14.13 Can Economic Performance Predict Pediatric Surgical Capacity in Sub-Saharan Africa?

Posted on December 22, 2014

M. T. Okoye1, E. T. Nguyen1, A. L. Kushner1,2,3, E. A. Ameh4, B. C. Nwomeh3,5  1Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA 2Columbia University College Of Physicians And Surgeons,Surgery,New York, NY, USA 3Surgeons OverSeas (SOS),New York, NY, USA 4National Hospital,Pediatric Surgery,Abuja, FCT, Nigeria 5Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction:

The relationship between economic status and pediatric surgical capacity in low and middle income countries (LMICs) is poorly understood. In sub-Saharan Africa (SSA), Nigeria accounts for 20% of the population, and has the highest Gross Domestic Product (GDP), but whether this economic advantage has translated to increased pediatric surgical capacity is unknown. This study compares the pediatric surgical capacity between Nigeria and other countries within the region.

Methods:

The Pediatric Personnel, Infrastructure, Procedures, Equipment and Supplies (PediPIPES) survey, a recent tool that is useful in assessing and comparing the capacity of health facilities to deliver essential and emergency surgical care (EESC) to children, was conveniently distributed to surgeons throughout sub-Saharan Africa.  Descriptive statistics were computed.

Results:

In this report, data from hospitals in Nigeria (n=24) and hospitals in 18 other sub-Saharan African countries (n=26) were compared, as in Table 1:

 

Conclusion:
Despite better economic indicators in Nigeria, there were no distinct advantages over the other countries in the ability to deliver EESC to children. Attention to developing pediatric surgical capacity in SSA remains poor, highlighting the urgent need for more resources for pediatric surgical capacity building efforts across the entire region.
 

14.14 A Collaborative Experience in Caring for Infants Born with Esophageal Atresia in Belize

Posted on December 22, 2014

S. F. Rosati1, D. Parrish1, J. Haynes2, R. Maarouf1, C. Oiticica2, P. Lange2, D. Lanning2  1Virginia Commonwealth University,Department Of General Surgery,Richmond, VA, USA 2Virginia Commonwealth University,Division Of Pediatric Surgery,Richmond, VA, USA

Introduction:
 

Children born with congenital anomalies in low-income countries often face a multitude of challenges.  Access to pediatric surgical services is limited due to a lack of medical facilities, an adequate transportation system, and a lack of trained surgeons, anesthesiologists, and nurses, all of which leads to a high mortality rate. This is a report of a 5-year collaborative effort between the World Pediatric Project (WPP), the Children’s Hospital of Richmond (CHoR) at Virginia Commonwealth University, and multiple organizations within the country of Belize to provide care for infants born with esophageal atresia (EA).

Methods:
 

After IRB approval, we reviewed medical records of children with EA treated in conjunction with the World Pediatric Project, which is a nonprofit organization that provides tertiary surgical care to children in Central America and the Caribbean. From 2009-2014, neonatologists and pediatric surgeons at our institution have collaborated with the WPP to care for infants born in Belize with EA. Six infants with EA (five also with an associated tracheoesophageal fistula) were transferred to our institution for surgical repair.

Results:
 

A total of six infants, two boys and four girls, have been transferred to our institution for operative correction of their EA.  After the first patient was transferred to our institution, multiple opportunities for improving the process were identified.  A protocol was created to help diagnose infants with EA, outline initial management, and facilitate obtaining travel documents.  At the time of transfer, their ages ranged from 2 weeks to 2 months old. All six of the patients had gastrostomy tubes placed in Belize prior to transfer for decompression of their stomach and placement of a venous catheter for TPN after arrival.  Of the five infants with TEF, two underwent open repair and three had a thoracoscopic repair. The infant with a pure atresia underwent thoracoscopic converted to open repair. There were no peri- or post-operative complications.  All six infants were orally fed post–operatively and were transferred back to Belize where they are thriving.  Pediatric surgeons from CHoR see them annually.

Conclusion:
 

Caring for infants born with congenital anomalies, specifically EA, can be  challenging requiring the cooperation of a variety of specialties, including pediatric surgeons, neonatologists, pediatricians, and nutritionists. These challenges become even more complex with infants born in low-income countries. This report demonstrates how newborns with EA±TEF in a developing country can be successfully transferred to the US, receive medical and surgical care, and return to their country.  While this endeavor is challenging, the process can be facilitated by having a protocol in place, a well-organized local nonprofit organization, and a hospital that is committed to providing international care to children. 
 

14.15 Prevalence of injuries due to falls in Nepal: A countrywide population based survey

Posted on December 22, 2014

S. Devkota1, S. Gupta2,3, S. Ghimire1, A. Ranjit4, M. Swaroop5, A. L. Kushner3,6, B. C. Nwomeh3,7  1Chitwan Alpine Polyclinic And Diagnostic Center,Chitwan, , Nepal 2University Of California – San Francisco , East Bay,Surgery,Oakland, CA, USA 3Surgeons OverSeas,New York, NY, USA 4Johns Hopkins – Center For Surgical Trials And Outcomes Research,Baltimore, MD, USA 5Northwestern University Feinberg School Of Medicine,Surgery – Trauma/Critical Care And Center For Global Health,Chicago, IL, USA 6Johns Hopkins Bloomberg School Of Public Health,International Health,Baltimore, MD, USA 7Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction:  An estimated 424 000 fatal falls occur globally each year, making it the second leading cause of unintentional injury-related deaths after road traffic injuries. Over 80% of fall-related fatalities occur in low- and middle-income countries, with regions of the Western Pacific and South East Asia accounting for more than two thirds of deaths.  Data from low-income South Asian countries like Nepal are lacking, particularly at the population level. 

Methods:  A nationally representative cross-sectional study was performed in 15 of the 75 districts in Nepal, randomly selected proportional to population, using the Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool. Three villages were randomly selected within each district, one urban and two rural. The SOSAS survey is divided into two portions: (1) demographic data including the household’s access to healthcare and recent deaths in the household and (2) assessment of a representative spectrum of surgical conditions, including injuries.  Data was collected regarding an individuals’ experience of injury including road traffic injuries, falls, penetrating trauma and burns.  Data included anatomic location, timing of injury and whether or not healthcare was sought, and if not, the reason for barrier to care.  Descriptive statistics was used to analyse the data.

Results:  Of the 2695 individuals from 1,350 households interviewed, 141 individuals reported injuries secondary to falls (5.2%, 95% CI 4.4% to 6.1%), with a mean age of 30.7 (SD 20.0); 58% were male.  Falls represented 44.3% of total injuries (n=320) reported (95%CI 38.8% to 50.0%).    The most common locations of injuries due to falls were in the extremity, 73.2% (SD 3.7%, 95% CI 65.7% to 80.8%, Table 1); the upper extremities were the most common site in the extremities that were involved (52.1%). Twelve individuals had an unmet surgical need (8.5%, 95% CI 4.5% to 14.4%).  Reasons for barrier to care included:  no money for healthcare (n=3), facility/personnel not available (n=7) and fear/no trust (n=2).  Of the 80 recent deaths, 7 were due to injuries from falls (8.8%, 95% CI 3.6% to 17.2%), with a mean age of 46 years (SD 22.8).  Surgical care was not delivered to those who died; reasons included no time (n=4), facility/personnel not available (n=1), fear/no trust (n=1) and no need (n=1). 

Conclusion:  This study provides population-based data on injury prevalence in Nepal, identifying injuries due to falls as a major public health problem.  While health education to reduce the risk of falls remains essential, these data highlight persistent barriers to access to care for the injured and the need to improve trauma care systems in Nepal.

 

14.16 Knowledge of Colorectal Carcinoma screening Among General Population in Western Region of Nepal

Posted on December 22, 2014

S. Nepal1, A. Shrestha2, J. Parajuli2, S. Sharma1, M. Acharya3, S. Baral2  1Manipal Teaching Hopital,Department Of Surgery,Pokhara, KASKI, Nepal 2Manipal Teaching Hopital,Medicine,Pokhara, KASKI, Nepal 3Manipal Teaching Hopital,Emergency,Pokhara, KASKI, Nepal

Introduction: Colorectal Carcinoma has emerged as third most common malignant tumor, second leading cause of death among cancer patients in the world and has been increasing in developing countries. In this study our objective was to determine the knowledge and attitude of CRC and to understand the factors that contribute to low screening rates in our region.

Methods: We interviewed 800 participants aged 40 years and above with 200 participants each from Kaski, Baglung, Parbat and Syangja district which are in Western region of Nepal. We used questionnaires to determine the socio-demographic characteristic, knowledge about CRC, screening, as well as screening test.

Results:The majority participants were illiterate with monthly income less than Nrs 10,000 ($100).Regarding lifestyle practices most of them were smokers (68%) and consumed alcohol (48%).Among the participants, 20% of them said there exists no cancer as Colorectal Carcinoma. The rest of them who knew CRC exists the knowledge about it and is screening were very poor. Only 25% and 10% of them knew about FOBT and Colonoscopy but none of them had idea about barium enema and flexible sigmoidoscopy .Majority of them (55%) agreed to do screening tests even if they did not have any symptom and 40% of the participants said the disease had good prognosis if diagnosed early.

Conclusion:The result of the current study provide information about the need for education campaigns about CRC and its screening to reduce the incidence of deaths due to CRC.

 

14.17 Impacting the Global Trauma Burden — Training First Responders in Mozambique

Posted on December 22, 2014

A. Merchant1, K. Mcqueen1, O. Gunter1  1Vanderbilt University Medical Center,Trauma And Critical Care,Nashville, TN, USA

Introduction: Over half of prehospital deaths in low-income countries are the result of airway compromise, respiratory failure or uncontrolled hemorrhage; all three of these conditions can be addressed using basic first aid measures. For both hospital personnel and laypersons, a  basic trauma resuscitation training in modified ABC techniques can be easily learned and applied to increase the number of first responders in Mozambique, a resource-challenged country. This approach supports WHO guidelines to reduce the impact of an injury once it occurs and optimize its outcome.

Methods: In March 2014, a trauma training session was administered to 100 people in Mozambique: half were hospital personnel from 7 district medical centers and the other half were selected laypersons. Five of the hospitals advertised surgical capability; two other medical centers were chosen based on long transport times to main hospitals and need for patient stabilization. This training session included a pre-test, intervention, and post-test to evaluate and demonstrate first response skills of airway management, hemorrhage control, and cervical spine precautions using resources available in hospital and street settings. Paired t-tests and linear regression curves were used to analyze the data.

Results: Laypersons answered 26.9% of the pre-test questions correctly and showed 86.9% improvement in their scores after the intervention; hospital personnel initially answered 41.7% correctly and improved their scores by 44%. All participants were able to open an airway, externally control hemorrhage, and transport a patient with appropriate precautions. In addition, hospital personnel were able to verbalize intravenous fluid resuscitation and oxygen application during assessment.

Conclusion: The trauma training session served as new information that improved knowledge and skills for both groups, as well as increased the number of first responders in Mozambique. This knowledge can minimize secondary and tertiary injuries by providing effective prehospital care in developing nations with limited trauma resources. Thus, this study supports WHO recommendations to utilize the strengths of a developing nation – population – as the first step in establishing an organized trauma triage system.

 

14.18 Geriatric Emergency General Surgery – Survival and Outcomes in a Low-Middle Income Country

Posted on December 22, 2014

A. A. Shah1,2, H. Zafar2, R. Riviello1, C. K. Zogg1, S. Zafar4, A. Latif5, Z. Rehman2, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 3Harvard School Of Medicine,Center For Surgery And Public Health, Brigham And Women’s Hospital,Brookline, MA, USA 4Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 5Johns Hopkins University School Of Medicine,Department Of Anesthesia,Baltimore, MD, USA

Introduction:  Geriatric surgical outcomes remain grossly understudied in low-middle income healthcare settings. The purpose of this study was to compare epidemiology and outcomes between old and young adults presenting to a tertiary care facility in South Asia for emergency general surgical (EGS) conditions.

Methods:  Discharge data from a university hospital were obtained for all adult patients (≥16 years) presenting between March 2009 and April 2014 with ICD-9-CM diagnosis codes consistent with an EGS condition, as described by the American Association for the Surgery of Trauma (AAST). The patient population was dichotomized into old (>65 years) and young (≤65 years) adults. Multivariate analyses, accounting for age, gender, year of admission, type of admission, admitting specialty, length of stay (LOS), major complications and Charlson Comorbidity Index, were used to compare the two populations. Outcomes of interest included all-cause mortality, major complications and LOS.

Results: A total of 13,893 patients were included. Patients >65 years constituted 15.3% (n=2,123) of the patient population. Old adults were more likely to be male (OR[95%CI]:1.14 [1.02-1.27]) and present through the ED (OR[95%CI]: 1.22[1.09-1.38]). They more commonly presented with gastrointestinal bleeding (OR[95%CI]: 2.63[1.99-3.46]) and for resuscitation (OR[95%CI]: 2.17 [1.67-2.80]). After multivariate adjustment, age >65 years independently accounted for a 60% increase in mortality (OR[95%CI]: 1.60[1.18-2.16]). Elderly patients also had a higher likelihood of developing major complications (OR[95%CI]: 2.09[1.67-2.61]). There were no significant differences in lengths of hospital stay between elderly and young-adult patients (4.3 vs. 4.5 days, respectively).

Conclusion: Older adults seem to suffer from a different set of EGS conditions compared to their younger counterparts. The results of this study will assist in formulating specialized management guidelines and help prioritize care for geriatric patients with EGS conditions in low-middle income healthcare settings.

14.19 An Estimation of Cost Arising From Motorcycles Injuries in Kigali, Rwanda

Posted on December 22, 2014

J. Allen Ingabire1, J. Byiringiro1, F. J. Calland2, J. Okiria1  1National University Of Rwanda,College Of Health Sciences And Medicine,School Of Medicine,Department Of Surgery,Butare, SOUTH, Rwanda 2University Of Virginia,Surgery Depatment,Charlottesville, VA, Virgin Islands, U.S.

Introduction: Motorcycles has become a popular mean of transport in Kigali, Rwanda and their injuries are associated with a high number of admissions in the main referral hospital of Kigali. These accidents are associated with a high financial burden to the country. This study aimed at evaluates the total cost arising from motorcycles injuries of patients admitted at University Teaching Hospital of Kigali.

Methods: Retrospective cross-sectional cost study of motorcycles injured patients admitted in University Teaching Hospital of Kigali from January-December, 2011. Data were collected from patient medical, police, insurance and financial records as well as patient interviews. Cost analysis was based upon the standard road accident cost conceptual framework.

Results:A total of 1232 road traffic injuries were reported during the study period and Motorcycle injuries accounted for 73.05% (900 cases) of all injuries. Youths were more involved in motorcycle accident (53.2%) than other age group (16-30 years) .The majority of Motorcycles victims were motorcyclists, (30.86%) and Motorcycle-vehicle (41.61%) was the first cause of motorcycle injuries then motorcycle-pedestrian (30.86%). Head injuries and fractures were the predominant diagnoses (82.15%).The mean hospital stay was 15.43 days, permanent disability was confirmed in 11.5% (n=104), and mortality rate was 10.4% (n=94). The total economic cost of motorcycle injuries was US$ 4,141,300. This is made up of about 28.28% accident-related costs and 71.72% casualty-related costs. The accident-related costs totaling US$892,775 was made up of property damaged costs of 21.56% and administration costs of 6.72%. Whilst the casualty-related cost of US$886.665.50 was made up of labor output costs estimated at US$ 1,631550 (39.4%) was  the highest cost, followed by medical cost estimated atUS$901,150(21.76%),out-of-pocket expenditure (5.9%), intangible costs (4.35%) and the lowest cost was funeral costs totaling US$24,007 (0.58%). The average cost per patient was estimated at US$4,601. There was significant association between category of injured patients and total cost/patient (p>0.05).

 

 

Conclusion:Motorcycle injuries create a substantial disability and cost burden in Kigali, Rwanda. Prevention and early treatment should be promoted to decrease the morbidity and financial burden.
 

14.20 Improving Trauma and Emergency Care in China: Results from an International Training Collaborative

Posted on December 22, 2014

A. Chaturvedi1, Y. V. Pei2, A. Mohammed3, D. Clapp1, D. M. Allin4, C. Orner5, M. Narayan1  1University Of Maryland,R Adams Cowley Shock Trauma Center,Baltimore, MD, USA 2University Of Maryland,Department Of Emergency Medicine,Baltimore, MD, USA 3Calderdale Royal Hospital,Department Of Emergency Medicine,Halifax, WEST YORKSHIRE, United Kingdom 4University Of Kansas,Department Of Medicine,Lawrence, KS, USA 5Heart To Heart International,Olathe, KS, USA 6China 120,Trauma And Emergency Responce Center,Chengdu, SICHUAN, China

Introduction:
The practice of emergency medicine in China officially began only 28 years ago. However, due to a lack of standardized formal training for emergency medical practitioners, the practice of trauma and emergency care in China is still in early development. Pre-hospital providers in China are typically physicians and nurses who undergo fragmented training at sites that hold variable certification requirements. International speakers are often invited to participate in the instruction of medical professionals. The purpose of this study is to evaluate the impact of an English-based trauma and emergency medicine training module on participants’ confidence in knowledge and skills.

Methods:

An English-based training module was established in conjunction with several international institutions and the Chengdu 120 Center, Chengdu, China. 4 days of structured training in English with consecutive Chinese translation consisted of didactic presentations and practical skills stations targeting nurses and physicians. Participants completed surveys assessing pre and post confidence in knowledge and skills using a semantic differential scale.

Results:
A total of 101 surveys were collected from 63 doctors and 38 nurses from Chengdu. 48% of participants were male. 71% of all participants were between the ages of 20 and 39. Education ranged from high school to master’s level of training. 66% of participants reported having received formal training in trauma within the last 2 years and 56% reported having received formal training in disaster management. Of the 101 surveys, 86 (55 doctors and 31 nurses) were complete for statistical analysis. Student’s t test revealed a statistically significant increase in perceived confidence level in all of the 14 topics of instruction (p<.0001). An increase in confidence was reported in both physicians and nurses, regardless of the participant’s years of experience in his or her respective occupation. Improvement was also significant irrespective of the participant’s previous training experience within the last 2 years.

Conclusion:
Trauma and emergency medical services have limited capacity in most areas of China. Foreign instructors are often invited to participate in health provider instruction.  Potential barriers to the success of such a program include language and teaching style.  A structured educational program based in English with consecutive Chinese translation positively impacted confidence levels of first responders in Chengdu, China. Participants felt more competent in all areas of topics and skills of instruction, which may ultimately improve provider skills in pre-hospital management of trauma and emergencies. These responses were seen in physicians and nurses across all experience levels. The collaboration between local Chinese and international medical professionals may help improve current Chinese emergency medical practices.
 

15.01 Geographic Variation in Use of Video-Assisted Thoracoscopic Surgery (VATS) for Lung Cancer Resection

Posted on December 22, 2014

T. R. Grenda1, J. R. Thumma1, J. B. Dimick1  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction:  A growing body of evidence has emerged supporting the use of video-assisted thoracoscopic surgery (VATS) in lung cancer resection. While trends towards increased utilization of this approach have been observed, wide variations in use remain. The extent to which geography and hospital factors contribute to this variation remains poorly understood.   

Methods:  We used national Medicare data (2008-2012) to examine geographic variations in use of VATS for patients undergoing lung cancer resection. We identified patients undergoing open or VATS approach for lung cancer resection and assigned them to hospital referral regions (HRRs) corresponding to where they received treatment.  Rates of VATS utilization were calculated for each HRR and quartiles of HRR use were created according to HRR utilization rate. We then evaluated rates of VATS utilization across hospital characteristics and trends in time. 

 

Results:  A total of 49,077 patients underwent lung resection across 1,852 hospitals during the study period, with 23,911 (48.7%) resections performed using a VATS approach. Rates of VATS utilization varied dramatically from 0% in the lowest use HRR to 90.6% in the highest use HRR across 306 HRRs. Overall utilization rates increased over time from 32% in 2008 to 50% in 2012 (p<0.001). Mean VATS utilization rates were greater in hospitals with the highest total lung cancer resection volume compared to the lowest volume centers (58% vs 32%, p<0.001).  Non-critical access hospitals had a significantly higher utilization rate than critical access hospitals (38% vs. 19%, p=0.04). There was no significant difference in utilization between high-technology and non-technology hospitals (38% vs. 39%, respectively, p=0.51). 

Conclusion: Wide geographic variations in the utilization of VATS exist, which may limit a patient’s options for surgical approach based on where they live.  Further efforts are needed to understand the main drivers underlying these variations in order to broaden patient access to this technology. 
 

15.02 Do Hospital Compare Metrics Predict Changes in Functional Status After Surgery?

Posted on December 22, 2014

L. H. Nicholas1,2, L. H. Nicholas1,2  1Johns Hopkins School Of Public Health,Health Policy & Management,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: Public and private payers increasingly rely on measures of process compliance and patient satisfaction to determine hospital payments and to steer patients to hospitals where they will have better outcomes.  However, these measures do not correlate with risk-adjusted mortality, raising questions about their usefulness for patients and payers.  Given the low mortality rates associated with most elective surgical procedures, however, it is important to understand whether quality metrics correlate with changes in patient health and functional status. 

Methods: Medicare claims from 6,761 surgical admissions between July 2005 and December 2010 were linked to pre-and post admission survey measures of self-rated health and functional status collected as part of the nationally representative Health and Retirement Study.  Hospitals were classified by their terciles of performance on a composite process score reflecting compliance with Surgical Care Improvement Program (SCIP) measures and the proportion of patients who would recommend their hospital from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) during the period of each admission.  Multivariate regression was used to assess the relationship between risk-adjusted measures of patient self-rated health and counts of activities of daily living (ADL) limitations with the hospital's HCAHPS and SCIP scores.

Results: Compliance with SCIP measures averaged 76.5% in low-performing hospitals, 88.6% in medium-performing, and 94.1% in high-performing hospitals.  57.8% of patients recommended hospitals in the lowest HCAHPS tertile, 68.9% in the middle, and 78.2% in the highest.  Compared to patients treated in hospitals with the lowest SCIP and HCAHPS rankings, patients in higher-scoring hospitals had better self-rated health, fewer depressive symptoms, and fewer ADL limitations.  However, these differences largely reflect healther patients selecting hospitals with higher SCIP compliance and patient satisfaction.  After we controlled for patient health prior to hospitalization, there was no relationship between either SCIP compliance or HCAHPS score and patient health or functional status after admission. 

Conclusion: Hospitals with higher levels of SCIP compliance and higher patient satisfaction scores attract patients who are healthier than those choosing low-performing hospitals.  However, neither SCIP compliance nor HCAHPS rankings consistently correlate with changes in patient self-rated health and functional status with inpatient surgery.  Additional outcomes data collection may be needed to distinguish between high and low-quality hospitals. 

 

15.03 Transitional Care Needs Following Complex Surgery: A Population-Level Analysis

Posted on December 22, 2014

C. Balentine1,2,3, F. G. Bakaeen1,2, P. Kougias1,2, A. Naik2, P. J. Richardson2, D. H. Berger1,2, D. A. Anaya1,2  1Baylor College Of Medicine,Michael E DeBakey Department Of Surgery,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:
Recovery from major surgery is a complex process that frequently requires ongoing care as patients transition from acute care hospitals to home.  This transitional care (TC) can involve time in rehabilitation hospitals, skilled nursing facilities or long term care hospitals designed to help regain functional independence.  While there is considerable information on the need for TC following medical conditions such as heart failure and chronic lung disease, there is little data on the need for TC after surgery.  The purpose of this study is to determine the overall need for TC following complex general, cardiac and vascular surgery.

Methods:
A retrospective cohort study using VA administrative data from 2006-2010 evaluating all patients undergoing colorectal resection, pancreaticoduodenectomy, liver resection, coronary artery bypass, and abdominal aortic aneurysm repair. was performed.  Patients were categorized as needing TC if their discharge destination was being other than a home discharge.  Chi-square was used to compare rates of TC use.

Results:
We found that TC needs were common among all of the operations assessed.  Pancreaticoduodenectomy had the greatest overall proportion of TC utilization as 119 of 1,064 patients (11%) needed TC after discharge.  TC use was higher during 2006-2008 (11.6-15.5%) compared to the final two study years (8-8.4%) though this difference was not statistically significant.  Colorectal (1,850 patients out of 20,449, 9%) and coronary bypass (2,047 patients out of 23,658, 8.7%) operations required TC at similar rates and there was minimal variation in TC usage during the study period.  A total of 54 out of 761 individuals having liver resections needed TC at discharge and this rate steadily declined from 12% in 2006 to 4% in 2010 (p<0.07).  Finally, open and endovascular aneurysm repair had the lowest rates of TC as only 325 of 7,409 patients (4.4%) required TC, and these rates did not fluctuate significantly during the study period.

Conclusion:
Following complex surgery, a significant proportion of patients will require additional assistance in the form of TC as they attempt to recover their preoperative functional status.  While the rate of TC utilization for liver resections seems to be declining over time, the other complex operations studied showed remarkably consistent rates of TC use from year to year.  Further studies are needed to identify underlying reasons for TC use.
 

15.04 Post-discharge Care Fragmentation: Readmission, Distance of Travel, and Postoperative Mortality

Posted on December 22, 2014

T. C. Tsai1,2, E. J. Orav3,4, A. K. Jha2,3  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Harvard School Of Public Health,Health Policy And Management,Boston, MA, USA 3Brigham And Women’s Hospital,Medicine,Boston, MA, USA 4Harvard School Of Public Health,Biostatistics,Boston, MA, USA

Introduction:  Despite policies aimed incentivizing clinical integration, little data exist on whether fragmentation of care is associated with worse outcomes for elderly patients undergoing major surgery. We assessed the state-level variation in post-discharge surgical care fragmentation; whether post-discharge surgical care fragmentation was associated with worse outcomes; and whether accounting for distances between hospitals may explain differences in outcomes for those who are readmitted to a different hospital than the original hospital where the index procedure was performed.  

Methods:  We used the 100% inpatient file for Medicare claims from 2009 through 2011.  Data on hospital structural features including zip code of location were obtained from the 2011 American Hospital Association Annual Survey.  We identified patients who underwent coronary artery bypass graft, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement.  

Results: There were 93,062 patients that underwent the surgical procedures of interest who were subsequently readmitted within 30-days of discharge; 23,278 of these patients (25%) were readmitted to a hospital other than the one where their procedure was performed.  Patients who were readmitted to a different hospital generally lived farther from the index hospital than those who were readmitted to the index hospital (20.7 miles vs. 7.4 miles, p<0.001).  We found large state-level variations in the proportion of surgical patients who were readmitted elsewhere.  Patients readmitted to a different hospital that was the same distance from their home as the index hospital had 48% higher odds of mortality (OR 1.48, 95% CI 1.24-1.78, p<0.001) than patients who were admitted to the index hospital.  

Conclusion: 1 in 4 older Americans undergoing major surgery are readmitted to a hospital different than the one where the initial operation was performed. Even taking distance traveled into account, post-surgical care fragmentation is associated with a substantially higher risk of death.  Focusing on clinical integration may improve outcomes for older Americans undergoing complex surgery. 

15.05 Disruptive and Incremental Innovation: A Snapshot of Surgical Literature

Posted on December 22, 2014

L. E. Grimmer1, M. C. Nally1, J. C. Kubasiak1, M. Luu1, J. Myers1  1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction: "Disruptive innovations" are defined as novel solutions to existing problems which are cheaper, simpler and more convenient than the current solution.  Examples of disruptive innovations include coronary angioplasty rivaling CABG, or TIPS replacing spleno-renal shunts. This is in contrast to "incremental innovations" which modify and improve on the current solution through increased complexity and cost, such as single incision surgery improving upon traditional laparoscopy. Despite widespread application of this innovation framework in other professional fields, classification of surgical innovations as disruptive or incremental has not been previously studied. We hypothesized that a standardized inventory of items related to disruptive and incremental innovations can be applied to surgical literature.

Methods:  Each article in the most recent issues of ten high impact surgical journals was included; editorials and guidelines reviews were excluded. Of 200 articles, 51 lacked an identifiable innovation, and 149 were scored on the following items: cost of implementation, overall healthcare cost, level of infrastructure required, level of care needed during procedure, level of training, level of difficulty, number of operative/non-operative procedures performed, extent of tissue excised or dissected, invasiveness and incision size.

Results: Compared to the current solutions, the innovations proposed in the literature had higher initial cost (55% increased v 8% decreased cost) and overall system cost (21% inc v 11% dec).  Innovations also required more resources (40% inc v 5% dec), more training (38% inc v 3% dec) and were more difficult to perform (37% inc v 5% dec). Innovations tended toward more tissue excised/dissected (26% inc v 13% dec), but offered smaller incisions (18% smaller incision v 11% larger) and less invasive procedures (22% less v 19% more).

Conclusion: Surgical literature is dominated by resource-intense, interval improvements to existing solutions, characteristic of incremental innovations, with a relative dearth of disruptive innovations. 
 

15.06 Who Gets It? A Survey of Physician Attitudes Regarding Disaster Resource Allocation

Posted on December 22, 2014

W. Jacoby1, S. Agarwal1, H. Jung1, A. E. Liepert1, P. J. Mercier1, A. P. O’Rourke1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
Resource allocation during disasters poses clinical, administrative and ethical challenges–overwhelming available healthcare resources and obviating the standard of care.  The lack of  evidence-based standards or consensus-based goals for health care resource allocation in a disaster setting leads to uncertainly for providers being asked to distribute resources. To this end, limited research has been conducted to ascertain the opinions of the health care professionals who will actually be providing care if a disaster strikes.

Methods:
Data was obtained from a brief IRB-approved survey conducted at a quaternary care, academic institution. Personal experiences with disaster planning and awareness, opinions of main goal of crisis care, understanding of possible important disaster resource allocation factors (age, life expectancy, DNR status),and knowledge of triggers for declaring crisis care were ascertained.  The anonymous survey was electronically distributed to a random sample of faculty physicians and residents. Analysis of descriptive characteristics and for possible relationships between baseline awareness and patterns of allocation was performed.

Results:
Analysis of physician responses demonstrated a 39% response rate (yield from 1233 surveys distributed).   Mean years in practice was 12 years. Thirty-five percent of physicians stated they had been involved in disaster planning, but only 21% knew the institutional disaster plan or where to find these plans. Eighteen percent felt they had received adequate training to receive a large surplus of patients. The majority of physicians said that scope of practice (89%) and legal standards (65%) change during disaster scenarios, and just over half (52%) said ethical norms changed. A minority (24%) of physicians had experience with disasters or resource allocation, and most (82%) do not feel they have received adequate training in this area.

Conclusion:
The majority of physicians at a large academic hospital are ill prepared to deal with resource allocation in disasters. This early single institution analysis provides the first reported insights into baseline physician attitudes and can be a basis for targeting institutional education initiatives and future surveys in disaster planning and management.
 

15.07 Hospital Quality and Variations in Episode-Based Spending for Surgical Care

Posted on December 22, 2014

T. C. Tsai1,2, F. Greaves2, E. J. Orav3,4, M. Zinner1, A. Jha2,3  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Harvard School Of Public Health,Health Policy And Management,Boston, MA, USA 3Brigham And Women’s Hospital,Medicine,Boston, MA, USA 4Harvard School Of Public Health,Biostatistics,Boston, MA, USA

Introduction:  The rise of new payment models, such as bundled payments after major surgical procedures, has led policymakers and clinical leaders to increase their focus on episodes of care.  Despite interest in this area, we know little about how much longer-term costs vary after major procedures and whether high quality surgical hospitals, those with high performance on process measures or patient experience, have lower long-term costs after procedures.  Therefore, we examined variations in long-term costs after major procedures, the relationship between key structural factors and Medicare costs, and assessed if higher quality hospitals had higher costs. 

Methods:  Using 2011 national Medicare 20% claims files, we calculated episodes of care associated with an index admission and 30 and 90 of post-discharge care for patients undergoing coronary artery bypass graft, pulmonary lobectomy, abdominal aortic aneurysm repair, colectomy, and hip replacement.  All Medicare payments were standardized to national fee-schedules to allow for national comparisons.  Our main predictors of quality were hospital patient satisfaction as measured by the HCAHPS survey and hospital perioperative mortality. We used bivariate and multivariate models adjusting for case-mix to assess the relationship between hospital characteristics, quality, and long-term costs.  

Results: We identified 51,249 patients.  Average 30-day spending was $32,514.  While spending on the index admission was the largest component of the episode, spending on post-acute care had the largest variation, varying from $2,998 for endovascular abdominal aortic aneurysm repair to $9,667 for hip replacement. Patients who went to hospitals with low satisfaction resulted in $2,626 more in spending than patients who went to hospitals with high satisfaction ($36,637 vs. $34,011, p<0.001). Similarly, patients receiving care at hospitals with high mortality resulted in $1,890 more in spending than patients who went to hospitals with low mortality ($38,952 vs. $34,062, p<0.001).  Patterns were consistent for 90 days.  Spending on post-acute care accounted for the largest variation in spending between high and low quality hospitals (59%).

Conclusion: Elderly patients receiving surgical care at low-quality hospitals result in higher spending than patients receiving care at high quality hospitals, and these patterns persisted out to 90-days.  Post-acute care accounted for the largest variation in spending between high and low-quality hospitals.  Because low-quality surgical care represents a serious cost to Medicare over the course of an episode, policies such as bundled payments may serve as an important step to aligning cost and quality for surgical care.

 

15.08 Risk evaluation of organ donation from donors with primary malignant gliomas

Posted on December 22, 2014

S. Amaefuna1, J. D. Mezrich2, J. S. Kuo1  1University Of Wisconsin,Neurological Surgery,Madison, WI, USA 2University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  Progress in organ transplantation to treat end-stage organ disease has resulted in organ demand greatly outpacing supply. The escalating organ shortage and rising mortality rates for the estimated 123,000 patients on the U.S. organ wait-list motivated our reevaluation of common practices related to organ donation from individuals with primary central nervous system (CNS) tumors. Malignancy is generally considered a contraindication to organ donation, with rare exceptions including non-metastatic primary brain tumors (PBT). Glioblastoma multiforme (GBM) is a WHO grade IV glioma that accounts for over 45.2% of malignant PBTs in the U.S. Therefore, less than 0.5% of 13,000 U.S. patients dying from malignant gliomas annually serve as organ donors. Although a hallmark feature of GBM is infiltration into surrounding brain, metastatic capacity outside the CNS is poorly documented.

Methods:  Using literature review of all available papers reporting on GBM and extra-neural metastasis, we evaluated and assessed the implications of available data on the rarity of extra-neural metastasis (ENM) of GBM regarding the risk of donor-derived transmission (DDT) of cancer to organ recipients. We evaluated and present recent reports on DDT rates among recipients of cadaveric organs from GBM patients. 

Results: Careful screening of papers for only pathologically confirmed metastatic events were considered high quality, reliable data. Literature review revealed only clinical case reports suggesting a maximum incidence of metastasis that is likely significantly lower than 2%, and highlights that such rare GBM metastatic events preferentially target pulmonary, lymph, hepatic and bone tissues. 

Conclusion: These findings imply that kidneys from donors with GBM may be considered for transplantation, and the morbidity and possible mortality of wait-listed renal allograft recipients may outweigh the apparent small risk of DDT from donors with GBM. Further studies are required to validate this implication before implementing any changes in donor evaluation policy. Furthermore, re-evaluation of policies regarding other lower grade primary brain tumors are being considered for study in order to support the goal of increasing donor organs.

 

15.09 Health care revisits following ambulatory surgery

Posted on December 22, 2014

G. D. Sacks1,2, M. M. Gibbons1, S. O. Raetzman4, M. L. Barrett5, P. L. Owens3, C. A. Steiner3  1University Of California – Los Angeles,Surgery,Los Angeles, CA, USA 2Robert Wood Johnson Clinical Scholars Program, UCLA,Los Angeles, CA, USA 3Agency For Healthcare Research And Quality (AHRQ),Center For Delivery, Organization And Markets (CDOM),Rockville, MD, USA 4Truven Health Analytics,Bethesda, MD, USA 5ML Barrett, Inc,Del Mar, CA, USA

Introduction:
Revisits to health care settings following inpatient hospitalization, particularly those resulting in hospital readmission, have emerged as an indicator of health care quality. The prevalence and etiology of revisits following ambulatory surgery, however, remain unknown.

Methods:
We performed a retrospective analysis using the 2010-2011 Healthcare Cost and Utilization Project State Ambulatory Surgery, Inpatient, and Emergency Department Databases for 7 geographically dispersed states (California, Florida, Georgia, Missouri, Nebraska, New York, and Tennessee) of index operations representing a broad range of specialties: laparoscopic cholecystectomy (LC), abdominal hernia repair (AHR), anterior cruciate ligament repair (ACLR), spine surgery (SS), hysterectomy (HYST), and transurethral retrograde prostatectomy (TURP) in low surgical risk adults (defined as no acute care visit in previous 30 days, length of stay less than 2 days, no other surgery on the same day, no infection coded and discharged home the same day). We identified cases resulting in a revisit within 30 days of an operation to the emergency department (ED), hospital-owned ambulatory surgery setting (AS), or inpatient (IP) setting. Rates, site, and reason for revisit were analyzed.

Results:
Of the 482,034 index operations, revisits occurred after 45,760 surgeries (9.5%). The majority of revisits were to the ED (n=28,302, 61.8%), followed by IP readmissions (n=13,027, 28.5%). Few revisits were to an AS (n=4,431, 9.7%). Revisits were most common following TURP (14.5%) and AHR (10.9%) and least common for ACLR (5.1%). Across all operations, medical complications of surgery accounted for 42.1% of revisits, surgical complications for 26.6%, and 31.3% were for clinical issues unrelated to the index operation. The distribution of each revisit type varied by operation. Medical complications were the most common reason for revisit following LC (50.3%), AHR (39.6%), and HYST (43.3%), while surgical complications were most common for ACLR (35.5%), SS (36.6%), and TURP (56.6%). Unrelated readmissions ranged from 23.1% for TURP to 39.6% for AHR. Similarly, the distribution of revisit setting varied by operation.

Conclusion:
Health care revisits following ambulatory surgery in low risk patients occur with significant frequency across a wide variety of operations.  Most revisits were either surgically or medically related to the operation, although one-third of revisits were for clinical issues unrelated to the index operation. Considering the burden associated with revisits, these findings highlight the importance of expanding the focus of health policy interventions and local quality improvement efforts targeting revisits to include ambulatory surgery patients.
 

15.10 Robotic-Assisted Surgery: A Primer on Best Practices for Privileging and Credentialing

Posted on December 22, 2014

A. M. Al-Ayoubi1, C. M. Forleiter3, M. Barsky1, A. Bogis1, S. Rehmani1, S. Belsley3, R. Flores2, F. Y. Bhora1  1Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital/Department Of Thoracic Surgery,New York, NY, USA 2Mount Sinai School Of Medicine,Mount Sinai Hospital/Department Of Thoracic Surgery,New York, NY, USA 3Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital/Department Of Surgery,New York, NY, USA

Introduction: The recent surge of robotic-assisted surgery necessitates effective guidelines to ensure safe outcomes. We provide a stepwise algorithm for granting privileges and credentials in robotic-assisted surgery. This algorithm reflects increasing level of responsibility and complexity of the surgical procedures performed. Furthermore, it takes into account volume, outcomes, surgeon's proficiency and appropriateness of robotic usage.

Methods: We performed a literature review for available strategies to grant privileges and credentials for robotic usage. The following terms were queried: robot, robotic, surgery and credentialing. We provide this algorithm based on review of the literature, our institutional experience, as well as the experience of other medical centers around the US.

Results:

46 manuscripts were identified in the published English language literature through August 2014. Two pathways for robotic training exist: residency- and non-residency-trained. In the US, JCAHO requires hospitals to credential and privilege physicians on their medical staff. Table 1 shows our algorithm for granting robotic privileges in a graduated fashion. A credentialing designee (CD) oversees and reviews all requests. Residency trained surgeons must fulfill 20 cases with program directors’ attestation to obtain Full privileges. Non-residency trained surgeons are required to fulfill the following: simulation, didactics including online modules, wet labs (cadaver or animal) and observation of at least 2 cases for Provisional privileges.

To serve as a proctor, a surgeon with Full privileges must complete 25 cases in the same specialty with good outcomes and be approved by the CD and the chair. A minimum number of cases (10) is required to maintain privileges. Cases are monitored via departmental QA/QI committee review. Investigational uses of the robot require IRB approval. Complex operations may require additional proctoring and QA/QI review.

Conclusion: Safety concerns with the introduction of novel and complex technologies such as robotic-assisted surgery must be paramount. Our algorithm takes into consideration appropriate utilization, restraint of trade and state reporting ramifications. Furthermore, it serves as a basic guideline for institutions that wish to implement a robotic-assisted surgery program.
 

15.11 The “Weekend Effect" in Urgent General Surgical Procedures

Posted on December 22, 2014

M. A. Zapf1, A. Kothari1, T. Markossian2, G. Gupta1, P. Wai1, J. Driver1, P. Kuo1  1Loyola University Chicago Stritch School Of Medicine,Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Public Health Sciences,Maywood, IL, USA

Introduction: There is growing concern that the quality of inpatient care may differ on weekends vs. weekdays.  We aimed to assess the “weekend effect” in common urgent general surgical procedures.

Methods: The Healthcare Cost and Utilization Project Florida State Inpatient Database (2007-2010) was queried to identify inpatient stays with admission from the ER or urgent care center followed by surgery on the same day.  Included were patients undergoing appendectomy, cholecystectomy for acute cholecystitis, and inguinal, femoral, ventral, incisional or umbilical hernia repair with diagnosis of obstructed or gangrenous hernia.  Outcomes included length of stay (LOS), inpatient mortality, hospital-adjusted charges and complications not present on admission.  We assessed patient outcomes using univariate analysis and with multilevel mixed-effects regression modeling that was used to examine the association between patients’ outcomes and admissions day (weekend vs. weekday), controlling for hospital characteristics, patients’ demographic and clinical characteristics, and type of surgery.

Results:A total of 80,861 same day surgeries were identified, of which 19,078 (23.6%) occurred during the weekend.  Patient characteristics were similar between groups.  Patients operated on during the weekend had greater LOS (3.05 ± 0.033 v 2.98 ± 0.016 p<0.05) and an increase in charges by $185 (p<0.05), both of which were also significant in the multiple regression modeling.  Inpatient mortality was similar between groups, however patients undergoing weekend surgeries were more likely to develop wound complications (OR 1.28, 95% CI 1.08-1.52 p<0.05) and pneumonia (OR 1.29, 95% CI 1.10-1.52 p<0.05). When procedures were considered in isolation (table), weekend procedures were associated with distinctive subgroups of inferior outcomes.

Conclusion:Patients undergoing weekend surgery for common urgent general surgical operations are at risk for significantly increased postoperative complications, length of stay and hospital charges.  In an age of quality improvement, health systems should consider processes that bolster weekend perioperative care.  As the cause of the “weekend effect” is still unknown, future studies should focus on elucidating the institutional characteristics that may overcome this disparity.

Table 1. Shaded boxes: p<0.05 in weekend vs. weekday
 

15.12 Is a Colectomy Always Just a Colectomy? Examining the Effect of Concurrent Procedures on Outcomes

Posted on December 22, 2014

K. D. Simmons1, R. L. Hoffman1, L. E. Kuo1, E. K. Bartlett1, D. N. Holena1, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction:
Studies of surgical outcomes can be confounded by operative complexity, one aspect of which is the performance of concurrent procedures.  Complexity is difficult to assess from claims data due to the absence of established measures.  However, surgical databases often include information on concurrent procedures.  Thus, we hypothesized that the presence or absence of same-day procedures would be useful as a step toward including operative complexity in risk adjustment.  Toward this end, we compared the association between concurrent procedures and surgical outcomes to examine the possible role for this information in risk adjustment and prediction.

Methods:

All records in which colon resection was performed at some point during inpatient admission were pulled from three state databases (California, Florida, and New York) between 2007 and 2012.  Our primary outcome was in-hospital mortality; secondary outcomes were post-operative complications.  For each outcome, we developed multivariate logistic regression model based on patient demographic, hospital, and admission characteristics; indications for colectomy; and the presence or absence of other procedures performed on the same day.  Likelihood ratio tests were done to assess the effects of removing individual covariates on model fit.

Results:

We analyzed 209,508 colectomies, of which 40,787 (19.5%) were not performed on the same day as any other procedures.  Overall mortality was 6.3%.  Mortality was higher among patients with another procedure performed on the same day as colectomy (7.3%) than among patients for whom no other procedures were performed on the same day (2.2%, p<.001).  In multivariate regression, having another same-day procedure was significantly associated with mortality (odds ratio 2.62, p<.001).  Moreover, including this measure of complexity significantly improved the fit of the model (chi-squared = 895.98, p<.0001). The only covariates with greater contributions to adjusted mortality were age, number of comorbidities, colon cancer, and emergency admission.  Similarly, same-day procedures were associated with higher complication rates, as shown in the table.

Conclusion:
The risk of complications and mortality following colon resection is increased among patients who have at least one other procedure on the same day.  This measure may be underutilized as a source of variation in outcomes and may provide a window into operative complexity.

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