Background When compared with ultrasound, CT scans are more expensive, have substantial radiation exposure and lower sensitivity, specificity, positive, and negative predictive values for patients ...with gallstone disease. Study Design We reviewed data on patients emergently admitted with complicated gallstone disease between January 2005 and May 2010. Use of CT and ultrasound imaging on admission was described. Multivariate logistic regression was used to evaluate factors predicting receipt of CT. Results Five hundred and sixty-two consecutive patients presented emergently with complicated gallstone disease. Mean age was 45 years. Seventy-two percent of patients were female, 46% were white, and 41% were Hispanic. Seventy-two percent of patients had an ultrasound during the initial evaluation and 41% had a CT. Both studies were performed in 25% of patients (n = 141), 16% (n = 93) had CT only, and 47% (n = 259) had ultrasound only. CT was performed first in 67% of those who underwent both studies. Evening imaging (7 pm −7 am , odds ratio OR = 4.44; 95% CI, 2.88−6.85), increased age (OR = 1.14 per 5-year increase; 95% CI, 1.07−1.21), leukocytosis (OR = 1.67; 95% CI, 1.10−2.53), and hyperamylasemia (OR = 2.02; 95% CI, 1.16−3.51) predicted use of CT. Conclusions Our study demonstrates the overuse of CT in evaluation of complicated gallstone disease. Evening imaging was the biggest predictor of CT use, suggesting that CT is performed not to clarify the diagnosis, but rather a surrogate for the indicated study. Surgeons and emergency physicians should be trained to perform right upper quadrant ultrasound to avoid unnecessary studies in the appropriate clinical setting.
There have been few programs designed to improve surgical resident well-being, and such efforts often lack formal evaluation.
General surgery residents participated in the Energy Leadership ...Well-Being and Resiliency Program. They were assessed at baseline and 1 year after implementation using the Energy Leadership Index (measures emotional intelligence), Maslach Burnout Inventory General Survey, Perceived Stress Scale, the Beck Depression Inventory, and the annual required ACGME resident survey. Scores before and after implementation were compared using paired t-tests for continuous variables and chi-square tests for categorical variables.
Forty-nine general surgery residents participate in the program. One year after implementation, resident score on the Energy Leadership Index improved (from 3.16 ± 0.24 to 3.24 ± 0.32; p = 0.03). Resident perceived stress decreased from baseline (Perceived Stress Scale score, from 17.0 ± 7.2 to 15.7 ± 6.2; p = 0.05). Scores on the emotional exhaustion scale of the Maslach Burnout Inventory decreased (from 16.8 ± 8.4 to 14.4 ± 8.5; p = 0.04). Resident-reported satisfaction improved in many areas; satisfaction with leadership skills, work relationships, communication skills, productivity, time management, personal freedom, and work-life balance, increased during the 1-year intervention (p = NS). On the annual ACGME resident survey, residents' evaluation of the program as positive or very positive increased from 80% to 96%.
This study demonstrates that formal implementation of a program to improve resident well-being positively impacted residents' perceived stress, emotional exhaustion, emotional intelligence, life satisfaction, and their perception of the residency program. Formal evaluation and reporting of such efforts allow for reproducibility and scalability, with the potential for widespread impact on resident well-being.
Abstract Background For patients presenting with symptomatic cholelithiasis, cholecystectomy is the definitive treatment modality. Our goal was to evaluate the surgical follow-up and outcomes in ...patients seen in the emergency department (ED) for an episode of symptomatic cholelithiasis and discharged home for elective follow-up. Methods We performed a retrospective review of consecutive patients seen in the ED for cholelithiasis and discharged without hospital admission between August 2009 and May 2014. All patients were followed for 2 y from the date of the initial ED visit. We evaluated outpatient surgeon visits, elective and emergent cholecystectomy rates, and additional ED visits. Cumulative incidence and Kaplan–Meier curves were used to examine the time from the initial ED visit to outpatient surgeon evaluation and the time from the initial ED visit to ED readmission. Results Seventy-one patients were discharged from the ED with a diagnosis of symptomatic gallstones. Patients who had an elective cholecystectomy in the 2 y after the initial visit were 12.6%. In this group, the mean time from the initial ED visit to outpatient surgeon follow-up was 7.7 d, and all elective cholecystectomies occurred within 1 mo of the initial visit. Of the 62 patients who did not have an elective cholecystectomy, only 14.5% of patients in this group had outpatient surgeon follow-up at mean time of 137 d from the initial ED visit for symptomatic gallstones. In addition, 37.1% of patients in this group had additional ED visits for gallstone-related symptoms, with 17.7% of patients having two or more additional ED visits, and 12.9% required emergent and/or urgent cholecystectomy. Additional ED visits (43.5%) occurred within 1 mo and 60.9% within 3 mo of their initial ED visit. In patients with additional ED visits for symptomatic cholelithiasis, 60.9% had more than one abdominal ultrasound or computed tomography scan during the course of multiple visits. Conclusions Failure to achieve a timely surgical follow-up leads to multiple ED readmissions and emergent gallstone-related hospitalizations, including emergency cholecystectomy. System-level interventions to ensure outpatient surgical follow-up within 1–2 wk of the initial ED visit has the potential to improve outcomes for patients with symptomatic biliary colic.
Background Controversy exists regarding the use of concurrent cholecystectomy during Roux-en-Y gastric bypass performed for morbid obesity. Methods A decision model was developed to evaluate the ...cost-effectiveness of current strategies: routine concurrent cholecystectomy, Roux-en-Y gastric bypass alone with or without postoperative ursodiol therapy, and selective cholecystectomy based on preoperative findings on ultrasonography. Probabilities were obtained from a comprehensive literature review. Costs and hospital days were obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. One-way sensitivity analyses were performed. Results The least expensive strategy was to perform RYGB alone without preoperative ultrasonography, with an average cost (over RYGB costs) of $537 per patient. RYGB with concurrent cholecystectomy had a cost of $631. Selective cholecystectomy based on preoperative ultrasonography was dominated by the other 2 strategies. Our model was most sensitive to the probability of developing gallbladder-related symptoms after RYGB alone. When the incidence of gallbladder-related symptoms was <4.6%, the dominant strategy was to perform a RYGB alone without preoperative ultrasonography. For values >6.9%, performing concurrent cholecystectomy at the time of the RYGB was superior to other strategies. When ursodiol was used, the least expensive strategy was to perform a concurrent cholecystectomy during RYGB. Conclusion The main factor determining the most cost-effective strategy is the incidence of gallbladder-related symptoms after RYGB. The use of ursodiol was associated with an increase in cost that does not justify its use after RYGB. Finally, selective cholecystectomy based on preoperative ultrasonography was dominated by the other strategies in the scenarios evaluated.
IMPORTANCE: In the United States from 2009 to 2013, the incidence of breast cancer was the highest of any cancer and the death rate was second to that of lung cancer. Approximately 5% to 10% of ...breast cancers are inheritable. OBSERVATIONS: BRCA1 and BRCA2 germline mutations account for up to 30% of inheritable breast cancers and are the most commonly assessed mutations in patients presenting with early-onset breast cancer, triple-negative breast cancer, bilateral breast cancer, and a family history of breast cancer. Less common non-BRCA mutations have also been identified and contribute to hereditary breast cancer syndromes. Although established in BRCA mutations, indications and interpretations of genetic testing in non-BRCA mutations are not well defined. Furthermore, costs associated with genetic testing are highly variable and dependent on laboratory pricing, insurance coverage, and individual risk factors. CONCLUSIONS AND RELEVANCE: Genetic testing is a powerful tool that allows for the detection of BRCA and non-BRCA germline mutations in individuals with high risks of breast cancer, which in turn aids in the individualization of treatment. Given the magnitude of this disease, it is of great benefit for physicians, including general surgeons, to understand the indications, interpretations, and costs associated with genetic testing in patients with breast cancer. Cost is an especially important part of the genetic testing process and point of discussion with patients.
Background Guidelines for post resection surveillance of colorectal cancer recommend a collection of the patient’s history and physical examination, testing for carcinoembryonic antigen (CEA), and ...colonoscopy. No consistent guidelines exist for the use of abdominal computed tomography (CT) and position emission tomography (PET)/PET-CT. The goal of our study was to describe current trends, the impact of oncologic follow-up on guideline adherence, and the patterns of use of nonrecommended tests. Methods We used Texas Cancer Registry−Medicare-linked data (2000-2009) to identify physician visits, CEA testing, colonoscopy, abdominal CT, and PET/PET-CT scans in patients ≥66 years old with stage I-III colorectal cancer who underwent curative resection. Compliance with guidelines was assessed with a composite measure of physician visits, CEA tests, and colonoscopy use from start of surveillance. Results In patients who survived 3 years, the overall compliance with guidelines was 25.1%. In patients seen regularly by a medical oncologist, compliance with guidelines increased to 61.5% compared with 8.8% for those not seen by a medical oncologist regularly ( P < .0001). The use of abdominal CT and PET/PET-CT increased from 57.5% and 9.5%, respectively, in 2001 to 65.8% and 24.6% ( P < .0001) in 2006. Patients who saw a medical oncologist were more likely to get cross-sectional imaging than those who did not ( P < .0001). Conclusion Compliance with current minimum guidelines for post treatment surveillance of colorectal cancer is low and the use of nonrecommended testing has increased over time. Both compliance and use of nonrecommended tests are markedly increased in patients seen by a medical oncologist. The comparative effectiveness of CT and PET/PET-CT in the surveillance of colorectal cancer patients needs further examination.
Data exist on the morbidity and mortality of patients undergoing pancreaticoduodenectomy (PD), but there are few reports about hospital readmissions after this procedure. Our aim was to evaluate the ...number of and reasons for readmission after PD and the factors influencing readmission. We reviewed the initial hospitalization and readmissions for 1643 patients undergoing PD compared patients requiring readmission to patients that did not require readmission. Twenty-six percent of patients were readmitted a total of 678 times after PD. Patients readmitted were younger than those not readmitted (61.8 versus 64.6 years,
P < 0.0001). Vessel resection, abscess formation, wound infection, postoperative percutaneous biliary stents, estimated blood loss >1000 ml, and age ≤65 years were independently associated with readmission. The length of stay for all patients decreased over time, from 10.5 days in 1996 to 7 days in 2003. The percentage of patients being readmitted also decreased from 33% in 1996 to 20% (
P = 0.004) in 2003. The readmission rate after PD was 26%. Younger age, blood loss, postoperative complications, and vessel resection were independent risk factors for readmission. The early hospital readmission rate has not increased in association with a decreased LOS, supporting the idea that reduction in LOS did not lead to increased readmission rates.
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