to be inadequate (58% vs 92%). CONCLUSION: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic. Overall, respondents reported decreased stroke admissions as well as decreased cases of MT with no clear preponderance in intubation policy during MT. DATA ACCESS STATEMENT: The corresponding author will consider requests for sharing survey data. The study was exempt from institutional review board approval as it did not involve patient level data.


Assuntos
COVID-19 , Saúde Global/tendências , Disparidades em Assistência à Saúde/tendências , Padrões de Prática Médica/tendências , Acidente Vascular Cerebral/terapia , Trombectomia/tendências , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Humanos , Controle de Infecções/tendências , Intubação Intratraqueal/tendências , Admissão do Paciente/tendências , Acidente Vascular Cerebral/diagnóstico , Fatores de Tempo
15.
J Am Coll Surg ; 232(6): 900-909.e1, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33831540

RESUMO

BACKGROUND: Surgeon experience, hospital volume, and teaching hospital status may play a role in the success of digit replantation. This study aims to analyze factors that influence digit replantation success rates. STUDY DESIGN: We examined patients with traumatic digit amputations, between 2000 and 2015, from the National Health Insurance Research Database (NHIRD) of Taiwan, which comprises data of more than 99% of its population. We measured the number of traumatic digit amputations and success rate of replantation. Chi-square and ANOVA tests were used for descriptive statistics. Regression models were built to analyze the association among patient, surgeon, and hospital characteristics, and replant success. RESULTS: We identified 13,416 digit replantation patients using the eligibility criteria. The overall replantation failure rate was significantly higher in medium- and high-volume hospitals (low-volume: 11%, medium-volume: 17%, and high-volume: 15%, p < 0.001). Teaching hospitals had significantly higher replantation failure rates [(15.5% vs 7.6%), odds ratio (OR) 2.0; confidence interval (CI) 1.1-3.7]. Lower surgeon case volume resulted in a significantly higher failure rate in the thumb replantation (OR 0.89; CI 0.85-0.94). CONCLUSIONS: Teaching hospitals had greater odds of replantation failure, owing to being high volume centers and attempting more replantations. However, the effect of residents performing the replantation during their training should be considered. Teaching units are mandatory for resident training; however, a balance should be established to provide training, but with sufficient supervision to achieve optimal replant success. A national protocol to triage digit amputation cases to high volume centers with experienced microsurgeons will help improve the replantation success rate.


Assuntos
Amputação Traumática/cirurgia , Traumatismos dos Dedos/cirurgia , Microcirurgia/estatística & dados numéricos , Reimplante/estatística & dados numéricos , Triagem/organização & administração , Adolescente , Adulto , Idoso , Feminino , Traumatismos dos Dedos/etiologia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Humanos , Internato e Residência/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Cirurgiões/estatística & dados numéricos , Resultado do Tratamento , Adulto Jovem
16.
J Gastrointest Surg ; 25(6): 1370-1379, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33914214

RESUMO

BACKGROUND: Inter-hospital transfer (IHT) may help reduce failure-to-rescue (FTR) by transferring patients to centers with a higher level of expertise than the index hospital. We sought to identify factors associated with an IHT and examine if IHT was associated with improved outcomes after complex gastrointestinal cancer surgery. METHODS: Medicare Inpatient Standard Analytic Files were utilized to identify patients with >1 postoperative complication following resection for esophageal, pancreatic, liver, or colorectal cancer between 2013 and 2017. Multivariable logistic regression was used to examine the association of different factors with the chance of IHT, as well as the impact of IHT on failure-to-rescue (FTR) and expenditures. RESULTS: Among 39,973 patients with >1 postoperative complications, 3090 (7.7%) patients were transferred to a secondary hospital. The median LOS at the index hospital prior to IHT was 10 days (IQR, 6-17 days). Patients who underwent IHT more often had experienced multiple complications at the index hospital compared with non-IHT patients (57.7% vs. 38.9%) (p<0.001). Transferred patients more commonly had undergone surgery at a low-volume index hospital (n=218, 60.2%) compared with non-IHT (n=10,351, 25.9%) patients (p<0.001). On multivariate analysis, hospital volume remained strongly associated with transfer to an acute care hospital (ACH) (OR 5.53; 95% CI 3.91-7.84; p<0.001), as did multiple complications (OR 2.01, 95% CI 1.56-2.57). The incidence of FTR was much higher among IHT-ACH patients (20.2%) versus non-IHT patients (11.5%) (OR 1.51, 95% CI 1.11-2.05) (p<0.001). Medicare expenditures were higher among patients who had IHT-ACH ($72.1k USD; IQR, $48.1k-$116.7k) versus non-IHT ($38.5k USD; IQR, $28.1k-$59.2k USD) (p<0.001). CONCLUSION: Approximately 1 in 13 patients had an IHT after complex gastrointestinal cancer surgery. IHT was associated with high rates of FTR, which was more pronounced among patients who underwent surgery at an index low-volume hospital. IHT was associated with higher overall CMS expenditures.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Neoplasias Gastrointestinais , Idoso , Análise Custo-Benefício , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Neoplasias Gastrointestinais/cirurgia , Mortalidade Hospitalar , Hospitais com Baixo Volume de Atendimentos , Humanos , Medicare , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
17.
World J Surg ; 45(8): 2415-2425, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33891137

RESUMO

BACKGROUND: Regionalization of sarcoma care may improve outcomes. Concerns exist regarding the burdens of travel and its effects on care. We evaluate the presence of a "distance bias". METHODS: Retrospective cohort study of patients with extremity soft tissue sarcoma (stage I-III) within the NCDB. Travel distance (TD) and hospital volume (VOL) were categorized into quartiles. Alternating statistical models were used for analysis. RESULTS: 1,035 hospitals contributed 11,979 cases. Median and maximum VOL were 5 and 45 cases/year. VOL quartiles were "low-volume" (LV) (892 hospitals, < 3 cases/yr.), "intermediate low-volume" (ILV) (89, 3-5 cases/yr.), "intermediate high-volume" (IHV) (39, 6-12 cases/yr.), and "high-volume" (HV) (15, > 12 cases/yr.). TD quartiles: "short-travel" (ST) (< 8 mi), "intermediate-short travel" (IST) (8-17), "intermediate long-travel" (ILT) (18-49), and "long-travel" (LT) (> 50). VOL but not TD is associated with improved survival [HR 0.65 (CI 0.52-0.83)] and rate of R0 resection [1.87 (CI 1.4-2.5)] but has no effect on amputation rates. Matched analyses demonstrate similar results. CONCLUSIONS: Hospital volume but not distance traveled to treatment facility is associated with improved survival and R0 resections for extremity soft tissue sarcomas. Despite the inconveniences of travel, patients may benefit from treatment at high volume centers.


Assuntos
Hospitais com Baixo Volume de Atendimentos , Sarcoma , Extremidades , Acesso aos Serviços de Saúde , Hospitais com Alto Volume de Atendimentos , Humanos , Estudos Retrospectivos , Sarcoma/cirurgia
18.
J Plast Reconstr Aesthet Surg ; 74(10): 2645-2653, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33888434

RESUMO

BACKGROUND: Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed. METHODS: Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost. RESULTS: In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p < 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p < 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[ß], 0.454; 95% Confidence Interval, 0.346-0.596; p < 0.001) and increased hospital cost (Exp[ß], 1.351; 95% Confidence Interval, 1.285-1.421; p < 0.001). CONCLUSIONS: Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.


Assuntos
Neoplasias Colorretais/cirurgia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Pelve/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/economia , Neoplasias Urogenitais/cirurgia , Parede Abdominal/cirurgia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Reconstrutivos/estatística & dados numéricos , Retalhos Cirúrgicos/efeitos adversos , Resultado do Tratamento , Estados Unidos
19.
J Vasc Surg ; 74(3): 851-860, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33775748

RESUMO

BACKGROUND: A nationwide variation in mortality stratified by hospital volume exists after open repair of complex abdominal aortic aneurysms (AAAs). In the present study, we assessed whether the rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) would better explain the lower mortality rates among higher volume hospitals. METHODS: Using the 2004 to 2018 Vascular Quality Initiative database, we identified all patients who had undergone open repair of elective or symptomatic AAAs, in which the proximal clamp sites were at least above one renal artery. We divided the patients into hospital quintiles according to the annual hospital volume and compared the risk-adjusted outcomes. Multivariable logistic regression, adjusted for patient characteristics, operative factors, and hospital volume, was used to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue. RESULTS: We identified 3566 patients who had undergone open repair of elective or symptomatic complex AAAs (median age, 71 years; 29% women; 4.1% black; 48% Medicare insurance). The unadjusted rates of 30-day postoperative mortality, overall complications, and failure-to-rescue were 5.0%, 44%, and 10%, respectively. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with the specific failure-to-rescue rate ranging from 12% to 22%. On adjusted analysis, the risk-adjusted mortality rate was 2.5 times greater for the lower volume hospitals relative to the higher volume hospitals (7.4% vs 3.0%; P < .01). Although the risk-adjusted complication rates were similar between these hospital groups (30% vs 27%; P = .06), the failure-to-rescue rate was 2.3 times greater for the lower volume hospitals relative to the higher volume hospitals (6.3% vs 2.7%; P = .02). CONCLUSIONS: Higher volume hospitals had lower mortality rates after open repair of complex AAAs because they were better at the "rescue" of patients after the occurrence of postoperative complications. Both an understanding of the clinical mechanisms underlying this association and the regionalization of open repair might improve patient outcomes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/mortalidade , Falha da Terapia de Resgate , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Complicações Pós-Operatórias/mortalidade , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/tendências , Bases de Dados Factuais , Falha da Terapia de Resgate/tendências , Feminino , Mortalidade Hospitalar/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
20.
J Am Coll Surg ; 233(1): 90-98, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33766724

RESUMO

BACKGROUND: Volume of operative cases may be an important factor associated with improved survival for early-stage pancreatic cancer. Most high-volume pancreatic centers are also academic institutions, which have been associated with additional healthcare costs. We hypothesized that at high-volume centers, the value of the extra survival outweighs the extra cost. STUDY DESIGN: This retrospective cohort study used data from the California Cancer Registry linked to the Office of Statewide Health Planning and Development database from January 1, 2004 through December 31, 2012. Stage I-II pancreatic cancer patients who underwent resection were included. Multivariable analyses estimated overall survival and 30-day costs at low- vs high-volume pancreatic surgery centers. The incremental cost-effectiveness ratio (ICER) and incremental net benefit (INB) were estimated, and statistical uncertainty was characterized using net benefit regression. RESULTS: Of 2,786 patients, 46.5% were treated at high-volume centers and 53.5% at low-volume centers. There was a 0.45-year (5.4 months) survival benefit (95% CI 0.21-0.69) and a $7,884 extra cost associated with receiving surgery at high-volume centers (95% CI $4,074-$11,694). The ICER was $17,529 for an additional year of survival (95% CI $7,997-$40,616). For decision-makers willing to pay more than $20,000 for an additional year of life, high-volume centers appear cost-effective. CONCLUSIONS: Although healthcare costs were greater at high-volume centers, patients undergoing pancreatic surgery at high-volume centers experienced a survival benefit (5.4 months). The extra cost of $17,529 per additional year is quite modest for improved survival and is economically attractive by many oncology standards.


Assuntos
Adenocarcinoma/cirurgia , Hospitais com Alto Volume de Atendimentos , Neoplasias Pancreáticas/cirurgia , Adenocarcinoma/economia , Adenocarcinoma/mortalidade , Idoso , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/economia , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatectomia/economia , Pancreatectomia/estatística & dados numéricos , Neoplasias Pancreáticas/economia , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/economia , Pancreaticoduodenectomia/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , Análise de Sobrevida
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