Association between institutional procedural preference and in-hospital outcomes in laparoscopic surgeries; Insights from a retrospective cohort analysis of a nationwide surgical database in Japan.
ABSTRACT: To assess the use of laparoscopic surgeries (LS) and the association between its performance and hospitals' preference for LS over open surgeries.LS is increasingly used in many abdominal surgeries, albeit both with and without solid guideline recommendations. To date, the hospitals' preference (LS vs. open surgeries) and its association with in-hospital outcomes has not been evaluated.We enrolled patients undergoing 8 types of gastrointestinal surgeries in 2011-2013 in the Japanese National Clinical Database. We assessed the use of LS and the occurrences of surgery-related morbidity and mortality during the study period. Further, for 4 typical LS procedures, we assessed the hospitals' preference for LS by modeling the propensity to perform LS (over open surgeries) from patient-level factors, and estimating each institution's observed/expected (O/E) ratio for LS use. Institutions with O/E>2 were defined as LS-dominant. Using hierarchical logistic regression models, we assessed the association between LS preference and in-hospital outcomes.Among 1,377,118 patients undergoing gastrointestinal procedures in 2,336 participating hospitals, use of LS increased in all 8 procedures (35.1% to 44.7% for distal gastrectomy (DG), and 27.5% to 43.2% for right hemi colectomy (RHC)). Those operated at LS-dominant hospitals were at an increased risk of operative death (OR 1.83 [95%CI, 1.37-2.45] for DG, 1.79 [95%CI, 1.43-2.25] for RHC) compared to standard O/E level hospitals (0.5?O/E<2.0).LS use widely increased during 2011-2013 in Japan. Facilities with higher than expected LS use had higher mortality compared to other hospitals, suggesting a need for careful patient selection and dissemination of the procedure.
Project description:OBJECTIVES: To determine whether older Veterans Health Administration (VA) health care enrollees obtain most high-risk surgeries in non-VA hospitals under Medicare, whether residence in less populous areas increases this reliance on non-VA care or the likelihood of obtaining it in hospitals with higher mortality rates, and whether directing VA enrollees to better hospitals would add a substantial travel burden. DATA SOURCES: VA and Medicare hospital discharge data from 2000 and 2001 for VA enrollees 65 years or older who received any of 14 high-risk elective procedures, including heart, vascular, and cancer surgeries. STUDY DESIGN/DATA EXTRACTION: We compared urban, suburban, and rural patients on use of VA versus non-VA hospitals, use of non-VA hospitals of higher versus lower mortality rates, travel times to get to these hospitals, and the additional travel burden if they had gone to lower mortality hospitals. PRINCIPAL FINDINGS: Regardless of residence, VA enrollees obtained most high-risk surgeries in non-VA hospitals. Urban veterans were most likely to get heart or cancer surgeries in lower mortality hospitals, but rural veterans were most likely to get vascular surgeries in lower mortality hospitals. Average travel times to lower or higher mortality hospitals did not differ greatly. CONCLUSIONS: Accessing better hospitals need not add a great travel burden for rural veterans.
Project description:OBJECTIVE:To assess the budget impact of using ulipristal acetate (UPA) 5 mg to treat women with uterine fibroids (UF) causing moderate to severe symptoms. DESIGN:We modelled trends in the number of surgical procedures for symptomatic UF, with and without the use of UPA for preoperative or intermittent treatment and assessed the budget impact of UPA use from the French national healthcare insurance system perspective. SETTING:A French national hospital database (PMSI) that records admissions and relative procedures to public and private hospitals. PARTICIPANTS:Women eligible for surgical procedures for uterine fibroids. MAIN OUTCOME MEASURES:Economic impact of UPA treatment. RESULTS:This study based on observational retrospective data shows that the current use of UPA in its preoperative indication was associated with 5645 fewer surgeries from 2013 to 2015. Extrapolation suggests 17 885 fewer surgeries from 2016 to 2019. Overall, preoperative use of UPA results in substantial cost savings for the French national healthcare insurance system, with a cumulated budget impact estimated at €-5 million from 2013 to 2015 and €-13.5 million from 2016 to 2019. In addition, treating women nearing the menopause (?48 years old) with intermittent treatment from 2017 to 2019 could produce an incremental cost saving of €19 million. CONCLUSIONS:This study shows that the use of UPA in women eligible for surgical procedures for UF is associated with considerable savings for the French national healthcare insurance system in both preoperative and intermittent indications by decreasing the need to perform surgeries.
Project description:BACKGROUND:Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded LS-MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures, and cost the US healthcare system about $300 million dollars per year. However, why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood. OBJECTIVE:To characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain. DESIGN:Qualitative study using semi-structured interviews. PARTICIPANTS:Veterans Affairs PCPs identified from administrative data as having high or low rates of guideline-concordant LS-MRI ordering in 2016. APPROACH:Providers were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. Directed content analysis of transcripts was conducted to identify and compare environmental-, patient-, and provider-level factors contributing to unneeded LS-MRI. KEY RESULTS:Fifty-five PCPs participated (8.6% response rate). Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns. Low- and high-guideline-concordant providers reported similar patient factors (beliefs in value of imaging and pressure on providers). However, provider groups differed in how provider-level factors (guideline familiarity and agreement, the extent to which they acquiesced to patients, and belief in the value of LS-MRI) contributed to LS-MRI ordering patterns. CONCLUSIONS:Results describe how diverse environmental, patient, and provider factors contribute to unneeded LS-MRI for acute, uncomplicated low-back pain. Prior research using a single intervention to reduce unneeded LS-MRI has been ineffective. Results suggest that multifaceted de-implementation strategies may be required to reduce unneeded LS-MRI.
Project description:INTRODUCTION:After the outbreak of COVID-19 unprecedented changes in the healthcare systems worldwide were necessary resulting in a reduction of urological capacities with postponements of consultations and surgeries. MATERIAL AND METHODS:An email was sent to 66 urological hospitals with focus on robotic surgery (RS) including a link to a questionnaire (e.g. bed/staff capacity, surgical caseload, protection measures during RS) that covered three time points: a representative baseline week prior to COVID-19, the week of March 16th-22nd and April 20th-26th 2020. The results were evaluated using descriptive analyses. RESULTS:27 out of 66 questionnaires were analyzed (response rate: 41%). We found a decrease of 11% in hospital beds and 25% in OR capacity with equal reductions for endourological, open and robotic procedures. Primary surgical treatment of urolithiasis and benign prostate syndrome (BPS) but also of testicular and penile cancer dropped by at least 50% while the decrease of surgeries for prostate, renal and urothelial cancer (TUR-B and cystectomies) ranged from 15 to 37%. The use of personal protection equipment (PPE), screening of staff and patients and protection during RS was unevenly distributed in the different centers-however, the number of COVID-19 patients and urologists did not reach double digits. CONCLUSION:The German urological landscape has changed since the outbreak of COVID-19 with a significant shift of high priority surgeries but also continuation of elective surgical treatments. While screening and staff protection is employed heterogeneously, the number of infected German urologists stays low.
Project description:Use of intensive care after major surgical procedures and whether routinely admitting patients to intensive care units (ICUs) improve outcomes or increase costs is unknown.The authors examined frequency of admission to an ICU during the hospital stay for Medicare beneficiaries undergoing selected major surgical procedures: elective endovascular abdominal aortic aneurysm (AAA) repair, cystectomy, pancreaticoduodenectomy, esophagectomy, and elective open AAA repair. The authors compared hospital mortality, length of stay, and Medicare payments for patients receiving each procedure in hospitals admitting patients to the ICU less than 50% of the time (low use), 50 to 89% (moderate use), and 90% or greater (high use), adjusting for patient and hospital factors.The cohort ranged from 7,878 patients in 162 hospitals for esophagectomies to 69,989 patients in 866 hospitals for endovascular AAA. Overall admission to ICU ranged from 35.6% (endovascular AAA) to 71.3% (open AAA). Admission to ICU across hospitals ranged from less than 5% to 100% of patients for each surgical procedure. There was no association between hospital use of intensive care and mortality for any of the five surgical procedures. There was a consistent association between high use of intensive care with longer length of hospital stay and higher Medicare payments only for endovascular AAA.There is little consensus regarding the need for intensive care for patients undergoing major surgical procedures and no relationship between a hospital's use of intensive care and hospital mortality. There is also no consistent relationship across surgical procedures between use of intensive care and either length of hospital stay or payments for care.
Project description:Importance:Increasing use of robotic surgery for common surgical procedures with limited evidence and unclear clinical benefit is raising concern. Analyses of population-based trends in practice and how hospitals' acquisition of robotic surgical technologies is associated with their use are limited. Objective:To characterize trends in the use of robotic surgery for common surgical procedures. Design, Setting, and Participants:This cohort study used clinical registry data from Michigan from January 1, 2012, through June 30, 2018. Trends were characterized in the use of robotic surgery for common procedures for which traditional laparoscopic minimally invasive surgery was already considered a safe and effective approach for most surgeons when clinically feasible. A multigroup interrupted time series analysis was performed to determine how procedural approaches (open, laparoscopic, and robotic) change after hospitals launch a robotic surgery program. Data were analyzed from March 1 through April 19, 2019. Exposures:Initiation of robotic surgery. Main Outcomes and Measures:Procedure approach (ie, robotic, open, or laparoscopic). Results:The study cohort included 169?404 patients (mean [SD] age, 55.4 [16.9] years; 90?595 women [53.5%]) at 73 hospitals. The use of robotic surgery increased from 1.8% in 2012 to 15.1% in 2018 (8.4-fold increase; slope, 2.1% per year; 95% CI, 1.9%-2.3%). For certain procedures, the magnitude of the increase was greater; for example, for inguinal hernia repair, the use of robotic surgery increased from 0.7% to 28.8% (41.1-fold change; slope, 5.4% per year; 95% CI, 5.1%-5.7%). The use of robotic surgery increased 8.8% in the first 4 years after hospitals began performing robotic surgery (2.8% per year; 95% CI, 2.7%-2.9%). This trend was associated with a decrease in laparoscopic surgery from 53.2% to 51.3% (difference, -1.9%; 95% CI, -2.2% to -1.6%). Before adopting robotic surgery, hospitals' use of laparoscopic surgery increased 1.3% per year. After adopting robotic surgery, the use of laparoscopic surgery declined 0.3% (difference in trends, -1.6%; 95% CI, -1.7% to -1.5%). Conclusions and Relevance:These results suggest that robotic surgery has continued to diffuse across a broad range of common surgical procedures. Hospitals that launched robotic surgery programs had a broad and immediate increase in the use of robotic surgery, which was associated with a decrease in traditional laparoscopic minimally invasive surgery.
Project description:Cooperation with multiple departments is essential for the treatment of patients with rectal cancer and other pelvic cancers. In our department, we experienced two cases of rectal cancer that underwent robotic low anterior resection (LAR) and simultaneous resection of other pelvic organs (case 1 with prostatectomy and case 2 with hysterectomy) using the da Vinci Xi system. Here, we show the precise procedures of these two robotic surgeries. Under general anesthesia and lithotomy position, five da Vinci ports were symmetrically placed along the umbilical horizontal line with a 7 cm interval, and a 5 mm AirSeal Access Port was added in the right or left upper quadrant. Patients were placed with 22-degree Trendelenburg and 8-degree tilt to the right. The operators used the center port on the umbilicus as a camera port and chose the docking arms with either two-left-one-right or one-left-two-right setting depending on their preference. This port setting was quite useful for the operators from multiple departments to change the docking arms, even if their preference may be different. Moreover, assistants could use the remaining two ports to provide a well-expanded and safer surgical field. "With a familiar view" and "with a wide view" are our two concepts to safely perform extended pelvic surgeries. We have employed this symmetrical horizontal port site position as a general setting for usual rectal surgeries.
Project description:A variety of diacylglycerol (DG) molecular species are produced in stimulated cells. Conventional (?, ?II and ?) and novel (?, ?, ? and ?) protein kinase C (PKC) isoforms are known to be activated by DG. However, a comprehensive analysis has not been performed. In this study, we analyzed activation of the PKC isozymes in the presence of 2-2000 mmol% 16:0/16:0-, 16:0/18:1-, 18:1/18:1-, 18:0/20:4- or 18:0/22:6-DG species. PKC? activity was strongly increased by DG and exhibited less of a preference for 18:0/22:6-DG at 2 mmol%. PKC?II activity was moderately increased by DG and did not have significant preference for DG species. PKC? activity was moderately increased by DG and exhibited a moderate preference for 18:0/22:6-DG at 2 mmol%. PKC? activity was moderately increased by DG and exhibited a preference for 18:0/22:6-DG at 20 and 200 mmol%. PKC? activity moderately increased by DG and showed a moderate preference for 18:0/22:6-DG at 2000 mmol%. PKC? was not markedly activated by DG. PKC? activity was the most strongly increased by DG and exhibited a preference for 18:0/22:6-DG at 2 and 20 mmol% DG. These results indicate that conventional and novel PKCs have different sensitivities and dependences on DG and a distinct preference for shorter and saturated fatty acid-containing and longer and polyunsaturated fatty acid-containing DG species, respectively. This differential regulation would be important for their physiological functions.
Project description:Hartmann's procedure for perforated diverticulitis can be characterised by high morbidity and mortality rates. While the scientific community focuses on laparoscopic lavage as an alternative for laparotomy, the option of laparoscopic sigmoidectomy seems overlooked. We compared morbidity and hospital stay following acute laparoscopic sigmoidectomy (LS) and open sigmoidectomy (OS) for perforated diverticulitis.This retrospective cohort parallel to the Ladies trial included patients from 28 Dutch academic or teaching hospitals between July 2010 and July 2014. Patients with LS were matched 1:2 to OS using the propensity score for age, gender, previous laparotomy, CRP level, gastrointestinal surgeon, and Hinchey classification.The propensity-matched cohort consisted of 39 patients with LS and 78 patients with OS, selected from a sample of 307 consecutive patients with purulent or faecal perforated diverticulitis. In both groups, 66 % of the patients had Hartmann's procedure and 34 % had primary anastomosis. The hospital stay was shorter following LS (LS 7 vs OS 9 days; P = 0.016), and the postoperative morbidity rate was lower following LS (LS 44 % vs OS 66 %; P = 0.016). Mortality was low in both groups (LS 3 % vs OS 4 %; P = 0.685). The stoma reversal rate after Hartmann's procedure was higher following laparoscopy, with a probability of being stoma-free at 12 months of 88 and 62 % in the laparoscopic and open groups, respectively (P = 0.019). After primary anastomosis, the probability of reversal was 100 % in both groups.In this propensity score-matched cohort, laparoscopic sigmoidectomy is superior to open sigmoidectomy for perforated diverticulitis with regard to postoperative morbidity and hospital stay.
Project description:The aortic arch repair is one of the most complex surgeries and carries a high risk of complications as well as mortality. Since 1975, when the arch repair was first done by Randall B. Griepp using hypothermic circulatory arrest, many new technologies were introduced. But even with the use of antegrade and retrograde perfusion techniques and improvement of surgical techniques and grafts, the rate of mortality, cerebral, spinal, and visceral damage was much higher as compared to any other cardiac surgeries. With further developments aimed at less invasive approaches, thoracic endovascular aortic repair (TEVAR) along with de-branching of supra-aortic vessels or the frozen elephant trunk was introduced. Here, in this article, we review the myriad of approaches to the aortic arch and have come to a conclusion that while traditional open surgery is considered as the gold standard for treatment of extensive aortic arch pathologies, one school of thought suggests hybrid techniques such as the frozen elephant trunk and aortic arch vessel de-branching as more appropriate procedures for high-risk patients, where co-morbidities may contraindicate cardiopulmonary bypass and longer operative times required for traditional repair. No randomized trials are present to compare between open and hybrid or endovascular procedure in normal or high-risk patients. The meta-analysis of most of the studies defines open surgery as the gold standard for arch pathology because the hybrid procedures did not provide any proven survival benefits or decrease in stroke rate and spinal ischemia when compared to open surgery in early, mid, or long-term results.