Blockchain Papers

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Sam Arman, Michael E. Hopkins, Simon McKean

In the United Kingdom, at the outbreak of the COVID-19 pandemic in March 2020, the national health service (NHS) took the unprecedented step of restructuring all of its services and workforce to cope with the expected influx of infected patients.1 Following a UK-wide lockdown and implementation of strict government guidelines, rates of COVID-19 infection reduced significantly and there was hope of a return to normal practice. However, the risks of exposure to the Sars-Cov2 virus to patients and healthcare staff remained. These risks were acutely felt amongst otolaryngologists due to the prevalence of the virus in the nose and throat in both symptomatic and asymptomatic patients.2 A significant number of extra measures and precautions were introduced to mitigate the potential spread of the virus amongst patients and healthcare staff during surgery. This was predicted to reduce the efficiency of surgical lists and limit the ability of departments to clear the backlog of patients awaiting surgery.3 The aim of this study was to investigate whether elective otolaryngology surgical services could return to pre-pandemic levels in an area where cases of COVID-19 infection were expected to, and indeed did, remain far below national rates. Retrospective and prospective data were collected for all fixed-term otolaryngology consultants at a single rural hospital during the period of 1 August-28 February for 2019/20 and 2020/21. Data recorded included number of theatre lists, number of planned (PLO) and performed operations (PFO), number of cancellations and reasons for cancellation. Data were also collected regarding the number of COVID-19 infections per week during 2020/21 at local and national levels. Statistical analysis was performed using SPSS statistical software and Chi-squared testing was used to compare categorical data. Our hospital trust covers a population of approximately 235 000 people with a population density of 8 people/Km2. The department normally performs approximately 1500 operations per year. Over the 2-year period, there were three substantive consultants performing surgery in the following sub-specialties: Otology, Rhinology, General ENT, General Paediatric ENT, Paediatric airway and Thyroid and Parathyroid surgery. The department also provides facial plastics services for the removal of all benign and malignant skin lesions from the head and neck under local anaesthetic. All surgical lists were planned and booked in advance by the operating consultant. At the beginning of August 2020, all ENT elective surgery was allowed to restart. New hospital protocols were introduced for all elective procedures under general anaesthetic (GA). These included patient shielding for a minimum of 2 weeks prior to surgery, a negative COVID-19 PCR test, mandatory FFP3 masks for all aerosol-generating procedures (AGPs) and fallow time following extubation. Our primary objective was to see whether normal ENT elective services could restart to pre-pandemic levels; this was interrupted by a surge in COVID-19 infections in December 2020 as all non-urgent surgery was cancelled. We therefore analysed the period 1 August-30 November (interwave recovery [IR]) and the period 1 December-28 February (second wave [SW]) with the previous year. There were zero cases of COVID-19 infection reported locally or nationally in August-February 2019/20. In 2020/21, there were 2949 cases of COVID-19 infection in our local authority area.4 This represents 0.07% of the 3 868 809 cases reported in the United Kingdom over the same period.5 The trend in the 7-day positive rate during this period at local and national levels is demonstrated in the graph (Figure 1). From 1 August 2019 to 28 February 2020, there were 123 planned theatre sessions compared to 111 in 2020/21 with the number of operations planned dropping from 4.5 to 4.1 per session. The total numbers of PLO, PFO and local anaesthetic skin procedures (LASP) are demonstrated in Table 1. In the year prior to COVID-19, 81% of PLO were performed and this was 9% higher than the second year, and this falls to a 5% decrease during the IR period. Overall, there was a 31.2% reduction in the number of PFO, and again, this falls in the IR to a 4.1% (144 vs. 138) decrease year on year. However, there were 1.8 operations performed per session during the IR in 2020/21 compared to 2.2 in 2019/20. There was a significant increase in the number of local anaesthetic skin procedures (LASP) in 2020/21 (p ≤ .00001) and this accounted for 27% of PFO in the IR compared to 6% the previous year. If we exclude LASP, there was a 26.1% decrease in the number of GA procedures performed between August and November year on year. There was a significant increase in the number of cancelled operations in 2020/21 compared to 2019/20 (p = .011); however, during August-November, there was no significant increase (p = .259). In 2019/20, 19% of PLO were cancelled compared to 28.3% in 2020/21. This percentage drops when analysing the IR (22%) to the same period in 2019/20 (17%). Overall, this represents a 15.5% increase in the number of cancellations and equates to a cancellation every 1.8 operational sessions; however, during the IR, this relates to a cancellation every 2.0 operational sessions. The reasons for cancelled operations are categorised and are shown in Figure 2. Our study shows that there has been a change in ENT elective surgical provision at our hospital since its re-introduction. It is unclear why fewer procedures were planned per list in 2020/21, but may possibly represent the expected delays caused by changes in standard operating procedures in response to the pandemic. These changes have been seen globally with the introduction of donning and doffing of personal protective equipment (PPE), the adaptation of theatres to protect essential apparatus from contamination and the refinement of surgical techniques to reduce the risk of transmission.6 The 31.2% reduction in PFO during 2020/21 can be mainly attributed to the second wave and the cancellation of all non-urgent surgery from the end of December 2020. During the IR period, there was a 4.1% decrease in PFO; however, on a per-session basis, this equates to an 18.1% reduction. This suggests that during periods of low community COVID-19 transmission, elective services are still unable to return to pre-pandemic levels. The reasons for this are likely multifactorial; however, the impact of wearing PPE during surgery cannot be underestimated, as it is known to affect surgical performance and non-technical skills.7 The return of near-normal operating surgical volume during the IR period may be explained by the significant increase in the number of LASP, as this accounted for 27% of all PFO. This significant increase (p ≤ .00001) is important as without LASP, the number of PFO would likely have dropped further, as LASP were not required to isolate pre-operatively or undergo covid-19 PCR testing as were not deemed AGPs. Consequently, last-minute vacancies left by cancellations could be filled at short notice. We found a significant increase in the number of operations cancelled in 2020/21 (p = .011). This was expected with a surge of COVID-19 during the winter months, as there was no significant increase in cancellations seen between August and November. We can therefore assume that during periods of low community transmission, hospital capacity is not affected and patients are willing to undergo surgery despite the extra safety and shielding requirements. Despite low numbers of community infections, necessary safety protocols have reduced the efficiency of surgical lists and their ability to adapt to change. The current NHS elective waiting list currently stands at over 4.5 million patients8 and previous studies have estimated that clearing a backlog of cases created by the pandemic may take 84 weeks, but this assumes activity returning at 110% of pre-pandemic levels.9 Our study suggests that this level of activity would be difficult to attain in otolaryngology and therefore we would expect clearance of waiting lists to take significantly longer. We suggest extensive triaging of patients on long waiting lists to ensure that procedures are still clinically indicated, as it is likely that in some cases, such as otitis media with effusion, criteria for intervention may no longer be met. However, we recognise that sufficient time will need to be provided to clinicians in order to facilitate this effectively. Surgical trainees across all specialties have been adversely affected by the pandemic with a significant reduction in operative experience and a greater than 50% reduction in logbook numbers.10 This has resulted in GMC-approved curriculum derogations by the joint committee on surgical training (JCST) to enable the progression of trainees at all levels.11 Our study has demonstrated that a rapid return to pre-pandemic activity is unlikely in the near-term even as rates of COVID-19 infection fall following a successful vaccination programme. The challenges trainees have faced in gaining sufficient operative experience will likely continue, although improve from present. This is important to acknowledge, as it will have implications for trainees attaining Certification of Completion of Training (CCT) this year and in the future. The study has its limitations. A lower-than-average number of COVID-19 cases cannot be assumed to have had less of an impact on the hospital providing ENT elective services. A smaller population and a smaller number of hospital beds available would mean even small increase in the 7-day positive rate could potentially impact the hospital's ability to provide elective surgery. Due to a lack of full-time substantive consultants, we were only able to compare a small number directly year to year. Our hospital was also without a full-time head & neck consultant during the second year and this meant sending patients to other centres in order to facilitate their care. The policies and guidelines implemented prior to restarting elective surgery were based on the best practice at that time and may not reflect advances in knowledge and the impact vaccination may have on future elective services. Low rates of COVID-19 infection do not necessarily mean that ENT elective services can return to pre-COVID levels. Implementation of new safety protocols to protect patients and staff has reduced the efficiency and speed at which elective ENT surgery can be delivered. This is likely to continue to impact waiting lists at a time when surgical activity is needed to exceed pre-pandemic levels. It is likely that workloads will increase, as extra theatre lists become more commonplace; however, in order to clear the backlog, NHS trusts will need to become more innovative in their approach. None. This study took the form of an audit, so National Research Ethics Service approval was not required. The local audit department approved the study. Sam Arman: Project lead involved with design, data collection and data analysis. Michael Hopkins: Involved with data analysis, editing and proofing final submission. Simon McKean: Project supervisor, involved with editing final publication None.

Catherine L. Mavroudis, Jason Tong, Rachel R. Kelz

The cost of surgical care is a substantial part of the rising costs of healthcare in the United States: an operation performed in this country costs 1 to 1.5 times more than that in other countries. The total cost of surgical care in the United States constitutes approximately half of inpatient costs, though only a third of inpatient volume.1–3 This multifactorial problem may be in part due to the pseudo-competitive market for healthcare delivery in the United States, in which the supply and demand curves are distorted by regionalization and payer mix. In response to these pressures, health system formation has increased dramatically in the past decade4 with an unclear impact on surgical value. To date, the true effect of health system formation remains undetermined. Proponents have suggested that health systems are able to spread evidence-based protocols and quality improvement initiatives across all hospitals within a given system. This would further improve both outcomes and efficiency through financial and intellectual economies of scale, and thereby improve value.5 Opponents have raised concerns that system expansion poses risks to patient safety due to inadequately supported changes in infrastructure, staffing, and patient population.6 In practice, not all health systems provide an equal opportunity to improve the value of surgical care. At one extreme, a large, geographically disparate system with hospitals scattered across the country may be able to realize the financial benefits of large-scale supply-chain sourcing, but is unlikely to be able to concentrate complex surgical volume in order for patients to realize potential clinical benefits of operating at scale. On the other hand, a smaller network of hospitals within a single region may be well-suited towards building a hub-and-spoke operative referral network, with resources concentrated on bringing patients to the best surgical infrastructure in one central hospital. Unfortunately, it is also more likely to have the advantage in contract negotiations with payers, thus driving up the cost of care and potentially limiting access for patients due to payer mix. Until we have a clear understanding of what it means to be a health system, we will not be able to evaluate the value of health system formation in surgery. To demonstrate the wide variation in system structure, we present the following case series of health systems in the United States. Using the American Hospital Association (AHA) annual survey dataset,7 we identified 413 systems that contained at least one surgical hospital, defined for this purpose as a hospital with at least 3 operating rooms. We generated multiple random two-percent samples. In studying both hospital and system characteristics, we found few similarities across systems, resulting in significant differences across samples. Two such samples can be seen in Table 1. In the first, we see that system size ranged from two to 27 hospitals. Six out of 7 health systems were in one state, while one 27-hospital system was spread across 14 states. Five systems contained hospitals of at least two different bed-size categories (eg, small and medium), while two contained only small hospitals. Three systems had at least one hospital that was a designated trauma center; five had at least one academic medical center. Four health systems were defined as “independent” system clusters by the AHA, which are “largely horizontal affiliations of autonomous hospitals,” while three were “centralized,” with centrally organized hospital services, physician arrangements, and insurance products.7 The second sample highlights the individuality of each system. These random samples of health systems demonstrate wide variation across the characteristics studied, with more observed differences than discernable similarities. TABLE 1 - A Case Series of Health System Characteristics Among 2 Random Samples of Health Systems in the United States Sample 1 System ID A B C D E F G H No. of hospitals 4 6 27 6 2 2 2 7 No. of states in system 1 1 14 1 1 1 1 1 Bed size category Small (<100 beds) 1 0 25 5 0 2 2 5 Medium (100–299 beds) 2 3 2 1 1 0 0 2 Large (≥300 beds) 1 3 0 0 1 0 0 0 No. of trauma center hospitals 0 2 0 0 1 0 0 4 No. of academic medical center hospitals 3 4 2 0 2 0 0 2 System cluster Ind. Cent. Ind. Ind. Cent. Unk. Ind. Cent. Sample 2 System ID I C J K L M N O No. of hospitals 104 27 2 6 2 73 2 32 No. of states in system 16 14 2 1 1 18 1 4 Bed size category Small (<100 beds) 56 25 2 4 1 29 2 26 Medium (100–299 beds) 25 2 0 1 1 22 0 5 Large (≥300 beds) 23 0 0 1 0 22 0 1 No. of trauma center hospitals 45 0 0 0 1 32 2 14 No. of academic medical center hospitals 40 2 0 0 0 35 1 3 System cluster Dec. Ind. Unk. Ind. Ind. Dec. Ind. Dec. (1) System Clusters: Ind., Independent, Cent., Centralized, Dec., Decentralized, Unk. = Unknown/Missing.(2) Due to random chance, system C was included in both samples. Our findings suggest that system designation does not confer information about hospital structure or the role of each hospital within the system. The heterogeneity of health system structure implies substantial differences in the organization of healthcare delivery across systems. The structure of health systems must be better characterized before their value—or lack thereof—can be determined. In order to do this, as a health services research community, we must develop a cohesive scientific taxonomy analogous to that which exists for cell biology—understanding each organelle, its role within the cell, and that cell's role in maintaining the vitality of a larger organism. The interactions between patients, hospitals, and health systems are no less complex, and the ramifications for the future of our health system are significant. Delineating the characteristics of health systems that confer optimal conditions for high-value care will enable the construction of health systems that maximize the value of healthcare for the patient, payer, and provider. Systems must be accountable to their outcomes to deliver on the promise of improved healthcare delivery, as they enjoy financial privileges associated with the business relationships between entities. Although our examples are focused on surgery and in-hospital care, these principles can be applied across the breadth of medicine. By doing so, we may be able to see substantial gains in the value of care delivery across the United States.

Joseph Bernstein

The practice of orthopaedic surgery has become highly specialized. According to a recent American Academy of Orthopaedic Surgeons (AAOS) census, 77% of members reported a specialty interest [1]. Along those lines, Morrell et al. [12] estimate that at least 90% of graduating orthopaedic surgery residents pursue fellowship training. It would be no surprise, therefore, to discover that the AAOS Board of Specialty Societies boasts 22 member groups. To some, greater specialization is no doubt a step in the wrong direction. Back in the days of the giants, this nostalgic argument goes, a “real” surgeon would be happy to fix a femur fracture and straighten a spine on the same day. (In fact, the true giants would fix a fracture and straighten a spine only after removing an appendix and delivering a baby or two.) Today's orthopaedic surgeons, by contrast, are feckless and feeble. A more reasonable view acknowledges the benefits of specialization. For one, surgeons who do only one procedure are apt to become quite efficient [6]. Better still, the high-volume specialist-surgeon will produce superior results [7]. Specialization similarly enhances career prospects: The Top Doctor lists are filled almost exclusively with specialists and academic advancement criteria emphasize depth over breadth. Of course, a reasonable view would also acknowledge the costs of specialization. Specialists—like all of us—see the world through the prism of experience. As such, they can easily overlook or discount important findings. This so-called “availability bias” would spur a neurosurgeon to attribute index finger pain to a cervical radiculopathy and a hand surgeon to blame the median nerve—with both of them relatively blinded to the possibility that a metabolic abnormality, say, is the true cause. Yet even if specialists could break free of their cognitive constraints, patients may still pay as they shuffle from expert to expert in search of total care. This cost comprises not only hassle and dollars, but a potential for poor communication and other forms of uncoordinated care [3]. There is, furthermore, a problem of distribution. Specialists quite rationally tend to congregate in larger urban areas: Places with enough patients to keep them busy in their own narrow practice enclaves. Hence, specialization can lead to a manpower shortage (and impeded access to care) in small towns and a glut (with overtreatment) in big cities. In addition, too much specialization within a surgeon's practice exposes that surgeon to the risk his or her practice might implode if the demand for a particular service disappears. Simply put: The surgeon who knows how to do only knee replacements will be out of work if a medical cure for arthritis is discovered. Of course, it is highly unlikely that a medical cure for arthritis will be discovered so quickly that the surgeon will be unable to adapt, but the risk is not zero. (Those who place the risk at zero have never witnessed a cardiothoracic surgeon crying about the discovery of coronary stents). Maintaining mastery over many surgical procedures is an excellent hedge against the possibility that one of these procedures falls out of favor. But there is an even more pressing reason for surgeons to resist too much specialization: It just might be bad for the soul. In his classic book The Wealth of Nations, Adam Smith noted that the division of labor leads to “universal opulence.” Smith clearly recognized the benefits specialization and is rightly considered one of its greatest champions. But Smith went on to assert “The man whose whole life is spent in performing a few simple operations … generally becomes as stupid and ignorant as it is possible for a human creature to become.” According to Smith, repeatedly doing the same operation (a word we may want to take in its modern medical sense) creates a “torpor of [the] mind.” This torpor, Smith claims, is a state in which the specialist becomes unable to conceive of any “generous, noble, or tender sentiment, and consequently of forming any just judgment concerning many even of the ordinary duties of private life.” In modern parlance: Burnout. So what to do? Because specialization imposes costs on patients, it may be reasonable to insist on professional rules to limit it somewhat. (The broad ABOS recertification examination can be considered such a step, as are normative standards that ask orthopaedic surgeons to provide general emergency room coverage in their community). In addition, our leaders should educate young orthopaedic surgeons about specialization's hidden costs. This knowledge will let enlightened self-interest—what Smith called the “invisible hand”—motivate the correct course of action. Pierre J. Hoffmeyer MD Professor of Orthopaedic Surgery University Hospital of Geneva Hyperspecialization in orthopaedic surgery is here to stay. This is especially true in economically favored regions benefitting from high levels of resources [4]. Hyperspecialization has political support because of increasing public pressure stemming from the needs and demands of an aging and active population [2]. In this setting of economic affluence, orthopaedic surgeons have been able to narrow their surgical practice to one joint, to one disease process, or even to one technique. The corollary is that as the number of hyperspecialized experts increases, the quality of the holistic approach towards musculoskeletal care diminishes. How this situation of increasing hyperspecialization will progress will depend on many issues touching on education, legal environment, and economics. Young surgeons training in academic centers are educated by teachers who themselves are highly specialized. These specialists serve not only as mentors but also as role models. It is likely that trainees will follow in the footsteps of their teachers. It is doubtful that this situation is likely to change soon given the structure and organization of most major teaching institutions. The legal environment plays a major role in the molding of surgical practice. In fact, the first question facing a surgeon entangled in a medicolegal issue is how competent he or she is in performing a given procedure. A diploma attesting to the completion of a general orthopaedic education is no longer sufficient to demonstrate competence. Today, proofs of fellowship training as well as the performance of the appropriate numbers of specialized interventions have become mandatory if the surgeon is to convince opposing parties that he or she is competent to safely and effectively perform a given operation. This vision of capability embodied by the high-volume surgeon specialist will undoubtedly persevere [2, 8]. Arguably, regional economics differentiate surgical practice in affluent constituencies from less-prosperous areas. Well-equipped regions with high-quality infrastructures allowing rapid travel to centers of highly specialized expertise will have a large range of hyperspecialized surgeons providing expertise in all the domains of orthopaedics and traumatology. For the individual patient, this could mean better care, fewer complications, and improved efficiency for a given procedure [8, 11]. Conversely, hyperspecialization will entail higher costs because of the increased number of specialists working in a technology-rich environment. For less-favored regions, one surgeon will have to tackle a broad spectrum of diseases, master many techniques, and be knowledgeable in many areas. He or she will have to deal with a variety of situations, but perhaps not as efficiently or complication-free for a given procedure as the hyperspecialized surgeon. Although a generalist approach might appear to be cheaper in the short-term, patients may not always benefit from the latest, safest, and most efficient techniques [2, 11]. Since it appears hyperspecialists are here to stay, solutions must be found. The obvious answer lies in education. All practitioners of orthopaedic surgery, regardless of specialization, must possess a broad base of knowledge in the musculoskeletal field. One should not confound technical and procedural skills with overall expertise and knowledge [13]. The education of surgical trainees and fellows needs to emphasize the necessity of a broad culture in terms of diseases and trauma of the musculoskeletal system regardless of the field of hyperspecialization. This knowledge should be controlled in the recertification process, specializing on the joint, technique, or disease in which the surgeon is focused as well as on his or her general level of knowledge in the broader field of orthopaedics and traumatology. Augusto Sarmiento MD Professor and Chairman Emeritus University of Miami Dr. Bernstein identifies several important issues concerning exaggerated subspecialization in medicine and does not hide his personal concerns regarding its uncontrolled explosion. However, his attempts to propose solutions to the problem do not match his clear exposure of the unhealthy consequences of failure to arrest the progression of the trend. His suggestions along this line are rather timid and sometimes even unrealistic, such as “asking orthopaedic surgeons to provide general emergency room coverage in their community.” This suggestion falls in shallow water even if the fear of litigation could be eliminated. Dr. Bernstein further suggests, “In addition, our leaders should educate young orthopaedic surgeons about specialization's hidden costs.” In this instance, who will educate the “leaders” who have been the ones primarily responsible for the creation and perpetuation of the problem? I commend CORR® for publishing this thoughtful article on a subject that needs a forceful and aggressive debate. However, in his column, Dr. Bernstein underestimates the fact that greed has crept into our profession to the point where many consider it as being primarily a profitable business. Unfortunately, greed is at the very essence of the subspecialization problem. The current situation will not be assuaged with warm compresses and a few aspirins. The entire issue of education of the physician must be brought to the frontline [14-16]. This is a golden opportunity for orthopaedics, as a major and instrumental profession, to provide leadership to a force that requires active input from a variety of disciplines within the medical establishment as well as from other social and political bodies. Harmful, exaggerated fragmentation of our discipline has allowed several traditional medical and paramedical professions to assume the care of musculoskeletal conditions, long a territory exclusively managed by the orthopaedist. For example, podiatrists and chiropractors have expanded the scope of their disciplines into orthopaedic territory, and more recently, nurse practitioners and physician assistants have claimed the right to provide care for conditions they consider themselves qualified to treat. If we cannot appropriately correct the already ridiculous degree of fragmentation in orthopaedics, the overall situation will continue to deteriorate to a degree that could seriously compromise the vitality of our profession. K. Daniel Riew MD Professor, Department of Orthopaedic Surgery Washington University in St. Louis Dr. Bernstein's article is an excellent summary of the benefits and risks of overspecialization. His arguments against specialization are all valid. I would add what Konrad Lorenz said about scientists, (even more appropriate for specialists): They “are people who know more and more about less and less, until they know everything about nothing” [5]. But as a hyperspecialist who specializes only in cervical spine, I have to respectfully disagree with the final message. In my opinion, not only is specialization inevitable, it is the correct path for science, education, and patient benefit. The history of medicine has demonstrated an inexorable path towards subspecialization. In The Evolution of Orthopaedic Surgery [9], author Leslie Klenerman tells us how orthopaedics became a specialty and seceded from general surgery: “It is little more than a generation since orthopaedic surgery began its astounding and near exponential ascent from relative obscurity under the dominance of general surgery to itself become a major influence.” But Klenerman notes that the forces are inexorably pushing the subspecialties away from orthopaedics: “How much longer will the interests of specialization within it, allow it to remain united before it too falls victim to the fragmentation that destroyed the supremacy of its erstwhile master?” The desire to subspecialize is driven by at least three factors. First, we live in a world of information overload. MEDLINE adds more than 5000 articles per weekday. Even if we assume that only 1% of these pertain to orthopaedics, it is nearly impossible for most busy physicians to stay current with all the articles. Would we want the next generation of surgeons to be trained by generalists who cannot keep up, or specialists, current with the literature in their area? Second, legally, general practitioners are held to the same standards as subspecialists. Therefore, if a generalist mismanages a cervical spine fracture, they will be held to the same standards as a cervical spine surgeon. Unless they are current with all aspects of cervical spine care, they are placing themselves at medicolegal risk. Third, in surgery, volume drives success, improves outcomes, shortens operative times, decreases complications, and improves efficiency. We are the cognoscenti when it comes to orthopaedic problems. Who among us would choose to have a delicate tumor removed from our dominant hand by a general orthopaedic surgeon, instead of a hyperspecialized hand surgeon who has great experience with such tumors? Knowing that the results would be highly likely to be better, would we not want the same for all of our family and friends? If we would want these for our loved ones, do our patients deserve any less? A generalist still serves a useful purpose and there are many downsides to everyone becoming a hyperspecialist. However, in my opinion, this is not an adequate reason to recommend that we remain a “jack of all trades and a master of none.”

Salvador Macip

No abstract is available for this record.