CT and ultrasound (US) are increasingly recommended to establish the diagnosis of appendicitis, but population-based rates of misdiagnosis (negative appendectomy NA) have not improved over time. The ...objective of this study was to determine the relationship between CT/US and NA in common practice.
Using data from the Group Health Cooperative on all patients undergoing appendectomy between 1980 and 1999, a longitudinal study was conducted to determine the frequency of NA over time and a case-control, medical record–based study of a subset of patients from the 1990s was conducted to determine the accuracy of CT/US.
Of 4,058 patients undergoing appendectomy (mean age 31 ± 18.6 SD years, 49.6% women), 631 (15.5%) had an NA. The overall incidence of NA remained stable over time at 1.5/10,000 patient-years, as did the age and gender adjusted rate (incident rate ratio 0.95, 95% CI 0.97, 1.01). In 1999, nearly 40% of patients had either CT or US. The aggregate sensitivity of these tests was only 74.2% (95% CI 65.7, 83.7), with a positive predictive value of 95.1% (95% CI 91.5, 96.8). CT scans were 88.3% sensitive, with 97.2% positive predictive value (95% CI 92.9, 100). Ultrasounds were 69.5% sensitive, with a positive predictive value of 94.1% (95% CI 89.6, 96.4). More than one in five tests obtained in patients with NA were positive for appendicitis (21.7% for CT and 20.8% for US).
The rate of NA was unchanged over time despite the introduction and use of CT/US, and this appeared to be related to the inconsistent performance characteristics of the tests. This study cautions against overreliance on CT/US in diagnosing appendicitis and emphasizes the need for test benchmarking in routine practice before establishing protocols for presumed appendicitis.
Process improvement in surgery Minami, Christina A., MD; Sheils, Catherine R., BA; Bilimoria, Karl Y., MD, MS ...
Current problems in surgery,
02/2016, Letnik:
53, Številka:
2
Journal Article
ABSTRACT INTRODUCTION Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed ( ...Improving Nursing Facility Outcomes using Real-Time Metrics , INFORM ) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission. METHODS Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions. RESULTS The INFORM collaborative identified areas for improvement including improving accuracy and timeliness of discharge information, facilitating congruent medication reconciliation, and developing care plans to support functional improvement. DISCUSSION Hospital and SNF stakeholder engagement prioritized the challenges in patient transitions from inpatient to skilled nursing facility settings. Innovative solutions that address barriers to safe and effective transitions of care are critical to improving clinical outcomes, decreasing adverse events and avoiding readmission.
Anorectal melanoma (AM) is a rare tumor with a poor prognosis. Treatment with abdominoperineal resection (APR) over wide local excision (WLE) is still debated. This study aimed to compare median ...survival of WLE and APR in patients with AM.
A systematic review of the literature was performed. Only series that allowed calculation of median survival were included.
Fourteen studies met inclusion criteria. Average median survival of stage I WLE patients (N = 34) and stage I APR patients (N = 31) was 44 and 22 months, respectively (
P = .001). For stage II patients, 7 underwent WLE, and 10 underwent APR with an average median survival of 36 and 14 months, respectively (
P = .19).
This study identified no stage-specific survival advantage to APR in favor of AM. Given that WLE is a more limited intervention associated with at least comparable survival, we propose that it be considered the initial treatment of choice for AM.
Background Long-term outcomes and processes of care in patients undergoing pulmonary resection for lung cancer may vary by surgeon type. Associations between surgeon specialty and processes of care ...and long-term survival have not been described. Methods A cohort study (1992 through 2002, follow-up through 2005) was conducted using Surveillance, Epidemiology, and End-Results-Medicare data. The American Board of Thoracic Surgery Diplomates list was used to differentiate board-certified thoracic surgeons from general surgeons (GS). Board-certified thoracic surgeons were designated as cardiothoracic surgeons (CTS) if they performed cardiac procedures and as general thoracic surgeons (GTS) if they did not. Results Among 19,745 patients, 32% were cared for by GTS, 45% by CTS, and 24% by GS. Patient age, comorbidity index, and resection type did not vary by surgeon specialty (all p > 0.10). Compared with GS and CTS, GTS more frequently used positron emission tomography (36% versus 26% versus 26%, respectively; p = 0.005) and lymphadenectomy (33% versus 22% versus 11%, respectively; p ω 0.001). After adjustment for patient, disease, and management characteristics, hospital teaching status, and surgeon and hospital volume, patients treated by GTS had an 11% lower hazard of death compared with those who underwent resection by GS (hazard ratio, 0.89; 99% confidence interval, 0.82 to 0.97). The risks of death did not vary significantly between CTS and GS (hazard ratio, 0.94; 99% confidence interval, 0.88 to 1.01) or GTS and CTS (hazard ratio, 0.94; 99% confidence interval, 0.87 to 1.03). Conclusions Lung cancer patients treated by GTS had higher long-term survival rates than those treated by GS. General thoracic surgeons performed preoperative and intraoperative staging more often than GS or CTS.
Background Practice guidelines recommend routine use of pulmonary function tests (PFTs), computed tomography (CT), and positron emission tomography (PET) for the workup of resectable lung cancer ...patients. Little is known about the frequency of guideline concordance in routine practice. Methods A cohort study (2007 to 2013) of 15,951 lung cancer patients undergoing lobectomy or pneumonectomy was conducted with MarketScan, a claims database of individuals with employer-provided health insurance. Guideline concordance was defined by claims for PFT within 180 days of resection and for CT and PET within 90 days of resection. Generalized linear models were used to evaluate temporal trends, patient characteristics, and costs associated with guideline-concordant care. Results Overall, 61% of patients received guideline-concordant care, increasing from 57% in 2007 to 66% in 2013 ( p < 0.001). Compared with patients who received guideline-discordant care, patients with guideline-concordant care more frequently underwent repeat testing (PFT: 21% versus 12%, p < 0.001; CT: 46% versus 22%, p < 0.001; PET: 2.3% versus 1.1%, p < 0.001). Health plan–adjusted mean total test-related costs were higher among guideline-concordant patients who underwent repeat testing than patients who did not ($4,304 versus $3,454, p < 0.001). Conclusions Forty percent of lung cancer patients treated with surgical procedures did not receive recommended noninvasive cancer staging and physiologic assessment before resection. Guideline concordance was associated with repeat testing, and repeat testing was associated with higher costs. These findings support the need for quality improvement interventions that can increase guideline concordance while curbing potential excess use of diagnostic tests.
Background To determine the effectiveness of pharmacologic prophylaxis in preventing clinically relevant venous thromboembolic (VTE) events and deaths after surgery. The Surgical Care Improvement ...Project recommends that VTE pharmacologic prophylaxis be given within 24 hours of the operation. The bulk of evidence supporting this recommendation uses radiographic end points. Study Design The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement initiative with data linked to hospital admission/discharge and vital status records. We compared the rates of death, clinically relevant VTE, and a composite adverse event (CAE) in the 90 days after elective, colon/rectal resections, based on receipt of pharmacologic prophylaxis (within 24 hours of surgery) at 36 Surgical Care and Outcomes Assessment Program hospitals (2005–2009). Results Of 4,195 (mean age 61.1 ± 15.6 years; 54.1% women) patients, 56.5% received pharmacologic prophylaxis. Ninety-day death (2.5% vs 1.6%; p = 0.03), VTE (1.8% vs 1.1%; p = 0.04), and CAE (4.2% vs 2.5%; p = .002) were lower in those who received pharmacologic prophylaxis. After adjustment for patient and procedure characteristics, the odds were 36% lower for CAE (odds ratio = 0.64; 95% CI, 0.44−0.93) with pharmacologic prophylaxis. In any given quarter, hospitals where patients more often received pharmacologic prophylaxis (highest tertile of use) had the lowest rates of CAE (2.3% vs 3.6%; p = 0.05) compared with hospitals in the lowest tertile. Conclusions Using clinical end points, this study demonstrates the effectiveness of VTE pharmacologic prophylaxis in patients having elective colorectal surgery. Hospitals that used pharmacologic prophylaxis more often had the lowest rates of adverse events.
We sought to determine the prevalence of low health literacy (LHL) among patients in a preoperative clinic, the characteristics associated with LHL, and the association between LHL and adherence to ...preoperative instructions.
We conducted a cohort study and interviewed patients at a VA preoperative clinic. We administered a health literacy test and collected sociodemographic information. When patients returned for their scheduled surgical procedures, adherence to preoperative instructions was assessed.
Of 332 participants, 12% (n = 40) had LHL. Low health literacy was more prevalent among older adults (more than 65 years) compared with those under age 65. Patients with LHL were more likely to be nonadherent to preoperative medication instructions (odds ratio = 1.9; 95% confidence interval: 0.8 to 4.8), but this was of borderline statistical significance.
Low health literacy was common among older patients and appeared to be associated with lower adherence to preoperative medication instructions.
Abstract Objective Randomized trials show that pneumatic dilatation ≥30mm (PD) and laparoscopic myotomy (LM) provide equivalent symptom relief and disease-related quality of life for patients with ...achalasia. However, there remain questions about the safety, burden, and costs of treatment options. Methods We performed a retrospective cohort study of achalasia patients initially treated with PD or LM (2009-2014) using the Truven Health MarketScan® Research Databases. All patients had one year of follow-up after initial treatment. We compared safety, healthcare utilization, and total and out-of-pocket costs using generalized linear models. Results Among 1,061 patients, 82% were treated with LM. LM patients were younger (median age 49 vs. 52 years, p<0.01) but were similar in terms of sex (p=0.80) and prevalence of comorbid conditions (p=0.11). There were no significant differences in the one-year cumulative risk of esophageal perforation (LM 0.8% vs. PD 1.6%, p=0.32) or 30-day mortality (LM 0.3% vs. PD 0.5%, p=0.71). LM was associated with an 82% lower rate of re-intervention (p<0.01), 29% lower rate of subsequent diagnostic testing (p<0.01), and 53% lower rate of re-admission (p<0.01). Total and out-of-pocket costs were not significantly different (p>0.05). Conclusions In the United States, LM appears to be the preferred treatment for achalasia. Both LM and PD appear to be safe interventions. Along a short time-horizon, the costs of LM and PD were not different. Mirroring findings from randomized trials, LM is associated with fewer re-interventions, less diagnostic testing, and fewer hospitalizations.
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