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Race and socioeconomic status independently influence surgical treatment: Amputation versus revascularization for lower extremity ischemia
S108
Surgical Forum Abstracts
J Am Coll Surg
“lack of awareness” was significantly associated with an increased risk (odds ratio 6.94, 95% CI 3.52-13.6) of the IV cannula in-situ being unnecessary (p⬍0.001). In a multivariate model, this relationship remained significant after an adjustment for the patients knowledge about consultant’s name which was not associated with the IV cannula appropriateness (p⫽0.095)
1.5% to 0.8% and overall complications from 11% to 7% in eight diverse hospitals from Tanzania to the United States. Since then, the Checklist has been adopted by 3,200 hospitals in 93 countries. The benefits of the Checklist depend upon individual hospitals’ ability to implement it effectively, producing consistent, high-quality utilization.
CONCLUSIONS: This is the first study to assess patient awareness in relation to the main risk factors for CRBSI. A patient-based educational programme focusing on appropriateness, would have a far reaching benefits
METHODS: In order to generate hypotheses regarding factors that increase implementation effectiveness, we conducted in-depth, qualitative interviews with implementation leaders and surgeons at five hospitals in Washington State that had implemented a modified form of the WHO Surgical Safety Checklist.
Race and socioeconomic status independently influence surgical treatment: Amputation versus revascularization for lower extremity ischemia
RESULTS: An iterative analysis identified contextual factors and supportive activities that increase implementation effectiveness. Factors include alignment with institutional and team values, senior leadership, multidisciplinary leadership, internal motivation, physician employment, organizational culture and prior history of quality improvement. Activities include educating and training, facilitating ease of use, valuing staff input, modifying the Checklist for local use, piloting, framing to promote Checklist use, monitoring and providing feedback.
Tyler S Durazzo BS, Richard J Gusberg MD, FACS Yale University School of Medicine, New Haven, CT INTRODUCTION: Surgical options for patients with lower extremity ischemia include amputation and revascularization. While reimbursement rates are similar, revascularization is significantly more labor intensive and time consuming. We hypothesized that race and socioeconomic status independently influence the choice of treatment. METHODS: All adult discharge records (Nationwide Inpatient Sample) of patients with primary diagnosis of lower extremity ischemia from 2002-2005 were examined (n ⫽ 578,423). Univariate analysis determined variables of interest, and multiple logistic regression analysis determined the independent contribution of each. Regression models were then applied to subsets of data. RESULTS: Black patients were 2.84 times more likely to undergo amputation than whites (95% CI 2.78-2.90), Hispanics were 2.03x more likely (CI 1.97-2.09). After correcting for severity of ischemia, insurance type, income, relevant comorbidities, and other variables, blacks were still nearly twice as likely to undergo amputation (1.95, CI 1.82-2.08, p⬍0.00001), and Hispanics 1.28x more likely. The black to white amputation odds ratio (OR) was highest among those with the less severe ischemia (OR without gangrene: 2.04, OR with gangrene: 1.79). The greatest racial disparity existed among those living in the wealthiest 25% of zip codes (OR wealthiest quartile: 2.28, CI 1.98-2.63; OR poorest quartile: 1.72, CI 1.59-1.85). CONCLUSIONS: Minority patients are more likely to receive amputation than whites, even after correcting for differences in presentation, socioeconomic status, and other variables. Further prospective studies are warranted to determine the cause. The possibility exists that subconscious racial bias, precipitated by issues of case time and financial incentive, contributes to this disparity.
Factors associated with effective implementation of a surgical safety checklist Dante M C Foster MD, MSt, Atul Gawande MD, MPH, FACS, Sara Singer PhD, MBA, William Berry MD, MPH, MPA Harvard School of Public Health, Boston, MA INTRODUCTION: In 2009, implementation of the WHO Surgical Safety Checklist program was found to reduce 30-day mortality from
CONCLUSIONS: Checklist implementation is most effective in the setting of multidisciplinary leadership, alignment of institutional and team values, internal motivation and commitment to quality improvement. Ongoing investigation in a large group of US and international hospitals will test this conclusion, make significant contributions to implementation science and maximize future Checklist implementation results. This is essential in a world with everexpanding surgical volumes where 11% of the global burden of disease stems from surgically treatable conditions (World Bank, 2002).
Evaluating robotic procedures using balanced scorecards Iahn Gonsenhauser MBA, Susan D Moffatt-Bruce MD, PhD The Ohio State University Medical Center, Columbus, OH INTRODUCTION: Objective: Assess the implementation of a robotic surgery quality-assessment program by comparing robotic procedures from a variety of disciplines to open and laparoscopic procedures of the same type using balanced scorecards. METHODS: A retrospective review of data from n⫽1594 robotic (R) and non-robotic (NR) procedures was conducted (Jan 2008-May 2009). Procedures included were CABG (R n⫽51, NR n⫽253 ), lobectomy (R n⫽27, NR n⫽ 15), nephrectomy (R n⫽98, NR n⫽147) and hysterectomy (R n⫽513, NR n⫽490). Balanced scorecards were populated with quarterly data from January 2007 through May 2009. Operative times, length of stay (LOS), conversion rates, return-to-surgery rates (RSR), readmission rates (RR), ASA & wound class, and cancellation rates were compared RESULTS: ASA values between techniques were not significantly different for any procedure. LOS was significantly (p⬍0.005) decreased for robotic nephrectomy, hysterectomy, and CABG. OP Time was significantly longer (p⬍0.005) for robotic lobectomy and CABG, significantly shorter (p⬍0.005) for robotic hysterectomy,
Surgical Forum Abstracts
J Am Coll Surg
“lack of awareness” was significantly associated with an increased risk (odds ratio 6.94, 95% CI 3.52-13.6) of the IV cannula in-situ being unnecessary (p⬍0.001). In a multivariate model, this relationship remained significant after an adjustment for the patients knowledge about consultant’s name which was not associated with the IV cannula appropriateness (p⫽0.095)
1.5% to 0.8% and overall complications from 11% to 7% in eight diverse hospitals from Tanzania to the United States. Since then, the Checklist has been adopted by 3,200 hospitals in 93 countries. The benefits of the Checklist depend upon individual hospitals’ ability to implement it effectively, producing consistent, high-quality utilization.
CONCLUSIONS: This is the first study to assess patient awareness in relation to the main risk factors for CRBSI. A patient-based educational programme focusing on appropriateness, would have a far reaching benefits
METHODS: In order to generate hypotheses regarding factors that increase implementation effectiveness, we conducted in-depth, qualitative interviews with implementation leaders and surgeons at five hospitals in Washington State that had implemented a modified form of the WHO Surgical Safety Checklist.
Race and socioeconomic status independently influence surgical treatment: Amputation versus revascularization for lower extremity ischemia
RESULTS: An iterative analysis identified contextual factors and supportive activities that increase implementation effectiveness. Factors include alignment with institutional and team values, senior leadership, multidisciplinary leadership, internal motivation, physician employment, organizational culture and prior history of quality improvement. Activities include educating and training, facilitating ease of use, valuing staff input, modifying the Checklist for local use, piloting, framing to promote Checklist use, monitoring and providing feedback.
Tyler S Durazzo BS, Richard J Gusberg MD, FACS Yale University School of Medicine, New Haven, CT INTRODUCTION: Surgical options for patients with lower extremity ischemia include amputation and revascularization. While reimbursement rates are similar, revascularization is significantly more labor intensive and time consuming. We hypothesized that race and socioeconomic status independently influence the choice of treatment. METHODS: All adult discharge records (Nationwide Inpatient Sample) of patients with primary diagnosis of lower extremity ischemia from 2002-2005 were examined (n ⫽ 578,423). Univariate analysis determined variables of interest, and multiple logistic regression analysis determined the independent contribution of each. Regression models were then applied to subsets of data. RESULTS: Black patients were 2.84 times more likely to undergo amputation than whites (95% CI 2.78-2.90), Hispanics were 2.03x more likely (CI 1.97-2.09). After correcting for severity of ischemia, insurance type, income, relevant comorbidities, and other variables, blacks were still nearly twice as likely to undergo amputation (1.95, CI 1.82-2.08, p⬍0.00001), and Hispanics 1.28x more likely. The black to white amputation odds ratio (OR) was highest among those with the less severe ischemia (OR without gangrene: 2.04, OR with gangrene: 1.79). The greatest racial disparity existed among those living in the wealthiest 25% of zip codes (OR wealthiest quartile: 2.28, CI 1.98-2.63; OR poorest quartile: 1.72, CI 1.59-1.85). CONCLUSIONS: Minority patients are more likely to receive amputation than whites, even after correcting for differences in presentation, socioeconomic status, and other variables. Further prospective studies are warranted to determine the cause. The possibility exists that subconscious racial bias, precipitated by issues of case time and financial incentive, contributes to this disparity.
Factors associated with effective implementation of a surgical safety checklist Dante M C Foster MD, MSt, Atul Gawande MD, MPH, FACS, Sara Singer PhD, MBA, William Berry MD, MPH, MPA Harvard School of Public Health, Boston, MA INTRODUCTION: In 2009, implementation of the WHO Surgical Safety Checklist program was found to reduce 30-day mortality from
CONCLUSIONS: Checklist implementation is most effective in the setting of multidisciplinary leadership, alignment of institutional and team values, internal motivation and commitment to quality improvement. Ongoing investigation in a large group of US and international hospitals will test this conclusion, make significant contributions to implementation science and maximize future Checklist implementation results. This is essential in a world with everexpanding surgical volumes where 11% of the global burden of disease stems from surgically treatable conditions (World Bank, 2002).
Evaluating robotic procedures using balanced scorecards Iahn Gonsenhauser MBA, Susan D Moffatt-Bruce MD, PhD The Ohio State University Medical Center, Columbus, OH INTRODUCTION: Objective: Assess the implementation of a robotic surgery quality-assessment program by comparing robotic procedures from a variety of disciplines to open and laparoscopic procedures of the same type using balanced scorecards. METHODS: A retrospective review of data from n⫽1594 robotic (R) and non-robotic (NR) procedures was conducted (Jan 2008-May 2009). Procedures included were CABG (R n⫽51, NR n⫽253 ), lobectomy (R n⫽27, NR n⫽ 15), nephrectomy (R n⫽98, NR n⫽147) and hysterectomy (R n⫽513, NR n⫽490). Balanced scorecards were populated with quarterly data from January 2007 through May 2009. Operative times, length of stay (LOS), conversion rates, return-to-surgery rates (RSR), readmission rates (RR), ASA & wound class, and cancellation rates were compared RESULTS: ASA values between techniques were not significantly different for any procedure. LOS was significantly (p⬍0.005) decreased for robotic nephrectomy, hysterectomy, and CABG. OP Time was significantly longer (p⬍0.005) for robotic lobectomy and CABG, significantly shorter (p⬍0.005) for robotic hysterectomy,