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The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

Objective To examine the effect of surgeon sex on postoperative outcomes of patients undergoing common surgical procedures.Design Population based, retrospective, matched cohort study from 2007 to 2015.Setting Population based cohort of all patients treated in Ontario, Canada.Participants Patients undergoing one of 25 surgical procedures performed by a female surgeon were matched by patient age, patient sex, comorbidity, surgeon volume, surgeon age, and hospital to patients undergoing the same operation by a male surgeon.Interventions Sex of treating surgeon.Main outcome measure The primary outcome was a composite of death, readmission, and complications. We compared outcomes between groups using generalised estimating equations.Results 104 630 patients were treated by 3314 surgeons, 774 female and 2540 male. Before matching, patients treated by female doctors were more likely to be female and younger but had similar comorbidity, income, rurality, and year of surgery. After matching, the groups were comparable. Fewer patients treated by female surgeons died, were readmitted to hospital, or had complications within 30 days (5810 of 52 315, 11.1%, 95% confidence interval 10.9% to 11.4%) than those treated by male surgeons (6046 of 52 315, 11.6%, 11.3% to 11.8%; adjusted odds ratio 0.96, 0.92 to 0.99, P=0.02). Patients treated by female surgeons were less likely to die within 30 days (adjusted odds ratio 0.88; 0.79 to 0.99, P=0.04), but there was no significant difference in readmissions or complications. Stratified analyses by patient, physician, and hospital characteristics did not significant modify the effect of surgeon sex on outcome. A retrospective analysis showed no difference in outcomes by surgeon sex in patients who had emergency surgery, where patients do not usually choose their surgeon.Conclusions After accounting for patient, surgeon, and hospital characteristics, patients treated by female surgeons had a small but statistically significant decrease in 30 day mortality and similar surgical outcomes (length of stay, complications, and readmission), compared with those treated by male surgeons. These findings support the need for further examination of the surgical outcomes and mechanisms related to physicians and the underlying processes and patterns of care to improve mortality, complications, and readmissions for all patients.

Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications. We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model. We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2–3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9–2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6–6.8; AF 12.0%). Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration:ClinicalTrials.gov, no. NCT00512109.

Operative mortality is lower at hospitals with a high volume of certain surgical procedures. In this analysis of Medicare data, operative mortality declined for eight surgical procedures studied over a decade. Higher hospital volumes explained much of the decline for three of the operations. Fueled by a growing number of studies reporting inverse relationships between hospital volume and surgical mortality, 1 – 3 there was considerable interest in the United States during the previous decade in concentrating selected operations in high-volume hospitals. The Leapfrog Group, a consortium of large corporations and public agencies that purchase health care, has been among the most prominent advocates of volume-based referral. In 2000, it established minimum volume standards for several surgical procedures as part of a broader, value-based purchasing initiative. 4 Private payers and professional organizations in the United States have also established minimum volume standards as part of Centers of . . .

Though we've long known that higher surgical volume results in lower postoperative mortality, surgeons are balking at a new “Volume Pledge” campaign. But the biggest problem is that such a pledge can't improve the quality of care at low-volume hospitals. On May 18, 2015, leaders at three hospital systems — Dartmouth–Hitchcock Medical Center, the Johns Hopkins Hospital and Health System, and the University of Michigan Health System — publicly announced a “Take the Volume Pledge” campaign to prevent certain surgical procedures from being performed by their surgeons who perform relatively few of them or at their hospitals where relatively few such procedures are performed. The Pledge, promoted by long-time advocates of quality improvement such as John Birkmeyer and Peter Pronovost, challenges other large health systems to join them in restricting the performance of 10 surgical procedures — including gastrointestinal, cardiovascular, . . .

Public reporting of adherence to surgical safety checklists was mandated for all hospitals in Ontario, beginning in July 2010. In this study of administrative data, checklist introduction was not associated with significant reductions in operative mortality or complications. A study published in 2009 showed that implementation of the 19-item World Health Organization (WHO) Surgical Safety Checklist substantially reduced the rate of surgical complications, from 11.0% to 7.0%, and reduced the rate of in-hospital death from 1.5% to 0.8%. 1 The WHO estimated that at least 500,000 deaths per year could be prevented through worldwide implementation of this checklist. 2 This dramatic effect of a relatively simple and accessible intervention resulted in its widespread adoption. In the United Kingdom, a nationwide program was implemented by the National Health Service within weeks after publication of the WHO study, 3 and almost 6000 hospitals . . .

This analysis of Medicare data suggests that 13% of patients are readmitted to the hospital within 30 days after major surgery. Readmission rates vary across hospitals and correlate with surgical volume and surgical mortality, two measures of surgical quality. Reducing hospital-readmission rates is a priority for both policymakers and clinical leaders. The focus on readmissions has been driven by a belief that reducing the frequency with which patients return to the hospital can both improve care and lower costs. To date, much of the focus has been on readmissions after hospitalization for medical conditions, in which discharge planning and care coordination are often suboptimal. 1 – 4 The Centers for Medicare and Medicaid Services (CMS) plans to include surgical procedures as it expands its readmissions penalty program. 5 Using medical-readmission rates as a measure of hospital quality is controversial. Although hospitals vary . . .

Objective To compare patient outcomes of restrictive versus liberal blood transfusion strategies in patients with cardiovascular disease not undergoing cardiac surgery. Design Systematic review and meta-analysis. Data sources Randomised controlled trials involving a threshold for red blood cell transfusion in hospital. We searched (to 2 November 2015) CENTRAL, Medline, Embase, CINAHL, PubMed, LILACS, NHSBT Transfusion Evidence Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, ISRCTN Register, and EU Clinical Trials Register. Authors were contacted for data whenever possible. Trial selection Published and unpublished randomised controlled trials comparing a restrictive with liberal transfusion threshold and that included patients with cardiovascular disease. Data extraction and synthesis Data extraction was completed in duplicate. Risk of bias was assessed using Cochrane methods. Relative risk ratios with 95% confidence intervals were presented in all meta-analyses. Mantel-Haenszel random effects models were used to pool risk ratios. Main outcome measures 30 day mortality, and cardiovascular events. Results 41 trials were identified; of these, seven included data on patients with cardiovascular disease. Data from a further four trials enrolling patients with cardiovascular disease were obtained from the authors. In total, 11 trials enrolling patients with cardiovascular disease (n=3033) were included for meta-analysis (restrictive transfusion, n=1514 patients; liberal transfusion, n=1519). The pooled risk ratio for the association between transfusion thresholds and 30 day mortality was 1.15 (95% confidence interval 0.88 to 1.50, P=0.50), with little heterogeneity (I2=14%). The risk of acute coronary syndrome in patients managed with restrictive compared with liberal transfusion was increased (nine trials; risk ratio 1.78, 95% confidence interval 1.18 to 2.70, P=0.01, I2=0%). Conclusions The results show that it may not be safe to use a restrictive transfusion threshold of less than 80 g/L in patients with ongoing acute coronary syndrome or chronic cardiovascular disease. Effects on mortality and other outcomes are uncertain. These data support the use of a more liberal transfusion threshold (>80 g/L) for patients with both acute and chronic cardiovascular disease until adequately powered high quality randomised trials have been undertaken in patients with cardiovascular disease. Registration PROSPERO CRD42014014251.

Delay of surgery for hip fracture is associated with increased risk of morbidity and mortality, but the effects of surgical delays on mortality and resource use in the context of other emergency surgeries is poorly described. Our objective was to measure the independent association between delay of emergency surgery and in-hospital mortality, length of stay and costs. We identified all adult patients who underwent emergency noncardiac surgery between January 2012 and October 2014 at a single tertiary care centre. Delay of surgery was defined as the time from surgical booking to operating room entry exceeding institutionally defined acceptable wait times, based on a standardized 5-level priority system that accounted for surgery type and indication. Patients with delayed surgery were matched to those without delay using propensity scores derived from variables that accounted for details of admission and the hospital stay, patient characteristics, physiologic instability, and surgical urgency and risk. Of 15 160 patients, 2820 (18.6%) experienced a delay. The mortality rates were 4.9% (138/2820) for those with delay and 3.2% (391/12 340) for those without delay (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.30–1.93). Within the propensity-matched cohort, delay was significantly associated with mortality (OR 1.56, 95% CI 1.18–2.06), increased length of stay (incident rate ratio 1.07, 95% CI 1.01–1.11) and higher total costs (incident rate ratio 1.06, 95% CI 1.01–1.11). Delayed operating room access for emergency surgery was associated with increased risk of inhospital mortality, longer length of stay and higher costs. System issues appeared to underlie most delays and must be addressed to improve the outcomes of emergency surgery.

In eight hospitals throughout the world, implementation of a 19-item surgical safety checklist was associated with improved outcomes. Use of the checklist may improve the safety of surgical procedures in hospitals in various economic circumstances. In eight hospitals throughout the world, implementation of a 19-item surgical safety checklist was associated with improved outcomes. Surgical care is an integral part of health care throughout the world, with an estimated 234 million operations performed annually. 1 This yearly volume now exceeds that of childbirth. 2 Surgery is performed in every community: wealthy and poor, rural and urban, and in all regions. The World Bank reported that in 2002, an estimated 164 million disability-adjusted life-years, representing 11% of the entire disease burden, were attributable to surgically treatable conditions. 3 Although surgical care can prevent loss of life or limb, it is also associated with a considerable risk of complications and death. The risk of complications is poorly characterized in . . .