Does the Vascular Surgery Board of the American Board of Surgery work?

Recommendations to form an independent American Board of Vascular Surgery were made several years ago by leaders in vascular surgery. All major vascular societies in the United States voted by majority rule to approve the formation of this organization. Although the Vascular Surgery Board of the American Board of Surgery is well intentioned, its focus and intentions are outdated because it is subservient to the American Board of Surgery.     

How much do standardized forms improve the documentation of quality of care?

BACKGROUND: Chart abstraction is a common method for measuring the quality of surgical care. In this study we examine how the use of standardized operative dictation and history forms improves documentation rates of bariatric quality measures. MATERIALS AND METHODS: Two independent reviewers evaluated 201 patient charts from two multi-surgeon bariatric surgery practices for documentation of five intraoperative and seven preoperative bariatric quality measures. Group 1 used fully standardized templates to dictate or collect both, while Group 2 did not. Documentation rates were compared between the groups. RESULTS: Operative reports more consistently documented quality assessment information for cases where a dictation template was used versus where it was not (89% versus 58%, respectively, P < 0.001). The greatest discrepancies between the two groups were found in "exploration of the abdomen" (95% in Group 1 versus 43% in Group 2, P < 0.001) and in "evaluation of the gallbladder" (76% versus 28%, P < 0.001). In comparison, overall documentation rates for preoperative comorbidities were greater in both groups but remained higher for Group 1, who used fully standardized forms (98% versus 74%, P < 0.001). Group 1 had statistically significant higher rates of documentation for all seven comorbidities. CONCLUSIONS: The use of standardized dictation templates and history forms is associated with significantly higher documentation rates of quality measures in bariatric surgery. The adoption of these methods into routine use will be needed to allow for wide scale quality assessment and improvement for surgical practices.     

Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?

BACKGROUND: Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure. METHODS: Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured. RESULTS: There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv). CONCLUSIONS: SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.     

Is trauma centre care helpful for less severely injured patients?

BACKGROUND: Trauma centres have been shown to reduce the number of preventable deaths from serious injuries. This is due largely to the rapid response of surgeons and health care teams to resuscitate, evaluate, and operate if necessary. Less is known about the effectiveness of trauma centre care on those patients who have not incurred immediate life-threatening problems and may not be as critically injured. The purpose of this study was to review the use of physician and hospital resources for this patient population to determine whether trauma team and trauma centre care is helpful or even needed. METHODS: This was a retrospective study of consecutive trauma patients (n=1592) admitted from 1998 to 2002 to the trauma service of an urban level I trauma centre and recorded in the hospital trauma registry. Patients were triaged in a tiered response to more or less severely injured. All patients' care was directed by trauma surgeons. RESULTS: Of the 1592 patients, 398 (25%) received a full trauma team response (Class I), 1194 were less seriously injured (Class II). The ISS for the Class I patients was 19+/-18 and for Class II patients 10+/-10. Nineteen percent of Class II patients had an ISS>15. Overall mortality in Class II patients was 2% including 20 unexpected deaths. Four hundred and three Class II patients (34%) had multisystem injuries. Of the Class II patients 423 (35%) were sent to the ICU or OR from the ED, 106 of whom required an immediate operation and 345 required an operation prior to discharge. Complications developed in 129 patients (11%), the majority of which were pulmonary. CONCLUSIONS: A large proportion of those patients thought initially to be less severely injured required resources available in a trauma centre, including specialty care, intensive care, and operating room accessibility. Over one-third of these patients had multisystem injuries and almost 20% were considered major trauma, needing prioritisation of care and expertise ideally found in a trauma centre environment. Complications developed in a sizable number of patients. This patient population, because of its heterogeneity and propensity for critical illness, deserves the resources of a trauma centre.     

How not to neglect the care of elderly breast cancer patients?

Breast cancer is one of the leading causes of cancer mortality in women. Its incidence increases with increasing age; those over 70 years constitute more than one-third of the current breast cancer population. Despite significant advances in the field of breast cancer treatment, elderly patients have seen neither a meaningful improvement in treatment strategies, nor a decline in breast cancer-specific mortality. Studies have shown that a high percentage of elderly breast cancer patients do not receive standard treatment because of their age, co-morbidities, and sometimes due to their personal choice. However, in routine clinical practice there is no comprehensive assessment in place, on which to base treatment decisions, to ensure that elderly patients receive clinically appropriate treatment. We have reviewed the current literature and discuss differences in treatment of breast cancer between young and older patients. We also discuss different ways to optimise the treatment of breast cancer in elderly patients and the need for further research in this area.     

How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer

BACKGROUND: Patients with severe chronic obstructive pulmonary disease (COPD) have a poor quality of life and limited life expectancy. This study examined whether these patients were relatively disadvantaged in terms of medical and social care compared with a group with inoperable lung cancer. METHODS: An open two group comparison was made of 50 patients with severe COPD (forced expiratory volume in one second (FEV(1)) <0.75 l and at least one admission for hypercapnic respiratory failure) and 50 patients with unresectable non-small cell lung cancer (NSCLC). A multi-method design was used involving standardised quality of life tools, semi-structured interviews, and review of documentation. RESULTS: The patients with COPD had significantly worse activities of daily living and physical, social, and emotional functioning than the patients with NSCLC (p<0.05). The Hospital Anxiety and Depression Scale (HADS) scores suggested that 90% of patients with COPD suffered clinically relevant anxiety or depression compared with 52% of patients with NSCLC. Patients were generally satisfied with the medical care received, but only 4% in each group were formally assessed or treated for mental health problems. With regard to social support, the main difference between the groups was that, while 30% of patients with NSCLC received help from specialist palliative care services, none of the patients with COPD had access to a similar system of specialist care. Finally, patients in both groups reported a lack of information from professionals regarding diagnosis, prognosis and social support, although patients' information needs were disparate and often conflicting. CONCLUSION: This study suggests that patients with end stage COPD have significantly impaired quality of life and emotional well being which may not be as well met as those of patients with lung cancer, nor do they receive holistic care appropriate to their needs.     

How well do you know the back of your hand? Toward evidence-based knowledge

Familiarity with the back of one's hand has long been used as a reference criterion for knowledge despite a lack of supporting evidence. The present study prospectively tests normal subjects' knowledge of dorsal hand features. Sixty surgical, medical, and allied hospital employees (30 men, 30 women) were asked 5 questions with binary answers about features on the dorsum of their dominant hands while their hands were concealed. The proportion of correct answers to each question ranged from 0.45 to 0.65, and none was significantly different from 0.50. Similarly, the mean percentage of correct answers for all subjects and all questions was 54%, which was not significantly different from 50%. Thus, the accuracy of the answers approximated random guesses. Hand specialists scored significantly higher (75%) than other occupation groups. Men and women scored equally as a whole. These data refute the use of the hand idiom as a reference criterion for knowledge.