The impact of resident involvement in minimally-invasive urologic oncology procedures

Introduction: Robotic and laparoscopic surgical training is an integral part of resident education in urology, yet the effect of resident involvement on outcomes of minimally-invasive urologic procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a large multi-institutional prospective database.Methods: Relying on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2005-2011), we abstracted the 3 most frequently performed minimally-invasive urologic oncology procedures. These included radical prostatectomy, radical nephrectomy and partial nephrectomy. Multivariable logistic regression models were constructed to assess the impact of trainee involvement (PGY 1-2: junior, PGY 3-4: senior, PGY ≥5: chief) versus attending-only on operative time, length-of-stay, 30-day complication, reoperation and readmission rates.Results: A total of 5459 minimally-invasive radical prostatectomies,1740 minimally-invasive radical nephrectomies and 786 minimally-invasive partial nephrectomies were performed during the study period, for which data on resident surgeon involvement was available. In multivariable analyses, resident involvement was not associated with increased odds of overall complications, reoperation, or readmission rates for minimally-invasive prostatectomy, radical and partial nephrectomy. However, operative time was prolonged when residents were involved irrespective of the type of procedure. Length-of-stay was decreased with senior resident involvement in minimally-invasive partial nephrectomies (odds ratio [OR] 0.49, p = 0.04) and prostatectomies (OR 0.68, p = 0.01). The major limitations of this study include its retrospective observational design, inability to adjust for the case complexity and surgeon/hospital characteristics, and the lack of information regarding the minimally-invasive approach utilized (whether robotic or laparoscopic).Conclusions: Resident involvement is associated with increased operative time in minimally-invasive urologic oncology procedures. However, it does not adversely affect the complication, reoperation or readmission rates, as well as length-of-stay.

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Impact of Resident Participation on Operative Time and Outcomes in Otologic Surgery

Otolaryngology ◽

10.1177/0194599817737270 ◽

2017 ◽

Vol 158 (1) ◽

pp. 151-154 ◽

Cited By ~ 3

Author(s):

Thomas Muelleman ◽

Matthew Shew ◽

Robert J. Muelleman ◽

Mark Villwock ◽

Kevin J. Sykes ◽

...

Keyword(s):

Operative Time ◽

Linear Models ◽

Surgical Complication ◽

Medical Center ◽

Case Series ◽

Complication Rates ◽

Continuous Variables ◽

Improvement Program ◽

Resident Involvement ◽

The Impact

Objectives To describe the impact of resident involvement in tympanoplasty on operative time and surgical complication rates. Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods Current Procedural Terminology codes were used to identify patients in the 2011-2014 public use files of the American College of Surgeons National Surgical Quality Improvement Program who underwent a tympanoplasty or tympanomastoidectomy. Cases were included if the database indicated whether the operating room was staffed with an attending alone or an attending with residents. Categorical and continuous variables were compared with chi-square, Fisher’s exact, and Mann-Whitney U tests. Generalized linear models with a log-link and gamma distribution were used to examine the factors affecting operative time. Results Overall, 1045 cases met our study criteria (tympanoplasty, n = 797; tympanomastoidectomy, n = 248). Resident involvement increased mean operative time for tympanoplasties by 46% (107 vs 73 minutes, P < .001) and tympanomastoidectomies by 49% (175 vs 117 minutes, P < .001). While controlling for confounding factors, the variable with the largest impact on operative time was resident involvement. There were no significant differences observed in the rate of surgical complications between attending-alone and attending-resident cases. Conclusion Resident involvement in tympanoplasty and tympanomastoidectomy did not affect the surgical complication rate. Resident involvement increased operative time for tympanoplasties and tympanomastoidectomies; however, the specific reasons for the increase are not explained by the available data.

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876 The impact of resident involvement in minimally invasive urologic oncology procedures

European Urology Supplements ◽

10.1016/s1569-9056(14)60862-9 ◽

2014 ◽

Vol 13 (1) ◽

pp. e876

Author(s):

N. Ruhotina ◽

B. Varda ◽

A. Sood ◽

J. Meyers ◽

M. Schmid ◽

...

Keyword(s):

Minimally Invasive ◽

Urologic Oncology ◽

Resident Involvement ◽

The Impact

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The Impact of New Surgical Techniques on Geographical Unwarranted Variation: The Case of Benign Hysterectomy

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18136722 ◽

2021 ◽

Vol 18 (13) ◽

pp. 6722

Author(s):

Daniel Adrian Lungu ◽

Elisa Foresi ◽

Paolo Belardi ◽

Sabina Nuti ◽

Andrea Giannini ◽

...

Keyword(s):

Length Of Stay ◽

Minimally Invasive ◽

Geographical Variation ◽

Average Length ◽

Surgical Techniques ◽

Minimally Invasive Procedures ◽

Invasive Procedures ◽

Invasive Approach ◽

Average Length Of Stay ◽

The Impact

Since the 1980s, the international literature has reported variations for healthcare services, especially for elective ones. Variations are positive if they reflect patient preferences, while if they do not, they are unwarranted, and thus avoidable. Benign hysterectomy is among the most frequent elective surgical procedures in developed countries, and, in recent years, it has been increasingly delivered through minimally invasive surgical techniques, namely laparoscopic or robotic. The question therefore arises over what the impact of these new surgical techniques on avoidable variation is. In this study we analyze the extent of unwarranted geographical variation of treatment rates and of the adoption of minimally invasive procedures for benign hysterectomy in an Italian regional healthcare system. We assess the impact of the surgical approach on the provision of benign hysterectomy, in terms of efficiency (by measuring the average length of stay) and efficacy (by measuring the post-operative complications). Geographical variation was observed among regional health districts for treatment rates and waiting times. At a provider level, we found differences for the minimally invasive approach. We found a positive and significant association between rates and the percentage of minimally invasive procedures. Providers that frequently adopt minimally invasive procedures have shorter average length of stay, and when they also perform open hysterectomies, fewer complications.

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Do females have worse surgical outcomes after radical cystectomy? Impact of gender on 30-day complications in a national cohort.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.6_suppl.402 ◽

2021 ◽

Vol 39 (6_suppl) ◽

pp. 402-402

Author(s):

Srinath Kotamarti ◽

Michael Silver ◽

Andrew Wood ◽

Ervin Teper ◽

David Silver ◽

...

Keyword(s):

Length Of Stay ◽

Radical Cystectomy ◽

Surgical Outcomes ◽

Operative Time ◽

Perioperative Outcomes ◽

Categorical Variables ◽

Improvement Program ◽

Invasive Approach ◽

Cancer Of The Bladder ◽

National Cohort

402 Background:: Men have higher rates of bladder cancer and are more likely to undergo cystectomy than women, yet women seem to have worse oncologic outcomes. This is attributed to biologic factors including adverse histologic variants and social factors including delay in diagnosis. There is early evidence that women also have worse surgical outcomes. We further examined the role of gender in 30-day perioperative outcomes following radical cystectomies in a national cohort. Methods: We examined the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2012 to 2016. The database was searched for CPT codes reflecting radical cystectomy and a diagnosis of “cancer of the bladder.” Frailty was estimated by the modified frailty index (functional status, diabetes, chronic obstructive pulmonary disorder, history of chronic heart failure, and hypertension requiring medication.) To compare demographic and perioperative characteristics between genders, Chi-Square analyses were performed for categorical variables, student’s t test to compare averages, and the Wilcoxon rank sum test for operative time and length of stay (LOS). Results: 4,681 radical cystectomies were identified including 842 (18.0%) females. Of the female cohort, average age was 68.6 (+/-11.2 years), 77.3% was Caucasian and 278 (33%) had a BMI of at least 30. There were no differences appreciated between genders with regards to age, average ASA score, frailty, or minimally-invasive approach (all p=NS). Compared to males, female gender was associated with longer operative time (350 vs. 336 min, p<0.009), length of stay (LOS) (8 vs 7, p<0.001) and lower rates of discharge to home (79.9% vs 87.0%, p<0.0001). Reoperation (4.8% vs. 6.0%), readmission (22.2% vs 20.6%), and death within 30 days (1.9% vs. 2.0%) were similar. Clavien 3 or greater was also similar among gender (Table). Conclusions: Female patients comprise a minority of radical cystectomies with slightly longer LOS and less home discharge than men, yet 30-day major complications, reoperation and mortality appear similar. [Table: see text]

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792 OUTCOMES AFTER TOTALLY MINIMALLY INVASIVE VERSUS HYBRID OR OPEN IVOR LEWIS ESOPHAGECTOMY: RESULTS FROM THE INTERNATIONAL ESODATA STUDY GROUP.

Diseases of the Esophagus ◽

10.1093/dote/doab052.792 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Berend Van Der Wilk ◽

Eliza R C Hagens ◽

Ben M Eyck ◽

Suzanne S Gisbertz ◽

Richard Hillegersberg ◽

...

Keyword(s):

Length Of Stay ◽

Minimally Invasive ◽

Anastomotic Leakage ◽

Hospital Length Of Stay ◽

Mortality Data ◽

Study Group ◽

Ivor Lewis ◽

Open Esophagectomy ◽

Ivor Lewis Esophagectomy ◽

The Impact

Abstract To compare complications following totally minimally invasive (TMIE), laparoscopically assisted (hybrid) and open Ivor Lewis esophagectomy in patients with esophageal cancer. Three randomized trials have reported benefits for minimally invasive esophagectomy. Two studies compared TMIE versus open esophagectomy and another compared hybrid versus open Ivor Lewis esophagectomy. Only small retrospective studies compared TMIE with hybrid Ivor Lewis esophagectomy. Methods Data were used from the International Esodata Study Group assessing patients undergoing TMIE, hybrid or open Ivor Lewis esophagectomy. Primary outcome was pneumonia, secondary outcomes included incidence and severity of anastomotic leakage, (major) complications, length of stay, escalation of care and 90-day mortality. Data were analyzed using multivariate multilevel models. Results In total, 4733 patients were included in this study (TMIE:1472, hybrid:1364 and open:1897). Patients undergoing TMIE had lower incidence of pneumonia compared to hybrid (10.9% vs 16.3%, Odds Ratio (OR):0.56, 95%CI: 0.40–0.80) and open esophagectomy (10.9% vs 17.4%, OR:0.60, 95%CI: 0.42–0.84) and had shorter length of stay (median 10 days (IQR 8–16)) compared to hybrid (14 (11–19), p = 0.041) and open esophagectomy (11 (9–16), p = 0.027). Patients undergoing TMIE had higher rate of anastomotic leakage compared to hybrid (15.1% vs 10.7%, OR:1.47, 95%CI: 1.01–2.13) and open esophagectomy (7.3%, OR:1.73, 95%CI: 1.26–2.38). No differences were reported between hybrid and open esophagectomy. Conclusion Compared to hybrid and open Ivor Lewis esophagectomy, TMIE resulted in a lower pneumonia rate, a shorter hospital length of stay but a higher anastomotic leakage rate. The impact of these individual complications on survival and long-term quality of life should be further investigated.

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Costs and benefits of different methods of esophagectomy for esophageal cancer

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492317731389 ◽

2017 ◽

Vol 25 (7-8) ◽

pp. 513-517 ◽

Cited By ~ 8

Author(s):

Alongkorn Yanasoot ◽

Kamtorn Yolsuriyanwong ◽

Sakchai Ruangsin ◽

Supparerk Laohawiriyakamol ◽

Somkiat Sunpaweravong

Keyword(s):

Esophageal Cancer ◽

Postoperative Pain ◽

Minimally Invasive ◽

Operative Time ◽

Minimally Invasive Esophagectomy ◽

Laparoscopic Approach ◽

Costs And Benefits ◽

Invasive Approach ◽

Invasive Esophagectomy ◽

Open Esophagectomy

Background A minimally invasive approach to esophagectomy is being used increasingly, but concerns remain regarding the feasibility, safety, cost, and outcomes. We performed an analysis of the costs and benefits of minimally invasive, hybrid, and open esophagectomy approaches for esophageal cancer surgery. Methods The data of 83 consecutive patients who underwent a McKeown’s esophagectomy at Prince of Songkla University Hospital between January 2008 and December 2014 were analyzed. Open esophagectomy was performed in 54 patients, minimally invasive esophagectomy in 13, and hybrid esophagectomy in 16. There were no differences in patient characteristics among the 3 groups Minimally invasive esophagectomy was undertaken via a thoracoscopic-laparoscopic approach, hybrid esophagectomy via a thoracoscopic-laparotomy approach, and open esophagectomy by a thoracotomy-laparotomy approach. Results Minimally invasive esophagectomy required a longer operative time than hybrid or open esophagectomy ( p = 0.02), but these patients reported less postoperative pain ( p = 0.01). There were no significant differences in blood loss, intensive care unit stay, hospital stay, or postoperative complications among the 3 groups. Minimally invasive esophagectomy incurred higher operative and surgical material costs than hybrid or open esophagectomy ( p = 0.01), but there were no significant differences in inpatient care and total hospital costs. Conclusion Minimally invasive esophagectomy resulted in the least postoperative pain but the greatest operative cost and longest operative time. Open esophagectomy was associated with the lowest operative cost and shortest operative time but the most postoperative pain. Hybrid esophagectomy had a shorter learning curve while sharing the advantages of minimally invasive esophagectomy.

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MP63-19 PREDICTORS OF READMISSION FOLLOWING OPEN AND MINIMALLY INVASIVE PARTIAL NEPHRECTOMY USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE

The Journal of Urology ◽

10.1016/j.juro.2015.02.2351 ◽

2015 ◽

Vol 193 (4S) ◽

Author(s):

Ahmed Serhan ◽

Ahmad Shabsigh

Keyword(s):

Quality Improvement ◽

Minimally Invasive ◽

Partial Nephrectomy ◽

Quality Improvement Program ◽

Improvement Program ◽

Surgical Quality

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Evaluation of Targeted Pharmacist Interventions to Reduce Length of Stay in an Acute Care Practice Model

Annals of Pharmacotherapy ◽

10.1177/1060028018815064 ◽

2018 ◽

Vol 53 (5) ◽

pp. 471-477 ◽

Cited By ~ 2

Author(s):

Mary-Haston Leary ◽

Kathryn Morbitzer ◽

Bobbi Jo Walston ◽

Stephen Clark ◽

Jenna Kaplan ◽

...

Keyword(s):

Length Of Stay ◽

Acute Care ◽

Positive Impact ◽

Pharmacy Practice ◽

Care Practice ◽

Readmission Rates ◽

A Value ◽

Pharmacist Interventions ◽

Semistructured Interviews ◽

The Impact

Background: Despite widespread recognition of the need for innovative pharmacy practice approaches, the development and implementation of value-based outcomes remains difficult to achieve. Furthermore, gaps in the literature persist because the majority of available literature is retrospective in nature and describes only the clinical impact of pharmacists’ interventions. Objective: Length of stay (LOS) is a clinical outcome metric used to represent efficiency in health care. The objective of this study was to evaluate the impact of pharmacist-driven interventions on LOS in the acute care setting. Methods: A separate samples pretest-posttest design was utilized to compare the effect of pharmacist interventions across 3 practice areas (medicine, hematology/oncology, and pediatrics). Two time periods were evaluated: preimplementation (PRE) and a pilot period, postimplementation of interventions (POST). Interventions included targeted discharge services, such as discharge prescription writing (with provider cosignature). Participating pharmacists completed semistructured interviews following the pilot. Results: A total of 924 patients (466 PRE and 458 POST) were included in the analysis. The median LOS decreased from 4.95 (interquartile range = 3.24-8.5) to 4.12 (2.21-7.96) days from the PRE versus POST groups, respectively ( P < 0.011). There was no difference in readmission rates between groups (21% vs 19.1%, P = 0.7). Interviews revealed several themes, including positive impact on professional development. Conclusion and Relevance: This pilot study demonstrated the ability of pharmacist interventions to reduce LOS. Pharmacists identified time as the primary barrier and acknowledged the importance of leaders prioritizing pharmacists’ responsibilities. This study is novel in targeting LOS, providing a value-based outcome for clinical pharmacy services.

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