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Seib CD, Wren SM. AI Imaging Analysis Needs Evaluation Before Implementation. JAMA Surg 2024:2817241. [PMID: 38598188 DOI: 10.1001/jamasurg.2024.0629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
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Wright K, Squires S, Cisco R, Trickey A, Kebebew E, Suh I, Seib CD. Disparities in access to high-volume parathyroid surgeons in the United States: A call to action. Surgery 2024; 175:48-56. [PMID: 37940435 PMCID: PMC10942749 DOI: 10.1016/j.surg.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/13/2023] [Accepted: 03/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Parathyroidectomy by a high-volume surgeon is associated with a reduced risk of perioperative complications and of failure to cure primary and secondary hyperparathyroidism. There are limited data on disparities in access to high-volume parathyroid surgeons in the United States. METHODS We used publicly available 2019 Medicare Provider Utilization and Payment data to identify all surgeons who performed >10 parathyroidectomies for Medicare fee-for-service beneficiaries, anticipating that fee-for-service beneficiaries likely represent only a subset of their high-volume practices. High-volume parathyroid surgeon characteristics and geographic distribution were evaluated. Inequality in the distribution of surgeons was measured by the Gini coefficient. The association between neighborhood disadvantage, based on the Area Deprivation Index, and proximity to high-volume parathyroid surgeons was evaluated using a one-way analysis of variance with Bonferroni-corrected pairwise comparisons. A sensitivity analysis was performed restricting to high-volume parathyroid surgeons within each hospital referral region, evidence-based regional markets for tertiary medical care. RESULTS We identified 445 high-volume parathyroid surgeons who met inclusion criteria with >10 parathyroidectomies for Medicare fee-for-service beneficiaries. High-volume parathyroid surgeons were 71% male sex, and 59.8% were general surgeons. High-volume parathyroid surgeons were more likely to practice in a Metropolitan Statistical Area with a population >1 million than in less populous metropolitan or rural areas. The number of high-volume parathyroid surgeons per 100,000 fee-for-service Medicare beneficiaries in the 53 most populous Metropolitan Statistical Areas ranged from 0 to 4.94, with the highest density identified in Salt Lake City, Utah. In 2019, 50% of parathyroidectomies performed by high-volume parathyroid surgeons were performed by 20% of surgeons in this group, suggesting unequal distribution of surgical care (Gini coefficient 0.41). Patients in disadvantaged neighborhoods were farther from high-volume parathyroid surgeons than those in advantaged neighborhoods (median distance: disadvantaged 27.8 miles, partially disadvantaged 20.7 miles, partially advantaged 12.1 miles, advantaged 8.4 miles; P < .001). This association was also shown in the analysis of distance to high-volume parathyroid surgeons within the hospital referral region (P < .001). CONCLUSION Older adults living in disadvantaged neighborhoods have less access to high-volume parathyroid surgeons, which may adversely affect treatment and outcomes for patients with primary and secondary hyperparathyroidism. This disparity highlights the need for actionable strategies to provide equitable access to care, including improved regionalization of high-volume parathyroid surgeon services and easing travel-related burdens for underserved patients.
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Affiliation(s)
- Kyla Wright
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Robin Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Amber Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA.
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Seib CD, Ganesan C, Tamura MK. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:eL230280. [PMID: 37983791 DOI: 10.7326/l23-0280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Division of General Surgery, Palo Alto Veterans Affairs Health Care System, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California
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Kim J, Seib CD. Operative Management of Thyroid Disease in Older Adults. J Endocr Soc 2023; 7:bvad070. [PMID: 37324534 PMCID: PMC10267953 DOI: 10.1210/jendso/bvad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Indexed: 06/17/2023] Open
Abstract
As the population ages, both domestically and globally, clinicians will increasingly find themselves navigating treatment decisions for thyroid disease in older adults. When considering surgical treatment, individualizing risk assessment is particularly important, as older patients can present with very different health profiles. While fit, independent individuals may benefit from thyroidectomy with minimal risk, those with multiple comorbidities and poor functional status are at higher risk of perioperative complications, which can have adverse health effects and detract from long-term quality of life. In order to optimize surgical outcomes for older adults, strategies for accurate risk assessment and mitigation are being explored. Surgical decision-making also should consider the characteristics of the thyroid disease being treated, given many benign thyroid disorders and some well-differentiated thyroid cancers can be appropriately managed nonoperatively without compromising longevity. Shared decision-making becomes increasingly important to respect the health priorities and optimize outcomes for older adults with thyroid disease. This review summarizes the current knowledge of thyroid surgery in older adults to help inform decision-making among patients and their physicians.
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Affiliation(s)
- Jina Kim
- Inova Schar Cancer Institute, Inova Health System, Fairfax, VA 22031, USA
| | - Carolyn D Seib
- Correspondence: Carolyn Dacey Seib, MD, MAS, Stanford University, 300 Pasteur Drive, H3680, Stanford, CA 94305, USA.
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Seib CD, Ganesan C, Furst A, Pao AC, Chertow GM, Leppert JT, Suh I, Montez-Rath ME, Harris AHS, Trickey AW, Kebebew E, Kurella Tamura M. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:624-631. [PMID: 37037034 PMCID: PMC10866201 DOI: 10.7326/m22-2222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function. OBJECTIVE To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management. DESIGN Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting. SETTING Veterans Health Administration. PATIENTS Patients with a new biochemical diagnosis of PHPT in 2000 to 2019. MEASUREMENTS Sustained decline of at least 50% from pretreatment eGFR. RESULTS Among 43 697 patients with PHPT (mean age, 66.8 years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9 years. The weighted cumulative incidence of eGFR decline was 5.1% at 5 years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60 years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60 years or older (HR, 1.08 [CI, 0.87 to 1.34]). LIMITATION Analyses were done in a predominantly male cohort using observational data. CONCLUSION Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine; Division of General Surgery, Palo Alto Veterans Affairs Health Care System; and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (C.D.S.)
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Adam Furst
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California (G.M.C.)
| | - John T Leppert
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York (I.S.)
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, and Center for Innovation to Implementation, Veterans Affairs Palo Alto, Palo Alto, California (A.H.S.H.)
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California (E.K.)
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (M.K.T.)
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Harris AHS, Trickey AW, Eddington HS, Seib CD, Kamal RN, Kuo AC, Ding Q, Giori NJ. A Tool to Estimate Risk of 30-day Mortality and Complications After Hip Fracture Surgery: Accurate Enough for Some but Not All Purposes? A Study From the ACS-NSQIP Database. Clin Orthop Relat Res 2022; 480:2335-2346. [PMID: 35901441 PMCID: PMC10538935 DOI: 10.1097/corr.0000000000002294] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 06/03/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical repair of hip fracture carries substantial short-term risks of mortality and complications. The risk-reward calculus for most patients with hip fractures favors surgical repair. However, some patients have low prefracture functioning, frailty, and/or very high risk of postoperative mortality, making the choice between surgical and nonsurgical management more difficult. The importance of high-quality informed consent and shared decision-making for frail patients with hip fracture has recently been demonstrated. A tool to accurately estimate patient-specific risks of surgery could improve these processes. QUESTIONS/PURPOSES With this study, we sought (1) to develop, validate, and estimate the overall accuracy (C-index) of risk prediction models for 30-day mortality and complications after hip fracture surgery; (2) to evaluate the accuracy (sensitivity, specificity, and false discovery rates) of risk prediction thresholds for identifying very high-risk patients; and (3) to implement the models in an accessible web calculator. METHODS In this comparative study, preoperative demographics, comorbidities, and preoperatively known operative variables were extracted for all 82,168 patients aged 18 years and older undergoing surgery for hip fracture in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2011 and 2017. Eighty-two percent (66,994 of 82,168 ) of patients were at least 70 years old, 21% (17,007 of 82,168 ) were at least 90 years old, 70% (57,260 of 82,168 ) were female, and 79% (65,301 of 82,168 ) were White. A total of 5% (4260 of 82,168) of patients died within 30 days of surgery, and 8% (6786 of 82,168) experienced a major complication. The ACS-NSQIP database was chosen for its clinically abstracted and reliable data from more than 600 hospitals on important surgical outcomes, as well as rich characterization of preoperative demographic and clinical predictors for demographically diverse patients. Using all the preoperative variables in the ACS-NSQIP dataset, least absolute shrinkage and selection operator (LASSO) logistic regression, a type of machine learning that selects variables to optimize accuracy and parsimony, was used to develop and validate models to predict two primary outcomes: 30-day postoperative mortality and any 30-day major complications. Major complications were defined by the occurrence of ACS-NSQIP complications including: on a ventilator longer than 48 hours, intraoperative or postoperative unplanned intubation, septic shock, deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, sepsis, intraoperative or postoperative myocardial infarction, intraoperative or postoperative cardiac arrest requiring cardiopulmonary resuscitation, acute renal failure needing dialysis, pulmonary embolism, stroke/cerebral vascular accident, and return to the operating room. Secondary outcomes were six clusters of complications recently developed and increasingly used for the development of surgical risk models, namely: (1) pulmonary complications, (2) infectious complications, (3) cardiac events, (4) renal complications, (5) venous thromboembolic events, and (6) neurological events. Tenfold cross-validation was used to assess overall model accuracy with C-indexes, a measure of how well models discriminate patients who experience an outcome from those who do not. Using the models, the predicted risk of outcomes for each patient were used to estimate the accuracy (sensitivity, specificity, and false discovery rates) of a wide range of predicted risk thresholds. We then implemented the prediction models into a web-accessible risk calculator. RESULTS The 30-day mortality and major complication models had good to fair discrimination (C-indexes of 0.76 and 0.64, respectively) and good calibration throughout the range of predicted risk. Thresholds of predicted risk to identify patients at very high risk of 30-day mortality had high specificity but also high false discovery rates. For example, a 30-day mortality predicted risk threshold of 15% resulted in 97% specificity, meaning 97% of patients who lived longer than 30 days were below that risk threshold. However, this threshold had a false discovery rate of 78%, meaning 78% of patients above that threshold survived longer than 30 days and might have benefitted from surgery. The tool is available here: https://s-spire-clintools.shinyapps.io/hip_deploy/ . CONCLUSION The models of mortality and complications we developed may be accurate enough for some uses, especially personalizing informed consent and shared decision-making with patient-specific risk estimates. However, the high false discovery rate suggests the models should not be used to restrict access to surgery for high-risk patients. Deciding which measures of accuracy to prioritize and what is "accurate enough" depends on the clinical question and use of the predictions. Discrimination and calibration are commonly used measures of overall model accuracy but may be poorly suited to certain clinical questions and applications. Clinically, overall accuracy may not be as important as knowing how accurate and useful specific values of predicted risk are for specific purposes.Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Alex H. S. Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA, USA
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA, USA
| | - Hyrum S. Eddington
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA, USA
| | - Carolyn D. Seib
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA, USA
| | - Robin N. Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Alfred C. Kuo
- San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA, USA
| | - Qian Ding
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, CA, USA
| | - Nicholas J. Giori
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Stoltz DJ, Liebert CA, Seib CD, Bruun A, Arnow KD, Barreto NB, Pratt JS, Eisenberg D. Preventive Health Screening in Veterans Undergoing Bariatric Surgery. Am J Prev Med 2022; 63:979-986. [PMID: 36100538 DOI: 10.1016/j.amepre.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/02/2022] [Accepted: 06/23/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Individuals with obesity are vulnerable to low rates of preventive health screening. Veterans with obesity seeking bariatric surgery are also hypothesized to have gaps in preventive health screening. Evaluation in a multidisciplinary bariatric surgery clinic is a point of interaction with the healthcare system that could facilitate improvements in screening. METHODS This is a retrospective cohort study of 381 consecutive patients undergoing bariatric surgery at a Veterans Affairs Hospital from January 2010 to October 2021. Age- and sex-appropriate health screening rates were determined at initial referral to a multidisciplinary bariatric surgery clinic and at the time of surgery. Rates of guideline concordance at both time points were compared using McNemar's test. Univariate and multivariate analyses were performed to identify the risk factors for nonconcordance. RESULTS Concordance with all recommended screening was low at initial referral and significantly improved by time of surgery (39.1%‒63.8%; p<0.001). Screening rates significantly improved for HIV (p<0.001), cervical cancer (p=0.03), and colon cancer (p<0.001). Increases in BMI (p=0.005) and the number of indicated screening tests (p=0.029) were associated with reduced odds of concordance at initial referral. Smoking history (p=0.012) and increasing distance to the nearest Veterans Affairs Medical Center (p=0.039) were associated with reduced odds of change from nonconcordance at initial referral to concordance at the time of surgery. CONCLUSIONS Rates of preventive health screening in Veterans with obesity are low. A multidisciplinary bariatric surgery clinic is an opportunity to improve preventive health screening in Veterans referred for bariatric surgery.
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Affiliation(s)
- Daniel J Stoltz
- Department of Surgery, Stanford University School of Medicine, Stanford, California.
| | - Cara A Liebert
- Department of Surgery, Stanford University School of Medicine, Stanford, California; Surgical Services, VA Palo Alto Health Care System, Palo Alto, California
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Stanford, California; Surgical Services, VA Palo Alto Health Care System, Palo Alto, California; Stanford-Surgery Policy Improvement Research Education (S-SPIRE) Center, Stanford, California
| | - Aida Bruun
- Surgical Services, VA Palo Alto Health Care System, Palo Alto, California
| | - Katherine D Arnow
- Stanford-Surgery Policy Improvement Research Education (S-SPIRE) Center, Stanford, California
| | - Nicolas B Barreto
- Stanford-Surgery Policy Improvement Research Education (S-SPIRE) Center, Stanford, California
| | - Janey S Pratt
- Department of Surgery, Stanford University School of Medicine, Stanford, California; Surgical Services, VA Palo Alto Health Care System, Palo Alto, California
| | - Dan Eisenberg
- Department of Surgery, Stanford University School of Medicine, Stanford, California; Surgical Services, VA Palo Alto Health Care System, Palo Alto, California; Stanford-Surgery Policy Improvement Research Education (S-SPIRE) Center, Stanford, California
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Seib CD, Ganesan C, Arnow KD, Pao AC, Leppert JT, Barreto NB, Kebebew E, Kurella Tamura M. Kidney Stone Events Following Parathyroidectomy vs Nonoperative Management for Primary Hyperparathyroidism. J Clin Endocrinol Metab 2022; 107:e2801-e2811. [PMID: 35363858 PMCID: PMC9202696 DOI: 10.1210/clinem/dgac193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary hyperparathyroidism (PHPT) is associated with an increased risk of kidney stones. Few studies account for PHPT severity or stone risk when comparing stone events after parathyroidectomy vs nonoperative management. OBJECTIVE Compare the incidence of kidney stone events in PHPT patients treated with parathyroidectomy vs nonoperative management. DESIGN Longitudinal cohort study with propensity score inverse probability weighting and multivariable Cox proportional hazards regression. SETTING Veterans Health Administration integrated health care system. PATIENTS A total of 44 978 patients with > 2 years follow-up after PHPT diagnosis (2000-2018); 5244 patients (11.7%) were treated with parathyroidectomy. MAIN OUTCOMES MEASURE Clinically significant kidney stone event. RESULTS The cohort had a mean age of 66.0 years, was 87.8% male, and 66.4% White. Patients treated with parathyroidectomy had higher mean serum calcium (11.2 vs 10.8mg/dL) and were more likely to have a history of kidney stone events. Among patients with baseline history of kidney stones, the unadjusted incidence of ≥ 1 kidney stone event was 30.5% in patients managed with parathyroidectomy (mean follow-up, 5.6 years) compared with 18.0% in those managed nonoperatively (mean follow-up, 5.0 years). Patients treated with parathyroidectomy had a higher adjusted hazard of recurrent kidney stone events (hazard ratio [HR], 1.98; 95% CI, 1.56-2.51); however, this association declined over time (parathyroidectomy × time: HR, 0.80; 95% CI, 0.73-0.87). CONCLUSION In this predominantly male cohort with PHPT, patients treated with parathyroidectomy continued to be at higher risk of kidney stone events in the immediate years after treatment than patients managed nonoperatively, although the adjusted risk of stone events declined with time, suggesting a benefit to surgical treatment.
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Affiliation(s)
- Carolyn D Seib
- Correspondence: Carolyn Dacey Seib, MD, MAS, Stanford University, 300 Pasteur Dr, H3680, Stanford, CA 94305, USA.
| | - Calyani Ganesan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Katherine D Arnow
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Alan C Pao
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - John T Leppert
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Nicolas B Barreto
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, CA 94304, USA
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
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Alobuia WM, Meng T, Cisco RM, Lin DT, Suh I, Tamura MK, Trickey AW, Kebebew E, Seib CD. Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims. Surgery 2022; 171:8-16. [PMID: 34229901 PMCID: PMC8688157 DOI: 10.1016/j.surg.2021.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/16/2021] [Accepted: 05/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored. METHODS Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models. RESULTS Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95% confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy. CONCLUSION Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.
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Affiliation(s)
- Wilson M. Alobuia
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Robin M. Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Dana T. Lin
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Insoo Suh
- Division of Endocrine Surgery, NYU Langone Health, New York, NY
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, CA.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Carolyn D. Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA
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10
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Seib CD, Meng T, Suh I, Harris AHS, Covinsky KE, Shoback DM, Trickey AW, Kebebew E, Tamura MK. Risk of Fracture Among Older Adults With Primary Hyperparathyroidism Receiving Parathyroidectomy vs Nonoperative Management. JAMA Intern Med 2022; 182:10-18. [PMID: 34842909 PMCID: PMC8630642 DOI: 10.1001/jamainternmed.2021.6437] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Primary hyperparathyroidism (PHPT) contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing fracture risk in older adults is unknown. OBJECTIVE To compare the incidence of clinical fracture among older adults with PHPT treated with parathyroidectomy vs nonoperative management. DESIGN, SETTING, AND PARTICIPANTS This was a population-based, longitudinal cohort study of all Medicare beneficiaries with PHPT from 2006 to 2017. Multivariable, inverse probability weighted Cox proportional hazards and Fine-Gray competing risk regression models were constructed to determine the association of parathyroidectomy vs nonoperative management with incident fracture. Data analysis was conducted from February 17, 2021, to September 14, 2021. MAIN OUTCOMES AND MEASURES The primary outcome was clinical fracture at any anatomic site not associated with major trauma during the follow-up period. RESULTS Among the 210 206 Medicare beneficiaries with PHPT (mean [SD] age, 75 [6.8] years; 165 637 [78.8%] women; 183 433 [87.3%] White individuals), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis, and 147 070 (70.0%) were managed nonoperatively. During a mean (SD) follow-up period of 58.5 (35.5) months, the unadjusted incidence of fracture was 10.2% in patients treated with parathyroidectomy. During a mean (SD) follow-up of 52.5 (33.8) months, the unadjusted incidence of fracture was 13.7% in patients observed nonoperatively. On multivariable analysis, parathyroidectomy was associated with lower adjusted rates of any fracture (hazard ratio [HR], 0.78; 95% CI, 0.76-0.80]) and hip fracture (HR, 0.76; 95% CI, 0.72-0.79). At 2, 5, and 10 years, parathyroidectomy was associated with adjusted absolute fracture risk reduction of 1.2% (95% CI, 1.0-1.4), 2.8% (95% CI, 2.5-3.1), and 5.1% (95% CI, 4.6-5.5), respectively, compared with nonoperative management. On subgroup analysis, there were no significant differences in the association of parathyroidectomy with fracture risk by age group, sex, frailty, history of osteoporosis, or meeting operative guidelines. Fine-Gray competing risk regression confirmed parathyroidectomy was associated with a lower probability of any fracture and hip fracture when accounting for the competing risk of death (HR, 0.84; 95% CI, 0.82-0.85; and HR, 0.83; 95% CI, 0.80-0.85, respectively). CONCLUSIONS AND RELEVANCE This longitudinal cohort study found that parathyroidectomy was associated with a lower risk of any fracture and hip fracture among older adults with PHPT, suggesting a clinically meaningful benefit of operative management in this population.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California.,Geriatric Research, Education and Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | | | - Dolores M Shoback
- Endocrine Research Unit, Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Stanford, California
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11
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Graves CE, Hope TA, Kim J, Pampaloni MH, Kluijfhout W, Seib CD, Gosnell JE, Shen WT, Roman SA, Sosa JA, Duh QY, Suh I. Superior sensitivity of 18F-fluorocholine: PET localization in primary hyperparathyroidism. Surgery 2021; 171:47-54. [PMID: 34301418 DOI: 10.1016/j.surg.2021.05.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Preoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of 18F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism. METHODS Patients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous 18F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of 18F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard. RESULTS In 101 patients, 18F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. 18F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of 18F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%). CONCLUSION Long-term results in the first cohort in the United States to use 18F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.
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Affiliation(s)
- Claire E Graves
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, University of California Davis, Sacramento, CA, USA. https://twitter.com/clairegravesmd
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/thomashopemd
| | - Jina Kim
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, Inova Schar Cancer Institute, Fairfax, VA, USA
| | - Miguel H Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Wouter Kluijfhout
- Department of Surgery, University of Utrecht, Utrecht, The Netherlands
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Stanford, CA, USA. https://twitter.com/daceyseib
| | - Jessica E Gosnell
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Wen T Shen
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/wshen16
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/pheosurgeon
| | - Julie A Sosa
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/jasosamd
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/endosurgsf
| | - Insoo Suh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, NYU Langone Health, New York, NY, USA.
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12
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Seib CD, Suh I, Meng T, Trickey A, Smith AK, Finlayson E, Covinsky KE, Kurella Tamura M, Kebebew E. Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism. JAMA Surg 2021; 156:334-342. [PMID: 33404646 DOI: 10.1001/jamasurg.2020.6175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown. Objective To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults. Design, Setting, and Participants This population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020. Main Outcomes and Measures The primary outcome was parathyroidectomy within 1 year of diagnosis. Results Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n = 131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P < .001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]). Conclusions and Relevance In this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions. Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California.,Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California.,Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Amber Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California
| | | | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
| | | | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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13
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Ganesan C, Weia B, Thomas IC, Song S, Velaer K, Seib CD, Conti S, Elliott C, Chertow GM, Kurella Tamura M, Leppert JT, Pao AC. Analysis of Primary Hyperparathyroidism Screening Among US Veterans With Kidney Stones. JAMA Surg 2021; 155:861-868. [PMID: 32725208 DOI: 10.1001/jamasurg.2020.2423] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Approximately 3% to 5% of patients with kidney stones have primary hyperparathyroidism (PHPT), a treatable cause of recurrent stones. However, the rate of screening for PHPT in patients with kidney stones remains unknown. Objectives To estimate the prevalence of parathyroid hormone (PTH) testing in veterans with kidney stones and hypercalcemia and to identify the demographic, geographic, and clinical characteristics of veterans who were more or less likely to receive PTH testing. Design, Setting, and Participants This cohort study obtained Veterans Health Administration (VHA) health records from the Corporate Data Warehouse for veterans who received care in 1 of the 130 VHA facilities across the United States from January 1, 2008, through December 31, 2013. Historical encounters, medical codes, and laboratory data were assessed. Included patients had diagnostic or procedural codes for kidney or ureteral stones, and excluded patients were those with a previous serum PTH level measurement. Data were collected from January 1, 2006, to December 31, 2014. Data analysis was conducted from June 1, 2019, to January 31, 2020. Exposures Elevated serum calcium concentration measurement between 6 months before and 6 months after kidney stone diagnosis. Main Outcomes and Measures Proportion of patients with a serum PTH level measurement and proportion of patients with biochemical evidence of PHPT who underwent parathyroidectomy. Results The final cohort comprised 7561 patients with kidney stones and hypercalcemia and a mean (SD) age of 64.3 (12.3) years. Of these patients, 7139 were men (94.4%) and 5673 were white individuals (75.0%). The proportion of patients who completed a serum PTH level measurement was 24.8% (1873 of 7561). Across the 130 VHA facilities included in the study, testing rates ranged from 4% to 57%. The factors associated with PTH testing included the magnitude of calcium concentration elevation (odds ratio [OR], 1.07 per 0.1 mg/dL >10.5 mg/dL; 95% CI, 1.05-1.08) and the number of elevated serum calcium concentration measurements (OR, 1.08 per measurement >10.5 mg/dL; 95% CI, 1.06-1.10) as well as visits to both a nephrologist and a urologist (OR, 6.57; 95% CI, 5.33-8.10) or an endocrinologist (OR, 4.93; 95% CI, 4.11-5.93). Of the 717 patients with biochemical evidence of PHPT, 189 (26.4%) underwent parathyroidectomy within 2 years of a stone diagnosis. Conclusions and Relevance This cohort study found that only 1 in 4 patients with kidney stones and hypercalcemia were tested for PHPT in VHA facilities and that testing rates varied widely across these facilities. These findings suggest that raising clinician awareness to PHPT screening indications may improve evaluation for parathyroidectomy, increase the rates of detection and treatment of PHPT, and decrease recurrent kidney stone disease.
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Affiliation(s)
- Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Benjamin Weia
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - I-Chun Thomas
- Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Shen Song
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kyla Velaer
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Simon Conti
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Chris Elliott
- Department of Urology, Santa Clara Valley Medical Center, San Jose, California
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - John T Leppert
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Urology, Stanford University School of Medicine, Palo Alto, California
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14
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Seib CD, Meng T, Suh I, Cisco RM, Lin DT, Morris AM, Trickey AW, Kebebew E. Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines. Surgery 2021; 169:87-93. [PMID: 32654861 PMCID: PMC7736152 DOI: 10.1016/j.surg.2020.04.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/29/2020] [Accepted: 04/29/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings. METHODS We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy. RESULTS Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]). CONCLUSION The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, CA.
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Emergency Medicine, Stanford University School of Medicine, CA
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco, CA
| | - Robin M Cisco
- Department of Surgery, Stanford University School of Medicine, CA
| | - Dana T Lin
- Department of Surgery, Stanford University School of Medicine, CA
| | - Arden M Morris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, CA
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15
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Seib CD, Roose JP, Hubbard AE, Suh I. Ensemble machine learning for the prediction of patient-level outcomes following thyroidectomy. Am J Surg 2020; 222:347-353. [PMID: 33339618 DOI: 10.1016/j.amjsurg.2020.11.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/17/2020] [Accepted: 11/25/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Accurate prediction of thyroidectomy complications is necessary to inform treatment decisions. Ensemble machine learning provides one approach to improve prediction. METHODS We applied the Super Learner (SL) algorithm to the 2016-2018 thyroidectomy-specific NSQIP database to predict complications following thyroidectomy. Cross-validation was used to assess model discrimination and precision. RESULTS For the 17,987 patients undergoing thyroidectomy, rates of recurrent laryngeal nerve injury, post-operative hypocalcemia prior to discharge or within 30 days, and neck hematoma were 6.1%, 6.4%, 9.0%, and 1.8%, respectively. SL improved prediction of thyroidectomy-specific outcomes when compared with benchmark logistic regression approaches. For postoperative hypocalcemia prior to discharge, SL improved the cross-validated AUROC to 0.72 (95%CI 0.70-0.74) compared to 0.70 (95%CI 0.68-0.72; p < 0.001) when using a manually curated logistic regression algorithm. CONCLUSION Ensemble machine learning modestly improves prediction for thyroidectomy-specific outcomes. SL holds promise to provide more accurate patient-level risk prediction to inform treatment decisions.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, United States.
| | - James P Roose
- University of California, Berkeley, Division of Biostatistics, Berkeley, United States
| | - Alan E Hubbard
- University of California, Berkeley, Division of Biostatistics, Berkeley, United States
| | - Insoo Suh
- University of California, San Francisco, Section of Endocrine Surgery, San Francisco, United States
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16
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Kwan SY, Lancaster E, Dixit A, Inglis-Arkell C, Manuel S, Suh I, Shen WT, Seib CD. Reducing Opioid Use in Endocrine Surgery Through Patient Education and Provider Prescribing Patterns. J Surg Res 2020; 256:303-310. [PMID: 32712445 PMCID: PMC7855097 DOI: 10.1016/j.jss.2020.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/31/2020] [Accepted: 06/16/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Postoperative opioid use can lead to dependence, contributing to the opioid epidemic in the United States. New persistent opioid use after minor surgeries occurs in 5.9% of patients. With increased documentation of persistent opioid use postoperatively, surgeons must pursue interventions to reduce opioid use perioperatively. METHODS We performed a prospective cohort study to assess the feasibility of a preoperative intervention via patient education or counseling and changes in provider prescribing patterns to reduce postoperative opioid use. We included adult patients undergoing thyroidectomy and parathyroidectomy from January 22, 2019 to February 28, 2019 at a tertiary referral, academic endocrine surgery practice. Surveys were administered to assess pain and patient satisfaction postoperatively. Prescription, demographic, and comorbidity data were collected from the electronic health record. RESULTS Sixty six patients (74.2% women, mean age 58.6 [SD 14.9] y) underwent thyroidectomy (n = 35), parathyroidectomy (n = 24), and other cervical endocrine operations (n = 7). All patients received a preoperative educational intervention in the form of a paper handout. 90.9% of patients were discharged with prescriptions for nonopioid pain medications, and 7.6% were given an opioid prescription on discharge. Among those who received an opioid prescription, the median quantity of opioids prescribed was 135 (IQR 120-150) oral morphine equivalents. On survey, four patients (6.1%) reported any postoperative opioid use, and 94.6% of patients expressed satisfaction with their preoperative education and postoperative pain management. CONCLUSIONS Clear and standardized education regarding postoperative pain management is feasible and associated with high patient satisfaction. Initiation of such education may support efforts to minimize unnecessary opioid prescriptions in the population undergoing endocrine surgery.
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Affiliation(s)
- Stephanie Y. Kwan
- University of California- San Francisco, School of Medicine, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Elizabeth Lancaster
- University of California- San Francisco, Department of Surgery, 513 Parnassus Ave, Room S-321, San Francisco, CA, USA 94143
| | - Anjali Dixit
- University of California- San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Christina Inglis-Arkell
- University of California- San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Solmaz Manuel
- University of California- San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Insoo Suh
- University of California- San Francisco, Department of Surgery, Section of Endocrine Surgery, 1600 Divisadero St, 4 Floor, San Francisco, CA, USA 94115
| | - Wen T. Shen
- University of California- San Francisco, Department of Surgery, Section of Endocrine Surgery, 1600 Divisadero St, 4 Floor, San Francisco, CA, USA 94115
| | - Carolyn D. Seib
- Stanford University, Department of Surgery, 300 Pasteur Drive, H3680, Stanford, CA 94305
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17
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Seib CD, Arya S. Postoperative Function as a Measure of Quality in Geriatric Surgical Care-Can We Do Better? JAMA Surg 2020; 155:958-959. [PMID: 32822480 DOI: 10.1001/jamasurg.2020.2863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Division of General Surgery, VA Palo Alto Health Care System, Palo Alto, California
| | - Shipra Arya
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Division of Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, California
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18
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Sukpanich R, Sanglestsawai S, Seib CD, Gosnell JE, Shen WT, Roman SA, Sosa JA, Duh QY, Suh I. The Influence of Cosmetic Concerns on Patient Preferences for Approaches to Thyroid Lobectomy: A Discrete Choice Experiment. Thyroid 2020; 30:1306-1313. [PMID: 32204688 DOI: 10.1089/thy.2019.0821] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Newer transoral thyroidectomy techniques that aim to avoid scars in the neck and maximize cosmetic outcomes have become more prevalent. We conducted a discrete choice experiment (DCE) to evaluate the influence of cosmetic concerns and other factors on patients' decision-making processes when choosing among different thyroidectomy approaches. Methods: A questionnaire was developed to identify key attributes driving patient preferences around thyroidectomy approaches using mixed analyses of patient focus groups, expert opinion, and literature review. These attributes included (i) risk of recurrent laryngeal nerve (RLN) injury, (ii) risk of mental nerve injury, (iii) travel distance for surgery, (iv) out-of-pocket cost, and (v) incision site. Using fractional factorial design, discrete choice sets consisting of randomly generated hypothetical scenarios across all attributes were created. A face-to-face DCE survey was administered to patients being evaluated in clinic for thyroid lobectomy for noncancerous thyroid disease. Participants chose among scenarios constructed from the choice sets of attributes. Analyses were conducted using a mixed logit model, and the trade-offs between different attributes that patients were willing to accept were quantified. Results: The DCE was completed by 109 participants (86 [79%] women; mean age 51.3 ± 3.0 years). Overall, the risk of having RLN and/or mental nerve injury, travel distance, and cost were the most influential attributes. Participants aged ≤60 years significantly preferred an approach without a neck incision and were willing to accept an additional $2332 USD in out-of-pocket cost, 693 miles of travel distance, 0.6% increased risk of RLN injury, and 2.2% risk of mental nerve injury. Patients aged >60 years significantly preferred a conventional neck incision and were willing to pay an additional $3401 out-of-pocket and travel 1011 miles to avoid a scarless approach. Conclusions: The risk of nerve injury, travel distance, and cost were the most important drivers for patients choosing among surgical approaches for thyroidectomy. Cosmetic considerations also influenced patient choices, but in opposing ways depending on patient age.
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Affiliation(s)
- Rupporn Sukpanich
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of General Surgery, Rajavithi Hospital, Rangsit University, Bangkok, Thailand
| | - Santi Sanglestsawai
- Department of Agricultural and Resource Economics, Kasetsart University, Bangkok, Thailand
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Jessica E Gosnell
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Wen T Shen
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sanziana A Roman
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Julie A Sosa
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Quan-Yang Duh
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Insoo Suh
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
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Lancaster E, Inglis-Arkell C, Hirose K, Seib CD, Wick E, Sosa JA, Duh QY. Variability in Opioid-Prescribing Patterns in Endocrine Surgery and Discordance With Patient Use. JAMA Surg 2020; 154:1069-1070. [PMID: 31411647 DOI: 10.1001/jamasurg.2019.2518] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Christina Inglis-Arkell
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco
| | - Kenzo Hirose
- Department of Surgery, University of California, San Francisco
| | - Carolyn D Seib
- Department of Surgery, University of California, San Francisco
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
| | - Julie A Sosa
- Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
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Ramirez JL, Gasper WJ, Seib CD, Finlayson E, Conte MS, Sosa JA, Iannuzzi JC. Patient complexity by surgical specialty does not correlate with work relative value units. Surgery 2020; 168:371-378. [PMID: 32336468 DOI: 10.1016/j.surg.2020.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/23/2020] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units. STUDY DESIGN The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units. RESULTS Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units. CONCLUSION Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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Affiliation(s)
- Carolyn D. Seib
- Department of Surgery, Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California
- Divisions of General Surgery, Stanford University School of Medicine, Stanford, California
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Address correspondence to: Carolyn D. Seib, MD, MAS, Department of Surgery, Stanford University, 300 Pasteur Drive, H3680, Stanford, CA 94305
| | - Julie Chen
- Divisions of Endocrinology, Gerontology and Metabolism, Stanford University School of Medicine, Stanford, California
| | - Andrei Iagaru
- Divisions of Nuclear Medicine and Molecular Imaging, Stanford University School of Medicine, Stanford, California
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Suh I, Viscardi C, Chen Y, Nwaogu I, Sukpanich R, Gosnell JE, Shen WT, Seib CD, Duh QY. Technical Innovation in Transoral Endoscopic Endocrine Surgery: A Modified “Scarless” Technique. J Surg Res 2019; 243:123-129. [DOI: 10.1016/j.jss.2019.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/27/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
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Affiliation(s)
- Jamie E Anderson
- Department of Surgery, University of California Davis Medical Center, Sacramento
| | - Carolyn D Seib
- Department of Surgery, University of California San Francisco Medical Center, San Francisco
| | - Michael J Campbell
- Department of Surgery, University of California Davis Medical Center, Sacramento
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Ramirez JL, Gasper WJ, Seib CD, Finlayson E, Conte MS, Sosa JA, Iannuzzi JC. Patient Complexity Varies by Surgical Specialty and Does Not Strongly Correlate with Work Relative Value Units. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Seib CD, Rochefort H, Chomsky-Higgins K, Gosnell JE, Suh I, Shen WT, Duh QY, Finlayson E. Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations. JAMA Surg 2019; 153:160-168. [PMID: 29049457 DOI: 10.1001/jamasurg.2017.4007] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established. Objective To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations. Design, Setting, and Participants A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017. Main Outcomes and Measures The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes. Results A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001). Conclusions and Relevance Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco
| | - Holly Rochefort
- Department of Surgery, University of California, San Francisco
| | | | | | - Insoo Suh
- Department of Surgery, University of California, San Francisco
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
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Seib CD, Chomsky-Higgins K, Gosnell JE, Shen WT, Suh I, Duh QY, Finlayson E. Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism. World J Surg 2018; 42:3215-3222. [PMID: 29696330 DOI: 10.1007/s00268-018-4629-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is a common endocrine disorder that predominantly affects patients >60 and is increasing in prevalence. Identifying risk factors for poor outcomes after parathyroidectomy in older adults will help tailor operative decision making. The impact of frailty on surgical outcomes in parathyroidectomy has not been established. METHODS We performed a retrospective review of patients ≥40 years who underwent parathyroidectomy in the 2005-2010 ACS NSQIP. Frailty was assessed using the modified frailty index (mFI). Multivariable regression was used to determine the association of frailty with 30-day complications, length of stay (LOS), and reoperation. RESULTS We identified 13,123 patients ≥40 who underwent parathyroidectomy for PHPT. The majority of patients were not frail, with 80% with a low NSQIP mFI score (0-1 frailty traits), 19% with an intermediate mFI score (2-3), and 0.9% with a high mFI score (≥4). Overall 30-day complications were rare, occurring in 141 (1.1%) patients. Increasing frailty was associated with an increased risk of complications with adjusted odds ratios (ORs) of 1.76 (95% CI 1.20-2.59; p = 0.004) for intermediate and 8.43 (95% CI 4.33-16.41; p < 0.001) for high mFI score. Patient age was independently associated with an increased risk of complications only when ≥75, as was African-American race. Anesthesia with local, monitored anesthesia care, or regional block was the only factor associated with decreased odds of complications. A high NSQIP mFI was also associated with a significant 4.77-day adjusted increase in LOS (95% CI 4.28-5.25; p < 0.001) and increased odds of reoperation (OR 4.20, 95% CI 1.64-10.74; p = 0.003). CONCLUSION Patient frailty is associated with increased complications, reoperation and prolonged LOS in patients undergoing parathyroidectomy for PHPT. The risks of surgical management should be weighed against potential benefits in frail patients with PHPT to individualize treatment decisions in this vulnerable population.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA.
| | - Kathryn Chomsky-Higgins
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Jessica E Gosnell
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
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Chen Y, Chomsky-Higgins K, Nwaogu I, Seib CD, Gosnell JE, Shen WT, Duh QY, Suh I. Hidden in Plain Sight: Transoral and Submental Thyroidectomy as a Compelling Alternative to “Scarless” Thyroidectomy. J Laparoendosc Adv Surg Tech A 2018; 28:1374-1377. [DOI: 10.1089/lap.2018.0146] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yufei Chen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Kathryn Chomsky-Higgins
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | | | - Carolyn D. Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Jessica E. Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Wen T. Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
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Nwaogu I, Sedaghati M, Sukpanich R, Chomsky-Higgins KH, Chen Y, Seib CD, Suh I, Shen WT, Gosnell JE, Duh QY. Parathyroid Cryopreservation: Clinical Applications in the Era of Synthetic Parathyroid Hormone. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chen Y, Nwaogu I, Chomsky-Higgins KH, Seib CD, Gosnell JE, Shen WT, Duh QY, Suh I. Postoperative Pain and Opioid Use after Thyroid and Parathyroid Surgery: A Novel, Prospective Short Messaging Service-Based Survey. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chen Y, Chomsky-Higgins KH, Nwaogu I, Seib CD, Gosnell JE, Shen WT, Duh QY, Suh I. Transoral and Submental Thyroidectomy. VideoEndocrinology 2018. [DOI: 10.1089/ve.2018.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yufei Chen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Kathryn H. Chomsky-Higgins
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Iheoma Nwaogu
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Carolyn D. Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Jessica E. Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Wen T. Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Insoo Suh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
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Chomsky-Higgins KH, Chen Y, Nwaogu I, Gosnell JE, Seib CD, Shen WT, Suh I, Duh QY. Blue Dye Injection Technique for Resection of Nodal Recurrence in Thyroid Cancer. VideoEndocrinology 2018. [DOI: 10.1089/ve.2018.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kathryn H. Chomsky-Higgins
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
- Department of Surgery, University of California, East Bay, Oakland, California
| | - Yufei Chen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Iheoma Nwaogu
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Jessica E. Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Carolyn D. Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Wen T. Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Insoo Suh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
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Pasternak JD, Seib CD, Seiser N, Tyrell JB, Liu C, Cisco RM, Gosnell JE, Shen WT, Suh I, Duh QY. Differences Between Bilateral Adrenal Incidentalomas and Unilateral Lesions. JAMA Surg 2016. [PMID: 26200882 DOI: 10.1001/jamasurg.2015.1683] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adrenal incidentalomas are found in 1% to 5% of abdominal cross-sectional imaging studies. Although the workup and management of unilateral lesions are well established, limited information exists for bilateral incidentalomas. OBJECTIVE To compare the natural history of patients having bilateral incidentalomas with those having unilateral incidentalomas. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of a prospective database of consecutive patients referred to an academic multidisciplinary adrenal conference. The setting was a tertiary care university hospital among a cohort of 500 patients with adrenal lesions between July 1, 2009, and July 1, 2014. MAIN OUTCOMES AND MEASURES Prevalence, age, imaging characteristics, biochemical workup, any intervention, and final diagnosis. RESULTS Twenty-three patients with bilateral incidentalomas and 112 patients with unilateral incidentalomas were identified. The mean age at diagnosis of bilateral lesions was 58.7 years. The mean lesion size was 2.4 cm on the right side and 2.8 cm on the left side. Bilateral incidentalomas were associated with a significantly higher prevalence of subclinical Cushing syndrome (21.7% [5 of 23] vs 6.2% [7 of 112]) (P = .009) and a significantly lower prevalence of pheochromocytoma (4.3% [1 of 23] vs 19.6% [22 of 112]) (P = .003) compared with unilateral lesions, while rates of hyperaldosteronism were similar in both groups (4.3% [1 of 23] vs 5.4% [6 of 112]) (P > .99). Only one patient with bilateral incidentalomas underwent unilateral resection. The mean follow-up was 4 years (range, 1.2-13.0 years). There were no occult adrenocortical carcinomas. CONCLUSIONS AND RELEVANCE Bilateral incidentalomas are more likely to be associated with subclinical Cushing syndrome and less likely to be pheochromocytomas. Although patients with bilateral incidentalomas undergo a workup similar to that in patients with unilateral lesions, differences in their natural history warrant a greater index of suspicion for subclinical Cushing syndrome.
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Affiliation(s)
- Jesse D Pasternak
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Carolyn D Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Natalie Seiser
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - J Blake Tyrell
- Division of Endocrinology, Department of Medicine, University of California, San Francisco
| | - Chienying Liu
- Division of Endocrinology, Department of Medicine, University of California, San Francisco
| | - Robin M Cisco
- Department of Surgery, Good Samaritan Hospital, San Jose, California
| | - Jessica E Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Wen T Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Insoo Suh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
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Campbell MJ, Seib CD, Candell L, Gosnell JE, Duh QY, Clark OH, Shen WT. The underestimated risk of cancer in patients with multinodular goiters after a benign fine needle aspiration. World J Surg 2015; 39:695-700. [PMID: 25446471 DOI: 10.1007/s00268-014-2854-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
IMPORTANCE Ultrasound-guided fine needle aspiration (FNA) is an excellent tool for evaluating patients with solitary thyroid nodules, with a false-negative malignancy rate of <3%. The utility of FNA in patients with a cervical multinodular goiter (MNG) is unknown, because biopsy and surveillance of thyroids with numerous nodules may be impractical. OBJECTIVE To evaluate the incidence and risk factors for unsuspected thyroid cancer on final pathology in patients with a non-functional, cervical MNG who had a benign preoperative FNA and underwent thyroidectomy. DESIGN, SETTING AND PARTICIPANTS Retrospective review of patients with non-functional, cervical MNG at a high-volume tertiary referral center between 2005 and 2012. MAIN OUTCOME MEASURE(S) Incidence of thyroid cancer on surgical pathology. RESULTS Of the 134 patients included in the study, 31 (23.1%) were found to have thyroid cancer on final pathology. Twenty-one (15.7%) patients had a microscopic papillary cancer (<1 cm) and 10 (7.5%) patients had other forms of thyroid cancer [five follicular, four papillary (>1 cm), and one patient with a papillary and follicular cancer]. On univariate analysis, male gender had a near-significant association with non-micropapillary thyroid cancer (p = 0.06). On multivariate analysis, male gender (OR = 10.2, 95% CI 1.35-76.8) and FNA cytology not reviewed at our institution (OR = 6.0, 95% CI 1.2-30) were independently associated with non-micropapillary thyroid cancer. CONCLUSIONS AND RELEVANCE The incidence of thyroid cancer in patients with MNG and benign FNA is significant. Men and patients in whom the FNA cytology is not reviewed by an experienced cytopathologist may be at an increased risk for an undetected thyroid cancer.
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Affiliation(s)
- Michael J Campbell
- University of California, Davis, 2221 Stockton Bvd, 3rd Floor Cypress Bldg, Sacramento, CA, 95817, USA,
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Campbell MJ, Candell L, Seib CD, Gosnell JE, Duh QY, Clark OH, Shen WT. Unanticipated thyroid cancer in patients with substernal goiters: are we underestimating the risk? Ann Surg Oncol 2014; 22:1214-8. [PMID: 25316492 DOI: 10.1245/s10434-014-4143-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rate of unexpected thyroid cancers found at the time of thyroidectomy is thought to be similar in patients with cervical and substernal multinodular goiters (MNGs). METHODS The objective of this study was to compare the prevalence of undiagnosed cancer found in patients undergoing a thyroidectomy for a cervical or substernal MNG. We conducted a review of patients with a preoperative diagnosis of an MNG (both cervical and substernal) at a tertiary referral center between 2005 and 2012. RESULTS We identified 538 patients who underwent thyroidectomy for an MNG (144 with substernal MNGs and 394 with cervical MNGs). Patients with substernal MNGs were older (59.6 vs. 52.3; p < 0.001), more likely to be men (34 vs. 11.1 %; p < 0.001), and less likely to have a history of radiation exposure to the neck (2.1 vs. 12.4 %; p < 0.001). Thyroid cancer (>1 cm) was found in 13.7 % of substernal MNG specimens and in 6.3 % of cervical MNG specimens (p = 0.003). On multivariate analysis, substernal location [odds ratio (OR) = 2.360; confidence interval (CI), 1.201-4.638] was the only variable independently associated with an unexpected thyroid cancer on surgical pathology. CONCLUSION The rate of postoperatively discovered thyroid cancer is significant in patients with substernal MNGs and is increased when compared to patients with cervical MNGs. Surgeons should counsel their patients regarding the possibility of this unexpected result.
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Seib CD, Harari A, Conte FA, Duh QY, Clark OH, Gosnell JE. Utility of serum thyroglobulin measurements after prophylactic thyroidectomy in patients with hereditary medullary thyroid cancer. Surgery 2014; 156:394-8. [PMID: 24882762 DOI: 10.1016/j.surg.2014.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 03/19/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Prophylactic thyroidectomy can be curative for patients with hereditary medullary thyroid cancer (MTC) caused by RET proto-oncogene mutations. Calcitonin is a sensitive tumor marker used to follow patients. We suggest that thyroglobulin (Tg) levels should also be monitored postoperatively in these patients. METHODS We reviewed patients with RET mutations who underwent prophylactic thyroidectomy between 1981 and 2011 at an academic endocrine surgery center. Patients were excluded if they had no postoperative Tg levels recorded. RESULTS Of the 22 patients who underwent prophylactic thyroidectomy, 14 were included in the final analysis. The average age at thyroidectomy was 9.8 years (range, 4-29). Tg levels were detectable 1.5 months to 31 years postoperatively in 11 patients (79%), all of whom were <15 years old at thyroidectomy. Median thyroid-stimulating hormone (TSH) was 2.5 mIU/L and 13.4 mIU/L in patients with undetectable and detectable Tg, respectively. Of those with detectable Tg, 5 had cervical ultrasonographic examination: Two showed no residual tissue in the thyroid bed, and 3 showed remnant thyroid tissue. CONCLUSION Tg levels can identify patients with remnant thyroid tissue after prophylactic thyroidectomy. Ultrasonography can determine whether thyroid tissue remains posterolaterally that is at risk of MTC recurrence. Maintaining normal TSH may prevent growth of remaining thyroid follicular cells.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Avital Harari
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Felix A Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Orlo H Clark
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jessica E Gosnell
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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Seib CD, Greenblatt DY, Campbell MJ, Shen WT, Gosnell JE, Clark OH, Duh QY. Adrenalectomy outcomes are superior with the participation of residents and fellows. J Am Coll Surg 2014; 219:53-60. [PMID: 24702888 DOI: 10.1016/j.jamcollsurg.2014.02.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/10/2014] [Accepted: 02/19/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Adrenalectomy is a complex procedure performed in many settings, with and without residents and fellows. Patients often ask, "Will trainees be participating in my operation?" and seek reassurance that their care will not be adversely affected. The purpose of this study was to determine the association between trainee participation and adrenalectomy perioperative outcomes. STUDY DESIGN We performed a cohort study of patients who underwent adrenalectomy from the 2005 to 2011 American College of Surgeons NSQIP database. Trainee participation was classified as none, resident, or fellow, based on postgraduate year of the assisting surgeon. Associations between trainee participation and outcomes were determined via multivariate linear and logistic regression. RESULTS Of 3,694 adrenalectomies, 732 (19.8%) were performed by an attending surgeon with no trainee, 2,315 (62.7%) involved a resident, and 647 (17.5%) involved a fellow. The participation of fellows was associated with fewer serious complications (7.9% with no trainee, 6.0% with residents, and 2.8% with fellows; p < 0.001). In a multivariate model, the odds of serious 30-day morbidity were lower when attending surgeons operated with residents (odds ratio = 0.63; 95% CI, 0.45-0.89). Fellow participation was associated with significantly lower odds of overall (odds ratio = 0.51; 95% CI, 0.32-0.82) and serious (odds ratio = 0.31; 95% CI, 0.17-0.57) morbidity. There was no significant association between trainee participation and 30-day mortality. CONCLUSIONS In this analysis of multi-institutional data, the participation of residents and fellows was associated with decreased odds of perioperative adrenalectomy complications. Attending surgeons performing adrenalectomies with trainee assistance should reassure patients of the equivalent or superior care they are receiving.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | | | | | - Wen T Shen
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jessica E Gosnell
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Orlo H Clark
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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Hochberg MS, Seib CD, Berman RS, Kalet AL, Zabar SR, Pachter HL. Perspective: Malpractice in an academic medical center: a frequently overlooked aspect of professionalism education. Acad Med 2011; 86:365-368. [PMID: 21248606 DOI: 10.1097/acm.0b013e3182086d72] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Understanding how medical malpractice occurs and is resolved is important to improving patient safety and preserving the viability of a physician's career in academic medicine. Every physician is likely to be sued by a patient, and how the physician responds can change his or her professional life. However, the principles of medical malpractice are rarely taught or addressed during residency training. In fact, many faculty at academic medical centers know little about malpractice.In this article, the authors propose that information about the inciting causes of malpractice claims and their resolution should be incorporated into residency professionalism curricula both to improve patient safety and to decrease physician anxiety about a crucial aspect of medicine that is not well understood. The authors provide information on national trends in malpractice litigation and residents' understanding of malpractice, then share the results of their in-depth review of surgical malpractice claims filed during 2001-2008 against their academic medical center. The authors incorporated those data into an evidence-driven curriculum for residents, which they propose as a model for helping residents better understand the events that lead to malpractice litigation, as well as its process and prevention.
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Affiliation(s)
- Mark S Hochberg
- New York University School of Medicine, New York, New York 10016, USA.
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Affiliation(s)
- Carolyn D. Seib
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Flavio G. Rocha
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Dick G. Hwang
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brent T. Shoji
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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