Mahiben Maruthappu

The influence of volume and experience on individual surgical performance: a systematic review.

OBJECTIVE To systematically review studies evaluating the influence of surgical experience on individual performance. BACKGROUND Experience, measured in case volume or years of practice, is recognized as a key driver of individual surgical performance, giving rise to a learning curve. However, this topic has not been reviewed at the cross-specialty level. METHODS MEDLINE, EMBASE, PsycINFO, AMED, and the Cochrane Database of Systematic Reviews were searched (from inception to February 2013). Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Ninety-one data points per study were extracted. RESULTS The search strategy yielded 6950 citations. Fifty-seven studies were eligible, including 1,061,913 cases and 35 procedure types, performed by 17,912 surgeons. Forty-five studies monitored case volume, and 6 studies measured experience as both case volume and years of practice. Of these 51 studies, 44 found that increased case volume was associated with significantly improved health outcomes. Several studies noted a plateau phase or maturation in the surgical learning curve. Acquisition of this phase was procedure specific and outcome specific, ranging from 25 to 750 procedures. Twelve studies assessed the impact of years of surgical practice, 11 of which found that increased years of experience was associated with significantly improved health outcomes. Two studies noted a plateau phase, where increases in years of experience were no longer associated with improvements in operative outcomes. Three studies identified performance deterioration after the plateau phase. CONCLUSIONS Increasing surgical case volume and years of practice are associated with improved performance, in a procedure-specific manner. Performance may deteriorate toward the end of a surgeons career.

Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis

BACKGROUND The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships. METHODS For this longitudinal analysis, we obtained data from the World Bank and WHO (1990-2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates. RESULTS Data were available for 75 countries, representing 2.106 billion people, for the unemployment analysis and for 79 countries, representing 2.156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40,000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000-07 trends. Most of these deaths were in non-UHC countries. INTERPRETATION Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008-10 economic crisis was associated with about 260,000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone. FUNDING None.

Should double lung transplant be performed with or without cardiopulmonary bypass

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether double lung transplantation should be performed with or without cardiopulmonary bypass (CPB) in order to improve postoperative clinical outcomes. Altogether 386 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All 14 papers assessed a range of postoperative outcomes and broadly speaking, six papers found significantly worse outcomes with CPB use, six found no difference and two found a mixture of both depending on the specific outcomes assessed. Dalibon et al. [J Cardiothorac Vasc Anesth 2006;20:668-672] found that mortality was significantly worse in the CPB group at 48 h, one month and one year [P = 0.001, odds ratio (OR) = 246.1; P = 0.083, OR = 2.6; P = 0.001, OR = 5.3, respectively]. Other papers revealed poor outcomes in the CPB group in a range of measures including diffuse alveolar damage (P = 0.009), chest radiograph infiltrate score (P = 0.005), longer intubation time (P = 0.002), longer intensive care unit stay (P = 0.05), and greater incidence of pulmonary reimplantation response (P = 0.03). However, Myles et al. [J Cardiothorac Vasc Anesth 1997;11:177-183] found that only acute postoperative outcomes were significantly worse in their CPB group (P < 0.001); medium- and long-term survival outcomes were not significantly different (P = 0.055). de Boer et al. [Transplantation 2002;73:1621-1627] even found that there was an improved one-year survival rate with CPB use (OR = 0.25, P = 0.038) and that the number of human leukocyte antigen DR (HLA-DR) mismatches influenced this effect. Those papers suggesting no deleterious effects of CPB generally measured similar postoperative outcomes to those mentioned above, with one study also assessing incidence of primary graft failure, which was not significantly different (P = 0.37). We conclude that CPB should continue to be used where clinically indicated for a specific reason (for example, where there is pulmonary hypertension or a requirement for concomitant cardiac repair). However, given that the evidence for using CPB for all elective cases is relatively weak, and the fact that there are strong arguments in the literature for both methods, either approach would be clinically acceptable.

How effective is bipolar radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether, in patients undergoing cardiac surgery, concomitant bipolar radiofrequency ablation had an acceptable success rate to justify the additional procedure. Altogether 263 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The consensus in the literature was that bipolar radiofrequency ablation was highly successful in restoring sinus rhythm. One meta-analysis of six non-randomized studies demonstrated that 76% of patients were in sinus rhythm compared with 16% in atrial fibrillation 3 months postoperatively. One randomized controlled trial found that the sinus rhythm conversion rate for any maze procedure was highly significant compared with the control group (P = 0.001). Another found that Cardioblate radiofrequency ablation was significantly better at restoring sinus rhythm at 1 year (75 vs 39% control, P = 0.019). Prospective studies showed a similar rate of sinus rhythm return at 1 year (89%). Notably some studies demonstrated a significant reduction in the New York Heart Association class when sinus rhythm was restored compared with those remaining in atrial fibrillation (P < 0.0001), demonstrating the value of this procedure beyond simply restoring sinus rhythm. In another study, the investigators found that both ablation and total procedure times were shorter with bipolar compared with monopolar ablation. These authors strongly recommend bipolar radiofrequency ablation due to a shorter procedure time, ability to avoid performing a standard left atriotomy and a greater guarantee of transmurality. With the current limited evidence, we conclude that bipolar radiofrequency ablation has a higher success rate in restoring sinus rhythm as an adjunct to cardiac surgery compared with no ablation for at least 1 year. The procedure had a high survival rate. There is randomized evidence to suggest the superiority of bipolar radiofrequency ablation over microwave ablation but limited evidence to suggest the superiority of bipolar over unipolar radiofrequency ablation. Factors found to be accurate predictors of ablation failure include a larger preoperative atrial diameter, permanent vs paroxysmal atrial fibrillation and longer duration of atrial fibrillation.

Trends in Mortality From Ischemic Heart Disease and Cerebrovascular Disease in Europe: 1980 to 2009.

Background— Trends in cardiovascular mortality across Europe demonstrate significant geographical variation, and an understanding of these trends has a central role in global public health. Methods and Results— Ischemic heart disease and cerebrovascular disease age-standardized death rates (as per International Classification of Diseases, ninth and tenth revisions) were collated from the World Health Organization mortality database for member states of the European Union. Trends were characterized by using Joinpoint regression analysis. An overall trend for reduction in ischemic heart disease mortality was observed, most pronounced in Western Europe (>60% for the Netherlands, United Kingdom, and Ireland) for both sexes from 1980 to 2009. Eastern European states, Romania, Croatia, and Slovakia, had modest mortality reductions. Most recently (2009), Lithuania had the highest mortality for males and females (318.1/100 000 and 166.1/100 000, respectively), followed by Latvia and Slovakia. France had the lowest mortality: 39.8/100 000 for males and 14.7/100 000 for females. Analysis of cerebrovascular disease mortality revealed that Austria had the largest reduction for both sexes (76.8% males, 76.5% females) from 1980 to 2009. The smallest improvement over this period was seen in Lithuania, Poland, and Cyprus (–5% to +20% approximately). France has the lowest present-day cerebrovascular disease mortality for both males and females (23.9/100 000 and 17.3/100 000, respectively). Conclusions— There is a growing disparity in cardiovascular mortality between Western and Eastern Europe, for which diverse explanations are discussed. The need for population-wide health promotion and primary prevention policies is emphasized.

Surgical care in low and middle-income countries: Burden and barriers

Surgically correctable pathology accounts for a sizeable proportion of the overall global burden of disease. Over the last decade the role of surgery in the public health agenda has increased in prominence and attempts to quantify surgical capacity suggest that it is a significant public health issue, with a great disparity between high-income, and low- and middle-income countries (LMICs). Although barriers such as accessibility, availability, affordability and acceptability of surgical care hinder improvements in LMICs, evidence suggests that interventions to improve surgical care in these settings can be cost-effective. Currently, efforts to improve surgical care are mainly coordinated by academia and intuitions with strong surgical and global health interests. However, with the involvement of various international organisations, policy makers, healthcare managers and other stakeholders, a collaborative approach can be achieved in order to accelerate progress towards improved and sustainable surgical care. In this article, we discuss the current burden of global surgical disease and explore some of the barriers that may be encountered in improving surgical capacity in LMICs. We go on to consider the role that international organisations can have in improving surgical care globally. We conclude by discussing surgery as a global health priority and possible solutions to improving surgical care globally.

Beyond the body: A systematic review of the nonphysical effects of a surgical career

BACKGROUND Training as a physician has been demonstrated to be a source of personal and familial distress; we sought to assess and analyze the holistic impact of a surgical career by examining nonphysical effects on surgeons and their families. METHODS The MEDLINE database was searched systematically from inception to June 2014 in accordance with PRISMA guidance. Two reviewers independently reviewed articles using predefined inclusion and exclusion criteria. RESULTS We found 71 articles that met our inclusion criteria. Fifty-four studies (77%) assessed burnout with a reported prevalence of 12.6-58% (mean, 34.6%; SD, 11.0%). Workload was found to be the most significant contributor to burnout. Rates of psychiatric morbidity ranged between 16 and 37% (mean, 25.3%; SD, 6.6%) and rates of suicidal ideation, especially among more senior surgeons and those involved in malpractice, was higher than the general population. Depression was reported in 30.8-37.5% (mean, 33.9%; SD, 3.1%). All were strongly associated with workload and burnout, indicative of a likely synergistic effect. Other risk factors included junior status and younger age, poor professional relationships, work-home conflicts and poor work-life balance. Protective factors included marriage or spousal support, career satisfaction, autonomy, and academic practice. CONCLUSION Surgeons have a high prevalence of burnout, psychiatric morbidity, and depression, with suicidal ideation rates higher than the general population. Professional factors contribute significantly to these phenomena. Although personal and familial factors are protective, they are eroded by the overwhelming impact of professional factors; nevertheless, career satisfaction rates remain high.

Changes in government spending on healthcare and population mortality in the European union, 1995–2010: a cross-sectional ecological study

Objective Economic measures such as unemployment and gross domestic product are correlated with changes in health outcomes. We aimed to examine the effects of changes in government healthcare spending, an increasingly important measure given constrained government budgets in several European Union countries. Design Multivariate regression analysis was used to assess the effect of changes in healthcare spending as a proportion of total government expenditure, government healthcare spending as a proportion of gross domestic product and government healthcare spending measured in purchasing power parity per capita, on five mortality indicators. Additional variables were controlled for to ensure robustness of data. One to five year lag analyses were conducted. Setting and Participants European Union countries 1995–2010. Main outcome measures Neonatal mortality, postneonatal mortality, one to five years of age mortality, under five years of age mortality, adult male mortality, adult female mortality. Results A 1% decrease in government healthcare spending was associated with significant increase in all mortality metrics: neonatal mortality (coefficient −0.1217, p = 0.0001), postneonatal mortality (coefficient −0.0499, p = 0.0018), one to five years of age mortality (coefficient −0.0185, p = 0.0002), under five years of age mortality (coefficient −0.1897, p = 0.0003), adult male mortality (coefficient −2.5398, p = 0.0000) and adult female mortality (coefficient −1.4492, p = 0.0000). One per cent decrease in healthcare spending, measured as a proportion of gross domestic product and in purchasing power parity, was both associated with significant increases (p < 0.05) in all metrics. Five years after the 1% decrease in healthcare spending, significant increases (p < 0.05) continued to be observed in all mortality metrics. Conclusions Decreased government healthcare spending is associated with increased population mortality in the short and long term. Policy interventions implemented in response to the financial crisis may be associated with worsening population health.

Poor adherence of randomised trials in surgery to CONSORT guidelines for non-pharmacological treatments (NPT): a cross-sectional study.

Objective To systematically assess adherence of randomised trials in surgery to Consolidated Standards of Reporting Trials (CONSORT) guidelines for non-pharmacological treatments (NPT). Surgical trials are considered more difficult to design and execute than pharmacological trials. Furthermore, the original CONSORT statement does not address some aspects that are vital to the transparent reporting of surgical trials. The CONSORT-NPT extension was designed to address these issues but adherence in medical and surgical journals has not been assessed. Design Cross-sectional study. Sample We identified eight general medical and eight surgical journals, indexed in PubMed and published in 2011, with the highest impact factors in their respective categories. Main outcomes Adherence to CONSORT statement and CONSORT-NPT extension items. Results We identified 54 surgical trials (22 published in medical journals and 32 in surgical journals). There were eight items for which there was less than 30% overall compliance (seven were specific to the CONSORT-NPT extension). These seven items are related to: a full description of the care providers, centres and blinding status in the abstract (n=7/54, 13%), eligibility criteria for centres performing the interventions (n=13/54, 24%), how adherence of care providers with the protocol was assessed or enhanced (n=7/54, 13%), how clustering by care providers or centres was addressed as it relates to sample size (n=3/54, 6%), how care providers were allocated to each group (n=9/54, 17%), how clustering by care providers or centres was addressed as it relates to statistical methods (n=2/54, 4%), a description of care providers (case volume, qualification, expertise, etc) and centres (volume) in each group (n=0/54, 0%). Conclusions Adherence of surgical trials to CONSORT-NPT extension items is much poorer than to the standard CONSORT statement. Adherence also appears to be superior in general medical journals compared with surgical journals. Raising awareness and conducting qualitative research to identify areas for specific intervention will be important going forward.

What size of left atrium significantly impairs the success of maze surgery for atrial fibrillation

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was in adults with atrial fibrillation (AF), what preoperative size of left atrium impairs maze surgery success in terms of recurrence of AF. Altogether 422 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal. date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Nine of 12 papers found that preoperative left atrial (LA) size was significantly larger in patients who experienced recurrent AF. When left atrial diameter (LAD) was found to be statistically different between sinus conversion and recurrent AF groups the mean LAD was consistently >60 mm in the recurrent AF group, whereas it was <60 mm in all but one of the sinus conversion groups. In terms of a cut-off value for LA size, a left atrial volume index >135 ml/m(2) was found to confer 100% specificity for maze failure and a LAD >60 mm was found to be 100% sensitive for maze failure. A preoperative LAD <48.3 mm was shown in one study to be 100% sensitive for sinus conversion by the maze procedure. Despite much evidence highlighting preoperative LAD as a risk factor for maze failure, relatively few studies seek to define a definitive cut-off value for LA size beyond which the risks of the procedure (such as bleeding, infection or stroke) outweigh the chance of sinus recovery. We conclude that since mean preoperative LAD in AF groups is consistently over 60 mm caution should be exercised when offering these patients the maze procedure. Furthermore, the relationship between preoperative LAD and maze failure appears continuous and so patients should be counselled as to their increased risk of failure the further they deviate from a LAD of 60 mm. There is some evidence for and no available evidence to the contrary that a LAD < 43 mm is associated with complete maze success. Hence, these patients should be offered the maze procedure unless there are alternate strong contraindications.