Disparities in access to surgery for glioblastoma multiforme at high-volume Commission on Cancer–accredited hospitals in the United States

OBJECTIVE Although it has been shown that surgery for glioblastoma (GBM) at high-volume facilities (HVFs) may be associated with better postoperative outcomes, the use of such hospitals may not be equally distributed. The authors aimed to evaluate racial and socioeconomic differences in access to surgery for GBM at high-volume Commission on Cancer (CoC)–accredited hospitals. METHODS The National Cancer Database was queried for patients with GBM that was newly diagnosed between 2004 and 2015. Patients who received no surgical intervention or those who received surgical intervention at a site other than the reporting facility were excluded. Annual surgical case volume was calculated for each hospital, with volume ≥ 90th percentile defined as an HVF. Multivariable logistic regression was performed to identify patient-level predictors for undergoing surgery at an HVF. Furthermore, multiple subgroup analyses were performed to determine the adjusted odds ratio of the likelihood of undergoing surgery at an HVF in 2016 as compared to 2004 for each patient subpopulation (by age, race, sex, educational group, etc.). RESULTS A total of 51,859 patients were included, with 10.7% (n = 5562) undergoing surgery at an HVF. On multivariable analysis, Hispanic White patients (OR 0.58, 95% CI 0.49–0.69, p < 0.001) were found to have significantly lower odds of undergoing surgery at an HVF (reference = non-Hispanic White). In addition, patients from a rural residential location (OR 0.55, 95% CI 0.41–0.72, p < 0.001; reference = metropolitan); patients with nonprivate insurance status (Medicare [OR 0.78, 95% CI 0.71–0.86, p < 0.001], Medicaid [OR 0.68, 95% CI 0.60–0.78, p < 0001], other government insurance [OR 0.68, 95% CI 0.52–0.86, p = 0.002], or who were uninsured [OR 0.61, 95% CI 0.51–0.72, p < 0.001]); and lower-income patients ($50,354–$63,332 [OR 0.68, 95% CI 0.63–0.74, p < 0.001], $40,227–$50,353 [OR 0.84, 95% CI 0.76–0.92, p < 0.001]; reference = ≥ $63,333) were also found to be significantly associated with a lower likelihood of surgery at an HVF. Subgroup analyses revealed that elderly patients (age ≥ 65 years), both male and female patients and non-Hispanic White patients, and those with private insurance, Medicare, metropolitan residential location, median zip code–level household income in the first and second quartiles, and educational attainment in the first and third quartiles had increased odds of undergoing surgery at an HVF in 2016 compared to 2004 (all p ≤ 0.05). On the other hand, patients with other governmental insurance, patients with a rural residence, and those from a non-White racial category did not show a significant difference in odds of surgery at an HVF over time (all p > 0.05). CONCLUSIONS The present analysis from the National Cancer Database revealed significant disparities in access to surgery at an HVF for GBM within the United States. Furthermore, there was evidence that these racial and socioeconomic disparities may have widened between 2004 and 2016. The findings should assist health policy makers in the development of strategies for improving access to HVFs for racially and socioeconomically disadvantaged populations.

Standards of Care

In the 1950s and early 1960s, Harry Benjamin and his colleague Elmer Belt corresponded at length about which transsexuals they would and would not approve for genital surgery. Benjamin defined transsexuality primarily through a desire for medical transition, but merely being a transsexual in this definition did not automatically result in surgical eligibility. Benjamin and Belt remained preoccupied with the possibility that transsexuals would regret their surgeries and seek legal or personal revenge, and thus their assessments of who should have surgery focused more on the possibility of a bad outcome than adherence to gender norms or classification as transsexual. The informal clinical practices they worked out to protect themselves in these early years of American trans medicine would ultimately go on to structure more formalized Standards of Care. Benjamin and Belt's fears, and their resulting decision-making processes, thus played a crucial role in the production of the category “transsexual.” Throughout their correspondence and clinical practice, the transsexual emerged as a threat to medical providers, and a subject incapable of making their own bodily decisions, needing to be protected from themselves. While assessments of gender identity and gendered behavior factored into these decisions, their decisions about who might regret transition treated gender as primarily practical and functional, and made an unshakable internal gender identity a necessary but insufficient criterion for granting a patient access to surgery.

EP.TU.44Improving Access to Surgery: The F1 ‘Theatre Day’ Programme

Aims To identify barriers in theatre attendance, facilitate access and maximise learning opportunities for surgical F1s (Foundation Year 1 Doctors) at a DGH (District General Hospital). Methods Between December 2019- December 2020, each F1 doctor was offered a day to spend in elective theatre during their General Surgery rotation (excluding emergency COVID rota periods). This was following feedback from the August- December 2019 cohort. Each ‘Theatre Day’ was scheduled during normal working hours when there was sufficient staff. Post-participation questionnaires were completed. Results Prior to implementation of the Programme, 3/8 F1s surveyed had not attended any elective surgery lists (1 had not attended theatre at all). All indicated that they would have been interested in attending a timetabled elective theatre day; 88% highlighted a ‘lack of staff’ and 63% indicated that ‘feeling guilty’ were barriers in attending theatre. 21 F1s were offered a ‘Theatre Day’: 17 agreed to participate and 16 completed post-participation questionnaires. Only 47% confirmed that they were considering a career in surgery prior to participation: all agreed that spending time in theatre was a useful learning opportunity and 94% agreed that the Programme should be continued. Conclusions Spending time in theatre appears to be valued as a useful learning opportunity for F1s, whether or not they are aspiring surgeons. Common barriers to self-organised theatre attendance appear to be an anticipated ‘lack of staff’ or feelings of ‘guilt’. A senior-led scheduling of one day in theatre should circumnavigate these barriers and ensure that access is available to all.

Access to paediatric surgery: the geography of inequality in Nigeria

BackgroundAbout 96.3 million children and adolescents aged 0–19 years reside in Nigeria, comprising 54% of the population. Without adequate access to surgery for commonly treatable diseases, many face disability and increased risk of mortality. Due to this population’s unique perioperative needs, increasing access to paediatric surgical care requires a situational evaluation of the distribution of paediatric surgeons and anaesthesiologists. This study’s aim is to identify the percentage of Nigerian youth who reside within 2 hours of paediatric surgical care at the state and national level.MethodsThe Association of Paediatric Surgeons of Nigeria and the Nigeria Society of Anaesthetists provided surgical and anaesthesia workforce data by state. Health facilities with paediatric surgeons were converted to point locations and integrated with ancillary geospatial layers and population estimates from 2016 and 2017. Catchment areas of 2 hours of travel time around a facility were deployed as the benchmark indicator to establish timely access.ResultsAcross Nigeria’s 36 states and Federal Capital Territory, the percentage of Nigeria’s 0–19 population residing within 2 hours of a health facility with a paediatric surgical and anaesthesia workforce ranges from less than 2% to 22.7%–30.5%. In 3 states, only 2.1%–4.8% of the population can access a facility within 2 hours, 12 have 4.9%–13.8%, and 8 have 13.9%–22.6%.ConclusionThere is significant variation across Nigerian states regarding access to surgical care, with 69.5%–98% of Nigeria’s 0–19 population lacking access. Developing paediatric surgical services in underserved Nigerian states and investing in the training of paediatric surgical and anaesthesia workforce for those states are key components in improving the health of Nigeria’s 0–19 population and reducing Nigeria’s burden of surgical disease, in line with Nigeria’s National Surgical, Obstetrics, Anaesthesia and Nursing Plan.

230 Acute Bowel Obstruction - Are We in The Loop?

Aim Acute bowel obstruction (ABO) is a common surgical emergency associated with high mortality and morbidity. The aim of this audit is to compare the quality of local management of ABO against recommendations set by the NCEPOD. Method A prospective audit of all patients presented with ABO over 8 weeks from February 2020 at a tertiary centre. Data was collected from electronic records. Results 34 patients were reviewed with a mean age of 69.8 years. 24 presented with small bowel obstruction and 10 with large bowel obstruction. 25 (73.5%) patients had a CT with IV contrast with a median time to scan of 5 hours. 25 (73.5%) patients were reviewed by consultants within 14 hours and 5/7 high-risk cases were discussed within an hour. Adequate pain control was achieved in 26 (76.5%) cases. All patients had BMI recorded and 29 (85.3%) had MUST score documented. 16/25 (64.0%) patients aged above 64 had their frailty score assessed and 11/25 (44.0%) received geriatrician input. 32 (94.1%) patients had their treatment plan discussed with them and family was informed in 19 (55.9%) cases. 19 (55.9%) patients underwent emergency operation and there was a delay in access to surgery in 7/19 (36.8%) cases. Morbidity and mortality risk was calculated in 3/19 (15.8%) cases. Conclusions This audit has highlighted numerous positive management measures but also the need for improved radiological resources, better emergency capacity planning and risk assessment. There needs to be a focus on predicting outcomes, especially in the elderly and setting limitations and expectations before surgery.

Barriers and potential solutions for improved surgical care for children with hernia in Eastern Uganda

Five billion people lack timely, affordable access to surgery. A large proportion of these are children. Qualitative research investigating the barriers to surgical care for children and ways of overcoming them is lacking. This study focused on children with hernia, a very common paediatric surgical condition for which surgery is the only effective treatment. The main aim of this qualitative study was to explore barriers to surgical care for children and identify potential solutions. Data were collected from parents of children with hernia and from health care providers at Soroti Regional Referral Hospital in eastern Uganda. Parents’ experiences, motives and barriers when accessing care were explored. The health care providers’ knowledge, perceptions and practices relating to children with hernia were investigated. The data were analysed using thematic content analysis. Traditional beliefs and gender inequality were considered major issues. Possible solutions included partnering with the local community in efforts to increase knowledge and acceptability in the community in general and by parents in particular. A formation of a surgical team dedicated to the management of children with surgical conditions was suggested as way to improve quality and increase volume of surgery for children.