on March 31, 2011 |
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Topics: Bariatric, Service Lines, Surgery
Our General Surgery research team is currently attending the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons in San Antonio, TX, and I wanted to provide some early thoughts on the conference thus far. After attending a full day of scientific sessions and making our rounds across the vendor floor, I've reflected some of the main themes below.
As anticipated, minimally invasive surgery at the forefront, with procedural expansion top of mind:
Between scientific sessions, vendor-sponsored educational sessions, and vendor floor exhibits, it's no surprise that much of the focus this year is around less invasive surgery and the advantages it can bring. And while there have been no shortage of references to the baseline, well-established procedures like the lap cholecystectomy, the clear direction lies in expanding the range and types of procedures in which MIS approaches can be deployed. Much of the physician-led content has placed a great deal of focus on explaining evidence and early experiences with far more aggressive and potentially high-impact uses of laparoscopy, as well as more advanced minimally invasive approaches in procedures of which there has been less widespread adoption. Spanning the uses of laparoscopy in hepatobiliary, pancreatic, colorectal, and bariatric procedures, there is clearly great interest in pushing the bounds of conventional surgical approaches, but rarely the established literature to support truly superior outcomes or benefits from these minimally invasive approaches.There are clearly some procedures, such as the whipple, that will remain heavily dependent upon open procedures and inpatient stays, but there is still an ambitious movement to make surgery less disruptive to the patient while achieving the same resolution of disease.
Continue reading:
SAGES 2011: Honing and Expanding Minimally Invasive Surgery
on March 31, 2011 |
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Topics: Women's Services, Service Lines
Uterine fibroid and uterine arterial embolizations (UFE/UAE) have shown substantial increases in growth in recent years due to shorter recovery time, lower risk of pelvic prolapse, and lower cost compared to hysterectomy. In addition, UFE has gained traction as it is able to spare the uterus (hysterectomy does not) and recent studies show that fertility rates are comparable for UFE and myomectomy, though not guaranteed for either. Growth in UFE/UAE has led to a small drop in hysterectomy volumes as patients prefer the less invasive procedure. Many patients receiving UFE have heretofore foregone treatment and are able to undergo UFE rather than hysterectomy since the fibroids are likely not as severe. This drop in hysterectomy volumes can present a financial challenge for hospitals as per-patient profitability is higher for hysterectomy procedures than UFE. There is still relatively little known about post-procedure health and the type of follow up required by patients presenting a challenge for hospitals as they work to identify future procedure growth.
In a Dutch meta-analysis published by the American Journal of Obstetrics and Gynecology, researchers examined four randomized trials comparing UAE and hysterectomy or myomectomy patients (515 patients in total). Researchers confirm that patients undergoing UAE had less blood loss and a shorter hospital length of stay (60 vs. 86 hours) though note that UAE patients had a higher chance of re-intervention at one, two, and five years. While the authors note that patients receiving both procedures were equally satisfied, the study did not break this down by patients who had to undergo follow-up work.
As gynecology has seen a shift of many procedures to the outpatient setting, it is possible that UFE may soon follow suit. While these are still largely performed as inpatient procedures requiring an overnight stay, advances in technology and physician familiarity may allow them to be performed with less observation. However, considering the higher re-procedure rate of UAE, hospitals should carefully consider if this is the right option given the new imperatives surrounding quality. Providing high quality, low cost care is a top-of-mind issue for many organizations wanting to keep re-procedure rates at a minimum. With UFE gaining ground as patients request the less invasive procedure, hospitals should impose consistent criteria regarding which patients receive UFE, hysterectomy, or myomectomy. Despite the higher re-intervention rate, UFE's positive short-term outcomes and benefit to patients will make it a procedure to watch for the near term.
on March 30, 2011 |
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Topics: Service Lines, Vascular, Cardiovascular
Kansas City, MO--In a recent study examining over 5,000 PCI patients across four centers in the Saint Luke's Health System, Dr. David M. Safley and colleagues found that, compared to manual compression, vascular closure devices showed reduced rates of major, entry site, and other/unknown bleeding as well as reduced rates of stroke, pseudoaneurysm, and a trend toward lower in-hospital mortality. While major bleeding served as the study's primary endpoint, other endpoints included: myocardial infarction and renal failure as well as GI, retroperitoneal, and genital/urinary bleeding.
The study was designed such that an equal number of PCI patients--1,162--with comparable baseline characteristics were assigned to vascular closure device and manual compression groups, respectively; propensity scoring was then used to match 1,162 pairs of patients who--after receiving either a vascular closure device or medical compression post-PCI--obtained hemostasis. From January 1, 2006 through June 30, 2009, all patients in both groups underwent femoral PCI; among these, 80 percent received single-vessel PCI, and 67.9 percent presented with ACS.
Results indicated that, for patients considered at high-risk for major bleeding by the National Cardiovascular Data Registry (NCDR), vascular closure devices were associated with a 70 percent reduction in bleeding when compared to manual compression--3.1 percent versus 10.3 percent. However, for patients classified as having moderate or low risk for major bleeding, bleeding reductions for the vascular closure device cohort were numerically lower, albeit not statistically significant, when compared to the manual compression one; moderate- and low-risk patients displayed 34 and 61 percent reductions in major bleeding, respectively.
In addition to the primary endpoint of major bleeding, which occurred in 2.4 percent of the vascular closure device group versus 5.2 percent of the manual compression group, entry site bleeding, other/unknown bleeding, stroke, and pseudoaneurysm all showed statistically significant reductions favoring the vascular closure device cohort. While not statistically significant (P=0.07), the vascular closure device group likewise trended toward a shorter length-of-stay than its manual compression counterpart.
| Complication |
Closure Device |
Manual Compression |
P Value |
| Major Bleeding |
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| Entry Site Bleeding |
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| Other/Unknown Bleeding |
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| Stroke |
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| Pseudoaneurysm |
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| In-hospital mortality |
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Despite outperforming manual compression with regard to reductions in complications across the above categories, the vascular closure device cohort showed equivalent rates of MI, renal failure as well as retroperitoneal, GI, and genital/urinary bleeding -- the study's other endpoints -- when compared to the manual compression group.
On a device-specific level, suture-based and collagen plug-based vascular closure devices both demonstrated reductions in the composite endpoint--major bleeding, vascular occlusion, pseudoaneurysm, significant dissection, or arteriovenous fistula at the access site and peripheral embolization--when compared to manual compression. In fact, suture-based and collagen plug-based devices exhibited complication rates of 1.4 and 3.4 percent, respectively, versus 6.5 percent in each of their respective manual compression groups. Compared against each other, suture-based devices demonstrated more favorable results than their collagen plug-based counterparts in terms of reductions in the composite endpoint--1.4 versus 3.4 percent.
At present, the implications of this study's outcomes remain subject to ongoing debate. From a clinical perspective, some physicians such as Dr. Robert J. Applegate of Wake Forest University School of Medicine argue that the study has value insofar as it suggests that vascular closure devices may reduce the likelihood of major bleeding for those deemed at high risk for this complication; as such, it provides further evidence to support numerous observational studies suggesting an association between vascular closure devices and reduced bleeding. That said, skeptics such as Dr. Sunil V. Rao of Duke University Medical Center contest that randomized data are necessary for the study to have any meaningful implications. Specifically, a meta-analysis of new vascular closure devices is imperative as past meta-analyses have involved only older devices. From a business standpoint, hospitals likewise continue to debate the merits of vascular closure devices given the costs they may add to a given procedure. Although these devices range in price, some may increase costs by several hundred dollars or more for a particular procedure. At the same time, by eliminating the time burden that manual compression puts on nurses and potentially reducing patients' length-of-stay, vascular closure devices may actually promote cost-savings for some institutions. Technology Insights will continue to monitor the vascular closure device pipeline as well as clinical and strategic debates associated with these devices as they continue.
For more information on this topic, please visit: Closure Devices Reduce Major Bleeding Compared with Manual Compression
