Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic.
JAMA network open
2021; 4 (12): e2138038
Importance: The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States.Objective: To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19.Design, Setting, and Participants: This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021.Exposures: 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19.Main Outcomes and Measures: Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications.Results: A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures among patients aged ≥65 years [30.2%]). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P<.001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P<.001) and cataract procedures (IRR, 0.11; 95% CI, -0.11 to 0.32; P=.03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P=.10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P<.001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r=-0.00025; 95% CI, -0.0042 to -0.0009; P=.003), but there was no correlation during the COVID-19 surge (r=-0.00034; 95% CI, -0.0075 to 0.00007; P=.11).Conclusions and Relevance: This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.
View details for DOI 10.1001/jamanetworkopen.2021.38038
View details for PubMedID 34878546
A Closer Look at "Taller-Than-Wide" Thyroid Nodules: Examining Dimension Ratio to Predict Malignancy.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
To evaluate nodule height-to-width ratio as a continuous variable predicting likelihood of thyroid malignancy.Retrospective cohort study.All study information was collected from a single academic tertiary care hospital.Subjects included adult patients with thyroid nodules who underwent thyroid surgery between 2010 and 2020. The following variables were collected: patient demographics, nodule dimensions via ultrasound, fine-needle aspiration biopsy results, and surgical pathology results. Statistical analysis included logistic regression modeling malignancy with variables of interest. We used a receiver operating characteristic curve to assess the discriminatory value of variables.Height-to-width ratio, as a continuous variable, was associated with malignancy (with each 0.1 increase in ratio; odds ratio [OR], 1.25; 95% CI, 1.14-1.37). The same relationship was true for height-to-length ratio (OR, 1.36; 95% CI, 1.24-1.56). The area under the receiver operating characteristic curve for height-to-width ratio was 63.7%. In line with current emphasis on the transverse ultrasound view, we determined 4 different height-to-width ratio intervals: <0.8, 0.8 to <1.0, 1.0 to <1.5, and ≥1.5. Likelihood ratios of malignancy for each interval were 0.6, 1.0, 2.3, and 4.9, respectively.Our results support the association between greater height-to-width ratio and malignancy but suggest that a multilevel rather than binary variable improves prediction. The likelihood ratios at different intervals give a more nuanced view of how height-to-width ratio predicts malignancy. With continuing review of guidelines for thyroid nodule biopsy, it is important to consider these data for any point total attributed to shape.
View details for DOI 10.1177/01945998211051310
View details for PubMedID 34637345
- Surgical Procedures in Veterans Affairs Hospitals During the COVID-19 Pandemic. Annals of surgery 2020; Publish Ahead of Print
Association of Sex With Postoperative Mortality Among Patients With Heart Failure Who Underwent Elective Noncardiac Operations.
JAMA network open
2019; 2 (11): e1914420
Importance: Sex differences in postoperative outcomes in patients with heart failure (HF) have not been well characterized. Women generally experience a lower postoperative mortality risk after noncardiac operations. It is unclear if this pattern holds among patients with HF.Objectives: To determine if the risk of postoperative mortality is associated with sex among patients with HF who underwent noncardiac operations and to determine if sex is associated with the relationship between HF and postoperative mortality.Design, Setting, and Participants: This multisite cohort study used data from the US Department of Veterans Affairs Surgical Quality Improvement Project database for all patients who underwent elective noncardiac operations from October 1, 2009, to September 30, 2016, with a minimum of 1 year follow-up. The data analysis was conducted from May 1, 2018, to August 31, 2018.Exposures: Heart failure, left ventricular ejection fraction, and sex.Main Outcomes and Measures: Postoperative mortality at 90 days.Results: Among 609 735 patients who underwent elective noncardiac operations from 2009 to 2016, 47 997 patients had HF (7.9%; mean [SD] age, 68.6 [10.1] years; 1391 [2.9%] women) and 561 738 patients did not have HF (92.1%; mean [SD] age, 59.4 [13.4] years; 50 862 [9.1%] women). Among patients with HF, female sex was not independently associated with 90-day postoperative mortality (adjusted odds ratio [aOR], 0.97; 95% CI, 0.71-1.32). Although HF was associated with increased odds of postoperative mortality in both sexes compared with their peers without HF, the odds of postoperative mortality were higher among women with HF (aOR, 2.44; 95% CI, 1.73-3.45) than men with HF (aOR, 1.64; 95% CI, 1.54-1.74), suggesting that HF may negate the general protective association of female sex with postoperative mortality (P for interaction of HF*sex=.03). This pattern was consistent across all levels of left ventricular ejection fraction.Conclusions and Relevance: Although HF was associated with increased odds of postoperative mortality in both sexes compared with their peers without HF, the odds of postoperative mortality were higher among women with HF than men with HF, suggesting that HF may negate the general protective association of female sex with postoperative mortality risk in noncardiac operations.
View details for DOI 10.1001/jamanetworkopen.2019.14420
View details for PubMedID 31675085
Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia.
BMC health services research
2019; 19 (1): 579
BACKGROUND: Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals.METHODS: We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results.RESULTS: The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine.CONCLUSIONS: The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.
View details for DOI 10.1186/s12913-019-4383-8
View details for PubMedID 31419972
Incontinence in Phelan-McDermid Syndrome.
Journal of pediatric gastroenterology and nutrition
2019; 69 (2): e39-e42
The aim of the study was to evaluate gastrointestinal symptoms and continence in the context of Phelan-McDermid Syndrome (PMS).A prospective evaluation of children with PMS (n = 17) at the National Institutes of Health.Parent-reported history of symptoms were common: constipation (65%), reflux (59%), choking/gagging (41%), and more than half received gastrointestinal specialty care. No aspiration was noted in 11/11 participants who completed modified barium swallows. Four participants met criteria for functional constipation, 2 of whom had abnormal colonic transit studies. Stool incontinence was highly prevalent (13/17) with nonretentive features present in 12/17. Participants who were continent had significantly smaller genetic deletions (P = 0.01) and higher nonverbal mental age (P = 0.03) compared with incontinent participants.Incontinence is common in PMS and associated with intellectual functioning and gene deletion size. Management strategies may differ based on the presence of nonretentive fecal incontinence, functional constipation, and degree of intellectual disability for children with PMS.
View details for DOI 10.1097/MPG.0000000000002342
View details for PubMedID 30921255
View details for PubMedCentralID PMC6658348
Increased Prevalence of Hepatic Steatosis in Young Adults With Lifelong HIV.
The Journal of infectious diseases
2019; 220 (2): 266-269
Little is known about the effects of lifelong human immunodeficiency virus (HIV) or antiretroviral therapy on hepatic steatosis and fibrosis. Using transient elastography, we evaluated 46 young adults with lifelong HIV and 20 matched HIV-negative controls. Steatosis was present in 33% of persons with HIV and only 10% of controls (P = .04). Hepatic fibrosis scores were not elevated and did not differ between groups. Metabolic parameters, particularly increased waist circumference, and not HIV-specific factors, were significantly associated with steatosis. While this finding should be examined in larger cohorts, modifiable metabolic disturbances may be important targets to optimize liver health in this population.
View details for DOI 10.1093/infdis/jiz096
View details for PubMedID 30852587
View details for PubMedCentralID PMC6581896
Effect of Antiretroviral Therapy on Bone and Renal Health in Young Adults Infected With HIV in Early Life.
The Journal of clinical endocrinology and metabolism
2017; 102 (8): 2896-2904
HIV antiretroviral (ARV) therapy is associated with renal and bone toxicity, but little is known about the potential cumulative effects in adults exposed to ARVs from birth.To prospectively evaluate renal and bone health in young adults with lifelong HIV and extensive ARV exposure.Cross-sectional comparison of bone mineral density (BMD) by dual-energy X-ray absorptiometry, bone turnover, and renal function in young adults infected with HIV in early life (n = 65) to matched healthy controls (n = 23) and longitudinal evaluation (mean follow-up = 4.4 years) within a subset of the HIV cohort (n = 33).Government outpatient research clinic.Albumin/creatinine ratio, protein/creatinine ratio, anion gap, N-terminal telopeptides, and osteocalcin were significantly increased in persons with HIV compared with controls, whereas whole-body BMD and BMD z scores were lower. Within the HIV group, duration of tenofovir disoproxil fumarate (TDF) correlated with higher anion gap but did not correlate with bone parameters. Longer duration of didanosine and stavudine use correlated with lower BMD and BMD z scores. Longitudinal analyses revealed that BMD and bone metabolism significantly improved over time. No subject had an estimated glomerular filtration rate (eGFR) <60, but decline in eGFR correlated with increasing years of TDF exposure.Subclinical markers of renal dysfunction were increased in HIV-infected young adults and associated with TDF exposure, whereas lower bone density was associated with didanosine and stavudine exposure. The tendency for improvement in markers of bone health over time and the availability of less toxic ARV alternatives may herald improvements in renal and bone health for perinatally infected patients in adulthood.
View details for DOI 10.1210/jc.2017-00197
View details for PubMedID 28531309
View details for PubMedCentralID PMC5546869
T-cell Activation and E-selectin Are Associated With Coronary Plaque in HIV-infected Young Adults.
The Pediatric infectious disease journal
2017; 36 (1): 63-65
We evaluated immune activation and coronary artery plaque in young adults with human immunodeficiency virus acquired in early life (n = 31). Coronary plaque was positively associated with lipids, immune activation marker %CD8+CD38+DR+ and E-selectin, a marker of endothelial inflammation. Immune activation and endothelial inflammation may drive coronary plaque formation during the early stages of atherosclerosis in the context of chronic human immunodeficiency virus.
View details for DOI 10.1097/INF.0000000000001354
View details for PubMedID 27749650
View details for PubMedCentralID PMC5154863