Samuel R. G. Finlayson

Trends in surgery for Crohn's disease in the era of infliximab.

Objective:To examine the use of surgical procedures for Crohns disease since the introduction of infliximab. Summary Background Data:Prior studies have shown that the overall rate of surgery for Crohns disease has not changed significantly since the introduction of infliximab, an immunomodulator considered particularly effective in treating Crohns fistulas. How infliximab has affected individual rates of specific types of procedures, particularly surgery for intestinal fistulas, is unknown. Methods:We used the Nationwide Inpatient Sample to identify all hospital admissions for Crohns disease for each year from 1993 through 2004. Cases of Crohns disease and relevant surgical interventions were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Using US Census data to establish population denominators, trends in population-based rates of use of these procedures were examined over time. Trends were tested for significance with Spearman rank correlation tests. Results:From 1993 to 2004, there was no statistically significant change in population-based rates of small bowel and right colon resection, while rates of left colon resection, other colon resection, and rectal resection declined moderately. However, rates of surgical repair of fistulas of the small intestine, the most commonly performed fistula operation, increased by 60%, from 1.5 per 1,000,000 in 1993 to 2.4 per 1,000,000 in 2004 (P = 0.04). Conclusions:During the period of adoption of infliximab as a novel treatment for Crohns disease, overall rates of bowel resections have either remained relatively stable or decreased moderately, while rates of small bowel fistula repair have increased significantly. These findings call into question the effectiveness of infliximab in preventing the need for surgery for Crohns disease at the population level.

Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature.

AbstractIntroductionThe global surgery workforce is in crisis in many low- and middle-income countries (LMICs). The shortage of surgery, obstetrics, and anesthesia providers is an important cause of the unmet need for surgical care in LMICs. The goal of this paper is to summarize the available literature about surgical physicians in LMICs and to describe ongoing initiatives to supplement the existing surgical workforce data.MethodsWe performed a systematic search and literature review of the English-language literature regarding the number of surgeons, obstetrician–gynecologists, and anesthesiologists practicing in LMICs.nResultsLiterature describing the number of surgeons, obstetricians, and anesthesiologists practicing in LMICs represents a small minority of LMICs, and indicates consistently low levels of surgical physicians. Our literature search yielded comprehensive data for only six countries. No national data were found for 23 of the 57 countries considered by the World Health Organization (WHO) to be in health workforce ‘crisis.’ Across LMICs, general surgeon density ranged from 0.13 to 1.57 per 100,000 population, obstetrician density ranged from 0.042 to 12.5 per 100,000, and anesthesiologist density ranged from 0 to 4.9 per 100,000. Total anesthesiologist, obstetrician, and surgeon density was significantly correlated with gross domestic product (GDP) per capita (r2xa0=xa00.097, pxa0=xa00.0002).ConclusionThe global surgery workforce is in crisis, yet is poorly characterized by the current English-language literature. There is a critical need for systematically collected, national-level data regarding surgery providers in LMICs to guide improvements in surgery access and care. The Harvard Global Surgery Workforce Initiative and the WHO global surgical workforce database are working to address this need by surveying Ministries of Health and surgical professional organizations around the world.

Readmission destination and risk of mortality after major surgery: an observational cohort study

BACKGROUNDnHospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations.nnnMETHODSnBy use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission.nnnFINDINGSn9,440,503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186,336 (65·8%) of 283,131 patients who were readmitted after coronary artery bypass grafting, to 142,142 (83·2%) of 170,789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189,384 [23%] of 834,070 patients readmitted to index hospital vs 36,792 [13%] of 276,976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio [OR] 0·74, 95% CI 0·66-0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45-0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61-0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91-0·94) than did patients who were less likely to be readmitted to the index hospital.nnnINTERPRETATIONnIn the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care.nnnFUNDINGnNone.

Impact of sepsis on risk of postoperative arterial and venous thromboses: large prospective cohort study

Objectives To evaluate the impact of preoperative sepsis on risk of postoperative arterial and venous thromboses. Design Prospective cohort study using the National Surgical Quality Improvement Program database of the American College of Surgeons (ACS-NSQIP). Setting Inpatient and outpatient procedures in 374 hospitals of all types across the United States, 2005-12. Participants 2 305 380 adults who underwent surgical procedures. Main outcome measures Arterial thrombosis (myocardial infarction or stroke) and venous thrombosis (deep venous thrombosis or pulmonary embolism) in the 30 days after surgery. Results Among all surgical procedures, patients with preoperative systemic inflammatory response syndrome or any sepsis had three times the odds of having an arterial or venous postoperative thrombosis (odds ratio 3.1, 95% confidence interval 3.0 to 3.1). The adjusted odds ratios were 2.7 (2.5 to 2.8) for arterial thrombosis and 3.3 (3.2 to 3.4) for venous thrombosis. The adjusted odds ratios for thrombosis were 2.5 (2.4 to 2.6) in patients with systemic inflammatory response syndrome, 3.3 (3.1 to 3.4) in patients with sepsis, and 5.7 (5.4 to 6.1) in patients with severe sepsis, compared with patients without any systemic inflammation. In patients with preoperative sepsis, both emergency and elective surgical procedures had a twofold increased odds of thrombosis. Conclusions Preoperative sepsis represents an important independent risk factor for both arterial and venous thromboses. The risk of thrombosis increases with the severity of the inflammatory response and is higher in both emergent and elective surgical procedures. Suspicion of thrombosis should be higher in patients with sepsis who undergo surgery.

Hospital-level Variation in Secondary Complications After Surgery.

Objectives:To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality. Background:Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or “index” complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails. Methods:We used American College of Surgeons’ National Surgical Quality Improvement Program data (2008–2012) to define hospital rates of secondary complications after 5 common index complications: pneumonia, surgical site infection (SSI), urinary tract infection, transfusion/bleed events, and acute myocardial infarction (MI). Hospitals were divided into quintiles on the basis of risk- and reliability-adjusted rates of secondary complications, and these rates were compared along with mortality. Results:A total of 524,860 patients were identified undergoing one of the 62 elective, inpatient operations. After index pneumonia, secondary complication rates varied from 57.99% in the highest quintile to 22.93% in the lowest [adjusted odds ratio (OR), 4.64; confidence interval (CI), 3.95–5.45). Wide variation was seen after index SSI (58.98% vs 14.81%; OR, 8.53; CI, 7.41–9.83), urinary tract infection (38.41% vs 8.60%; OR, 7.81; CI, 6.48–9.40), transfusion/bleeding events (27.14% vs 12.88%; OR, 2.54; CI, 2.31–2.81), and acute MI (64.45% vs 23.86%, OR, 6.87; CI, 5.20–9.07). Hospitals in the highest quintile had significantly greater mortality after index pneumonia (10.41% vs 6.20%; OR, 2.17; CI, 1.6–2.94), index MI (18.25% vs 9.65%; OR, 2.67; CI, 1.80–3.94), and index SSI (2.75% vs 0.82%; OR, 3.93; CI, 2.26–6.81). Conclusions:Hospital-level rates of secondary complications (failure to arrest complications) vary widely, are associated with mortality, and may be useful for quality improvement and benchmarking.

International migration of surgeons, anaesthesiologists, and obstetricians.

www.thelancet.com/lancetgh Vol 3 (S2) April 2015 S11 The data provided by our study are relevant to both lower and higher income countries, and can help policy makers understand and predict the supply and demand of their future surgical workforce. For lower-income countries, addressing the shortage of surgical providers is fundamental to meeting the increasing need for surgical care. For higher-income countries that still depend on an influx of surgical professionals from lower-income countries, there should be much greater domestic capacity to meet the demand for surgeons, anaesthesiologists, and obstetricians. The internationally ratifi ed Global Code of Practice on the International Recruitment of Health Personnel aims to bring awareness in all countries to the importance of national workforce planning, resource allocation, and data collection. Although previous studies of international migration of physicians have used data from even fewer high-income countries, our study is limited by the inclusion of only 14 out of 75 high-income countries. This study is also limited by the fact that not all countries categorise specialists and subspecialists the same way, limiting comparisons between particular specialties. It is important to emphasise that the study results are based on the emigration of medical graduates, not necessarily fully trained specialists. Also, our study design did not address internal migration or the geographical maldistribution of the surgical workforce within countries due to migration into urban settings and to non-governmental organisations and administration, nor did we capture the surgical workforce migrating regionally between lowincome or middle-income countries. These limitations translate into a likely underestimation of the degree of migration out of the most severely affected settings, and we acknowledge that in analysing the surgical work force, one should also International migration of surgeons, anaesthesiologists, and obstetricians

An Efficient Risk Adjustment Model to Predict Inpatient Adverse Events after Surgery

AbstractBackgroundnRisk adjustment is an important component of surgical outcomes and quality analyses. Current models include numerous preoperative variables; however, the relative contribution of these variables may be limited. This research seeks to identify a model with the fewest number of variables necessary to perform an adequate risk adjustment to predict any inpatient adverse event for use in resource-limited settings.MethodsAll patients from the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2010 were included. Outcomes were inpatient mortality or any surgical complication captured by NSQIP. Models were built by sequential addition of preoperative risk variables selected by their area under the receiver operator characteristic curve (AUC).ResultsAmong 863,349 patients, the single variable with the highest AUC was American Society of Anesthesiologists (ASA) classification (AUCxa0=xa00.7127). AUC values reached 0.7923 with five variables (ASA classification, wound classification, functional status prior to surgery, albumin, and age) and 0.7945 with six variables. The sixth variable was one of the following: alkaline phosphatase, weight loss, principal anesthesia technique, gender, or emergency status. The model with the highest discrimination that did not require laboratories included ASA classification, functional status prior to surgery, wound classification, and age (AUCxa0=xa00.7810). Including all 66 preoperative variables produced little additional gain (AUCxa0=xa00.8006).ConclusionsSix variables are sufficient to develop a risk adjustment tool for inpatient surgical mortality and morbidity. This research has important implications for the field of surgical outcomes research by improving efficiency of data collection. This limited model can aid the expansion of risk-adjusted analyses to resource-limited settings worldwide.

Racial Variation in the Use of Life-Sustaining Treatments among Patients Who Die After Major Elective Surgery

BACKGROUNDnAlthough various studies have documented increased life-sustaining treatments among racial minorities in medical patients, whether similar disparities exist in surgical patients is unknown.nnnMETHODSnA retrospective cohort study using the Nationwide Inpatient Sample (2006 to 2011) examining patients older than 39xa0years who died after elective colectomy was performed. Primary predictor variable was race, and main outcome was the use of life-sustaining treatment.nnnRESULTSnIn univariate analysis, significant differences existed in use of cardiopulmonary resuscitation (CPR; black, 35.9%; Hispanic, 29.0%; other, 24.5%; white, 11.7%; P = .002) and reintubation (Hispanic, 75.0%; other, 69.0%; black, 52.3%; white, 45.2%; P = .01). In multivariate analysis, black (odds ratio [OR], 3.67; P = .01) and Hispanic (OR, 4.21; P = .03) patients were more likely to have undergone CPR, and Hispanic patients (OR, 4.24; P = .01) were more likely to have been reintubated (reference: white).nnnCONCLUSIONSnBlacks and Hispanics had increased odds of experiencing CPR, and Hispanics were more likely to have been reintubated before death after a major elective operation. These variations may imply worse quality of death and increased associated costs.

An International Collaborative Standardizing a Comprehensive Patient-Centered Outcomes Measurement Set for Colorectal Cancer

Importance Global health systems are shifting toward value-based care in an effort to drive better outcomes in the setting of rising health care costs. This shift requires a common definition of value, starting with the outcomes that matter most to patients. Objective The International Consortium for Health Outcomes Measurement (ICHOM), a nonprofit initiative, was formed to define standard sets of outcomes by medical condition. In this article, we report the efforts of ICHOM’s working group in colorectal cancer. Evidence Review The working group was composed of multidisciplinary oncology specialists in medicine, surgery, radiation therapy, palliative care, nursing, and pathology, along with patient representatives. Through a modified Delphi process during 8 months (July 8, 2015 to February 29, 2016), ICHOM led the working group to a consensus on a final recommended standard set. The process was supported by a systematic PubMed literature review (1042 randomized clinical trials and guidelines from June 3, 2005, to June 3, 2015), a patient focus group (11 patients with early and metastatic colorectal cancer convened during a teleconference in August 2015), and a patient validation survey (among 276 patients with and survivors of colorectal cancer between October 15, 2015, and November 4, 2015). Findings After consolidating findings of the literature review and focus group meeting, a list of 40 outcomes was presented to the WG and underwent voting. The final recommendation includes outcomes in the following categories: survival and disease control, disutility of care, degree of health, and quality of death. Selected case-mix factors were recommended to be collected at baseline to facilitate comparison of results across treatments and health care professionals. Conclusions A standardized set of patient-centered outcome measures to inform value-based health care in colorectal cancer was developed. Pilot efforts are under way to measure the standard set among members of the working group.

Training Surgical Residents for a Career in Academic Global Surgery: A Novel Training Model

Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Womens Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early experiences.