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In the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care.An environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used.We identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature.There are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.

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.

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).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.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.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.

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. 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. 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. 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.

There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self-reported unemployment and neighbourhood level socioeconomic status in Australia.A retrospective administrative data review was conducted at a tertiary care centre over a 10-year period (2008-2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed.106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50-2.82), OR 1.37 (1.15-1.64)), all complications (OR 1.43 (1.31-1.56), OR 1.21 (1.14-1.28)), failure to rescue (OR 2.03 (1.39-2.95), OR 1.38 (1.11-1.72)) and return to theatre (OR 1.42 (1.27-1.59), OR 1.24 (1.14-1.36)) (P 0.005 for all).Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.

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.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.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.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.

Background Port site hernias are a recognized complication of laparoscopic surgery and carry a high risk of strangulation because of the small size of the defect involved. Most hernias occur in trocar sites that are larger than 10 mm. This has resulted in the accepted practice that fascial defects larger than 10 mm are closed, incorporating the peritoneum and fascia, whereas defects less than 10 mm are not closed. Results We report a port site hernia at a 5-mm port site in a 90-year-old woman after ventral rectoplexy. A systematic review of literature found 27 cases of 5-mm port site herniation: 10 cases in general surgery and 17 cases in gynecological surgery. Conclusion The possibility of herniation through 5-mm port sites should be known to avoid a delay in recognition, diagnosis, and treatment.

In the US, racial disparities in outcomes following coronary artery bypass grafting (CABG) are well documented. TRICARE insurance data represent a large population with universal insurance that allows for the robust assessment of the impact of such insurance on disparities in health care. This study examined racial differences in specific aspects of surgical care quality following CABG, using metrics endorsed by the National Quality Forum that included the prescription of beta-blockers and statins at discharge and thirty-day readmissions. There were no risk-adjusted differences in outcomes between African American and white patients insured through TRICARE. Our study provides a window into the potential impacts of universal insurance and an equal-access health care system on racial disparities in surgical care quality following CABG.

Background Prior opioid use has been shown to be associated with adverse outcomes in surgical and trauma patients. We sought to evaluate the influence of prior opioid use on prescription opioid requirements after orthopedic trauma. Materials and methods This was a retrospective review of TRICARE claims (2006-2014). We evaluated the records of 11,752 patients treated for orthopedic injuries. Surveillance for prior opioid exposure extended to 6 mo before the traumatic event, with similar postinjury surveillance. Preinjury opioid use was categorized as unexposed, exposed without sustained use (nonsustained users), and sustained use (6 mo or longer of continuous opioid prescriptions without interruption). Multivariable Cox proportional hazard models were used to adjust for confounding and determine factors independently associated with the discontinuation of prescription opioid use after traumatic injury. Results Prior opioid exposure among nonsustained users (hazard ratio 0.78; 95% CI 0.74, 0.83) and sustained use at the time of injury (hazard ratio 0.40; 95% CI: 0.35, 0.47) were associated with lower likelihoods of opioid discontinuation. Additional factors associated with lower likelihoods of opioid discontinuation included our proxy for lower socioeconomic status, history of depression or anxiety, injury severity, and intensive care unit admission. Conclusions Prior opioid use is one of the strongest predictors of continued use following treatment, along with socioeconomic status, behavioral health disorders, and severity of injury. Appropriate discharge planning and early engagement of ancillary services in individuals with one or more of the risk factors identified here may reduce the likelihood of sustained opioid use after injury.

Medicaid expansion has reduced obstacles faced in receiving care. Emergency general surgery (EGS) is a clinical event where delays in appropriate care impact outcomes. Therefore, we assessed the association between non-Medicaid expansion policy and multiple outcomes in homeless patients requiring EGS. We used 2014 State Inpatient Database to identify homeless individuals admitted with a primary EGS diagnosis who underwent an EGS procedure. States were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression was used to examine associations between non-Medicaid expansion states and (1) length of stay and (2) total index hospital charges within the homeless population. Multivariable logistic regression was used to assess the associations between non-Medicaid expansion and (1) mortality, (2) surgical complications, (3) discharge against medical advice, and (4) home healthcare. A total of 6930 homeless patients were identified. Of these, 435 (6.2%) were in non-expansion states. Non-Medicaid expansion was associated with higher charges (coef: $46,264, 95% CI 40,388–52,139). There were non-significant differences in mortality (OR 1.4, 95% CI 0.79–2.62; p = 0.2) or surgical complications (OR 1.16, 95% CI 0.7–1.8; p = 0.4). However, homeless individuals living in non-expansion states did have higher odds of being discharged against medical advice (OR 2.1, 95% CI 1.08–4.05; p = 0.02), and lower odds of receiving home healthcare (OR 0.6, 95% CI 0.4–0.8; p = 0.01). Homeless patients living in Medicaid expansion states had lower odds of being discharged against medical advice, higher likelihood of receiving home healthcare and overall lower total index hospital charges.

Objective Assess outcomes in survivors of firearm injuries after 6 to 12 months and compared them with a similarly injured trauma population. Background For every individual in the United States who died of a firearm injury in 2017, three survived, living with the burden of their injury. Current firearm research largely focuses on mortality and short-term health outcomes, while neglecting the long-term consequences. Methods We contacted adult patients with a moderate-to-severe injury from a firearm or motor vehicle crash (MVC) treated at 3 level I trauma centers in Boston between 2015 and 2018. Patients were contacted 6 to 12 months postinjury to measure: presence of daily pain; screening for post-traumatic stress disorder (PTSD); new functional limitations; return to work; and physical and mental health-related quality of life. We matched each firearm injury patient to MVC patients using Coarsened Exact Matching. Adjusted Generalized Linear Models were used to compare matched patients. Results Of 177 eligible firearm injury survivors, 100 were successfully contacted and 63 completed the study. Among them, 67.7% reported daily pain, 53.2% screened positive for PTSD, 38.7% reported a new functional limitation in an activity of daily living, and 59.1% have not returned to work. Compared with population norms, overall physical and mental health-related quality of life was significantly reduced among firearm injury survivors. Compared with matched MVC survivors (n = 255), firearm injury survivors were significantly more likely to have daily pain [adjusted odds ratio (OR) 2.30, 95% confidence interval (CI) 1.08-4.87], to screen positive for PTSD (adjusted OR 3.06, 95% CI 1.42-6.58), and had significantly worse physical and mental health-related quality of life. Conclusions This study highlights the need for targeted long-term follow-up care, physical rehabilitation, mental health screening, and interventions for survivors of firearm violence.

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’s 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. Funding Agencies|Gillian Reny Stepping Strong Center for Trauma Innovation; National Center for Disaster Medicine and Public Health

United States state-level firearm legislation is linked to rates of firearm-related suicides, pediatric injuries, nonfatal injuries, hospital discharges, and mortality. Our objective was to evaluate the burden of firearm-related injuries requiring surgery for states with strict as opposed to nonstrict firearm legislation.The 2014 Healthcare Cost and Utilization Project State Inpatient Database was utilized to extract data for all available 28 states and the District of Columbia. States were dichotomized into strict and nonstrict legislative categories using the 2014 Brady and Gifford's scores (15 strict, 14 nonstrict). Patients with a firearm injury requiring surgery were identified and the incidence of surgery aggregated to the county level. Negative binomial regression with an offset for county-level residential population was used to estimate the incident rate ratio for surgical volume comparing counties in strict and nonstrict states. Models were stratified by injury intent and adjusted for county population characteristics.A total of 11,939 patients were hospitalized with firearm-related injuries, with 65% (n = 7759) undergoing an operative procedure. The adjusted incidence rate of firearm-related surgery per 100,000 people was 1.29 (95% confidence interval; 1.13-1.46, P 0.001) times higher and the adjusted cost of hospitalization per 100,000 people was $6028.69 ($3744.61-$8312.78, P = 0.001) greater for counties in nonstrict states than those for counties in strict states. The burden of health care for these injuries is invariably shifted to state- and county-level finances.The rate of firearm-related surgical intervention was higher for states with nonstrict firearm legislation than that for states with strict legislation. States should reevaluate their firearm legislation to potentially reduce the burden of firearm-related surgery and health care costs.

The increased use of prescription opioid medications has contributed to an epidemic of sustained opioid use, misuse, and addiction. Adults of working age are thought to be at greatest risk for prescription opioid dependence.To develop a risk score (the Stopping Opioids After Surgery score) for sustained prescription opioid use after surgery in a working-age population using readily available clinical information.In this case-control study, claims from TRICARE (the insurance program of the US Department of Defense) for working-age adult (age 18-64 years) patients undergoing 1 of 10 common surgical procedures from October 1, 2005, to September 30, 2014, were queried. A logistic regression model was used to identify variables associated with sustained prescription opioid use. The point estimate for each variable in the risk score was determined by its β coefficient in the model. The risk score for each patient represented the summed point totals, ranging from 0 to 100, with a lower score indicating lower risk of sustained prescription opioid use. Data were analyzed from September 25, 2018, to February 5, 2019.Exposures were age; race; sex; marital status; socioeconomic status; discharge disposition; procedure intensity; length of stay; intensive care unit admission; comorbid diabetes, liver disease, renal disease, malignancy, depression, or anxiety; and prior opioid use status.The primary outcome was sustained prescription opioid use, defined as uninterrupted use for 6 months following surgery. A risk score for each patient was calculated and then used as a predictor of sustained opioid use after surgical intervention. The area under the curve and the Brier score were used to determine the accuracy of the scoring system and the Hosmer-Lemeshow goodness-of-fit test was used to evaluate model calibration.Of 86 356 patients in the analysis (48 827 [56.5%] male; mean [SD] age, 46.5 [14.5] years), 6365 (7.4%) met criteria for sustained prescription opioid use. The sample used for model generation consisted of 64 767 patients, while the validation sample had 21 589 patients. Prior opioid exposure was the factor most strongly associated with sustained opioid use (odds ratio, 13.00; 95% CI, 11.87-14.23). The group with the lowest scores (31) had a mean (SD) 4.1% (2.5%) risk of sustained opioid use; those with intermediate scores (31-50) had a mean (SD) risk of 14.9% (6.3%); and those with the highest scores (50) had a mean (SD) risk of 35.8% (3.6%).This study developed an intuitive and accessible opioid risk assessment applicable to the care of working-age patients following surgery. This tool is scalable to clinical practice and can potentially be incorporated into electronic medical record platforms to enable automated calculation and clinical alerts that are generated in real time.

[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.

IntroductionPrehospital haemorrhage control has saved thousands of lives in the military over the last decade. While uncontrolled haemorrhage is a leading cause of preventable injury death in the USA for individuals under 45, military prehospital haemorrhage control techniques have not fully translated to the civilian sector in the USA. The effective implementation of haemorrhage control for civilian prehospital trauma is dependent on a more complex array of system and personnel-level factors than the military.ObjectiveThis protocol describes the methodology of a scoping review on haemorrhage control strategies in the prehospital setting; specifically, education, logistics and implementation of these strategies. The aim of the review is to identify research gaps and create recommendations for future research surrounding prehospital layperson haemorrhage control.MethodsThe protocol uses the framework published by The Joanna Briggs Institute and Arksey and O’Malley, while following the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols guidelines. The search strategy was refined with the help of a medical librarian. Three peer-reviewed databases (EMBASE, PubMed and Web of Science), databases dedicated to grey literature sources, and reference mining will be used. Two investigators will independently screen and extract data. Discrepancies will be resolved by a third investigator. The extracted data will undergo descriptive analysis of the contextual data and a quantitative analysis using the appropriate statistical methods. In addition, this search strategy will be supplemented by a grey literature search.Ethics and disseminationResearch ethics approval is not required for this scoping review. This scoping review will serve to highlight existing gaps within the literature to guide further research and develop future strategies to improve prehospital haemorrhage management. The results of this review will be presented at relevant national and international conferences and published in a peer-reviewed journal.

Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients.The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]).1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52).Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.

Background Racial disparities in trauma outcomes have been documented, but little is known about racial differences in post-discharge healthcare utilization. This study compares the utilization of post-discharge healthcare services by African-American and Caucasian trauma patients. Methods Trauma patients with an Injury Severity Score (ISS)≥9 from three Level-I trauma centers were contacted between 6 and 12 months post-injury. Utilization of trauma-related healthcare services was asked. Coarsened exact matching (CEM) was used to match African-American and Caucasian patients. Conditional logistic regression then compared matched patients in terms of post-discharge healthcare utilization. Results 182 African-American and 1,117 Caucasian patients were followed. Of these, 141 African-Americans were matched to 628 Caucasians. After CEM, we found that African-American patients were less likely to use rehabilitation services [OR:0.64 (95% CI:0.43–0.95)] and had fewer injury-related outpatient visits [OR:0.59 (95% CI:0.40–0.86)] after discharge. Conclusions This study shows the existence of racial disparities in post-discharge healthcare utilization after trauma for otherwise similarly injured, matched patients.

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 meta-analysis 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.

[Extract] Healthcare disparities in quality represent one of the greatest challenges in achieving uniformly high-quality care. Research reporting disparities in surgical outcomes are abundant. The cornerstone of delivering high-quality healthcare is ensuring optimal access for all patients. A relative lack of access to surgical services might be a contributing factor to disparities in surgical outcomes. Access is "the timely use of personal health services to achieve the best possible outcomes." Use of services, the process of entering and staying in the system, and the actual quality of care received are all involved. Disparities in access arise when the system disproportionately underperforms for a specific group of patients relative to the historically advantaged population.8, 9 Surgery, because of its time sensitive, often high-acuity nature, is greatly dependent on access.

The World Health Organization Surgical Safety Checklist (WHO SSC) 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, and there is limited evidence on the effects of the checklist in the long term. A retrospective review was conducted using administrative databases to examine the effects of the implementation of the checklist on postoperative outcomes. Data from 21,306 surgical procedures, performed over a 5-year time period at a tertiary care centre in Australia where the WHO SSC was introduced in the middle of this period, were analysed using multivariate logistic regression. Postoperative mortality rates decreased from 1.2 to 0.92% [p = 0.038, OR 0.74 (0.56–0.98)], and length of admission decreased from 5.2 to 4.7 days (p = 0.014). The reduction in mortality rates reached significance at the 2–3 years post-implementation period [p = 0.017, OR 0.61 (0.41–0.92)]. The observed decrease in mortality rates was independent of the surgical procedure duration. Implementation of the WHO SSC was associated with a statistically significant reduction in mortality and length of admission over a 5-year time period. This is the first study demonstrating a reduction in postoperative mortality after the implementation of the checklist in an Australian setting. In this study, a relatively longer period examined, comparative to previous international studies, may have allowed factors like surgical culture change to take effect.

IMPORTANCE: More than 500 000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively. OBJECTIVE: To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised). DESIGN, SETTING, AND PARTICIPANTS: This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks. INTERVENTIONS: Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application. MAIN OUTCOMES AND MEASURES: Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test. RESULTS: A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P

Introduction:Uncontrolled bleeding is a leading cause of preventable death in trauma. The “Stop the Bleed” campaign has trained over 130,000 lay people in the US to act to control bleeding. Current hemorrhage control courses, the most well-known being the American College of Surgeon’s Basic Bleeding Control (ACS B-con) course, require in-person training. Scaling this course nationwide is time and resource intensive. Furthermore, groups have advocated that young people, who are disproportionately affected by physical trauma, be universally trained in hemorrhage control.Aim:Compare the effectiveness of teaching the ACS B-con course to high school (HS) students utilizing three different delivery mechanisms: in-person live, video-recorded, and virtual-live training.Methods:432 students (aged 15-18) will be recruited from two HS settings: 300 from a local HS and 132 from a national online HS platform. Local HS students will be randomized into two arms: a control arm (in-person live training) and virtual training through a pre-recorded lecture. Online HS students will undergo virtual-live training. The primary outcome is correct tourniquet application following training. Secondary outcomes are the acquisition of personal resilience-associated traits using a validated instrument, motivation for further training, and perception of the importance of live training. Tourniquet application data will be assessed using a non-inferiority design using two pairwise comparisons of the intervention arms to the control (in-person). Pre- to post-training survey data will be assessed using paired univariates tests. Sub-analysis of the impact of demographic variables on these relationships will be assessed.Discussion:In addition to integration of cardiopulmonary resuscitation courses into HS curricula, there is momentum to develop effective programs to educate HS students to provide care for the injured and control bleeding before first responders arrive. This trial will help determine the most effective delivery mechanism to teach a hemorrhage control course to HS students at scale.

This study compares injury and death rates during active shooter incidents with vs without semiautomatic rifles.