JAMA surgery最新文献

{"title":"Addressing Pregnancy Loss in Surgical Residency-A Call for Policy Protection.","authors":"Cleo Siderides, Caitlin J Cain-Trivette, Kelly A Garrett","doi":"10.1001/jamasurg.2024.6045","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6045","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005715","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Racial and Ethnic Disparities in Use of Helicopter Transport After Severe Trauma in the US.","authors":"Christian Mpody, Maíra I Rudolph, Alexandra Bastien, Ibraheem M Karaye, Tracey Straker, Felix Borngaesser, Matthias Eikermann, Olubukola O Nafiu","doi":"10.1001/jamasurg.2024.6402","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6402","url":null,"abstract":"<p><strong>Importance: </strong>In the US, traumatic injuries are a leading cause of mortality across all age groups. Patients with severe trauma often require time-sensitive, specialized medical care to reduce mortality; air transport is associated with improved survival in many cases. However, it is unknown whether the provision of and access to air transport are influenced by factors extrinsic to medical needs, such as race or ethnicity.</p><p><strong>Objective: </strong>To examine the current trends of racial and ethnic disparities in air transport use for patients who sustain severe trauma.</p><p><strong>Design, setting, and participants: </strong>This population-based cohort study used data from the National Trauma Data Bank from 2016 to 2022. Participants were patients older than 15 years who sustained a severe injury and required an urgent surgical procedure or intensive care unit (ICU) admission at level I or II trauma centers with helicopter service.</p><p><strong>Exposure: </strong>Severe injury requiring treatment at a level I or II trauma center.</p><p><strong>Main outcomes and measures: </strong>The primary mode of transport, categorized as either helicopter ambulance or ground ambulance. A multifaceted approach was used to narrow the observed racial and ethnic disparities in helicopter deployment. The secondary outcome was mortality after helicopter transport vs ground ambulance transport.</p><p><strong>Results: </strong>Data were included for 341 286 patients at 458 level I or II trauma centers with helicopter service. Their mean (SD) age was 47 (20) years; 243 936 patients (71.6%) were male and 96 633 (28.4%) female. Asian individuals were less likely to receive helicopter transport compared with White individuals (6.8% vs 21.8%; aRR, 0.38; 95% CI, 0.30-0.48; P < .001), driven by lower use for Asian patients in teaching hospitals (aRR, 0.29; 95% CI, 0.21-0.40; P < .001) and level I trauma centers (aRR, 0.33; 95% CI, 0.24-0.44; P < .001). In addition, Black patients were less likely to receive helicopter transport (8.7% vs 21.8%; aRR, 0.42; 95% CI, 0.36-0.49; P < .001), particularly in teaching hospitals (aRR, 0.41; 95% CI, 0.33-0.50; P < .001) and level I trauma centers (aRR, 0.40; 95% CI, 0.34-0.49; P < .001). A similar but less pronounced disparity was noted for Hispanic patients. Helicopter transport was associated with a lower mortality risk compared with ground transport (37.7% vs 42.6%; adjusted relative risk [aRR], 0.87; 95% CI, 0.85-0.89; P < .001).</p><p><strong>Conclusion and relevance: </strong>This study found that racial and ethnic minority patients, particularly Asian and Black patients, and notably those treated at level I teaching hospitals were less likely to receive airlift services compared with White patients. The current expansion of helicopter emergency medical services has yet to translate into equitable care for patients of all races and ethnicities.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005648","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Facility Medicaid Payer Burden and Nonelective Admission for Chronic Limb-Threatening Ischemia.","authors":"Steven Medvedovsky, Sherene E Sharath, Panos Kougias","doi":"10.1001/jamasurg.2024.6394","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6394","url":null,"abstract":"<p><strong>Importance: </strong>Chronic limb-threatening ischemia (CLTI) is a major public health issue that requires considerable human and physical resources to provide optimal patient care. It is essential to characterize the disease severity and resource needs of patients with CLTI presenting to facilities of varying resource capacities.</p><p><strong>Objective: </strong>To investigate the association between facility-level Medicaid payer proportions and the incidence of nonelective admissions among patients admitted for CLTI.</p><p><strong>Design, setting, and participants: </strong>In this retrospective multicenter cohort study, 876 026 CLTI-related inpatient admissions at 8769 US facilities from January 1, 1998, through October 31, 2020, were identified in the National Inpatient Sample. Facilities were ranked into quintiles according to increasing Medicaid burden, defined as the annualized proportion of Medicaid patient discharges for all hospitalizations. Inpatient admissions for CLTI were identified using International Classification of Diseases codes for rest pain, foot ulcers, and gangrene. Patients younger than 18 years or older than 100 years were excluded, as were those with missing admission type. Statistical analysis was conducted from January to August 2024.</p><p><strong>Exposure: </strong>Facility-level Medicaid burden quintiles.</p><p><strong>Main outcomes and measures: </strong>Emergency and urgent admissions defined as nonelective admissions.</p><p><strong>Results: </strong>The study included 876 026 CLTI-related admissions (mean [SD] patient age, 68.6 [14.5] years; 54.3% men). Increasing nonelective admission rates were associated with increasing facility Medicaid burden (low Medicaid burden, 59.7%; low-moderate Medicaid burden, 62.2%; moderate Medicaid burden, 63.6%; moderate-high Medicaid burden, 63.6%; and high Medicaid burden, 66.8%; P < .001). This trend persisted across all CLTI-related diagnoses (patients with rest pain: low Medicaid burden, 29.8%; high Medicaid burden, 36.1%; patients with lower-limb ulceration: low Medicaid burden, 63.5%; high Medicaid burden, 71.5%; and patients with gangrene: low Medicaid burden, 61.2%; high Medicaid burden, 67.4%; P < .001). In the adjusted model, odds of nonelective admission for CLTI indications increased progressively among facilities as Medicaid burden increased from low to high (adjusted odds ratio for low-moderate Medicaid burden, 1.05 [95% CI, 1.00-1.11]; P = .06; adjusted odds ratio for high Medicaid burden, 1.44 [95% CI, 1.36-1.52]; P < .001).</p><p><strong>Conclusions and relevance: </strong>High Medicaid burden facilities were associated with increased nonelective admissions for CLTI. This highlights an important mismatch: that resource-constrained facilities are at greater odds of seeing more resource-intensive admissions. Facility-level patient cohort characteristics should be considered when planning for resource allocation to achieve equitable patient care.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005725","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Oral vs Intravenous Antibiotics for Fracture-Related Infections: The POvIV Randomized Clinical Trial.","authors":"William T Obremskey, Robert V O'Toole, Saam Morshed, Paul Tornetta, Clinton K Murray, Clifford B Jones, Daniel O Scharfstein, Tara J Taylor, Anthony R Carlini, Jennifer M DeSanto, Renan C Castillo, Michael J Bosse, Madhav A Karunakar, Rachel B Seymour, Stephen H Sims, David A Weinrib, Christine Churchill, Eben A Carroll, Holly T Pilson, James Brett Goodman, Martha B Holden, Anna N Miller, Debra L Sietsema, Philip F Stahel, Hassan Mir, Andrew H Schmidt, Jerald R Westberg, Brian Mullis, Karl D Shively, Robert A Hymes, Sanjit R Konda, Heather A Vallier, Mary Alice Breslin, Christopher S Smith, Colin V Crickard, J Spence Reid, Mitch Baker, W Andrew Eglseder, Christopher LeBrun, Theodore Manson, Daniel C Mascarenhas, Jason Nascone, Andrew N Pollak, Michael G Schloss, Marcus F Sciadini, Yasmin Degani, Theodore Miclau, David B Weiss, Seth R Yarboro, Eric D McVey, Reza Firoozabadi, Julie Agel, Eduardo J Burgos, Vamshi Gajari, Andres Rodriguez-Buitrago, Rajesh R Tummuru, Karen M Trochez","doi":"10.1001/jamasurg.2024.6439","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6439","url":null,"abstract":"<p><strong>Importance: </strong>Fracture-related infection (FRI) is a serious complication following fracture fixation surgery. Current treatment of FRIs entails debridement and 6 weeks of intravenous (IV) antibiotics. Lab data and retrospective clinical studies support use of oral antibiotics, which are less expensive and may have fewer complications than IV antibiotics.</p><p><strong>Objective: </strong>To evaluate the effectiveness of treatment of FRI with oral vs IV antibiotics.</p><p><strong>Design, setting, and participants: </strong>The POvIV multicenter, prospective randomized clinical trial was conducted across 24 trauma centers in the US among patients aged 18 to 84 years who had fracture repair or arthrodesis with fixation with implants and developed an FRI without radiographic evidence of osteomyelitis. Patients were enrolled between March 2013 and September 2018 and followed up for 12 months after hospitalization for treatment of their FRI.</p><p><strong>Intervention: </strong>Oral vs IV antibiotics following FRI.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was number of surgical interventions, and the primary hypothesis was noninferiority of oral vs IV antibiotics with respect to the number of study injury-related surgical interventions by 1 year. Unadjusted modified intent-to-treat (mITT) and adjusted per-protocol (PP) analyses were prespecified. A post hoc adjusted mITT analysis was conducted to resolve discrepancies between the results of the prespecified mITT and PP analyses. Recurrence of a deep surgical site infection was a key secondary outcome.</p><p><strong>Results: </strong>Among 233 total patients, mean (SD) age was 46.0 (13.9) years, and 53 patients were female (22.7%). The mean number of surgical interventions within 1 year was 1.3 and 1.1 for the oral and IV groups, respectively. The upper bound of the 95% confidence interval of the mean difference with unadjusted mITT analysis was 0.59, which was lower than the prespecified noninferiority margin of 0.67, indicating noninferiority of oral to IV antibiotics. Adjusted PP analysis did not support noninferiority of the number of reoperations. A post hoc adjusted mITT analysis also showed noninferiority. The treatment effects estimates for the key secondary outcome of reinfection showed a similar pattern as those for the primary outcome.</p><p><strong>Conclusions and relevance: </strong>In this prospective randomized clinical trial, oral antibiotic treatment was noninferior to IV treatment with respect to the primary outcome of number of surgical interventions based on mITT analysis. However, there is some uncertainty in these findings based on preplanned and post hoc secondary analyses. A similar pattern of treatment effect estimates was observed for the secondary outcome of recurrence of infection.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT01714596.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005744","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association Between Surgeon Stress and Major Surgical Complications.","authors":"Jake Awtry, Sarah Skinner, Stephanie Polazzi, Jean-Christophe Lifante, Tanujit Dey, Antoine Duclos","doi":"10.1001/jamasurg.2024.6072","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6072","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;Surgeon stress can influence technical and nontechnical skills, but the consequences for patient outcomes remain unknown.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To investigate whether surgeon physiological stress, as assessed by sympathovagal balance, is associated with postoperative complications.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;This multicenter prospective cohort study included 14 surgical departments involving 7 specialties within 4 university hospitals in Lyon, France. Exclusion criteria consisted of patient age younger than 18 years, palliative surgery, incomplete operative time-stamping data, procedures with a duration of less than 20 minutes, and invalid surgeon heart rate variability (HRV) data. Data were accrued between November 1, 2020, and December 31, 2021, with 30-day follow-up completed on May 8, 2022. Analyses were performed from January 1 to May 31, 2024.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Exposure: &lt;/strong&gt;Sympathovagal balance of the attending surgeon in the first 5 minutes of surgery.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;Major surgical complications, extended intensive care unit stay, and mortality within 30 days, after adjustment via mixed-effects multivariable logistic regression for surgeon age, professional status, the time of incision, the random effect of the surgeon, and a composite risk score incorporating patient comorbidities and surgery characteristics. Sympathovagal balance was quantified by the low frequency to high frequency (LF:HF) ratio derived from HRV data measured by chest monitors worn intraoperatively. The LF:HF ratio was normalized at the surgeon level to the median value observed for each surgeon during the study period to control for baseline differences.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 793 surgical procedures performed by 38 attending surgeons were included in the analysis. Median patient age was 62 (IQR, 47-72) years, and 412 (52.0%) were female, with a median of 2 (IQR, 1-4) comorbidities. Median surgeon age was 46 (IQR, 39-52) years, 39 (78.9%) were male, and 22 (57.9%) were professors. Median surgeon heart rate was 88 (IQR, 77-99) beats per minute. Median surgeon LF:HF ratio was 7.16 (IQR, 4.52-10.72) before and 1.00 (IQR, 0.71-1.32) after normalization. Increased surgeon sympathovagal balance during the first 5 minutes of surgery was associated with significantly reduced major surgical complications (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.98; P = .04), though not with reduced intensive care unit stay (AOR, 0.34; 95% CI, 0.11-1.01; P = .05) or mortality (AOR, 0.18; 95% CI, 0.03-1.03; P = .05).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions and relevance: &lt;/strong&gt;Increased surgeon stress at the beginning of a procedure was associated with improved clinical patient outcomes. The results are illustrative of the complex relationship between physiological stress and performance, identify a novel association between measurable surgeon human factors and patien","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142983616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Turning Stress Into Success-Surgery as Professional Sport.","authors":"Steven Yule, Jennifer Yule, Calum Arthur","doi":"10.1001/jamasurg.2024.6041","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6041","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142982752","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effective Deimplementation of Low-Value Preoperative Testing: Choosing Wisely, From Policy to Practice.","authors":"Margaret E Smith, Alex B Haynes","doi":"10.1001/jamasurg.2024.6040","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6040","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142983621","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Tranexamic Acid in General Surgery-Who Benefits the Most?","authors":"Marjorie Liggett, Hasan Alam","doi":"10.1001/jamasurg.2024.6060","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6060","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142983646","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Safety and Efficacy of Tranexamic Acid in General Surgery.","authors":"Lily J Park, Maura Marcucci, Sandra N Ofori, Flavia K Borges, Rahima Nenshi, Charlotte Tiffanie Bendtz Kanstrup, Michael Rosen, Giovanni Landoni, Vladimir Lomivorotov, Thomas W Painter, Denis Xavier, Maria Jose Martinez-Zapata, Wojciech Szczeklik, Christian S Meyhoff, Matthew T V Chan, Marko Simunovic, Jessica Bogach, Pablo E Serrano, Kumar Balasubramanian, Margherita Cadeddu, Ilun Yang, Won Ho Kim, P J Devereaux","doi":"10.1001/jamasurg.2024.6048","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6048","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;Perioperative bleeding is common in general surgery. The POISE-3 (Perioperative Ischemic Evaluation-3) trial demonstrated efficacy of prophylactic tranexamic acid (TXA) compared with placebo in preventing major bleeding without increasing vascular outcomes in noncardiac surgery.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To determine the safety and efficacy of prophylactic TXA, specifically in general surgery.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;Subgroup analyses were conducted that compared randomized treatment with TXA vs placebo according to whether patients underwent general surgery or nongeneral surgery in the POISE-3 blinded, international, multicenter randomized clinical trial. Participants were 45 years or older, were undergoing noncardiac surgery, had increased cardiovascular risk, and were expected to require at least an overnight hospital admission after surgery. Among 26 581 eligible patients identified, 17 046 were excluded, resulting in 9535 patients randomized to the POISE-3 trial. Participants were enrolled from June 2018 through July 2021. The data were analyzed during December 2023.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Intervention: &lt;/strong&gt;Prophylactic, 1-g bolus of intravenous TXA or placebo at the start and end of surgery.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;The primary efficacy outcome was a composite of life-threatening bleeding, major bleeding, or bleeding into a critical organ. The primary safety outcome was a composite of myocardial injury after noncardiac surgery, nonhemorrhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism at 30 days. Cox proportional hazards models were conducted, incorporating tests of interaction.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Among 9535 POISE-3 participants, 3260 underwent a general surgery procedure. Mean age was 68.6 (SD, 9.6) years, 1740 were male (53.4%), and 1520 were female (46.6%). Among general surgery patients, 8.0% and 10.5% in the TXA and placebo groups, respectively, had the primary efficacy outcome (hazard ratio [HR], 0.74; 95% CI, 0.59-0.93; P = .01) and 11.9% and 12.5% in the TXA and placebo groups, respectively, had the primary safety outcome (HR, 0.95; 95% CI, 0.78-1.16; P = .63). There was no significant interaction by type of surgery (general surgery vs nongeneral surgery) on the primary efficacy (P for interaction = .81) and safety (P for interaction = .37) outcomes. Across subtypes of general surgery, TXA decreased the composite bleeding outcome in hepatopancreaticobiliary surgery (HR, 0.55; 95% CI, 0.34-0.91 [n = 332]) and colorectal surgery (HR, 0.67; 95% CI, 0.45-0.98 [n = 940]). There was no significant interaction across subtypes of general surgery (P for interaction = .68).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions and relevance: &lt;/strong&gt;In this study, TXA significantly reduced the risk of perioperative bleeding without increasing cardiovascular risk in patients undergoing general surgery procedures.&lt;/p&gt;&lt;p&gt;","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142983575","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing.","authors":"Alexis G Antunez, Ruby J Kazemi, Caroline Richburg, Cecilia Pesavento, Andrew Vastardis, Erin Kim, Abigail L Kappelman, Devak Nanua, Hiba Pediyakkal, Faelan Jacobson-Davies, Shawna N Smith, James Henderson, Valerie Gavrila, Anthony Cuttitta, Hari Nathan, Lesly A Dossett","doi":"10.1001/jamasurg.2024.6063","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6063","url":null,"abstract":"<p><strong>Importance: </strong>Routine preoperative blood tests and electrocardiograms before low-risk surgery do not prevent adverse events or change management but waste resources and can cause patient harm. Given this, multispecialty organizations recommend against routine testing before low-risk surgery.</p><p><strong>Objective: </strong>To determine whether a multicomponent deimplementation strategy (the intervention) would reduce low-value preoperative testing before low-risk general surgery operations.</p><p><strong>Design, setting, and participants: </strong>This study had a pre-post quality improvement interventional design using interrupted time series and difference-in-difference analytic approaches. The setting was a single academic, quaternary referral hospital with 2 freestanding ambulatory surgery centers and a central preoperative clinic. Included in the study were adult patients undergoing nonurgent outpatient inguinal hernia repairs, lumpectomy, or laparoscopic cholecystectomy between June 2022 and August 2023. Eligible clinicians included those treating at least 1 patient during both the preintervention and postintervention periods.</p><p><strong>Interventions: </strong>All clinicians were exposed to the multicomponent deimplementation intervention, and their testing practices were compared before and after the intervention. The strategy components were evidenced-based decisional support, multidisciplinary stakeholder engagement, educational sessions, and consensus building with surgeons and physician assistants staffing a preoperative clinic.</p><p><strong>Main outcomes and measures: </strong>The primary end point of the trial was the rate of unnecessary preoperative tests across each trial period.</p><p><strong>Results: </strong>A total of 1143 patients (mean [SD] age, 58.7 [15.5] years; 643 female [56.3%]) underwent 261 operations (23%) in the preintervention period, 510 (45%) in the intervention period, and 372 (33%) in the postintervention period. Unnecessary testing rates decreased over each period (intervention testing rate, -16%; 95% CI, -4% to -27%; P = .01; postintervention testing rate, -27%; 95% CI, -17% to -38%; P = .003) and within each test category. The decrease in overall testing was not observed at other hospitals in the state on adjusted difference-in-difference analysis.</p><p><strong>Conclusions and relevance: </strong>In this quality improvement study, a multicomponent deimplementation strategy was associated with a reduction in unnecessary preoperative testing before low-risk general surgery operations. The resulting changes in testing practice patterns were not associated with temporal trends within or outside the study hospital. Results suggest that this intervention was effective, applicable to common general surgery operations, and adaptable for expansion into appropriate clinical settings.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142983626","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}