Anthony G. Charles

Trends in Emergent Hernia Repair in the United States

IMPORTANCE Abdominal wall hernia is one of the most common conditions encountered by general surgeons. Rising rates of abdominal wall hernia repair have been described; however, population-based evidence concerning incidence rates of emergent hernia repair and changes with time are unknown. OBJECTIVE To examine trends in rates of emergent abdominal hernia repair within the United States for inguinal, femoral, ventral, and umbilical hernias from January 1, 2001, to December 31, 2010. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of adults with emergent hernia repair using National Center for Health Statistics data, a nationally representative sample of inpatient hospitalizations in the United States that occurred from January 1, 2001, to December 31, 2010. All emergent hernia repairs were identified during the study period. MAIN OUTCOMES AND MEASURES Incidence rates per 100,000 person-years, age, and sex adjusted to the 2010 US census population estimates were calculated for selected subcategories of emergent hernia repairs and time trends were evaluated. RESULTS An estimated 2.3 million inpatient abdominal hernia repairs were performed from 2001 to 2010; of which an estimated 567,000 were performed emergently. A general increase in the rate of total emergent hernias was observed from 16.0 to 19.2 emergent hernia repairs per 100,000 person-years in 2001 and 2010, respectively. In 2010, emergent hernia rates were highest among adults 65 years and older, with 71.3 and 42.0 emergent hernia repairs per 100,000 person-years for men and women, respectively. As expected, femoral hernia rates were higher among women while emergent inguinal hernia rates were higher among men. Rates of emergent incisional hernia repair were high but relatively stable among older women, with 24.9 and 23.5 per 100,000 person-years in 2001 and 2010, respectively. However, rates of emergent incisional hernia repair among older men rose significantly, with 7.8 to 32.0 per 100,000 person-years from 2001 to 2010, respectively. CONCLUSIONS AND RELEVANCE These increasing rates of emergent incisional hernia repair are troublesome owing to the significantly increased risk morbidity and mortality associated with emergent hernia repair. While this increased mortality risk is multifactorial, it is likely associated with older age and the accompanying serious comorbidities.

The Employed Surgeon: A Changing Professional Paradigm

OBJECTIVE To identify trends and characteristics of surgeon employment in the United States. Surgeons are increasingly choosing hospital or large group employment as their practice environment. DESIGN American Medical Association Physician Masterfile data were analyzed for the years 2001 to 2009. SETTING Surgeons identified within the American Medical Association Masterfile. PARTICIPANTS Surgeons were defined using definitions from the American Medical Association specialty data and the American Board of Medical Specialties certification data and included active, nonfederal, and nonresident physicians younger than 80 years of age. MAIN OUTCOME MEASURES Employment status and trends. RESULTS The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices. CONCLUSIONS General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice. The trend is especially notable among younger surgeons and among female surgeons. The trend denotes a professional paradigm shift of major importance.

Under-Reporting of Road Traffic Mortality in Developing Countries: Application of a Capture-Recapture Statistical Model to Refine Mortality Estimates

Road traffic injuries are a major cause of preventable death in sub-Saharan Africa. Accurate epidemiologic data are scarce and under-reporting from primary data sources is common. Our objectives were to estimate the incidence of road traffic deaths in Malawi using capture-recapture statistical analysis and determine what future efforts will best improve upon this estimate. Our capture-recapture model combined primary data from both police and hospital-based registries over a one year period (July 2008 to June 2009). The mortality incidences from the primary data sources were 0.075 and 0.051 deaths/1000 person-years, respectively. Using capture-recapture analysis, the combined incidence of road traffic deaths ranged 0.192–0.209 deaths/1000 person-years. Additionally, police data were more likely to include victims who were male, drivers or pedestrians, and victims from incidents with greater than one vehicle involved. We concluded that capture-recapture analysis is a good tool to estimate the incidence of road traffic deaths, and that capture-recapture analysis overcomes limitations of incomplete data sources. The World Health Organization estimated incidence of road traffic deaths for Malawi utilizing a binomial regression model and survey data and found a similar estimate despite strikingly different methods, suggesting both approaches are valid. Further research should seek to improve capture-recapture data through utilization of more than two data sources and improving accuracy of matches by minimizing missing data, application of geographic information systems, and use of names and civil registration numbers if available.

Repeat imaging in trauma transfers: a retrospective analysis of computed tomography scans repeated upon arrival to a Level I trauma center.

BACKGROUND: The repetition of computed tomography (CT) imaging in caring for injured patients transferred between institutions is common, but it is not well studied. Our objective is to quantify and describe the characteristics associated with repeating chest and abdominal CT images for patients transferred to trauma centers and to determine whether repeat imaging leads to delays in definitive care or disparate outcomes. METHODS: This is a retrospective review of adult, blunt trauma patients transferred to two Level I trauma centers between January 2004 and May 2008 who underwent CT imaging of the chest, abdomen, or both. RESULTS: 60% of patients had at least one study repeated upon arrival to the trauma center. Variables associated with repeat imaging include Injury Severity Scores between 24 and 33 versus <15 (odds radio [OR], 1.6; 95% confidence interval [CI], 1.05–2.4), transfer to University of North Carolina (OR, 1.5; 95% CI, 1.01–2.2), transport by helicopter (OR, 1.6; 95% CI, 1.2–2.2), transfer in any year before 2008 (OR, 2.4; 95% CI, 1.6–3.6 for 2007; OR, 3.4; 95% CI, 2.2–5.3 for 2006; OR, 3.0; 95% CI, 1.8–5.0 for 2005; OR, 2.8; 95% CI, 1.7–4.7 for 2004), and triage alert level higher than the least severe level III (OR, 1.6; 95% CI, 1.01–2.7 for level II; OR, 2.2; 95% CI, 1.2–4.1 for level I). In adjusted models, there was no evidence that repeat imaging neither shortened the total time to definitive care nor altered patient outcomes. CONCLUSIONS: Injured patients often undergo imaging that gets repeated, adding cost and radiation exposure while not significantly altering outcomes. The current policy push to digitize medical records must include provisions for the interoperability and use of imaging software. LEVEL OF EVIDENCE: III, therapeutic study.

Surgery and Global Public Health: The UNC-Malawi Surgical Initiative as a Model for Sustainable Collaboration

Addressing global health disparities in the developing world gained prominence during the first decade of the twenty-first century. The HIV/AIDS epidemic triggered much interest in and funding for health improvement and mortality reduction in low- and middle-income nations, particularly in sub-Saharan Africa. Alliances between U.S. academic medical centers and African nations were created through the departments of internal medicine and infectious disease. However, the importance of addressing surgical disease as part of global public health is becoming recognized as part of international health development efforts. We propose a novel model to reduce the global burden of surgical diseases in resource poor settings by incorporating a sustained institutional surgical presence with our residency training experience by placing a senior surgical resident to provide continuity of care and facilitate training of local personnel. We present the experiences of the University of North Carolina (UNC) Department of Surgery as part of the UNC Project in Malawi as an example of this innovative approach.

The Epidemiology, Management, Outcomes and Areas for Improvement of Burn Care in Central Malawi: an Observational Study

This report describes the epidemiology of burn injuries and quantifies the appropriateness of use of available interventions at Kamuzu Central Hospital, Malawi, between July 2008 and June 2009 (370 burn patients). Burns accounted for 4.4% of all injuries and 25.9% of all burns presenting to the hospital were admitted. Most patients (67.6%) were < 15 years old and 56.2% were male. The most frequent cause was scalding (51.4%). Burns occurred most frequently in the cool, dry season and in the evening. The mean burn surface area (second/third degree) was 14.1% and most burns (74%) presented within 8 h. The commonest procedure was debridement and/or amputation. The mean hospital stay was 21.1 days, in-hospital mortality was 27% and wound infection rate was 31%. Available interventions (intravenous fluids, nutrition therapy, physiotherapy) were misapplied in 59% of cases. It is concluded that primary prevention should address paediatric and scald burns, and secondary prevention should train providers to use available interventions appropriately.

Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury

OBJECT Disparities in access to inpatient rehabilitation services after traumatic brain injury (TBI) have been identified, but less well described is the likelihood of discharge to a higher level of rehabilitation for Hispanic or black patients compared with non-Hispanic white patients. The authors investigate racial disparities in discharge destination (inpatient rehabilitation vs skilled nursing facility vs home health vs home) following TBI by using a nationwide database and methods to address racial differences in prehospital characteristics. METHODS Analysis of discharge destination for adults with moderate to severe TBI was performed using National Trauma Data Bank data for the years 2007-2010. The authors performed propensity score weighting followed by ordered logistic regression in their analytical sample and in a subgroup analysis of older adults with Medicare. Likelihood of discharge to a higher level of rehabilitation based on race/ethnicity accounting for prehospital and in-hospital variables was determined. RESULTS The authors identified 299,205 TBI incidents: 232,392 non-Hispanic white, 29,611 Hispanic, and 37,202 black. Propensity weighting resulted in covariate balance among racial groups. Hispanic (adjusted OR 0.71, 95% CI 0.68-0.75) and black (adjusted OR 0.94, 95% CI 0.91-0.97) populations were less likely to be discharged to a higher level of rehabilitation than were non-Hispanic whites. The subgroup analysis indicated that Hispanic (adjusted OR 0.79, 95% CI 0.71-0.86) and black (OR 0.87, 95% CI 0.81-0.94) populations were still less likely to receive a higher level of rehabilitation, despite uniform insurance coverage (Medicare). CONCLUSIONS Adult Hispanic and black patients with TBI are significantly less likely to receive intensive rehabilitation than their non-Hispanic white counterparts; notably, this difference persists in the Medicare population (age ≥ 65 years), indicating that uniform insurance coverage alone does not account for the disparity. Given that insurance coverage and a wide range of prehospital characteristics do not eliminate racial disparities in discharge destination, it is crucial that additional unmeasured patient, physician, and institutional factors be explored to eliminate them.

Survival after burn in a sub-Saharan burn unit: Challenges and opportunities

BACKGROUND Burns are among the most devastating of all injuries and a major global public health crisis, particularly in sub-Saharan Africa. In developed countries, aggressive management of burns continues to lower overall mortality and increase lethal total body surface area (TBSA) at which 50% of patients die (LA50). However, lack of resources and inadequate infrastructure significantly impede such improvements in developing countries. METHODS This study is a retrospective analysis of patients admitted to the burn center at Kamuzu Central Hospital in Lilongwe, Malawi between June 2011 and December 2012. We collected information including patient age, gender, date of admission, mechanism of injury, time to presentation to hospital, total body surface area (TBSA) burn, comorbidities, date and type of operative procedures, date of discharge, length of hospital stay, and survival. We then performed bivariate analysis and logistic regression to identify characteristics associated with increased mortality. RESULTS A total of 454 patients were admitted during the study period with a median age of 4 years (range 0.5 months to 79 years). Of these patients, 53% were male. The overall mean TBSA was 18.5%, and average TBSA increased with age--17% for 0-18 year olds, 24% for 19-60 year olds, and 41% for patients over 60 years old. Scald and flame burns were the commonest mechanisms, 52% and 41% respectively, and flame burns were associated with higher mortality. Overall survival in this population was 82%; however survival reduced with increasing age categories (84% in patients 0-18 years old, 79% in patients 19-60 years old, and 36% in patients older than 60 years). TBSA remained the strongest predictor of mortality after adjusting for age and mechanism of burn. The LA50 for this population was 39% TBSA. DISCUSSION Our data reiterate that burn in Malawi is largely a pediatric disease and that the high burn mortality and relatively low LA50 have modestly improved over the past two decades. The lack of financial resources, health care personnel, and necessary infrastructure will continue to pose a significant challenge in this developing nation. Efforts to increase burn education and prevention in addition to improvement of burn care delivery are imperative.

Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries

IMPORTANCE More than 90% of thermal injury-related deaths occur in low-resource settings. While baseline assessment of burn management capabilities is necessary to guide capacity building strategies, limited data exist from low and middle-income countries (LMICs). OBJECTIVE The objective of our review is to assess burn management capacity in LMICs. EVIDENCE REVIEW A PubMed literature review was performed based on studies assessing baseline surgical capacity in individual LMICs. Seven criteria were used to assess burn management capabilities: presence of surgeon, presence of anesthesiologist, basic resuscitation capabilities, acute burn management, management of burn complications, endotracheal intubation and skin grafts. FINDINGS Fourteen studies were reviewed using data from 458 hospitals in fourteen countries. Of these, 82.3% (284/345) of hospitals had the capacity to provide basic resuscitation and 84.9% (275/324) were capable of providing acute burn management. Endotracheal intubation was only available at 38.3% (51/133) of hospitals. Moreover, only 35.6% (111/312) and 37.9% (120/317) of hospitals were able to provide skin grafts and treat burn complications, respectively. CONCLUSION Many hospitals in LMICs are capable of initial burn management and basic resuscitation. However, deficiencies still exist in the capacity to systematically provide advanced burn care. Efforts should be made to better document resources in order to guide burn management resource allocation.

Hospital-based injury data in Malawi: strategies for data collection and feasibility of trauma scoring tools

Injury is a major cause of morbidity and mortality in developing countries. Utilizing a partnership between Kamuzu Central Hospital (KCH) and the University of North Carolina Departments of Surgery, we describe an approach to injury surveillance, examine the utility of trauma scoring systems, and outline steps necessary before such scoring systems can be reliably instituted in a resource-constrained setting.