J. Andrew McClure

The increasing incidence of gallbladder disease in children: A 20year perspective.

OBJECTIVE The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario. STUDY DESIGN A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test. RESULTS There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%). CONCLUSIONS There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

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

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

The Impact of the Choosing Wisely Campaign in Urology

OBJECTIVE To determine if 3 of the Canadian Urological Associations Choosing Wisely recommendations (released in 2013-2014) related to urologic care altered physician and patient behavior. METHODS Administrative data from Ontario, Canada between 2008 and 2017 was used. We identified 3 cohorts: First, we determined how many men >66 years of age had a serum testosterone level before starting testosterone therapy. Second, we determined how many boys undergoing an orchiopexy underwent abdominal imaging before their surgery. Third, we determined how many men with low risk prostate cancer underwent a Bone Scan after diagnosis. Piece-wise linear regression was used to evaluate for a significant change after Choosing Wisely. RESULTS We identified 13,113 men who had their initial prescription for testosterone filled. Serum testosterone measurement increased over time, from approximately 43% to 68%. There were 9319 boys who underwent an orchiopexy. The use of pre-orchiopexy ultrasound was generally stable (approximately 55%). We identified 27,174 men with low risk prostate cancer. The use of bone scans after diagnosis decreased over time from approximately 24% to 20%. In all 3 of these groups, there was no significant change after Choosing Wisely (P = .74, P = .70, P = .72 respectively). CONCLUSION In Ontario, there was no evidence of a significant change in 3 practice patterns that were featured in Choosing Wisely Urology recommendations. Further thought may be needed on how to translate these and future recommendations into behavior change.

Repair of congenital esophageal atresia with tracheoesophageal fistula repair in Ontario over the last 20 years: Volume and outcomes

BACKGROUND/PURPOSE This study was designed to determine the volume, postoperative surgical outcomes and, if possible, the relationship between outcome and institutional / surgeon volume in neonates undergoing repair of esophageal atresia with tracheoesophageal fistula (EA-TEF) over the last 20years in Ontario. METHODS Using administrative databases, a population based cohort study of patients undergoing EA-TEF repair in Ontario between 1993 and 2012 was conducted. RESULTS 465 patients with the diagnosis of EA-TEF met inclusion criteria. The mean number of EA-TEF repairs per year per was 5.8. There was a significant difference in hospital annual volume between institutions (range 12.3-3.35: p<0.05). The average number of cases/surgeon for the last 10 study years ranged between 0.5 and 2 cases/year. Primary outcome revealed that repair of recurrent fistula or intestinal interposition was 5.3%, with no reportable difference between institutions. Secondary outcomes revealed that 45.6% underwent dilatation for esophageal strictures, and 19.8% underwent some type of drainage procedure of the chest. These rates were not significantly different between institutions. CONCLUSION This study provides insight into the outcomes following EA-TEF repair in Ontario and the difficulty in determining surgeon or institution volume outcome relationships, as both primary and secondary outcome event rates are very low. LEVEL OF EVIDENCE 2.

The Impact of Multiple Prostate Biopsies on Risk for Major Complications Following Radical Prostatectomy: a Population-Based Cohort Study.

OBJECTIVE To evaluate the impact of multiple transrectal ultrasound-guided prostate biopsies (TRUS-Bx) before radical prostatectomy (RP) on surgical outcomes. MATERIALS AND METHODS Administrative databases were used to identify all patients who had a RP performed in the province of Ontario from April 1, 2002, to March 31, 2013. TRUS-Bx prior to RP were identified and patients were categorized as having one or more than one prior TRUS-Bx. The primary end point was a composite index of serious surgical complications. Secondary outcomes included oncological interventions, functional-related events, and general health service-related outcomes. RESULTS Among 27,637 patients, 4780 (17.3%) had ≥2 biopsies performed before RP. The proportion of patients who experienced the composite end point was similar between those with one TRUS-Bx compared to those with ≥2 TRUS-Bx (1.05% vs 1.19%, OR 1.14, 95% CI 0.85-1.52). Patients with ≥2 biopsies were more likely to have a perioperative blood transfusion compared to patients with only 1 biopsy (15.5% vs 12.8%, OR 1.25, 95% CI 1.15-1.37), while readmission rate and 30-day mortality were similar. The need for radiotherapy and androgen deprivation therapy within the first year after RP was higher in patients with a single biopsy. Patients with multiple TRUS-Bx were more likely to require post-RP urodynamic evaluation and bladder neck contracture-related interventions but were not at increased odds of surgery for incontinence or erectile dysfunction. CONCLUSION Perioperative outcomes after RP are similar between men with single or multiple TRUS-Bx, although multiple TRUS-Bx were associated with an increased odds of perioperative blood transfusion.

Corticosteroid Usage Is Associated With Increased Artificial Urinary Sphincter Reoperation

OBJECTIVE To determine if oral corticosteroid use is associated with an increased risk of artificial urinary sphincter (AUS)-related reoperation. MATERIALS AND METHODS Administrative data from Ontario were used to conduct a retrospective cohort study. Men >65 years of age who underwent implantation of an AUS between 2002 and 2013 were included. Prescriptions for oral corticosteroids were identified, and men were considered exposed from the date the prescription was dispensed to 180 days after the expected end of the prescription. The primary outcome was AUS reoperation. Data were analyzed using a Cox proportional hazards model with corticosteroid usage modeled as a time-varying covariate. RESULTS We identified 747 men who met our inclusion criteria (median age of 71 years; interquartile range [IQR]: 68-75), of which 592 (79.3%) had a prior radical prostatectomy. The median duration of follow-up was 3.2 years (IQR: 1.3-5.9). One hundred seventy-five (23.4%) patients were exposed to corticosteroids during the study period (median duration of use was 21 days; IQR: 5-100). We identified an AUS reoperation in 176 men (23.6%). After adjusting for age, radiation exposure, and year of implantation, exposure to corticosteroids was significantly associated with the risk of AUS reoperation (hazard ratio: 1.68, 95% confidence interval: 1.03-2.75, P = .04). Radiation after AUS implantation was also significantly associated with AUS reoperation (hazard ratio: 2.07, 95% confidence interval: 1.06-4.07, P = .03). CONCLUSION There is a significantly increased risk of AUS reoperation among men using oral corticosteroids.

A Population Based Cohort Study of the Impact of Infectious Complications Requiring Hospitalization after Prostate Biopsy on Radical Prostatectomy Surgical Outcomes

OBJECTIVE To compare radical prostatectomy outcomes in men with and without exposure to a major infectious event within 30-days of a prior TRUS-biopsy. MATERIALS AND METHODS This retrospective cohort study included men who underwent radical prostatectomy from 2002 to 2013 in Ontario, Canada. Several linked administrative databases were used. Exposure was defined as hospitalization with evidence of a urinary tract infection or sepsis during the first 30-days after a prostate biopsy. The primary outcome was a composite of procedures indicative of a likely serious complication of radical prostectomy within the first 12 months after surgery. Secondary outcomes included oncological, functional, and hospital related events within 2 years of radical prostatectomy. RESULTS A total of 26,254 patients were included in this study and 530 (2.02%) had a post-TRUS-biopsy infection. A similar proportion of patients with and without a post-TRUS-biopsy infectious event experienced the composite primary outcome (1.7% vs 1.1%; odds ratio [OR] 1.61, 95% confidence interval [CI] 0.82-3.14; P = .16). However, exposed patients had significantly higher odds of perioperative blood transfusion (OR 1.61, 95% CI 1.30-2.00; P <.001), bladder neck contracture (OR 1.35, 95% CI 1.12-1.63; P = .002), and 30-day hospital readmission (OR 2.08, 95% CI 1.47-2.95; P <.001), and a small but significant increase in length of hospital stay (P = 0.005). No other significant differences were observed. CONCLUSION Although prior infectious events are associated with increased risk of blood transfusion, bladder neck contracture, and hospital readmission following radical prostatectomy, results from this study suggest that major surgical complications, are not adversely affected by TRUS-biopsy related infections.

Identifying Primary Spontaneous Pneumothorax from Administrative Databases: A Validation Study

Introduction. Primary spontaneous pneumothorax (PSP) is a disorder commonly encountered in healthy young individuals. There is no differentiation between PSP and secondary pneumothorax (SP) in the current version of the International Classification of Diseases (ICD-10). This complicates the conduct of epidemiological studies on the subject. Objective. To validate the accuracy of an algorithm that identifies cases of PSP from administrative databases. Methods. The charts of 150 patients who consulted the emergency room (ER) with a recorded main diagnosis of pneumothorax were reviewed to define the type of pneumothorax that occurred. The corresponding hospital administrative data collected during previous hospitalizations and ER visits were processed through the proposed algorithm. The results were compared over two different age groups. Results. There were 144 cases of pneumothorax correctly coded (96%). The results obtained from the PSP algorithm demonstrated a significantly higher sensitivity (97% versus 81%, p = 0.038) and positive predictive value (87% versus 46%, p < 0.001) in patients under 40 years of age than in older patients. Conclusions. The proposed algorithm is adequate to identify cases of PSP from administrative databases in the age group classically associated with the disease. This makes possible its utilization in large population-based studies.