Writing a Presidential address is an interesting exercise, and for those of you who have been fortunate enough to lead an organization, you know that not a day goes by, since you become ...President-elect, that you don't think about something that you should include, some experience with a mentor you have had that is worthy of documentation, a message you hope the audience remembers after you are finished, and the hope that it will measure up to the memorable presidential addresses that you have heard in many societies, including the American Surgical Association.
Diversifying the medical work force is critical to reducing health care disparity and improving patient outcomes. This manuscript offers a comprehensive review of best practices to improve both the ...recruitment and the retention of underrepresented minorities in training programs and beyond.
There is significant variation in rectal cancer outcomes in the USA, and reported outcomes have been inferior to those in other countries. In recognition of this fact, the American College of ...Surgeons (ACS) recently launched the Commission on Cancer (CoC) National Accreditation Program for Rectal Cancer (NAPRC) in an effort to further optimize rectal cancer care. Large surgical databases will play an important role in tracking surgical and oncologic outcomes. Our study sought to explore the trends in surgical outcomes over the decade prior to the NAPRC using a large national database.
The ACS National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017 was used to select colorectal cancer cases which were divided into abdominal-colonic (AC) and pelvic-rectal (PR) cohorts based upon the operation performed. Outcomes of interest were occurrence of any major surgical complication, mortality within 30 days of procedure, and postoperative length of stay (LOS). Chi-square and two sample t-tests were used to evaluate association between various risk factors and outcomes. Modified Poisson regression was used to compare and estimate the unadjusted and adjusted effect of procedure type on the outcomes. STATA 15.1 was used for analysis and statistical significance was set at 0.05.
A total of 34,159 patients were analyzed. AC cases constituted 50.7% of the overall cohort. The two groups were relatively similar in demographic distribution, but the PR patients had higher rates of hypoalbuminemia and were sicker (ASA class 3 or greater). Rates of non-sphincter preserving operations ranged from 30 to 34%. Higher complication rates in the PR cohort were mainly infectious and surgical site complications, while rates of deep vein thrombosis and pulmonary embolism were similar between the two cohorts. On bivariate analysis, rates of mortality were similar between the two groups (AC: 1.02% vs PR: 0.91%, p = 0.395), while PR patients were found to be 1.36 times (95% CI: 1.32–1.41) more likely to have major complications and 1.40 times (95% CI: 1.35–1.44) more likely to have an extended LOS as compared to the AC patients. After multivariable analysis, PR patients continued to have a higher likelihood of major complications (IRR: 1.31, 95% CI 1.25–1.36) and extended LOS (IRR: 1.38, 95% CI: 1.33–1.43). 10-year trends showed a significant reduction in the percentage of patients with prolonged lengths of hospitalization as well as a reduction of nearly 20% in the mean LOS, but without improvement in morbidity or mortality.
Patients undergoing PR operations were more likely to have had major complications than were patients who underwent AC procedures; unfortunately no improvement in the rate of these complications or in mortality occurred. Perhaps the significant reduction in LOS is due in part to an increased prevalence of minimally invasive surgery and/or enhanced recovery protocols. Data were found to be lacking within NSQIP for several important variables including key oncologic data, stratification by surgical volume, and patient geographic location. We anticipate that the NAPRC should help improve PR surgical and oncologic outcomes including decreasing morbidity and mortality rates during the next decade.
•This is the first retrospective multivariable analysis exploring trends in surgical outcomes for rectal cancer in the decade prior to NAPRC.•Patients are more likely to have major complications undergoing pelvic compared to abdominal procedures.•No improvement in complication or mortality rates has occurred.•Significant reduction in length of stay may be partly due to increased use of minimally invasive surgery and/or enhanced recovery protocols.•NAPRC should help improve surgical and oncologic outcomes including decreasing morbidity and mortality rates over the next decade.
Hospital readmissions are resource intensive, associated with increased morbidity, and often used as hospital-level quality indicators. The factors that determine hospital readmission after blunt ...thoracic trauma have not been sufficiently defined. We sought to identify predictors of hospital readmission in patients with traumatic rib fractures.
We performed an 8-year (2011-2019) retrospective chart review of patients with traumatic rib fractures who required unplanned readmission within 30 days of discharge at a Level 1 trauma center. Patient characteristics, injury severity, and hospital complications were examined using quantitative analysis to identify readmission risk factors.
There were 13,046 trauma admissions during the study period. The traumatic rib fracture cohort consisted of 3,720 patients. The cohort included 206 patients who were readmitted within 30 days of discharge. The mean age of the traumatic rib fracture cohort was 57 years, with a 6-day median length of stay. The 30-day mortality rate was 5%. Use of anticoagulation (11.0 vs. 5.4; p = 0.029), diagnosis of a psychiatric disorder (10.2 vs. 5.3; p = 0.01), active smoking (7.3 vs. 5.0; p = 0.008), associated hemothorax (8.3 vs. 5.2; p = 0.010), higher abdominal Abbreviated Injury Scale (33.3 vs. 8.4 vs. 6.5; p = 0.002), rapid response activation (8.9 vs. 5.2; p = 0.005), admission to intensive care unit (7.7 vs. 4.5; p = 0.001), and diagnosis of in-hospital pneumonia (10.1 vs. 5.4; p = 0.022) were predictors of hospital readmission. On multivariate analysis, prescribed anticoagulation (odds ratio OR, 2.22; p = 0.033), active smoking (OR, 1.58; p = 0.004), higher abdominal Abbreviated Injury Scale (OR, 1.50; p = 0.054), and diagnosis of a psychiatric disorder (OR, 2.00; p = 0.016) predicted hospital readmission.
In patients with traumatic rib fractures, those with anticoagulant use, those who actively smoke, those with a psychiatric diagnosis, or those with associated abdominal injuries are at the highest risk of rehospitalization following discharge. Quality improvement should focus on strategies and protocols directed toward these groups to reduce nonelective readmissions.
Prognostic and Epidemiological; Level IV.
OBJECTIVE:The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic ...surgery.
SUMMARY OF BACKGROUND DATA:Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion.
METHODS:The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper.
RESULTS:The ASA has produced a handbook entitledEnsuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals.
CONCLUSION:Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition—doing good for our patients.
Functional dependency has been associated with increased risk of adverse events following many surgical procedures. We hypothesized that dependent patients would have an increased risk of ...complications following thyroidectomy.
We performed a retrospective review of total thyroidectomies performed from 1/2012–12/2019 as identified by CPT codes using the National Surgical Quality Improvement Project (NSQIP) database. Functional dependent status was identified from within the NSQIP database with partially or totally dependent combined into the dependent group.
A total of 64,978 patients were included, with 0.53% identified as functionally dependent (FD). Functional dependency was associated with an increased risk of wound disruption, pneumonia, UTI, stroke, cardiac arrest, PE/DVT, and sepsis/septic shock. Dependent patients had higher rates of unplanned intubation, ventilator use, and significant bleeding.
On multivariate analysis, FD patients were more likely to suffer from major complications and have an increased length of stay.
Dependent status was associated with an increased risk of complications following thyroidectomy. Focused preoperative and disposition planning for these patients can help to minimize adverse outcomes and optimize resource utilization.
•Functional dependent status has been associated with worse perioperative outcomes.•Dependent patients also have worse outcomes following thyroidectomies.•Outcomes included major complications and increased length of stay.
PDF
