Kyla M. Bennett

Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting "do-not-resuscitate" orders.

Objective:To describe the outcomes of elderly patients with do-not-resuscitate (DNR) status who undergo emergency general surgery and to improve understanding of the relationship between preoperative DNR status and postoperative mortality. Background:Preoperative DNR status has previously been shown to predict increased postoperative mortality, although the reasons for this association are not well understood. Methods:Patients 65 years or older undergoing emergency operation for 1 of 10 common general surgical diagnoses were extracted from the 2005–2010 National Surgical Quality Improvement database. Propensity score techniques were used to match patients with and without preoperative DNR orders on indication for procedure, patient demographics, comorbid disease burden, acute physical status at the time of operation, and procedure complexity. The postoperative outcomes of this matched cohort were then compared. Results:A total of 25,558 patients were included for analysis (DNR, n =1061; non-DNR, n =24,497). DNR patients seemed to be more acutely and chronically ill than non-DNR patients in the overall study sample but did not seem to be treated less aggressively before or during their operations. Propensity-matching techniques resulted in the creation of a cohort of DNR and non-DNR patients who were well matched for all preoperative and intraoperative variables. DNR patients from the matched cohort had a significantly higher postoperative mortality rate than non-DNR patients (36.9% vs 22.3%, P < 0.0001) despite having a similar rate of major postoperative complications (42.1% vs 40.2%, P = 0.38). DNR patients in the propensity-matched cohort were much less likely to undergo reoperation (8.3% vs 12.0%, P = 0.006) than non-DNR patients and were significantly more likely to die in the setting of a major postoperative complication (56.7% vs 41.4%, P = 0.001). Conclusions:Emergency general surgery in elderly patients with preoperative DNR orders is associated with significant rates of postoperative morbidity and mortality. One reason for the excess mortality in these patients, relative to otherwise similar patients who do not have preoperative DNR orders, may be their greater reluctance to pursue aggressive management of major complications in the postoperative period.

Defining the impact of resident participation on outcomes after appendectomy.

Objective:To determine whether resident participation impacts complication rates after appendectomy. Background:The effect of resident participation on postoperative outcomes has not been well defined. Methods:Data from the National Surgical Quality Improvement Program Participant User File from 2005 through 2009 were used to assess the association between resident participation during appendectomy and postoperative complication rates. Multivariate logistic regression analysis was used to adjust for patient comorbidity, surgical approach, and severity of appendiceal disease. Similar analyses were performed to determine whether outcomes after appendectomy are influenced by the postgraduate training level of the participating surgical resident. Results:A total of 54,467 appendectomy procedures were included in our analysis. Resident participation was an independent risk factor for major complications [adjusted odds ratio 1.27 (95% CI 1.14–1.42), P < 0.0001] after appendectomy. Increasing seniority of the participating resident was associated with longer operative time and higher postoperative complications rates. Conclusions:Resident participation represents an independent risk factor for postoperative complications after appendectomy.

The Impact of Functional Dependency on Outcomes After Complex General and Vascular Surgery

OBJECTIVEnTo describe the outcomes of functionally dependent patients who undergo major general or vascular surgery and to determine the relationship between functional health status and early postoperative outcomes.nnnBACKGROUNDnIn contrast to frailty, functional health status is a relatively easy entity to define and to measure and therefore may be a more practical variable to assess in patients who are being considered for major surgery. To date, few studies have assessed the impact of functional health status on surgical outcomes.nnnMETHODSnPatients undergoing 1 of 10 complex general or vascular operations were extracted from the 2005 to 2010 America College of Surgeons National Surgical Quality Improvement Program database. Propensity score techniques were used to match patients with and without preoperative functional dependency on known patient- and procedure-related factors. The postoperative outcomes of this matched cohort were then compared.nnnRESULTSnA total of 10,246 functionally dependent surgical patients were included for analysis. These patients were more acutely and chronically ill than functionally independent patients, and they had higher rates of mortality and morbidity for each of the 10 procedures analyzed. Propensity-matching techniques resulted in the creation of a cohort of functionally independent and dependent patients who were well matched for known patient- and procedure-related variables. Dependent patients from the matched cohort had a 1.75-fold greater odds of postoperative death (95% confidence interval: 1.54-1.98, P < 0.0001) than functionally independent patients.nnnCONCLUSIONSnPreoperative functional dependency is an independent risk factor for mortality after major operation. Functional health status should be routinely assessed in patients who are being considered for complex surgery.

Patient Socioeconomic Status Is an Independent Predictor of Operative Mortality

Objective:To evaluate the impact of patient socioeconomic status (SES) on operative mortality within the context of associated factors. Summary of Background Data:Outcomes disparities among surgical patients are a significant concern. Previous studies have suggested that the correlation between SES and outcomes is attributable to other patient- or hospital-level explanatory factors such as race or hospital wealth. These studies have typically focused on a single explanation for the existence of these inequalities. Methods:Analyzing more than 1 million records of the Nationwide Inpatient Sample, we used multimodel inference to evaluate the effects of socioeconomic predictors on surgical mortality. Results:Using univariate and multivariate logistic regression, we find that patients SES is a strong predictor of operative mortality. Multivariate regressions incorporated many additional hospital- and patient-level covariates. A single-level increase in patient SES results in a mean decrease in operative mortality risk of 7.1%. Conclusions:SES at the level of the individual patient has a statistically significant effect on operative mortality. Mortality is greatest among patients in the lowest socioeconomic strata. The effect of patient SES on mortality is not mitigated by other explanatory hospital- or patient-level factors.

Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review

s, or otherwise presenting non-original data; 6 articles were not related to surgery; 8 used or referred to telemedicine outside of direct patient care; 148 articles presented studies performed outside the US; 80 articles described the use of telemedicine in phases of surgical care other than postoperative (eg preoperative, intraoperative, etc). This left 21 articles for final review (Fig. 1). Of the included studies, 3 were randomized controlled trials, 6 were pilot or feasibility studies, 4 were retrospective record reviews, 2 were case series, and 6 were surveys. These studies are summarized in Table 1. Telemedicine protocols Telemedicine was used during the postoperative period on 3 primary timetables: for scheduled follow-up, for routine and ongoing monitoring, or for management of issues as they arose. Seven studies examined the potential for replacing follow-up clinic visits with a telephone call or an online videoconference, either from the patient’s home or from an affiliated remote clinic site. Among the studies using telemedicine for ongoing monitoring, patients’ reported symptoms were collected either by automated telephone survey or videophone with live patient interviews. Specific objective clinical data were collected using text messages for daily surgical drain output, electronic transmission of home spirometry results, and more complex multi-modal monitoring of symptoms, blood pressure, and medication adherence. The 2 case series included reported the use of text messaging and smartphone digital photography to manage specific concerns as they arose. Many of these protocols required that participants have access to particular kinds of technology, such as smartphones or computers, or access to the internet. Some studies provided all or part of the necessary technology to participants, but many did not, to the exclusion of otherwise eligible participants. In their study of a remote medication adherence protocol in kidney Figure 1. Flow diagram depicting systematic review strategy. Vol. 222, No. 5, May 2016 Gunter et al Telemedicine for Post-Discharge Surgical Care 917 transplant patients, McGillicuddy and colleagues excluded 12.2% of patients who had agreed to participate due to inadequate cellular coverage in their homes. Sathiyakumar and associates excluded patients who did not have access to the technology required to complete remote follow-up using Skype, though they did not report how many patients were ultimately excluded for this; they did have 1 patient drop out of the study due to a weak internet connection. In a similar study using Skype to replace follow-up clinic visits, Sharareh and Schwarzkopf excluded 56.4% of approached patients because they “did not have appropriate electronic devices or did not have internet access to be able to undergo telemedicine appointments.” Although Viers and coworkers provided webcams for participants to complete remote follow-up via videoconference, they excluded 26% of the patients they approached either because they did not have the appropriate equipment or because they were not comfortable with the technology. Patient and provider satisfaction In surveys of patients’ willingness to use telemedicine, the majority of patients reported being willing to participate and thought it would aid communication with their provider. In studies in which patients had already participated in a postoperative protocol using telemedicine, they reported high satisfaction and ease of use. In addition to patient satisfaction, providers also expressed satisfaction with various modalities of telemedicine. A national survey of burn centers by Holt and coauthors found that 62% of burn centers were interested in learning more about telemedicine implementation. Outcomes (clinical and time and money saved) The studies that reported patient travel distance, time, and cost demonstrated universal and significant savings in all domains (Fig. 2). Patients who participated in telemedicine protocols also avoided taking time off from work, having a person accompany them who also had to take time away from personal responsibilities, and having to spend at least 1 night in a hotel. Beyond savings to individual patients and their families or caregivers, Hwa and Wren reported a significant saving to their health system. Performing postoperative follow-up over the telephone rather than in the clinic made 110 additional clinic slots available for new patients over the 10-month study period. Table 1. Summary of Included Studies First author, year n Specialty Study design Intervention Results Prospective RCTs Cleeland, 2011 79 Thoracic surgery RCT Automated telephone questionnaire with triggered alerts to provider after thoracotomy for lung cancer or lung metastases. T ephone symptom monitoring resulted in faster esolution of postoperative symptoms, lower ymptom severity, and less symptom interference ith daily activities. McGillicuddy, 2013 19 Transplant surgery RCT Smartphone-based (Droid X, Motorola) medication adherence and blood pressure selfmanagement system using a wireless Bluetooth blood pressure monitor (FORA D15b, Fora Care Inc) and a wireless GSM electronic medication tray (Med Minder, Maya, Inc,) in renal transplant recipients compared to standard care. P ients in the smartphone group had better edication adherence (p < 0.05) and lower ystolic blood pressure (p 1⁄4 0.009) at 3 months ompared with standard care patients; physicians ade more medication adjustments in martphone group; patients using the martphone system reported high satisfaction nd ease of use with the system. Viers, 2015 55 Urology RCT Online videoconferencing via internally designed interface using Vidyo Software and SBR Health Software for routine follow-up after radical prostatectomy, compared with in-person clinic visit. E ivalent clinic efficiency between ideoconference and in-person visits; high atient and provider satisfaction in the ideoconference group; no acute urologic issues t 3 months follow-up; significant travel time nd distance saved in videoconference group Pilot and feasibility studies Albert, 2013 18 Orthopaedic surgery Feasibility study Smartphone accelerometer to determine level of activity in amputees. S artphone accelerometer adds objective data egarding patient activity data to subjective linical assessments, which could more ppropriately match patients with the prosthesis hat meets their needs. Hwa, 2013 110 General surgery Pilot study Telephone follow-up after open hernia repair or laparoscopic cholecystectomy in VA patients. S ificant travel saved for patients; no omplications occurred as a result of telephone ollow-up; telephone follow-up opened 110 linic spots over study period. Sathiyakumar, 2015 17 Orthopaedic trauma Pilot study Online videoconferencing via Skype used for 2 of 4 follow-up appointments after closed extremity fracture compared with in-person clinic visits. P ients were accepting of Skype follow-up and aved significant travel time and distance; one omplication each in control arm and Skype rm; no rehospitalizations Sharareh, 2014 78 Orthopaedic surgery Nonrandomized prospective study Online videoconferencing via Skype used for routine postoperative follow-up after total joint arthroplasty compared with in-person clinic visit. P ients receiving Skype follow-up had fewer nscheduled clinic visits (3 vs 14, p 1⁄4 0.01), ade fewer calls to the clinic (6 vs 40, p < 0.01), nd were more satisfied with their postoperative are (9.88 vs 8.10 on 10-point scale, p 1⁄4 0.05); 1 omplication in the Skype group, not related to elemedicine use.

Does Intent Matter? The Medical and Societal Burden of Self-inflicted Injury

BACKGROUNDnThe objective of our study was to assess the impact of injury intentionality on the outcomes and healthcare resource utilization of severely injured patients in the United States.nnnMETHODSnThe National Trauma Data Bank for the years 2001 through 2006 was used for our analysis. Adult patients with an injury severity score >or=15 were divided into three groups based on injury intentionality: unintentional, assault, and self-inflicted. Demographic and injury characteristics, unadjusted and risk-adjusted mortality rates, and healthcare resource utilization variables were compared for these three groups using t tests, analysis of variance, and multivariable regression analyses where appropriate. Stata/SE version 9.2 was used for all statistical analyses. p values <0.05 were considered significant.nnnRESULTSnA total of 138,589 patients were included for analysis. After adjustment for potentially confounding variables, self-inflicted injury remained a significant predictor of increased mortality (mortality 42.3%, adjusted odds ratio for death = 2.31, 95% confidence interval 1.97-2.71), and injury by assault a significant predictor of decreased mortality (mortality 18.3%, adjusted odds ratio for death = 0.83, 95% confidence interval 0.74-0.92), when compared with unintentional injury (mortality 15.1%). Patients surviving self-inflicted injury required longer intensive care unit stays and overall hospital stays than survivors of unintentional injury.nnnCONCLUSIONSnPatients who are treated for self-inflicted injury have higher risk-adjusted mortality and utilize comparatively higher levels of healthcare resources than victims of assault or patients sustaining unintentional injury. The findings of our study emphasize the need for trauma center participation in the development and maintenance of aggressive primary and secondary suicide prevention programs.

Will the clinicians support the researchers and teachers? Results of a salary satisfaction survey of 947 academic surgeons.

Objective:To determine whether academic surgeons are satisfied with their salaries, and if they are willing to forego some compensation to support departmental academic endeavors. Background:Increasing financial constraints have led many academic surgery departments to rely on increasingly on clinical revenue generation for the cross-subsidization of research and teach missions. Methods:Members of 3 academic surgical societies (n = 3059) were surveyed on practice characteristics and attitudes about financial compensation. Univariate and multivariate logistic regression analyses were performed to identify determinants of salary satisfaction and willingness to forego compensation to support academic missions. Results:One thousand thirty-eight (33.9%) surgeons responded to our survey, 947 of whom maintain an academic practice. Of these academic surgeons, 49.7% expressed satisfaction with their compensation. Length of career, administrative responsibility for compensation and membership in the American Surgical Association or the Society of University Surgeons were predictive of salary satisfaction on univariate analysis. Frequent emergency call duty, increased clinical activity, and greater perceived difference between academic and private practice compensation were predictive of salary dissatisfaction. On multivariate analysis, increased clinical activity was inversely associated with both salary satisfaction (adjusted odds ratio [AOR], 0.77; [95% CI: 0.64, 0.94]; P = 0.009) and amount of compensation willingly killed for an academic practice (AOR, 0.71; [0.61, 0.83]; P < 0.0005). Conclusions:Increasing reliance on clinical revenue to subsidize nonclinical academic missions is disaffecting many academic surgeons. Redefined mission priorities, enhanced nonfinancial rewards, utilization of nonclinical revenue sources (eg, philanthropy, grants), increased efficiency of business practices and/or redesign of fund flows may be necessary to sustain recruitment and retention of young academic surgeons.

Temporal Trends in Lung Transplant Center Volume and Outcomes in the United States

Publicly available program-specific data from the scientific registry of transplant recipients were used to determine the association between adult lung transplant center volume and 1-year recipient mortality from 2000 to 2007. We found a significant inverse association between the center volume of adult lung transplants and 1-year recipient mortality that is growing more pronounced over time. We conclude that procedure volume is an increasingly important determinant of lung transplant center volume and that policies that improve the performance of low-volume centers or reduce the number of patients who use such centers may be warranted.

Current practice of thoracic outlet decompression surgery in the United States

Background: Thoracic outlet syndrome (TOS) and its management are relatively controversial topics. Most of the literature reporting the outcomes of surgical decompression for TOS derives from single‐center experiences. The objective of our study was to describe the current state of TOS surgery among hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program database. Methods: Our study sample consisted of patients from the 2005 to 2014 American College of Surgeons National Surgical Quality Improvement Program database who underwent first or cervical rib resection as their index procedure and whose constellation of diagnosis and procedure codes identified them as having neurogenic, arterial, or venous TOS. Patient and procedure characteristics were determined, as were the 30‐day incidence of specific complications including nerve injury. Multimodel inference was used for multivariable analysis of the composite outcome of readmission or reoperation ≤30 days. Results: We identified 1431 patients undergoing operation for TOS: 83% for neurogenic TOS, 3% for arterial TOS, and 12% for venous TOS. Vascular surgeons performed 90% of procedures. Only four patients (0.3%) demonstrated evidence of nerve injury. The rate of bleeding complication requiring transfusion was also quite low, at 1.4%. The 30‐day incidence of readmission or reoperation, or both, in our study cohort was 8.6%. The risk of this outcome was increased in patients with a higher American Society of Anesthesiologists Physical Status Classification, those whose procedure was for non‐neurogenic symptoms, and those whose procedure took longer to complete. Conclusions: The findings of our study will provide surgeons who advocate for the surgical management of TOS with reassurance that such intervention is associated with an extremely low risk of disability resulting from iatrogenic nerve injury and major bleeding events.

Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients

Background: The optimal approach to carotid revascularization in female patients with carotid artery stenosis is widely debated. Information available is largely derived from clinical trials that include only highly selected patients. The goal of this study was to compare the early clinical outcomes in women who undergo carotid artery stenting (CAS) vs carotid endarterectomy (CEA). Methods: Female patients undergoing CAS or CEA between January 1, 2012 and December 31, 2015, and who were included in the Procedure Targeted American College of Surgeons National Surgical Quality Improvement Program were assessed for their incidence of early postoperative complications. The primary outcome measure was 30‐day incidence of a major adverse clinical event (MACE; defined as death, stroke, transient ischemic attack, or myocardial infarction/arrhythmia). Univariable analyses were used to compare results between female patients undergoing CEA and those undergoing CAS. Propensity score matching techniques were used to create a cohort of 125 CAS and CEA patients who were well matched for all known patient‐, disease‐, and procedure‐related factors. Analysis of comparative outcomes between the propensity‐matched groups was then performed. Results: The overall study population consisted of 5620 female CEA patients and 131 female CAS patients. Of these patients, 290 (5.2%) from the CEA group and 16 (12.2%) from the CAS group sustained a MACE in the first 30 days after their procedures. Within the propensity‐matched cohort, the 30‐day incidence of postoperative MACE in the CAS group of this cohort was 11.2% (14 patients) compared with 4.0% (5 patients; odds ratio, 1.01 [95% confidence interval, 1.01‐7.77]; P = .04) in the CEA group. Conclusions: Our analysis of a “real‐world” clinical registry suggests that CAS may be inferior to CEA in female patients who require carotid artery revascularization.