Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist
Author list: Mark G. Shrime, Blake C. Alkire, Caris Grimes, Tiffany E. Chao, Dan Poenaru, Stephane Verguet
Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold.
The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created.
Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed.
Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.
Patient Preparation for Transitions of Surgical Care: Is Failing to Prepare Surgical Patients Preparing Them to Fail?
Author list: Luke A. Martin, Samuel R. G. Finlayson, Benjamin S. Brooke
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.
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.
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).
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.
Regret in Surgical Decision Making: A Systematic Review of Patient and Physician Perspectives
Author list: Ana Wilson, Sean M. Ronnekleiv-Kelly, Timothy M. Pawlik
Regret is a powerful motivating factor in medical decision making among patients and surgeons. Regret can be particularly important for surgical decisions, which often carry significant risk and may have uncertain outcomes. We performed a systematic review of the literature focused on patient and physician regret in the surgical setting.
A search of the English literature between 1986 and 2016 that examined patient and physician self-reported decisional regret was carried out using the MEDLINE/PubMed and Web of Science databases. Clinical studies performed in patients and physicians participating in elective surgical treatment were included.
Of 889 studies identified, 73 patient studies and 6 physician studies met inclusion criteria. Among the 73 patient studies, 57.5% examined patients with a cancer diagnosis, with breast (26.0%) and prostate (28.8%) cancers being most common. Interestingly, self-reported patient regret was relatively uncommon with an average prevalence across studies of 14.4%. Factors most often associated with regret included type of surgery, disease-specific quality of life, and shared decision making. Only 6 studies were identified that focused on physician regret; 2 pertained to surgical decision making. These studies primarily measured regret of omission and commission using hypothetical case scenarios and used the results to develop decision curve analysis tools.
Self-reported decisional regret was present in about 1 in 7 surgical patients. Factors associated with regret were both patient- and procedure related. While most studies focused on patient regret, little data exist on how physician regret affects shared decision making.
Intraoperative Identification of the Parathyroid Gland with a Fluorescence Detection System
Author list: Yoshiaki Shinden, Akihiro Nakajo, Hideo Arima, Kiyonori Tanoue, Munetsugu Hirata, Yuko Kijima, Kosei Maemura, Shoji Natsugoe
Intraoperative identification of the difficult-to-spot parathyroid gland is critical during surgery for thyroid and parathyroid disease. Recently, intrinsic fluorescence of the parathyroid gland was identified, and a new method was developed for intraoperative detection of the parathyroid with an original fluorescent detection apparatus. Here, we describe a method for intraoperative detection of the parathyroid using a ready-made photodynamic eye (PDE) system without any fluorescent dye or contrast agents.
Seventeen patients who underwent surgical treatment for thyroid or parathyroid disease at Kagoshima University Hospital were enrolled in this study. Intrinsic fluorescence of various tissues was detected with the PDE system. Intraoperative in vivo and ex vivo intrinsic fluorescence of the parathyroid, thyroid, lymph nodes and fat tissues was measured and analyzed.
The parathyroid gland had a significantly higher fluorescence intensity than the other tissues, including the thyroid glands, lymph nodes and fat tissues, and we could identify them during surgery using the fluorescence-guided method. Our method could be applicable for two intraoperative clinical procedures: ex vivo tissue identification of parathyroid tissue and in vivo identification of the location of the parathyroid gland, including ectopic glands.
The PDE system may be an easy and highly feasible method to identify the parathyroid gland during surgery.
Looking for the Word “Angiogenesis” in the History of Health Sciences: From Ancient Times to the First Decades of the Twentieth Century
Author list: Gianfranco Natale, Guido Bocci, Paola Lenzi
This review deals with the origin of the term “angiogenesis”, with an attention to John Hunter who is credited with this neologism. A part of the literature refers to a Hunter’s work dating 1787, and the other part claims the first use of the term “angiogenesis” in the Hunter’s masterpiece published in 1794. Since we were unable to find the term “angiogenesis” in Hunter’s works, this review attempts to bring a new contribution to the historical research of this important concept, moving from ancient times to the first decades of the twentieth century, when “angiogenesis” begun to appear on titles of scientific articles. The development of the knowledge on the cardiocirculatory system and the principal steps of this fascinating subject were examined, with particular regard to microvascular bed and vessel sprouting, and to the intriguing observations on blood vessel neoformation that have been also made in the premicroscopic era. In Hunter’s works, the concept of angiogenesis indeed emerges, but not the term “angiogenesis”. The scientific language occurring during Hunter’s time was still old-fashioned, and the term “angiogenesis” was not one of those he used, rather a much later neologism that sounds too modern to appear in that context. Would the first appearance of the term “angiogenesis” occur in late nineteenth century in studies dealing with embryogenesis and organ vascularization? The present study aims to explore the scientific literature and to open a debate to better define this matter.
A Historical Glance at the Arabo-Islamic Surgical Instruments During the Ages
Author list: Gregory Tsoucalas, Markos Sgantzos
Arabo-Islamic physicians demonstrated exceptional skill and innovation in surgery, by having used the instruments introduced by ancient Greeks and Greco-Roman surgeons. In many cases they have manufactured their own innovative designs promoting further the success of the difficult surgical operations of their era. The surgical instruments and the surgeon’s boxes, used to regularise the plethora of the metallic items, were decorated with fine designs, in order to depict the Arab civilisation. For the first time surgery became a separate medical art, while Arabo-Islamic medicine re-introduced ancient Greek and Byzantine surgery to the world.
Enteral Diet Enriched with ω-3 Fatty Acid Improves Oxygenation After Thoracic Esophagectomy for Cancer: A Randomized Controlled Trial
Author list: Yasunori Matsuda, Daiki Habu, Sigeru Lee, Satoru Kishida, Harushi Osugi
Although the anti-inflammatory effects of immunomodulating diets (IMDs) have recently attracted attention, the efficacy of enteral feeding of such diets after radical surgery remains controversial. Thus, we conducted a new prospective, randomized controlled study to elucidate any beneficial effect of an IMD containing eicosapentaenoic acid (EPA) and γ-linolenic acid (GLA) in patients undergoing radical esophagectomy for thoracic esophageal cancer.
From November 2009 to July 2011, 87 consecutive patients were randomized to receive either an IMD enriched with EPA, GLA, and antioxidants (n = 42) or a standard isocaloric, isonitrogenous diet (control group, n = 45) after esophagectomy with radical lymphadenectomy. The primary outcome measure was changes in the oxygenation status (PaO2/FIO2 ratio), and the secondary outcome measures were body composition, inflammation-related factors, coagulation markers, cholesterol concentrations, and major clinical outcomes.
Oxygenation was significantly better on postoperative days (PODs) 4, 6, and 8 in the IMD than control group (366.5 ± 63.3 vs. 317.3 ± 58.8, P = 0.001; 361.5 ± 52.6 vs. 314.0 ± 53.2, P < 0.001; 365.4 ± 71.2 vs. 315.2 ± 56.9, P = 0.001, respectively). Changes in the ratio of body weight on PODs 14 and 21 and lean body weight on POD 21 were significantly greater in the IMD than control group. No significant differences were observed in other measures.
An enteral IMD enriched with EPA and GLA improved oxygenation and maintained the body composition of patients undergoing radical esophagectomy, indicating the potential efficacy of such a diet after esophagectomy.