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High volume cataract lists are cost-effective, reduce waiting times, and facilitate surgical teaching. We propose a stepwise training model that incorporates human factor principles and a reflective pedagogical approach, which has not been documented previously. Surgical training in ophthalmology is effective when a modular approach is utilised. High volume lists further enhance training by increasing exposure to a newer way of learning and working. We evaluated the efficiency and safety of trainee-assisted cataract surgery across a single NHS eye unit and an independent sector (IS) provider. We examined results from audits of surgical efficiency and safety in trainee-assisted high-volume lists, including a single-centre comparative evaluation of consultant-only and trainee lists. The quantitative and qualitative information gained from these projects helped us to implement a modular, structured training programme that utilises a reflective cycle of pedagogy, suitable for any grade of trainee. Our projects included an audit following cataract surgery performed by a surgical trainee over a 5-month period, which showed excellent post-op refractive results and no cases of intra-operative and post-operative complications. A single-centre observational study demonstrated comparable surgical throughput and safety results for trainee and solo consultant high volume lists. Systemic and ocular complication rates were reported to be similar for low and medium risk cataract surgery among trainee supervised IS and NHS lists. Cataract surgery outcomes and patient feedback support the effectiveness of the surgical training model. Combining Gibbs' reflective cycle of critical reflection with the International Council of Ophthalmology's principles helped us to develop the QM Model of modular teaching for cataract surgery, which we believe is suitable for utilisation in all surgical centres in the NHS and IS settings, for both low volume and high-volume surgical lists regardless of trainee experience.

High-volume hospitals are purported to provide “best” outcomes. We undertook this study to evaluate the outcomes after pancreaticoduodenectomy when high-volume surgeons relocate to a low-volume hospital (ie, no pancreaticoduodenectomies in >5 years). Outcomes after the last 50 pancreaticoduodenectomies undertaken at a high-volume hospital in 2012 (ie, before relocation) were compared with the outcomes after the first 50 pancreaticoduodenectomies undertaken at a low-volume hospital (ie, after relocation) in 2012 to 2013. Patients undergoing pancreaticoduodenectomies at a high-volume vs a low-volume hospital were not different by age or sex. Patients who underwent pancreaticoduodenectomy at the low-volume hospital had shorter operations with less blood loss, spent less time in the intensive care unit, and had shorter length of stay (P < .05 for each); 30-day mortality and 30-day readmission rates were not different. The salutary benefits of undertaking pancreaticoduodenectomy at a high-volume hospital are transferred to a low-volume hospital when high-volume surgeons relocate. The “best” results follow high-volume surgeons.

Abstract Rationale Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers. Objectives To determine if higher annual ECMO patient volume is associated with lower case-mix–adjusted hospital mortality rate. Methods We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0–28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group–specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008–2013. Measurements and Main Results From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquartile range was 18–50% for neonates, 25–66% for pediatrics, and 33–92% for adults. For 1989–2013, higher age group–specific ECMO volume was associated with lower odds of ECMO mortality for neonates and adults but not for pediatric cases. In 2008–2013, the volume–outcome association remained statistically significant only among adults. Patients receiving ECMO at hospitals with more than 30 adult annual ECMO cases had significantly lower odds of mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.46–0.80) compared with adults receiving ECMO at hospitals with less than six annual cases. Conclusions In this international, case-mix–adjusted analysis, higher annual hospital ECMO volume was associated with lower mortality in 1989–2013 for neonates and adults; the association among adults persisted in 2008–2013.

Background We sought to evaluate trends in selection of high volume (HV) hospitals for pancreatic surgery, as well as examine trends in preoperative complications, mortality, and failure to rescue (FTR). Method Patients who underwent pancreatic resection between 2000 and 2011 were identified from the Nationwide Inpatient Sample (NIS). Preoperative morbidity, mortality, and FTR were examined over time. Hospital volume was stratified into tertiles based on the number of pancreatic resections per year for each time period. Logistic regression models were used to assess the effect of hospital volume on risk of complication, postoperative mortality, and FTR over time. Result A total of 35,986 patients were identified. Median hospital volume increased from 13 in 2000–2003 to 55 procedures/year in 2008–2011 ( P  < 0.001). Morbidity remained relatively the same over time at low volume (LV), intermediate volume (IV), and HV hospitals (all P  > 0.05). Overall postoperative mortality was 5 %, and it decreased over time across all hospital volumes ( P  < 0.05). FTR was more common at LV (12.0 %) and IV (8.5 %) volume hospitals compared with HV hospitals (6.4 %). The improvement in FTR over time was most pronounced at LV and IV hospitals versus HV hospitals ( P  = 0.001). Conclusion Median hospital volume for pancreatic surgery has increased over the past decade. While the morbidity remained relatively stable over time, mortality improved especially in LV and IV hospitals. This improvement in mortality seems to be related to a decreased FTR.

BackgroundImprovement in mortality has been shown for esophagectomies performed at high-volume centers.ObjectiveThis study aimed to determine if centralization of esophageal cancer surgery occurred in the US, and to establish its impact on postoperative mortality. In addition, we aimed to analyze the relationship between regionalization of cancer care and health disparities.MethodsA retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000–2014. Adult patients (≥ 18 years of age) diagnosed with esophageal cancer and who underwent esophagectomy were included. Yearly hospital volume was categorized as low (< 5 procedures), intermediate (5–20 procedures), and high (> 20 procedures). Multivariable analyses on the potential effect of hospital volume on patient outcomes were performed, and the yearly rate of esophagectomies was estimated using Poisson regression.ResultsA total of 5235 patients were included. Esophagectomy at low- [odds ratio (OR) 2.17] and intermediate-volume (OR 1.62) hospitals, compared with high-volume hospitals, was associated with a significant increase in mortality. The percentage of esophagectomies performed at high-volume centers significantly increased during the study period (29.2–68.5%; p < 0.0001). The trend towards high-volume hospitals was different among the different US regions: South (7.7–54.3%), West (15.0–67.6%), Midwest (37.3–67.7%), and Northeast (55.8–86.8%) [p < 0.0001]. Overall, the mortality rate of esophagectomy dropped from 10.0 to 3.5% (p = 0.006), with non-White race, public insurance, and low household income patients also showing a significant reduction in mortality.ConclusionsA spontaneous centralization for esophageal cancer surgery occurred in the US. This process was associated with a decrease in the mortality rate, without contributing to health disparities.

Environmental DNA analysis has revolutionized the way we study rare, invasive, and endangered taxa. However, if eDNA testing is to become an increasingly reliable tool, high detection sensitivity is crucial. Current eDNA sampling methods, like filtration and precipitation, can only process small volumes of water per sample. If only a few samples are collected, eDNA from the target organism might be missed, leading to false‐negative results. We developed an eDNA collection method for lentic systems that improved detection sensitivity while keeping the total number of samples low. Unlike filtration and precipitation, which mainly target extracellular DNA, this method specifically targets eDNA in larger particle sizes and is not limited to processing small volumes of water. A 64‐micrometer mesh tow net was used to process >3,000 L of water per eDNA sample. We compared the tow net method to a common collection method, a 0.45 μm cellulose nitrate filter that processes about 1 L of water per eDNA sample. Paired tow and filter samples were collected at 37 locations and tested for two taxa: an aquatic plant, Northern watermilfoil (Myriophyllum sibiricum), and aquatic mollusks, including Helisoma anceps, using Kompetitive Allele Specific PCR (KASP) assays. We detected M. sibiricum significantly more frequently in tow samples than filter samples. Mollusks were detected in all eDNA samples (tow nets and filters), but when eDNA samples were diluted 25‐fold to mimic a low target concentration scenario, mollusk DNA was detected significantly more frequently in tow samples than filter samples. This high‐volume eDNA sampling method, using a tow net to process thousands of liters of water, can improve detection sensitivity for multiple taxa, making it a useful tool for researchers and managers. Current eDNA sampling methods, like filtration and precipitation, process relatively small volumes of water per sample. If only a few samples are collected, eDNA from the target organism might be missed leading to false‐negative results. Tow nets, a high‐volume eDNA collection tool for lentic systems, process thousands of liters of water per eDNA sample and significantly improve detection sensitivity over cellulose nitrate filters for an aquatic plant and mollusk.

\"Push\" or \"pull\" techniques with the use of snares, forceps, baskets, and grasping devices are conventionally used to manage esophageal food bolus impaction (FBI). A novel cap-assisted technique has recently been advocated to reduce time taken for food bolus (FB) removal. This study aimed to compare the effectiveness of the cap-assisted technique against conventional methods of esophageal FB removal in a randomized controlled trial. Consecutive patients with esophageal FBI requiring endoscopic removal, from 3 Australian tertiary hospitals between 2017 and 2019, were randomized to either the cap-assisted technique or the conventional technique. Primary outcomes were technical success and FB retrieval time. Secondary outcomes were technical success rate, en bloc removal rate, procedure-related complication, length of hospital stay, and cost of consumables. Over 24 months, 342 patients with esophageal FBI were randomized to a cap-assisted (n = 171) or conventional (n = 171) technique. Compared with the conventional approach, the cap-assisted technique was associated with (i) shorter FB retrieval time (4.5 ± 0.5 minutes vs 21.7 ± 0.9 minutes, P < 0.001), (ii) shorter total procedure time (23.0 ± 0.6 minutes vs 47.0 ± 1.3 minutes, P < 0.0001), (iii) higher technical success rate (170/171 vs 160/171, P < 0.001), (iv) higher rate of en bloc removal (159/171 vs 48/171, P < 0.001), and (v) lower rate of procedure-related mucosal tear and bleeding (0/171 vs 13/171, P < 0.001). There were no major adverse events or deaths within 30 days in either group. The total cost of consumables was higher in the conventional group (A$19,644.90 vs A$6,239.90). This multicenter randomized controlled trial confirmed that the cap-assisted technique is more effective and less costly than the conventional approach and should be first-line treatment for esophageal FBI.

BackgroundAlthough major cancer surgery at a high-volume hospital is associated with lower postoperative mortality, the use of such hospitals may not be equally distributed.ObjectiveOur aim was to study socioeconomic and racial differences in cancer surgery at Commission on Cancer (CoC)-accredited high-volume hospitals.MethodsThe National Cancer Database (NCDB) was used to identify patients undergoing surgery for colon, esophageal, liver, and pancreatic cancer from 2003 to 2012. Annual hospital volume for each cancer was categorized using quartiles of patient volume. Patient-level predictors of surgery at a high-volume hospital, trends in the use of a high-volume hospital, and adjusted likelihood of surgery at a high-volume hospital in 2012 versus 2003 were analyzed.ResultsAfrican American patients were less likely to undergo surgery at a high-volume hospital for esophageal (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49–0.73) and pancreatic cancer (OR 0.83, 95% CI 0.74–0.92), while uninsured patients and those residing in low educational attainment zip codes were less likely to undergo surgery at a high-volume hospital for esophageal, liver, and pancreatic cancer. In 2012, African Americans, uninsured patients, and those from low educational attainment zip codes were no more likely to undergo surgery at a high-volume hospital than in 2003 for any cancer type. These differences were not seen in colon cancer patients, for whom significant regionalization was not seen.ConclusionsDifferences in the use of CoC-accredited high-volume hospitals for major cancer surgery were seen nationwide and persisted over the duration of the study. Strategies to increase referrals and/or access to high-volume hospitals for African American and socioeconomically disadvantaged patients should be explored.

Adrenocortical carcinoma (ACC) is rare with poor survival. Do treatment and outcomes vary by volume? NCDB (2004–2017) was searched for patients with ACC. High-volume centers (HVCs) were defined by ≥ 15 ACC and low-volume centers by ≤ 7 total cases. Multivariable Cox and logistic regression analysis were performed. ACC patients at HVCs were significantly more likely to have surgery, chemotherapy, and had lower 90-day readmission. HVCs were significantly more likely than LVCs to administer chemotherapy to surgical NonMetastatic (NM)-ACC patients. There was no significant difference in overall survival (OS), 90-day mortality, length of stay, or radiation treatments between the two. Operative Metastatic (M)-ACC at HVC had significantly improved OS, more chemotherapy administered, and lower 90-day mortality. NM-ACC and M-ACC treated at HVCs were more likely to have surgery and multimodality therapy. NM-ACC having surgery at HVCs and LVCs had similar OS. M-ACC at HVCs had improved OS and 90-day mortality. •Operative stage 4 adrenocortical cancer at high volume centers had better survival.•Adrenocortical carcinoma at high volume centers more likely to have surgery.•Adrenocortical carcinoma at high volume centers more likely to have chemotherapy.

Background The objective of the current study was to characterize the association between travel distance/hospital volume relative to outcomes following resection of cholangiocarcinoma. Methods Patients were identified using the 2004–2015 National Cancer Database and stratified into quartiles according to travel distance/hospital volume. Multivariable regression models were utilized to examine the impact of travel distance and hospital volume on quality-of-care metrics and overall survival. Results Among 5125 patients, the majority of patients had T1/2 ( N  = 2006, 41.1%) and N0 disease ( N  = 2498, 50.9%). Median hospital quartile surgical volumes in cases/year were low volume (LV) 6, intermediate low volume (ILV) 7, intermediate high volume (IHV) 12, and high volume (HV) 24 cases/year. Median travel distance quartiles in miles were short travel (ST) 2.7, intermediate short travel (IST) 7.9, intermediate long travel (ILT) 18.9, and long travel (LT) 84.7. Longer travel distances were associated with better overall survival, as every 10 miles was associated with a 2% decrease in mortality ( p  = 0.02). Differences in quality-of-care metrics were largely mediated through travel distance. Conclusions Travel distance and hospital volume were associated with certain quality-of-care metrics among patients with cholangiocarcinoma. After controlling for hospital volume and travel distance simultaneously, only travel distance was associated with decreased risk of mortality.