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Consider routine penicillin allergy testing in obstetrics
PARK CITY, UTAH – When attendees at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology were asked if their institutions test to confirm alleged penicillin allergies, the only hands that went up were from clinicians at Duke University.
That’s a problem, according to Robert Heine, MD, a maternal-fetal medicine specialist at Duke, in Durham, N.C. “We, as a group, need to be doing [penicillin] allergy testing,” he said.
It’s become clear in recent years that patients who say they have a penicillin allergy often don’t have one, or remember a mild reaction from childhood that doesn’t preclude the use of beta-lactam antibiotics as adults. For decades, however, clinicians have taken those claims at face value, and duly noted them in charts and switched patients to non–beta-lactam antibiotics that don’t work as well.
That’s what happened at Duke in 2014. A total of 81 women with documented penicillin allergies were put on gentamicin and clindamycin to protect against cesarean wound infections and 16% ended up with infections anyway. Among the 864 women who received cefazolin – the first-line cesarean prophylaxis choice at Duke – the infection rate was 7%.
“Beta-lactam antibiotic prophylaxis reduced the risk of surgical site infections after cesareans by 60%,” said Benjamin Harris, MD, the lead investigator and an ob.gyn. resident at Duke, who presented the findings at the meeting.
When the investigators took a closer look at the 81 women who reported penicillin allergies, most of them had rashes and other mild reactions noted in their charts.
Findings such as those led Dr. Heine to push for routine testing. “I brought Duke into it kicking and screaming,” he said. The biggest obstacle was concern over liability, specifically that pregnant women would go into anaphylaxis and deliver prematurely, he said.
After a lot of lobbying, Dr. Heine and his colleagues started routine penicillin allergy testing in March 2016. There hasn’t been a single reaction among the 80-plus pregnant women tested so far, he reported.
Duke administrators were also concerned about reimbursement, but it hasn’t turned out to be a problem. Reimbursements from public and private payers “cover our costs,” a little over $100 per test, Dr. Heine said.
Dr. Heine said he can imagine outpatient testing at some point, but for now women are checked into triage. They get a fetal heart tone before 24 weeks, and a fetal heart rate monitor afterward. “We try to do it before 20 weeks so we don’t have to worry about the fetus,” he said.
When penicillin allergies are in the chart, or women say they are allergic, ask what type of reaction they had in the past. Type 1 reactions should be confirmed with testing. It’s okay to skip testing and give beta-lactams for non–type 1 reactions, but “if a woman has a non–type 1, and they’re already set up for testing, I’m going to do it anyway because getting the penicillin allergy off her chart is good for her and her life,” Dr. Heine said.
Dr. Heine and Dr. Harris reported having no financial disclosures.
PARK CITY, UTAH – When attendees at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology were asked if their institutions test to confirm alleged penicillin allergies, the only hands that went up were from clinicians at Duke University.
That’s a problem, according to Robert Heine, MD, a maternal-fetal medicine specialist at Duke, in Durham, N.C. “We, as a group, need to be doing [penicillin] allergy testing,” he said.
It’s become clear in recent years that patients who say they have a penicillin allergy often don’t have one, or remember a mild reaction from childhood that doesn’t preclude the use of beta-lactam antibiotics as adults. For decades, however, clinicians have taken those claims at face value, and duly noted them in charts and switched patients to non–beta-lactam antibiotics that don’t work as well.
That’s what happened at Duke in 2014. A total of 81 women with documented penicillin allergies were put on gentamicin and clindamycin to protect against cesarean wound infections and 16% ended up with infections anyway. Among the 864 women who received cefazolin – the first-line cesarean prophylaxis choice at Duke – the infection rate was 7%.
“Beta-lactam antibiotic prophylaxis reduced the risk of surgical site infections after cesareans by 60%,” said Benjamin Harris, MD, the lead investigator and an ob.gyn. resident at Duke, who presented the findings at the meeting.
When the investigators took a closer look at the 81 women who reported penicillin allergies, most of them had rashes and other mild reactions noted in their charts.
Findings such as those led Dr. Heine to push for routine testing. “I brought Duke into it kicking and screaming,” he said. The biggest obstacle was concern over liability, specifically that pregnant women would go into anaphylaxis and deliver prematurely, he said.
After a lot of lobbying, Dr. Heine and his colleagues started routine penicillin allergy testing in March 2016. There hasn’t been a single reaction among the 80-plus pregnant women tested so far, he reported.
Duke administrators were also concerned about reimbursement, but it hasn’t turned out to be a problem. Reimbursements from public and private payers “cover our costs,” a little over $100 per test, Dr. Heine said.
Dr. Heine said he can imagine outpatient testing at some point, but for now women are checked into triage. They get a fetal heart tone before 24 weeks, and a fetal heart rate monitor afterward. “We try to do it before 20 weeks so we don’t have to worry about the fetus,” he said.
When penicillin allergies are in the chart, or women say they are allergic, ask what type of reaction they had in the past. Type 1 reactions should be confirmed with testing. It’s okay to skip testing and give beta-lactams for non–type 1 reactions, but “if a woman has a non–type 1, and they’re already set up for testing, I’m going to do it anyway because getting the penicillin allergy off her chart is good for her and her life,” Dr. Heine said.
Dr. Heine and Dr. Harris reported having no financial disclosures.
PARK CITY, UTAH – When attendees at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology were asked if their institutions test to confirm alleged penicillin allergies, the only hands that went up were from clinicians at Duke University.
That’s a problem, according to Robert Heine, MD, a maternal-fetal medicine specialist at Duke, in Durham, N.C. “We, as a group, need to be doing [penicillin] allergy testing,” he said.
It’s become clear in recent years that patients who say they have a penicillin allergy often don’t have one, or remember a mild reaction from childhood that doesn’t preclude the use of beta-lactam antibiotics as adults. For decades, however, clinicians have taken those claims at face value, and duly noted them in charts and switched patients to non–beta-lactam antibiotics that don’t work as well.
That’s what happened at Duke in 2014. A total of 81 women with documented penicillin allergies were put on gentamicin and clindamycin to protect against cesarean wound infections and 16% ended up with infections anyway. Among the 864 women who received cefazolin – the first-line cesarean prophylaxis choice at Duke – the infection rate was 7%.
“Beta-lactam antibiotic prophylaxis reduced the risk of surgical site infections after cesareans by 60%,” said Benjamin Harris, MD, the lead investigator and an ob.gyn. resident at Duke, who presented the findings at the meeting.
When the investigators took a closer look at the 81 women who reported penicillin allergies, most of them had rashes and other mild reactions noted in their charts.
Findings such as those led Dr. Heine to push for routine testing. “I brought Duke into it kicking and screaming,” he said. The biggest obstacle was concern over liability, specifically that pregnant women would go into anaphylaxis and deliver prematurely, he said.
After a lot of lobbying, Dr. Heine and his colleagues started routine penicillin allergy testing in March 2016. There hasn’t been a single reaction among the 80-plus pregnant women tested so far, he reported.
Duke administrators were also concerned about reimbursement, but it hasn’t turned out to be a problem. Reimbursements from public and private payers “cover our costs,” a little over $100 per test, Dr. Heine said.
Dr. Heine said he can imagine outpatient testing at some point, but for now women are checked into triage. They get a fetal heart tone before 24 weeks, and a fetal heart rate monitor afterward. “We try to do it before 20 weeks so we don’t have to worry about the fetus,” he said.
When penicillin allergies are in the chart, or women say they are allergic, ask what type of reaction they had in the past. Type 1 reactions should be confirmed with testing. It’s okay to skip testing and give beta-lactams for non–type 1 reactions, but “if a woman has a non–type 1, and they’re already set up for testing, I’m going to do it anyway because getting the penicillin allergy off her chart is good for her and her life,” Dr. Heine said.
Dr. Heine and Dr. Harris reported having no financial disclosures.
AT IDSOG
Key clinical point:
Major finding: Among 81 women with documented penicillin allergies who received gentamicin and clindamycin, 16% developed surgical site infections. In contrast, among the 864 women who received cefazolin, the infection rate was 7%.
Data source: A single-center review at Duke University.
Disclosures: The investigators reported having no relevant financial disclosures.
Remediation for surgical trainees may lower attrition
Remediation programs and program director attitudes can make the difference in attrition rates among general surgery residents, according to a survey-based study.
A study by the Association of American Medical Colleges, projects a shortage of 29,000 general surgeons by 2030. Some residency programs are taking steps lower program dropout rates, which has been reported as high as 26% in some programs, according to Alexander Schwed, MD, general surgeon at Harbor–University of California, Los Angeles Medical Center.
Dr. Schwed and his colleagues conducted a survey of 21 general surgery residency program directors. In those programs, the overall attrition rate was found to be much lower than expected – 8.8% over a 5-year period (JAMA Surg. 2017 Aug 16. doi: 10.1001/jamasurg.2017.2656).
The survey showed that programs that implemented resident remediation had lower attrition rates, (21.0% vs 6.8%; P less than .001).
“The association between increased use of remediation by residency programs and low rates of resident attrition is novel,” the investigators wrote. “Nevertheless, based on our findings, high-attrition programs could lower their attrition rates through the increased use of resident remediation and increased focus on resident education.”
Both high- and low-attrition programs selected to participate in the study showed relatively similar median numbers of residents, with low-attrition programs reporting a median of 28 participants per year, and high-attrition programs reporting with 35.
Other similarities between low- and high-attrition programs include percentage of female and minority residents, median of 33.3% and 39.8% respectively, and the number of cases performed by first-, second-, and third-year residents.
The other difference between the six low-attrition programs and the five high-attrition programs was the attitude of the program directors regarding their role in the training of residents, according to researchers.
Investigators asked directors a series of questions using a Likert scale with 1 representing “strongly disagree” and 4 representing “strongly agree.”
Program directors from high- and low-attrition programs tended to agree strongly (scoring 3.8 and 3.2, respectively) with the statement that one of their main roles as a program leader was to “redirect residents who should not be surgeons.”
When asked whether “some degree of resident attrition is a necessary phenomenon,” directors from low-attrition programs scored 2.2, while those from high-attrition programs indicated stronger agreement with an overall score of 3.2.
Directors from programs with high dropout rates were also more likely to consider a 6% dropout rate to be too low, compared with directors from low-attrition programs who thought it was too high.
“When we recruit residents, we are very careful to recruit those who seem to buy into our mission, our vision, and our ideals and fit in well with our culture,” said Sharmila Dissanaike, MD, FACS, department of surgery chair at Texas Tech University Health Sciences Center, Lubbock, in an interview. “We emphasize teamwork, collegiality, and an ‘all for one and one for all’ type of mentality.”
This kind of recruitment includes having current residents be a part of the process, Dr. Dissanaike explained, and encouraging current and potential residents to have an informal dinner to get to know one another better.
For the department of surgery at Texas Tech, the collaborative culture combined with a remediation program has resulted in a drop in attrition from 20% down to 7% in recent years, Dr. Dissanaike said. In addition, the current success of her program can be partly attributed to a recent decision to maintain the number of incoming residents at five, she said.*
Larger programs can achieve similar improvement, she noted and the rising demand for surgeons makes it essential to find a solution that incorporates the benefits of both types of programs.
“We need more surgeons, we need more Graduate Medical Education spots, we need more training spots for general surgeons,” said Dr. Dissanaike. “I think within those large programs we need to find ways to structure smaller groups, maybe little pods, to help support residents so they don’t get lost.”
Dr. Schwed and his colleagues expressed concern that institutional barriers, such as the focus on test scores, may impede directors from embracing remediation.
“Greater emphasis on the written and oral General Surgery Qualifying Examination pass rates, which are now publicly posted and used by residency review committees, will likely exert pressure on program directors, who may fear that attempting to remediate a resident with poor medical knowledge may affect their program’s 5-year board pass rates,” the investigators wrote. “Our study suggests that such fears may be unfounded because programs with high levels of remediation and low attrition had similar board pass rates as those with high attrition.”
Dr. Schwed and his coinvestigators acknowledged that the programs studied may not be representative of U.S. residencies and selection bias may have affected the findings.
Researchers reported no relevant financial disclosures.
*Correction, 10/26/17: An earlier version of this article misstated the number of incoming residents in the program.
[email protected]
On Twitter @eaztweets
Remediation programs and program director attitudes can make the difference in attrition rates among general surgery residents, according to a survey-based study.
A study by the Association of American Medical Colleges, projects a shortage of 29,000 general surgeons by 2030. Some residency programs are taking steps lower program dropout rates, which has been reported as high as 26% in some programs, according to Alexander Schwed, MD, general surgeon at Harbor–University of California, Los Angeles Medical Center.
Dr. Schwed and his colleagues conducted a survey of 21 general surgery residency program directors. In those programs, the overall attrition rate was found to be much lower than expected – 8.8% over a 5-year period (JAMA Surg. 2017 Aug 16. doi: 10.1001/jamasurg.2017.2656).
The survey showed that programs that implemented resident remediation had lower attrition rates, (21.0% vs 6.8%; P less than .001).
“The association between increased use of remediation by residency programs and low rates of resident attrition is novel,” the investigators wrote. “Nevertheless, based on our findings, high-attrition programs could lower their attrition rates through the increased use of resident remediation and increased focus on resident education.”
Both high- and low-attrition programs selected to participate in the study showed relatively similar median numbers of residents, with low-attrition programs reporting a median of 28 participants per year, and high-attrition programs reporting with 35.
Other similarities between low- and high-attrition programs include percentage of female and minority residents, median of 33.3% and 39.8% respectively, and the number of cases performed by first-, second-, and third-year residents.
The other difference between the six low-attrition programs and the five high-attrition programs was the attitude of the program directors regarding their role in the training of residents, according to researchers.
Investigators asked directors a series of questions using a Likert scale with 1 representing “strongly disagree” and 4 representing “strongly agree.”
Program directors from high- and low-attrition programs tended to agree strongly (scoring 3.8 and 3.2, respectively) with the statement that one of their main roles as a program leader was to “redirect residents who should not be surgeons.”
When asked whether “some degree of resident attrition is a necessary phenomenon,” directors from low-attrition programs scored 2.2, while those from high-attrition programs indicated stronger agreement with an overall score of 3.2.
Directors from programs with high dropout rates were also more likely to consider a 6% dropout rate to be too low, compared with directors from low-attrition programs who thought it was too high.
“When we recruit residents, we are very careful to recruit those who seem to buy into our mission, our vision, and our ideals and fit in well with our culture,” said Sharmila Dissanaike, MD, FACS, department of surgery chair at Texas Tech University Health Sciences Center, Lubbock, in an interview. “We emphasize teamwork, collegiality, and an ‘all for one and one for all’ type of mentality.”
This kind of recruitment includes having current residents be a part of the process, Dr. Dissanaike explained, and encouraging current and potential residents to have an informal dinner to get to know one another better.
For the department of surgery at Texas Tech, the collaborative culture combined with a remediation program has resulted in a drop in attrition from 20% down to 7% in recent years, Dr. Dissanaike said. In addition, the current success of her program can be partly attributed to a recent decision to maintain the number of incoming residents at five, she said.*
Larger programs can achieve similar improvement, she noted and the rising demand for surgeons makes it essential to find a solution that incorporates the benefits of both types of programs.
“We need more surgeons, we need more Graduate Medical Education spots, we need more training spots for general surgeons,” said Dr. Dissanaike. “I think within those large programs we need to find ways to structure smaller groups, maybe little pods, to help support residents so they don’t get lost.”
Dr. Schwed and his colleagues expressed concern that institutional barriers, such as the focus on test scores, may impede directors from embracing remediation.
“Greater emphasis on the written and oral General Surgery Qualifying Examination pass rates, which are now publicly posted and used by residency review committees, will likely exert pressure on program directors, who may fear that attempting to remediate a resident with poor medical knowledge may affect their program’s 5-year board pass rates,” the investigators wrote. “Our study suggests that such fears may be unfounded because programs with high levels of remediation and low attrition had similar board pass rates as those with high attrition.”
Dr. Schwed and his coinvestigators acknowledged that the programs studied may not be representative of U.S. residencies and selection bias may have affected the findings.
Researchers reported no relevant financial disclosures.
*Correction, 10/26/17: An earlier version of this article misstated the number of incoming residents in the program.
[email protected]
On Twitter @eaztweets
Remediation programs and program director attitudes can make the difference in attrition rates among general surgery residents, according to a survey-based study.
A study by the Association of American Medical Colleges, projects a shortage of 29,000 general surgeons by 2030. Some residency programs are taking steps lower program dropout rates, which has been reported as high as 26% in some programs, according to Alexander Schwed, MD, general surgeon at Harbor–University of California, Los Angeles Medical Center.
Dr. Schwed and his colleagues conducted a survey of 21 general surgery residency program directors. In those programs, the overall attrition rate was found to be much lower than expected – 8.8% over a 5-year period (JAMA Surg. 2017 Aug 16. doi: 10.1001/jamasurg.2017.2656).
The survey showed that programs that implemented resident remediation had lower attrition rates, (21.0% vs 6.8%; P less than .001).
“The association between increased use of remediation by residency programs and low rates of resident attrition is novel,” the investigators wrote. “Nevertheless, based on our findings, high-attrition programs could lower their attrition rates through the increased use of resident remediation and increased focus on resident education.”
Both high- and low-attrition programs selected to participate in the study showed relatively similar median numbers of residents, with low-attrition programs reporting a median of 28 participants per year, and high-attrition programs reporting with 35.
Other similarities between low- and high-attrition programs include percentage of female and minority residents, median of 33.3% and 39.8% respectively, and the number of cases performed by first-, second-, and third-year residents.
The other difference between the six low-attrition programs and the five high-attrition programs was the attitude of the program directors regarding their role in the training of residents, according to researchers.
Investigators asked directors a series of questions using a Likert scale with 1 representing “strongly disagree” and 4 representing “strongly agree.”
Program directors from high- and low-attrition programs tended to agree strongly (scoring 3.8 and 3.2, respectively) with the statement that one of their main roles as a program leader was to “redirect residents who should not be surgeons.”
When asked whether “some degree of resident attrition is a necessary phenomenon,” directors from low-attrition programs scored 2.2, while those from high-attrition programs indicated stronger agreement with an overall score of 3.2.
Directors from programs with high dropout rates were also more likely to consider a 6% dropout rate to be too low, compared with directors from low-attrition programs who thought it was too high.
“When we recruit residents, we are very careful to recruit those who seem to buy into our mission, our vision, and our ideals and fit in well with our culture,” said Sharmila Dissanaike, MD, FACS, department of surgery chair at Texas Tech University Health Sciences Center, Lubbock, in an interview. “We emphasize teamwork, collegiality, and an ‘all for one and one for all’ type of mentality.”
This kind of recruitment includes having current residents be a part of the process, Dr. Dissanaike explained, and encouraging current and potential residents to have an informal dinner to get to know one another better.
For the department of surgery at Texas Tech, the collaborative culture combined with a remediation program has resulted in a drop in attrition from 20% down to 7% in recent years, Dr. Dissanaike said. In addition, the current success of her program can be partly attributed to a recent decision to maintain the number of incoming residents at five, she said.*
Larger programs can achieve similar improvement, she noted and the rising demand for surgeons makes it essential to find a solution that incorporates the benefits of both types of programs.
“We need more surgeons, we need more Graduate Medical Education spots, we need more training spots for general surgeons,” said Dr. Dissanaike. “I think within those large programs we need to find ways to structure smaller groups, maybe little pods, to help support residents so they don’t get lost.”
Dr. Schwed and his colleagues expressed concern that institutional barriers, such as the focus on test scores, may impede directors from embracing remediation.
“Greater emphasis on the written and oral General Surgery Qualifying Examination pass rates, which are now publicly posted and used by residency review committees, will likely exert pressure on program directors, who may fear that attempting to remediate a resident with poor medical knowledge may affect their program’s 5-year board pass rates,” the investigators wrote. “Our study suggests that such fears may be unfounded because programs with high levels of remediation and low attrition had similar board pass rates as those with high attrition.”
Dr. Schwed and his coinvestigators acknowledged that the programs studied may not be representative of U.S. residencies and selection bias may have affected the findings.
Researchers reported no relevant financial disclosures.
*Correction, 10/26/17: An earlier version of this article misstated the number of incoming residents in the program.
[email protected]
On Twitter @eaztweets
FROM JAMA SURGERY
Key clinical point:
Major finding: Of the 21 programs surveyed, there was an average attrition rate of 8.8% over 5 years.
Data source: Survey of 21 general surgery residency program directors between July 2010 and June 2015.
Disclosures: Investigators report no relevant financial disclosures.
Fewer complications, lower mortality with minimally invasive hernia repair
Minimally invasive surgical techniques are now used in nearly 80% of operations for paraesophageal hernia repair (PEH) and are associated with many outcome improvements, in comparison with open surgery, according to a retrospective study of data from nearly 100,000 cases.
“Many studies have shown improved perioperative outcomes in paraesophageal hernia repair with MIS [minimally invasive surgery] approaches, but the optimal approach is still debated,” wrote Patrick J. McLaren, MD, and his colleagues from the division of gastrointestinal and general surgery at Oregon Health & Science University, Portland. “In addition, the extent to which MIS has been adopted on the national level for PEH repair is unknown.” Their research letter was published online Aug. 23 in JAMA Surgery.
They found that the proportion of repair conducted using minimally invasive techniques increased from 9.8% in 2002 to 79.6% in 2012. At the same time, in-hospital mortality associated with paraesophageal hernia repair declined from 3.5% to 1.2%, and the rates of complications dropped from 29.8% to 20.6%.
Compared with open-repair procedures, minimally invasive surgery was associated with significantly lower in-hospital mortality (0.6% vs. 3%; P less than .001); wound complications (0.4% vs. 2.9%; P less than .001); septic complications (0.9% vs. 3.9%; P less than .001); and bleeding complications (0.6% vs. 1.8%; P less than .001), as well as urinary, respiratory, and cardiac complications, and intraoperative injury. No significant differences were seen between the two groups in the incidence of thromboembolic complications.
The mean length of hospital stay was 4.2 days in patients who underwent surgery using minimally invasive techniques, compared with 8.5 days in those who had open surgery.
The authors noted that early research on MIS for PEH raised the question of a possible higher risk of recurrence. While the study did not examine the incidence of hernia recurrence, the authors cited data showing that improvements in minimally invasive surgical techniques have been linked to a reduction in hiatal hernia recurrences.
“Studies have found that recurrences requiring reoperation after MIS repairs are low at 2.2%-6%,” the authors wrote. “Regardless, a role remains for open PEH repairs in cases of multiple prior abdominal operations and acute strangulation and in patients with an unstable condition.”
The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
This article was updated August 23, 2017.
Minimally invasive surgical techniques are now used in nearly 80% of operations for paraesophageal hernia repair (PEH) and are associated with many outcome improvements, in comparison with open surgery, according to a retrospective study of data from nearly 100,000 cases.
“Many studies have shown improved perioperative outcomes in paraesophageal hernia repair with MIS [minimally invasive surgery] approaches, but the optimal approach is still debated,” wrote Patrick J. McLaren, MD, and his colleagues from the division of gastrointestinal and general surgery at Oregon Health & Science University, Portland. “In addition, the extent to which MIS has been adopted on the national level for PEH repair is unknown.” Their research letter was published online Aug. 23 in JAMA Surgery.
They found that the proportion of repair conducted using minimally invasive techniques increased from 9.8% in 2002 to 79.6% in 2012. At the same time, in-hospital mortality associated with paraesophageal hernia repair declined from 3.5% to 1.2%, and the rates of complications dropped from 29.8% to 20.6%.
Compared with open-repair procedures, minimally invasive surgery was associated with significantly lower in-hospital mortality (0.6% vs. 3%; P less than .001); wound complications (0.4% vs. 2.9%; P less than .001); septic complications (0.9% vs. 3.9%; P less than .001); and bleeding complications (0.6% vs. 1.8%; P less than .001), as well as urinary, respiratory, and cardiac complications, and intraoperative injury. No significant differences were seen between the two groups in the incidence of thromboembolic complications.
The mean length of hospital stay was 4.2 days in patients who underwent surgery using minimally invasive techniques, compared with 8.5 days in those who had open surgery.
The authors noted that early research on MIS for PEH raised the question of a possible higher risk of recurrence. While the study did not examine the incidence of hernia recurrence, the authors cited data showing that improvements in minimally invasive surgical techniques have been linked to a reduction in hiatal hernia recurrences.
“Studies have found that recurrences requiring reoperation after MIS repairs are low at 2.2%-6%,” the authors wrote. “Regardless, a role remains for open PEH repairs in cases of multiple prior abdominal operations and acute strangulation and in patients with an unstable condition.”
The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
This article was updated August 23, 2017.
Minimally invasive surgical techniques are now used in nearly 80% of operations for paraesophageal hernia repair (PEH) and are associated with many outcome improvements, in comparison with open surgery, according to a retrospective study of data from nearly 100,000 cases.
“Many studies have shown improved perioperative outcomes in paraesophageal hernia repair with MIS [minimally invasive surgery] approaches, but the optimal approach is still debated,” wrote Patrick J. McLaren, MD, and his colleagues from the division of gastrointestinal and general surgery at Oregon Health & Science University, Portland. “In addition, the extent to which MIS has been adopted on the national level for PEH repair is unknown.” Their research letter was published online Aug. 23 in JAMA Surgery.
They found that the proportion of repair conducted using minimally invasive techniques increased from 9.8% in 2002 to 79.6% in 2012. At the same time, in-hospital mortality associated with paraesophageal hernia repair declined from 3.5% to 1.2%, and the rates of complications dropped from 29.8% to 20.6%.
Compared with open-repair procedures, minimally invasive surgery was associated with significantly lower in-hospital mortality (0.6% vs. 3%; P less than .001); wound complications (0.4% vs. 2.9%; P less than .001); septic complications (0.9% vs. 3.9%; P less than .001); and bleeding complications (0.6% vs. 1.8%; P less than .001), as well as urinary, respiratory, and cardiac complications, and intraoperative injury. No significant differences were seen between the two groups in the incidence of thromboembolic complications.
The mean length of hospital stay was 4.2 days in patients who underwent surgery using minimally invasive techniques, compared with 8.5 days in those who had open surgery.
The authors noted that early research on MIS for PEH raised the question of a possible higher risk of recurrence. While the study did not examine the incidence of hernia recurrence, the authors cited data showing that improvements in minimally invasive surgical techniques have been linked to a reduction in hiatal hernia recurrences.
“Studies have found that recurrences requiring reoperation after MIS repairs are low at 2.2%-6%,” the authors wrote. “Regardless, a role remains for open PEH repairs in cases of multiple prior abdominal operations and acute strangulation and in patients with an unstable condition.”
The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
This article was updated August 23, 2017.
FROM JAMA SURGERY
Key clinical point: Minimally invasive surgery for paraesophageal hernia repair is associated with significantly lower in-hospital mortality and complication rates than open repair.
Major finding: Compared with open-repair procedures, minimally invasive paraesophageal hernia repair was associated with significantly lower in-hospital mortality, wound, septic, bleeding, urinary, respiratory, and cardiac complications, and intraoperative injury.
Data source: A retrospective review of 97,393 inpatient admissions for paraesophageal hernia repair between 2002 and 2012.
Disclosures: The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
Antimicrobial development model links financial incentives with public health needs
A new model promoting the development and sustainable use of antimicrobials has been proposed by the Duke University Margolis Center for Health Policy.
Dubbed the “Priority Antimicrobial Value and Entry (PAVE) Award,” the model “provides developers quick access to a significant reward upon market entry of an effective antimicrobial, and provides strong incentives to shift reimbursement from insurance plans to population- and value-based contracts, not payments based on volume of sales,” according to a white paper detailing the proposal.
“This model builds on and reinforces the shift to quality and value in U.S. health care, with payments more directly linked to public health benefits and total costs,” Gregory Daniel, PhD, deputy director of the Margolis Center and lead author of the report, said in a viewpoint published online in JAMA (2017 Aug 3. doi: 10.1001/jama.2017.10164). “Along with strong push mechanisms that remove some of the financial risk associated with initial development of drug candidates, these measures could make a major contribution to the global effort to create and sustain a robust pipeline of antimicrobials that address current and growing public health needs – and would do so through an approach well suited to the reforming U.S. health care system.”
The proposal combines incentives provided from both the public and private sectors.
Payments from public funds would be largest in year 1 and would decrease over the next 5-6 years, with each payment “contingent upon developers demonstrating an increasing share of their revenue from population-based [alternative payment models] linked to value to society through availability, support for sustainable use, and continued data collection,” the report notes, describing a method that emphasizes value and delinks revenues from volume.
Delinking revenues from volume has been a part of two prominent proposals in Europe. One proposed by Chatham House, a London-based public policy institute, also proposed a number of financial incentives, such as public funding and tax credits, to help finance development in addition to MERs. A second being developed in the European Union, expected to be finalized later this year, would provide grants for early stage research, establishment of a nonprofit developer to manage and finance discovery through commercialization, a MER to developers that meet certain criteria, an annual licensing fee to developers for access to their product, and a dual-pricing model that allows for higher prices to be charged for appropriate use.
The Duke paper identifies a number of contracting models, such as a manufacturer contracting with a health plan on a per-member per-month basis to provide the drug as needed, or episode-based payments as needed, for all hospitalized patients identified with specific diagnosis-related groups.
“Successful implementation of the PAVE Award will require cooperation between developers, payers, and providers,” the Duke policy researchers stated. “The contract should encourage short- and long-term savings from reduced inappropriate use, as well as reduced infection-related costs, such as extended hospital stays, treatment complications, and additional infections.”
For infectious diseases physicians, there are a few specific roles in addition to any that are played beyond being a part of the medical research.
“For example, as the clinicians on the front lines seeing the patients, they are able to really identify what are the emerging threats on the horizon and where do we need to be targeting R&D. I think that is useful for helping to inform which antibiotics should be eligible to receive market entry rewards,” Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America, said in an interview. She also noted that physicians will be instrumental in “helping to create the political will to advance proposals like this because they are the ones who can really speak to what the need for patients is on the ground, in communities, and in hospitals.”
Physicians also will play a vital role in ensuring that any new antimicrobial drugs are not overused.
“Once these antibiotics are approved, infectious diseases physicians lead stewardship programs that are essential for ensuring that these drugs are used appropriately, and that is critical because if you start overusing the new antibiotics, resistance to them will develop quickly and you are back to where you started,” said Ms. Jezek, who was part of the advisory group that helped to inform the report.
A new model promoting the development and sustainable use of antimicrobials has been proposed by the Duke University Margolis Center for Health Policy.
Dubbed the “Priority Antimicrobial Value and Entry (PAVE) Award,” the model “provides developers quick access to a significant reward upon market entry of an effective antimicrobial, and provides strong incentives to shift reimbursement from insurance plans to population- and value-based contracts, not payments based on volume of sales,” according to a white paper detailing the proposal.
“This model builds on and reinforces the shift to quality and value in U.S. health care, with payments more directly linked to public health benefits and total costs,” Gregory Daniel, PhD, deputy director of the Margolis Center and lead author of the report, said in a viewpoint published online in JAMA (2017 Aug 3. doi: 10.1001/jama.2017.10164). “Along with strong push mechanisms that remove some of the financial risk associated with initial development of drug candidates, these measures could make a major contribution to the global effort to create and sustain a robust pipeline of antimicrobials that address current and growing public health needs – and would do so through an approach well suited to the reforming U.S. health care system.”
The proposal combines incentives provided from both the public and private sectors.
Payments from public funds would be largest in year 1 and would decrease over the next 5-6 years, with each payment “contingent upon developers demonstrating an increasing share of their revenue from population-based [alternative payment models] linked to value to society through availability, support for sustainable use, and continued data collection,” the report notes, describing a method that emphasizes value and delinks revenues from volume.
Delinking revenues from volume has been a part of two prominent proposals in Europe. One proposed by Chatham House, a London-based public policy institute, also proposed a number of financial incentives, such as public funding and tax credits, to help finance development in addition to MERs. A second being developed in the European Union, expected to be finalized later this year, would provide grants for early stage research, establishment of a nonprofit developer to manage and finance discovery through commercialization, a MER to developers that meet certain criteria, an annual licensing fee to developers for access to their product, and a dual-pricing model that allows for higher prices to be charged for appropriate use.
The Duke paper identifies a number of contracting models, such as a manufacturer contracting with a health plan on a per-member per-month basis to provide the drug as needed, or episode-based payments as needed, for all hospitalized patients identified with specific diagnosis-related groups.
“Successful implementation of the PAVE Award will require cooperation between developers, payers, and providers,” the Duke policy researchers stated. “The contract should encourage short- and long-term savings from reduced inappropriate use, as well as reduced infection-related costs, such as extended hospital stays, treatment complications, and additional infections.”
For infectious diseases physicians, there are a few specific roles in addition to any that are played beyond being a part of the medical research.
“For example, as the clinicians on the front lines seeing the patients, they are able to really identify what are the emerging threats on the horizon and where do we need to be targeting R&D. I think that is useful for helping to inform which antibiotics should be eligible to receive market entry rewards,” Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America, said in an interview. She also noted that physicians will be instrumental in “helping to create the political will to advance proposals like this because they are the ones who can really speak to what the need for patients is on the ground, in communities, and in hospitals.”
Physicians also will play a vital role in ensuring that any new antimicrobial drugs are not overused.
“Once these antibiotics are approved, infectious diseases physicians lead stewardship programs that are essential for ensuring that these drugs are used appropriately, and that is critical because if you start overusing the new antibiotics, resistance to them will develop quickly and you are back to where you started,” said Ms. Jezek, who was part of the advisory group that helped to inform the report.
A new model promoting the development and sustainable use of antimicrobials has been proposed by the Duke University Margolis Center for Health Policy.
Dubbed the “Priority Antimicrobial Value and Entry (PAVE) Award,” the model “provides developers quick access to a significant reward upon market entry of an effective antimicrobial, and provides strong incentives to shift reimbursement from insurance plans to population- and value-based contracts, not payments based on volume of sales,” according to a white paper detailing the proposal.
“This model builds on and reinforces the shift to quality and value in U.S. health care, with payments more directly linked to public health benefits and total costs,” Gregory Daniel, PhD, deputy director of the Margolis Center and lead author of the report, said in a viewpoint published online in JAMA (2017 Aug 3. doi: 10.1001/jama.2017.10164). “Along with strong push mechanisms that remove some of the financial risk associated with initial development of drug candidates, these measures could make a major contribution to the global effort to create and sustain a robust pipeline of antimicrobials that address current and growing public health needs – and would do so through an approach well suited to the reforming U.S. health care system.”
The proposal combines incentives provided from both the public and private sectors.
Payments from public funds would be largest in year 1 and would decrease over the next 5-6 years, with each payment “contingent upon developers demonstrating an increasing share of their revenue from population-based [alternative payment models] linked to value to society through availability, support for sustainable use, and continued data collection,” the report notes, describing a method that emphasizes value and delinks revenues from volume.
Delinking revenues from volume has been a part of two prominent proposals in Europe. One proposed by Chatham House, a London-based public policy institute, also proposed a number of financial incentives, such as public funding and tax credits, to help finance development in addition to MERs. A second being developed in the European Union, expected to be finalized later this year, would provide grants for early stage research, establishment of a nonprofit developer to manage and finance discovery through commercialization, a MER to developers that meet certain criteria, an annual licensing fee to developers for access to their product, and a dual-pricing model that allows for higher prices to be charged for appropriate use.
The Duke paper identifies a number of contracting models, such as a manufacturer contracting with a health plan on a per-member per-month basis to provide the drug as needed, or episode-based payments as needed, for all hospitalized patients identified with specific diagnosis-related groups.
“Successful implementation of the PAVE Award will require cooperation between developers, payers, and providers,” the Duke policy researchers stated. “The contract should encourage short- and long-term savings from reduced inappropriate use, as well as reduced infection-related costs, such as extended hospital stays, treatment complications, and additional infections.”
For infectious diseases physicians, there are a few specific roles in addition to any that are played beyond being a part of the medical research.
“For example, as the clinicians on the front lines seeing the patients, they are able to really identify what are the emerging threats on the horizon and where do we need to be targeting R&D. I think that is useful for helping to inform which antibiotics should be eligible to receive market entry rewards,” Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America, said in an interview. She also noted that physicians will be instrumental in “helping to create the political will to advance proposals like this because they are the ones who can really speak to what the need for patients is on the ground, in communities, and in hospitals.”
Physicians also will play a vital role in ensuring that any new antimicrobial drugs are not overused.
“Once these antibiotics are approved, infectious diseases physicians lead stewardship programs that are essential for ensuring that these drugs are used appropriately, and that is critical because if you start overusing the new antibiotics, resistance to them will develop quickly and you are back to where you started,” said Ms. Jezek, who was part of the advisory group that helped to inform the report.
MBSAQIP data helped target problem areas to cut readmissions
NEW YORK – Targeted interventions aimed at reducing patient readmission after bariatric surgery at a high-volume academic medical center led to a 61% overall decrease year over year. The center also saw a substantial reduction in readmissions linked to the top three factors of readmission identified by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, as well as a precipitous drop in the revisional surgery readmission rate.
“Our center, like so many others, has quarterly meetings in accordance with the MBSAQIP to look at our data. And this led to recognition of some common reasons for readmission,” said Chetan V. Aher, MD, a general surgeon at the department of surgery at Vanderbilt University Medical Center in Nashville, Tenn. Oral (PO) intolerance, dehydration, and nonemergent abdominal pain were the top reasons flagged by the MBSAQIP registry data at the medical center. Dr. Aher and his colleagues moved to focus on postoperative diet, administration of medications, management of patients who return to the hospital after surgery, and optimal staffing.
“Notably, the readmission rate for revisional procedures decreased by a whopping 90%,” Dr. Aher said. “I think a lot of these targeted interventions just really helped these patients who were at a higher risk to begin with to be readmitted.”
New dietary dos and don’ts
“We changed our postoperative diet,” Dr. Aher said. Instead of a soft food diet a couple of days after surgery, the full liquid diet was extended to 3 weeks post surgery.
The clinicians also implemented what they called a ‘no MEALS’ policy, which stands for no Meat, Eggs And Leftovers. “We were having problems with meat, although tender fish was okay, and some other things that went down easily,” Dr. Aher said at the American College of Surgeons Quality and Safety Conference. “We had some complaints about no eggs after surgery. A lot of patients love eggs,” he added. But they recommended avoiding eggs for 1 month after bariatric surgery to avoid nausea.
“Avoiding leftovers was also a big deal for patients,” Dr. Aher said. But patients who microwaved leftovers would “then come into the hospital with problems.”
Medication modifications
Another frequent cause of nausea was a “terrible and off-putting” taste when crushed tablets or medication capsules were added to the patient’s diet. Changing how patients took their medication “was a big help.” At the same time, there was a large institutional effort at Vanderbilt to start providing discharge medications in the hospital to increase postoperative compliance. “Bariatric surgery was one of the pilot programs for this,” Dr. Aher said. Discharge medications were filled by the pharmacy at Vanderbilt and delivered to the patient’s room, and a pharmacist or pharmacy intern explained how to use them. Compliance on medications increased, which may in turn have had an impact on readmissions.
Changes to patient management
Dr. Aher and his colleagues also changed where they treated patients who returned with problems. “Previously, when patients called in, the clinic diverted them to the emergency room. We stopped doing that, and increased our capacity to see these patients in the clinic instead.” This led to an increase in use of IV hydration in the clinic.
A meeting attendee asked if providing this service led to any problems with clinic capacity.
“Sometimes,” Dr. Aher said. “We don’t have a huge number of patients coming in for IV hydration, but when we had two come in on the same day, it did take up a couple of exam rooms.” To address this, the clinicians found other space in the clinic that would offer privacy for patients while not tying up exam rooms.
In addition, the clinic expanded nurse practitioner availability to 5 days a week to make the discharge process more consistent. “Of course, as we rolled all these things out, we made sure our educational material was updated accordingly,” Dr. Aher said.
The study demonstrates that a collaborative team effort and targeted interventions can result in a significant reduction in readmissions, Dr. Aher said. “Regular quality focused meetings are really important to facilitate recognition of various areas for improvement, especially in a high-volume center. Introducing an MBSAQIP registry serves as an excellent tool to effect these changes,” he said.
Dr. Aher had no relevant financial disclosures.
NEW YORK – Targeted interventions aimed at reducing patient readmission after bariatric surgery at a high-volume academic medical center led to a 61% overall decrease year over year. The center also saw a substantial reduction in readmissions linked to the top three factors of readmission identified by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, as well as a precipitous drop in the revisional surgery readmission rate.
“Our center, like so many others, has quarterly meetings in accordance with the MBSAQIP to look at our data. And this led to recognition of some common reasons for readmission,” said Chetan V. Aher, MD, a general surgeon at the department of surgery at Vanderbilt University Medical Center in Nashville, Tenn. Oral (PO) intolerance, dehydration, and nonemergent abdominal pain were the top reasons flagged by the MBSAQIP registry data at the medical center. Dr. Aher and his colleagues moved to focus on postoperative diet, administration of medications, management of patients who return to the hospital after surgery, and optimal staffing.
“Notably, the readmission rate for revisional procedures decreased by a whopping 90%,” Dr. Aher said. “I think a lot of these targeted interventions just really helped these patients who were at a higher risk to begin with to be readmitted.”
New dietary dos and don’ts
“We changed our postoperative diet,” Dr. Aher said. Instead of a soft food diet a couple of days after surgery, the full liquid diet was extended to 3 weeks post surgery.
The clinicians also implemented what they called a ‘no MEALS’ policy, which stands for no Meat, Eggs And Leftovers. “We were having problems with meat, although tender fish was okay, and some other things that went down easily,” Dr. Aher said at the American College of Surgeons Quality and Safety Conference. “We had some complaints about no eggs after surgery. A lot of patients love eggs,” he added. But they recommended avoiding eggs for 1 month after bariatric surgery to avoid nausea.
“Avoiding leftovers was also a big deal for patients,” Dr. Aher said. But patients who microwaved leftovers would “then come into the hospital with problems.”
Medication modifications
Another frequent cause of nausea was a “terrible and off-putting” taste when crushed tablets or medication capsules were added to the patient’s diet. Changing how patients took their medication “was a big help.” At the same time, there was a large institutional effort at Vanderbilt to start providing discharge medications in the hospital to increase postoperative compliance. “Bariatric surgery was one of the pilot programs for this,” Dr. Aher said. Discharge medications were filled by the pharmacy at Vanderbilt and delivered to the patient’s room, and a pharmacist or pharmacy intern explained how to use them. Compliance on medications increased, which may in turn have had an impact on readmissions.
Changes to patient management
Dr. Aher and his colleagues also changed where they treated patients who returned with problems. “Previously, when patients called in, the clinic diverted them to the emergency room. We stopped doing that, and increased our capacity to see these patients in the clinic instead.” This led to an increase in use of IV hydration in the clinic.
A meeting attendee asked if providing this service led to any problems with clinic capacity.
“Sometimes,” Dr. Aher said. “We don’t have a huge number of patients coming in for IV hydration, but when we had two come in on the same day, it did take up a couple of exam rooms.” To address this, the clinicians found other space in the clinic that would offer privacy for patients while not tying up exam rooms.
In addition, the clinic expanded nurse practitioner availability to 5 days a week to make the discharge process more consistent. “Of course, as we rolled all these things out, we made sure our educational material was updated accordingly,” Dr. Aher said.
The study demonstrates that a collaborative team effort and targeted interventions can result in a significant reduction in readmissions, Dr. Aher said. “Regular quality focused meetings are really important to facilitate recognition of various areas for improvement, especially in a high-volume center. Introducing an MBSAQIP registry serves as an excellent tool to effect these changes,” he said.
Dr. Aher had no relevant financial disclosures.
NEW YORK – Targeted interventions aimed at reducing patient readmission after bariatric surgery at a high-volume academic medical center led to a 61% overall decrease year over year. The center also saw a substantial reduction in readmissions linked to the top three factors of readmission identified by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, as well as a precipitous drop in the revisional surgery readmission rate.
“Our center, like so many others, has quarterly meetings in accordance with the MBSAQIP to look at our data. And this led to recognition of some common reasons for readmission,” said Chetan V. Aher, MD, a general surgeon at the department of surgery at Vanderbilt University Medical Center in Nashville, Tenn. Oral (PO) intolerance, dehydration, and nonemergent abdominal pain were the top reasons flagged by the MBSAQIP registry data at the medical center. Dr. Aher and his colleagues moved to focus on postoperative diet, administration of medications, management of patients who return to the hospital after surgery, and optimal staffing.
“Notably, the readmission rate for revisional procedures decreased by a whopping 90%,” Dr. Aher said. “I think a lot of these targeted interventions just really helped these patients who were at a higher risk to begin with to be readmitted.”
New dietary dos and don’ts
“We changed our postoperative diet,” Dr. Aher said. Instead of a soft food diet a couple of days after surgery, the full liquid diet was extended to 3 weeks post surgery.
The clinicians also implemented what they called a ‘no MEALS’ policy, which stands for no Meat, Eggs And Leftovers. “We were having problems with meat, although tender fish was okay, and some other things that went down easily,” Dr. Aher said at the American College of Surgeons Quality and Safety Conference. “We had some complaints about no eggs after surgery. A lot of patients love eggs,” he added. But they recommended avoiding eggs for 1 month after bariatric surgery to avoid nausea.
“Avoiding leftovers was also a big deal for patients,” Dr. Aher said. But patients who microwaved leftovers would “then come into the hospital with problems.”
Medication modifications
Another frequent cause of nausea was a “terrible and off-putting” taste when crushed tablets or medication capsules were added to the patient’s diet. Changing how patients took their medication “was a big help.” At the same time, there was a large institutional effort at Vanderbilt to start providing discharge medications in the hospital to increase postoperative compliance. “Bariatric surgery was one of the pilot programs for this,” Dr. Aher said. Discharge medications were filled by the pharmacy at Vanderbilt and delivered to the patient’s room, and a pharmacist or pharmacy intern explained how to use them. Compliance on medications increased, which may in turn have had an impact on readmissions.
Changes to patient management
Dr. Aher and his colleagues also changed where they treated patients who returned with problems. “Previously, when patients called in, the clinic diverted them to the emergency room. We stopped doing that, and increased our capacity to see these patients in the clinic instead.” This led to an increase in use of IV hydration in the clinic.
A meeting attendee asked if providing this service led to any problems with clinic capacity.
“Sometimes,” Dr. Aher said. “We don’t have a huge number of patients coming in for IV hydration, but when we had two come in on the same day, it did take up a couple of exam rooms.” To address this, the clinicians found other space in the clinic that would offer privacy for patients while not tying up exam rooms.
In addition, the clinic expanded nurse practitioner availability to 5 days a week to make the discharge process more consistent. “Of course, as we rolled all these things out, we made sure our educational material was updated accordingly,” Dr. Aher said.
The study demonstrates that a collaborative team effort and targeted interventions can result in a significant reduction in readmissions, Dr. Aher said. “Regular quality focused meetings are really important to facilitate recognition of various areas for improvement, especially in a high-volume center. Introducing an MBSAQIP registry serves as an excellent tool to effect these changes,” he said.
Dr. Aher had no relevant financial disclosures.
AT THE ACS QUALITY & SAFETY CONFERENCE
Key clinical point: A collaborative effort and target interventions can successfully reduce bariatric surgery readmissions.
Major finding: The overall bariatric surgery readmission rate dropped 61% in the year after intervention compared to the previous year.
Data source: Comparison of 471 bariatric procedures in 2015 to 539 others in 2016 at Vanderbilt University Medical Center.
Disclosures: Dr. Aher had no relevant financial disclosures.
Opioids overprescribed in elective hernia repair patients
A patient-centered study of postoperative analgesic needs found that surgeons may be overprescribing opioids for pain management after hernia repair operations.
The growing opioid public health crisis – and potential contribution of pain control prescriptions to the crisis – has prompted empirical work on surgeons’ prescribing and actual patient use of opioids (Ann Surg. 2017 Jul 10. doi: 10.1097/SLA.0000000000002365. [Epub ahead of print];J Arthroplasty. 2017;32[8]2395-2398). Excess pain medications are thought to raise the risk of patient dependence and to be potentially diverted to nonpatients’ use. A recent study (Ann Surg. 2017;265:709-16) found that a median of 30 opioid tablets were routinely prescribed by surgeons for pain management after hernia repair.
Konstantinos Mylonas, MD, a research fellow at Massachusetts General Hospital, Boston, and his coinvestigators conducted a prospective, observational study of 185 patients who had an outpatient inguinal hernia repair between October 2015 and September 2016. Participants completed a survey on their pain levels and opioid use during the 2- to 3-week period between their procedure and follow-up appointment (Surgery. 2017 Aug 1. doi: 10.1016/j.surg.2017.06.017).
For postop pain control, the patients were given 10 Vicodin (hydrocodone 5 mg/acetaminophen 325 mg) tablets, although all were advised that they may not require the medication but could instead use acetaminophen or ibuprofen as needed.
Of the 185 patients who were surveyed, 159 (86%) reported taking 4 or less of the 10 opioid tablets prescribed to them, with 110 (60%) reporting taking no tablets at all
While 13 (7%) of the patients did report using nine or more of the prescribed Vicodin tablets, none of the patients surveyed were still taking the pain medication within 7 days of their follow-up appointment.
When asked about how pain affected their returning to daily activities, 123 patients (66.5%) reported not having any pain interference, 42 (22.7%) mentioned slight problems, and 5 (2.7%) were noticeably affected. No patients were unable to return to their daily activities, and those 111 (75%) of the 147 patients who were employed were able to return to work within 3 days of surgery, according to the investigators.
As might be expected, those patients who experienced higher pain levels and persistent pain took more Vicodin tablets, but only one patient required a refill of the original prescription.
Patients were also not blinded to the study, which may have caused them to either take less opioid medication or not report their intake accurately. But the findings suggest that opioid prescribing could be tailored much more narrowly to patients’ needs and to individual procedures than is currently common practice. “Although our study was limited to a single procedure, performed by a single surgeon in a high-volume center, implementing patient-centered, procedure-specific opioid administration strategies may be conceivable across a variety of surgical disciplines,” the investigators concluded.
For the 750,000 inguinal hernia repairs done in the United States each year, prescribing 4 instead of 30 opioid tablets would decrease the number of opioid analgesics dispensed annually for hernia operation from 22.5 million to 3 million,” the investigators wrote. “As a result, 20 million fewer tablets per year would be available for potential diversion and abuse or as a stimulus for the start of opioid dependency.”
The researchers reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
A patient-centered study of postoperative analgesic needs found that surgeons may be overprescribing opioids for pain management after hernia repair operations.
The growing opioid public health crisis – and potential contribution of pain control prescriptions to the crisis – has prompted empirical work on surgeons’ prescribing and actual patient use of opioids (Ann Surg. 2017 Jul 10. doi: 10.1097/SLA.0000000000002365. [Epub ahead of print];J Arthroplasty. 2017;32[8]2395-2398). Excess pain medications are thought to raise the risk of patient dependence and to be potentially diverted to nonpatients’ use. A recent study (Ann Surg. 2017;265:709-16) found that a median of 30 opioid tablets were routinely prescribed by surgeons for pain management after hernia repair.
Konstantinos Mylonas, MD, a research fellow at Massachusetts General Hospital, Boston, and his coinvestigators conducted a prospective, observational study of 185 patients who had an outpatient inguinal hernia repair between October 2015 and September 2016. Participants completed a survey on their pain levels and opioid use during the 2- to 3-week period between their procedure and follow-up appointment (Surgery. 2017 Aug 1. doi: 10.1016/j.surg.2017.06.017).
For postop pain control, the patients were given 10 Vicodin (hydrocodone 5 mg/acetaminophen 325 mg) tablets, although all were advised that they may not require the medication but could instead use acetaminophen or ibuprofen as needed.
Of the 185 patients who were surveyed, 159 (86%) reported taking 4 or less of the 10 opioid tablets prescribed to them, with 110 (60%) reporting taking no tablets at all
While 13 (7%) of the patients did report using nine or more of the prescribed Vicodin tablets, none of the patients surveyed were still taking the pain medication within 7 days of their follow-up appointment.
When asked about how pain affected their returning to daily activities, 123 patients (66.5%) reported not having any pain interference, 42 (22.7%) mentioned slight problems, and 5 (2.7%) were noticeably affected. No patients were unable to return to their daily activities, and those 111 (75%) of the 147 patients who were employed were able to return to work within 3 days of surgery, according to the investigators.
As might be expected, those patients who experienced higher pain levels and persistent pain took more Vicodin tablets, but only one patient required a refill of the original prescription.
Patients were also not blinded to the study, which may have caused them to either take less opioid medication or not report their intake accurately. But the findings suggest that opioid prescribing could be tailored much more narrowly to patients’ needs and to individual procedures than is currently common practice. “Although our study was limited to a single procedure, performed by a single surgeon in a high-volume center, implementing patient-centered, procedure-specific opioid administration strategies may be conceivable across a variety of surgical disciplines,” the investigators concluded.
For the 750,000 inguinal hernia repairs done in the United States each year, prescribing 4 instead of 30 opioid tablets would decrease the number of opioid analgesics dispensed annually for hernia operation from 22.5 million to 3 million,” the investigators wrote. “As a result, 20 million fewer tablets per year would be available for potential diversion and abuse or as a stimulus for the start of opioid dependency.”
The researchers reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
A patient-centered study of postoperative analgesic needs found that surgeons may be overprescribing opioids for pain management after hernia repair operations.
The growing opioid public health crisis – and potential contribution of pain control prescriptions to the crisis – has prompted empirical work on surgeons’ prescribing and actual patient use of opioids (Ann Surg. 2017 Jul 10. doi: 10.1097/SLA.0000000000002365. [Epub ahead of print];J Arthroplasty. 2017;32[8]2395-2398). Excess pain medications are thought to raise the risk of patient dependence and to be potentially diverted to nonpatients’ use. A recent study (Ann Surg. 2017;265:709-16) found that a median of 30 opioid tablets were routinely prescribed by surgeons for pain management after hernia repair.
Konstantinos Mylonas, MD, a research fellow at Massachusetts General Hospital, Boston, and his coinvestigators conducted a prospective, observational study of 185 patients who had an outpatient inguinal hernia repair between October 2015 and September 2016. Participants completed a survey on their pain levels and opioid use during the 2- to 3-week period between their procedure and follow-up appointment (Surgery. 2017 Aug 1. doi: 10.1016/j.surg.2017.06.017).
For postop pain control, the patients were given 10 Vicodin (hydrocodone 5 mg/acetaminophen 325 mg) tablets, although all were advised that they may not require the medication but could instead use acetaminophen or ibuprofen as needed.
Of the 185 patients who were surveyed, 159 (86%) reported taking 4 or less of the 10 opioid tablets prescribed to them, with 110 (60%) reporting taking no tablets at all
While 13 (7%) of the patients did report using nine or more of the prescribed Vicodin tablets, none of the patients surveyed were still taking the pain medication within 7 days of their follow-up appointment.
When asked about how pain affected their returning to daily activities, 123 patients (66.5%) reported not having any pain interference, 42 (22.7%) mentioned slight problems, and 5 (2.7%) were noticeably affected. No patients were unable to return to their daily activities, and those 111 (75%) of the 147 patients who were employed were able to return to work within 3 days of surgery, according to the investigators.
As might be expected, those patients who experienced higher pain levels and persistent pain took more Vicodin tablets, but only one patient required a refill of the original prescription.
Patients were also not blinded to the study, which may have caused them to either take less opioid medication or not report their intake accurately. But the findings suggest that opioid prescribing could be tailored much more narrowly to patients’ needs and to individual procedures than is currently common practice. “Although our study was limited to a single procedure, performed by a single surgeon in a high-volume center, implementing patient-centered, procedure-specific opioid administration strategies may be conceivable across a variety of surgical disciplines,” the investigators concluded.
For the 750,000 inguinal hernia repairs done in the United States each year, prescribing 4 instead of 30 opioid tablets would decrease the number of opioid analgesics dispensed annually for hernia operation from 22.5 million to 3 million,” the investigators wrote. “As a result, 20 million fewer tablets per year would be available for potential diversion and abuse or as a stimulus for the start of opioid dependency.”
The researchers reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
FROM SURGERY
Key clinical point:
Major finding: Of 185 patients surveyed, 159 (86%) reported taking 4 or less opioid tablets of a 10-tablet prescription.
Data source: Observational study of 185 elective inguinal hernia repair patients between October 2015 and September 2016.
Disclosures: Investigators reported no relevant financial disclosures.
NASH did not increase risk of poor liver transplantation outcomes
Adults with nonalcoholic steatohepatitis (NASH) fared as well on key outcome measures as other liver transplant recipients, despite having significantly more comorbidities, according to the results of a single-center retrospective cohort study.
Major morbidity, mortality, and rates of graft survival after 90 days were similar between patients who underwent transplantation for NASH and those who underwent it for another cirrhotic liver condition, wrote Eline H. van den Berg, MD, of University Medical Center Groningen (the Netherlands) with her associates. “These results are comforting, considering the expected increase of patients with NASH cirrhosis in the near future,” the researchers concluded. “Future analysis regarding the recurrence of nonalcoholic fatty liver disease, development of long-term complications, long-term graft patency, and occurrence of comorbid diseases after LT [liver transplantation] is mandatory to better understand the natural history and risk profile of NASH patients and to prevent and treat its complications.” The findings were published online in Digestive and Liver Disease (Dig Liver Dis. 2017 Aug 11. doi: 10.1016/j.dld.2017.08.022).
Nonalcoholic fatty liver disease begins as steatosis and can progress to NASH, fibrosis, and cirrhosis. The global obesity epidemic is amplifying its incidence, and about 26% of patients who develop NASH ultimately develop cirrhosis. Cirrhosis itself increases the risk of in-hospital death or prolonged length of postoperative stay, but patients with NASH also have obesity and cardiovascular disease, which might “tremendously increase” the risk of poor postoperative outcomes, the researchers said. Because prior research had focused mainly on mortality and had reported conflicting results, they used the Clavien-Dindo classification system to retrospectively study rates of complications among 169 adults who underwent liver transplantation at their center from 2009 through 2015, including 34 (20%) patients with NASH cirrhosis.
Patients with NASH were significantly older than other transplant recipients (59 versus 55 years, P = .01) and had markedly higher rates of obesity (62% versus 8%; P less than .01), diabetes mellitus (74% versus 20%; P less than .01), metabolic syndrome (83% versus 38%; P less than .01), hypertension (61% versus 30%; P less than .01), and cardiovascular disease (29% versus 11%; P less than .01). Despite these differences, the groups had statistically similar rates of postoperative mortality (3% in both groups), 90-day graft survival posttransplantation (94% and 90%, respectively), and major postoperative complications, including biopsy-proven acute cellular rejection (3% and 7%), hepatic artery thrombosis (0% and 7%), relaparotomy (15% and 24%), primary nonfunction (0% and 1.6%), retransplantation (6% and 7%), sepsis (12% and 13%), gastrointestinal infection (24% and 36%), fever of unknown origin (18% and 14%), and renal replacement therapy (15% and 24%).
After accounting for age, sex, transplant year, and donor characteristics, NASH patients were at significantly increased risk of grade 2 urogenital infections, compared with other patients (odds ratio, 3.4; 95% confidence interval, 1.1 to 10.6; P = .03). Grade 1 complications also were more common with NASH than otherwise (77% versus 59%), and the difference remained statistically significant in the multivariable analysis (OR, 1.6; 95% CI, 1.03 to 2.63; P = .04).
The study used a strict, internationally accepted definition of NASH – all patients either had cases confirmed by biopsy, had metabolic syndrome, or had obesity and type 2 diabetes mellitus, and, further, none had hepatitis or alcoholic liver disease. None of the patients in the study received transplants for acute liver failure or noncirrhotic liver disease, and none were 70 years or older, which is the cutoff age for liver transplantation in the Netherlands.
The investigators received no funding for the study and reported having no conflicts of interest.
Adults with nonalcoholic steatohepatitis (NASH) fared as well on key outcome measures as other liver transplant recipients, despite having significantly more comorbidities, according to the results of a single-center retrospective cohort study.
Major morbidity, mortality, and rates of graft survival after 90 days were similar between patients who underwent transplantation for NASH and those who underwent it for another cirrhotic liver condition, wrote Eline H. van den Berg, MD, of University Medical Center Groningen (the Netherlands) with her associates. “These results are comforting, considering the expected increase of patients with NASH cirrhosis in the near future,” the researchers concluded. “Future analysis regarding the recurrence of nonalcoholic fatty liver disease, development of long-term complications, long-term graft patency, and occurrence of comorbid diseases after LT [liver transplantation] is mandatory to better understand the natural history and risk profile of NASH patients and to prevent and treat its complications.” The findings were published online in Digestive and Liver Disease (Dig Liver Dis. 2017 Aug 11. doi: 10.1016/j.dld.2017.08.022).
Nonalcoholic fatty liver disease begins as steatosis and can progress to NASH, fibrosis, and cirrhosis. The global obesity epidemic is amplifying its incidence, and about 26% of patients who develop NASH ultimately develop cirrhosis. Cirrhosis itself increases the risk of in-hospital death or prolonged length of postoperative stay, but patients with NASH also have obesity and cardiovascular disease, which might “tremendously increase” the risk of poor postoperative outcomes, the researchers said. Because prior research had focused mainly on mortality and had reported conflicting results, they used the Clavien-Dindo classification system to retrospectively study rates of complications among 169 adults who underwent liver transplantation at their center from 2009 through 2015, including 34 (20%) patients with NASH cirrhosis.
Patients with NASH were significantly older than other transplant recipients (59 versus 55 years, P = .01) and had markedly higher rates of obesity (62% versus 8%; P less than .01), diabetes mellitus (74% versus 20%; P less than .01), metabolic syndrome (83% versus 38%; P less than .01), hypertension (61% versus 30%; P less than .01), and cardiovascular disease (29% versus 11%; P less than .01). Despite these differences, the groups had statistically similar rates of postoperative mortality (3% in both groups), 90-day graft survival posttransplantation (94% and 90%, respectively), and major postoperative complications, including biopsy-proven acute cellular rejection (3% and 7%), hepatic artery thrombosis (0% and 7%), relaparotomy (15% and 24%), primary nonfunction (0% and 1.6%), retransplantation (6% and 7%), sepsis (12% and 13%), gastrointestinal infection (24% and 36%), fever of unknown origin (18% and 14%), and renal replacement therapy (15% and 24%).
After accounting for age, sex, transplant year, and donor characteristics, NASH patients were at significantly increased risk of grade 2 urogenital infections, compared with other patients (odds ratio, 3.4; 95% confidence interval, 1.1 to 10.6; P = .03). Grade 1 complications also were more common with NASH than otherwise (77% versus 59%), and the difference remained statistically significant in the multivariable analysis (OR, 1.6; 95% CI, 1.03 to 2.63; P = .04).
The study used a strict, internationally accepted definition of NASH – all patients either had cases confirmed by biopsy, had metabolic syndrome, or had obesity and type 2 diabetes mellitus, and, further, none had hepatitis or alcoholic liver disease. None of the patients in the study received transplants for acute liver failure or noncirrhotic liver disease, and none were 70 years or older, which is the cutoff age for liver transplantation in the Netherlands.
The investigators received no funding for the study and reported having no conflicts of interest.
Adults with nonalcoholic steatohepatitis (NASH) fared as well on key outcome measures as other liver transplant recipients, despite having significantly more comorbidities, according to the results of a single-center retrospective cohort study.
Major morbidity, mortality, and rates of graft survival after 90 days were similar between patients who underwent transplantation for NASH and those who underwent it for another cirrhotic liver condition, wrote Eline H. van den Berg, MD, of University Medical Center Groningen (the Netherlands) with her associates. “These results are comforting, considering the expected increase of patients with NASH cirrhosis in the near future,” the researchers concluded. “Future analysis regarding the recurrence of nonalcoholic fatty liver disease, development of long-term complications, long-term graft patency, and occurrence of comorbid diseases after LT [liver transplantation] is mandatory to better understand the natural history and risk profile of NASH patients and to prevent and treat its complications.” The findings were published online in Digestive and Liver Disease (Dig Liver Dis. 2017 Aug 11. doi: 10.1016/j.dld.2017.08.022).
Nonalcoholic fatty liver disease begins as steatosis and can progress to NASH, fibrosis, and cirrhosis. The global obesity epidemic is amplifying its incidence, and about 26% of patients who develop NASH ultimately develop cirrhosis. Cirrhosis itself increases the risk of in-hospital death or prolonged length of postoperative stay, but patients with NASH also have obesity and cardiovascular disease, which might “tremendously increase” the risk of poor postoperative outcomes, the researchers said. Because prior research had focused mainly on mortality and had reported conflicting results, they used the Clavien-Dindo classification system to retrospectively study rates of complications among 169 adults who underwent liver transplantation at their center from 2009 through 2015, including 34 (20%) patients with NASH cirrhosis.
Patients with NASH were significantly older than other transplant recipients (59 versus 55 years, P = .01) and had markedly higher rates of obesity (62% versus 8%; P less than .01), diabetes mellitus (74% versus 20%; P less than .01), metabolic syndrome (83% versus 38%; P less than .01), hypertension (61% versus 30%; P less than .01), and cardiovascular disease (29% versus 11%; P less than .01). Despite these differences, the groups had statistically similar rates of postoperative mortality (3% in both groups), 90-day graft survival posttransplantation (94% and 90%, respectively), and major postoperative complications, including biopsy-proven acute cellular rejection (3% and 7%), hepatic artery thrombosis (0% and 7%), relaparotomy (15% and 24%), primary nonfunction (0% and 1.6%), retransplantation (6% and 7%), sepsis (12% and 13%), gastrointestinal infection (24% and 36%), fever of unknown origin (18% and 14%), and renal replacement therapy (15% and 24%).
After accounting for age, sex, transplant year, and donor characteristics, NASH patients were at significantly increased risk of grade 2 urogenital infections, compared with other patients (odds ratio, 3.4; 95% confidence interval, 1.1 to 10.6; P = .03). Grade 1 complications also were more common with NASH than otherwise (77% versus 59%), and the difference remained statistically significant in the multivariable analysis (OR, 1.6; 95% CI, 1.03 to 2.63; P = .04).
The study used a strict, internationally accepted definition of NASH – all patients either had cases confirmed by biopsy, had metabolic syndrome, or had obesity and type 2 diabetes mellitus, and, further, none had hepatitis or alcoholic liver disease. None of the patients in the study received transplants for acute liver failure or noncirrhotic liver disease, and none were 70 years or older, which is the cutoff age for liver transplantation in the Netherlands.
The investigators received no funding for the study and reported having no conflicts of interest.
FROM DIGESTIVE AND LIVER DISEASES
Key clinical point: Adults with nonalcoholic steatohepatitis (NASH) fared as well as on key outcome measures as other liver transplant recipients, despite having significantly more comorbidities.
Major finding: Patients with and without NASH had statistically similar rates of postoperative mortality (3% in both groups), 90-day graft survival (94% and 90%, respectively), and major postoperative complications.
Data source: A single-center retrospective cohort study of 169 adult liver transplant recipients, of whom 20% were transplanted for NASH cirrhosis.
Disclosures: The investigators received no funding for the study and reported having no conflicts of interest.
Big changes coming for thyroid cancer staging
BOSTON – When the American Joint Committee on Cancer’s Eighth Edition Cancer Staging Manual becomes effective for U.S. practice on Jan. 1, 2018, substantially more patients with thyroid cancer will meet the definition for stage I disease, but their survival prognosis will remain as good as it was for the smaller slice of patients defined with stage I thyroid cancer by the seventh edition, Bryan R. Haugen, MD, predicted during a talk at the World Congress on Thyroid Cancer.
Under current stage definitions in the seventh edition, roughly 60% of thyroid cancer patients have stage I disease, but this will kick up to about 80% under the eighth edition, said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. Despite this influx of more patients, “survival rates in stage I patients haven’t changed,” with a disease-specific survival (DSS) of 98%-100% for stage I patients in the eighth edition compared with 97%-100% in the seventh edition, he noted.
Dr. Haugen credited this apparent paradox to the revised staging system’s superior discrimination among various grades of disease progression. “The eighth edition better separates patients based on their projected survival.” As more patients fit stage I classification with its highest level of projected survival, fewer patients will classify with more advanced disease and its worse projected survival.
For example, in the seventh edition patients with stage IV disease had a projected DSS rate of 50%-75%; in the eighth edition that rate is now less than 50%. The projected DSS rate for patients with stage II disease has down shifted from 97%-100% in the seventh edition to 85%-95% in the eighth. For patients with stage III thyroid cancer the DSS rate of 88%-95% in the seventh edition became 60%-70% in the eighth edition.
‘The new system will take some getting used to,” Dr. Haugen admitted, and it involves even more “big” changes, he warned. These include:
• Changing the cutpoint separating younger from older patients to 55 years of age in the eighth edition, a rise from the 45-year-old cutpoint in the seventh edition.
• Allowing tumors classified as stage I to be as large as 4 cm, up from the 2 cm or less defining stage I in the seventh edition.
• Reserving stage II designation for patients with tumors larger than 4 cm. In the seventh edition tumors had to be 2-4 cm in size.
• Expanding stage II disease to include not only patients with disease confined to their thyroid, but also patients with N1 lymph node spread or gross extrathyroidal extension. In the seventh edition tumor spread like this put patients into stage III.
• Specifying in the eighth edition that stage III disease must feature gross extrathyroidal extension into the larynx, trachea, esophagus, or recurrent laryngial nerve. To qualify for stage IV in the eighth edition, spread must extend into prevertebral fascia or encase major vessels, for stage IVA, or involve distant metastases for stage IVB.
• Paring down three stage IV subgroups, A, B, and C, in the seventh edition to just an A or B subgroup in the eighth edition.
Dr. Haugen coauthored a recent editorial that laid out an assessment of the eighth edition in greater detail (Thyroid. 2017 Jun;27[6]:751-6).
[email protected]
On Twitter @mitchelzoler
BOSTON – When the American Joint Committee on Cancer’s Eighth Edition Cancer Staging Manual becomes effective for U.S. practice on Jan. 1, 2018, substantially more patients with thyroid cancer will meet the definition for stage I disease, but their survival prognosis will remain as good as it was for the smaller slice of patients defined with stage I thyroid cancer by the seventh edition, Bryan R. Haugen, MD, predicted during a talk at the World Congress on Thyroid Cancer.
Under current stage definitions in the seventh edition, roughly 60% of thyroid cancer patients have stage I disease, but this will kick up to about 80% under the eighth edition, said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. Despite this influx of more patients, “survival rates in stage I patients haven’t changed,” with a disease-specific survival (DSS) of 98%-100% for stage I patients in the eighth edition compared with 97%-100% in the seventh edition, he noted.
Dr. Haugen credited this apparent paradox to the revised staging system’s superior discrimination among various grades of disease progression. “The eighth edition better separates patients based on their projected survival.” As more patients fit stage I classification with its highest level of projected survival, fewer patients will classify with more advanced disease and its worse projected survival.
For example, in the seventh edition patients with stage IV disease had a projected DSS rate of 50%-75%; in the eighth edition that rate is now less than 50%. The projected DSS rate for patients with stage II disease has down shifted from 97%-100% in the seventh edition to 85%-95% in the eighth. For patients with stage III thyroid cancer the DSS rate of 88%-95% in the seventh edition became 60%-70% in the eighth edition.
‘The new system will take some getting used to,” Dr. Haugen admitted, and it involves even more “big” changes, he warned. These include:
• Changing the cutpoint separating younger from older patients to 55 years of age in the eighth edition, a rise from the 45-year-old cutpoint in the seventh edition.
• Allowing tumors classified as stage I to be as large as 4 cm, up from the 2 cm or less defining stage I in the seventh edition.
• Reserving stage II designation for patients with tumors larger than 4 cm. In the seventh edition tumors had to be 2-4 cm in size.
• Expanding stage II disease to include not only patients with disease confined to their thyroid, but also patients with N1 lymph node spread or gross extrathyroidal extension. In the seventh edition tumor spread like this put patients into stage III.
• Specifying in the eighth edition that stage III disease must feature gross extrathyroidal extension into the larynx, trachea, esophagus, or recurrent laryngial nerve. To qualify for stage IV in the eighth edition, spread must extend into prevertebral fascia or encase major vessels, for stage IVA, or involve distant metastases for stage IVB.
• Paring down three stage IV subgroups, A, B, and C, in the seventh edition to just an A or B subgroup in the eighth edition.
Dr. Haugen coauthored a recent editorial that laid out an assessment of the eighth edition in greater detail (Thyroid. 2017 Jun;27[6]:751-6).
[email protected]
On Twitter @mitchelzoler
BOSTON – When the American Joint Committee on Cancer’s Eighth Edition Cancer Staging Manual becomes effective for U.S. practice on Jan. 1, 2018, substantially more patients with thyroid cancer will meet the definition for stage I disease, but their survival prognosis will remain as good as it was for the smaller slice of patients defined with stage I thyroid cancer by the seventh edition, Bryan R. Haugen, MD, predicted during a talk at the World Congress on Thyroid Cancer.
Under current stage definitions in the seventh edition, roughly 60% of thyroid cancer patients have stage I disease, but this will kick up to about 80% under the eighth edition, said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. Despite this influx of more patients, “survival rates in stage I patients haven’t changed,” with a disease-specific survival (DSS) of 98%-100% for stage I patients in the eighth edition compared with 97%-100% in the seventh edition, he noted.
Dr. Haugen credited this apparent paradox to the revised staging system’s superior discrimination among various grades of disease progression. “The eighth edition better separates patients based on their projected survival.” As more patients fit stage I classification with its highest level of projected survival, fewer patients will classify with more advanced disease and its worse projected survival.
For example, in the seventh edition patients with stage IV disease had a projected DSS rate of 50%-75%; in the eighth edition that rate is now less than 50%. The projected DSS rate for patients with stage II disease has down shifted from 97%-100% in the seventh edition to 85%-95% in the eighth. For patients with stage III thyroid cancer the DSS rate of 88%-95% in the seventh edition became 60%-70% in the eighth edition.
‘The new system will take some getting used to,” Dr. Haugen admitted, and it involves even more “big” changes, he warned. These include:
• Changing the cutpoint separating younger from older patients to 55 years of age in the eighth edition, a rise from the 45-year-old cutpoint in the seventh edition.
• Allowing tumors classified as stage I to be as large as 4 cm, up from the 2 cm or less defining stage I in the seventh edition.
• Reserving stage II designation for patients with tumors larger than 4 cm. In the seventh edition tumors had to be 2-4 cm in size.
• Expanding stage II disease to include not only patients with disease confined to their thyroid, but also patients with N1 lymph node spread or gross extrathyroidal extension. In the seventh edition tumor spread like this put patients into stage III.
• Specifying in the eighth edition that stage III disease must feature gross extrathyroidal extension into the larynx, trachea, esophagus, or recurrent laryngial nerve. To qualify for stage IV in the eighth edition, spread must extend into prevertebral fascia or encase major vessels, for stage IVA, or involve distant metastases for stage IVB.
• Paring down three stage IV subgroups, A, B, and C, in the seventh edition to just an A or B subgroup in the eighth edition.
Dr. Haugen coauthored a recent editorial that laid out an assessment of the eighth edition in greater detail (Thyroid. 2017 Jun;27[6]:751-6).
[email protected]
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM WCTC 2017
Cerebral NIRS may be flawed for assessing infant brains after stage 1 palliation of HLHS
The regional oxygenation index (rSO2) based on near infrared spectroscopy (NIRS) measurement is frequently used to assess the adequacy of oxygen delivery after stage 1 palliation of hypoplastic left heart syndrome (HLHS). However, a recent study showed that cerebral rSO2 has low sensitivity and should not be considered reassuring even at rSO2 of 50 or greater. In addition, values below 30 were not found to be sensitive for detecting compromised oxygen delivery, according to a report published online in the Journal of Thoracic and Cardiovascular Surgery.
Erin Rescoe, MD, of Boston Children’s Hospital, and her colleagues at Harvard Medical School, Boston, performed a retrospective study of 73 neonates assessed with cerebral venous oxyhemoglobin saturation (ScvO2) measured by co-oximetry from the internal jugular vein, which is considered the preferred method for assessing the adequacy of tissue oxygen delivery, compared with cerebral rSO2 after stage 1 palliation of HLHS (doi: 10.1016/j.jtcvs.2017.03.154).
To determine the suggested benefit of NIRS as an effective trend monitor, the researchers used their interpolated data to examine changes in rSO2 and changes in ScvO2 at hourly intervals and compared these values.Of particular concern is the result showing that, in all instances where ScvO2 was less than 30%, rSO2 was greater than 30%. In terms of the sensitivity (the true positive rate) and specificity (the true negative rate) of using NIRS, time-matched pairs of rSO2 and ScvO2 showed that the receiver operating characteristic curves for rSO2 as a diagnostic test to detect ScvO2 less than 30%, less than 40%, and less than 50% were 0.82, 0.84, and 0.87, respectively, showing good specificity, with a value of rSO2 less than 30% indicating that ScvO2 will be less than 30% 99% of the time.
“However, the sensitivity of rSO2 in the range of clinical interest in detecting ScvO2 less than 30% is extremely low,” according to the researchers. Thus, NIRS is likely to produce false negatives, missing patients with clinically low postoperative oxygen saturation.
In fact, rSO2 was less than 30% less than 1% of the time that ScvO2 was less than 30%. Similar results were seen in comparing values at the less than 40% mark (equivalent less than 1% of the time). Better results showed at the less than 50% mark, with equivalence seen 46% of the time.
NIRS measures a composite of arterial and venous blood, according to Dr. Rescoe and her colleagues. Therefore, to do a more direct comparison, they adjusted their NIRS results by calculating an rSO2-based ScvO2 designed to remove arterial contamination from the rSO2 signal: rSO2-based ScvO2 = (rSO2 arterial oxygen saturation x 0.3)/0.7.
This significantly improved the sensitivity of rSO2 to detect ScvO2 at less than 30% to 6.5%, to 29% for rSO2 at less than 40%, and 77.4% for rSO2 less than 50%.
The researchers “were surprised by the extremely low sensitivity of cerebral NIRS to detect even the most severe aberrations in DO2” (i.e., ScvO2 less than 30%, which has been found to be associated with poor outcomes).
“Cerebral rSO2 in isolation should not be used to detect low ScvO2, because its sensitivity is low, although correction of rSO2 for arterial contamination significantly improves sensitivity. Cerebral rSO2 of 50 or greater should not be considered reassuring with regard to ScvO2, although values less than 30 are specific for low ScvO2,” the researchers concluded.
The study was sponsored by the Gerber Foundation, the Hess Family Philanthropic Fund, and Boston Children’s Hospital Heart Center Strategic Investment Fund. The authors disclosed that they had no financial conflicts.
The use of postoperative cerebral venous oxygen saturation monitoring (ScvO2) through an internal jugular vein catheter allows better monitoring of circulation, which may lead to better outcomes, but it is invasive and challenging. NIRS, being noninvasive, has proved attractive, but clinical interpretation in terms of both absolute values and trends is difficult, Edward Buratto, MBBS, and his colleagues noted in their invited commentary (doi: 10.1016/j.jtcvs.2017.04.061).
Dr. Rescoe and her colleagues have analyzed the correlation of NIRS-derived data with ScvO2 measured by co-oximetry from the internal jugular vein in 73 neonates after stage 1 palliation for hypoplastic left heart syndrome. They demonstrated that cerebral rSO2 correlated poorly with low ScvO2, and they suggest that cerebral rSO2 not be used in isolation. This problem was somewhat ameliorated by correction of the signal for arterial contamination. NIRS appears to be too valuable a tool to be simply discarded, they said, suggesting that a perioperative risk assessment that would include multisite NIRS and hemodynamic monitoring might still allow early determination of low-cardiac output.
“Two numbers are better than one,” wrote Dr. Buratto and his colleagues. “Whether the NIRS technology will add any useful information to a simple bedside assessment by an astute clinician is yet to be seen.”
Edward Buratto, MBBS, Steve Horton, PhD, and Igor E. Konstantinov, MD, are from the Department of Cardiothoracic Surgery, The Royal Children’s Hospital; the Department of Pediatrics, University of Melbourne; and Murdoch Children’s Research Institute, Melbourne. They reported having no financial conflicts of interest.
The use of postoperative cerebral venous oxygen saturation monitoring (ScvO2) through an internal jugular vein catheter allows better monitoring of circulation, which may lead to better outcomes, but it is invasive and challenging. NIRS, being noninvasive, has proved attractive, but clinical interpretation in terms of both absolute values and trends is difficult, Edward Buratto, MBBS, and his colleagues noted in their invited commentary (doi: 10.1016/j.jtcvs.2017.04.061).
Dr. Rescoe and her colleagues have analyzed the correlation of NIRS-derived data with ScvO2 measured by co-oximetry from the internal jugular vein in 73 neonates after stage 1 palliation for hypoplastic left heart syndrome. They demonstrated that cerebral rSO2 correlated poorly with low ScvO2, and they suggest that cerebral rSO2 not be used in isolation. This problem was somewhat ameliorated by correction of the signal for arterial contamination. NIRS appears to be too valuable a tool to be simply discarded, they said, suggesting that a perioperative risk assessment that would include multisite NIRS and hemodynamic monitoring might still allow early determination of low-cardiac output.
“Two numbers are better than one,” wrote Dr. Buratto and his colleagues. “Whether the NIRS technology will add any useful information to a simple bedside assessment by an astute clinician is yet to be seen.”
Edward Buratto, MBBS, Steve Horton, PhD, and Igor E. Konstantinov, MD, are from the Department of Cardiothoracic Surgery, The Royal Children’s Hospital; the Department of Pediatrics, University of Melbourne; and Murdoch Children’s Research Institute, Melbourne. They reported having no financial conflicts of interest.
The use of postoperative cerebral venous oxygen saturation monitoring (ScvO2) through an internal jugular vein catheter allows better monitoring of circulation, which may lead to better outcomes, but it is invasive and challenging. NIRS, being noninvasive, has proved attractive, but clinical interpretation in terms of both absolute values and trends is difficult, Edward Buratto, MBBS, and his colleagues noted in their invited commentary (doi: 10.1016/j.jtcvs.2017.04.061).
Dr. Rescoe and her colleagues have analyzed the correlation of NIRS-derived data with ScvO2 measured by co-oximetry from the internal jugular vein in 73 neonates after stage 1 palliation for hypoplastic left heart syndrome. They demonstrated that cerebral rSO2 correlated poorly with low ScvO2, and they suggest that cerebral rSO2 not be used in isolation. This problem was somewhat ameliorated by correction of the signal for arterial contamination. NIRS appears to be too valuable a tool to be simply discarded, they said, suggesting that a perioperative risk assessment that would include multisite NIRS and hemodynamic monitoring might still allow early determination of low-cardiac output.
“Two numbers are better than one,” wrote Dr. Buratto and his colleagues. “Whether the NIRS technology will add any useful information to a simple bedside assessment by an astute clinician is yet to be seen.”
Edward Buratto, MBBS, Steve Horton, PhD, and Igor E. Konstantinov, MD, are from the Department of Cardiothoracic Surgery, The Royal Children’s Hospital; the Department of Pediatrics, University of Melbourne; and Murdoch Children’s Research Institute, Melbourne. They reported having no financial conflicts of interest.
The regional oxygenation index (rSO2) based on near infrared spectroscopy (NIRS) measurement is frequently used to assess the adequacy of oxygen delivery after stage 1 palliation of hypoplastic left heart syndrome (HLHS). However, a recent study showed that cerebral rSO2 has low sensitivity and should not be considered reassuring even at rSO2 of 50 or greater. In addition, values below 30 were not found to be sensitive for detecting compromised oxygen delivery, according to a report published online in the Journal of Thoracic and Cardiovascular Surgery.
Erin Rescoe, MD, of Boston Children’s Hospital, and her colleagues at Harvard Medical School, Boston, performed a retrospective study of 73 neonates assessed with cerebral venous oxyhemoglobin saturation (ScvO2) measured by co-oximetry from the internal jugular vein, which is considered the preferred method for assessing the adequacy of tissue oxygen delivery, compared with cerebral rSO2 after stage 1 palliation of HLHS (doi: 10.1016/j.jtcvs.2017.03.154).
To determine the suggested benefit of NIRS as an effective trend monitor, the researchers used their interpolated data to examine changes in rSO2 and changes in ScvO2 at hourly intervals and compared these values.Of particular concern is the result showing that, in all instances where ScvO2 was less than 30%, rSO2 was greater than 30%. In terms of the sensitivity (the true positive rate) and specificity (the true negative rate) of using NIRS, time-matched pairs of rSO2 and ScvO2 showed that the receiver operating characteristic curves for rSO2 as a diagnostic test to detect ScvO2 less than 30%, less than 40%, and less than 50% were 0.82, 0.84, and 0.87, respectively, showing good specificity, with a value of rSO2 less than 30% indicating that ScvO2 will be less than 30% 99% of the time.
“However, the sensitivity of rSO2 in the range of clinical interest in detecting ScvO2 less than 30% is extremely low,” according to the researchers. Thus, NIRS is likely to produce false negatives, missing patients with clinically low postoperative oxygen saturation.
In fact, rSO2 was less than 30% less than 1% of the time that ScvO2 was less than 30%. Similar results were seen in comparing values at the less than 40% mark (equivalent less than 1% of the time). Better results showed at the less than 50% mark, with equivalence seen 46% of the time.
NIRS measures a composite of arterial and venous blood, according to Dr. Rescoe and her colleagues. Therefore, to do a more direct comparison, they adjusted their NIRS results by calculating an rSO2-based ScvO2 designed to remove arterial contamination from the rSO2 signal: rSO2-based ScvO2 = (rSO2 arterial oxygen saturation x 0.3)/0.7.
This significantly improved the sensitivity of rSO2 to detect ScvO2 at less than 30% to 6.5%, to 29% for rSO2 at less than 40%, and 77.4% for rSO2 less than 50%.
The researchers “were surprised by the extremely low sensitivity of cerebral NIRS to detect even the most severe aberrations in DO2” (i.e., ScvO2 less than 30%, which has been found to be associated with poor outcomes).
“Cerebral rSO2 in isolation should not be used to detect low ScvO2, because its sensitivity is low, although correction of rSO2 for arterial contamination significantly improves sensitivity. Cerebral rSO2 of 50 or greater should not be considered reassuring with regard to ScvO2, although values less than 30 are specific for low ScvO2,” the researchers concluded.
The study was sponsored by the Gerber Foundation, the Hess Family Philanthropic Fund, and Boston Children’s Hospital Heart Center Strategic Investment Fund. The authors disclosed that they had no financial conflicts.
The regional oxygenation index (rSO2) based on near infrared spectroscopy (NIRS) measurement is frequently used to assess the adequacy of oxygen delivery after stage 1 palliation of hypoplastic left heart syndrome (HLHS). However, a recent study showed that cerebral rSO2 has low sensitivity and should not be considered reassuring even at rSO2 of 50 or greater. In addition, values below 30 were not found to be sensitive for detecting compromised oxygen delivery, according to a report published online in the Journal of Thoracic and Cardiovascular Surgery.
Erin Rescoe, MD, of Boston Children’s Hospital, and her colleagues at Harvard Medical School, Boston, performed a retrospective study of 73 neonates assessed with cerebral venous oxyhemoglobin saturation (ScvO2) measured by co-oximetry from the internal jugular vein, which is considered the preferred method for assessing the adequacy of tissue oxygen delivery, compared with cerebral rSO2 after stage 1 palliation of HLHS (doi: 10.1016/j.jtcvs.2017.03.154).
To determine the suggested benefit of NIRS as an effective trend monitor, the researchers used their interpolated data to examine changes in rSO2 and changes in ScvO2 at hourly intervals and compared these values.Of particular concern is the result showing that, in all instances where ScvO2 was less than 30%, rSO2 was greater than 30%. In terms of the sensitivity (the true positive rate) and specificity (the true negative rate) of using NIRS, time-matched pairs of rSO2 and ScvO2 showed that the receiver operating characteristic curves for rSO2 as a diagnostic test to detect ScvO2 less than 30%, less than 40%, and less than 50% were 0.82, 0.84, and 0.87, respectively, showing good specificity, with a value of rSO2 less than 30% indicating that ScvO2 will be less than 30% 99% of the time.
“However, the sensitivity of rSO2 in the range of clinical interest in detecting ScvO2 less than 30% is extremely low,” according to the researchers. Thus, NIRS is likely to produce false negatives, missing patients with clinically low postoperative oxygen saturation.
In fact, rSO2 was less than 30% less than 1% of the time that ScvO2 was less than 30%. Similar results were seen in comparing values at the less than 40% mark (equivalent less than 1% of the time). Better results showed at the less than 50% mark, with equivalence seen 46% of the time.
NIRS measures a composite of arterial and venous blood, according to Dr. Rescoe and her colleagues. Therefore, to do a more direct comparison, they adjusted their NIRS results by calculating an rSO2-based ScvO2 designed to remove arterial contamination from the rSO2 signal: rSO2-based ScvO2 = (rSO2 arterial oxygen saturation x 0.3)/0.7.
This significantly improved the sensitivity of rSO2 to detect ScvO2 at less than 30% to 6.5%, to 29% for rSO2 at less than 40%, and 77.4% for rSO2 less than 50%.
The researchers “were surprised by the extremely low sensitivity of cerebral NIRS to detect even the most severe aberrations in DO2” (i.e., ScvO2 less than 30%, which has been found to be associated with poor outcomes).
“Cerebral rSO2 in isolation should not be used to detect low ScvO2, because its sensitivity is low, although correction of rSO2 for arterial contamination significantly improves sensitivity. Cerebral rSO2 of 50 or greater should not be considered reassuring with regard to ScvO2, although values less than 30 are specific for low ScvO2,” the researchers concluded.
The study was sponsored by the Gerber Foundation, the Hess Family Philanthropic Fund, and Boston Children’s Hospital Heart Center Strategic Investment Fund. The authors disclosed that they had no financial conflicts.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point:
Major finding: In terms of sensitivity, rSO2 was less than 30% less than 1% of the time that ScvO2 was less than 30%.
Data source: A retrospective single institution study of 73 neonates assessed after stage 1 palliation
Disclosures: The study was sponsored by the Gerber Foundation, the Hess Family Philanthropic Fund, and Boston Children’s Hospital Heart Center Strategic Investment Fund. The authors disclosed that they had no financial conflicts.
ERAS program cuts complications after radical cystectomy
NEW YORK – Prior to October 2014, urology patients undergoing radical cystectomy at a 950-bed, tertiary care hospital experienced postoperative morbidity at a relative high rate, according to NSQIP data.
“Despite improvements in surgical techniques and perioperative care protocols, the rate of the overall morbidity for radical cystectomy was higher than we would like to see,” said Tracey Hong, RN, BScN, of the Clinical Quality and Patient Safety Department at Vancouver (B.C.) General Hospital. “We took this as an opportunity to improve our patient outcomes and experience.”
Vancouver General joined the American College of Surgeons National Surgical Improvement Quality Program (ACS NSQIP) in 2011. The enhanced recovery after surgery (ERAS) perioperative protocol the institution adopted in late 2014 was associated with a 32% decrease in overall morbidity. The rate dropped from 31.3% in the pre-ERAS study period from May 2011 to September 2014, to 21.1% after implementation, from October 2014 to September 2016, according to a study Ms. Hong presented at the American College of Surgeons Quality and Safety Conference.
The investigators compared outcomes between all 92 people undergoing elective radical cystectomy during the first time period to 152 consecutive patients treated under the ERAS protocol. Median length of stay decreased from 8 days before ERAS to 7 days after, a significant difference (P less than .05).
The researchers also assessed outcomes based on how adherent clinicians were to 12 key elements of the 26-item ERAS initiative. These elements included preoperative counseling, preoperative anesthesia consultation, and carbohydrate loading on the morning of surgery. Intraoperatively, they tracked normothermia, use of multimodal anesthesia, use of goal-directed fluid therapy using a monitor, timely antibiotics, and adequate postoperative nausea and vomiting prophylaxis. The four postoperative key measures were mobilization at least once by postoperative day 0, full fluids and mobilization twice on postoperative day 1, and starting solid food by postoperative day 4.
A total 52% of the ERAS cases were associated with 75% or greater adherence to these 12 key items. Adherence with the intraoperative fluid therapy and all the postoperative elements proved to be the most challenging, Ms. Hong said.
The more adherent cases experienced a lower overall postoperative morbidity rate, 15.2%, compared with 27.4% among the less adherent group. The 15.2% morbidity among the more adherent cases also compared favorably with the 31.1% rate for cases prior to ERAS adoption.
“We will continue working on improving compliance,” Ms. Hong said. “We need to increase adherence to goal-directed fluid therapy and the postoperative components,” Ms. Hong said.
Three main strategies remain essential to the ongoing success of the ERAS program, Ms. Hong said. Empowering patients to be active participants and to engage in their own health outcomes is one. “Second, we involve a multidisciplinary team at an early stage so they take ownership and get engaged in the program,” she said. “Last but not least, we continue to measure the outcomes in 100% of cases.”
Continuous auditing and sharing results with the team on a regular basis will be necessary to maintain engagement in the ERAS protocol going forward, Ms. Hong added. “Tenacity is vital.”
Ms. Hong had no relevant financial disclosures.
NEW YORK – Prior to October 2014, urology patients undergoing radical cystectomy at a 950-bed, tertiary care hospital experienced postoperative morbidity at a relative high rate, according to NSQIP data.
“Despite improvements in surgical techniques and perioperative care protocols, the rate of the overall morbidity for radical cystectomy was higher than we would like to see,” said Tracey Hong, RN, BScN, of the Clinical Quality and Patient Safety Department at Vancouver (B.C.) General Hospital. “We took this as an opportunity to improve our patient outcomes and experience.”
Vancouver General joined the American College of Surgeons National Surgical Improvement Quality Program (ACS NSQIP) in 2011. The enhanced recovery after surgery (ERAS) perioperative protocol the institution adopted in late 2014 was associated with a 32% decrease in overall morbidity. The rate dropped from 31.3% in the pre-ERAS study period from May 2011 to September 2014, to 21.1% after implementation, from October 2014 to September 2016, according to a study Ms. Hong presented at the American College of Surgeons Quality and Safety Conference.
The investigators compared outcomes between all 92 people undergoing elective radical cystectomy during the first time period to 152 consecutive patients treated under the ERAS protocol. Median length of stay decreased from 8 days before ERAS to 7 days after, a significant difference (P less than .05).
The researchers also assessed outcomes based on how adherent clinicians were to 12 key elements of the 26-item ERAS initiative. These elements included preoperative counseling, preoperative anesthesia consultation, and carbohydrate loading on the morning of surgery. Intraoperatively, they tracked normothermia, use of multimodal anesthesia, use of goal-directed fluid therapy using a monitor, timely antibiotics, and adequate postoperative nausea and vomiting prophylaxis. The four postoperative key measures were mobilization at least once by postoperative day 0, full fluids and mobilization twice on postoperative day 1, and starting solid food by postoperative day 4.
A total 52% of the ERAS cases were associated with 75% or greater adherence to these 12 key items. Adherence with the intraoperative fluid therapy and all the postoperative elements proved to be the most challenging, Ms. Hong said.
The more adherent cases experienced a lower overall postoperative morbidity rate, 15.2%, compared with 27.4% among the less adherent group. The 15.2% morbidity among the more adherent cases also compared favorably with the 31.1% rate for cases prior to ERAS adoption.
“We will continue working on improving compliance,” Ms. Hong said. “We need to increase adherence to goal-directed fluid therapy and the postoperative components,” Ms. Hong said.
Three main strategies remain essential to the ongoing success of the ERAS program, Ms. Hong said. Empowering patients to be active participants and to engage in their own health outcomes is one. “Second, we involve a multidisciplinary team at an early stage so they take ownership and get engaged in the program,” she said. “Last but not least, we continue to measure the outcomes in 100% of cases.”
Continuous auditing and sharing results with the team on a regular basis will be necessary to maintain engagement in the ERAS protocol going forward, Ms. Hong added. “Tenacity is vital.”
Ms. Hong had no relevant financial disclosures.
NEW YORK – Prior to October 2014, urology patients undergoing radical cystectomy at a 950-bed, tertiary care hospital experienced postoperative morbidity at a relative high rate, according to NSQIP data.
“Despite improvements in surgical techniques and perioperative care protocols, the rate of the overall morbidity for radical cystectomy was higher than we would like to see,” said Tracey Hong, RN, BScN, of the Clinical Quality and Patient Safety Department at Vancouver (B.C.) General Hospital. “We took this as an opportunity to improve our patient outcomes and experience.”
Vancouver General joined the American College of Surgeons National Surgical Improvement Quality Program (ACS NSQIP) in 2011. The enhanced recovery after surgery (ERAS) perioperative protocol the institution adopted in late 2014 was associated with a 32% decrease in overall morbidity. The rate dropped from 31.3% in the pre-ERAS study period from May 2011 to September 2014, to 21.1% after implementation, from October 2014 to September 2016, according to a study Ms. Hong presented at the American College of Surgeons Quality and Safety Conference.
The investigators compared outcomes between all 92 people undergoing elective radical cystectomy during the first time period to 152 consecutive patients treated under the ERAS protocol. Median length of stay decreased from 8 days before ERAS to 7 days after, a significant difference (P less than .05).
The researchers also assessed outcomes based on how adherent clinicians were to 12 key elements of the 26-item ERAS initiative. These elements included preoperative counseling, preoperative anesthesia consultation, and carbohydrate loading on the morning of surgery. Intraoperatively, they tracked normothermia, use of multimodal anesthesia, use of goal-directed fluid therapy using a monitor, timely antibiotics, and adequate postoperative nausea and vomiting prophylaxis. The four postoperative key measures were mobilization at least once by postoperative day 0, full fluids and mobilization twice on postoperative day 1, and starting solid food by postoperative day 4.
A total 52% of the ERAS cases were associated with 75% or greater adherence to these 12 key items. Adherence with the intraoperative fluid therapy and all the postoperative elements proved to be the most challenging, Ms. Hong said.
The more adherent cases experienced a lower overall postoperative morbidity rate, 15.2%, compared with 27.4% among the less adherent group. The 15.2% morbidity among the more adherent cases also compared favorably with the 31.1% rate for cases prior to ERAS adoption.
“We will continue working on improving compliance,” Ms. Hong said. “We need to increase adherence to goal-directed fluid therapy and the postoperative components,” Ms. Hong said.
Three main strategies remain essential to the ongoing success of the ERAS program, Ms. Hong said. Empowering patients to be active participants and to engage in their own health outcomes is one. “Second, we involve a multidisciplinary team at an early stage so they take ownership and get engaged in the program,” she said. “Last but not least, we continue to measure the outcomes in 100% of cases.”
Continuous auditing and sharing results with the team on a regular basis will be necessary to maintain engagement in the ERAS protocol going forward, Ms. Hong added. “Tenacity is vital.”
Ms. Hong had no relevant financial disclosures.
AT THE ACS QUALITY & SAFETY CONFERENCE
Key clinical point: An enhanced recovery after surgery protocol can reduce postoperative morbidity after radical cystectomy.
Major finding: Investigators report a 32% decrease in overall morbidity after adoption of ERAS pathways.
Data source: Comparison between 92 patients before and 152 patients after implementation of ERAS protocol.
Disclosures: Tracey Hong, BScN, had no relevant financial disclosures.