Showing papers by "Atul A. Gawande published in 2016"

Size and distribution of the global volume of surgery in 2012.

Abstract: Introduction Surgical care is essential for managing diverse health conditions --such as injuries, obstructed labour, malignancy, infections and cardiovascular disease--and an indispensable component of a functioning health system. (1-3) International organizations, including the World Health Organization (WHO) and the World Bank, have highlighted surgery as an important component for global health development. (3,4) However, surgical care requires coordination of skilled human resources, specialized supplies and infrastructure. As low- and middle-income countries expand their economies and basic public health improves, noncommunicable diseases and injuries comprise a growing proportion of the disease burden. (5) Investments in health-care systems have increased in the last decade, but the effect on surgical capacity is mostly unknown. (6,7) Based on modelling of available data, it was estimated that 234.2 million operations were performed worldwide in 2004. (8) The majority of these procedures took place in high-income countries (58.9%; 138.0 million), despite their relative lower share of the global population. Here, we estimated the global volume of surgery in 2012. We also estimated the proportion of surgery due to caesarean delivery, since studies done in low-income countries have found that emergency obstetric procedures--especially caesarean deliveries--represent a high proportion of the total surgical volume. (9,10) Methods Population and health databases For the years 2005 to 2012, we obtained population and health data for 194 WHO Member States. These data included total population, life expectancy at birth, percentage of total urban population, gross domestic product (GDP) per capita in United States dollars (US$) and total health expenditure per capita in US$. (6,11) For 11 Member States, where certain population or health data were not available from either WHO or the World Bank, we used data from other similar sources. (12,13) All US$ were adjusted for inflation to the year 2012, using the consumer price index for general inflation. (14) For Member States with reported surgical data, we also obtained population and health data from the year for which surgical volume was reported. We classified Member States based on their health spending. Member States spending US$ 0-100 per capita on health were classified as very-low-expenditure Member States (n = 50); US $101-400 as low-expenditure Member States (n = 54); US$ 401-1000 as middle-expenditure Member States (n = 46); and over US$ 1000 as high-expenditure Member States (n = 44). (8) Surgical data sources Operations were defined as procedures performed in operating theatres that require general or regional anaesthesia or profound sedation to control pain. We searched PubMed for the most recent annual surgical volume reported after 2004, using each Member State name along with the following keywords and phrases for all WHO Member States: "surgery", "procedures", "operations", "national surgical volume" and "national surgical rate". Depending on the Member State, we conducted our search in English, French and/or Spanish. To obtain email addresses for ministers or officials working for the ministry of health or individuals responsible for auditing surgical data at a national level, we searched the internet for the websites of ministries of health or national statistical offices. We contacted these persons to request the most recently reported total volume of operations based on the above definition. From the database of the Organisation for Economic Co-operation and Development (OECD) we obtained surgical volume for 26 countries; 14 of these countries had total surgical volume data as well as detailed data for a subset of procedures (termed a shortlist by OECD), while the other 12 countries only had data for the shortlist. (15) For the 14 countries, we used both data sets in combination with publicly available data on total health expenditure to define the relationship between the shortlist and the reported total surgical volume. …

Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions.

Abstract: Objective:To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies.Summary Background Data:Improved communication is increasingly recognized as a central element in providing goal-concordant care and reduci

Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

Abstract: Importance Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes. Objectives To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality. Design, Setting, and Participants Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. The year of analysis was 2012. Cesarean delivery rates were available for 54 countries for 2012. For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years. For the 22 countries for which no cesarean rate data were available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percent of urban population, and geographic region. Exposures Cesarean delivery rate. Main Outcomes and Measures The relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100 000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births). Results The estimated number of cesarean deliveries in 2012 was 22.9 million (95% CI, 22.5 million to 23.2 million). At a country-level, cesarean delivery rate estimates up to 19.1 per 100 live births (95% CI, 16.3 to 21.9) and 19.4 per 100 live births (95% CI, 18.6 to 20.3) were inversely correlated with maternal mortality ratio (adjusted slope coefficient, −10.1; 95% CI, −16.8 to −3.4; P = .003) and neonatal mortality rate (adjusted slope coefficient, −0.8; 95% CI, −1.1 to −0.5; P P P = .004). Conclusions and Relevance National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

Quantity and Quality of Life: Duties of Care in Life-Limiting Illness.

Abstract: Everyone dies. Dying today typically involves a period of protracted illness, disability, and intense involvement of medical professionals. Although the experience is woefully understudied, a significant body of evidence is emerging to guide clinicians, health systems, and society toward better practices for people facing serious, life-threatening conditions. That evidence has shown, importantly, that the amount of suffering that people endure in their last year of life is considerable. Singer et al1 recently reported on the experience of 7204 adults older than 50 years who died while being followed up as part of a longitudinal study of US health and retirement. The researchers found that, during their last year, 51% of study participants were often troubled by moderate to severe pain, and 46% to 53% also experienced at least a month of depression, periodic confusion, dyspnea, and incontinence during that time.1 Furthermore, among those who died between 1998 and 2010, none of these symptoms decreased in occurrence during their last year of life, but rather occurrence of pain, depression, and periodic confusion actually increased. Medical care for the symptoms people experience at the end of life does not seem to have gotten better; it may have gotten worse. It could be argued that the findings simply reflect people following their wishes to trade the quality of their lives for therapies that extend their lives. But this is not the case. In 2014, the Institute of Medicine (IOM) published Dying in America, which included an extensive review of the medical literature on the end of life, including the efficacy of expert palliative care.2 Palliative care is a field dedicated to assisting seriously ill people with setting and achieving goals aside from just survival, which may include control of symptoms, attending to life projects, connecting with loved ones, or other vital objectives. The literature has established that when care is provided with a narrow focus on disease control, without palliative care expertise directed at eliciting these broader goals and tailoring care to include them, patients experience more pain, more anxiety, and more family exhaustion; they receive more nonbeneficial care and more hospitalization; and they do not live longer. Indeed, studies suggest that earlier involvement of palliative care specialists, either through consultation or enrollment in hospice, can produce increased survival.3,4 Another cause of physical suffering and family distress identified in the IOM report is that the majority of people reach the end of life cognitively impaired by illness, treatment, or frailty, and they are unable to make their own decisions about their care. They must rely on a proxy to make their medical choices. Only with advance planning conversations can they ensure alignment between the treatment they receive and their goals and values. But most people do not have these conversations with their clinicians or family members. Treatment therefore often violates their preferences, usually in the direction of undervaluing measures to support the quality of their remaining life. The picture of care at the end of life that emerges is therefore disturbing. A widespread perception among both the medical profession and the public at large has been that seeking palliative care consultation or hospice services, or even just having advance planning discussions, amounts to “giving up” and is only relevant when people no longer have options for disease-based therapy. This view is incorrect and harmful. It is also sometimes regarded as uniquely American. However, in this issue of JAMA, dedicated to the topic of death, dying, and the end of life, Bekelman et al5 report findings that suggest otherwise. The authors analyzed data from patients older than 65 years who died with cancer in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States.5 Among these countries, the United States actually had the lowest proportion of patients whose site of death was the hospital (22% vs up to 51% elsewhere). To be sure, the United States registered the highest rate of intensive care unit admission and chemotherapy administration in the last 180 days of life, indicating a mixed and still complex picture of care at the end of life. High use of intensive care and other technologies is a general characteristic of US health care,6 and the study found that use of chemotherapy in the last 30 days of life declined in the United States, just as in the other countries, to approximately 10%. All of these countries appeared to be making a radical transition away from nearly universal reliance on hospitalization at death for cancer patients, with the United States, perhaps surprisingly, having moved the farthest and fastest away from institutionalization at death. Other research shows the United States now has perhaps the highest level of hospice capacity and use, and the highest likelihood of death at home, in the developed world.7 Data from another study in this issue of JAMA, by Wright et al,8 indicate that this shift has likely been beneficial. The authors report survey data from family members of 1146 elderly patients who died with advanced lung or colorectal cancer. Patients who died in the hospital proved the least likely to be reported to have excellent quality of care near death (just 41% did) or to die where they had wished to (only 18% preferred to die in the hospital and did so). By contrast, patients who had been enrolled in hospice for at least 3 days had the best reported quality of life near death and best alignment of care with their wishes. Opinion

Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment

Abstract: Background Despite numerous studies of geographic variation in healthcare cost and utilization at the local, regional, and state levels across the U.S., a comprehensive characterization of geographic variation in outcomes has not been published. Our objective was to quantify variation in US health outcomes in an all-payer population before and after risk-adjustment. Methods and Findings We used information from 16 independent data sources, including 22 million all-payer inpatient admissions from the Healthcare Cost and Utilization Project (which covers regions where 50% of the U.S. population lives) to analyze 24 inpatient mortality, inpatient safety, and prevention outcomes. We compared outcome variation at state, hospital referral region, hospital service area, county, and hospital levels. Risk-adjusted outcomes were calculated after adjusting for population factors, co-morbidities, and health system factors. Even after risk-adjustment, there exists large geographical variation in outcomes. The variation in healthcare outcomes exceeds the well publicized variation in US healthcare costs. On average, we observed a 2.1-fold difference in risk-adjusted mortality outcomes between top- and bottom-decile hospitals. For example, we observed a 2.3-fold difference for risk-adjusted acute myocardial infarction inpatient mortality. On average a 10.2-fold difference in risk-adjusted patient safety outcomes exists between top and bottom-decile hospitals, including an 18.3-fold difference for risk-adjusted Central Venous Catheter Bloodstream Infection rates. A 3.0-fold difference in prevention outcomes exists between top- and bottom-decile counties on average; including a 2.2-fold difference for risk-adjusted congestive heart failure admission rates. The population, co-morbidity, and health system factors accounted for a range of R2 between 18–64% of variability in mortality outcomes, 3–39% of variability in patient safety outcomes, and 22–70% of variability in prevention outcomes. Conclusion The amount of variability in health outcomes in the U.S. is large even after accounting for differences in population, co-morbidities, and health system factors. These findings suggest that: 1) additional examination of regional and local variation in risk-adjusted outcomes should be a priority; 2) assumptions of uniform hospital quality that underpin rationale for policy choices (such as narrow insurance networks or antitrust enforcement) should be challenged; and 3) there exists substantial opportunity for outcomes improvement in the US healthcare system.

Bethesda Categorization of Thyroid Nodule Cytology and Prediction of Thyroid Cancer Type and Prognosis

Abstract: Background: Since its inception, the Bethesda System for Reporting Thyroid Cytopathology (TBS) has been widely adopted. Each category conveys a risk of malignancy and recommended next steps, though it is unclear if each category also predicts the type and extent of malignancy. If so, this would greatly expand the utility of the TBS by providing prognostic information in addition to baseline cancer risk. Methods: All patients prospectively enrolled into the authors' thyroid nodule database from 1995 to 2013 with histologically proven malignancy were analyzed. The primary ultrasound-guided fine-needle aspiration cytology (AUS, atypia of unknown significance; FN, follicular neoplasm; SUSP, suspicious; M, malignant) was correlated with the type of thyroid cancer and histological features known to impact prognosis and recurrence, including lymph node metastasis (LNM), lymphovascular invasion, and extrathyroidal extension (ETE). Primary cytology was separately correlated with higher risk malignancy. Results: A ...

Implementation of the Surgical Safety Checklist in South Carolina Hospitals Is Associated with Improvement in Perceived Perioperative Safety

Abstract: Background Previous research suggests that surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality as well as improvement in teamwork and communication. These findings stem from evaluations of individual or small groups of hospitals. Studies with more hospitals have assessed the relationship of checklists with teamwork at a single point in time. The objective of this study was to evaluate the impact of a large-scale implementation of SSCs on staff perceptions of perioperative safety in the operating room. Study Design As part of the Safe Surgery 2015 initiative to implement SSCs in South Carolina hospitals, we administered a validated survey designed to measure perception of multiple dimensions of perioperative safety among clinical operating room personnel before and after implementation of an SSC. Results Thirteen hospitals administered baseline and follow-up surveys, separated by 1 to 2 years. Response rates were 48.4% at baseline (929 of 1,921) and 42.7% (815 of 1,909) at follow-up. Results suggest improvement in all of the 5 dimensions of teamwork (relative percent improvement ranged from +2.9% for coordination to +11.9% for communication). These were significant after adjusting for respondent characteristics, hospital fixed-effects, multiple comparisons, and clustering robust standard errors by hospital (all p Conclusions A large-scale initiative to implement SSCs is associated with improved staff perceptions of mutual respect, clinical leadership, assertiveness on behalf of safety, team coordination and communication, safe practice, and perceived checklist outcomes.

A checklist for endonasal transsphenoidal anterior skull base surgery.

Abstract: OBJECT Approximately 250 million surgical procedures are performed annually worldwide, and data suggest that major complications occur in 3%-17% of them. Many of these complications can be classified as avoidable, and previous studies have demonstrated that preoperative checklists improve operating room teamwork and decrease complication rates. Although the authors' institution has instituted a general preoperative "time-out" designed to streamline communication, flatten vertical authority gradients, and decrease procedural errors, there is no specific checklist for transnasal transsphenoidal anterior skull base surgery, with or without endoscopy. Such minimally invasive cranial surgery uses a completely different conceptual approach, set-up, instrumentation, and operative procedure. Therefore, it can be associated with different types of complications as compared with open cranial surgery. The authors hypothesized that a detailed, procedure-specific, preoperative checklist would be useful to reduce errors, improve outcomes, decrease delays, and maximize both teambuilding and operational efficiency. Thus, the object of this study was to develop such a checklist for endonasal transsphenoidal anterior skull base surgery. METHODS An expert panel was convened that consisted of all members of the typical surgical team for transsphenoidal endoscopic cases: neurosurgeons, anesthesiologists, circulating nurses, scrub technicians, surgical operations managers, and technical assistants. Beginning with a general checklist, procedure-specific items were added and categorized into 4 pauses: Anesthesia Pause, Surgical Pause, Equipment Pause, and Closure Pause. RESULTS The final endonasal transsphenoidal anterior skull base surgery checklist is composed of the following 4 pauses. The Anesthesia Pause consists of patient identification, diagnosis, pertinent laboratory studies, medications, surgical preparation, patient positioning, intravenous/arterial access, fluid management, monitoring, and other special considerations (e.g., Valsalva, jugular compression, lumbar drain, and so on). The Surgical Pause is composed of personnel introductions, planned procedural elements, estimation of duration of surgery, anticipated blood loss and fluid management, imaging, specimen collection, and questions of a surgical nature. The Equipment Pause assures proper function and availability of the microscope, endoscope, cameras and recorders, guidance systems, special instruments, ultrasonic microdoppler, microdebrider, drills, and other adjunctive supplies (e.g., Avitene, cotton balls, nasal packs, and so on). The Closure Pause is dedicated to issues of immediate postoperative patient disposition, orders, and management. CONCLUSIONS Surgical complications are a considerable cause of death and disability worldwide. Checklists have been shown to be an effective tool for reducing preventable errors surrounding surgery and decreasing associated complications. Although general checklists are already in place in most institutions, a specific checklist for endonasal transsphenoidal anterior skull base surgery was developed to help safeguard patients, improve outcomes, and enhance teambuilding.

Effectiveness of the WHO Safe Childbirth Checklist program in reducing severe maternal, fetal, and newborn harm in Uttar Pradesh, India: study protocol for a matched-pair, cluster-randomized controlled trial.

Abstract: Effective, scalable strategies to improve maternal, fetal, and newborn health and reduce preventable morbidity and mortality are urgently needed in low- and middle-income countries. Building on the successes of previous checklist-based programs, the World Health Organization (WHO) and partners led the development of the Safe Childbirth Checklist (SCC), a 28-item list of evidence-based practices linked with improved maternal and newborn outcomes. Pilot-testing of the Checklist in Southern India demonstrated dramatic improvements in adherence by health workers to essential childbirth-related practices (EBPs). The BetterBirth Trial seeks to measure the effectiveness of SCC impact on EBPs, deaths, and complications at a larger scale. This matched-pair, cluster-randomized controlled, adaptive trial will be conducted in 120 facilities across 24 districts in Uttar Pradesh, India. Study sites, identified according to predefined eligibility criteria, were matched by measured covariates before randomization. The intervention, the SCC embedded in a quality improvement program, consists of leadership engagement, a 2-day educational launch of the SCC, and support through placement of a trained peer “coach” to provide supportive supervision and real-time data feedback over an 8-month period with decreasing intensity. A facility-based childbirth quality coordinator is trained and supported to drive sustained behavior change after the BetterBirth team leaves the facility. Study participants are birth attendants and women and their newborns who present to the study facilities for childbirth at 60 intervention and 60 control sites. The primary outcome is a composite measure including maternal death, maternal severe morbidity, stillbirth, and newborn death, occurring within 7 days after birth. The sample size (n = 171,964) was calculated to detect a 15% reduction in the primary outcome. Adherence by health workers to EBPs will be measured in a subset of births (n = 6000). The trial will be conducted in close collaboration with key partners including the Governments of India and Uttar Pradesh, the World Health Organization, an expert Scientific Advisory Committee, an experienced local implementing organization (Population Services International, PSI), and frontline facility leaders and workers. If effective, the WHO Safe Childbirth Checklist program could be a powerful health facility-strengthening intervention to improve quality of care and reduce preventable harm to women and newborns, with millions of potential beneficiaries. BetterBirth Study Protocol dated: 13 February 2014; ClinicalTrials.gov: NCT02148952 ; Universal Trial Number: U1111-1131-5647.

Cluster randomized trial to evaluate the impact of team training on surgical outcomes.

Abstract: Background The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation. Methods A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals. Results Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P < 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P < 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals. Conclusion Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Identification of Novel Oncogenic Mutations in Thyroid Cancer.

Abstract: Background Thyroid cancer patients frequently have favorable outcomes. However, a small subset develops aggressive disease refractory to traditional treatments. Therefore, we sought to characterize oncogenic mutations in thyroid cancers to identify novel therapeutic targets that may benefit patients with advanced, refractory disease. Study Design Data on 239 thyroid cancer specimens collected between January 2009 and September 2014 were obtained from the Dana Farber/Brigham and Women's Cancer Center. The tumors were analyzed with the OncoMap-4 or OncoPanel high-throughput genotyping platforms that survey up to 275 cancer genes and 91 introns for DNA rearrangement. Results Of the 239 thyroid cancer specimens, 128 (54%) had oncogenic mutations detected. These 128 tumors had 351 different mutations detected in 129 oncogenes or tumor suppressors. Examination of the 128 specimens demonstrated that 55% (n = 70) had 1 oncogenic mutation, and 45% (n = 48) had more than 1 mutation. The 351 oncogenic mutations were in papillary (85%), follicular (4%), medullary (7%), and anaplastic (4%) thyroid cancers. Analysis revealed that 2.3% (n = 3 genes) of the somatic gene mutations were novel. These included AR (n = 1), MPL (n = 2), and EXT2 (n = 1), which were present in 4 different papillary thyroid cancer specimens. New mutations were found in an additional 13 genes known to have altered protein expression in thyroid cancer: BLM , CBL , CIITA , EP300 , GSTM5 , LMO2 , PRAME , SBDS , SF1 , TET2 , TNFAIP3 , XPO1 , and ZRSR2 . Conclusions This analysis revealed that several previously unreported oncogenic gene mutations exist in thyroid cancers and may be targets for the development of future therapies. Further investigation into the role of these genes is warranted.

Clinical, Sonographic, and Pathological Characteristics of RAS-Positive Versus BRAF-Positive Thyroid Carcinoma.

Abstract: Context: Mutations in the BRAF and RAS oncogenes are responsible for most well-differentiated thyroid cancer. Yet, our clinical understanding of how BRAF-positive and RAS-positive thyroid cancers differ is incomplete. Objective: We correlated clinical, radiographic, and pathological findings from patients with thyroid cancer harboring a BRAF or RAS mutation. Design: Prospective cohort study. Setting: Academic, tertiary care hospital. Patients: A total of 101 consecutive patients with well-differentiated thyroid cancer. Main Outcome Measure: We compared the clinical, sonographic, and pathological characteristics of patients with BRAF-positive cancer to those with RAS-positive cancer. Results: Of 101 patients harboring these mutations, 71 were BRAF-positive, whereas 30 were RAS-positive. Upon sonographic evaluation, RAS-positive nodules were significantly larger (P = .04), although BRAF-positive nodules were more likely to harbor concerning sonographic characteristics (hypoechogenicity [P < .001]; irregular...

A Model for Better Leveraging the Point of Preoperative Assessment: Patients and Providers Look Beyond Operative Indications When Making Decisions

Abstract: Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.

Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

Abstract: Importance Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes. Objectives To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality. Design, Setting, and Participants Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. The year of analysis was 2012. Cesarean delivery rates were available for 54 countries for 2012. For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years. For the 22 countries for which no cesarean rate data were available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percent of urban population, and geographic region. Exposures Cesarean delivery rate. Main Outcomes and Measures The relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100 000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births). Results The estimated number of cesarean deliveries in 2012 was 22.9 million (95% CI, 22.5 million to 23.2 million). At a country-level, cesarean delivery rate estimates up to 19.1 per 100 live births (95% CI, 16.3 to 21.9) and 19.4 per 100 live births (95% CI, 18.6 to 20.3) were inversely correlated with maternal mortality ratio (adjusted slope coefficient, −10.1; 95% CI, −16.8 to −3.4; P = .003) and neonatal mortality rate (adjusted slope coefficient, −0.8; 95% CI, −1.1 to −0.5; P P P = .004). Conclusions and Relevance National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

Economic Impact of Surgical Complications on Hospitals.

Abstract: Discussion | Cubital tunnel syndrome is diagnosed by a combination of patient symptoms, physical examination findings, and nerve conduction studies. Patients present with reports of intermittent or persistent numbness or tingling in the ulnar nerve distribution distal to the elbow, often exacerbated by prolonged flexion of the elbow or direct pressure on the ulnar nerve. Long-term compression can result in loss of sensation in the small and ring fingers, weakness of grip, loss of coordination, and atrophy of the interosseous muscles. Nerve conduction studies objectively confirm the point of compression. Studies have failed to definitively support 1 method of decompression over the other.2 The open in situ method appears to be gaining traction as a favored procedure in clinical practice.3 The in situ method release decompresses the points of compression; however, the nerve is still under tension when the elbow is flexed.4 It is also at risk for symptomatic subluxation postoperatively. The concern for devascularizing the nerve during transposition has been addressed and does not appear to offer long-term morbidity.5 Transposition continues to be favored at our facility with a low rate of serious complications. None of 5 different methods of ulnar nerve decompression were found to have a statistically significant increased rate of local morbidity. Body mass index, diabetes, tourniquet time, and perioperative antibiotic use did not affect post operative local complications. Tobacco users had a statistically significant higher risk of local complications. The surgeons at our institution will continue to do the decompressive surgery they feel most appropriate for a particular patient, while emphasizing the benefits of nicotine cessation. Educational efforts will be focused toward emphasizing the anatomy of antebrachial cutaneous nerve branches.6