Dhruv Khullar

The Impact of Smoking on Surgical Outcomes

t m t w c c s d p b t b c v a u a i Smoking substantially increases a patient’s risk of surgical complications. Despite this, almost half of all surgeons do not routinely counsel their patients to stop smoking before an operation. Studies show that although up to 75% of smokers who undergo surgery would like to quit, only about 5% will stop smoking permanently around the time of elective surgery. The intent of this article is to raise surgeon awareness of the deleterious impact of smoking on surgical outcomes and emphasize the unique opportunity in the teachable moment of surgery to enable patients to succeed in their efforts to quit smoking.

Evolution of treatment options for vein of Galen malformations

OBJECT Vein of Galen aneurysmal malformations (VGAMs) continue to account for high morbidity and mortality rates in the pediatric population. Whereas in the past, mortality rates were nearly 100%, recent developments in endovascular embolization and improvements in neonatal care have improved prognoses. It is now possible that some patients can achieve normal neurological development following embolization of the VGAM. Access to the lesion can be gained via transarterial or transvenous routes. In this paper the authors review the pathophysiological characteristics of VGAM and discuss the evolution of treatment options. METHODS A PubMed literature search was performed for vein of Galen malformation treatment options, beginning in the 1970s. A total of 22 papers were reviewed in full, and outcome data for 615 patients from 1983 to 2010 were compiled. Articles were reviewed if they focused primarily on the treatment of VGAM and reported outcomes for at least 5 treated patients. RESULTS Of the 265 patient outcomes reported between 1983 and 2000, 200 received endovascular therapy. Of these patients 72% had a favorable outcome, and a 15% mortality rate was found. Microsurgery was found to have an 84.6% mortality rate. Furthermore, 76.7% of untreated patients died. More recently, endovascular embolization has become the mainstay of VGAM treatment. Of the 350 patients assessed between 2001 and 2010, 337 were treated endovascularly, mostly via the transarterial approach. Of these patients, 84.3% were found to have good or fair outcomes, and a 15.7% mortality rate was found. Neonates had the worst clinical outcomes following endovascular treatment, with a 35.6% mortality rate, whereas infants and children had significantly better outcomes, with mortality rates of 6.5% and 3.2%, respectively. CONCLUSIONS Endovascular embolization has considerably improved outcomes in patients with VGAM. In the past, the prognosis for patients with VGAM was dismal, and successful procedures were considered to be those that partially or completely obliterated the lesion, but did not necessarily improve the patients symptoms. More recently, with the continued development and improvement of endovascular techniques, many patients are found to be neurologically normal on follow-up, and mortality rates have dropped substantially when compared with microsurgical treatment.

Behavioral Economics and Physician Compensation — Promise and Challenges

Health care organizations embracing new payment models may find that applying behavioral economics can boost the effect of new incentives. By creating more favorable decision-making environments, we can take advantage of cognitive biases to encourage high-value care.

Association Between Teaching Status and Mortality in US Hospitals

Importance Few studies have analyzed contemporary data on outcomes at US teaching hospitals vs nonteaching hospitals. Objective To examine risk-adjusted outcomes for patients admitted to teaching vs nonteaching hospitals across a broad range of medical and surgical conditions. Design, Setting, and Participants Use of national Medicare data to compare mortality rates in US teaching and nonteaching hospitals for all hospitalizations and for common medical and surgical conditions among Medicare beneficiaries 65 years and older. Exposures Hospital teaching status: major teaching hospitals (members of the Council of Teaching Hospitals), minor teaching hospitals (other hospitals with medical school affiliation), and nonteaching hospitals (remaining hospitals). Main Outcomes and Measures Primary outcome was 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions. Results The sample consisted of 21 451 824 total hospitalizations at 4483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3339 (74.3%) were nonteaching hospitals. Unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor teaching hospitals, and 9.6% at nonteaching hospitals, with a 1.5% (95% CI, 1.3%-1.7%; P < .001) mortality difference between major teaching hospitals and nonteaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted (8.3% mortality at major teaching vs 9.2% at minor teaching and 9.5% at nonteaching), but the difference in mortality between major and nonteaching hospitals was smaller (1.2% [95% CI, 1.0%-1.4%]; P < .001). After stratifying by hospital size, 187 large (≥400 beds) major teaching hospitals had lower adjusted overall 30-day mortality relative to 76 large nonteaching hospitals (8.1% vs 9.4%; 1.2% difference [95% CI, 0.9%-1.5%]; P < .001). This same pattern of lower overall 30-day mortality at teaching hospitals was observed for medium-sized (100-399 beds) hospitals (8.6% vs 9.3% and 9.4%; 0.8% difference between 61 major and 1207 nonteaching hospitals [95% CI, 0.4%-1.3%]; P = .003). Among small (⩽99 beds) hospitals, 187 minor teaching hospitals had lower overall 30-day mortality relative to 2056 nonteaching hospitals (9.5% vs 9.9%; 0.4% difference [95% CI, 0.1%-0.7%]; P = .01). Conclusions and Relevance Among hospitalizations for US Medicare beneficiaries, major teaching hospital status was associated with lower mortality rates for common conditions compared with nonteaching hospitals. Further study is needed to understand the reasons for these differences.

The impact of smoking on neurosurgical outcomes

Cigarette smoking is a common health risk behavior among the general adult population, and is the leading preventable cause of morbidity and mortality in the US. The surgical literature shows that active tobacco smoking is a major risk factor for perioperative morbidity and complications, and that preoperative smoking cessation is an effective measure to lower these risks associated with active smoking. However, few studies have examined the effects of smoking and perioperative complications following neurosurgical procedures. The goal of this review was to highlight the scientific data that do exist regarding the impact of smoking on neurosurgical outcomes, to promote awareness of the need for further work in the specific neurosurgical context, and to suggest ways that neurosurgeons can promote smoking cessation in their patients and lead efforts nationally to emphasize the importance of preoperative smoking cessation. This review indicates that there is limited but good evidence that smoking is associated with higher rates of perioperative complications following neurosurgical intervention. Specific research is needed to understand the effects of smoking and perioperative complications. Neurosurgeons should encourage preoperative smoking cessation as part of their clinical practice to mitigate perioperative morbidity associated with active smoking.

Optimism and the Socioeconomic Status Gradient in Adolescent Adiposity

PURPOSE To assess whether dispositional optimism is associated with adiposity and to explore whether dispositional optimism mediates the relationship between parent education and adiposity (body mass index [BMI] z-score). METHODS Multivariate regression analyses of data were collected from 1,298 non-Hispanic black and white adolescents aged 12-19 years from a single Midwestern public school district. RESULTS Less optimistic adolescents had higher BMI z-scores (r = -.09, p < .001). Addition of dispositional optimism to the regression model caused an approximately 10% attenuation of the parent education and BMI z-score relationship. Sobel tests confirmed that this attenuation indicated partial mediation. CONCLUSION Lower dispositional optimism is associated with higher adiposity and this association accounts for some of the influence of parent education on adolescent adiposity.

Helping Smokers Quit Around the Time of Surgery

Elective surgery offers a powerful opportunity for physicians to help smokers quit, yet 25% to 30% of patients smoke perioperatively, and approximately 10 million patients who smoke undergo surgical procedures annually.1- 2 Approximately 42% of all surgeons and 70% of anesthesiologists do not routinely counsel patients to stop smoking before an operation or do not refer them to appropriate cessation services.3

Addressing the Challenge of Gray-Zone Medicine

Health care is not a binary world in which interventions are either effective or ineffective, appropriate or inappropriate. Since much health care occurs in gray zones, we need payment and incentive systems that are designed to work within those zones.

How 10 leading health systems pay their doctors.

We conducted interviews with senior executives at 10 leading health systems to better understand how organizations use performance-based compensation. Of the organizations interviewed, five pay physicians using productivity-independent salaries, and five use productivity-adjusted salaries. Performance-based pay is more prevalent in primary care than in subspecialties, and the most consistently identified performance domains are quality, service, productivity, and citizenship. Most organizations have less than 10% of total compensation at risk, with payments distributed across three to five domains, each containing several metrics. Approaches with many metrics--and little at-risk compensation for each metric-may offer weak incentive to achieve any particular goal.

Primary Care Spending Rate — A Lever for Encouraging Investment in Primary Care

The proportion of a health system’s resources that it devotes to primary care — including clinician incomes, performance payments, case-management activities, and health information technologies — could be used for assessing its orientation toward high-value care.