The COVID-19 Pandemic and the Surgical Workload of the UPR-affiliated Hospitals.

OBJECTIVE: To evaluate how the COVID-19 pandemic (declared in March 2020) affected our surgical workload. METHODS: Using the University of Puerto Rico Department of Surgery database, we evaluated the number of surgical cases and their characteristics for the years 2019 through 2021. The variables examined included age, sex, American Society of Anesthesiology classification, type of surgery (elective/emergency), whether the patient had been admitted or was an outpatient, and outcome. RESULTS: The total number of surgical cases decreased 30%, falling from 5,040 in 2019 to 3,564 in 2020, but then increasing about 10% to 3,935 in 2021. The number of elective surgery cases dropped 33%, going from 4,383 in 2019 to 2,924 in 2020. The number of emergency surgeries had a minor decrease of 16%, diminishing from 650 to 546 between 2019 and 2020, inclusive. Patients undergoing elective surgery during 2020 were found to be older, were more frequently men, and required inpatient admission more often. Three significant periods were identified and correlated to the number of surgical cases, the first being the COVID-19 lockdown (March 2020) and the second and third being the increases in infections caused by the Delta and Omicron variants of the virus (July 2021 and December 2021, respectively). CONCLUSION: The COVID-19 pandemic resulted in a significant decrease in the number of surgical cases. Two years after the pandemic, we have not recovered and continue to have fewer surgical cases than we did in 2019.

Increasing Proportion of Elderly Patients that make use of the Surgery Services of the UPR-affiliated Hospitals.

OBJECTIVE: To evaluate how the proportion of elderly patients aged 65 and above has increased in our surgical services over a 5-year period. METHODS: We compared the ages and characteristics of the surgical cases in 2014 with those in 2019, a 5-year interval, using the information from the University of Puerto Rico (UPR) General Surgery Database. The variables examined included age, gender, American Society of Anesthesiology (ASA) classification and outcome. RESULTS: In the UPR General Surgery Database information was available for 4,906 surgical cases performed in 2014 and for 4,954 such cases performed in 2019. The mean age of the patients increased from 48 (±23) years to 50 (±22) years in the 5-year interval. The gender distribution indicated that 56% were women and 44% were men, with no significant difference between the 2 periods evaluated. A statistically significant (P<0.001) increase in patients, 65 years of age and older occurred from 2014 (27%) to 2019 (31%). Patients aged 65 years and older were sicker, as indicated by more frequent ASA classifications of 3 or greater (in 2014: 13% vs. 32% and in 2019: 31% vs. 59%; P<0.001). Postoperative morbidity and/or mortality were slightly higher in the older group (5%, 3%) when compared to the younger group (3%, 2%). CONCLUSION: Elderly patients represent about one-third of the surgical workload, a proportion that is expected to grow as the general population ages. The rapid aging of the population presents important challenges, such as shifting disease burden and increased expenditures on health and the long-term care of the elderly, for which we will have to prepare.

Insurance Type and Surgical-Patient Characteristics in the UPR-Affiliated Hospitals.

OBJECTIVE: The characteristics of surgical patients were examined according to type of health insurance to determine whether differences existed between these groups. METHODS: We evaluated the characteristics of cases in the UPR General Surgery Department's database (entered from January 1, 2018 through December 31, 2018) by insurance type. The variables examined included age, gender, inpatient/outpatient status, wound classification, type of surgery, American Society of Anesthesiology (ASA) scores and whether a given patient had diabetes, was a smoker, or suffered from hypertension. This database had no trauma cases. RESULTS: Information was available for 5,097 cases during the study period. The mean age of the group was 51 (±22) years. The gender distribution indicated that 56% were women and 44% were men. The insurance types were distributed as follows: government/no insurance, 40%; Medicare, 12%; and private insurance, 48%. The government-insured/uninsured patients were younger (mean age, 41 ±24) and had had emergency surgery more frequently (18%) than had privately insured patients (10%). Medicare patients were significantly older (mean age, 72 ±12), and had had higher incidences of diabetes (46%) and hypertension (81%), presenting with ASA scores greater than or equal to 3 in 73% of cases. More privately insured individuals than those in other groups had had elective surgery (90%); 48% had been outpatients when they had their surgery, 58% had had clean wounds, and 61% of the patients having elective surgery were women. CONCLUSION: There were significant differences (P<.05) in the characteristics of patients with different types of health insurance. The frequency of emergency surgery was found to be significantly higher in the government-insured/uninsured group than in the privately insured group.

The Effect of Hurricane Maria on the Surgical Workload of the UPR-affiliated Hospitals.

OBJECTIVE: The Caribbean islands are regularly affected by hurricanes in a seasonal manner, but major (category 4 and 5) hurricanes are infrequent, and what happens in their aftermath is important for future planning. METHODS: We reviewed the surgical cases entered into the University of Puerto Rico (UPR) General Surgery Department database from January 1, 2016, through December 31, 2017. This database collects patient and procedural information from the surgical services of the UPR-affiliated hospitals. To analyze the impact that Hurricane Maria had on the surgical population, we compared cases per month using September 2017 (the month that Maria struck Puerto Rico) as the reference month. A chi-square goodness-of-fit test was used to evaluate differences between months. RESULTS: Information was available for 9,059 cases during the study period. The mean age of the group was 49±14 years, the gender distribution being 56% women, 44% men. The study found a statistically significant difference (p<0.001) in the number of surgical cases per month, with fewer patients in September 2017 (n = 210) compared to other months, representing a 57% decline in the number of cases. These patients tended to be sicker, with an increase in the number who had an American Society of Anesthesiologists physical status classification of 3 or greater. Within 3 months after the natural disaster, the volume of patients started to return to normal. CONCLUSION: We found that this major hurricane resulted in a decreased surgical workload, mostly because elective surgery cases were fewer, but that the patients that came for surgical care tended to be sicker and had, for the most part, poorly controlled systemic diseases. The volume of surgical cases did not reach normal levels until 3 months after the natural disaster.

Body Mass Index and Surgical Outcome in a Puerto Rican Population.

OBJECTIVE: To determine the impact of body mass index (BMI) on postoperative morbidity and 30-day mortality in the population served by the University of Puerto Rico (UPR)-affiliated hospitals. METHODS: We reviewed the surgical data entered into the UPR General Surgery Department database from January 1, 2014, through June 30, 2016. This database collects patient and procedural information from the UPR-affiliated hospitals. We compared the postoperative morbidity and 30-day mortality rates of 5 different BMI groups: underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), obese, classes I and II (30-39.9 kg/m2), and morbidly obese (>=40 kg/m2). Multivariable regression analyses, adjusted for age, gender, and surgery type, were used to evaluate the risks for each BMI category. RESULTS: Information on 9,856 patients was reviewed. The mean age of the sample population was 52 (±20) years; 57% were women and 43% were men. The postoperative morbidity and 30-day mortality rates of the underweight group were significantly higher than those of the normal-weight group (6.1% vs. 3.1% and 2.1% vs. 0.5%, respectively; p<0.001). The morbidly obese also had significantly higher (p<0.001) postoperative morbidity (5.3% vs. 2.1%) and 30-day mortality rates (2.7% vs. 0.5%) compared to normal-weight patients. The odds of 30-day mortality were significantly higher for the underweight (odds ratio [OR], 5.64; 95% confidence interval [CI], 2.47-12.92) and morbidly obese patients (OR, 7.23; 95% CI, 3.01-17.39). The overweight patients had no increased risk, and the obese patients had a slight increase in morbidity (OR, 1.54; 95% CI, 1.08-2.21) but no significant increase in 30-day mortality (p>0.05). CONCLUSION: Patients at the extremes of the BMI have more postoperative complications and higher 30-day mortality rates than do patients with mid-range scores.

Imaging-Associated Radiation Trends in a Puerto Rican Pediatric Surgical Population: Is Over-Radiation an Issue in Our Emergency Departments?

The increased use of CT scans has raised concerns regarding the risks of early radiation exposure in the Puerto Rico pediatric population. Available literature sustains that repeated exposure to imaging-related radiation in the pediatric population is associated with a 3-fold increase in the risk of developing pediatric hematogenous and central nervous system malignancies. It is for this reason that an international effort known as the Image Gently Campaign was created, mostly based on the "As Low As Reasonably Achievable" (ALARA) principle described by the Center for Disease Control. With this in mind, our aim was to identify whether there are any discrepancies in imaging tendencies outside our pediatric academic center in Puerto Rico and to determine whether our patients are at increased risk of over-radiation. There were 181 patients; five were excluded because of incomplete data. Our results show that children with appendicitis who are evaluated at nontertiary centers are more likely to have a CT scan performed (93%, OR: 4.054; 95% confidence interval: 2.6-6.4), as opposed to a nonradiating imaging study. In the Pediatric University Hospital, a CT scan was performed as the initial study in 23 per cent of the patients (OR: 0.09; 95% confidence interval: 0.05-0.18), favoring ultrasound as the diagnostic modality of choice. Our concern is that if this trend does not change, our pediatric population might have an increased risk of developing associated malignancies. We believe a local effort toward educational strategies should be implemented to prevent radiation overexposure in our pediatric patients.

Assessing the Decrease in the Surgical Population of the University of Puerto Rico-Affiliated Hospitals.

OBJECTIVE: To evaluate the magnitude of the decrease in the surgical population of the University of Puerto Rico (UPR)-affiliated hospitals. METHODS: We examined all the surgical cases that were entered into the Surgical Database from January 1, 2013, through December 31, 2015. This database collects patient and procedural information from the surgical services of the UPR-affiliated hospitals. Thus, the number of surgical patients for the 3-year study period was determined and their characteristics recorded. The group was subdivided into 3 subgroups, according to year: 2013, 2014, and 2015. All the variables studied were tabulated for the 3 subgroups and the values compared. The differences between subgroups were evaluated using the chi2 test or ANOVA, whichever was appropriate, with a p-value of less than 0.05 being considered significant. RESULTS: During the 3-year period, the Surgical Database collected information on 14,626 cases. The mean age of the group was 48 (±23) years. The gender distribution indicated that 55% of the sample members were women and 45% were men. A 14% decline in the number of surgical cases occurred from 2013 through 2015. The changes were not limited to a decline in numbers; the patients were sicker, as evidenced by a statistically significant (p<0.05) increase in the number of patients who presented with an American Society of Anesthesiologist (ASA) physical status classification of 3 or higher. CONCLUSION: A moderately steady decline in the number of surgical cases at the UPR-affiliated hospitals was noted. We believe multiple factors are responsible for this trend, such as a decreasing population and the current economic and healthcare crises occurring in Puerto Rico.

Prevalence of Diabetes Mellitus in the Surgical Population of the University of Puerto Rico Affiliated Hospitals: A Study using the Surgery Database.

OBJECTIVE: To evaluate the prevalence of diabetes mellitus in the surgical population of the University of Puerto Rico (UPR)-affiliated hospitals. METHODS: We examined all the surgical cases that were entered into the Surgical Database from April 1, 2014 through September 30, 2014. This database collects patient and procedural information from different surgical services of various UPR-affiliated hospitals (the University District Hospital, the University Pediatric Hospital, the UPR Carolina Hospital, the Dr. Isaac Gonzalez Oncologic Hospital, the PR Cardiovascular Center [thoracic service], the Pavia Hospital [colorectal service], and the Auxilio Mutuo Hospital [colorectal and oncological services]). The prevalence of diabetes mellitus (types 1 and 2 combined) was estimated, and the nondiabetic and diabetic groups were compared. The difference between groups was evaluated using a Chi2 test, Student's t-test, or ANOVA, whichever was appropriate, with a p-value of less than 0.05 being considered significant. RESULTS: Information from 2,603 surgical patients was available. The mean age of the group was 49 (±23) years. The gender distribution indicated that 56% were women and 44% were men. Diabetes was present in 21% of the surgical population, increasing to 40% in patients aged 65 and over. The surgical procedures most frequently required by diabetic patients were in the categories of general surgery (36%), colorectal surgery (22%), vascular surgery (16%) and oncologic surgery (14%). Complications (5%, diabetic group vs. 2%, nondiabetic group; p < 0.05) and postoperative mortality (2%, diabetic group vs. 0.2%, nondiabetic group; p < 0.05) were significantly higher in the diabetic group than in the nondiabetic group. CONCLUSION: Our surgical population has a high prevalence of diabetes, and these diabetic patients showed higher complication and mortality rates from surgery than did the non-diabetic patients. Surgeons must consider the specific needs of these diabetic patients in order to provide optimal care.

Database of Surgical Procedures: A Summary of Selected Characteristics of the Surgical Population of the University of Puerto Rico-Affiliated Hospitals.

OBJECTIVE: To evaluate the age distribution and selected characteristics of the cases recorded in the University of Puerto Rico (UPR) Surgical Database. METHODS: All the surgical cases (from 1/1/2013 to 12/31/2013) in the Surgery Department's database were examined. This database collects patient and procedural information from the surgical services of the UPR-affiliated hospitals (University District Hospital; University Pediatric Hospital; UPR Carolina Hospital; Oncologic Hospital (Dr. I. González Martínez), Pavia Hospital-colorectal service; and Auxilio Mutuo Hospital colorectal and oncologic services). The patients in the group were subdivided by age (less than 60 or equal or greater than 65 years). The difference between age groups was evaluated using a chi2, t-test, or ANOVA, whichever was appropriate, with a p-value less than 0.05 being considered significant. RESULTS: Information on 5,263 surgical patients was available for the study period. The mean age was 48 years (±23 years), with 28% of the patients being over 65 years of age. The age group with the highest rate of surgery was that of 61 to 70 years. The gender distribution was found to be similar to that of the general population: 55%, female, and 45%, male. The distribution by surgical service was as follows: general surgery, 32%; colorectal surgery, 21%; oncologic surgery, 22%; and others, 25%. The surgeries were elective in 87% of the cases and emergency procedures in 13% of them. Complications were reported in 3% of the cases; the mortality rate was 1%. CONCLUSION: Despite the fact that only 14% of our population was 65 years of age or older, 28% of the patients requiring surgery were in this age group. Older patients now represent a significant proportion of the surgical workload. Our study found that 75% of the surgical procedures performed were in the areas of general, oncologic, and colorectal surgery.

Gender Distribution of General Surgery Residents at the University of Puerto Rico.

OBJECTIVE: To determine whether the number of women accepted to the University of Puerto Rico (UPR) general surgery residency program has increased in recent years. METHODS: We examined the gender distribution of residents accepted in their first postgraduate year (PGY-1) by the UPR Surgery Department from 1958 to 2014. This information was obtained from the database of graduate residents, which collects information on gender, medical school from which they graduated, the years in which they were in the residency program, and, their specialty. We evaluated all the residents admitted to PGY-1 positions in surgery (1958-2014) and of those admitted to PGY-1 categorical general surgery positions (1983-2014). The study was IRB approved. RESULTS: Since 1958 the number of female residents admitted as PGY-1s to the UPR Surgery Department has augmented, starting with 2% in the 1960s and rising to 36% in 2014. The percentage of categorical female residents was 11% in the 1983 to 1990 period, 14% in the 1991 to 2000 period, 18% in the 2001 to 2010 period, and 35% in the 2011 to 2014 period. CONCLUSION: We found an increase in the number of women admitted to the general surgery program over the last several years. However, despite this increase some degree of gender inequality remains in most surgery programs. Currently, 60% of undergraduate students and 50% of medical students are women, but only 36% of surgical residents are women. Future studies need to address the reasons for the small number of women in surgical programs.

Racial and ethnic disparities in lifetime risk of corpus uterine cancer: a comparative study of Puerto Rico and the United States SEER population.

BACKGROUND: Corpus uterine cancer is the most common gynecologic malignancy in Puerto Rico and the United States. METHODS: We assessed the lifetime risk of developing and dying of corpus uterine cancer in women living in Puerto Rico (PR) and among Hispanics, non-Hispanic whites (NHW), and non-Hispanic blacks (NHB) in the United States. Data from the PR Central Cancer Registry and the Surveillance, Epidemiology, and End Results program were analyzed from 1993-2004. RESULTS: In PR, the probability of developing corpus uterine cancer increased from 1.21% in 1993-1995 to 1.69% in 2002-2004. The probability of developing this malignancy from 2002-2004 was 1.59% for NHB, 1.80% for Hispanics and 2.54% for NHW. The ratio of estimated probabilities only showed significant lower risk in PR as compared to NHW (.67, 95% CI = .59-.74). The probability of dying from corpus uterine cancer during 2002-2004 was .47% for Hispanics, .49% for NHW, .53% for PR and .76% for NHB. The ratio of estimated probabilities only showed significant lower risk of death in PR as compared to NHB (.70, 95% CI = .54-.85). CONCLUSIONS: The lifetime risk of developing corpus uterine cancer has increased in PR, suggesting higher exposure to risk factors in this population. Despite the lower lifetime risk of this malignancy in PR as compared to NHW, the similar lifetime risk of death in these groups suggests a disparity that may be influenced by differences in disease etiology and/or access or response to treatment. Assessment of risk factors, in addition to access to health services, is required to further understand these patterns.