Defining major surgical complications using administrative data in Ontario: a validation study.

BACKGROUND: Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data. METHODS: This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system. RESULTS: The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications. CONCLUSION: Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

COVID-19 and the duration of operating room procedures in Ontario: a population-based retrospective study.

BACKGROUND: Studies have estimated that a large backlog of procedures was generated by emergency measures implemented in Ontario, Canada, at the onset of the COVID-19 pandemic, when nonessential and scheduled procedures were postponed. Understanding the impact of the COVID-19 pandemic on the time needed to perform a procedure may help to determine the resources needed to tackle the substantial backlog caused by the deferral of cases. The purpose of this study was to examine the duration of operating room (OR) procedures before and after the onset of the COVID-19 pandemic to inform planning around changes in required resources. METHODS: A population-based, retrospective cohort study was conducted using Ontario Health Insurance Plan claims data and other administrative health care data from Apr. 1, 2019, to Sept. 30, 2020. Statistical analysis was conducted using multivariate regression, with procedure duration as the outcome variable. RESULTS: Results showed that the average duration of nonelective procedures increased by 34 minutes during the COVID-19 period and by 19 minutes after the resumption of scheduled procedures. Controlling for physician, patient and hospital characteristics, and the procedure code submitted, procedure duration increased by 12 minutes in the nonelective COVID-19 period and by 5 minutes when scheduled procedures resumed, compared with the pre-COVID-19 period. CONCLUSION: Procedures may take longer in the COVID-19 period. This will affect wait times, which had already increased because of the deferral of procedures at the beginning of the pandemic, and will have an impact on Ontario's ability to provide patients with timely care.

Resident Trainees Increase Surgical Time: A Comparison of Obstetric and Gynaecologic Procedures in Academic Versus Community Hospitals.

OBJECTIVE: The impact of resident involvement in the operating room for common procedures in obstetrics and gynaecology can shed light on the resource demands of teaching. The objective of this study was to quantify the increased surgical time associated with teaching obstetrics and gynaecology resident trainees across a range of procedures known to require surgical assistance. METHODS: This population-based retrospective cohort study compared surgical duration between academic (teaching) hospitals and community (non-teaching) hospitals. The cohort was made up of adult residents of Ontario between fiscal years 2002 and 2013 who were undergoing commonly performed obstetrics and gynaecologic procedures. The most commonly billed procedures requiring surgical assistance were included: cesarean section, anterior or posterior repair, anterior and posterior repair, salpingo-oophorectomy, myomectomy, ectopic pregnancy, total or subtotal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy. Linked administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) were used to define patient-, surgeon-, institution-, and procedure-related variables to limit confounding. Surgical duration, determined by anaesthetic billing records, was analyzed using a negative binomial regression. RESULTS: The total cohort included 337 389 surgical procedures. Of these procedures, 28% (94 203 procedures) were conducted in academic settings. The mean surgical duration of the procedures of interest (excluding vaginal hysterectomy) was significantly longer in academic hospitals compared with community hospitals. With many controls for case variability, this time differential reflects the burden of teaching resident trainees and other learners in the academic environment. The operating time increased between 6% and 20% for cases completed in academic centres versus in the community. As an example, the mean surgical duration of cesarean sections was 20.6 minutes (19%) longer in academic centres. Furthermore, the data highlighted a trend of increased teaching time for laparoscopic procedures compared with open procedures. The time ratio was the greatest for salpingo-oophortectomy and surgical management of ectopic pregnancies. The additional cost of carrying out these nine procedures in academic centres during the study period was $16.3 million. CONCLUSION: The cost of teaching resident trainees is increased operative time. This increased surgical cost in a publicly funded system must be considered as funding models evolve.

Association between day of the week of elective surgery and postoperative mortality.

BACKGROUND: In prior studies, higher mortality was observed among patients who had elective surgery on a Friday rather than earlier in the week. We investigated whether mortality after elective surgery was associated with day of the week of surgery in a Canadian population and whether the association was influenced by surgeon experience and volume. METHODS: We conducted a population-based retrospective cohort study in the province of Ontario, Canada. We included adults who underwent 1 of 12 elective daytime surgical procedures from Apr. 1, 2002, to Dec. 31, 2012. The primary outcome was 30-day mortality. We used generalized estimating equations to compare outcomes for surgeries performed on different days of the week, adjusting for patient and surgeon factors. RESULTS: A total of 402 899 procedures performed by 1691 surgeons met our inclusion criteria. The median length of hospital stay was 6 (interquartile range 5-8) days. Surgeon experience varied significantly by day of week (p < 0.001), with surgeons operating on Fridays having the least experience. Nearly all of the patients who had their procedure on a Friday had postoperative care on the weekend, as compared with 49.1% of those whose surgery was on a Monday (p < 0.001). We found no difference in the 30-day mortality between procedures performed on Fridays and those performed on Mondays (adjusted odds ratio 1.08, 95% confidence interval 0.97-1.21). INTERPRETATION: Although surgeon experience differed across days of the week, the risk of 30-day mortality after elective surgery was similar regardless of which day of the week the procedure took place.

Hyponatremia and sodium picosulfate bowel preparations in older adults.

OBJECTIVES: Bowel preparations are commonly prescribed drugs. Case reports and our clinical experience suggest that sodium picosulfate bowel preparations can precipitate severe hyponatremia in some older adults. At present, this risk is poorly quantified. We investigated the association between sodium picosulfate use and the risk of hyponatremia in older adults. METHODS: We conducted a population-based retrospective cohort study using six linked administrative databases in Ontario, Canada. All Ontario residents over the age of 65 years who filled an outpatient bowel preparation prescription before colonoscopy were eligible. We enrolled new users of either sodium picosulfate (n=99,237) or polyethylene glycol (n=48,595). The primary outcome was hospitalization with hyponatremia within 30 days of the bowel preparation assessed by database codes. The secondary outcomes were hospitalization with urgent head computed tomography (CT) (a proxy for acute central nervous system disturbance) and all-cause mortality. RESULTS: The baseline characteristics of the two groups, including patient demographics, comorbid conditions, and concomitant medications, were nearly identical. Compared with polyethylene glycol, sodium picosulfate was associated with a higher risk of hospitalization with hyponatremia (absolute risk increase: 0.05%, 95% confidence interval (CI): 0.04-0.06%, relative risk (RR): 2.4, 95% CI: 1.5-3.9), but not hospitalization with urgent CT head (RR: 1.1, 95% CI: 0.7-1.4) or mortality (RR: 0.9, 95% CI: 0.7-1.3). CONCLUSIONS: Sodium picosulfate bowel preparations lead to more hyponatremia than polyethylene glycol. There was no evidence of increased risk of acute neurologic symptoms or mortality. The absolute increase in risk of hospitalization with hyponatremia remains low but may be avoidable through appropriate fluid intake or preferential use of polyethylene glycol in some older adults.

Wait times for diagnostic colonoscopy among outpatients with colorectal cancer: a comparison with Canadian Association of Gastroenterology targets.

BACKGROUND: Timely access to colonoscopy is a nationally recognized issue in Canada, with previous studies documenting significant wait times for a variety of indications. However, specific wait times for colonoscopy among patients diagnosed with colorectal cancer remain unknown. METHODS: A review of all outpatient cases of colorectal cancer diagnosed at colonoscopy in London, Ontario, in 2010 was performed. Wait times from the date of referral to colonoscopy were reviewed and compared with maximal wait times established by the Canadian Association of Gastroenterology (CAG) stratified according to indication. Cancer stage at the time of diagnosis was compared with colonoscopy wait times. RESULTS: A total of 106 colorectal cancer patients meeting the inclusion and exclusion criteria were included in the study. Forty-six per cent of patients waited longer than CAG targets, with a mean (± SD) wait time of 79 ± 101 days. Higher cancer stage was associated with shorter wait time, likely as a result of triaging. CONCLUSION: Long wait times for diagnostic colonoscopy among patients with colorectal cancer remain an issue, with a significant proportion of cases not meeting maximal CAG wait time targets.

Rates, Predictive Factors, and Adverse Outcomes of Fusion Surgery for Lumbar Degenerative Disorders in Ontario, Canada, Between 2006 and 2015: A Retrospective Cohort Study.

BACKGROUND: The addition of fusion surgery to the decompression for lumbar degenerative disorders remains controversial. The purpose of this study is to compare the rate and outcome of decompression and fusion versus decompression alone. METHODS: This population-based retrospective cohort study used several linked administrative databases to identify patients who underwent spinal decompression surgery in Ontario, Canada, from 2006 to 2015. Patients who had previous spine surgery, concurrent lumbar disc replacement, or a diagnosis other than degenerative disc disease were excluded. Adjusted logistic regression was used to assess our outcomes. RESULTS: We identified 33,912 patients, of whom 9748 (28.74%) underwent fusion. Overall, fusion rates increased from 27.66% to 31.33% over the study period (P = 0.025). Factors associated with fusion included: older age, female sex, American Society of Anesthesiologists score ≥3, previous total joint replacement, and surgery by an orthopedic surgeon. Fusion surgery was associated with increased odds of 30-day mortality (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.01-3.09; P = 0.046), 30-day (OR 1.94, 95% CI 1.53-2.46; P < 0.0001) and 90-day reoperation (OR 1.66, 95% CI 1.35-2.05; P < 0.0001), and 30-day readmission (OR 1.23, 95% CI 1.02-1.49; P = 0.027) when adjusting for confounding variables. The odds of suffering a complication after fusion and decompression surgery vs. decompression surgery alone were 4.3-fold greater (95% CI 3.78-5.09; P < 0.0001). CONCLUSIONS: As compared with decompression alone, spinal fusion for degenerative lumbar disorders is associated with increased odds of adverse outcomes. These findings highlight the need for spine surgeons to consider carefully their indications for fusion procedures in the setting of degenerative spinal disorders.

Opioid use after outpatient elective general surgery: quantifying the burden of persistent use.

Purpose: Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids. Methods: This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined. Results: Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135-225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons. Conclusion: Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population.

Family physicians' choices of and opinions on colorectal cancer screening modalities.

OBJECTIVE: To determine FPs' choices of and opinions on colorectal cancer (CRC) screening options in the context of a new provincewide screening program. METHODS: Mailed survey, using a modified Dillman protocol, which asked about 5 recommended CRC screening modalities. SETTING: Ontario. PARTICIPANTS: Computer-generated random sample of 894 eligible FPs and GPs from a commercially available physician directory. MAIN OUTCOME MEASURES: Physicians' preferences for personal CRC screening; perceptions of patients' preferences for CRC screening; knowledge of screening test characteristics; and opinions on cost-effectiveness and mortality reduction of screening modalities. RESULTS: Of the 894 eligible FPs and GPs who received the mailed survey, 465 physicians responded (response rate of 52%). Respondents were diverse in demographic and practice characteristics. Decennial colonoscopy and biennial fecal occult blood testing (FOBT) were the 2 most popular screening methods. There was a statistically significant difference between physicians' preferences of screening options and their perceptions about patient preferences (P<.001), with 50.8% of physicians preferring colonoscopy (vs 39.6% FOBT) but 64.1% believing the average patient prefers FOBT (vs 29.0% colonoscopy). Opinions on the cost-effectiveness and effect on mortality of screening modalities and FOBT sensitivity, but not colonoscopy wait times, significantly influenced both physician preferences and their perceptions of patient preferences. Of the respondents, 54.4% believed colonoscopy had the greatest mortality reduction, while 66.1% chose FOBT as the most cost-effective CRC screening method. CONCLUSION: There was a significant difference between primary care physicians' preferences and their perceptions of patient preferences for CRC screening (P<.001). Screening choice was influenced by physicians' perceptions of FOBT sensitivity and their opinions on cost-effectiveness and mortality reduction of the screening modality. Colonoscopy wait times did not influence physicians' screening choices. As some screening programs emphasize FOBT for most people, this might result in fewer physican-patient discussions about options of other screening modalities. Further research into patient preferences for screening is warranted.

Early Rescue from Acute Severe Clostridium Difficile: A Novel Treatment Strategy.

BACKGROUND: Severe Clostridium difficile infections (CDI) can lead to significant impediments to effective treatment. We developed a novel treatment protocol utilizing bedside gastrointestinal lavage (GIL) for the management of patients with severe, complicated CDI. We describe the development and early outcomes of non-operative bedside GIL in hospitalized patients with severe, complicated CDI following the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework at the Idea stage. We compared our results with those of a cohort of patients managed with colectomy. METHODS: We conducted a retrospective cohort study of hospitalized patients with severe, complicated CDI who failed conventional medical therapy and were referred for surgical consultation at two academic tertiary-care hospitals between January 2009 and January 2015. After surgical assessment, the attending surgeon decided to proceed either with bedside GIL or directly to colectomy. Bedside GIL involved nasojejunal tube insertion followed by flushing with 8 L of polyethylene glycol 3350/electrolyte solution over 48 h. Both patient groups received standard medical treatment with vancomycin 500 mg q 6 h enterally and metronidazole 500 mg intravenously three times daily for 14 d. The main outcomes of interest were the incidence of colectomy, complications, and mortality rate. RESULTS: Nineteen and seventeen patients underwent GIL and direct colectomy, respectively. There were no significant differences between the groups in terms of demographics, American Society of Anesthesiologists class, disease severity, need for intensive care unit admission, mechanical ventilation, vasopressor use, serum lactate concentration, or proportion presenting with hypotension, acute kidney injury, or a white blood cell count >16,000/mcL or <4,000/mcL (p > 0.1). The in-hospital mortality rate was 26% (5/19) and 41% (7/17) for the GIL and colectomy groups, respectively (p = 0.35). Only one patient in the GIL group failed the protocol, requiring colectomy. There were no significant differences in complications in the two groups. CONCLUSIONS: Bedside GIL appeared to be safe for the treatment of patients with severe, complicated CDI who had failed conventional medical therapy. It did not appear to increase the risk of morbidity or death compared with the traditional strategy of proceeding directly to colectomy.

Colonoscopy and flexible sigmoidoscopy practice patterns in Ontario: a population-based study.

OBJECTIVE: To conduct a population-based study on the provision of large bowel endoscopic services in Ontario. METHODS: Data from the following databases were analyzed: the Ontario Health Insurance Plan, the Institute for Clinical Evaluative Sciences Physicians Database and Statistics Canada. The flexible sigmoidoscopy and colonoscopy rates per 10,000 persons (50 to 74 years of age) by region between April 1, 2001, and March 31, 2002, were calculated, as well as the numbers and types of physicians who performed each procedure. RESULTS: In 2001/2002, a total of 172,108 colonoscopies and 43,400 flexible sigmoidoscopies were performed in Ontario for all age groups. The colonoscopy rate was approximately five times that of flexible sigmoidoscopy; rates varied from 463.1 colonoscopies per 10,000 people in the north to 286.8 colonoscopies per 10,000 people in the east. Gastroenterologists in all regions tended to perform more procedures per physician, but because of the large number of general surgeons, the total number of procedures performed by each group was almost the same. CONCLUSION: Population-based rates of colonoscopies and flexible sigmoidoscopies are low in Ontario, as are the procedure volumes of approximately one-quarter of physicians.

The impact of teaching on the duration of common urological operations.

INTRODUCTION: The ability of academic (teaching) hospitals to offer the same level of efficiency as non-teaching hospitals in a publicly funded healthcare system is unknown. Our objective was to compare the operative duration of general urology procedures between teaching and non-teaching hospitals. METHODS: We used administrative data from the province of Ontario to conduct a retrospective cohort study of all adults who underwent a specified elective urology procedure (2002-2013). Primary outcome was duration of surgical procedure. Primary exposure was hospital type (academic or non-teaching). Negative binomial regression was used to adjust relative time estimates for age, comorbidity, obesity, anesthetic, and surgeon and hospital case volume. RESULTS: 114 225 procedures were included (circumcision n=12 280; hydrocelectomy n=7221; open radical prostatectomy n=22 951; transurethral prostatectomy n=56 066; or mid-urethral sling n=15 707). These procedures were performed in an academic hospital in 14.8%, 13.3%, 28.6%, 17.1%, and 21.3% of cases, respectively. The mean operative duration across all procedures was higher in academic centres; the additional operative time ranged from 8.3 minutes (circumcision) to 29.2 minutes (radical prostatectomy). In adjusted analysis, patients treated in academic hospitals were still found to have procedures that were significantly longer (by 10-21%). These results were similar in sensitivity analyses that accounted for the potential effect of more complex patients being referred to tertiary academic centres. CONCLUSIONS: Five common general urology operations take significantly longer to perform in academic hospitals. The reason for this may be due to the combined effect of teaching students and residents or due to inherent systematic inefficiencies within large academic hospitals.

A sticky situation: management of spray polyurethane foam insulation in body orifices.

Spray polyurethane foam insulation is commonly used in the construction industry to fill gaps, seal, and insulate. We present three cases of intentional spray foam insertion in body orifices and discuss the management of such situations in the emergency department. This series includes a case of oral foam insertion used in a suicide attempt by suffocation and two cases of rectal insertion. All of these cases had potential long-term consequences; one was life-threatening. To our knowledge, this is the first published report on the medical management and removal of foam insulation from body orifices. In all three cases, the foam insulation material was successfully removed after allowing the material to harden.

Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis.

BACKGROUND & AIMS: The rate of new or missed colorectal cancer (CRC) after colonoscopy and their risk factors in usual practice are unknown. Our objective was to evaluate the rate and risk factors in a population-based study. METHODS: We analyzed data from the Canadian Institute for Health Information, the Ontario Health Insurance Program, and Ontario Cancer Registry for all patients (> or =20 years of age) with a new diagnosis of right-sided, transverse, splenic flexure/descending, rectal or sigmoid CRC in Ontario from April 1, 1997 to March 31, 2002, who had a colonoscopy within the 3 years before their diagnosis. Patients with new or missed cancers were those whose most recent colonoscopy was 6 to 36 months before diagnosis. We examined characteristics that might be risk factors for new or missed CRC. RESULTS: We identified a diagnosis of CRC in 3288 (right sided), 777 (transverse), 710 (splenic flexure/descending), and 7712 (rectal or sigmoid) patients. The rates of new or missed cancers were 5.9%, 5.5%, 2.1%, and 2.3%, respectively. Independent risk factors for these cancers in men and women were older age; diverticular disease; right-sided or transverse CRC; colonoscopy by an internist or family physician; and colonoscopy in an office. CONCLUSIONS: Because having an office colonoscopy and certain patient, procedure, and physician characteristics are independent risk factors for new or missed CRC, physicians must inform patients of the small risk (2% to 6%) of these cancers after colonoscopy. The influence of type of physician and setting on the accuracy of colonoscopy, potentially modifiable risk factors, warrants further study.

Association of socioeconomic status and receipt of colorectal cancer investigations: a population-based retrospective cohort study.

BACKGROUND: Although the Canadian health care system was designed to ensure equal access, inequities persist. It is not known if inequities exist for receipt of investigations used to screen for colorectal cancer (CRC). We examined the association between socioeconomic status and receipt of colorectal investigation in Ontario. METHODS: People aged 50 to 70 years living in Ontario on Jan. 1, 1997, who did not have a history of CRC, inflammatory bowel disease or colorectal investigation within the previous 5 years were followed until death or Dec. 31, 2001. Receipt of any colorectal investigation between 1997 and 2001 inclusive was determined by means of linked administrative databases. Income was imputed as the mean household income of the person's census enumeration area. Multivariate analysis was performed to evaluate the relationship between the receipt of any colorectal investigation and income. RESULTS: Of the study cohort of 1,664,188 people, 21.2% received a colorectal investigation in 1997-2001. Multivariate analysis demonstrated a significant association between receipt of any colorectal investigation and income (p < 0.001); people in the highest-income quintile had higher odds of receiving any colorectal investigation (adjusted odds ratio [OR] 1.38; 95% confidence interval [CI] 1.36-1.40) and of receiving colonoscopy (adjusted OR 1.50; 95% CI 1.48-1.53). INTERPRETATION: Socioeconomic status is associated with receipt of colorectal investigations in Ontario. Only one-fifth of people in the screening-eligible age group received any colorectal investigation. Further work is needed to determine the reason for this low rate and to explore whether it affects CRC mortality.