Atul A. Gawande

Bio: Atul A. Gawande is an academic researcher from Brigham and Women's Hospital. The author has contributed to research in topics: Checklist & Population. The author has an hindex of 78, co-authored 281 publications receiving 33928 citations. Previous affiliations of Atul A. Gawande include University of Maryland, Baltimore & Massachusetts Eye and Ear Infirmary.

In-hospital Death following Inpatient Surgical Procedures in the United States, 1996–2006

Abstract: Background Over the past decade, improvements in perioperative care have been widely introduced throughout the United States, yet there is no clear indication that the death rate following surgery has improved. We sought to evaluate the number of deaths after surgery in the United States over a 10-year period and to evaluate trends in postoperative mortality.

Demand-side interventions for maternal care: evidence of more use, not better outcomes

Abstract: Background: Reducing maternal and neonatal mortality is essential to improving population health. Demand-side interventions are designed to increase uptake of critical maternal health services, but associated change in service uptake and outcomes is varied. We undertook a literature review to understand current evidence of demand-side intervention impact on improving utilization and outcomes for mothers and newborn children. Methods: We completed a rapid review of literature in PubMed. Title and abstracts of publications identified from selected search terms were reviewed to identify articles meeting inclusion criteria: demand-side intervention in low or middle-income countries (LMIC), published after September 2004 and before March 2014, study design describing and reporting on >1 priority outcome: utilization (antenatal care visits, facility-based delivery, delivery with a skilled birth attendant) or health outcome measures (maternal mortality ratio (MMR), stillbirth rate, perinatal mortality rate (PMR), neonatal mortality rate (NMR)). Bibliographies were searched to identify additional relevant papers. Articles were abstracted using a standardized data collection template with double extraction on a sample to ensure quality. Quality of included studies was assessed using McMaster University’s Quality Assessment Tool from the Effective Public Health Practice Project (EPHPP). Results: Five hundred and eighty two articles were screened with 50 selected for full review and 16 meeting extraction criteria (eight community mobilization interventions (CM), seven financial incentive interventions (FI), and one with both). We found that demand-side interventions were effective in increasing uptake of key services with five CM and all seven FI interventions reporting increased use of maternal health services. Association with health outcome measures were varied with two studies reporting reductions in MMR and four reporting reduced NMR. No studies found a reduction in stillbirth rate. Only four of the ten studies reporting on both utilization and outcomes reported improvement in both measures. Conclusions: We found strong evidence that demand-side interventions are associated with increased utilization of services with more variable evidence of their impact on reducing early neonatal and maternal mortality. Further research is needed to understand how to maximize the potential of demand-side interventions to improve maternal and neonatal health outcomes including the role of quality improvement and coordination with supply-side interventions.

Surgery for Hyperparathyroidism in Image-Negative Patients

Abstract: Hypothesis Patients with primary hyperparathyroidism and negative preoperative localization imaging have a different outcome than patients with positive imaging. Design Prospective single-surgeon case series. Setting Referral center. Patients Forty-two patients with primary hyperparathyroidism, indications for surgery, and both cervical ultrasonographic results and technetium Tc 99m sestamibi nuclear images that were nonlocalizing over a 5- year span. Main Outcome Measures Extent of surgery required to produce cure; operative findings. Results Of 430 patients undergoing surgery for primary hyperparathyroidism, 351 underwent both ultrasonographic and sestamibi imaging. Among 351 patients, the imaging results of 42 patients did not show an adenoma, and these patients underwent cervical exploratory surgery. Of 42 patients, 41 were cured at a mean follow-up of 90 days; 1 patient underwent surgical reexploration and was cured by removal of a mediastinal adenoma. To achieve initial cure, 12 of 42 patients (28.6%) required partial thyroidectomy, 9 (21.4%) required partial thymectomy, 17 (40.5%) required paratracheal dissection to access or devascularize an obscure adenoma. Pathologic examination disclosed single adenoma in 26 of 42 patients (61.9%), parathyroid hyperplasia in 14 (33.3%), and double adenoma in 2 (4.8%). Conclusions Patients whose preoperative localization studies fail to localize solitary adenoma commonly require extensive surgery to cure hyperparathyroidism. Lack of localization may be a reasonable criterion on which to base referral of the patient to a high-volume medical center.

Beyond volume: does hospital complexity matter?: an analysis of inpatient surgical mortality in the United States.

Abstract: Background Hospitals show wide variation in outcomes and systems of care. It is unclear whether hospital complexity-the range of services and technologies provided-affects outcomes and in what direction. We sought to determine whether complexity was associated with inpatient surgical mortality. Methods Using national Medicare data, we identified all fee-for-service inpatients who underwent 1 of 5 common high-risk surgical procedures in 2008-2009 and measured complexity by the number of unique primary diagnoses admitted to each hospital over the 2-year period. We calculated 30-day postoperative mortality rates, adjusting for patient and hospital characteristics, and used multivariable Poisson regression models to test for an association between hospital complexity and mortality rates. We then used this model to generate predicted mortality rates for low-volume and high-volume hospitals across the spectrum of hospital complexity. Results A total of 2691 hospitals were analyzed, representing a total of 382,372 admissions. After adjusting for hospital characteristics, including hospital volume, increasing hospital complexity was associated with lower surgical mortality rates. Patients receiving care at the hospitals in the lowest quintile of unique diagnoses had a 27% higher risk of death than those at the highest quintile. The effect of complexity was largest for low-volume hospitals, which were capable of achieving mortality rates similar to high-volume hospitals when in the most complex quintile. Conclusions Hospital complexity matters and is associated with lower surgical mortality rates, independent of hospital volume. The effect of complexity on outcomes for nonsurgical services warrants investigation.

What do we know about the safe surgery checklist now

Abstract: I n 2009, when The New England Journal of Medicine published the 8-city trial of the World Health Organization’s Safe Surgery Checklist, the idea that a formal system of planning and communication could significantly improve patient outcomes was outside the surgical mainstream. The pre-post study found substantial reductions in complications and deaths, with the improvements significant in both higher and lower income settings.1 However, the study had notable weaknesses. There was no control group, nor was the intervention applied on all units in the study hospitals. The program had not been demonstrated to be replicable at a large scale, and the sustainability of the effect had not been proved. A series of subsequent studies with strong control groups have since replicated the substantial value of using a systematic checklist-based approach to surgical team planning and communication. For instance, van Klei et al2 demonstrated in more than 25,000 patients that the odds ratio of 30-day mortality was 0.44 for patients whose teams completed the checklist compared with 1.16 for those whose teams did not. Beneficial findings were also demonstrated at a large scale: the SURPASS trial showed that a comprehensive surgical checklist approach reduced mortality rates by 47% in 7 Dutch hospitals compared with controls,3 and Neily et al4 demonstrated using a step-wedge methodology that introduction of a checklist-driven system of briefing and debriefing in 74 Veterans Administration (VA) hospitals through a concerted team training program led to an 18% reduction in mortality. As a result, several countries have introduced a safe surgery checklist program nationally. For instance, after several years of flat surgical inpatient mortality, NHS Scotland carried out a concerted nationwide implementation program that it credited with making major reductions in inpatient mortality that meant more than 9000 fewer lives lost.5 Recently, however, Urbach et al6 examined the effects of a law mandating surgical checklist use in Ontario hospitals and found only a modest mortality reduction that did not reach statistical significance. Given these conflicting data, a remaining concern about the validity of even the prior controlled studies was that they had not been randomized. The study by Haugen and colleagues7 in the current issue of Annals of Surgery therefore makes a major contribution by reporting the results of the first cluster randomized trial of a surgical safety checklist, in this case employing random allocation of dates of implementation of the intervention among different units within 2 hospitals in Norway. Analysis of outcomes focused on a cohort of patients with a significant rate of morbidity and in-hospital mortality (19.9% and 1.6%, respectively) and followed a step-wedge methodology. The study confirmed that use of the checklist resulted in substantial improvement in outcomes—with a relative risk reduction in major complications of 0.42 (95% confidence interval, 0.33–0.50). The number needed to treat to prevent morbidity was just 12. Deaths fell from 1.6% to 1.0%, which is potentially substantial, but the study was not powered to detect if this was a significant difference (P = 0.151). Importantly, the authors also confirmed a dose effect by assessing the actual use of the checklist through direct observation: they found an even larger reduction in major complications when teams completed all portions of the checklist—a finding consistent with that of van Klei et al.2 Such findings confirm that research on the effectiveness of quality tools such as checklists must include assessment of use, as no quality tool, particularly one that relies upon team communication and interaction, can be expected to make a difference if it is not actually used in any meaningful sense. This work also affirms emerging evidence that institution of an effective safe surgery checklist program at a large scale requires a deliberate implementation process and at least some form of monitoring and learning with frontline teams.8 Haugen and colleagues7,9 are to be complimented not only for the thoroughness of the process but also for the details on the implementation efforts shared in this article and in prior publications. They detail several precepts of their implementation that we believe may be key to success in team-based interventions. First, they modified the checklist to fit with local context. Although modification must be undertaken in a thoughtful manner, this is key to ensuring that the instrument fits the local workflow and circumstances. Second, after modification,

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4 Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature. The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification. Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.

Cancer statistics, 2019.

Abstract: Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2015, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2016, were collected by the National Center for Health Statistics. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2006-2015) was stable in women and declined by approximately 2% per year in men, whereas the cancer death rate (2007-2016) declined annually by 1.4% and 1.8%, respectively. The overall cancer death rate dropped continuously from 1991 to 2016 by a total of 27%, translating into approximately 2,629,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with the most notable gaps for the most preventable cancers. For example, compared with the most affluent counties, mortality rates in the poorest counties were 2-fold higher for cervical cancer and 40% higher for male lung and liver cancers during 2012-2016. Some states are home to both the wealthiest and the poorest counties, suggesting the opportunity for more equitable dissemination of effective cancer prevention, early detection, and treatment strategies. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.

Cancer statistics, 2020.

Abstract: Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on population-based cancer occurrence. Incidence data (through 2016) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2017) were collected by the National Center for Health Statistics. In 2020, 1,806,590 new cancer cases and 606,520 cancer deaths are projected to occur in the United States. The cancer death rate rose until 1991, then fell continuously through 2017, resulting in an overall decline of 29% that translates into an estimated 2.9 million fewer cancer deaths than would have occurred if peak rates had persisted. This progress is driven by long-term declines in death rates for the 4 leading cancers (lung, colorectal, breast, prostate); however, over the past decade (2008-2017), reductions slowed for female breast and colorectal cancers, and halted for prostate cancer. In contrast, declines accelerated for lung cancer, from 3% annually during 2008 through 2013 to 5% during 2013 through 2017 in men and from 2% to almost 4% in women, spurring the largest ever single-year drop in overall cancer mortality of 2.2% from 2016 to 2017. Yet lung cancer still caused more deaths in 2017 than breast, prostate, colorectal, and brain cancers combined. Recent mortality declines were also dramatic for melanoma of the skin in the wake of US Food and Drug Administration approval of new therapies for metastatic disease, escalating to 7% annually during 2013 through 2017 from 1% during 2006 through 2010 in men and women aged 50 to 64 years and from 2% to 3% in those aged 20 to 49 years; annual declines of 5% to 6% in individuals aged 65 years and older are particularly striking because rates in this age group were increasing prior to 2013. It is also notable that long-term rapid increases in liver cancer mortality have attenuated in women and stabilized in men. In summary, slowing momentum for some cancers amenable to early detection is juxtaposed with notable gains for other common cancers.

Cancer statistics, 2018

Abstract: Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2014, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2015, were collected by the National Center for Health Statistics. In 2018, 1,735,350 new cancer cases and 609,640 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2005-2014) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2006-2015) declined by about 1.5% annually in both men and women. The combined cancer death rate dropped continuously from 1991 to 2015 by a total of 26%, translating to approximately 2,378,600 fewer cancer deaths than would have been expected if death rates had remained at their peak. Of the 10 leading causes of death, only cancer declined from 2014 to 2015. In 2015, the cancer death rate was 14% higher in non-Hispanic blacks (NHBs) than non-Hispanic whites (NHWs) overall (death rate ratio [DRR], 1.14; 95% confidence interval [95% CI], 1.13-1.15), but the racial disparity was much larger for individuals aged <65 years (DRR, 1.31; 95% CI, 1.29-1.32) compared with those aged ≥65 years (DRR, 1.07; 95% CI, 1.06-1.09) and varied substantially by state. For example, the cancer death rate was lower in NHBs than NHWs in Massachusetts for all ages and in New York for individuals aged ≥65 years, whereas for those aged <65 years, it was 3 times higher in NHBs in the District of Columbia (DRR, 2.89; 95% CI, 2.16-3.91) and about 50% higher in Wisconsin (DRR, 1.78; 95% CI, 1.56-2.02), Kansas (DRR, 1.51; 95% CI, 1.25-1.81), Louisiana (DRR, 1.49; 95% CI, 1.38-1.60), Illinois (DRR, 1.48; 95% CI, 1.39-1.57), and California (DRR, 1.45; 95% CI, 1.38-1.54). Larger racial inequalities in young and middle-aged adults probably partly reflect less access to high-quality health care. CA Cancer J Clin 2018;68:7-30. © 2018 American Cancer Society.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer.

Abstract: Background: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer. Methods: The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Gr...