Effect of surgeon-specific feedback on surgical outcomes: a systematic review of the literature.

BACKGROUND: Surgeon-specific outcome reporting provides an opportunity for quality assurance and improved surgical results. It is becoming increasingly prevalent and remains contentious amongst surgeons. The purpose of this systematic review was to evaluate the extent to which published literature supports the concept that feedback of surgeon-level outcomes reduces morbidity and/or mortality. No systematic reviews have previously been completed on this subject. METHODS: Medline and Embase were systematically searched for studies published prior to the 1st of January 2022. Feedback was defined as a summary of clinical performance over a specified period of time provided in written, electronic or verbal format. Studies were required to provide surgeon-specific feedback to multiple individual consultant surgeons with the primary purpose being to determine if feedback improved outcomes. Primary outcome(s) needed to relate to surgical outcomes as opposed to process measures only. All surgical specialties and procedures were eligible for inclusion. RESULTS: Seventeen studies were included in the review, traversing a wide range of specialties and procedures. Sixteen were non-randominsed and one randomized. Fifteen were before and after studies. The balance of the non-randomized studies support the concept that provision of surgeon-specific feedback can improve surgical outcomes, while the single randomized study suggests feedback may not be effective. CONCLUSIONS: This systematic review supports the use of surgeon-level feedback to improve outcomes. The strength of this finding is limited by reliance on before and after studies, further randomized studies on this subject would be insightful.

Survey of New Zealand Arthroplasty Surgeons on Surgeon-Level Outcome Reporting.

BACKGROUND: Surgeon-specific outcome monitoring has become increasingly prevalent over the last 3 decades. The New Zealand Orthopaedic Association monitors individual surgeon performance through 2 mechanisms: arthroplasty revision rates derived from the New Zealand Joint Registry and a practice visit program. Despite remaining confidential, surgeon-level outcome reporting remains contentious. The purpose of this survey was to evaluate the opinions of hip and knee arthroplasty surgeons in New Zealand on the perceived importance of outcome monitoring, current methods used to evaluate surgeon-specific outcomes, and potential improvements identified through literature review and discussion with other registries. METHODS: The survey consisted of 9 questions on surgeon-specific outcome reporting, using a five-point Likert scale, and 5 demographic questions. It was distributed to all current hip and knee arthroplasty surgeons. There were 151 hip and knee arthroplasty surgeons who completed the survey, a response rate of 50%. RESULTS: Respondents agreed that monitoring arthroplasty outcomes is important and that revision rates are an acceptable measure of performance. Reporting risk-adjusted revision rates and more recent timeframes were supported, as was including patient-reported outcomes when monitoring performance. Surgeons did not support public reporting of surgeon-level or hospital-level outcomes. CONCLUSION: The findings of this survey support the use of revision rates to confidentially monitor surgeon-level arthroplasty outcomes and suggest that concurrent use of patient-reported outcome measures would be acceptable.

Selective omission of the donor cross-match before renal transplantation: efficacy, safety and effects on cold storage time.

BACKGROUND: A donor lymphocyte cross-match (XM) test performed before renal transplantation is considered mandatory but may delay the transplant and increase the cold storage time. With careful documentation of sensitizing events and with knowledge of previous antibody screening results, it is often possible to predict the XM result for a given donor HLA mismatch. In this study, a policy was adopted of omitting the pretransplant XM in patients in whom a negative result was predicted with absolute confidence. METHODS: Recipients were selected for cadaveric donor kidney transplantation using a computer algorithm based on HLA match, sensitization status, time on the waiting list and donor and recipient age. The immediate pretransplant cross-match test was omitted in non-sensitized recipients and in sensitized recipients where antibody specificities were precisely defined and not against donor HLA. RESULTS: From October 1997 to May 1999, 53 of 96 (55%) consecutive cadaveric kidney donor transplants were performed without a pretransplant XM. In all cases, a negative donor HLA-specific antibody XM was confirmed after transplantation. Omission of the pre-transplant XM was associated with a significant reduction in cold ischemic time (15.0 hr vs. 18.2 hr, P=0.01) and a reduced incidence of delayed graft function (13% vs. 33%, P=0.03). However, there was no difference in transplant outcome at 1 year. CONCLUSION: Rigorous attention to priming events together with careful antibody screening allows the pre-transplant XM test to be safely omitted in approximately half the patients awaiting renal transplantation. This policy allows a modest reduction in cold ischemia time, but it remains to be seen whether this is of clinical benefit.

HLA and Mooren's ulceration.

BACKGROUND: Mooren's ulcer is a progressive intractable destructive peripheral ulceration of the cornea, probably of autoimmune aetiology. The disease is rare in the northern hemisphere but is more common in southern and central Africa and the Indian subcontinent. Although rare, its predominance in certain racial groups and their second generation migrants worldwide indicates a genetic as well as a geographic predisposition. The highly polymorphic human leucocyte antigens (HLA) confer genetic susceptibility to several autoimmune disorders. Therefore, a possible link between Mooren's ulcer and HLA type was investigated. METHODS: Patients (n=22) with non-infective destructive peripheral corneal inflammatory disease were recruited worldwide. Differential diagnosis confirmed Mooren's ulceration in 12 cases. HLA typing (HLA-A, B, C, DRB, DQB) was performed by serology and PCR using sequence specific primers. The patients came from varied ethnic backgrounds and their HLA typing results were compared with published data from ethnically matched control populations. RESULTS: Of the 12 patients with Mooren's ulcer, 10 (83%) were HLA-DR17(3) positive (including all nine patients of Asian, Indonesian, and black African origin), and 10 (83%) were HLA-DQ2 positive. The frequency of HLA-DR17(3) and DQ2 was higher in the Mooren's ulcer group compared to published data from ethnically matched control populations, where the expected antigen frequencies range between 5% and 40%. CONCLUSION: These results suggest a possible association between HLA-DR17(3) and/or DQ2 and susceptibility to Mooren's ulcer.

Clinicopathologic correlations of soluble amyloid beta-protein precursor in cerebrospinal fluid in patients with Alzheimer disease and controls.

The authors compared concentrations of soluble beta-amyloid protein precursor (s beta PP) in cerebrospinal fluid (CSF) in 45 patients diagnosed with probable Alzheimer disease (AD) and 26 normal older control volunteers. Soluble beta-amyloid protein precursor concentrations were measured in 125 CSF samples using an enzyme-linked immunosorbent assay. All subjects had Mini-Mental State Examination (MMSE) and Clinical Dementia Rating Scale (CDRS) scores and assessment of disease duration. The s beta PP concentrations in CSF in the probable AD group (mean +/- SD = 493 +/- 268 micrograms/L) were decreased significantly compared with the age-matched control group (mean = 831 +/- 302 micrograms/L; p < 0.0001). In the probable AD group, MMSE scores correlated positively with s beta PP concentrations (correlation coefficient r = 0.53, p < 0.0001), and CDRS ratings and disease duration correlated inversely with s beta PP concentrations (r = -0.59, p < 0.0001 and r = -0.479, p = 0.0006, respectively). Although the decrease in CSF s beta PP from levels found in healthy elderly controls was significant in AD subjects, there was substantial overlap. In AD, CSF s beta PP was most reduced in patients in later stages of the disease. The s beta PP concentrations reflect disease severity, but utility in differential diagnosis has not been determined.

Modified immunoradiometric assay of parathyroid hormone-related protein: clinical application in the differential diagnosis of hypercalcemia.

We have developed a sensitive, specific solid-phase immunoradiometric assay (IRMA) of parathyroid hormone-related protein (PTH-RP) with use of affinity-purified polyclonal immunoglobulins. Antibodies recognizing PTH-RP(37-74) are immobilized to a polystyrene bead to "capture" analytes from the sample; antibodies to epitopes within the 1-36 amino acid region of PTH-RP are labeled with 125I. This IRMA recognizes PTH-RP(1-74) and PTH-RP(1-86) equivalently, but does not detect N-terminal or C-terminal fragments of PTH-RP, intact human parathyrin (PTH), or fragments of PTH. PTH-RP is not stable in plasma at 3-5 degrees C or room temperature, but a mixture of aprotinin (500 kallikrein units/L) and leupeptin (2.5 mg/L) improves PTH-RP stability in blood samples. In plasma collected in the presence of these protease inhibitors from normal volunteers and patients with various disorders of calcium metabolism, PTH-RP concentrations were above normal (greater than 1.5 pmol/L) in 91% (42 of 46) of patients with hypercalcemia associated with nonhematological malignancy. In plasma from patients with other hypercalcemic conditions (e.g., primary hyperparathyroidism, sarcoidosis, and vitamin D excess), PTH-RP was undetectable. Above-normal concentrations of PTH-RP and total calcium decreased to normal in a patient with an ovarian cyst adenocarcinoma after surgical removal of the tumor. We conclude that PTH-RP is related to and probably the causative agent of hypercalcemia in most patients with cancer, and that measurements of PTH-RP are useful in the diagnosis and management of patients with tumor-associated hypercalcemia.

Opioid antagonist challenges in buprenorphine maintained patients.

Following one month of sublingual buprenorphine treatment, 15 patients at either 2 mg (n = 7) or 3 mg (n = 8) were hospitalized and the buprenorphine was abruptly stopped by placebo substitution. On the morning following their last dose of buprenorphine, 10 patients were given 1 mg oral naltrexone and 5 were given 0.5 mg/kg intravenous naloxone in a double blind placebo controlled challenge. The naltrexone challenges produced no increase in opioid withdrawal symptoms, plasma MHPG levels, or blood pressure compared to placebo, while naloxone produced significant symptoms and blood pressure increases compared to placebo challenges.

Computer-assisted learning lessons in drug disposition and pharmacokinetics.

A suite of 18 computer-assisted learning (C.A.L.) lessons has been developed in drug disposition covering processes, concepts and techniques, and pharmacokinetics. Development of lesions and implementation (using CDC's PLATO Programmerless Courseware Development authoring language (Advanced Tutorial Model) for delivery on IBM-PC clones (some also using NPL's Microtext on BBC model B microcomputers) and evaluation by questionnaire proceeded in stages. Staff assessed the authoring system and library lessons for their potential usefulness. Students assessed the importance to their own learning of the features that good quality C.A.L. lessons should display. Finally, our lessons were assessed by students for the presence of these features, comparison with other forms of presentation, their teaching performance, and integration into the curriculum. The use of a programmerless authoring language allowed the authors to concentrate on lesson subject content. The students appreciated the ability to go at their own pace and that their active involvement was required. Lessons scored well in relation to private reading and lectures but less well in comparison with practical work and tutorials. Appropriate integration of C.A.L. into the curriculum was found to be important. Evaluation by questionnaire at each stage of development was valuable.

Age-related changes in serum immunoreactive parathyroid hormone and its biological action in healthy men and women.

Circulating levels of PTH and related parameters of calcium and phosphate metabolism were measured in healthy free-living elderly and young subjects residing in the Southwest to determine if parathyroid function changes with aging. Serum immunoreactive PTH (iPTH) was measured with two well characterized antisera; an amino (N)-terminal antiserum which cross-reacts with the biologically active domain (1-34) and recognizes intact hormone, and a midregion (44-68) antiserum which cross-reacts with intact hormone and biologically inactive midregion/C-terminal fragments. Serum iPTH in both RIAs was significantly increased in the elderly population. An age-related increase was also found for total urinary cAMP and serum alkaline phosphatase, whereas the tubular reabsorptive maximum for phosphate (TmP/GFR) decreased with age. No difference was found between men and women of the same age group for serum iPTH, urinary cAMP, or serum alkaline phosphatase. TmP/GFR declined with age in men, but not women. Correspondingly, serum phosphate was significantly lower in elderly men than in elderly women. Urinary calcium excretion was higher in elderly women than in men of the same age group. Neither serum total or ionized calcium decreased with age. In conclusion, the age-related increase in N-terminal PTH and alterations in associated parameters of phosphate and calcium metabolism are consistent with increased parathyroid function as men and women age. Factors other than PTH are responsible for the sex-related differences observed in TmP/GFR, calcium excretion, and serum phosphate. The cause of the increased circulating levels of apparently biologically active PTH is unclear, but extends beyond the age-related decrease in renal function.

Theoretical versus practical orientations in pre-clinical biochemistry teaching.

A pre-clinical lecture on the relevance of biochemical theory to clinical practice may adopt either a theoretical or a practical orientation. These two approaches were compared in an experiment involving seventy-one second-year medical students. Theory-orientated teaching was superior for promoting recall, while neither method showed overall superiority for promoting application. These results suggest hypotheses for future research.