Canada-trained pediatric surgeons: a cross-border survey of satisfaction and preferences

Objectives

The American and Canadian health care delivery systems impact pediatric surgical practice differently. We conducted a survey of Canada-trained pediatric surgeons practicing in the United States and Canada to compare their levels of satisfaction and to assess their health care system preferences.

Methods

Pediatric surgeons who graduated from Canadian training programs between 1983 and 2002 were invited to complete a web-based questionnaire. They rated their satisfaction on a scale ranging from 1 (most) to 5 (least) with issues pertaining to quality of life, compensation, work environment, academics, and patient care. Surgeons who had experience in both the American and Canadian systems marked their preferences for each system as it impacted the same areas.

Results

Sixty surgeons (65% practicing in the United States and 35% in Canada) of 94 eligible participants (64%) responded to the survey. Surgeons in the United States were more satisfied with their overall workload and patient care issues, whereas those in Canada were more satisfied with the system of health care reimbursement and the medicolegal environment. Among 38 surgeons who had experience in both systems, 26% had an overall preference for the Canadian system, 24% did for the American system, and half had no preference.

Conclusions

Canada-trained pediatric surgeons practicing in the United States are more satisfied with patient care issues, whereas those practicing in Canada are more satisfied with the medicolegal environment and the system of health care reimbursement. There is no overwhelming preference for either system among surgeons who had experience in both.     

¿Están los servicios de cirugía general y del aparato digestivo preparados para ofrecer docencia de calidad acorde con los nuevos planes de formación?

Introduction

In recent months we have witnessed an update of the residents training program and the regulation of important training aspects. Teaching units are an important aspect of the training process, which should be required to comply with the prerequisites adapted to changing times as a guarantee of quality.

Aim

To identify areas for improvement in training, and the baseline resources of the units to deal with the implementation of the new training program.

Material and methods

The study was carried out in all units with accredited educational programs in the Valencian Community with questionnaires answered by tutors and residents, and meetings held with them.

Results

The participation rate was high (100% of tutors and 92% of residents). Some deficiencies in the requirements of the surgical units and in the quality of the training felt by the residents are detected, mainly in the research and educational activity fields. Huge differences between hospitals are found.

Conclusions

More attention must be paid to fulfilling all the requirements needed for the accreditation of the teaching units, with an emphasis on educational and research activities. The implementation of the new training program requires monitoring to minimise the differences found between the units.     

Prenatal diagnosis and management of abdominal diseases in pediatric surgery

Purpose

The aim of this study was to investigate the prenatal courses and management of abdominal surgical diseases.

Methods

Of the 327 patients registered with our fetal treatment board since March 2002, 83 fetuses referred to the surgical department were enrolled for the current study. The prenatal diagnosis, sequential fetal images, and perinatal courses of these cases were reviewed retrospectively.

Results

Of the 83 cases, abdominal diseases were suspected in 34, lung and thoracic diseases in 25, genitourinary diseases in 12, and other anomalies in 12. Meconium peritonitis (MP), intestinal obstruction, and abdominal wall defects accounted for approximately 65% of the abdominal diseases. Five patients with prenatally diagnosed lung diseases underwent fetal surgical intervention, and 17 of the 22 liveborn patients survived. In contrast, none of the patients with prenatally diagnosed abdominal anomalies underwent fetal surgical intervention, yet, 23 of the 24 liveborn patients survived. However, preterm labor and hydrops were seen frequently in the patients with giant cystic MP, suggesting a fetal critical condition.

Conclusions

Although the clinical outcome of abdominal diseases seemed favorable with postnatal treatment, the current results suggested the occurrence of hidden mortality in utero and the potential need for fetal intervention for some abdominal conditions, such as MP.     

Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey

Purpose

Focused abdominal sonography for trauma (FAST) has been popularized for the initial evaluation of trauma patients. We sought to understand the scope of practice on a national level with specific attention to its use in the pediatric age group.

Methods

An electronic survey was sent to all American College of Surgeons level I trauma centers and the National Association of Children's Hospitals and Related Institutions that were freestanding children's hospitals.

Results

The survey was emailed to 124 centers, and 98 (79%) completed the survey. Of the surveyed centers, 23% cared for adults only, 28% were freestanding children's hospitals, and 49% managed both. At adults-only institutions, 96% use FAST and at children's hospitals, only 15%; it is used at 85% of centers that care for both. For the centers that use FAST on children, 88% have no age limit. Of all the institutions that typically use FAST, the individual performing the examination could be a surgeon (73%), an emergency department doctor (48%), or a radiologist (3%). Of the centers that perform FAST, 51% bill for the FAST examination.

Conclusions

Adult hospitals are much more likely to perform FAST examinations in the trauma patient, and many adult centers routinely use FAST to examine pediatric patients.     

Outcomes of surgical and radiologic placed implantable central venous access ports

Background

Recent literature suggests implantable central venous access ports (ICVAPs) can be placed by interventional radiologists with fewer complications and lower expenses when compared with surgeons. An analysis of outcomes and expenses of ICVAP placement by service was conducted.

Methods

Three hundred sixty-eight ICVAPs were placed over 3 years at a 230-bed community teaching hospital. A retrospective review of these procedures was conducted. Data recorded for each procedure included patient demographics, reason for placement, indwelling port days, complications, billed charges, and reimbursement.

Results

Two hundred seventy-six (75%) ICVAPs were placed by interventional radiologists, while surgeons placed the remaining 92 ports (25%). Short-term complications were identified in 7 interventional radiologist-placed ports (2.5%) and 1 surgically placed port (1.1%), P = .42. Billed charges were greater for interventional radiologist-placed ports ($5,301 vs $4,552, P = .0001). In contrast, reimbursement was greater for surgically placed ports: interventional radiologist 31.3% of charges, surgery 42.8%, P = .049.

Conclusion

Reimbursement and charges demonstrated significant differences between surgeons and interventional radiologists. Prior assertions that ports placed by interventional radiologists are less expensive with fewer complications may no longer be valid.     

PJ34, a poly-ADP-ribose polymerase inhibitor, modulates visceral mitochondrial activity and CD14 expression following thoracic aortic ischemia-reperfusion

Background

Visceral ischemia-reperfusion injury (VI) contributes to adverse outcomes following the repair of thoracoabdominal aneurysms. Experiments were designed to determine whether a poly-adenosine diphosphate-ribose polymerase (PARP) inhibitor modulates indexes of metabolic function (mitochondrial activity), inflammatory cell activation, and tissue inflammation (lipopolysaccharide receptor CD14 messenger ribonucleic acid) following VI.

Methods

129S1/SvImj mice were subjected to thoracic aortic occlusion followed by 48 hours of reperfusion. Normal saline was administered to 25 untreated control mice and PJ34 to 21 mice before and immediately after thoracic aortic ischemia-reperfusion. Sham mice (n = 13) underwent median sternotomy alone. At 48 hours, all animals were euthanized and tissues harvested for quantitative analysis.

Results

PJ34 improved intestinal (P < .05) but not hepatic mitochondrial activity following reperfusion. CD14 messenger ribonucleic acid levels in liver (P < .004), kidney (P < .003), and spinal cord (P < .03) tissue were less in PJ34-treated mice.

Conclusions

PJ34 preserved the metabolic function of intestinal but not hepatic tissue during reperfusion. PJ34 uniformly decreased the expression of an important marker of inflammatory cell activation and tissue inflammation in visceral tissue following VI. PARP inhibitors may serve as a therapeutic modality to abrogate the stress response to VI.     

Turning whine into wine: the fiscal impact of comprehensive documentation and billing for nonoperative pediatric surgical services

Purpose

Some pediatric surgeons rarely document nonoperative services, believing that the reimbursement provided for such care is negligible. We evaluated the impact of comprehensive documentation and billing for nonoperative, pediatric surgical care.

Methods

All bills submitted for inpatient, nonoperative care for 1 year were reviewed. Total receipts for documented admissions, consultations, critical care, and daily care were determined. The Evaluation and Management code billed for each service was recorded, and the total and average payments attributable to each Evaluation and Management code were calculated.

Results

Fifty-six percent of services were covered by Medicaid and 26% by a commercial insurer. There were 607 billed admission history and physical exams for which reimbursement totaled $43,493. Critical care services were provided to 49 patients and yielded $8964 in payments. Six hundred thirty-nine inpatient consultations were performed with a reimbursement of $42,830. Daily care services were billed 1044 times and produced $71,579 in payments. Overall reimbursement for documented, nonoperative services was $166,866. This represented 16.2% of total, noncontracted income for the practice.

Conclusion

Despite a payer mix heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what it would have been had only operative services been billed. The yield from properly documented, nonoperative care can be substantial.     

Utilidad de la tomografía computarizada para el diagnóstico de lesiones intestinales y mesentéricas en el trauma abdominal cerrado

Background

The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries.

Method

Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries.

Results

For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%.

Conclusion

The abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma.     

Wrong-site sinus surgery in otolaryngology

Objective

To determine the scope of wrong-site sinus surgery.

Study Design

Electronic mail survey.

Setting

E-mailed via the American Academy of Otolaryngology-Head and Neck Surgery's weekly newsletter.

Subjects and Methods

Members were asked about wrong-site sinus surgery in an 11-item survey.

Results

A total of 455 members responded (response rate 19.8%). Forty-two (9.3%) have heard of a case of wrong-site sinus surgery occurring. Twenty-one cases were analyzed; of these, 10 (48%) implicated radiographic error, and the Universal Protocol was followed in one third. In seventeen reports (81%), there was disclosure to the family, one case with delayed disclosure; there was no disclosure in three cases. Sixty-one percent (n = 266) are concerned about operating on the wrong sinus or side. Forty-nine percent (n = 216) routinely use a checklist preoperatively. There is large variation in site marking for sinus surgery. Sixty-five percent (n = 282) routinely review the computed tomography scan prior to surgery.

Conclusion

Approximately 10 percent of survey respondents know of a case of wrong-site sinus surgery occurring; the majority of respondents are concerned about a wrong-sinus or wrong-sided surgery occurring in their practice. Otolaryngologists should be vigilant regarding the potential for inverted computed tomography images; there should be national efforts to address this latent systems defect. Surgeons should be trained in understanding the role of and engaging in disclosure and in other techniques that are of greatest support to the patient. Consideration of sinus-specific checklists should be led by the societies representing sinus surgeons.     

Relative value units correlate with pediatric surgeons' operating time: when perceived myth becomes reality

Purpose

In 1992, the Congress implemented a Medicare payment system based on relative value units (RVUs). Today, RVUs are increasingly used to determine surgeon reimbursement from Medicare, Medicaid, and private third-party payers. We questioned whether current RVU assignments accurately reflect the quantity of time that surgeons spend operating.

Methods

Over a 12-month period, 59 common pediatric operations were identified and classified as general surgery (n = 34), urology (n = 13), or minimally invasive (n = 10). Only operations performed as an outpatient or requiring less than one inpatient day of direct surgeon involvement were included. By regression analysis, correlation coefficients were generated comparing average operating time per procedure to the corresponding RVU generated.

Results

Of 59 specific operations, a total of 744 general surgery cases, 1155 urological cases, and 370 minimally invasive cases were performed. RVU efficiency was greatest in general surgery (1 RVU = 5.18 operating minutes), followed by minimally invasive operations (1 RVU = 6.80 minutes) and urological operations (1 RVU = 8.59 minutes). Regression analysis proved minimally invasive operations to correlate best with RVUs with R² = 0.8376, followed by urology at R² = 0.6753, and then general surgery at R² = 0.649.

Conclusions

The RVU has emerged as the most dominant factor influencing reimbursement of practicing pediatric surgeons. Despite common surgeon bias, RVUs do correlate with current operating times. These data prove important as surgeons analyze cost, negotiate contracts, and strategically plan for fiscal success.     

Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System

Background

This study was designed to evaluate the impact of 3-dimensional vision on the performance of resident and experienced surgeons using the da Vinci Robot System (Intuitive Surgical, Sunnyvale, CA).

Methods

Four tasks were performed by 12 surgeons with varying experience. Performance times and errors were recorded using both 2-dimensional and 3-dimensional vision for each task.

Results

Performance time and error rates for all 4 skills confirm a significant advantage using 3-dimensional vision. Performance times were reduced by 34% to 46% using 3-dimensional imaging for all participants with statistical significance. Error rates were reduced by 44% and 66%.

Conclusion

Independent of the biomechanical advantages of the da Vinci Robot System, 3-dimensional vision allows for significant improvement in performance times and error rates for both inexperienced residents and advanced laparoscopic surgeons.     

Effect of graft size on graft fracture rate after anterior lumbar spinal fusion in a sheep model

Study design

Sheep anterior spinal fusion model with autogenous and xenogenous bone grafts.

Objective

To investigate whether the relationship between cross-sectional area of the bone graft and area of the adjacent vertebral endplates has an effect on graft fracture rate.

Summary of background data

Anterior spondylodesis with autogenous iliac crest transplant is a frequently performed operation to stabilize spinal motion segments but to date no precise recommendations with respect to minimum graft size are available in the literature.

Methods

Anterior spondylodesis using autogenous and xenogenous grafts of constant size in combination with an angular stable plate (Macs TL^®). Autogenous iliac crest graft was inserted in eight sheep and xenogenic, commercially available bovine graft (Tutobone^®) in the additional eight animals.The surface areas of the endplates of the fused intervertebral space were calculated using CT scans and contact radiographs of the specimens obtained after 24 weeks. The graft itself was evaluated for fractures and osteolysis.

Results

A fracture occurred in tricortical, autogenous grafts if the graft cross-sectional area was less than 21% of the area of the adjacent endplates. All xenogenic grafts fractured and therefore a comparable value could not be determined.

Conclusion

The results clearly indicate that the relation between graft cross-sectional area and endplate area defines the survival or fracture of the graft in anterior spinal fusion. Although it is difficult to directly apply the results to the clinical situation it is suggested to choose a sufficiently large graft, in order to reduce the risk of autogenous graft fracture in anterior spondylodesis.     

Efficacy of cognitive feedback in improving operative risk estimation

Background

Decision-making is an essential skill for surgeons, but systematic objective feedback is lacking. Cognitive feedback provides information about how risk factors relate to outcomes, and how individual surgeons mentally synthesize these relationships.

Methods

Pre-feedback, we assessed accuracy and reliability of 105 trainee surgeons'/medical students' estimates of operative mortality for major surgery for 28 patient vignettes with varying risk factors, using a published risk model as a gold standard. Post-feedback, participants were retested on a second case set.

Results

Post-feedback, both groups' estimates became more reliable. Pre-feedback, medical students were less accurate than trainee surgeons; post-feedback, their accuracy improved to match that of trainee surgeons, who did not improve further.

Conclusions

Cognitive feedback improved risk estimate reliability in both groups and accuracy in the medical students group. Lack of improvement in the surgical group implies a ceiling effect. These findings have implications for training and assessment of surgical decision-making.     

Explaining disparities in access to high-quality cardiac surgeons

Background

Racial disparities in access to coronary artery bypass graft (CABG) surgery are well documented. Recent evidence shows that even when patients receive CABG surgery, racial minorities are more likely to be treated by lower quality providers.

Methods

New York State (NYS) hospital discharge data for 1996 and 1997 for patients undergoing CABG surgery were combined with risk-adjusted mortality rates for cardiac surgeons calculated by the NYS Department of Health. Statistical analysis was performed to determine the relationship between patients' race and the quality of the surgeon performing the CABG, as measured by the surgeon's risk-adjusted mortality rate, after controlling for patient characteristics such as comorbidities and socioeconomic status; the hospital where the surgery was performed; and the number of surgeries the surgeon performed over a 3-year period.

Results

African Americans and Asian/Pacific Islanders are treated by surgeons with higher risk-adjusted mortality rates compared with whites. This association does not appear to be a result of inadequate risk adjustment. It is explained to some degree by the hospital to which these patients are admitted, and to a lesser degree by (1) the education and income level in the patient's zipcode of residence and (2) being treated by a low-volume surgeon. After controlling for these factors, race continues to be associated with treatment by a surgeon with a higher risk-adjusted mortality rate.

Conclusions

Efforts to achieve the “Healthy People 2010” goals of eliminating health disparities should address not only access to care, but also access to high-quality care.     

Fragmented international volunteerism: need for a global pediatric surgery network

Introduction

Pediatric general surgeons volunteering internationally often work independently, some without prior assessment of the needs of those they wish to assist. Consequently, care may be inefficient, duplicated, or misdirected. A study was performed to assess whether a network for pediatric surgery volunteer work exists.

Methods

A search of the Internet was performed to determine whether a pediatric surgery network exists. Worldwide pediatric surgery societies were identified and grouped by country according to income. Web sites for medical volunteer organizations were examined for links to a network of pediatric surgery volunteer work.

Results

A search of the Internet revealed no pediatric surgery volunteer network. Ninety-seven pediatric surgery societies were identified. Fifty-one of the organizations were identified as residing in low- and middle-income countries. Searching 50 Web sites for these societies revealed no existing pediatric surgery network. Of 45 Web sites for volunteer medical work, 1 surgery networking Web site was identified. Only 4 pediatric general surgery international volunteer opportunities were cited on that Web site.

Conclusions

This study demonstrated that no pediatric surgery volunteer network exists. By identifying pediatric surgery organizations in low- and middle-income countries, it is speculated that one might link the surgeons in these regions with those wishing to volunteer their services.     

Different reimbursement influences surviving of hip fracture in elderly patients

Objectives

Research has shown that early surgical intervention for hip fractures serves to decrease mortality. In 2004 the Ministry of Health decided to condition the reimbursement regime at the time of operation. The objectives of this study were to examine whether the reform succeeded to decrease inpatient mortality of hip fracture casualties.

Method

The study utilised data drawn from the Israeli Trauma Registry (ITR) for the years 1999-2006. The study population included patients aged 65 and older with an isolated diagnosis of hip fracture following trauma.

Results

Two years after the reform, the inpatient mortality decreased by 34% amongst patients undergoing fixation surgery, and by 30% amongst all operated patients. Median LOS decreased by 2 days. The proportion of patients undergoing hip fracture fixation surgery within 48 h increased by 35%.

Conclusions

The implementation of a payment limited by time for hip fracture fixation surgery increased the number of patients being operated within 48 h, shortened patient LOS, and decreased inpatient mortality.     

Use of tissue expanders in the repair of complex abdominal wall defects

Background/Purpose

Closure of abdominal wall defects in children poses a challenge for pediatric surgeons. We describe a technique using tissue expanders placed either intraperitoneally or in the abdominal wall to aid in the reconstruction of a variety of complex abdominal wall defects.

Methods

The tissue expanders are inserted under general anesthesia. Initial expansion is done in the operating room with attention to peak airway pressure, urine output, and end-tidal carbon dioxide. The expanders are inflated in the outpatient setting via percutaneous access until the calculated inflation volume is achieved. They are then removed; and definitive closure is accomplished using a combination of native tissue flaps, abdominal component separation techniques, biomaterials, and synthetic material.

Results

Six children underwent tissue expansion for treatment of abdominal wall defects (omphalocele, n = 3), trauma (n = 1), and thoracopagus twins (n = 1 pair). One to 4 expanders were used per patient, with all having a successful reconstruction of their abdominal walls. Two to 3 operations were required to restore abdominal domain and consisted of expander insertion, removal with reconstruction, and possible revision of the reconstruction.

Conclusions

Tissue expanders possess a broad range of applications for abdominal wall reconstruction and can be used in patients of all ages.     

Quality of life in kidney transplantation from marginal donors

Objective

Enhancement of the subjective components, recognition of overall needs, and careful consideration of subjectively perceived quality of life among dialysis and/or transplanted patients appear to be key objectives to promote optimized adherence to treatment and active cooperation of the patient. This study explores the relationship between self-rated health among recipients of kidney transplantations from deceased marginal donors (age older than 55 years) in relation to gender, age, time on dialysis, years after transplantation, and donor age.

Patients and Methods

Posttransplant quality of life was assessed with the Complete Form Health Survey (SF-36) in 70 recipients of kidney transplantations from marginal deceased donors.

Results

Donor age did not negatively influence health status perceived by the subjects. The vitality and mental health seemed to increase with greater donor ages, but the status of perceived health, vitality, social activities, and mental health were negatively influenced by the age of the transplant.

Conclusions

Our study shows that good general health and social well-functioning can be achieved also among recipients of organs from older donors. Thus, age alone should not be a barrier to organ donation, providing that the organ function is normal and that specific disease is absent in the organ.     

Use of simulect can reduce the incidence of acute rejection and demonstrates with superior 3-year patient and graft survival rates in renal transplantation

Background

Acute rejection is a major cause of graft loss in renal transplantation. Because the highest risk for acute rejection is in the first month posttransplantation, improved prophylaxis could be most beneficial in this period. Simulect administration provides 30 to 45 days of immunoprophylaxis against acute rejection during the critical period after transplantation.

Objectives

We sought to assess the incidence of acute rejection episodes and the safety and tolerability of Simulect plus Neoral immunosuppression. Patient and graft survival rates up to 3 years posttransplantation were evaluated.

Method

Forty-one transplant recipients received Simulect by intravenous infusion of an initial 20-mg dose on the day of renal transplantation and a second 20-mg dose on day 4 posttransplant. All renal recipients received immunosuppression with Neoral and steroid.

Results

There were eight cases (19.5%) of acute rejection within 1 year. The rejection episodes were easily reversed with steroid pulse therapy in seven patients except for graft loss. The 1-, 2-, and 3-year graft survival rates were 95%, 93%, and 88%, respectively. Overall, the 3-year patient survival rate was 100%.

Conclusions

Simulect in combination with Neoral and steroid-reduced the incidence of acute rejection without an increase in adverse events. The low incidence and severity of acute rejection may have led to the superior 3-year patient and graft survival rates in renal transplantation.     

To operate or not to operate? A multi-method analysis of decision-making in emergency surgery

Background

The ability to decide when to operate and when not to operate is a key surgical skill. The aim of this study was to investigate factors affecting that decision.

Methods

In phase 1, semistructured interviews were used to investigate how expert surgeons decide when to operate. In phase 2, clinical case vignettes were constructed, and 22 general surgeons at various stages of their training indicated whether they would operate and their confidence in patient outcomes.

Results

Interviews answers centered on the theme of “patient outcome,” which was defined similarly by all surgeons. In phase 2, surgeons chose to operate when they perceived the outcome with an operation to be better than the outcome without. Surgeons with <5 years of experience were less certain about what outcomes might be. These surgeons opted to perform significantly more operations (40 ± 4%) than surgeons with ≥5 years of experience (18 ± 2%).

Conclusions

A subjective, balanced assessment of the likelihood of patient outcome is crucial in deciding whether to operate. Novices face higher degrees of uncertainty, explaining differences in decisions taken.