Can We Measure the Quality of Breast Surgical Care?

Many studies have demonstrated gaps in healthcare quality for all medical and surgical specialties including breast surgical care. How to optimally measure and improve quality has generated debate at the local, state, and national level. Attempts to judge medical performance by private companies using non-risk-adjusted administrative databases may not be accurate and may unfairly penalize surgical care. An overview of concepts to measure and improve quality of breast cancer care is presented with specific examples relevant to breast surgeons. Breast surgeons and their professional organizations need to take ownership of quality measure programs because others will surely do so if we do not. Participation in one or more of these programs is beneficial because peer performance comparison allows identification of potential areas for individual or institutional improvement and demonstrates the commitment of breast surgeons to quality improvement. This commitment may gain even greater importance if trends continue toward performance-based physician payment, patient steerage, licensure, and board certification.     

Is the Quality of Life Better in Patients with Colostomy than Patients with Fecal Incontience?

Background A colostomy offers definitive treatment for individuals with fecal incontinence (FI). Patients and physicians remain apprehensive regarding this option because the quality of life (QOL) with a colostomy is presumably worse than living with FI. The aim of this study, therefore, was to compare the QOL of colostomy patients to patients with FI. Methods A cross-sectional postal survey of patients with FI or an end colostomy was undertaken. QOL measures used included the Short Form 36 General Quality of Life Assessment (SF-36) and the Fecal Incontinence Quality of Life score (FIQOL). Results The colostomy group included 39 patients and the FI group included 71 patients. The average FI score for FI group was 12 ± 4.9 (0 = complete continence, 20 = severe incontinence). In the colostomy group the average colostomy function score was 12.9 ± 3.8 (7 = good function, 35 = poor function). Analysis of the SF-36 revealed higher social function score in the colostomy group compared to the FI group. Analysis of the FIQOL revealed higher scores in the coping, embarrassment, lifestyle scales, and depression scales in the colostomy group compared to the FI group. Conclusion A colostomy is a viable option for patients who suffer from FI and offers a definitive cure with improved QOL.     

What are Predictors of Mortality in Patients with Pelvic Fractures?

Background  

Our knowledge of factors influencing mortality of patients with pelvic ring injuries and the impact of associated injuries is currently based on limited information.     

Is the Iliac Wing Curved Inward in Patients with Developmental Dysplasia of the Hip?

BackgroundThere is a paucity of studies on the iliac curvature in developmental dysplasia of the hip (DDH). Here, we examined the iliac curvature in DDH using three-dimensional computed tomography.MethodsWe allocated cases with a center-edge angle of < 20° to the DDH group (55 cases) and cases with a center-edge angle of > 25° to the control group (57 cases) and measured the straight line (line A) between the anterior and posterior superior iliac spines. We examined which part of the iliac bone line A passes through and classified the results into 4 categories (type A, inside the iliac bone; type B, through the iliac bone; type C, outside the iliac bone; and type D, both inside and outside the iliac bone) to evaluate the iliac wing curvature. After measuring the area and internal surface of the iliac wing using line A, we examined the correlation between these values, the interspinous distance, the superior iliac angle, and the center-edge angle.ResultsDistributions of the four types were compared between the two groups; there was no significant difference. The length of the portion of line A inside the ilium and the area formed by line A and the iliac wing, which shows the degree of iliac wing curvature, were not significantly different between the groups. There were no correlations between these values and the center-edge angle; however, there were weak positive correlations among the interspinous distance, the superior iliac angle, and the center-edge angle.ConclusionsThe inward nature of the iliac bone in patients with DDH is mainly due to the internal rotation of the entire iliac bone and less likely due to the curvature of the iliac bone.     

Patient Preparation for Transitions of Surgical Care: Is Failing to Prepare Surgical Patients Preparing Them to Fail?

Background

Transitions of care before and after surgery are critical for patient preparation. We sought to determine whether the degree of exposure to health information resources before and after surgery increases preparedness and decreases hospital readmission.

Methods

A national Web-based, cross-sectional survey was conducted of 1917 patients and caregivers who had a recent surgical encounter. Health information resources used before and after surgery were correlated with patient level of preparedness. We also evaluated the association between preparedness and hospital readmission.

Results

Compared to unprepared patients, those who felt prepared were most likely to be given multiple health information resources before surgery (92 vs. 77%, p < 0.001) and before leaving the hospital (91 vs. 69%, p = 0.02). Feeling prepared was positively correlated with the number of resources provided to patients by their surgical team and used before surgery and before leaving the hospital (p < 0.05, both). 30-day readmission was significantly lower among patients who felt prepared either before (7% prepared vs. 22% not prepared, p = <0.001) or after surgery (9% prepared vs. 23% not prepared, p < 0.001).

Conclusions

Patients with access to more health information resources during transitions before and after surgery feel better prepared and have lower rates of 30-day readmission.

     

Is the Standard of Care What We Think It Is?

For the most part, gynecologists are actually unaware of the issues involving surrogate versus quality of life outcomes, the "deceptive practice of medicine" and the true incidence of complications as they relate to the standard of care. An anonymous survey of 1958 practicing gynecologists attending seven national symposia revealed a significant number of unreported complications. Clearly, the standard of care (at least with regard to complication risk) is markedly different than has been suggested by the medical literature. Concomitantly, we suggest that physicians need to take a more active role in the policing of our own specialties.     

What Is the Learning Curve for the Anterior Approach for Total Hip Arthroplasty?

Background

There are many factors that may affect the learning curve for total hip arthroplasty (THA) and surgical approach is one of these. There has been renewed interest in the direct anterior approach for THA with variable outcomes reported, but few studies have documented a surgeon’s individual learning curve when using this approach.

Questions/purposes

(1) What was the revision rate for all surgeons adopting the anterior approach for placement of a particular implant? (2) What was the revision rate for surgeons who performed > 100 cases in this fashion? (3) Is there a minimum number of cases required to complete a learning curve for this procedure?

Methods

The Australian Orthopaedic Association National Joint Replacement Registry prospectively collects data on all primary and revision joint arthroplasty surgery. We analyzed all conventional THAs performed up to December 31, 2013, with a primary diagnosis of osteoarthritis using a specific implant combination and secondarily those associated with surgeons performing more than 100 procedures. Ninety-five percent of these procedures were performed through the direct anterior approach. Procedures using this combination were ordered from earliest (first procedure date) to latest (last procedure date) for each individual surgeon. Using the order number for each surgeon, five operation groups were defined: one to 15 operations, 16 to 30 operations, 31 to 50 operations, 51 to 100 operations, and > 100 operations. The primary outcome measure was time to first revision using Kaplan-Meier estimates of survivorship.

Results

Sixty-eight surgeons performed 5499 THAs using the specified implant combination. The cumulative percent revision at 4 years for all 68 surgeons was 3% (95% confidence interval [CI], 2.5–3.8). For surgeons who had performed over 100 operations, the cumulative revision rate was 3% (95% CI, 2.0–3.5). It was not until surgeons had performed over 50 operations that there was no difference in the cumulative percent revision compared with over 100 operations. The cumulative percent revision for surgeons performing 51 to 100 operations at 4 years was 3% (95% CI, 1.5–5.4) and over 100 operations 2% (95% CI, 1.2–2.7; hazard ratio, 1.40 [95% CI, 0.7–2.7]; p = 0.33).

Conclusions

There is a learning curve for the anterior approach for THA even when using a prosthesis combination specifically marketed for that approach. We found that 50 or more procedures need to be performed by a surgeon before the rate of revision is no different from performing 100 or more procedures. Surgeons should be aware of this initial higher rate of revision when deciding which approach delivers the best outcome for their patients.     

What Is the Utility of Biomarkers for Assessing the Pathophysiology of Hip Osteoarthritis? A Systematic Review

Background

Innovations in biologics offer great promise in the treatment of patients with orthopaedic conditions and in advancing our ability to monitor underlying disease pathophysiology. Our understanding of the pathophysiology of hip osteoarthritis (OA) has improved significantly in the last decade. Femoroacetabular impingement (FAI) and hip dysplasia are increasingly recognized and treated as forms of prearthritic hip disease, yet the inability of radiographic and MR imaging to identify patients before the onset of irreversible articular cartilage injury limits their use for early diagnosis and treatment of patients with these conditions. Molecular biomarkers, as objectively measureable indicators of the pathophysiology of hip OA, have the potential to improve diagnosis, disease staging, and prognosis of hip OA and prearthritic hip disease. Although research into molecular biomarkers of hip OA has been conducted, investigations in prearthritic hip disease have only recently begun.

Questions/purposes

The purpose of our review was to assess the use of molecular biomarkers in the pathophysiology of hip OA, including (1) diagnosis; (2) disease staging; and (3) prognosis. We additionally aimed to summarize the available literature investigating the use of biomarkers in (4) prearthritic hip disease, including FAI and hip dysplasia.

Methods

We conducted a systematic review of molecular biomarkers associated with hip OA or prearthritic hip disease by searching four major electronic databases for keywords “hip”, “osteoarthritis”, “biomarker”, and all synonyms. The search terms “femoroacetabular impingement” and “hip dysplasia” were also included. The biologic source of biomarkers was limited to serum, plasma, urine, and synovial fluid. The literature search yielded a total of 2740 results. Forty studies met all criteria and were included in our review. Studies were categorized regarding their relevance to (1) diagnosis; (2) disease staging; (3) prognosis; and/or (4) prearthritic hip disease.

Results

Biomarker studies were characterized as relevant to diagnosis (16 studies), disease staging (15 studies), prognosis (11 studies), and prearthritic hip disease (three studies). Sixteen different biomarkers demonstrated associations relevant to the diagnosis of hip OA, 16 biomarkers demonstrated similar associations for disease staging, and six for prognosis. Six biomarkers seemed to be the most promising, demonstrating associations with hip OA in multiple studies, including: urinary level of type II collagen telopeptide (n = 5 studies), serum cartilage oligomeric protein (n = 4 studies), and serum C-reactive protein (n = 4 studies). Only three studies investigated the role of biomarkers in prearthritic hip disease, including two in FAI and one in unspecified etiology of pain. There were no studies about biomarkers in hip dysplasia.

Conclusions

Molecular biomarkers are increasingly investigated for their use in evaluating the pathophysiology of hip OA, but less so for prearthritic hip disease. Several biomarkers have demonstrated significant associations with hip OA across multiple studies. Further validation of these biomarkers is needed to assess their clinical use and potential application to prearthritic hip disease.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4148-6) contains supplementary material, which is available to authorized users.     

Surgical Treatment of Femoroacetabular Impingement: What Are the Limits of Hip Arthroscopy?

The variety of hip pathology that can be addressed in a minimally invasive fashion in the young, pre-arthritic patient has rapidly grown in parallel with technical advances in hip arthroscopy. However, the indications and limits of arthroscopy must be carefully defined and indications must evolve correspondingly to avoid an increase in failure rates and unsatisfactory clinical outcomes. Some diagnoses may be better and more comprehensively addressed with open procedures or combined surgical approaches. The purpose of this article is to provide an unbiased and evidence-based review of conditions of the pre-arthritic hip to define our current understanding of the advantages, disadvantages, and limitations of an arthroscopic approach.