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.

/pdf/classification-of-surgical-complications-a-new-proposal-with-h643vehuw5.pdf

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

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.

https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.3322/caac.21551

Cancer statistics, 2019.

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.

https://acsjournals.onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21590

Cancer statistics, 2020.

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.

https://acsjournals.onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21442

Cancer statistics, 2018

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...

/pdf/2015-american-thyroid-association-management-guidelines-for-32kri8vrhd.pdf

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.

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.

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Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

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. …

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

In gripping accounts of true cases, surgeon Atul Gawande explores the power and the limits of medicine, offering an unflinching view from the scalpel's edge. Complications lays bare a science not in its idealized form but as it actually is--uncertain, perplexing, and profoundly human. "Complications "is a 2002 National Book Award Finalist for Nonfiction.

Complications: A Surgeon's Notes on an Imperfect Science

The Global Burden

http://www.atulgawande.com/documents/Analysisofsurgicalerrorsinclosedmalpracticeclaimsat4liabilityinsurers.pdf

Atul A. Gawande

Papers

Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

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

Complications: A Surgeon's Notes on an Imperfect Science

The Global Burden

Analysis of surgical errors in closed malpractice claims at 4 liability insurers