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1.
Plast Reconstr Surg ; 145(2): 459-467, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985641

RESUMO

BACKGROUND: Injuries to the upper extremity lymphatic system from cancer may require measures to prevent secondary lymphedema. Guidelines were established relating to the use of tourniquet and elective hand and upper extremity surgery. However, reports in the setting of hand surgery have indicated that prior guidelines may not be protective to the patient. METHODS: The study systematically reviewed the current literature evaluating elective hand surgery in breast cancer patients. The authors evaluated the risk of complications, including new or worsening lymphedema and infection. RESULTS: One hundred ninety-eight abstracts were identified, and a bibliographic review was performed. Nine studies pertained to our subject, and four were included for final review. All studies included patients with prior breast cancer treatment involving breast surgery and axillary lymph node dissection. Pneumatic tourniquets were used during nearly all operations. Patients without presurgery ipsilateral lymphedema had a 2.7 percent incidence of developing new lymphedema and a 0.7 percent rate of postoperative infection. Patients with presurgery lymphedema had a 11.1 percent incidence of worsening lymphedema and a 16.7 percent rate of infection. However, all cases of new or exacerbated lymphedema resolved within 3 months. Tourniquet use was not found to increase rates of lymphedema. CONCLUSIONS: Based on the available evidence, there is no increased risk of complications for elective hand surgery in patients with prior breast cancer treatment. Breast cancer patients with preexisting ipsilateral lymphedema carry slightly increased risk of postoperative infection and worsening lymphedema. It is the authors' opinion and recommendation that elective hand surgery with a tourniquet is not a contradiction in patients who have received previous breast cancer treatments.


Assuntos
Neoplasias da Mama/cirurgia , Mãos/cirurgia , Linfedema/cirurgia , Neoplasias da Mama/complicações , Neoplasias da Mama/radioterapia , Síndrome do Túnel Carpal/etiologia , Síndrome do Túnel Carpal/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/métodos , Linfedema/complicações , Mastectomia/efeitos adversos , Mastectomia/métodos , Segurança do Paciente , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Cirurgia de Second-Look/estatística & dados numéricos , Biópsia de Linfonodo Sentinela/efeitos adversos , Biópsia de Linfonodo Sentinela/métodos , Infecção da Ferida Cirúrgica/etiologia , Torniquetes , Resultado do Tratamento
2.
Ann R Coll Surg Engl ; 102(1): 28-35, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31232611

RESUMO

INTRODUCTION: Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes. MATERIALS AND METHODS: A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22. RESULTS: A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity. DISCUSSION: Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.


Assuntos
Analgesia/métodos , Doenças do Colo/cirurgia , Laparoscopia/métodos , Padrões de Prática Médica/estatística & dados numéricos , Doenças Retais/cirurgia , Idoso , Analgesia/estatística & dados numéricos , Analgesia Controlada pelo Paciente/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Conversão para Cirurgia Aberta/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Medição da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Estudos Prospectivos , Reoperação/estatística & dados numéricos , Resultado do Tratamento
3.
Ann R Coll Surg Engl ; 102(1): 18-24, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31233336

RESUMO

INTRODUCTION: Patient flow is the process by which movement of patients and clinical productivity is achieved. The objectives of this study were to implement and evaluate the NHS Improvement SAFER patient flow bundle, evaluate the impact of the Red2Green initiative, and assess the impact of frailty on patient flow. MATERIALS AND METHODS: All patients admitted to a neurosurgery unit from 1 September to 30 November 2017 were included. Using guidance set out by NHS, data were prospectively collected from daily ward lists and patient notes, including demographics, admission and discharge details, length of stay, anticipated discharge date, red days with reasons and frailty (Rockwood Clinical Frailty Scale). NHS reference costs were used for cost analyses. RESULTS: A total of 420 patients (55% elective) were included, totalling 3909 bed days. All patients received daily senior reviews before midday, and anticipated discharge dates were set at daily multidisciplinary team meetings. Ten per cent of patients were discharged before midday. There were 21% (837) red days, significantly more (76%) for emergency patients (639 vs 198 elective; P < 0.001); 63% red days were attributed to awaiting a bed in a local hospital; 25% (106) patients were classed as frail (50 elective), which was associated with a significantly longer length of stay (17.3 vs 6; P < 0.01), and more red days (615 vs 222; p<0.01). Considering excess bed charges and lost revenue (with penalties), red days cost over £1 million per year. CONCLUSIONS: SAFER has identified areas for improvement in patient flow, with obvious cost implications. It has created a platform for discussion within the referral network and identified a role for a geriatric liaison service.


Assuntos
Departamentos Hospitalares/estatística & dados numéricos , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Ocupação de Leitos/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Fragilidade/terapia , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Segurança do Paciente , Estudos Prospectivos , Estudos Retrospectivos , Triagem/métodos , Triagem/estatística & dados numéricos
4.
Medicine (Baltimore) ; 98(44): e17740, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689822

RESUMO

To identify independent factors associated with prolonged hospital length of stay (LOS) in elderly patients undergoing first-time elective open posterior lumbar fusion surgery.We retrospectively analyzed the data of 303 elderly patients (age range: 60-86 years) who underwent first-time elective open lumbar posterior fusion surgery at our center from December 2012 to December 2017. Preoperative and perioperative variables were extracted and analyzed for all patients, and multivariate stepwise regression analysis was used to determine the variables affecting the LOS and important predictors of LOS prolongation (P < .001).The mean age of the patients was 67.0 ±â€Š5.5 years, and the mean LOS was 18.5 ±â€Š11.8 days, ranging from 7 to 103 days. Of the total, 166 patients (54.8%) were men and 83 patients (27.4%) had extended LOS. Multiple linear regression analysis determined that age (P < .001), preoperative waiting time ≥7 days (P < .001), pulmonary comorbidities (P = .010), and diabetes (P = .010) were preoperative factors associated with LOS prolongation. Major complications (P = .002), infectious complications (P = .001), multiple surgeries (P < .001), and surgical bleeding (P = .018) were perioperative factors associated with LOS prolongation. Age (P < .001), preoperative waiting time ≥7 days (P < .001), infectious complications (P < .001), and multiple surgeries (P < .001) were important predictors of LOS prolongation.Extended LOS after first-time elective open posterior lumbar fusion surgery in elderly patients is associated with factors including age, preoperative waiting time, infectious complications, and multiple surgeries. Surgeons should recognize and note these relevant factors while taking appropriate precautions to optimize the modifiable factors, thereby reducing the LOS as well as hospitalization costs.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Fusão Vertebral/estatística & dados numéricos , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Listas de Espera
5.
Pan Afr Med J ; 33: 254, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31692805

RESUMO

Introduction: Postoperative complications are common; some are transient, others may be serious, but they are all important to patients. One of the most important gaps in surgical research is the lack of consensus over the preferred result, the type of measurement or of evaluation. Methods: We conducted a retrospective study of postoperative complications at the Surgery Department of the National Hospital Center of Nouakchott. Eight hundred thirty-four patients underwent surgery over a seven-month period (1 January 2017-31 July 2017). The demographic and clinical parameters were studied and analyzed statistically using SPSS software 20. Results: The study involved 834 patients, of whom 426 (51.1%) were men. The average age of patients was 34.81 years (1-90 years). Four hundred thirty-two (51.2%) patients underwent emergency surgery. The sex ratio (M/F) was 1.04. Arab-Berbers race accounted for 77.8%. Appendicular disease accounted for 41.12%, hepatobiliary disease accounted for 17.76%, and abdominal wall disease accounted for 16.1%). Thyroid disease accounted for 5.6%. One hundred eighty-three (21.94%) patients developed postoperative complications, including 4 (2.1%) deaths. Clavien-Dindo grade II was the most represented with 82.5% of complications and accounted for 17.91% of all operated patients. Surgical site infection accounted for 62.8% of all complications. Conclusion: This study shows that the Clavien-Dindo classification can be applied to patients who have undergone elective surgery and emergency surgery. We think that the lack of follow-up and the lack of means to fight the infection and the non-rigorous respect of asepsis and antisepsis procedures would play an important role.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências , Complicações Pós-Operatórias/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/classificação , Estudos Retrospectivos , Adulto Jovem
6.
Spine (Phila Pa 1976) ; 44(22): E1336-E1341, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31689256

RESUMO

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study was to evaluate the effect of preoperative dehydration on hospital length of stay (LOS), rates of 30-day postoperative complications, related reoperations, and readmissions. SUMMARY OF BACKGROUND DATA: Preoperative dehydration has long been associated with postoperative infection, deep vein thrombosis (DVT), acute renal failure, and an increased hospital LOS. To our knowledge, the effect of preoperative dehydration on complication rates for patients undergoing elective lumbar spine surgery has not been well described. METHODS: An analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 2006 to 2013 was performed. Patients undergoing elective lumbar procedures were identified and exclusion criteria eliminated patients who underwent any emergency procedures, infections, tumor cases, or revision surgeries. Patient dehydration was defined as preoperative blood urea nitrogen/creatinine (BUN/Cr) ratio greater than 20. RESULTS: Patients (4698; 34.5%) with preoperative dehydration based on BUN/Cr ratio were identified. Univariate analysis was suggestive of an association between preoperative dehydration and an increased risk of DVT (1.1% compared with 0.6%; P = 0.002), urinary tract infection (2.5% compared with 1.6%; P < 0.001), and need for transfusion postoperatively (17.6% compared with 14.4%; P < 0.001). However, on the basis of multivariate regression, no significant association between dehydration and increased odds of aforementioned outcomes was identified. CONCLUSION: Preoperative dehydration does not appear to negatively affect perioperative outcomes or readmission in patients undergoing elective lumbar spine surgery. LEVEL OF EVIDENCE: 3.


Assuntos
Desidratação/epidemiologia , Procedimentos Cirúrgicos Eletivos , Vértebras Lombares/cirurgia , Procedimentos Ortopédicos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/estatística & dados numéricos , Estudos Retrospectivos
7.
Z Gastroenterol ; 57(10): 1200-1208, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31610583

RESUMO

BACKGROUND: Elective surgery for recurrent uncomplicated diverticulitis is a matter of debate. "Smoldering diverticulitis" (SmD) describes a subtype of the disease which is characterized by frequently relapsing symptoms triggered by a "smoldering fire-like" ongoing inflammatory process. The aim of this study was to investigate the value of surgery in these patients. METHODS: Forty-four patients with the clinical signs of SmD were selected from a prospective database of 393 patients with elective surgery for diverticulitis. They were compared for morbidity and the effect of surgery on quality of life (QL) (Gastrointestinal QL-Index (GLQI)) with a group of 95 patients who had elective surgery for perforated diverticulitis. RESULTS: Morbidity was equivalent in both groups with shorter durations of surgery in the SmD group (159 (65-301) vs. 174 (100-443) minutes, p = 0.031). Six months after surgery, a significant improvement of QL was found in the SmD group (GLQI 115 (72-143) vs. 98 (56-139) preoperatively, p = 0.018). In the control groups, only a non-significant improvement of the preoperatively less suppressed quality of life was noted. Approximately 80 % of the patients were satisfied with the outcome of surgery. CONCLUSION: In patients with SmD like chronic recurrent disease surgery is effective to improve quality of life.


Assuntos
Diverticulite , Procedimentos Cirúrgicos Eletivos , Estudos de Casos e Controles , Diverticulite/diagnóstico , Diverticulite/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Humanos , Estudos Prospectivos , Qualidade de Vida
8.
Ann R Coll Surg Engl ; 101(8): 584-588, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31537105

RESUMO

INTRODUCTION: The National Institute for Health and Care Excellence published a draft consultation update on abdominal aortic aneurysm, which was expected to be published on 7 November 2018. This article analyses the readiness of NHS hospitals and their workforce to embrace the proposed guidelines. METHODS: The trust and individual surgeon-level anonymised data in the public domain for elective, rupture and complex abdominal aortic aneurysm cases were collected and analysed for all the acute care trusts providing these services from the Vascular Society of Great Briton and Ireland's prospective National Vascular Registry database. RESULTS: Of the 95 acute care trusts providing the service for the year 2017, the annual volume of infrarenal abdominal aortic aneurysm (both endovascular and open repairs) ranged between 0 and 137. Of these, 64 (67.36%) trusts had an annual volume of fewer than 60 cases. A total of 366 (approximately 75% of 490) vascular surgeons have performed 10 or fewer open abdominal aortic aneurysm repairs in three years (2014-2016) with a mean operating volume of 1.452 procedures per surgeon per three years (n = 254, median 0, interquartile range, IQR, 0-3, 0.484 procedures per surgeon per year) and about 51% of the vascular surgeons have only performed five or fewer procedures in those three years with a mean operating volume of 3.455 per surgeon per three years (n = 367, median 3, IQR 0-3, 1.151 per surgeon per year). CONCLUSION: The observations show that most UK acute hospitals lack the optimum case volume necessary to embrace the proposed change in the guideline.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Vasculares/normas , Aneurisma da Aorta Abdominal/epidemiologia , Ruptura Aórtica/epidemiologia , Ruptura Aórtica/cirurgia , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências , Medicina Baseada em Evidências/métodos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Irlanda/epidemiologia , Sistema de Registros , Medicina Estatal/normas , Medicina Estatal/estatística & dados numéricos , Reino Unido/epidemiologia , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos
9.
BMC Health Serv Res ; 19(1): 669, 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31533708

RESUMO

BACKGROUND: Measuring patient satisfaction has become an important parameter of the continuous quality assessment and improvement in anaesthesia services. The aim of this study was to assess the level of patient satisfaction with perioperative anaesthesia care and to determine the factors that influence satisfaction. METHOD: This study is an cross sectional design, conducted on 470 patients who underwent different types of surgeries at two National Referral Hospitals in Asmara, Eritrea between January and March of 2018. Patients were interviewed 24 h after the operation using a Tigrigna translated Leiden Perioperative Care Patient Satisfaction questionnaire (LPPSq). Descriptive and inferential analysis were made using SPSS (version 22). Statistical significance level was set at P < 0.05. RESULTS: The overall satisfaction score was 68.8%. Less fear and concern was observed among patients with satisfaction scores of 87.5%. Staff-patient relationship satisfaction score was 75%. Patients were least satisfied with information provision (45%). Multivariable analysis revealed that satisfaction of patients who did surgery at Halibet hospital is significantly higher (p < 0.001) than those patients who did at Orotta hospital. Moreover, those patients who did elective surgery had higher level of satisfaction that those who did emergency surgery (p < 0.001). CONCLUSION: Moderate level of satisfaction was observed among the patients. Generally, the study emphasized that the information provision about anesthesia and surgery was low. Patients described better staff-patient relationship and low fear and concern related to anesthesia and surgery was observed.


Assuntos
Anestesia/normas , Satisfação do Paciente/estatística & dados numéricos , Assistência Perioperatória/normas , Adulto , Anestesia/psicologia , Estudos Transversais , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tratamento de Emergência/psicologia , Tratamento de Emergência/normas , Eritreia , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Relações Profissional-Paciente , Encaminhamento e Consulta/estatística & dados numéricos , Inquéritos e Questionários , Adulto Jovem
11.
Mayo Clin Proc ; 94(9): 1786-1798, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31486381

RESUMO

OBJECTIVE: To compare recall of complications and surgical details discussed during informed consent and perception of the consent process in patients undergoing emergent vs elective surgery. METHODS: Studies were identified from PubMed, Cochrane, Web of Science, and Scopus from January 1, 1966, through April 18, 2018. Included studies compared patient recall and perception regarding informed consent in those undergoing emergent vs elective surgery. Pooled odds ratios (ORs) were calculated for recall of complications and surgical details, patient satisfaction, perception of sufficient information being delivered on surgical risks, report of having read written consent, and factors that interfered with consent. RESULTS: Eleven observational studies (3178 patients) were included. The rate of recall of surgical complications (255 of 504 [50.6%] vs 321 of 446 [72.0%]; OR, 0.29; 95% CI, 0.11-0.80) was lower in patients undergoing emergent vs elective surgery. Meta-analysis revealed a decreased rate of patient satisfaction with the consent process (319 of 459 [69.5%] vs 882 of 1064 [82.9%]; OR. 0.53; 95% CI, 0.34-0.83) and fewer patients having read the consent form (130 of 395 [32.9%] vs 424 of 714 [59.4%]; OR, 0.35; 95% CI, 0.27-0.46) when undergoing emergent compared with elective surgery. Patients undergoing emergent surgery listed pain, analgesic medications, and fatigue as factors likely to interfere with consent. CONCLUSION: Patients undergoing emergent surgery have poor recall of the informed consent process and surgical complications. Furthermore, patients report lower rates of satisfaction, and with fewer patients reading written consent documentation, our findings illuminate problems with the current communication process. There is a need to develop effective tools to improve informed consent in emergency surgery.


Assuntos
Procedimentos Cirúrgicos Eletivos/métodos , Tratamento de Emergência/métodos , Consentimento Livre e Esclarecido , Rememoração Mental , Determinação de Necessidades de Cuidados de Saúde , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Segurança do Paciente , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Medição de Risco , Estados Unidos
12.
Bone Joint J ; 101-B(9): 1081-1086, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474135

RESUMO

AIMS: The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon's cases and the total time spent in the operating theatre per day. MATERIALS AND METHODS: A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. RESULTS: A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days. CONCLUSION: The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081-1086.


Assuntos
Artroplastia do Joelho/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Duração da Cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/economia , Boston/epidemiologia , Bases de Dados Factuais/estatística & dados numéricos , Eficiência Organizacional/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Humanos , Tempo de Internação , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Salas Cirúrgicas/organização & administração , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia
13.
BMC Musculoskelet Disord ; 20(1): 374, 2019 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-31416443

RESUMO

BACKGROUND: The number of hip, knee and shoulder arthroplasties continues to rise worldwide. The Organization for Economic Cooperation and Development has launched an initiative (called PaRIS Initiative) for the systematic collection of Patient Reported Outcome Measures (PROMs) in patients undergoing elective hip and knee arthroplasty. The Rizzoli Orthopedic Institute (IOR) was selected as a pilot center for the launch of the Initiative in Italy given that IOR hosts the Registry of Orthopedic Prosthetic Implants (RIPO), a region-wide registry which collects joint implant data from all the hospitals in the Emilia-Romagna Region. In this specific geographic area information related to PROMs after joint replacement is unknown. This paper describes the protocol of a study (PaRIS-IOR) that aims to implement the collection of a set of PROMs within an existing implant registry in Italy. The study will also investigate the temporal trend of PROMs in relation to the type of prosthesis and the type of surgical intervention. METHODS: The PaRIS-IOR study is a prospective, single site, cohort study that consists of the administration of PROMs questionnaires to patients on the list for elective arthroplasty. The questionnaires will be administered to the study population within 30 days before surgery, and then at 6 and 12 months following surgery. The study population will consist of consecutive adult patients undergoing either hip, knee or shoulder arthroplasty. The collected data will be linked with those routinely collected by the RIPO in order to assess the temporal trend of PROMs in relation to the type of prosthesis and the type of surgical intervention. DISCUSSION: The PaRIS-IOR study could have important implications in targeting the factors influencing functional outcomes and quality of life reported by patients after hip, knee and shoulder arthroplasty, and will also represent the first systematic collection of PROMs related to arthroplasty in Italy. TRIAL REGISTRATION: Protocol version (1.0) and trial registration data are available on the platform www.clinicaltrial.gov with the identifier NCT03790267 , first posted on December 31, 2018.


Assuntos
Estudos Observacionais como Assunto , Medidas de Resultados Relatados pelo Paciente , Projetos de Pesquisa , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/instrumentação , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/instrumentação , Artroplastia do Joelho/estatística & dados numéricos , Artroplastia do Ombro/efeitos adversos , Artroplastia do Ombro/instrumentação , Artroplastia do Ombro/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/instrumentação , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Prospectivos , Qualidade de Vida , Sistema de Registros/estatística & dados numéricos , Resultado do Tratamento , Adulto Jovem
14.
Lancet ; 394(10203): 1022-1029, 2019 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-31422895

RESUMO

BACKGROUND: In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery. METHODS: NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results. FINDINGS: Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6-9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22-3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06-4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14-14·99, absolute risk increase 3%; p=0·019). INTERPRETATION: Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke. FUNDING: Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.


Assuntos
Disfunção Cognitiva/etiologia , Complicações Pós-Operatórias/etiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Estudos de Casos e Controles , Disfunção Cognitiva/epidemiologia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Delírio do Despertar/epidemiologia , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Período Perioperatório , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia
15.
Int J Health Care Qual Assur ; 32(6): 1013-1021, 2019 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-31282259

RESUMO

PURPOSE: The purpose of this paper is to examine from the viewpoint of resource utilization the Japanese surgical payment system which was revised in April 2016. DESIGN/METHODOLOGY/APPROACH: The authors collected data from surgical records in the Teikyo University electronic medical record system from April 1 till September 30, 2016. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated each surgeon's efficiency score using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. The authors compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and the Steel method. FINDINGS: The authors analyzed 2,558 surgical procedures performed by 109 surgeons. The difference in efficiency scores was significant (p = 0.000). The efficiency score of neurosurgery was significantly greater than obstetrics and gynecology, general surgery, orthopedics, emergency surgery, urology, otolaryngology and plastic surgery (p<0.05). ORIGINALITY/VALUE: The authors demonstrated that the surgeons' efficiency was significantly different among their specialties. This suggests that the Japanese surgical reimbursement scales fail to reflect resource utilization despite the revision in 2016.


Assuntos
Recursos em Saúde/economia , Custos Hospitalares , Salas Cirúrgicas/economia , Procedimentos Cirúrgicos Operatórios/economia , Bases de Dados Factuais , Eficiência Organizacional , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências/economia , Feminino , Custos de Cuidados de Saúde , Hospitais Universitários/economia , Humanos , Japão , Masculino , Salas Cirúrgicas/estatística & dados numéricos , Inovação Organizacional , Sistema de Pagamento Prospectivo , Estudos Retrospectivos , Estatísticas não Paramétricas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
16.
J Surg Res ; 243: 160-164, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31177035

RESUMO

BACKGROUND: The Social Vulnerability Index (SVI) is a composite scale formulated by the Centers for Disease Control and is geocoded as a percentile ranking at the census tract level. SVI is potentially applicable to assess risk and target populations that are likely to present emergently for disease that could have been treated electively and target local disparities. We applied the SVI to compare cholecystectomy patients presenting emergently versus electively. METHODS: We identified patients who had undergone cholecystectomy at our academic medical center over a 6-month period. We abstracted patient demographics, chronic symptom duration, and diagnosis from the medical record. Patient addresses were geocoded to identify their census tract of residence and estimated SVI. RESULTS: Two hundred and fifty five patients met inclusion criteria. Most patients (n = 185, 72.5%) had surgery in the emergent setting. Emergent patients lived in areas of greater social vulnerability compared with elective patients (median SVI 75th versus 64th percentile, P < 0.001). On multivariable analysis adjusting for chronicity of symptoms and patient proximity to the hospital, having high SVI (>70th percentile) was associated with higher odds of undergoing an emergent versus an elective procedure (OR 2.05, P = 0.04). CONCLUSIONS: The SVI has potential utility for examining health care disparities, performing comparably with a more complex model including individual risk factors. Because it is a composite measure geocoded at the census tract level for all communities in the United States, it has potential for targeting relatively discrete geographic areas for intervention. Being a geocoded measure also offers opportunity for linking with other data sets using geographic information systems.


Assuntos
Colecistectomia/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
17.
BMC Health Serv Res ; 19(1): 369, 2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31185989

RESUMO

BACKGROUND: Waiting times for elective treatments, including elective surgery, are a source of public concern and therefore are on policy makers' agenda. The long waiting times have often been tackled through the allocation of additional resources, in an attempt to reduce them, but results are not straightforward. At the same time, researchers have reported wide geographical variations in the provision of elective care not driven by patient needs or preferences but by other factors. The paper analyses the relationship between waiting times and treatment rates for nine high-volume elective surgical procedures in order to support decision making regarding the availability of these services for the citizens. Using the framework already proposed for the diagnostic services, we identify different patterns that can be followed to align the supply with patient needs in the Italian context. METHODS: After measuring the waiting times and the treatment rates for nine procedures in the 34 districts in Tuscany, we performed correlation analyses. Then, we plotted the results in a matrix cross-checking waiting times and rates. By doing so, we identified four different contexts that require a second step analysis to tackle unwarranted geographical variations and ensure timely care to patients. Finally, for each district and elective surgical procedure, we measured the economic impact of the different treatment rates in order to evaluate whether there are any supply criticalities and eventually some room for maneuver. We also included active and passive mobility of patients. RESULTS: The results show a high degree of variation both in treatment rates and waiting times, especially for the orthopaedic procedures: knee replacement, knee arthroscopy and hip replacement. The analysis performed for the nine interventions shows that the 34 districts are in varying positions in the waiting time-treatment rate matrix, suggesting that there is no straightforward relationship between rates and waiting times. Each combination in the matrix may have different determinants that require healthcare managers to adopt diversified strategies. The decision making process needs to be supported by a two-level analysis: the first one to put in place the matrix that cross-checks waiting times and treatment rates, the second one to analyse the characteristics of each quadrant and the improvement actions that can be proposed. CONCLUSIONS: In Italy, waiting times in elective surgical services are a main policy issue with a relevant geographical variation. Our analysis reveals that this variation is due to multiple elements. In order to avoid simplistic approaches that do not solve the problem but often lead to increased expenditure, policy makers and healthcare managers should follow a two-step strategy firstly identifying the type of context and secondly analysing the impact of elements such as resource productivity, resource availability, patients' preferences and care appropriateness. Only in some cases it is required to increase the service supply.


Assuntos
Tomada de Decisão Clínica , Assistência à Saúde/organização & administração , Procedimentos Cirúrgicos Eletivos , Listas de Espera , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Formulação de Políticas
18.
N Z Med J ; 132(1497): 32-36, 2019 06 21.
Artigo em Inglês | MEDLINE | ID: mdl-31220063

RESUMO

AIM: New Zealand has a high incidence of colorectal cancer. Most patients are treated with resectional surgery. There is a significant rate of complication associated with treatment. Costs of surgical treatment and effect of complications have not been previously investigated in New Zealand. The aim of this study was to define treatment costs of complications in patients undergoing resectional surgery for colorectal cancer. METHODS: Adult patients who underwent a resectional operation for colorectal adenocarcinoma at Northland DHB between January 2011 and December 2016 were identified. Actual costs and diagnoses-related group (DRG) costs were obtained. Demographic data and information on outcomes were identified using the hospital's results reporting system CONCERTO. RESULTS: Three hundred and ninety patients were included. One hundred and seven patients suffered a complication. Median cost per patient was $17,090. In those with complications, median cost was $28,485 compared to $14,697 in those without. Cost of complications increased as complication grade increased. Additional cost in patients with complications was on average $20,683 per patient, equating to a total of $2.2 million in this cohort. CONCLUSION: This study has defined the costs associated with colorectal cancer resection. Complications following colorectal surgery add significant costs. Significant investment in initiatives to reduce complications is justified.


Assuntos
Neoplasias Colorretais/economia , Neoplasias Colorretais/cirurgia , Complicações Pós-Operatórias/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colectomia/estatística & dados numéricos , Neoplasias Colorretais/epidemiologia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos
19.
Ir Med J ; 112(3): 896, 2019 03 14.
Artigo em Inglês | MEDLINE | ID: mdl-31045335

RESUMO

Introduction Elective and emergency paediatric general surgery is performed in numerous hospitals but with differing exclusion and transfer thresholds. Recent national guidelines detail necessary surgical, anaesthetic and nursing resources for safe and efficient delivery of services. Methods A retrospective review of paediatric surgical admissions was performed from January 2015 to December 2016. Charts of prolonged admissions or readmissions were reviewed. Results There was a total of 2,079 surgical admissions. 575 (27.2%) were elective and 1504 (71.2%) were emergency admissions. Significantly more surgical procedures were performed in 2016 (n=546, 56% versus n=433, 44.2%). Laparoscopic appendicectomy was the most commonly performed procedure. Re-admission rates were lower in 2016 (n=9, 0.8% versus n=21, 2.2%). All complications were Clavien-Dindo Grade I or II. Discussion Paediatric general surgery can be safely and efficiently performed by staffed and resourced Model III hospitals.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Hospitais , Humanos , Lactente , Tempo de Internação , Masculino , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Segurança , Fatores de Tempo
20.
BMC Res Notes ; 12(1): 245, 2019 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-31036075

RESUMO

OBJECTIVE: At present, cholecystectomy is carried out for thalassaemia patients with gall stone disease only if they develop symptoms of cholecystitis, except in the rare instance where an un-inflammed gall bladder is removed simultaneously with splenectomy. We carried out this retrospective analysis of case records to examine if patients with thalassaemia have a higher rate of peri operative complications compared to non-thalassaemics with gall stone disease, warranting a change of policy to justify elective cholecystectomy. RESULTS: Case records of 540 patients with thalassaemia were retrospectively analysed of which 98 were found to have gallstones. Records of 62 patients without thalassaemia with gall stone disease too were used for comparison. 19 of patients with thalassaemia and 52 of non-thalassaemic who had gallstones had undergone cholecystectomy. In all but 5 patients with thalassaemia cholecystectomy was done following attacks of acute cholecystitis as was the case in the non-thalassaemic controls. A significantly higher proportion of early and late complications had occurred in thalassaemia patients compared to non-thalassaemic patients post operatively. Six deaths related to sepsis following acute cholecystitis in the peri operative period were reported among 19 thalassaemia patients whereas no deaths were reported among 55 non-thalassaemic patients who underwent cholecystectomy for gallstones.


Assuntos
Colecistectomia Laparoscópica/estatística & dados numéricos , Colecistite Aguda/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Esplenectomia/estatística & dados numéricos , Talassemia beta/cirurgia , Adolescente , Adulto , Idoso , Estudos de Casos e Controles , Criança , Pré-Escolar , Colecistectomia Laparoscópica/métodos , Colecistectomia Laparoscópica/mortalidade , Colecistite Aguda/complicações , Colecistite Aguda/mortalidade , Colecistite Aguda/patologia , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/mortalidade , Feminino , Vesícula Biliar/patologia , Vesícula Biliar/cirurgia , Cálculos Biliares/patologia , Cálculos Biliares/cirurgia , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Baço/patologia , Baço/cirurgia , Esplenectomia/mortalidade , Análise de Sobrevida , Fatores de Tempo , Talassemia beta/complicações , Talassemia beta/mortalidade , Talassemia beta/patologia
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