Objective We sought to evaluate the use of video-assisted thoracoscopy among patients with lung cancer and its safety and effectiveness relative to conventional resection. Methods A cohort study ...(1994–2002) was conducted by using the Surveillance, Epidemiology, and End-Results Medicare database. Video-assisted thoracoscopy and conventional resection were hypothesized to be equivalent in terms of risks of death. Equivalency was defined by a confidence interval of 0.72 to 1.28 for the odds of 30-day death and 0.89 to 1.11 for the hazard of death, corresponding to a difference of no more than 1% for 30-day mortality and 5% for 5-year survival, respectively. Results Among 12,958 patients who underwent segmentectomy or lobectomy (mean age, 74 ± 5 years), 6% underwent video-assisted thoracoscopy. The use of video-assisted thoracoscopy increased from 1% to 9% between 1994 and 2002. Compared with those who underwent conventional resection, patients who underwent video-assisted thoracoscopy more frequently had smaller tumors ( P < .001) and stage I disease ( P = .03), underwent lymphadenectomy ( P < .001), and were cared for by higher-volume surgeons ( P < .001) and at higher-volume hospitals ( P < .001). After adjusting for differences in patient, cancer, management, and provider characteristics, the odds of early death were not significantly different between patients undergoing video-assisted thoracoscopy and those undergoing conventional resection, although equivalency was not demonstrated (adjusted odds ratio, 0.93; 95% confidence interval, 0.57–1.50). The hazard of death was equivalent for video-assisted thoracoscopy and conventional resection (adjusted hazard ratio, 0.99; 95% confidence interval, 0.90–1.08). Conclusions Video-assisted thoracoscopy was uncommonly used to manage lung cancer, although its use has increased over time. Video-assisted thoracoscopy and conventional resection were equivalent in terms of long-term survival.
There are several methods of contrast administration when performing computed tomography (CT) scanning for suspected appendicitis. In this systematic review we evaluated the diagnostic performance of ...CT with and without contrast material.
Twenty-three reports were identified using a Medline search.
The aggregated diagnostic performance characteristics of all modes of CT scanning were excellent with a range of sensitivity (83–97%), specificity (93–98%), positive predictive value (86–98%), negative predictive value (94–99%), and accuracy (92–97%). The diagnostic performance of CT without oral contrast was similar (sensitivity, 95% vs. 92% not statistically significant; negative predictive value, 96% for both protocols) or surprisingly better (specificity, 97% vs. 94%; positive predictive value, 97% vs. 89%; accuracy, 96% vs. 92%;
P < .0001) than with oral contrast.
Noncontrast CT techniques to diagnose appendicitis showed equivalent or better diagnostic performance compared with CT scanning with oral contrast. A prospective comparative trial of CT with and without oral contrast for appendicitis should be performed to assess the adequacy of this modality.
There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical ...quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a “perfect” operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.
Management of pleural space infections: A population-based analysis Farjah, Farhood, MD; Symons, Rebecca Gaston, MPH; Krishnadasan, Bahirathan, MD ...
Journal of thoracic and cardiovascular surgery,
02/2007, Letnik:
133, Številka:
2
Journal Article, Conference Proceeding
Recenzirano
Odprti dostop
Objective Management options for pleural space infections have changed over the last 2 decades. This study evaluated trends over time in the incidence of disease and use of different management ...strategies and their associated outcomes. Methods A retrospective study was performed by using a statewide administrative database of all hospitalizations for pleural space infections between 1987 and 2004. Results Four thousand four hundred twenty-four patients (age, 57.1 ± 18.6 years; 67% male; comorbidity index, 1.1 ± 1.9) were hospitalized with pleural space infections. The incidence rate increased 2.8% per year (95% confidence interval, 2.2%-3.4%; P < .001). Overall, 51.6% of patients underwent an operation, and the proportion increased from 42.4% in 1987 to 58.4% in 2004 ( P < .001). The risk of death within 30 days was less for patients undergoing operations compared with that for patients not undergoing operations (5.4% vs 16.6%, P < .001); however, patients undergoing operations were younger (52.9 ± 17.6 years vs 61.5 ± 18.6 years, P < .001) and had a lower comorbidity index (0.8 ± 1.6 vs 1.4 ± 2.1, P < .001). After adjusting for age, sex, comorbidity index, and insurance status, patients undergoing operative therapy had a 58% lower risk of death (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P < .001) than those undergoing nonoperative management. Conclusions The incidence of pleural space infections and the proportion of patients undergoing operative management have increased over time. Patients undergoing operations were younger and had less comorbid illness than those not undergoing operations but had a much lower risk of early death, even after adjusting for these factors.
Recent population-based studies have demonstrated that the use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is associated with a decrease in the rate of common ...bile duct (CBD) injury. The cost implications of a management strategy involving routine IOC use have not been adequately evaluated.
Decision analytic models were developed to analyze costs and benefits of routine IOC use during LC. The models were used to calculate the cost per life saved, cost per CBD injury avoided, and incremental cost of IOC when used routinely. Transition probabilities, costs, and outcomes were derived from published sources. Sensitivity analyses were used to account for uncertainty in these estimates.
Using base-case estimates, management of patients undergoing LC with routine IOC would cost $100 more per LC. Routine IOC would prevent 2.5 deaths for every 10,000 patients at a cost of $390,000 per life saved ($13,900 per life year saved). The cost per CBD injury avoided with IOC use is $87,143. The cost per CBD injury avoided is less for procedures done in high-risk patients (approximately $8,000) or by less experienced surgeons (approximately $61,000).
These models describe settings where the cost of IOC and the reduction in CBD injury rates make routine IOC use cost effective. Routine IOC use among less experienced surgeons and in high-risk operations is the most cost effective, but the cost implications of routine use for the general population should also be considered cost effective.
Abstract Background The benefits of minimally invasive surgery (MIS) for low-risk or minor liver resection are well established. There is growing interest in MIS for major hepatectomy (MH) and other ...challenging resections, but there remain unanswered questions of safety that prevent broad adoption of this technique. Study Design Retrospective cohort study of patients undergoing hepatectomy at 65 hospitals participating in the NSQIP Hepatopancreatobiliary Collaborative in 2014. We assessed serious morbidity or mortality (SMM, including organ-space infection and organ failure). Secondary outcomes included transfusion, bile leak, liver failure, reoperation or intervention, and 30-day readmission. We also measured factors considered to make resection more challenging (large tumors, cirrhosis, ≥3 concurrent resections, prior neoadjuvant chemotherapy, or morbid obesity). Results 2819 patients underwent hepatectomy (age 58±14 years, 53% female; 25% MIS). After adjusting for clinical and operative factors, the odds of SMM (OR=0.57, 95%CI: 0.34-0.96, p=0.03) and reoperation or intervention (OR=0.52 (0.29-0.93), p=0.03) were significantly lower for patients undergoing MIS compared with open. In the MH group (n=1,015; 13% MIS), there was no difference in the odds of SMM after MIS (OR=0.37, (0.13-1.11), p=0.08) however MIS MH met criteria for non-inferiority. There were no differences in liver-specific complications or readmission between the groups. Odds of SMM were significantly lower following MIS among patients who had received neoadjuvant chemotherapy (OR 0.33 (0.15-0.70), p=0.004). Conclusion In this large study of minimally invasive major hepatectomy, we demonstrate safety outcomes that are equivalent or superior to conventional open surgery. While the decision to offer MIS may be influenced by factors not included in this evaluation, (e.g. surgeon experience and other patient factors), these findings support its current use in major hepatectomies.
In this prospective observational cohort of patients with a history of diverticulitis, we assessed the correlation between the diverticulitis quality of life survey (DVQOL) and other patient-reported ...expressions of disease measures including work and activity impairment, and contentment with gastrointestinal-related health. Then, we assessed whether the DVQOL is better correlated with these measures than diverticulitis episode count. Our study results showed that the DVQOL has a stronger correlation with other disease measures than diverticulitis episode count, and our findings support the broader use of the DVQOL in assessing the burden of diverticulitis and monitoring response to management.
Abstract Background Randomized trials show that alvimopan hastens return of bowel function and reduces length of stay by one day among patients undergoing colorectal surgery. However, its ...effectiveness in routine clinical practice and impact on hospital costs remains uncertain. Study Design We performed a retrospective cohort study of patients undergoing elective colorectal surgery in Washington State (2009-2013) using data from a clinical registry (Surgical Care and Outcomes Assessment Program) linked to a statewide hospital discharge database (Comprehensive Hospital Abstract Reporting System). We used generalized estimating equations to evaluate the relationship between alvimopan and outcomes while adjusting for patient, operative, and management characteristics. Hospital charges were converted to costs using hospital-specific charge-to-cost ratios, and were adjusted for inflation to 2013 dollars. Results Among 14,781 patients undergoing elective colorectal surgery at 51 hospitals, 1,615 (11%) received alvimopan. Patients who received alvimopan had a LOS that was 1.8 days shorter (p<0.01) and costs that were $2,017 lower (p<0.01) compared to those who did not receive alvimopan. After adjustment, LOS was 0.9 days shorter (p<0.01), and hospital costs were $636 lower (p=0.02) among those receiving alvimopan compared to those who did not. Conclusions When used in routine clinical practice, alvimopan was associated with a shorter LOS and limited but significant hospital cost savings. Both efficacy and effectiveness data support the use of alvimopan in routine clinical practice, and its use could be measured as a marker of higher quality care.
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