This study investigates the impact of the COVID-19 pandemic on endocrine surgeons.
A survey on the professional, educational, and clinical impact was sent to active and corresponding members of the ...American Association of Endocrine Surgeons (AAES) in September 2020. Chi-square and paired t-test were used for analysis.
77 surgeons responded (14.8 %). All reported suspension of elective surgeries; 37.7 % were reassigned to other duties during this time. The median number of cases backlogged was 30 (IQR 15–50). Most surgeons reported decreased clinical volume (74.6 %). The use of virtual platforms for clinical and educational purposes increased from pre-COVID-19 levels (all p < 0.001). Use of in-office procedures (p < 0.001) and length of observation prior to discharge for thyroid surgery (p < 0.05) decreased.
The COVID-19 pandemic led to suspension of operations and decreased practice volume for endocrine surgeons. Surgeons increased use of virtual platforms, decreased in-office procedures, and decreased duration of observation for thyroid surgery in response.
•The COVID-19 pandemic led to suspension of elective endocrine surgical procedures.•Most surgeons reported decreased clinical volume and compensation during this time.•Use of virtual platforms for all facets of care significantly increased.•Use of ultrasound, fine needle-aspiration, and laryngoscopy decreased.•There was decreased duration of observation for patients undergoing thyroidectomy.
Despite meeting operative indications for primary hyperparathyroidism (PHPT), many patients never undergo parathyroidectomy. We hypothesized that patients with limited English proficiency (LEP) would ...be less likely to undergo parathyroidectomy than English-proficient (EP) patients.
We retrospectively analyzed patients with PHPT from an institution-wide registry who met operative criteria between 2010 and 2018. The cohort was stratified by English proficiency. Univariate associations between sociodemographic and clinical factors with parathyroidectomy were assessed. A multivariable logistic regression model was created to assess independent predictors of parathyroidectomy.
Among a cohort of 1,104 patients, 262 (24%) underwent parathyroidectomy. LEP patients (n = 135, 12%) were significantly younger (mean age 62 vs. 69, p < 0.001), more likely non-white race and ethnicity (p < 0.001), and less likely to have private insurance (p < 0.001). After adjusting for covariates, non-English and non-Spanish preferred language was an independent negative predictor of undergoing parathyroidectomy (OR 0.46, 95% CI 0.21–0.95, p = 0.037).
Limited English proficiency may be an independent barrier to appropriate surgical management of PHPT. Systems-level and disease-specific interventions are needed to address this disparity faced by patients with LEP.
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•Patients with limited English proficiency may be less likely to undergo parathyroidectomy for primary hyperparathyroidism (PHPT).•Additional social determinants may contribute to lack of surgical care for PHPT.•Consideration of these disparities and their intersectionality is important for interventions aimed at improving care for PHPT.
In a randomized trial comparing antibiotic therapy with appendectomy in patients with appendicitis, antibiotics were noninferior on the basis of EQ-5D scores. In the antibiotics group, nearly 3 in 10 ...participants had undergone appendectomy by 90 days, and complications were more common, especially in those with an appendicolith.
IMPORTANCE: Some studies based on proportions of patients with perforated appendicitis (PA) among all patients with acute appendicitis (AA) have found an association between socioeconomic status ...(SES) and risk of perforation. A potential limitation is their use of proportions, which assumes that incidence of AA is evenly distributed across populations at risk. This assumption may be invalid, and SES may have a more complex association with both AA and PA. OBJECTIVE: To generate population-based incidences of AA and PA and to examine geographic patterns of incidence alongside geographic patterns of SES. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of data from Washington’s Comprehensive Hospital Abstract Reporting System and the 2010 US census. Geographic methods were used to identify patterns of age- and sex-standardized incidence in Washington State between 2008 and 2012. The study included all patients discharged with International Classification of Diseases, Ninth Revision codes for AA or PA. Data were analyzed between November 2016 and December 2018. EXPOSURES: Location of primary residence. MAIN OUTCOMES AND MEASURES: Age- and sex-standardized incidence for AA and PA was generated for each census tract (CT). Global spatial autocorrelation was examined using Moran index (0.0 = completely random incidence; 1.0 = fully dependent on location). Clusters of low-incidence CTs (cold spots) and high-incidence CTs (hot spots) were identified for AA. Census-based SES data were aggregated for hot spots and cold spots and then compared. RESULTS: Statewide, over the 5-year study period, there were 35 730 patients with AA (including 9780 cases of PA), of whom 16 574 were women (46.4%). Median age of the cohort was 29 years (IQR, 16-48 years). Statewide incidence of AA and PA was 106 and 29 per 100 000 person-years (PY), respectively. Crude incidence was higher within the male population and peaked at age 10 to 19 years. Age- and sex-standardized incidence of AA demonstrated significant positive spatial autocorrelation (Moran index, 0.30; P < .001), but autocorrelation for PA was only half as strong (0.16; P < .001). Median incidence of AA was 118.1 per 100 000 PY among hot spots vs 86.2 per 100 000 PY among cold spots (P < .001). Socioeconomic status was higher in cold spots vs hot spots: mean proportion of college-educated adults was 56% vs 26% (P < .001), and mean per capita income was $44 691 vs $30 027 (P < .001). CONCLUSIONS AND RELEVANCE: Age- and sex-standardized incidence of appendicitis is not randomly distributed across geographic subunits, and geographic clustering of AA is twice as strong as PA. Socioeconomic advantages, such as higher income and secondary education, are strongly associated with lower incidence of AA. These findings challenge conventional views that AA occurs randomly and has no predisposing characteristics beyond age/sex. Socioeconomic status, and likely other geographically circumscribed factors, are associated with incidence of AA.
Venous thromboembolism (VTE) prophylaxis has become routine for patients undergoing most operations, but it remains controversial for breast operations due to a perceived low risk of VTE. There is ...limited evidence to support routine or extended VTE prophylaxis in breast surgery. We investigated the benefits and risks of the Caprini risk stratification tool and corresponding prevention program, including extended prophylaxis for high-risk groups, in patients undergoing operations for benign and malignant breast lesions.
Using Boston Medical Center data, we reviewed records of patients who underwent lumpectomy or total mastectomy (with or without axillary surgery and/or reconstruction), between 2011 and 2018, to collect information about operation, Caprini score, administration of prophylaxis, and postoperative VTE or bleeding events. Descriptive statistics were performed.
Seven hundred fifty patients underwent 881 operations; 48.9% were at low or moderate risk of VTE, 43.8% were at high risk, and 7.3% were at highest risk. There were no VTE events in the low- and moderate-risk groups, 5 (1.3%) in the high-risk, and 1 (1.6%) in the highest-risk group. One patient was diagnosed with VTE during hospitalization. None of the 5 patients who developed VTE after discharge was prescribed the recommended extended chemoprophylaxis. There were 19 bleeding events that did not require reoperation; 3 patients returned to the operating room. There was no correlation of bleeding with receipt of extended chemoprophylaxis.
The Caprini protocol can identify high-risk breast surgery patients who may benefit from extended VTE chemoprophylaxis, as well as low-risk patients who require no chemoprophylaxis. Furthermore, administration of extended chemoprophylaxis was not associated with an increased risk of bleeding.
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Current AJCC guidelines recommend evaluating ≥6 lymph nodes during gallbladder cancer resection but real world data suggest this is rarely achieved. We evaluated the extent of lymphadenectomy and ...survival among patients with gallbladder adenocarcinoma.
Patients with resected pT1b-T3 gallbladder adenocarcinoma were identified from the NCDB (2004–2017). Propensity scores were created for the odds of sufficient lymphadenectomy (≥6 nodes), patients were matched 1:1 and survival was analyzed using the Kaplan-Meier method.
Overall, 4760 patients were identified: 16.7% underwent sufficient lymphadenectomy, which was predictive of nodal disease (OR 1.77, 95%CI 1.51–2.08) and demonstrated a survival benefit in N0 (median OS 140.8 versus 44.4 months; p < 0.0001) and N1-2 disease (median OS 27.7 versus 17.7 months; p < 0.0001) after matching.
The majority of patients with gallbladder adenocarcinoma do not undergo the recommended nodal dissection, resulting in a survival disadvantage, likely due to understaging, decisions regarding adjuvant therapy and local tumor recurrence.
•National guidelines recommend ≥6 lymph nodes for gallbladder cancer surgery.•Most patients with gallbladder adenocarcinoma do not undergo this recommendation.•Sufficient lymphadenectomy is associated with nodal disease and a survival benefit.•Insufficient lymphadenectomy may lead to understaging and local tumor recurrence.
A majority of patients with primary hyperparathyroidism are not referred for surgical evaluation. We hypothesized that disparities in the rate of surgeon evaluation by language, race and ethnicity, ...and insurance contribute to this deficit.
We queried our institutional electronic health record registry for patients with first-incident hypercalcemia between 2010 and 2018 and subsequent biochemical diagnosis of primary hyperparathyroidism. We used the Kaplan-Meier method and Cox proportional hazards modeling to investigate estimated time to surgeon evaluation by language, race and ethnicity, and insurance status.
Of 1,333 patients with a diagnosis of primary hyperparathyroidism, 74% were female, 67% were White, 44% were privately insured, and 88% preferred English. Fewer than one third (n = 377; 28%) were evaluated by a surgeon. After adjusting for demographic and clinical factors, Asian (hazard ratio = 0.38; 95% confidence interval, 0.18–0.84; P = .016) and Black or African American patients (hazard ratio = 0.59; 95% confidence interval, 0.39–0.90; P = .014) had a lower rate of surgeon evaluation compared to White patients. Although patients with Medicaid had a lower rate of surgeon evaluation compared to privately insured patients (hazard ratio = 0.52; 95% confidence interval, 0.35–0.77; P = .001), there was no difference in rate for those with Medicare or who were uninsured. Patients with non-English and non-Spanish language had a lower rate of evaluation compared to those who preferred English (hazard ratio = 0.47; 95% confidence interval, 0.23–0.98; P = .043).
Rates of surgeon evaluation vary by race and ethnicity, insurance status, and preferred language. Evaluation of factors contributing to these disparities is needed to improve access to surgeon referral.
Background
Limited English proficiency (LEP) is common among hospitalized patients and may impact care. We synthesized the literature comparing clinical outcomes after in-hospital care for ...English-proficient(EP) versus LEP patients.
Methods
This systematic review searched PubMed, Embase, and Web of Science from database inception through June 7, 2020, to identify research investigating clinical outcomes in patients receiving hospital-based care (in the emergency department, inpatient ward, surgical/procedural suite, or intensive care unit) that compared patients with LEP to an EP group. We assessed mortality, length of stay (LOS), readmissions/revisits, and complications. Study quality was evaluated using the Newcastle-Ottawa Scale.
Results
Twenty-six studies met eligibility criteria. Study settings and populations were heterogeneous. Determination of primary language varied; a majority of studies (16/26) used patient self-report directly or via hospital records. Of 16 studies examining LEP and all-cause mortality, 13 found no significant association. Of 17 studies measuring LOS, 9 found no difference, 4 found longer LOS, 3 found shorter LOS, and 1 had mixed LOS results among patients with LEP. Several investigations suggested that LOS differences may be mediated at the hospital level. Nine studies evaluated inpatient readmissions. Among patients with LEP, there was evidence for increased readmissions in the setting of chronic medical conditions such as heart failure, but no evidence for increased readmissions among cohorts undergoing surgeries/procedures or with acute medical conditions. Five studies evaluated complications or harm related to a hospitalization, and no differences were found between language groups.
Discussion
The research community lacks a standardized definition of LEP. Most studies did not find an association between English proficiency and mortality or complications. LOS findings were mixed and may be influenced at the hospital level. Differences in readmissions by language were concentrated in chronic medical conditions. Given the paucity of studies examining LEP populations, additional research is imperative.
Prospero Registration Number
CRD42020143477
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