Thresholds for Surgery and Surgical Outcomes for Patients with Primary Hyperparathyroidism: A National Survey of Endocrine Surgeons

abstract A 1991 NIH Consensus Development Conference statement provided recommendations for the management of patients with asymptomatic and minimally symptomatic primary hyperparathyroidism (1° HPT), but adherence to these guidelines has not been documented. We conducted a cross-sectional survey of North American members of the American Association of Endocrine Surgeons inquiring about surgeon and 1° HPT patient characteristics, thresholds for surgery, and clinical outcomes. Multivariate regression was used to assess the relationship of physician characteristics to practice patterns and outcomes. Of 190 surgeons surveyed, 147 (77%) responded; 109 provided complete responses (57%). These surgeons spend 66% of their time in patient care and perform an average of 33 (range, 1–130) parathyroidectomies/yr. More than 72% of 1° HPT patients who underwent surgery were asymptomatic or minimally symptomatic. High volume surgeons (>50 cases/yr) had significantly lower thresholds for surgery with respect to abnormalities in preoperative creatinine clearance, bone densitometry changes, and levels of intact PTH and urinary calcium compared to their low volume colleagues (1–15 cases/yr). Overall reported surgical cure rates were 95.2% after primary operation and 82.7% after reoperation. Compared to high volume surgeons, low volume endocrine surgeons had significantly higher complication rates after primary operation (1.9% vs. 1.0% respectively; P < 0.01) and reoperation (3.8% vs. 1.5%; P < 0.001) as well as higher in-hospital mortality rates (1.0% vs. 0.04%; P < 0.05). Endocrine surgeons operate on a large number of asymptomatic or minimally symptomatic 1° HPT patients. Even among a group of highly experienced surgeons who typically see patients after referral from endocrinologists, clinical outcomes and criteria for surgery vary widely and appear to be associated with surgeon experience. Their criteria for surgery diverge from NIH guidelines. These results implore the endocrine community to examine the evidential basis for decisions made in the management of 1° HPT.

Download Full-text

Comparing clinical outcomes in high-volume and low-volume off-pump coronary bypass operation programs

The Annals of Thoracic Surgery ◽

10.1016/s0003-4975(01)02937-x ◽

2001 ◽

Vol 72 (3) ◽

pp. S1009-S1015 ◽

Cited By ~ 27

Author(s):

Phillip P Brown ◽

Michael J Mack ◽

April W Simon ◽

Salvatore L Battaglia ◽

Lynn G Tarkington ◽

...

Keyword(s):

Clinical Outcomes ◽

Coronary Bypass ◽

High Volume ◽

Bypass Operation ◽

Off Pump ◽

Coronary Bypass Operation ◽

Low Volume

Download Full-text

Variation in Use of Damage Control Laparotomy for Trauma By Trauma Centers in the United States, Canada, and Australasia

10.21203/rs.3.rs-728617/v1 ◽

2021 ◽

Author(s):

Derek J. Roberts ◽

Peter D. Faris ◽

Chad G. Ball ◽

Andrew W. Kirkpatrick ◽

Ernest E. Moore ◽

...

Keyword(s):

United States ◽

Damage Control ◽

High Volume ◽

The United States ◽

Trauma Centers ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Frequency Of Use ◽

Volume Level ◽

Level 1

Abstract Background: It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy.Methods: A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy.Results: Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States=156 (78.4%), Canada=26 (13.1%), and Australasia=17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p=0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada=7.49; 95% confidence interval (CI)=1.39-40.27], level-1 verification status (OR=6.02; 95% CI=2.01-18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score >15) patients (OR per-100 patients=1.62; 95% CI=1.20-2.18) and patients with penetrating injuries (OR per-5% increase=1.27; 95% CI=1.01-1.58) in the last year.Conclusions: The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.

Download Full-text

What do Patients Think About Minimally Invasive Total Hip Arthroplasty?

Annals of The Royal College of Surgeons of England ◽

10.1308/003588407x205431 ◽

2007 ◽

Vol 89 (7) ◽

pp. 685-688 ◽

Cited By ~ 3

Author(s):

C Gerrand ◽

G McNulty ◽

N Brewster ◽

J Holland ◽

A McCaskie

Keyword(s):

Minimally Invasive ◽

Hip Arthroplasty ◽

Complication Rates ◽

Minimally Invasive Techniques ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Patient Stay ◽

The Cost ◽

Invasive Techniques

INTRODUCTION The introduction of minimally invasive techniques for hip replacement into clinical practice has been driven by the perceived benefits of smaller incisions, shorter in-patient stays and faster rehabilitation. This may be at the cost of higher complication rates. The purpose of this study was to explore the opinions and priorities of patients in relation to these techniques. PATIENTS AND METHODS A cross-sectional survey was performed in an elective out-patient setting. RESULTS Of 44 patients approached, 36 agreed to participate. From most important to least important, patients rated the following items in order: ‘rate of complications’; ‘implant survival’; ‘length of rehabilitation’; ‘time in hospital’ and ‘length of scar’. Despite this, 21 of 35 (60%) responders stated they would accept the offer of minimally invasive techniques if made. CONCLUSIONS Patients appear to prioritise long-term outcomes and low complication rates over the shorter scars, reduced in-patient stay and reduced rehabilitation times potentially offered by minimally invasive hip arthroplasty. Despite this, the technique remains popular among patients.

Download Full-text

How has arthroscopic management of the iliopsoas evolved, and why? A survey of high-volume arthroscopic hip surgeons

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnaa023 ◽

2020 ◽

Vol 7 (2) ◽

pp. 322-328

Author(s):

Austin W Chen ◽

Matthew J Steffes ◽

Joseph R Laseter ◽

David R Maldonado ◽

Victor Ortiz-Declet ◽

...

Keyword(s):

High Volume ◽

Labral Repair ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Arthroscopic Management ◽

Literature Evidence ◽

Poor Outcomes ◽

High Level ◽

Hip Flexion ◽

Based Medicine

Abstract The rapid growth of hip preservation has left surgeons following trends based on limited, or even anecdotal, evidence in certain circumstances. A consensus as well as high-level research on how best to manage the iliopsoas is lacking. Arthroscopic treatment of the iliopsoas may be an example of how treatment patterns and trends can shift with limited evidence-based medicine. A cross-sectional survey of 16 high-volume hip preservation surgeons was conducted to gather perspectives and opinions on how and why the arthroscopic management of the iliopsoas has evolved. All participants completed the survey in person and anonymously. Of the surveyed surgeons, the mean career hip preservation volume was 1031.25 cases (250 to >3000) with an average annual volume of 162.08 cases (75–400). Of the surveyed surgeons’ caseload, 16.1% involved an iliopsoas tenotomy or fractional lengthening mostly commonly (75%) for recalcitrant internal snapping. Labral repair/reconstruction is performed concomitantly 87.5% of the time. Seventy-five percent of surgeons indicated a decrease in frequency of iliopsoas tenotomy over the course of their practice most commonly (56.3%) because of hip flexion weakness; however, 0% of the surgeons could cite literature evidence to support their practices. Perceived poor outcomes in individual practices was the most common (56.3%) source of this complication. Surgeons were less inclined to perform tenotomy on patients with borderline dysplasia (75%) or ligamentous laxity (56.3%).

Download Full-text

Variation in Annual Volume at a University Hospital Does Not Predict Mortality for Pancreatic Resections

HPB Surgery ◽

10.1155/2008/190914 ◽

2008 ◽

Vol 2008 ◽

pp. 1-6 ◽

Cited By ~ 2

Author(s):

Rita A. Mukhtar ◽

Omar M. Kattan ◽

Hobart W. Harris

Keyword(s):

San Francisco ◽

Postoperative Mortality ◽

High Volume ◽

Patient Characteristics ◽

Mortality Rates ◽

University Hospital ◽

Complication Rates ◽

Pancreatic Resections ◽

Annual Volume ◽

Low Volume

Annual volume of pancreatic resections has been shown to affect mortality rates, prompting recommendations to regionalize these procedures to high-volume hospitals. Implementation has been difficult, given the paucity of high-volume centers and the logistical hardships facing patients. Some studies have shown that low-volume hospitals achieve good outcomes as well, suggesting that other factors are involved. We sought to determine whether variations in annual volume affected patient outcomes in 511 patients who underwent pancreatic resections at the University of California, San Francisco between 1990 and 2005. We compared postoperative mortality and complication rates between low, medium, or high volume years, designated by the number of resections performed, adjusting for patient characteristics. Postoperative mortality rates did not differ between high volume years and medium/low volume years. As annual hospital volume of pancreatic resections may not predict outcome, identification of actual predictive factors may allow low-volume centers to achieve excellent outcomes.

Download Full-text

Impact of Surgeon Volume on Incidence of Neck Hematoma after Thyroid and Parathyroid Surgery: Ten Years’ Analysis of Nationwide In-patient Sample Database

The American Surgeon ◽

10.1177/000313481408001008 ◽

2014 ◽

Vol 80 (10) ◽

pp. 948-952 ◽

Cited By ~ 15

Author(s):

Ahmed Dehal ◽

Ali Abbas ◽

Mohammed Al-Tememi ◽

Farabi Hussain ◽

Samir Johna

Keyword(s):

High Volume ◽

International Classification Of Diseases ◽

Surgeon Volume ◽

Administrative Database ◽

Parathyroid Surgery ◽

Patient Sample ◽

Surgeon Experience ◽

Classification Of Diseases ◽

Low Volume ◽

The Impact

The study's objective is to examine the impact of surgeon experience on the incidence and the severity of neck hematoma after thyroid and parathyroid surgery using a nationwide database. The Nationwide In-patient Sample is a nationwide clinical and administrative database. We used the International Classification of Diseases, 9th Revision diagnosis and procedures codes to identify adult patients who underwent thyroid and parathyroid surgery and subsequently developed neck hematoma. Patient and hospital characteristics were collected along with surgeon volume to predict patient outcomes. Surgical procedures were stratified into three groups according to surgeon volume: low (less than 10 operations), intermediate (10 to 99), and high (100 or more). We identified 147,344 thyroid and parathyroid surgery performed between 2000 and 2009 nationwide. Overall incidence of postoperative neck hematoma was 1.5 per cent (n = 2210). This was 2.1, 1.4, and 0.9 per cent among procedures performed by low-volume, intermediate-volume, and high-volume surgeons, respectively. After adjusting for other confounders, compared with procedures performed by low-volume surgeons, those performed by intermediate- (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.6 to 0.8; P < 0.01) and high-volume surgeons (OR, 0.5; 95% CI, 0.4 to 0.6; P < 0.01) were less to likely to develop neck hematoma. Surgeon experience is significantly associated with the development of neck hematoma after thyroid and parathyroid surgery.

Download Full-text

Clinical and Economic Outcomes of Thyroid and Parathyroid Surgery in Children

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2008-0660 ◽

2008 ◽

Vol 93 (8) ◽

pp. 3058-3065 ◽

Cited By ~ 175

Author(s):

Julie Ann Sosa ◽

Charles T. Tuggle ◽

Tracy S. Wang ◽

Daniel C. Thomas ◽

Leon Boudourakis ◽

...

Keyword(s):

Outcome Measures ◽

Low Income ◽

Hospital Costs ◽

High Volume ◽

Income Group ◽

Economic Outcomes ◽

Complication Rates ◽

Cross Sectional ◽

Specific Complication ◽

Low Income Families

Abstract Context: Clinical and economic outcomes after thyroidectomy/parathyroidectomy in adults have demonstrated disparities based on patient age and race/ethnicity; there is a paucity of literature on pediatric endocrine outcomes. Objective: The objective was to examine the clinical and demographic predictors of outcomes after pediatric thyroidectomy/parathyroidectomy. Design: This study is a cross-sectional analysis of Healthcare Cost and Utilization Project–National Inpatient Sample hospital discharge information from 1999–2005. All patients who underwent thyroidectomy/parathyroidectomy were included. Bivariate and multivariate analyses were performed to identify independent predictors of patient outcomes. Subjects: Subjects included 1199 patients 17 yr old or younger undergoing thyroidectomy/parathyroidectomy. Main Outcome Measures: Outcome measures included in-hospital patient complications, length of stay (LOS), and inpatient hospital costs. Results: The majority of patients were female (76%), aged 13–17 yr (71%), and White (69%). Whites were more often in the highest income group (80% vs. 8% for Hispanic and 6% for Black; P < 0.01) and had private/HMO insurance (76% vs. 10% for Hispanic and 5% for Black; P < 0.001) rather than Medicaid (13% vs. 32% for Hispanic and 41% for Black; P < 0.001). Ninety-one percent of procedures were thyroidectomies and 9% parathyroidectomies. Children aged 0–6 yr had higher complication rates (22% vs. 15% for 7–12 yr and 11% for 13–17 yr; P < 0.01), LOS (3.3 d vs. 2.3 for 7–12 yr and 1.8 for 13–17 yr; P < 0.01), and higher costs. Compared with children from higher-income families, those from lower-income families had higher complication rates (11.5 vs. 7.7%; P < 0.05), longer LOS (2.7 vs. 1.7 d; P < 0.01), and higher costs. Children had higher endocrine-specific complication rates than adults after parathyroidectomy (15.2 vs. 6.2%; P < 0.01) and thyroidectomy (9.1 vs. 6.3%; P < 0.01). Conclusions: Children undergoing thyroidectomy/parathyroidectomy have higher complication rates than adult patients. Outcomes were optimized when surgeries were performed by high-volume surgeons. There appears to be disparity in access to high-volume surgeons for children from low-income families, Blacks, and Hispanics.

Download Full-text

Failure to Rescue As a Source of Variation in Hospital Mortality for Ovarian Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2012.43.2906 ◽

2012 ◽

Vol 30 (32) ◽

pp. 3976-3982 ◽

Cited By ~ 65

Author(s):

Jason D. Wright ◽

Thomas J. Herzog ◽

Zainab Siddiq ◽

Rebecca Arend ◽

Alfred I. Neugut ◽

...

Keyword(s):

Ovarian Cancer ◽

Complication Rate ◽

Major Complication ◽

High Volume ◽

Complication Rates ◽

Failure To Rescue ◽

High Volume Hospital ◽

Lower Complication ◽

Major Complication Rate ◽

Low Volume

Purpose Although the association between high surgical volume and improved outcomes from procedures is well described, the mechanisms that underlie this association are uncertain. There is growing recognition that high-volume hospitals may not necessarily have lower complication rates but rather may be better at rescuing patients with complications. We examined the role of complications, failure to rescue from complications, and mortality based on hospital volume for ovarian cancer. Patients and Methods The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1988 to 2009. Hospitals were ranked on the basis of their procedure volume. We determined the risk-adjusted mortality, major complication rate, and “failure to rescue” rate (mortality in patients with a major complication) for each tertile. Univariate and multivariate associations were then compared. Results We identified 36,624 patients. The mortality rate for the cohort was 1.6%. The major complication rate was 20.4% at low-volume, 23.4% at intermediate-volume, and 24.6% at high-volume hospitals (P < .001). However, the rate of failure to rescue (death after a complication) was markedly higher at low-volume (8.0%) compared with high-volume hospitals (4.9%; P < .001). After accounting for patient and hospital characteristics, women treated at low-volume hospitals who experienced a complication were 48% more likely (odds ratio [OR], 1.48; 95% CI, 1.11 to 1.99) to die than patients with a complication at a high-volume hospital. Conclusion Mortality is lower for patients with ovarian cancer treated at high-volume hospitals. The reduction in mortality does not appear to be the result of lower complications rates but rather a result of the ability of high-volume hospitals to rescue patients with complications.

Download Full-text

Consensus-based classification system for intra-operative management of labral tears during hip arthroscopy—aggregate recommendations from high-volume hip preservation surgeons

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnab043 ◽

2021 ◽

Author(s):

Ajay C Lall ◽

Shawn Annin ◽

Jeff W Chen ◽

Samantha Diulus ◽

Hari K Ankem ◽

...

Keyword(s):

Decision Making ◽

Classification System ◽

High Volume ◽

Operative Management ◽

Labral Repair ◽

Cross Sectional Survey ◽

Cross Sectional ◽

System A ◽

Labral Tears ◽

Comprehensive Classification

Abstract The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey. Provided the labrum was viable (torn tissue that is likely to heal) and stable, labral debridement would be performed by 76.92% of respondents for patients >40 years of age and by >84% of respondents for stable intra-substance labral tears in patients without dysplasia. If the labrum was viable but unstable, labral repair would be performed by >80% of respondents for patients ≤40 years of age and > 80% of respondents if the labral size was >3 mm and located anteriorly. Presence of calcified labra or the Os acetabuli mattered while deciding whether to repair a labrum. In non-viable (torn tissue that is unlikely to heal) and unstable labra, labral reconstruction would be performed by 84.62% of respondents if labral size was <3 mm. The majority of respondents would reconstruct calcified and non-viable, unstable labra that no longer maintained a suction seal. Surgeons performing arthroscopic hip labral treatment may utilize this comprehensive classification system, which takes into consideration patient age, labral characteristics (viability and stability) and bony morphology of the hip joint. When choosing between labral debridement, repair or reconstruction, consensus recommendations from high-volume hip preservation surgeons can enhance decision-making.

Download Full-text

Efficacy and Tolerability of High and Low-volume Bowel Preparation Compared: a Real-life Single-blinded Large-population Study

10.21203/rs.3.rs-123588/v1 ◽

2020 ◽

Author(s):

Vincenzo Occhipinti ◽

Paola Soriani ◽

Francesco Bagolini ◽

Valentina Milani ◽

Emanuele Rondonotti ◽

...

Keyword(s):

Clinical Outcomes ◽

Bowel Preparation ◽

Large Population ◽

Real Life ◽

High Volume ◽

Dose Schedule ◽

Similar Efficacy ◽

Detection Rates ◽

Split Dose ◽

Low Volume

Abstract Background: Low-volume (LV) preparations for colonoscopy have shown similar efficacy compared to high-volume (HV) ones in trials. However, real-life clinical outcomes data are lacking. Our aim was to assess patients’ free choice among HV preparations (4L polyethylene glycol, PEG) and LV (2L PEG plus bisacodyl) and to compare efficacy and tolerability. Methods: Consecutive outpatients referred for colonoscopy could choose either LV or HV preparation with schedules (day-before or split-dose) depending on their appointment time. Adequate bowel preparation according to Boston Bowel Preparation Scale, clinical outcomes and self-reported tolerability of HV and LV were blindly assessed.Results: 2,040 patients were enrolled and 1,815 (age 60.6 years, 50.2% men) finally included. LV was chosen by 52% of patients (50.8% of men, 54.9% of women). Split-dose schedule was more common with HV (44.7% vs. 38.2%, p=0.0055). HV and LV preparations showed similar adequate bowel preparation rates (89.2% vs. 86.6%, p=0.0983) but HV ones resulted higher in detection rates for polyps (PDR; OR 1.30, 95% CI 1.03–1.64, p=0.0254), adenomas (ADR; OR 1.28, 95% CI 0.99–1.65, p=0.0519) and advanced adenomas (AADR; OR 1.54, 95% CI 0.96–2.46, p= 0.0723) after adjustment for sex, age, indications. Visual Analogue Scale tolerability scored equally (7 [5-9]) but a ≥75% dose intake was more frequent with LV.Conclusions: in a real-life setting, LV preparation confirms similar efficacy and tolerability compared to HV. However, with higher PDR and a trend toward higher ADR and AADR, HV should still be considered the reference standard for clinical trials.

Download Full-text