Veterans Administration physician compensation: past, present, future.
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Anesthesiology↗
Biomedical subjects
Aaron S Fink
Publications and source records attributed to Aaron S Fink.
Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration.
BACKGROUND: Surgical site infections (SSIs) result in significant postoperative morbidity and mortality. Although many of these infections can be prevented by timely administration of preoperative antibiotics, data suggest that many patients do not receive such therapy. METHODS: A multidisciplinary team was convened that reviewed published guidelines, made antibiotic recommendations, and addressed administration issues. Responsibility for antibiotic administration was shifted from preoperative nursing staff to the anesthetist. Electronic quick orders were developed to encourage appropriate antibiotic selection and simplify order creation. RESULTS: Timely administration of preoperative antibiotics improved from 51% to 98% from February 2005 to February 2006. Appropriate antibiotic administered improved from 78% to 94%. The clean wound infection rate decreased from 2.7% to 1.4% over the same time period. CONCLUSION: A multidisciplinary approach to prophylactic antibiotic use, including computer-guided decision support, facilitates appropriate preoperative antibiotic use, resulting in a significant decrease in surgical wound infections.
Anesthesia Department, Hospital↗
Informed versus uninformed consent for prostate surgery: the value of electronic consents.
PURPOSE: We evaluated the documentation of informed consent for 2 common prostate operations using current, conventional, paper based consent forms. Based on the results of the review the conventional paper based consent system was replaced with a new, standardized electronic consent system. MATERIALS AND METHODS: We retrospectively reviewed the consent forms obtained for transurethral resection of the prostate and radical prostatectomy procedures during the 6-year period 1995 to 2000 at Atlanta Veterans Affairs Medical Center. Analysis focused on the basic elements of informed consent, including a description of the proposed treatment, and the purpose, benefits, risks and alternatives. Based on these findings we standardized the procedure specific information contained in consent forms and stored it electronically in a central network accessible to all urology providers throughout the medical center. RESULTS: Of the 222 total procedures 204 consent forms were available for review. Senior residents, junior residents and physician assistants obtained consent for 42.2%, 30.9% and 25.5% of procedures, respectively. Information on the purpose and benefits of treatment was missing in 4.4% of cases and deficient in 22.6%. General or procedure specific risks were documented inconsistently in 0% to 96% of cases. Alternative treatment options were missing in 49% of the consent forms and they were significantly deficient in the remaining 51%. Prognosis and surgical risks were documented variably for each procedure. For example, in the radical prostatectomy group 79 patients (88.8%) had appropriate documentation regarding the potential for significant blood loss and yet only 23 (25.8%) had documented consent for blood transfusion. Following the implementation of a new standardized electronic consent program 96.1% of the patients surveyed preferred the new system. CONCLUSIONS: Conventional nonstandardized consent forms have significant deficiencies and errors. The new system of electronic informed consent is standardized, legible and understandable, and it assists providers in fully informing patients about the treatment, risks, benefits and alternative therapies, thereby supporting ethical and legal standards, and improving the quality of care. In our opinion standardized electronic informed consent should be the new standard of care.
Humans↗
Evaluating alternative risk-adjustment strategies for surgery.
BACKGROUND: Comparison of institutional health care outcomes requires risk adjustment. Risk-adjustment methodology may influence the results of such comparisons. METHODS: We compared 3 risk-adjustment methodologies used to assess the quality of surgical care. Nurse reviewers abstracted data from a continuous sample of 2,167 surgical patients at 3 academic institutions. One risk adjustor was based on medical record data (National Surgical Quality Improvement Program [NSQIP]) whereas the other 2, the DxCG and Charlson Comorbidity Index (CCI), primarily used International Classification of Disease-9 (ICD-9) codes. Risk-assessment scores from the 3 systems were compared with each other and with mortality. RESULTS: Substantial disagreement was found in the risk assessment calculated by the 3 methodologies. Although there was a weak association between the CCI and DxCG, neither correlated well with the NSQIP. The NSQIP was best able to predict mortality, followed by the DxCG and CCI. CONCLUSION: In surgical patients, different risk-adjustment methodologies afford divergent estimates of mortality risk.
Evidence-Based Medicine↗
Evidence-based outcome data after hernia surgery: a possible role for the National Surgical Quality Improvement Program.
Since its inception in 1994, the National Surgical Quality Improvement Program (NSQIP) has been used to compare the performance of all Veterans Administration (VA) hospitals offering major surgical procedures. The program's outcome data are used to identify areas of both excellent and poor performance. The data can also be used to focus on specific procedures, especially high frequency operations such as inguinal herniorrhaphy. Following several successful feasibility studies, the NSQIP has been adopted by the American College of Surgeons (ACS) and is being offered nationwide in the non-VA sector. Given the profound decrease in operative mortality and morbidity seen within the VA, it seems realistic to expect similar improvements in global-and procedure specific-surgical outcomes within the non-VA sector.
Evidence-Based Medicine↗
Endoscopic retrograde cholangiopancreatography in chronic pancreatitis.
Endoscopic retrograde cholangiopancreatography (ERCP) plays an important diagnostic and therapeutic role in the management of chronic pancreatitis. New techniques are being developed which should further improve outcomes of endoscopic intervention. The ultimate role of these therapeutic interventions for chronic pancreatitis awaits prospective randomized data demonstrating their efficacy and safety in comparison to surgery. Until such time, these often difficult techniques should be performed by experienced endoscopists with significant experience in pancreatic disease, ideally within the context of controlled clinical trials.
Cholangiopancreatography, Endoscopic Retrograde↗
Quality of life: cost and future of bariatric surgery.
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Cost of Illness↗
Captopril inhibits secretin-induced pancreatic bicarbonate output.
BACKGROUND: Renin-angiotensin systems function at both the organ and systemic levels. Previous studies suggest that angiotensin II (Ang II) stimulates pancreatic secretion in vitro. In contrast, in vivo studies suggest that Ang II inhibits pancreatic secretion. To further assess Ang II's influence on pancreatic secretion, we examined the effect of captopril on secretin-stimulated pancreatic output. METHODS: After a 30-min basal period, four conscious dogs with chronic gastric and Herrera pancreatic fistulas received an intravenous bolus of captopril (0.1 mg/kg) followed by a continuous infusion (25 microg/kg/min). Control studies were performed with volume- and rate-matched saline infusion. After 1 h, secretin infusion was begun at 16 ng/kg/h, doubling the dose every 30 min. Pancreatic juice was analyzed for bicarbonate and protein. A paired t test was used to assess statistical significance. RESULTS: When compared to controls, pancreatic bicarbonate outputs were lower during captopril administration; the difference between captopril and control was statistically significant at the highest secretin dose. Protein outputs also appeared lower during captopril administration, although these differences were not statistically significant. CONCLUSION: These data suggest that Ang II may augment secretin-induced pancreatic secretion. Further, the data seemingly refute the inhibitory role attributed to Ang II in earlier studies.
Angiotensin II↗
The National Surgical Quality Improvement Program in non-veterans administration hospitals: initial demonstration of feasibility.
OBJECTIVE: To assess the feasibility of implementing the National Surgical Quality Improvement Program (NSQIP) methodology in non-VA hospitals. SUMMARY BACKGROUND DATA: Using data adjusted for patient preoperative risk, the NSQIP compares the performance of all VA hospitals performing major surgery and anonymously compares these hospitals using the ratio of observed to expected adverse events. These results are provided to each hospital and used to identify areas for improvement. Since the NSQIP's inception in 1994, the VA has reported consistent improvements in all surgery performance measures. Given the success of the NSQIP within the VA, as well as the lack of a comparable system in non-VA hospitals, this pilot study was undertaken to test the applicability of the NSQIP models and methodology in the nonfederal sector. METHODS: Beginning in 1999, three academic medical centers (Emory University, Atlanta, GA; University of Michigan, Ann Arbor, MI; University of Kentucky, Lexington, KY) volunteered the time of a dedicated surgical nurse reviewer who was trained in NSQIP methodology. At each academic center, these nurse reviewers used NSQIP protocols to abstract clinical data from general surgery and vascular surgery patients. Data were manually collected and then transmitted via the Internet to a secure web site developed by the NSQIP. These data were compared to the data for general and vascular surgery patients collected during a concurrent time period (10/99 to 9/00) within the VA by the NSQIP. Logistic regression models were developed for both non-VA and VA hospital data. To assess the models' predictive values, C-indices (0.5 = no prediction; 1.0 = perfect prediction) were calculated after applying the models to the non-VA as well as the VA databases. RESULTS: Data from 2,747 (general surgery 2,251; vascular surgery 496) non-VA hospital cases were compared to data from 41,360 (general surgery 31,393; vascular surgery 9,967) VA cases. The bivariate relationships between individual risk factors and 30-day mortality or morbidity were similar in the non-VA and VA patient populations for over 66% of the risk variables. C-indices of 0.942 (general surgery), 0.915 (vascular surgery), and 0.934 (general plus vascular surgery) were obtained following application of the VA NSQIP mortality model to the non-VA patient data. Lower C-indices (0.778, general surgery; 0.638, vascular surgery; 0.760, general plus vascular surgery) were obtained following application of the VA NSQIP morbidity model to the non-VA patient data. Although the non-VA sample size was smaller than the VA, preliminary analysis suggested no differences in risk-adjusted mortality between the non-VA and VA cohorts. CONCLUSIONS With some adjustments, the NSQIP methodology can be implemented and generates reasonable predictive models within non-VA hospitals.
Feasibility Studies↗
Insulin inhibits secretin-induced pancreatic bicarbonate output via cholinergic mechanisms.
INTRODUCTION: Exogenous insulin inhibits secretin-stimulated pancreatic bicarbonate output via a dose-dependent mechanism; this effect is prevented by pancreatic denervation. AIMS: To investigate possible cholinergic mediation, we examined the effect of bethanechol on secretin-stimulated pancreatic secretion during euglycemic, hyperinsulinemic clamp. METHODOLOGY: In four dogs with chronic pancreatic fistulas, euglycemic, hyperinsulinemic clamp (1.25 mU/kg/min) was begun after a 30-minute basal period; computer-assisted glucose administration maintained euglycemia. Control studies were performed with volume-matched and rate-matched vehicle infusion. After 1 hour, secretin infusion was begun at a dosage of 16 ng/kg/h; the dose was doubled every 30 minutes. The studies were then repeated during background bethanechol infusion (90 microg/kg/h) begun 30 minutes after clamp initiation. Pancreatic juice was analyzed for bicarbonate and protein; serum samples were analyzed for glucose and insulin. RESULTS: Exocrine outputs and serum glucose and insulin levels did not differ in the basal period. Insulin levels were significantly elevated during the euglycemic, hyperinsulinemic clamp (62 microU/mL versus 12 microU/mL; p < 0.01); glucose levels did not differ. As before, secretin-induced bicarbonate output was inhibited by euglycemic, hyperinsulinemic clamp. The inhibitory effect of insulin was reversed by bethanechol. Despite the euglycemic, hyperinsulinemic clamp, secretin-induced bicarbonate output was potentiated by bethanechol at higher secretin doses (p < 0.05). CONCLUSION: These data confirm that cholinergic mechanisms mediate insulin's inhibition of secretin-induced pancreatic bicarbonate output.
Animals↗
Angiotensin II evokes calcium-mediated signaling events in isolated dog pancreatic epithelial cells.
INTRODUCTION: Calcium-activated chloride conductance has been identified in normal pancreatic duct cells. Recent in vitro evidence suggests that angiotensin II (AngII) stimulates pancreatic secretion in both cystic fibrosis (CFPAC) and transformed pancreatic cells. AIMS: To investigate calcium-mediated stimulatory effects of AngII in both nontransformed dog pancreatic duct epithelial (DPDE) and CFPAC cells. METHODS: Western blots were performed in both cells seeking AngII receptors. In additional studies, DPDE and CFPAC cells were grown on vitrogen-coated glass cover slips and loaded with Indo-1-AM dye. Cells were placed in a confocal microscope's perfusion chamber and perfused with 100 microM AngII or ATP (control). Cells were excited with UV light, and intracellular calcium ([Ca+2]i) was read using fluorescence emission at 405 and 530 nm. Finally, single channels in the DPDE cells were examined using cell-attached patch clamps. Current amplitude histograms provided estimates of the conductance and open probability of channels. RESULTS: Western blots demonstrated presence of both AT and AT AngII receptors in DPDE and CFPAC cells; the density of AT receptors appeared lower than that of AT receptors. Basal intracellular calcium concentrations did not differ between DPDE (109 +/- 11 nM) and CFPAC (103 +/- 8 nM) cells. AngII significantly increased measured intracellular calcium concentrations in both DPDE (909 +/- 98 nM) and CFPAC (879 +/- 207 nM) cells, as did ATP (DPDE = 1722 +/- 228 nM; CFPAC = 1522 +/- 245 nM). In the patch clamp studies, a variety of different channels were observed; they appeared to be an 11pS nonselective cation (NSC) channel, a 4.6pS Na+ channel, a 3pS anion channel, and an 8pS chloride channel. The latter channel had characteristics similar to cystic fibrosis transmembrane conductance regulator (CFTR). Apical or basolateral application of AngII activated both the 11pS NSC and the 3pS channels. CONCLUSION: In nontransformed DPDE and CFPAC cells, specific AngII receptors mediate increases in [Ca ]. The latter effect of AngII may elicit activation of calcium-mediated chloride channels, suggesting a role for AngII as an alternative mediator of pancreatic ductal secretion.
Angiotensin II↗