Background Over the past 2 decades, researchers have recognized the value of qualitative research. Little has been done to characterize its application to surgery. We describe characteristics and ...overall prevalence of qualitative surgical research. Methods We searched PubMed and CINAHL using “surgery” and 7 qualitative methodology terms. Four researchers extracted information; a fifth researcher reviewed 10% of abstracts for inter-rater reliability. Results A total of 3,112 articles were reviewed. Removing duplicates, 28% were relevant ( N = 878; κ = 0.70). Common qualitative methodologies included phenomenology (34.3%) and grounded theory (30.2%). Interviews were the most common data collection method (81.9%) of patients (64%) within surgical oncology (15.4%). Postdischarge was the most commonly studied topic (30.8%). Overall, 41% of studies were published in nursing journals, while 8% were published in surgical journals. More than half of studies were published since 2011. Conclusion Results suggest qualitative surgical research is gaining popularity. Most is published in nonsurgical journals, however, utilizing only 2 methodologies (phenomenology, grounded theory). The surgical journals that have published qualitative research had study topics restricted to a handful of surgical specialties. Additional surgical qualitative research should take advantage of a greater variety of approaches to provide insight into rare phenomena and social context.
Background Ineffective communication among members of a multidisciplinary team is associated with operative error and failure to rescue. We sought to measure operative team communication in a ...simulated emergency using an established communication framework called “closed loop communication.” We hypothesized that communication directed at a specific recipient would be more likely to elicit a check back or closed loop response and that this relationship would vary with changes in patients’ clinical status. Methods We used the closed loop communication framework to code retrospectively the communication behavior of 7 operative teams (each comprising 2 surgeons, anesthesiologists, and nurses) during response to a simulated, postanesthesia care unit “code blue.” We identified call outs, check backs, and closed loop episodes and applied descriptive statistics and a mixed-effects negative binomial regression to describe characteristics of communication in individuals and in different specialties. Results We coded a total of 662 call outs. The frequency and type of initiation and receipt of communication events varied between clinical specialties ( P < .001). Surgeons and nurses initiated fewer and received more communication events than anesthesiologists. For the average participant, directed communication increased the likelihood of check back by at least 50% ( P = .021) in periods preceding acute changes in the clinical setting, and exerted no significant effect in periods after acute changes in the clinical situation. Conclusion Communication patterns vary by specialty during a simulated operative emergency, and the effect of directed communication in eliciting a response depends on the clinical status of the patient. Operative training programs should emphasize the importance of quality communication in the period immediately after an acute change in the clinical setting of a patient and recognize that communication patterns and needs vary between members of multidisciplinary operative teams.
The optimal approach to cytomegalovirus (CMV) prevention after lung transplantation is controversial. We recently completed a prospective, randomized, placebo-controlled study of CMV prevention in ...lung transplantation that demonstrated the short-term efficacy and safety of extending valganciclovir prophylaxis to 12 months vs 3 months of therapy. In the current analysis, we monitored a single-center subset of patients enrolled in the CMV prevention trial to determine if extended prophylaxis conferred a sustained long-term benefit and to assess its hematologic safety.
The sub-analysis included 38 randomized patients from Duke University Medical Center. All patients underwent consistent serial serum CMV monitoring and surveillance bronchoscopies. CMV was defined by viremia (≥ 500 CMV DNA copies/ml) or pneumonitis. The safety assessment included a review of all complete blood counts obtained from transplant onward.
During a mean follow-up of 3.9 years in each group, extended-course compared with short-course prophylaxis provided a sustained protective benefit with a lifetime CMV incidence of 12% vs 55%, respectively (hazard ratio, 0.13; 95% confidence interval, 0.03-0.61; p = 0.009), an effect that persisted after adjustment for clinical risk factors. Patients in each group underwent a comparable number of peripheral blood draws and bronchoscopies. Post-transplant white blood cell, neutrophil, and platelet counts were similar between each treatment group during the course of follow-up.
Extending valganciclovir prophylaxis to 12 months provides a durable long-term CMV protective benefit compared with short-course therapy, without increasing adverse hematologic effects.
Background Duration of stay for coronary artery bypass graft operation outcomes differs for black versus white patients, with differences often attributed to insurance. We examined black versus white ...differences in duration of stay among TRICARE-covered patients undergoing coronary artery bypass graft. Methods Patients aged 18–64 years with TRICARE who underwent isolated coronary artery bypass graft (ICD-9CM 36.10–36.20) between 2006–2010 and who identified as black or white race were identified. Negative binomial regression, stratified by sex and military versus civilian facility, examined the duration of stay controlling for patient- and hospital-level factors. Results Of 3,496 eligible patients, 2,904 underwent coronary artery bypass graft at 682 civilian and 592 at 11 military hospitals. Patients (mean age 56.2 years) were predominantly white (88.9%), male (88.7%), married (88.2%), and retired (87%). Black patients demonstrated longer duration of stay (8.6 vs 7.5 days, P > .001), and overall duration of stay was longer at military facilities (8.1 vs 7.5 days, P = .013). Among the men, mean duration of stay was 14% longer for black patients at civilian hospitals (95% confidence interval 1.07–1.22) with no race-based differences at military facilities. Conclusion Among coronary artery bypass graft patients with TRICARE coverage, black, male patients demonstrated greater duration of stay at civilian facilities. Further work should examine care at military hospitals to elucidate factors that drive the apparent mitigation of race-related variability in duration of stay.
Background Long-term survival after lung transplant is limited by the development of chronic and progressive airflow obstruction, a condition known as bronchiolitis obliterans syndrome (BOS). While ...prior studies strongly implicate cellular rejection as a strong risk factor for BOS, less is known about the clinical significance of human leukocyte antigen (HLA) antibodies and donor HLA-specific antibodies in long-term outcomes. Methods A single-center cohort of 441 lung transplant recipients, spanning a 10-year period, was prospectively screened for HLA antibodies after transplant using flow cytometry-based methods. The prevalence of and predictors for HLA antibodies were determined. The impact of HLA antibodies on survival after transplant and the development of BOS were determined using Cox models. Results Of the 441 recipients, 139 (32%) had detectable antibodies to HLA. Of these 139, 54 (39%) developed antibodies specific to donor HLA. The detection of posttransplant HLA antibodies was associated with BOS (HR, 1.54; P = .04) and death (HR, 1.53; P = .02) in multivariable models. The detection of donor-specific HLA antibodies was associated with death (HR, 2.42; P < .0001). The detection of posttransplant HLA antibodies was associated with pretransplant HLA-antibody detection, platelet transfusions, and the development of BOS and cytomegalovirus pneumonitis. Conclusions Approximately one-third of lung transplant recipients have detectable HLA antibodies, which are associated with a worse prognosis regarding graft function and patient survival.
Background Most hospitals in the United States are required to provide emergency care to all patients, regardless of insurance status. However, uninsured patients might be unable to access non-acute ...services, such as post-discharge inpatient care (PDIC). This could result in prolonged acute hospitalisation. We tested the hypothesis that insurance status would be independently associated with both PDIC and length of stay (LOS). Methods An observational study was undertaken using the California State Inpatient Database (2007-2011), which captures 98% of patients admitted to hospital in California. All patients with a diagnosis of orthopaedic lower limb trauma were identified using ICD-9-CM codes 820-828. Multivariable logistic and generalized linear regression models were used to adjust odds of PDIC and LOS for patient- and hospital-characteristics. Results There were 278,573 patients with orthopaedic lower limb injuries, 160,828 (57.7%) of which received PDIC. Uninsured patients had lower odds of PDIC (aOR 0.20, 95% CI 0.17-0.24) and significantly longer hospital LOS (predicted mean difference 1.06 95% CI 0.78-1.34 days) than those with private insurance. Conclusions Lack of health insurance is associated with reduced access to PDIC and prolonged hospital LOS. This potential barrier to hospital discharge could reduce the number of trauma beds available for acutely injured patients.
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