Socioeconomic disparities in rates of facial fracture surgeries for women and men at a regional tertiary care centre in Australia

Background: Assault is the most common mechanism of injury in patients presenting with facial trauma in Australia. For women, there is a propensity for maxillofacial injuries to stem from intimate partner violence (IPV). Those with a low socioeconomic status have higher rates of IPV. This study examines variations in the proportion of surgical procedures that are due to facial trauma for Australian women and men by employment status and residential socioeconomic status. Methods: A single centre retrospective study was conducted (2008–2018). The proportion of operative patients presenting with facial fractures was examined. Multivariable logistic regression adjusting for year and age, was performed for women and men. Results: Facial fractures comprised 1.51% (1602) of all surgeries, patients had a mean age of 32, and 81.3% were male. Unemployed patients were more likely to require surgery for a facial fracture (OR 2.36 (2.09–2.68), P <0.001), and there were no significant variations by index of economic resources (IER). Unemployed males had higher rates of facial fractures (OR 2.09 (1.82–2.39), P <0.001). Unemployed and disadvantaged IER females had higher rates of facial fractures (OR 5.02 (3.73–6.75), P <0.001 and OR 2.31(1.63–3.29), P <0.001). Conclusions: This study found disparities in rates of surgery for facial fractures; unemployment increased the rates for men and women, whereas disadvantaged IER increased rates for women. Studies have demonstrated higher rates of IPV for unemployed and low socioeconomic status women. Further research ascertaining the aetiology of these disparities is important both for primary prevention initiatives and to enable treating clinicians to better understand and address the role of IPV and alcohol consumption in these injuries

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

Background: Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia. Methods: A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed. Results: In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79), p = 0.036) and rural patients (OR 1.83(1.21–2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2–3.04), p = 0.007), and rural patients (OR 1.73(1.13–2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54), p = 0.015) and rural patients (OR 1.92(1.29–2.86), p = 0.001). Conclusions: This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients

Postoperative adverse events inconsistently improved by the World Health Organisation Surgical Safety Checklist: a systematic literature review of 25 studies

Background: The World Health Organization Surgical Safety Checklist (SSC) has been widely implemented in an effort to decrease surgical adverse events. Method: This systematic literature review examined the effects of the SSC on postoperative outcomes. The review included 25 studies: two randomised controlled trials, 13 prospective and ten retrospective cohort trials. A metaanalysis was not conducted as combining observational studies of heterogeneous quality may be highly biased. Results: The quality of the studies was largely suboptimal; only four studies had a concurrent control group, many studies were underpowered to examine specific postoperative outcomes and teamwork-training initiatives were often combined with the implementation of the checklist, confounding the results. The effects of the checklist were largely inconsistent. Postoperative complications were examined in 20 studies; complication rates significantly decreased in ten and increased in one. Eighteen studies examined postoperative mortality. Rates significantly decreased in four and increased in one. Postoperative mortality rates were not significantly decreased in any studies in developed nations, whereas they were significantly decreased in 75 % of studies conducted in developing nations. Conclusions: The checklist may be associated with a decrease in surgical adverse events and this effect seems to be greater in developing nations. With the observed incongruence between specific postoperative outcomes and the overall poor study designs, it is possible that many of the positive changes associated with the use of the checklist were due to temporal changes, confounding factors and publication bias

Postoperative adverse events not improved by the World Health Organization Surgical Safety Checklist at a tertiary care centre in Australia

Background: The World Health Organization Surgical Safety Checklist has been widely implemented in an effort to decrease surgical adverse events. The effects of the checklist on postoperative outcomes have not previously been examined in Australia. Methods: A retrospective review was conducted using administrative data over a 5-year time period to examine the effects of the implementation of the checklist on rates of postoperative outcomes in a sample of 6,028 surgical procedures at a tertiary care centre in Australia. Results: The adjusted total complication, postoperative mortality and readmission to hospital rates did not significantly change between pre and post implementation [9.4% to 10.4% (p=0.43, OR 1.1 (0.89-1.3)), 0.93% to 0.85% (p=0.70, OR 0.90 (0.51-1.6)), 4.5% to 5.0% (p=0.36, OR 1.1 (0.89-1.3))]. The findings remained insignificant when a sub analysis was conducted on high risk surgical groups; emergency cases and surgical procedures in the elderly. The data was separated into 6-month time periods for a nalysis of operative complication and mortality rates over time; these were consistent (mean 10% SD 1.06, mean 0.9% SD 0.31, respectively). Conclusion: Implementation of the WHO SSC was not associated with a statistically significant reduction in any operative outcomes examined over a 5-year time period in a regional tertiary care centre in Australia. This may be due to the checklist having a reduced effect in developed countries or due to the mandatory implementation of the checklist; leading to a tick and flick mentality surrounding its use. Further research is required to support the ongoing checklist use in Australia

Postoperative adverse events inconsistently improved by the World Health Organization Surgical Safety Checklist: a systematic literature review of 25 studies

Background: The World Health Organization Surgical Safety Checklist (SSC) has been widely implemented in an effort to decrease surgical adverse events. Method: This systematic literature review examined the effects of the SSC on postoperative outcomes. The review included 25 studies: two randomised controlled trials, 13 prospective and ten retrospective cohort trials. A metaanalysis was not conducted as combining observational studies of heterogeneous quality may be highly biased. Results: The quality of the studies was largely suboptimal; only four studies had a concurrent control group, many studies were underpowered to examine specific postoperative outcomes and teamwork-training initiatives were often combined with the implementation of the checklist, confounding the results. The effects of the checklist were largely inconsistent. Postoperative complications were examined in 20 studies; complication rates significantly decreased in ten and increased in one. Eighteen studies examined postoperative mortality. Rates significantly decreased in four and increased in one. Postoperative mortality rates were not significantly decreased in any studies in developed nations, whereas they were significantly decreased in 75 % of studies conducted in developing nations. Conclusions: The checklist may be associated with a decrease in surgical adverse events and this effect seems to be greater in developing nations. With the observed incongruence between specific postoperative outcomes and the overall poor study designs, it is possible that many of the positive changes associated with the use of the checklist were due to temporal changes, confounding factors and publication bias

Defining a research agenda for layperson prehospital hemorrhage control: A consensus statement

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military\u27s medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector.Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons.Evidence review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda.Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy.Conclusions and relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities

Lethality of civilian active shooter incidents with and without semiautomatic rifles in the United States.

[Extract] Semiautomatic rifles have been used in some of the largest active shooter incidents in US history.1 Many weapons were banned in 1994 under the federal assault weapons ban but were reintroduced to the public marketplace in 2004.2 Currently, there are no comprehensive assessments of injuries from different types of firearms. We compared the number of persons wounded, killed, and either wounded or killed during active shooter incidents with and without semiautomatic rifles

Emergency to elective surgery ratio as a disparities sensitive surgical access metric, a study of low socioeconomic status in Australia

Background The emergency to elective surgery ratio is a proposed indicator for global access to surgical care. There is a well-established link between low socioeconomic status and increased morbidity and mortality. This study examined the emergency to elective surgery ratios for low socioeconomic patients utilising both self-reported unemployment and the neighbourhood Index of Economic Resources (IER). Methods A retrospective study was conducted at a regional tertiary care centre in Australia, including data over a ten-year period (2008–2018). Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, rurality, and if surgeries were due to trauma or injuries, was performed. Results 84,014 patients underwent a surgical procedure in the period examined; 29.0% underwent emergency surgery, 5.31% were unemployed, and 26.6% lived in neighbourhoods with the lowest IER. Following multivariable testing, the rate of emergency surgery was higher for unemployed patients (OR 1.42 [1.32–1.52], p < 0.001), and for those from the lowest IER (OR 1.13 [1.08–1.19], p < 0.001). For unemployed patients, this disparity increased during the study period (OR 1.32 [2008–2012], OR 1.48 [2013–2018]). When stratified by specialty, most (7/11) had significant disparities for unemployed patients: Cardiac/Cardiothoracic, Otolaryngology, Maxillofacial/Dental, Obstetrics/Gynaecology, Orthopaedics, Plastics, and Vascular surgery. Conclusions Unemployed Australians and those residing in the most disadvantaged IER neighbourhoods had higher emergency to elective surgery rates. The disparity in emergency to elective surgery rates for unemployed patients was found in most surgical specialties and increased over the period examined. This suggests a widespread and potentially increasing disparity in access to surgical care for patients of socioeconomic disadvantage, specifically for those who are unemployed

Measuring the quality of surgical care provision to Aboriginal and Torres Strait Islander patients

[Excerpt] Aboriginal and/or Torres Strait Islander Australians have a life expectancy 8 years less than other Australians.(1) Access to equitable high-quality surgical care may be a contributing factor to this dis-parity. Aboriginal and Torres Strait Islander patients have a higher emergency to elective surgery ratio,(2,3) a global indicator of access to surgical care.(4) When Aboriginal and/or Torres Strait Islander Australians do access surgical care, they may experience higher rates of post-operative morbidity and mortality.(5–11) The focus must now shift from simply reporting disparities in surgical outcomes for Aboriginal and/or Torres Strait Islander Australians to identifying,measuring and addressing the process measures involved in these poor surgical outcomes

Surgical services for breast cancer patients in Australia, is there a gap for Aboriginal and/or Torres Strait Islander women?

Background: Breast cancer is the most commonly diagnosed cancer in Aboriginal and/or Torres Strait Islander women. When compared to other Australians, Aboriginal and/or Torres Strait Islander women have a higher breast cancer mortality rate. This systematic literature review examined disparities in breast cancer surgical access and outcomes for Aboriginal and/or Torres Strait Islander women. Methods: This systematic literature review, following the PRISMA guidelines, compared measures of breast cancer surgical care for Aboriginal and/or Torres Strait Islander people and other Australians. Results: The 13 included studies were largely state-based retrospective reviews of data collected prior to the year 2012. Eight studies reported more advanced breast cancer presentation among Aboriginal and/or Torres Strait Islander women. Despite the increased distance to a multidisciplinary, specialist team, there were no disparities in seeing a surgeon, or in the time from diagnosis to surgical treatment. Two studies reported disparities in the receipt of surgery and two reported no variations. Three studies reported disparities in the receipt of mastectomy versus breast conserving surgery, whilst four studies reported no variations. No studies examined postoperative surgical outcomes. Conclusions: Aboriginal and/or Torres Strait Islander women present with more advanced breast cancer. There may be disparities in the receipt of surgery and the type of surgery. However, the metrics tested were not related to optimal care guidelines, and the databases utilised contain limited data on individual factors contributing to surgical care decisions. It is therefore difficult to determine whether the reported differences in the receipt of surgical care reflect disparate or appropriate care