Plain English summaryThe 2011 standards for trustworthy development of healthcare guidelines published by the United States-based Institute of Medicine recommend that guideline developers involve patients and public representatives in the development process. The standards recommend that (1) patients and the public be actively involved as members on guideline development panels and (2) guideline developers seek patient and public input during review of the draft guideline. In this study, researchers reviewed the patient and public involvement strategies of guideline developers in the United States by looking at websites and guideline development practices. Of 101 organizations reviewed, only 8% require patient and public involvement on guideline development groups; 15% sometimes require it or describe it as optional. Only 24% of guideline developers always post draft guidelines for public comment. Thirteen percent of guideline developers ask patients or patient organizations to review draft guidelines at least some of the time. Only 20% of guideline developers create patient-targeted guideline products (e.g. patient summaries of guidelines). These low numbers show that there is a substantial gap between standards for patient and public involvement in guideline development and what is actually happening. This is a missed opportunity, as patient and public contributions to guideline development include assessing guideline priorities, introducing new topics, identifying important populations and outcomes, suggesting whether findings are meaningful, prompting holistic approaches to care, assessing how recommendations interact with patient values, and writing plain-language guideline versions. Guideline developers must commit to prioritizing patient and public involvement as one part of trustworthy guideline development.AbstractBackgroundThe United States-based Institute of Medicine 2011 standards for trustworthy clinical practice guideline development recommended patient and public involvement in guideline development via participation by patients and public representatives on guideline development groups and via external review and public comment strategies. Guideline developer compliance with these standards has not been assessed. This study aimed to identify the frequency with which United States guideline developers are employing participation, consultation, and communication patient and public involvement strategies.MethodsTwo reviewers independently extracted current patient and public involvement strategies of independent guideline developers, either (1) an organizational member of the Guidelines-International-Network North America and/or (2) having ≥2 guidelines in the National Guideline Clearinghouse between March 2011 and November 2015. Publicly available information was extracted from guideline developers’ websites, methodology manuals, and guidelines between November 2015 and December 2016. Disagreements were resolved by discussion.ResultsOf 101 organizations meeting inclusion criteria, only 8% require pa...
Purpose Breast cancer continues to be the most prevalent cancer affecting women. Many reconstructive options exist after oncologic resection. Breast reconstruction can have a lasting impact on many areas of the patient's life, and therefore, a high consideration for patient satisfaction is crucial. Patient‐reported outcome measures (PROMs) provide an important tool in the evaluation of different surgical methodologies. The aim of this comprehensive systematic review is to look at various surgical modalities in breast reconstruction as they relate to patient satisfaction. Methods A PubMed PRISMA search was performed. Criteria for inclusion included nipple‐sparing or skin‐sparing mastectomy with autologous or implant‐based reconstruction, level 2 volume displacement or volume replacement oncoplastic surgery, and measurement of patient‐reported outcomes using the BREAST‐Q or other validated PROMs. From the data set, weighted proportions were generated and analyzed using the Kruskal‐Wallis rank sum test and a post hoc Dunn's test. Results After obtaining 254 full text copies, 43 articles met inclusion criteria and were included. Analysis of BREAST‐Q data showed oncoplastic breast surgery was significantly preferred over mastectomy regardless of the type of reconstruction. Nipple‐sparing was significantly preferred over skin‐sparing mastectomy, autologous reconstruction was significantly preferred over implant‐based reconstruction, and prepectoral implant placement was preferred over subpectoral implant placement. Validated PROMs other than BREAST‐Q showed similar trends in all but type of mastectomy. Conclusions In this comprehensive systematic review, oncoplastic surgery showed the most favorable PROMs when compared to other reconstructive modalities. Autologous was preferred over implant‐based reconstruction, and prepectoral was preferred over subpectoral implant placement.
Objective Closed-incision negative pressure therapy (CINPT) with the Prevena system has been used and clinically evaluated in high-risk groin incisions to reduce the risk of postoperative complications. We performed a cost-effectiveness analysis evaluating CINPT in femoral-popliteal bypass with prosthetic graft. Methods A literature review looking at prospective randomized trials determined the probabilities and outcomes for femoral-popliteal bypass with and without CINPT. Reported utility scores were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure and postoperative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to accommodate for the uncertainty in the literature. Results Femoral-popliteal bypass with CINPT is less costly ($40,138 vs $41,774) and more effective (6.14 vs 6.13) compared to without CINPT. This resulted in a negative ICER of −234,764.03, which favored CINPT, indicating a dominant strategy. In one-way sensitivity analysis, surgery without CINPT was more cost-effective if the probability of successful surgery falls below 84.9% or if the cost of CINPT exceeds $3139. Monte Carlo analysis showed a confidence of 99.07% that CINPT is more cost-effective. Conclusions Despite the added device cost of CINPT, it is cost-effective in vascular surgical operations using groin incisions.
Prepectoral breast reconstruction is an increasingly prevalent form of breast reconstruction. Prepectoral breast reconstruction was abandoned in the past due to various complications but has recently made a resurgence due to the development of acellular dermal matrices and innovative techniques. The purpose of this review article is to discuss the history, techniques, benefits, and potential complications of prepectoral breast reconstruction. The article also reviews current literature to evaluate published complication rates. Complications evaluated include infection (3.67%), wound dehiscence (2.10%), skin necrosis (3.67%), seroma (2.89%), hematoma (1.34%), implant loss (3.28%), return to the OR (6.15%), contracture (3.61%), and rippling (7.38%). In conclusion, prepectoral breast reconstruction is a reliable, safe, and aesthetically feasible method of breast reconstruction. With increasing interest in this technique, it is important that surgeons and patients are familiar with prepectoral reconstruction and this article aims at providing this information.
Background: The coronavirus disease SARS-CoV-2 (COVID-19) has swiftly spread throughout the globe, greatly influencing all aspects of life. As in previous pandemics, concerns for limited resources and a sustainable medical workforce have been on the forefront of infrastructure modifications. Consequently, surgical specialties have needed to consider each surgical case for necessity and safety during the COVID-19 outbreak. At our institution, availability of SARS-CoV-2 assay has allowed preoperative testing of asymptomatic surgical patients. Aim/Objective: To better define the prevalence of asymptomatic carriers in a surgical population and to better understand the impact of testing on our personal protective equipment (PPE) supply. Methods: We began routine, preoperative testing for all asymptomatic patients coming to our academic medical centre on 30 March 2020. Scheduled surgeries were deemed urgent by the surgeon with a review for appropriateness by a novel surgical committee. A retrospective patient chart review was performed. Emergency surgeries were excluded. Asymptomatic patients with positive test results had their surgeries rescheduled at the discretion of the surgeon and patient. Patients who tested negative underwent surgery with staff using standard PPE. Results: Eighty-four asymptomatic surgical patients were tested preoperatively with three (3.6%) testing positive for SARS-CoV-2. Preoperative testing saved 498 N95 respirators over this time period. Discussion: This is the first report of routine COVID-19 preoperative testing in an asymptomatic surgical population. Within this population, there is a 3.6% rate of asymptomatic SARS-CoV-2 carriers. Through this practice, personnel exposure can be minimised and access to PPE can be preserved.
Background: Lymphedema is a chronic, debilitating disease that has been described as the largest breast cancer survivorship burden. Debulking surgery has been shown to improve extremity volume, improve patient quality of life, and decrease the incidence of cellulitis in the literature. This procedure is routinely covered in numerous other developed countries, yet it is still inconsistently covered in the United States. Methods: Extremity volumes from all patients who underwent debulking surgery of the upper extremity at two institutions between December 2017 and January 2020 with at least 12 months follow-up were included. Procedural costs were calculated using Medicare reimbursement data. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years. A decision tree was generated, and incremental cost-utility ratios were calculated. Sensitivity analyses were performed to evaluate our findings. Results: Debulking surgery is associated with a higher clinical effectiveness (quality-adjusted life year) of 27.05 compared to conservative management (23.34), with a relative cost reduction of $74,487. Rollback analysis favored debulking surgery as the cost-effective option compared to conservative management. The resulting negative incremental cost-utility ratio of −20,115.07 favored debulking surgery and indicated a dominant strategy. Conclusion: Our study supports the use of debulking surgery for the treatment of chronic lymphedema of the upper extremity.
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