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Gutierrez RD, Smith EJT, Matthay ZA, Gasper WJ, Hiramoto JS, Conte MS, Finlayson E, Walter LC, Iannuzzi JC. Risk factors and associated outcomes of postoperative delirium after open abdominal aortic aneurysm repair. J Vasc Surg 2024; 79:793-800. [PMID: 38042511 DOI: 10.1016/j.jvs.2023.11.040] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Open abdominal aortic aneurysm repair (OAR) is a major vascular procedure that incurs a large physiologic demand, increasing the risk for complications such as postoperative delirium (POD). We sought to characterize POD incidence, identify delirium risk factors, and evaluate the effect of delirium on postoperative outcomes. We hypothesized that POD following OAR would be associated with increased postoperative complications and resource utilization. METHODS This was a retrospective study of all OAR cases from 2012 to 2020 at a single tertiary care center. POD was identified via a validated chart review method based on key words and Confusion Assessment Method assessments. The primary outcome was POD, and secondary outcomes included length of stay, non-home discharge, 90-day mortality, and 1-year survival. Bivariate analysis as appropriate to the data was used to assess the association of delirium with postoperative outcomes. Multivariable binary logistic regression was used to identify risk factors for POD and Cox regression for variables associated with worse 1-year survival. RESULTS Overall, 198 OAR cases were included, and POD developed in 34% (n = 67). Factors associated with POD included older age (74 vs 69 years; P < .01), frailty (50% vs 28%; P < .01), preoperative dementia (100% vs 32%; P < .01), symptomatic presentation (47% vs 27%; P < .01), preoperative coronary artery disease (44% vs 28%; P = .02), end-stage renal disease (89% vs 32%; P < .01) and Charlson Comorbidity Index score >4 (42% vs 26%; P = .01). POD was associated with 90-day mortality (19% vs 5%; P < .01), non-home discharge (61% vs 30%; P < .01), longer median hospital length of stay (14 vs 8 days; P < .01), longer median intensive care unit length of stay (6 vs 3 days; P < .01), postoperative myocardial infarction (7% vs 2%; P = .045), and postoperative pneumonia (19% vs 8%; P = .01). On multivariable analysis, risk factors for POD included older age, history of end-stage renal disease, lack of epidural, frailty, and symptomatic presentation. A Cox proportional hazards model revealed that POD was associated with worse survival at 1 year (hazard ratio, 3.8; 95% confidence interval, 1.6-9.0; P = .003). CONCLUSIONS POD is associated with worse postoperative outcomes and increased resource utilization. Future studies should examine the role of improved screening, implementation of delirium prevention bundles, and multidisciplinary care for the most vulnerable patients undergoing OAR.
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Affiliation(s)
- Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Eric J T Smith
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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2
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Bongiovanni T, Gan S, Finlayson E, Ross JS, Harrison JD, Boscardin WJ, Steinman MA. Association of Race and Ethnicity With Postoperative Gabapentinoid and Opioid Prescribing Trends for Older Adults. J Surg Res 2024; 298:47-52. [PMID: 38554545 DOI: 10.1016/j.jss.2024.02.017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Disparities in opioid prescribing by race/ethnicity have been described in many healthcare settings, with White patients being more likely to receive an opioid prescription than other races studied. As surgeons increase prescribing of nonopioid medications in response to the opioid epidemic, it is unknown whether postoperative prescribing disparities also exist for these medications, specifically gabapentinoids. METHODS We conducted a retrospective cohort study using a 20% Medicare sample for 2013-2018. We included patients ≥66 years without prior gabapentinoid use who underwent one of 14 common surgical procedures. The primary outcome was the proportion of patients prescribed gabapentinoids at discharge among racial and ethnic groups. Secondary outcomes were days' supply of gabapentinoids, opioid prescribing at discharge, and oral morphine equivalent (OME) of opioid prescriptions. Trends over time were constructed by analyzing proportion of postoperative prescribing of gabapentinoids and opioids for each year. For trends by year by racial/ethnic groups, we ran a multivariable logistic regression with an interaction term of procedure year and racial/ethnic group. RESULTS Of the 494,922 patients in the cohort (54% female, 86% White, 5% Black, 5% Hispanic, mean age 73.7 years), 3.7% received a new gabapentinoid prescription. Gabapentinoid prescribing increased over time for all groups and did not differ significantly among groups (P = 0.13). Opioid prescribing also increased, with higher proportion of prescribing to White patients than to Black and Hispanic patients in every year except 2014. CONCLUSIONS We found no significant prescribing variation of gabapentinoids in the postoperative period between racial/ethnic groups. Importantly, we found that despite national attention to disparities in opioid prescribing, variation continues to persist in postoperative opioid prescribing, with a higher proportion of White patients being prescribed opioids, a difference that persisted over time.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California.
| | - Siqi Gan
- Division of Geriatrics, University of California San Francisco School of Medicine, San Francisco, California; Northern California Institute for Research and Education, San Francisco, California
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut; Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - James D Harrison
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - W John Boscardin
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco School of Medicine, San Francisco, California
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco School of Medicine, San Francisco, California; San Francisco VA Medical Center, San Francisco, California
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Hamouche F, Hakam N, Unno R, Ahn J, Yang H, Bayne D, Stoller ML, Smith S, Finlayson E, Smith J, Chi T. Reimagining Ambulatory Care in Urology: Conversion of the Urology Clinic into a Procedure Center Improves Patient's Experience. Telemed J E Health 2024; 30:748-753. [PMID: 37862049 DOI: 10.1089/tmj.2023.0272] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
Introduction: The coronavirus disease 2019 (COVID-19) pandemic made it necessary to practice social distancing and limited in-person encounters in health care. These restrictions created alternative opportunities to enhance patient access to care in the ambulatory setting. We hypothesized that by transforming clinics into centers that prioritize procedures and transitioning ambulatory appointments to telehealth, we could establish a secure, streamlined, and productive method for providing patient care. Methods: Clinic templates were restructured to allow the use of the physical space to perform procedure-based clinics exclusively, while switching to virtual telemedicine for all nonprocedural encounters. Staff members were given specific roles to support one of the patient care modalities for a given day (Procedures vs. Telehealth). Performance and patient satisfaction metrics were collected between two periods of time defined as P1 (February-June 2019) and P2 Post-COVID (February-June 2020) and compared. These served as proxies of periods when the clinic workflow and templates were structured in the traditional versus the emerging way. Statistical analysis was performed using bivariate analyses. Results: The percentage of procedures performed among all in-person visits were higher in P2 compared to P1 (45% vs. 29%, p < 0.001). Although total charges and relative value units were lower in P2, the overall revenue generated was higher compared to P1 ($4,597,846 vs. $4,517,427$, respectively). This increase in revenue was mainly driven by the higher relative income generated by procedures. Patient experience, reflected through patient-reported outcomes, was more favorable in P2 where patients seemed more likely to "Recommend this provider office" (90% vs. 85.7%, p = 0.01), report improved "Access overall" (56% vs. 49%, p = 0.02), and felt they were "Moving through your visit overall" (59% vs. 51%, p = 0.007). Conclusions: Our data suggest that reorganizing urology clinics into a space that is centered around outpatient procedures can represent a model that improves the patient's access to care and clinical experience, while simultaneously improving operational financial strength. This efficient care model could be considered for many practice settings and drive high-value outpatient care.
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Affiliation(s)
- Fadl Hamouche
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Nizar Hakam
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Rei Unno
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Justin Ahn
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Heiko Yang
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - David Bayne
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Marshall L Stoller
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Susan Smith
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Emily Finlayson
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - James Smith
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Thomas Chi
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
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4
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Colley A, Broering J, Lee K, Lin JA, Pierce L, Finlayson E, Sudore RL, Wick EC. "It Gives Me Peace of Mind So I Can Focus on Healing": Views on Advance Care Planning for Older Surgical Patients. J Palliat Med 2024. [PMID: 38386513 DOI: 10.1089/jpm.2023.0589] [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] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Introduction: The period of time before an elective operation may be an opportune time to engage older adults in advance care planning (ACP). Past interventions have not been readily incorporated into surgical workflows leaving a need for ACP tools that are generalizable, easy to implement, and effective. Design: This is a qualitative study. Setting and Subjects: Older adults with a history of cancer and a recent major operation were recruited through their surgical oncologist at a tertiary medical center in the United States. Interviews were conducted to determine how to adapt the validated PrepareForYourCare.org ACP program with electronic health record prompts for the perioperative setting and openness to introducing ACP during a presurgical visit. We used qualitative content analysis to determine themes. Results: Eight themes were identified: (1) ACP as static and private, (2) people expected a prompt, (3) family trusted to do the "right" thing, (4) lack of relationship or comfort with providers, (5) a team-based approach can be helpful, (6) surgeon's expertise (e.g., prognosis and surgical risk), (7) ACP belongs on the surgical checklist, and (8) patients would welcome a conversation starter. Discussion: Older surgical patients are interested in engaging with ACP, particularly if prompted, and believe it has a place on the preoperative "checklist." Conclusions: To effectively engage patients with ACP, a combination of routine prompts by the health care team and patient-centered follow-up may be required.
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Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jeannette Broering
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Katherine Lee
- Division of Palliative Medicine, University of California, San Francisco, California, USA
| | - Joseph A Lin
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Logan Pierce
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth C Wick
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
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Tang VL, Cenzer I, Keny C, John Boscardin W, Covinsky K, Finlayson E, Kotwal A. Social Strain is associated with Functional Decline in Older Adults after Surgery. J Gen Intern Med 2024; 39:351-353. [PMID: 37946019 PMCID: PMC10853096 DOI: 10.1007/s11606-023-08484-x] [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] [Received: 06/30/2023] [Accepted: 10/12/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Christina Keny
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ken Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ashwin Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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6
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Lin JA, Colley A, Pierce L, Finlayson E, Sudore RL, Wick EC. Clinician Review of Advanced Care Planning for Older Surgical Patients Requiring Intensive Care. Jt Comm J Qual Patient Saf 2024; 50:154-156. [PMID: 37926671 PMCID: PMC10890795 DOI: 10.1016/j.jcjq.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/21/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
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Colley A, Lin J, Pierce L, Johnson C, Bongiovanni T, Finlayson E, Sudore R, Wick EC. Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project. Surgery 2023; 174:844-850. [PMID: 37183132 PMCID: PMC10526751 DOI: 10.1016/j.surg.2023.04.031] [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: 12/15/2022] [Revised: 03/09/2023] [Accepted: 04/09/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND For patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. METHODS A resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. RESULTS The frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. CONCLUSION Although a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.
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Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California-San Francisco, CA. http://www.twitter.com/Alexis_ColleyMD
| | - Joseph Lin
- Department of Surgery, University of California-San Francisco, CA
| | - Logan Pierce
- Department of Medicine, University of California-San Francisco, CA
| | | | | | - Emily Finlayson
- Department of Surgery, University of California-San Francisco, CA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, CA
| | - Elizabeth C Wick
- Department of Surgery, University of California-San Francisco, CA.
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Ma M, Peters XD, Zhang LM, Hornor M, Christensen K, Coleman J, Finlayson E, Flood KL, Katlic M, Lagoo-Deenadayalan S, Robinson TN, Rosenthal RA, Tang VL, Ko CY, Russell MM. Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative. J Am Coll Surg 2023; 237:171-181. [PMID: 37185633 DOI: 10.1097/xcs.0000000000000723] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 05/17/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process. STUDY DESIGN The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed. RESULTS Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults. CONCLUSIONS This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.
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Affiliation(s)
- Meixi Ma
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL (Ma)
| | - Xane D Peters
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, Loyola University Medical Center, Maywood, IL (Peters, Hornor)
| | - Lindsey M Zhang
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of Chicago Medical Center, Chicago, IL (Zhang)
| | - Melissa Hornor
- Department of Surgery, Loyola University Medical Center, Maywood, IL (Peters, Hornor)
| | - Kataryna Christensen
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
| | - JoAnn Coleman
- Sinai Center for Geriatric Surgery, Sinai Hospital, Baltimore, MD (Coleman, Katlic)
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco, San Francisco, CA (Finlayson)
| | - Kellie L Flood
- Department of Medicine, Division of Geriatrics, Hospice, and Palliative Medicine, University of Alabama at Birmingham Medical Center, Birmingham, AL (Flood)
| | - Mark Katlic
- Sinai Center for Geriatric Surgery, Sinai Hospital, Baltimore, MD (Coleman, Katlic)
| | | | - Thomas N Robinson
- Department of Surgery, University of Colorado Denver, Aurora, CO (Robinson)
| | | | - Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA (Tang)
| | - Clifford Y Ko
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA (Ko, Russell)
| | - Marcia M Russell
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA (Ko, Russell)
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Bongiovanni T, Gan S, Finlayson E, Ross JS, Harrison JD, Boscardin WJ, Steinman MA. Trends in the Use of Gabapentinoids and Opioids in the Postoperative Period Among Older Adults. JAMA Netw Open 2023; 6:e2318626. [PMID: 37326989 PMCID: PMC10276300 DOI: 10.1001/jamanetworkopen.2023.18626] [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] [Received: 01/31/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance In response to the opioid epidemic, recommendations from some pain societies have encouraged surgeons to embrace multimodal pain regimens with the intent of reducing opioid use in the postoperative period, including by prescribing gabapentinoids. Objective To describe trends in postoperative prescribing of both gabapentinoids and opioids after a variety of surgical procedures by examining nationally representative Medicare data and further understand variation by procedure. Design, Setting, and Participants This serial cross-sectional study of gabapentinoid prescribing from January 1, 2013, through December 31, 2018, used a 20% US Medicare sample. Gabapentinoid-naive patients 66 years or older undergoing 1 of 14 common noncataract surgical procedures performed in older adults were included. Data were analyzed from April 2022 to April 2023. Exposure One of 14 common surgical procedures in older adults. Main Outcomes and Measures Rate of postoperative prescribing of gabapentinoids and opioids, defined as a prescription filled between 7 days before the procedure and 7 days after discharge from surgery. Additionally, concomitant prescribing of gabapentinoids and opioids in the postoperative period was assessed. Results The total study cohort included 494 922 patients with a mean (SD) age of 73.7 (5.9) years, 53.9% of whom were women and 86.0% of whom were White. A total of 18 095 patients (3.7%) received a new gabapentinoid prescription in the postoperative period. Of those receiving a new gabapentinoid prescription, 10 956 (60.5%) were women and 15 529 (85.8%) were White. After adjusting for age, sex, race and ethnicity, and procedure type in each year, the rate of new postoperative gabapentinoid prescribing increased from 2.3% (95% CI, 2.2%-2.4%) in 2014 to 5.2% (95% CI, 5.0%-5.4%) in 2018 (P < .001). While there was variation between procedure types, almost all procedures saw an increase in both gabapentinoid and opioid prescribing. In this same period, opioid prescribing increased from 56% (95% CI, 55%-56%) to 59% (95% CI, 58%-60%) (P < .001). Concomitant prescribing also increased from 1.6% (95% CI, 1.5%-1.7%) in 2014 to 4.1% (95% CI, 4.0%-4.3%) in 2018 (P < .001). Conclusions and Relevance The findings of this cross-sectional study of Medicare beneficiaries suggest that new postoperative gabapentinoid prescribing increased without a subsequent downward trend in the proportion of patients receiving postoperative opioids and a near tripling of concurrent prescribing. Closer attention needs to be paid to postoperative prescribing for older adults, especially when using multiple types of medications, which can have adverse drug events.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California, San Francisco, School of Medicine
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, School of Medicine
- Northern California Institute for Research and Education, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, School of Medicine
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - James D Harrison
- Division of Hospital Medicine, University of California, San Francisco, School of Medicine
| | - W John Boscardin
- Department of Medicine, University of California, San Francisco, School of Medicine
- Department of Epidemiology and Biostatistics, University of California, San Francisco, School of Medicine
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, School of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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10
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Smith EJT, Gasper WJ, Schneider PA, Finlayson E, Walter LC, Covinsky KE, Conte MS, Iannuzzi JC. Cognitive Impairment is Common in a Veterans Affairs Population with Peripheral Arterial Disease. Ann Vasc Surg 2023; 91:210-217. [PMID: 36581154 DOI: 10.1016/j.avsg.2022.11.029] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there are little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized. METHODS Cognitive impairment screening was prospectively performed for veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of <26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment. RESULTS Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, P = 0.03), Black versus White race (94% vs. 54%, P < 0.01), hypertension (66% vs. 31%, P = 0.01), prior stroke/TIA (79% vs. 58%, P = 0.03), diabetes treated with insulin (79% vs. 58%, P = 0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, P = 0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥70 years, diabetes treated with insulin, PTSD, and Black race. CONCLUSIONS Many veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.
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Affiliation(s)
- Eric J T Smith
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Peter A Schneider
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | - Ken E Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | | | - James C Iannuzzi
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA.
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11
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Colley A, Finlayson E, Zhao S, Boscardin J, Suskind A. High risk of complications after a "low risk" procedure: A national study of nursing home residents and older adults undergoing haemorrhoid surgery. Colorectal Dis 2023; 25:298-304. [PMID: 36097828 DOI: 10.1111/codi.16334] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/15/2022] [Accepted: 09/01/2022] [Indexed: 02/08/2023]
Abstract
AIM To evaluate 30-day complications and 1-year mortality for older adults undergoing haemorrhoid surgery. METHOD This retrospective cohort study evaluated older adults (age 66+) undergoing haemorrhoid surgery using Medicare claims and the minimum data set (MDS). Long-stay nursing home residents were identified, and propensity score matched to community-dwelling older adults. Generalized estimating equation models were created to determine the adjusted relative risk of 30-day complications, length of stay (LOS), and 1-year mortality. Among nursing home residents, functional and cognitive status were evaluated using the MDS-activities of daily living (ADL) score and the Brief Instrument of Mental Status. Faecal continence status was evaluated among a subset of nursing home residents. RESULTS A total of 3664 subjects underwent haemorrhoid surgery and were included in the analyses. Nursing home residents were at significantly higher risk for 30-day complications (52.3% vs. 32.9%, aRR 1.6 [95% CI: 1.5-1.7], p < 0.001), and 1-year mortality (24.9% vs. 16.1%, aRR 1.6 [95% CI: 1.3-1.8], p < 0.001). Functional and mental status showed an inflection point of decline around the time of the procedure, which did not recover to the baseline trajectory in the following year. Additionally, a subset of nursing home residents demonstrated worsening faecal incontinence. CONCLUSION This study demonstrated high rates of 30-day complications and 1-year mortality among all older adults (yet significantly worse among nursing home residents). Ultimately, primary care providers and surgeons should carefully weigh the potential harms of haemorrhoid surgery in older adults living in a nursing home.
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Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Shoujun Zhao
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Anne Suskind
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
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12
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Bongiovanni T, Gan S, Finlayson E, Ross J, Harrison JD, Boscardin J, Steinman MA. Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc 2022; 70:3560-3569. [PMID: 36000860 PMCID: PMC9771946 DOI: 10.1111/jgs.18005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/08/2022] [Revised: 07/05/2022] [Accepted: 07/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non-opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults. METHODS We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013-2018. We included patients >65 years old without prior gabapentinoid use who underwent common non-cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill>90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity. RESULTS Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non-White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at >90 days and having a higher care complexity were associated with prolonged use of gabapentin. CONCLUSIONS More than one-fifth of older adults prescribed gabapentin postoperatively filled a prescription >90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Siqi Gan
- University of California San Francisco Pepper Center, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Joseph Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
| | - James D Harrison
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - John Boscardin
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
- Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
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13
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Colley A, Finlayson E, Sosa JA, Wick E. "I Wish Someone had Asked Me Earlier"-Perspectives on Advance Care Planning in Surgery. Ann Surg 2022; 276:e649-e651. [PMID: 35848744 PMCID: PMC9643600 DOI: 10.1097/sla.0000000000005602] [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] [Indexed: 11/26/2022]
Abstract
Recent controversy has called into question the meaning and clinical utility of Advance Care Planning (ACP), however data have consistently shown potential benefit to patients and their surrogate decision makers. We present the concept of surgery-specific advance care planning and a structured, scalable approach to integrating it into clinical practice.
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Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California, San Francisco, San Francisco, California 94143
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California 94143
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, California 94143
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco, San Francisco, California 94143
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Colley A, Lin JA, Pierce L, Finlayson E, Sudore RL, Wick E. Missed Opportunities and Health Disparities for Advance Care Planning Before Elective Surgery in Older Adults. JAMA Surg 2022; 157:e223687. [PMID: 36001323 PMCID: PMC9403851 DOI: 10.1001/jamasurg.2022.3687] [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] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/30/2022] [Indexed: 11/14/2022]
Abstract
Importance Advance care planning (ACP) prepares patients and caregivers for medical decision-making, yet it is underused in the perioperative surgical setting, particularly among older adults undergoing high-risk procedures who are at risk for postoperative complications. It is unknown what patient factors are associated with perioperative ACP documentation among older surgical patients. Objective To assess ACP documentation among high-risk patients 65 years and older undergoing elective surgery. Design, Setting, and Participants In this observational cohort study including 3671 patients 65 years and older undergoing elective surgery at a tertiary academic center in California, electronic health record data were linked to the National Surgical Quality Improvement Project outcomes data and the California statewide death registry. The study was conducted from January 1 to December 31, 2019. Data were analyzed from January to May 2022. Exposures Elective surgery requiring an inpatient admission. Main Outcomes and Measures ACP documentation, defined as a discussion regarding goals of care documented in an ACP note, an advance directive, or a physician order for life-sustaining treatment (POLST) form, within 90 days before elective surgery requiring inpatient admission. Multivariate regression was performed to identify factors associated with missing ACP. Results Among 3671 patients (median [IQR] age 72 [65-94] years; 1784 [48.6%] female; 401 [10.9%] Asian, 155 [4.2%] Black, 284 [7.7%] Latino/Latina, 2647 [72.1%] White, and 184 [5.0%] of other races or ethnicities, including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, other, and unknown or declined to respond, combined owing to small numbers), 539 (14.7%) had ACP documentation in the 90-day presurgery window. Of these 539, 448 (83.1%) had advance directives, and 60 (11.1%) had POLST forms. The 30-day and 1-year mortality were 0.7% (n = 27) and 6.6% (n = 244), respectively. Missing ACP was significantly associated with male sex (adjusted odds ratio [aOR], 1.39; 95% CI, 1.14-1.69) and having a non-English preferred language (aOR, 1.78; 95% CI, 1.18-2.79). Medicare insurance was significantly associated with having ACP (aOR for missing ACP, 0.63; 95% CI, 0.40-0.95). Conclusions and Relevance In this study, perioperative ACP was uncommon, particularly in men, individuals with a non-English preferred language, and those without Medicare insurance coverage. The perioperative setting may represent a missed opportunity for ACP for older surgical patients. When addressing ACP for surgical patients, particular attention should be paid to overcoming language-related disparities.
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Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California, San Francisco
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco
| | - Logan Pierce
- Department of Medicine, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
| | - Rebecca L. Sudore
- Department of Medicine, Division of Geriatrics, University of California, San Francisco
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
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15
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Shah SK, Adler RR, Xiang L, Clark CJ, Cooper Z, Finlayson E, Kim DH, Lin KJ, Lipsitz SR, Weissman JS. Patients living with dementia have worse outcomes when undergoing high-risk procedures. J Am Geriatr Soc 2022; 70:2838-2846. [PMID: 35637607 PMCID: PMC9588582 DOI: 10.1111/jgs.17893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/01/2021] [Revised: 04/18/2022] [Accepted: 05/03/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with Alzheimer's Disease and Related Dementias (ADRD) undergoing inpatient procedures represent a population at elevated risk for adverse outcomes including postoperative complications, mortality, and discharge to a higher level of care. Outcomes may be particularly poor in patients with ADRD undergoing high-risk procedures. We sought to determine traditional (e.g., 30-day mortality) and patient-centered (e.g., discharge disposition) outcomes in patients with ADRD undergoing high-risk inpatient procedures. METHODS This retrospective cohort study analyzed electronic health records linked to fee-for-service Medicare claims data at a tertiary care academic health system. All patients from a large multi-hospital health system undergoing high-risk inpatient procedures from October 1, 2015 to September 30, 2017 with continuous Medicare Parts A and B enrollment in the 12 months prior to and 90 days following the procedure were included. RESULTS This study included 6779 patients. 536 (7.9%) had ADRD. A multivariable analysis of outcomes demonstrated higher risks for postoperative complications (OR 1.49, 95% CI 1.23-1.81) and 90-day mortality (OR 1.44 [95% CI 1.09-1.91]) in patients with ADRD compared to those without. Patients with ADRD were more likely to be discharged to a higher level of care (OR 1.70, 95% CI 1.32-2.18) and only 37.3% of patients admitted from home were discharged to home. CONCLUSIONS Compared to those without ADRD, patients living with ADRD undergoing high-risk procedures have poor traditional and patient-centered outcomes including increased risks for 90-day mortality, postoperative complications, longer hospital lengths of stay, and discharge to a higher level of care. These data may be used by patients, their surrogates, and their physicians to help align surgical decision-making with health care goals.
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Affiliation(s)
- Samir K Shah
- Division of Vascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Rachel R Adler
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Clancy J Clark
- Division of Surgical Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily Finlayson
- Department of Surgery, Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
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16
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Chou WH, Covinsky K, Zhao S, Boscardin WJ, Finlayson E, Suskind AM. Functional and cognitive outcomes after suprapubic catheter placement in nursing home residents: A national cohort study. J Am Geriatr Soc 2022; 70:2948-2957. [PMID: 35696283 PMCID: PMC9588579 DOI: 10.1111/jgs.17928] [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] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term functional and cognitive outcomes in nursing home residents after procedures are poorly understood. Our objective was to evaluate these outcomes after suprapubic tube (SPT) placement. METHODS We performed a retrospective, cohort study in the nursing home setting. Participants were long-term nursing home residents who underwent SPT placement from 2014 to 2016 in the United States. SPT placements were identified in Medicare Inpatient, Outpatient, and Carrier files using International Classification of Diseases and Current Procedural Terminology codes. Residents were identified through the Minimum Data Set (MDS) 3.0 for Nursing Home Residents. MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores were used to assess function and cognition, respectively. Outcomes of interest were worsening MDS-ADL and BIMS scores at 1 year postoperatively, 30-day postoperative complications, and 1-year mortality. Functional and cognitive trajectories were modeled to 1 year postoperatively using mixed-effect spline models. RESULTS From 2014 to 2016, 9647 residents with a mean age of 80.9 (SD 8.1) years underwent SPT placement. At 1 year postoperatively, 37.6% of residents died, while of survivors, 33.7% had worsening MDS-ADL and 36.2% worsened BIMS. Residents had steeper postoperative rates of functional decline compared to relatively stable preoperative trends that never recovered to baseline status. However, robustly characterizing an association between SPT placement and functional decline would require a propensity score matched cohort without SPT placement. Decline in cognitive status was not clearly associated with SPT placement, suggesting either the natural course of a vulnerable population or limitations of BIMS scores. CONCLUSIONS Outcomes important to older adults, such as functional ability and cognitive status, do not show improvement after SPT placement. These findings emphasize that this "minor" procedure should be considered with caution in this population and primarily for palliation.
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Affiliation(s)
| | - Kenneth Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA
| | - Shoujun Zhao
- Department of Urology, University of California, San Francisco, San Francisco, CA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Anne M. Suskind
- Department of Urology, University of California, San Francisco, San Francisco, CA
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17
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Greenberg AL, Lin JA, Colley A, Finlayson E, Bongiovanni T, Wick EC. Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California. JAMA Netw Open 2022; 5:e2220379. [PMID: 35793086 PMCID: PMC9260472 DOI: 10.1001/jamanetworkopen.2022.20379] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery. OBJECTIVE To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021. EXPOSURES Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI). MAIN OUTCOMES AND MEASURES Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not. RESULTS Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P < .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P < .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.
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Affiliation(s)
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco
| | - Alexis Colley
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
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18
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Smith EJ, Gasper WJ, Schneider P, Finlayson E, Walter LC, Covinsky KE, Conte MS, Iannuzzi JC. Unrecognized Cognitive Impairment Is Common In A VA Population With Peripheral Arterial Disease. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.041] [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: 11/01/2022]
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19
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Koprowski MA, Nagengast AK, Finlayson E, Brasel KJ. Surgical Trainees and The Geriatric Patient: A Scoping Review. J Surg Educ 2022; 79:179-189. [PMID: 34294567 DOI: 10.1016/j.jsurg.2021.06.019] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/25/2021] [Accepted: 06/26/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE There is an increasing emphasis on surgical trainees learning how to appropriately provide care for the geriatric patient. We hypothesized that little published formal curriculum on the topic exists. We sought to perform a scoping review to test this hypothesis. DESIGN PubMed, OVID Medline, and EMBASE databases were queried from inception, supplemented by hand search of references and the grey literature. Included English language abstracts and articles described trainee perceptions of geriatric patients and/or description of dedicated geriatric curricula for trainees. RESULTS There were 21 included abstracts or papers, which were categorized into 8 survey-based studies, 6 descriptions of curricular design, and 7 interventional studies with pre- and post-intervention knowledge tests. General surgery residents were most frequently included. Self-rated confidence and comfort were typically higher than objective measures of resident performance in the care of geriatric patients. Residents were commonly unaware of the standardized assessment tools and recommendations that exist. Medication and delirium management were frequently-identified topics posing the widest gaps in resident knowledge. CONCLUSION There are few published examples of curricula on the care of geriatric patients for surgical trainees. More work is needed for the creation of specialty-specific and needs-based geriatric surgical curricula.
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Affiliation(s)
- Marina Affi Koprowski
- Department of Surgery, Oregon Health and Science University (OHSU), Portland, Oregon
| | - Andrea K Nagengast
- Division of Trauma, Critical Care, and Acute Care Surgery, OHSU, Portland, Oregon
| | - Emily Finlayson
- Department of Surgery, University of California at San Francisco (UCSF), San Francisco, California
| | - Karen J Brasel
- Division of Trauma, Critical Care, and Acute Care Surgery, OHSU, Portland, Oregon.
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20
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Cohan JN, Ozanne EM, Hofer RK, Kelly YM, Kata A, Larsen C, Finlayson E. Ileostomy or ileal pouch-anal anastomosis for ulcerative colitis: patient participation and decisional needs. BMC Gastroenterol 2021; 21:347. [PMID: 34538236 PMCID: PMC8451075 DOI: 10.1186/s12876-021-01916-0] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Up to 30% of patients with ulcerative colitis will undergo surgery resulting in an ileal pouch-anal anastomosis (IPAA) or permanent end ileostomy (EI). We aimed to understand how patients decide between these two options. METHODS We performed semi-structured interviews with ulcerative colitis patients who underwent surgery. Areas of questioning included the degree to which patients participated in decision-making, challenges experienced, and suggestions for improving the decision-making process. We analyzed the data using a directed content and thematic approach. RESULTS We interviewed 16 patients ranging in age from 28 to 68 years. Nine were male, 10 underwent IPAA, and 6 underwent EI. When it came to participation in decision-making, 11 patients felt independently responsible for decision-making, 3 shared decision-making with the surgeon, and 2 experienced surgeon-led decision-making. Themes regarding challenges during decision-making included lack of support from family, lack of time to discuss options with the surgeon, and the overwhelming complexity of the decision. Themes for ways to improve decision-making included the need for additional information, the desire for peer education, and earlier consultation with a surgeon. Only 3 patients were content with the information used to decide about surgery. CONCLUSIONS Patients with ulcerative colitis who need surgery largely experience independence when deciding between IPAA and EI, but struggle with inadequate educational information and social support. Patients may benefit from early access to surgeons and peer guidance to enhance independence in decision-making. Preoperative educational materials describing surgical complications and postoperative lifestyle could improve decision-making and facilitate discussions with loved ones.
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Affiliation(s)
- Jessica N Cohan
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Rebecca K Hofer
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Yvonne M Kelly
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Anna Kata
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Craig Larsen
- Department of Surgery, New York Presbyterian-Queens, Flushing, NY, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA, USA
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Kalbfell E, Kata A, Buffington AS, Marka N, Brasel KJ, Mosenthal AC, Cooper Z, Finlayson E, Schwarze ML. Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery: A Secondary Analysis of a Randomized Clinical Trial. JAMA Surg 2021; 156:e211521. [PMID: 33978693 DOI: 10.1001/jamasurg.2021.1521] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown. Objective To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery. Design, Setting, and Participants This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018. Interventions Patients received a question prompt list brochure with 11 questions that they might ask their surgeon. Main Outcomes and Measures For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted. Results Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P = .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P = .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P = .22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%]; P = .77). Patients with complications were enthusiastic about ACP but did not think it was important to discuss their preferences for life-sustaining treatments with their surgeon preoperatively. Conclusions and Relevance Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively. Trial Registration ClinicalTrials.gov Identifier: NCT02623335.
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Affiliation(s)
- Elle Kalbfell
- Department of Surgery, University of Wisconsin-Madison
| | - Anna Kata
- Department of Surgery, Georgetown University Hospital, Washington, DC
| | | | | | - Karen J Brasel
- Department of Surgery, Oregon Health & Science University, Portland
| | - Anne C Mosenthal
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
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22
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Schwarze ML, Buffington A, Tucholka JL, Hanlon B, Rathouz PJ, Marka N, Taylor LJ, Zimmermann CJ, Kata A, Baggett ND, Fox DA, Schmick AE, Berlin A, Glass NE, Mosenthal AC, Finlayson E, Cooper Z, Brasel KJ. Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery: A Multisite Randomized Clinical Trial. JAMA Surg 2021; 155:6-13. [PMID: 31664452 DOI: 10.1001/jamasurg.2019.3778] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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 Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict. Objective To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery. Design, Setting, and Participants This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat. Interventions A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit. Main Outcomes and Measures Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery. Results Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal α = .01). Conclusions and Relevance The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly. Trial Registration ClinicalTrials.gov identifier: NCT02623335.
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Affiliation(s)
| | - Anne Buffington
- Department of Surgery, University of Wisconsin-Madison, Madison
| | | | - Bret Hanlon
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison
| | - Paul J Rathouz
- Department of Population Health, The University of Texas at Austin, Austin
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin-Madison, Madison
| | - Lauren J Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison
| | | | - Anna Kata
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | | | - Daniel A Fox
- School of Medicine, Northwestern University, Evanston, Illinois
| | - Andrea E Schmick
- Department of Medicine, University of Wisconsin-Madison, Madison
| | - Ana Berlin
- Division of General Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.,Adult Palliative Medicine Service, Division of Hematology/Oncology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Nina E Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Anne C Mosenthal
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
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23
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Kalbfell EL, Buffington A, Kata A, Brasel KJ, Mosenthal AC, Cooper Z, Finlayson E, Schwarze ML. Expressions of conflict following postoperative complications in older adults having major surgery. Am J Surg 2021; 222:670-676. [PMID: 34218931 DOI: 10.1016/j.amjsurg.2021.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/03/2021] [Revised: 05/17/2021] [Accepted: 06/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND After serious postoperative complications, patients and families may experience conflict about goals of care. METHODS We performed a multisite randomized clinical trial to test the effect of a question prompt list on postoperative conflict. We interviewed family members and patients age ≥60 who experienced serious complications. We used qualitative content analysis to analyze conflict and characterize patient experiences with complications. RESULTS Fifty-six of 446 patients suffered a serious complication. Participants generally did not report conflict relating to postoperative treatments and expressed support for the care they received. We did not appreciate a difference in conflict between intervention and usual care. Respondents reported feeling unprepared for complications, witnessing heated interactions among team members, and a failure to develop trust for their surgeon preoperatively. CONCLUSION Postoperative conflict following serious complications is well described but its incidence may be low. Nonetheless, patient and family observations reveal opportunities for improvement.
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Affiliation(s)
- Elle L Kalbfell
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Anne Buffington
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Anna Kata
- Department of Surgery, Georgetown University Hospital, Washington D.C, USA
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Anne C Mosenthal
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
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24
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Suskind AM, Zhao S, Nik-Ahd F, Boscardin WJ, Covinsky K, Finlayson E. Comparative outcomes for older adults undergoing surgery for bladder and bowel dysfunction. J Am Geriatr Soc 2021; 69:2210-2219. [PMID: 33818753 DOI: 10.1111/jgs.17118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/27/2021] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES To compare surgical outcomes between vulnerable nursing home (NH) residents and matched community-dwelling older adults undergoing surgery for bladder and bowel dysfunction. DESIGN Retrospective cohort study. PARTICIPANTS A total of 55,389 NH residents and propensity matched (based on procedure, age, sex, race, comorbidity, and year) community-dwelling older adults undergoing surgery for bladder and bowel dysfunction [female pelvic surgery, transurethral resection of the prostate, suprapubic tube placement, hemorrhoid surgery, rectal prolapse surgery]. Individuals were identified using Medicare claims and the Minimum Data Set (MDS) for NH residents between 2014 and 2016. MEASUREMENTS Thirty-day complications, 1-year mortality, and weighted changes in healthcare resource utilization (hospital admissions, emergency room visits, office visits) in the year before and after surgery. RESULTS NH residents demonstrated statistically significant increased risk of 30-day complications [60.1% v. 47.2%; RR 1.3 (95% CI 1.3-1.3)] and 1-year mortality [28.9% vs. 21.3%; RR 1.4 (95% CI 1.3-1.4)], compared to community-dwelling older adults. NH residents also demonstrated decreased healthcare resource utilization, compared to community-dwelling older adults, changing from 3.9 to 1.9 (vs.1.1 to 1.0) hospital admissions, 11 to 10.1 (vs. 9 to 9.7) office visits, and 3.4 to 2.2 (vs. 1.9 to 1.9) emergency room visits from the year before to after surgery. CONCLUSION Despite matching on several important clinical characteristics, NH residents demonstrated increased rates of 30-day complications and 1-year mortality after surgery for bowel and bladder dysfunction, while demonstrating decreased healthcare resource utilization. These mixed findings suggest that outcomes may be more varied among vulnerable older adults and warrant further investigation.
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Affiliation(s)
- Anne M Suskind
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Shoujun Zhao
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Farnoosh Nik-Ahd
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - W John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
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25
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Suskind AM, Covinsky K, Finlayson E. Comparative Outcomes for Pelvic Organ Prolapse Surgery among Nursing Home Residents and Matched Community Dwelling Older Adults. Reply. J Urol 2021; 206:175. [PMID: 33818151 DOI: 10.1097/ju.0000000000001756] [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: 11/25/2022]
Affiliation(s)
- Anne M Suskind
- Department of Urology, University of California San Francisco
| | | | - Emily Finlayson
- Department of Surgery, University of California San Francisco
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26
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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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27
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Whitlock EL, Braehler MR, Kaplan JA, Finlayson E, Rogers SE, Douglas V, Donovan AL. Derivation, Validation, Sustained Performance, and Clinical Impact of an Electronic Medical Record-Based Perioperative Delirium Risk Stratification Tool. Anesth Analg 2020; 131:1901-1910. [PMID: 33105280 DOI: 10.1213/ane.0000000000005085] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium is an important problem for surgical inpatients and was the target of a multidisciplinary quality improvement project at our institution. We developed and tested a semiautomated delirium risk stratification instrument, Age, WORLD backwards, Orientation, iLlness severity, Surgery-specific risk (AWOL-S), in 3 independent cohorts from our tertiary care hospital and describe its performance characteristics and impact on clinical care. METHODS The risk stratification instrument was derived with elective surgical patients who were admitted at least overnight and received at least 1 postoperative delirium screen (Nursing Delirium Screening Scale [NuDESC] or Confusion Assessment Method for the Intensive Care Unit [CAM-ICU]) and preoperative cognitive screening tests (orientation to place and ability to spell WORLD backward). Using data pragmatically collected between December 7, 2016, and June 15, 2017, we derived a logistic regression model predicting probability of delirium in the first 7 postoperative hospital days. A priori predictors included age, cognitive screening, illness severity or American Society of Anesthesiologists physical status, and surgical delirium risk. We applied model odds ratios to 2 subsequent cohorts ("validation" and "sustained performance") and assessed performance using area under the receiver operator characteristic curves (AUC-ROC). A post hoc sensitivity analysis assessed performance in emergency and preadmitted patients. Finally, we retrospectively evaluated the use of benzodiazepines and anticholinergic medications in patients who screened at high risk for delirium. RESULTS The logistic regression model used to derive odds ratios for the risk prediction tool included 2091 patients. Model AUC-ROC was 0.71 (0.67-0.75), compared with 0.65 (0.58-0.72) in the validation (n = 908) and 0.75 (0.71-0.78) in the sustained performance (n = 3168) cohorts. Sensitivity was approximately 75% in the derivation and sustained performance cohorts; specificity was approximately 59%. The AUC-ROC for emergency and preadmitted patients was 0.71 (0.67-0.75; n = 1301). After AWOL-S was implemented clinically, patients at high risk for delirium (n = 3630) had 21% (3%-36%) lower relative risk of receiving an anticholinergic medication perioperatively after controlling for secular trends. CONCLUSIONS The AWOL-S delirium risk stratification tool has moderate accuracy for delirium prediction in a cohort of elective surgical patients, and performance is largely unchanged in emergent/preadmitted surgical patients. Using AWOL-S risk stratification as a part of a multidisciplinary delirium reduction intervention was associated with significantly lower rates of perioperative anticholinergic but not benzodiazepine, medications in those at high risk for delirium. AWOL-S offers a feasible starting point for electronic medical record-based postoperative delirium risk stratification and may serve as a useful paradigm for other institutions.
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Affiliation(s)
| | | | | | | | | | | | - Anne L Donovan
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
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28
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Donovan AL, Braehler MR, Robinowitz DL, Lazar AA, Finlayson E, Rogers S, Douglas VC, Whitlock EL. An Implementation-Effectiveness Study of a Perioperative Delirium Prevention Initiative for Older Adults. Anesth Analg 2020; 131:1911-1922. [PMID: 33105281 DOI: 10.1213/ane.0000000000005223] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution. METHODS This hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of "high-risk" screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group <65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night. RESULTS During the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as "high risk" during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95-0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91-1.05, P = .52) per month during the QI period in comparison to baseline. CONCLUSIONS A perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.
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Affiliation(s)
- Anne L Donovan
- From the Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care
| | | | | | - Ann A Lazar
- Department of Preventive and Dental Sciences.,Department of Epidemiology and Biostatistics
| | - Emily Finlayson
- Department of Surgery and Philip R. Lee Institute for Health Policy Studies.,Division of Geriatrics, Department of Medicine
| | | | - Vanja C Douglas
- Department of Neurology, University of California, San Francisco, California
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29
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Tang VL, Cenzer I, McCulloch CE, Finlayson E, Cooper Z, Silvestrini M, Ngo S, Schmitt EM, Inouye SK. Preoperative Depressive Symptoms Associated with Poor Functional Recovery after Surgery. J Am Geriatr Soc 2020; 68:2814-2821. [PMID: 32898280 PMCID: PMC7744402 DOI: 10.1111/jgs.16781] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 03/05/2020] [Revised: 06/24/2020] [Accepted: 07/16/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND/OBJECTIVES Depression screening and treatment for older adults are recommended in Age-Friendly Health Systems. Few studies have evaluated the association between depressive symptoms and postoperative functioning. We aimed to determine the association between varying levels of depressive symptoms in the preoperative setting with postoperative functional recovery. DESIGN Prospective cohort study. SETTING Two academic hospitals in Boston, Massachusetts. PARTICIPANTS Surgical patients aged 70 and older (N = 560). MEASUREMENTS Participants were assessed preoperatively and 1 year postoperatively. Preoperative evaluation included the 15-item short-form Geriatric Depression Scale (GDS). Results were categorized as low (GDS = 0-1), moderate (2-5), or high (6-15) symptom burden. Primary outcome was 1-year instrumental activities of daily living functional decline. Secondary outcomes included hospital stay longer than 5 days, discharge to post-acute care (PAC) facility, and readmission within 30 days. RESULTS Mean participant age was 76.6 ± 5 years, 58% were women, 81% underwent an orthopedic operation, 13% gastrointestinal, 6% vascular; 13% had functional decline at 1 year after their operation (by symptom burden: low = 5.5%; moderate = 14.8%, and high = 38.6%). After adjusting for age, sex, and comorbidity, those with moderate or high depressive symptoms demonstrated greater odds of functional decline at 1 year compared with those with a low symptom burden (moderate: adjusted odds ratio [AOR] = 2.7; 95% confidence interval [CI] = 1.3-5.3; high: AOR = 9.3; 95% CI = 4.2-20.6), discharge to PAC facility (moderate: AOR = 1.7; 95%CI = 1.2-2.6; high: AOR = 2.7; 95% CI = 1.4-5.1) but demonstrated no significant association with 30-day readmission or hospital length of stay longer than 5 days. CONCLUSION Greater burden of preoperative depressive symptoms is associated with increased likelihood of functional decline at 1 year after surgery and of discharge to PAC facility. Preoperative assessment of the burden of depressive symptoms in older adults undergoing elective surgery may be helpful in identifying patients at high risk of poor outcomes.
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Affiliation(s)
- Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Hospital Medicine, Department of Medicine, Veterans Affairs Medical Center, San Francisco, California, USA
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
- Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Molly Silvestrini
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah Ngo
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Eva M Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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30
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Ma M, Zhang L, Rosenthal R, Finlayson E, Russell MM. The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon. Semin Colon Rectal Surg 2020; 31:100779. [PMID: 33041604 PMCID: PMC7531280 DOI: 10.1016/j.scrs.2020.100779] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons’ (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.
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Affiliation(s)
- Meixi Ma
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL USA.,Department of Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL USA
| | - Lindsey Zhang
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL USA.,Department of Surgery, University of Chicago, Chicago, IL USA
| | | | - Emily Finlayson
- Department of Surgery, University of California San Francisco, San Francisco, CA USA
| | - Marcia M Russell
- Department of Surgery, University of California Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
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Smith EJT, Ramirez JL, Wu B, Zarkowsky DS, Gasper WJ, Finlayson E, Conte MS, Iannuzzi JC. Living in a Food Desert is Associated with 30-day Readmission after Revascularization for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 70:36-42. [PMID: 32628994 DOI: 10.1016/j.avsg.2020.06.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Living in a food desert has been associated with increased cardiovascular risk; however, its impact on vascular surgery outcomes is unknown. This study hypothesized that living in a food desert would be associated with increased postoperative complications in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI). METHODS This was a single-center retrospective analysis of open and endovascular infrainguinal revascularization for CLTI between April 2013 and December 2015. A food desert was defined using the US Department of Agriculture's Food Access Research Atlas. Bivariate analyses were performed appropriate to the data. Binary logistic regression was performed assessing the association of food desert status with 30-day postoperative complications. RESULTS In total, 152 cases were included, of which 17% (n = 26) resided in food deserts. Patients in the food desert cohort were less likely to be low income (27% vs. 54%, P = 0.01). Living in a food desert was associated with increased 30-day readmission [(39% vs. 20%, P = 0.04), unadjusted OR: 2.5 (CI: 1.0-6.2)]. FD cases also had a higher proportion of wound complications [12 (46%) vs. 28 (22%), P = 0.01)]. The overall wound complication rate was 27% with the majority being due to infections (63%). On multivariable analysis, food desert status remained associated with increased odds of 30-day readmission (OR: 2.7, CI: 1.2-8.4, P = 0.047). Reasons for readmission in the food desert group were all due to wound complications (100% vs. 72%, P = 0.08). CONCLUSIONS Living in a food desert was associated with nearly three times the odds of 30-day readmission after lower extremity revascularization for CLTI. This increase in readmission may be explained through increased wound complications. These findings support considering access to healthy food as a potential modifiable risk factor for adverse outcomes, particularly in CLTI revascularization.
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Affiliation(s)
- Eric J T Smith
- Department of Surgery, University of California, San Francisco, CA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, CA
| | - Bian Wu
- Department of Surgery, University of California, San Francisco, CA
| | | | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, CA.
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32
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Tang VL, Jing B, Boscardin J, Ngo S, Silvestrini M, Finlayson E, Covinsky KE. Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery. JAMA Surg 2020; 155:412-418. [PMID: 32159753 PMCID: PMC7066523 DOI: 10.1001/jamasurg.2020.0091] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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: 10/09/2019] [Accepted: 01/16/2020] [Indexed: 01/12/2023]
Abstract
Importance More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults. Objective To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery. Design, Setting, and Participants Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery. Exposures Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy. Main Outcomes and Measures Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors. Results Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55%) were women, 99 (7%) underwent abdominal aortic aneurysm repair, 686 (51%) coronary artery bypass graft, and 556 (42%) colectomy; 223 (17%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29% vs 13%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21% vs 14%; aHR, 1.32; P = .05), the inability to walk several blocks (17% vs 11%; aHR, 1.64; P = .01), dementia (21% vs 12%; aHR, 1.91; P = .03), and depression (19% vs 12%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0%; 1 factor: 16.2%; 2 factors: 27.8%). Conclusions and Relevance In this older adult cohort, 223 participants (17%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.
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Affiliation(s)
- Victoria L. Tang
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
- Northern California Institute for Research and Education, San Francisco
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
| | - Sarah Ngo
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | - Molly Silvestrini
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
- Northern California Institute for Research and Education, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
- Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Kenneth E. Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
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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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34
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Arsoniadis EG, Finlayson E, Potenti F. Is there a role for specialized geriatric centers in treating geriatric cancer patients? Eur J Surg Oncol 2020; 46:383-386. [PMID: 32005554 DOI: 10.1016/j.ejso.2019.12.012] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/21/2019] [Accepted: 12/13/2019] [Indexed: 11/26/2022] Open
Abstract
As the population with colorectal cancer ages, the tailored approach required to manage older patients becomes all the more important for all providers and institutions treating colorectal cancer to adopt and improve the outcomes and well-being of this important and increasingly prevalent population. Joint guidelines from the American College of Surgeons and American Geriatric Association should be followed. Older cancer patients undergoing colorectal cancer surgery should be referred to centers with expertise in minimally invasive surgery. Likewise, older rectal cancer patients should be referred to centers with expertise in treating rectal cancer.
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Affiliation(s)
- Elliot G Arsoniadis
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA; Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Fabio Potenti
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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35
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Suskind AM, Zhao S, Boscardin WJ, Smith A, Finlayson E. Time Spent Away from Home in the Year Following High-Risk Cancer Surgery in Older Adults. J Am Geriatr Soc 2020; 68:505-510. [PMID: 31981366 DOI: 10.1111/jgs.16344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 07/02/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To understand where older adults spend time (at home, in the hospital, or in a nursing home) in the year following high-risk cancer surgery. DESIGN Retrospective cohort study. SETTING Medicare beneficiaries using data from Medicare Inpatient claims to ascertain hospital days and the Minimum Data Set to ascertain nursing home days. PARTICIPANTS Beneficiaries who underwent high-risk cancer surgery (cystectomy, pancreaticoduodenectomy, gastrectomy, or esophagectomy) were identified to determine cumulative time spent away from home in the year following surgery. MEASUREMENTS Adjusted percentages of time spent away from home (ie, days in a hospital or nursing home) were modeled for the year following surgery. RESULTS A total of 37 748 beneficiaries underwent high-risk cancer surgery during the study period, and 28.3% died within 1 year. Overall, beneficiaries spent 13.9 ± 26.2 days in the hospital (over 1.5 ± 2.0 hospital readmissions) and 37.2 ± 50.6 days in the nursing home (over 1.5 ± 1.0 admissions) in the year following surgery. Among beneficiaries who were alive and dead at 1 year, 18.5% and 30.1% of time was spent away from home, respectively. Beneficiaries who were initially discharged to a facility following surgery and died within 1 year spent 44.4% of their final year away from home. CONCLUSION Time spent away from home in the hospital and/or nursing home in the year following high-risk cancer surgery is substantial among Medicare beneficiaries. This information is crucial in counseling patients on postoperative expectations and may additionally influence preoperative decision making. J Am Geriatr Soc 68:505-510, 2020.
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Affiliation(s)
- Anne M Suskind
- Department of Urology, University of California, San Francisco, California
| | - Shoujun Zhao
- Department of Urology, University of California, San Francisco, California
| | - W John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Alexander Smith
- Department of Medicine, Division of Geriatrics and Palliative Medicine, University of California, San Francisco, California
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, California
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36
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Tang V, Finlayson E, Covinsky K. Including the Family in Perioperative Care of Older Adults-A Call for HELP. JAMA Intern Med 2020; 180:25-26. [PMID: 31633747 DOI: 10.1001/jamainternmed.2019.4202] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Victoria Tang
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
| | - Emily Finlayson
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Department of Surgery, University of California, San Francisco, San Francisco
| | - Ken Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
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37
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Tang VL, Covinsky K, Finlayson E, Jing B, Boscardin J, Ngo S. GERIATRIC MEASURES AS PREDICTORS OF 1-YEAR MORTALITY IN MAJOR SURGERY PATIENTS. Innov Aging 2019. [PMCID: PMC6840257 DOI: 10.1093/geroni/igz038.1670] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A growing proportion of older adults are undergoing major surgery despite the higher risk of post-operative mortality. Geriatric measures (i.e. physical, cognitive, and psychosocial function) are often not included in studies evaluating post-operative outcomes in older adults. Our goal was to determine the association of geriatric measures and 1-year mortality in older adults after major surgery. We analyzed longitudinal data from the Health and Retirement Study linked to Medicare claims (N=1364 participants), age ≥ 65 and who underwent abdominal aortic aneurysm [AAA] repair, coronary artery bypass graft [CABG], or colectomy. Our outcome was mortality within 1 year of the major operation. Predictors included the following geriatric measures: dependence in activities of daily living (ADL), dependence in independent activities of daily living (IADL), mobility ability, and dementia, and depression. We analyzed using multivariate cox proportional hazard models. Mean participant age was 76±6 years, 56% were women, 11% underwent a AAA repair, 50% CABG, 40% colectomy; 18% died within 1 year of their major operation. After adjusting for age, comorbidity burden, surgical type, gender, race, wealth, income, and education, the following measures were significantly associated with 1-year mortality: depression (adjusted HR (aHR): 1.53, p=0.03), dementia (aHR: 1.90, p=0.03), >1 ADL dependence (aHR: 2.35, p<0.01), >1 IADL dependence (aHR: 1.95, p<0.01), and inability to walk several blocks (aHR: 1.69, p<0.01). In this cohort, 18% of participants who underwent major surgery died within 1 year and function, cognition, and psychological well-being were significantly associated with mortality. These measures should be incorporated into pre-operative assessment.
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Affiliation(s)
- Victoria L Tang
- University of California San Francisco, San Francisco, California, United States
| | - Kenneth Covinsky
- University of California San Francisco, San Francisco, California, United States
| | - Emily Finlayson
- University of California San Francisco, San Francisco, California, United States
| | - Bocheng Jing
- University of California San Francisco, San Francisco, California, United States
| | - John Boscardin
- University of California San Francisco, San Francisco, California, United States
| | - Sarah Ngo
- University of California San Francisco, San Francisco, California, United States
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Finlayson E. MEASUREMENT OF GERIATRIC SURGERY OUTCOMES IN A NATIONAL REGISTRY. Innov Aging 2019. [PMCID: PMC6840697 DOI: 10.1093/geroni/igz038.1486] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The American College of Surgeons National Quality Improvement Program started a “Geriatric Pilot” in January 2014. This project has already collected 19 additional older adult specialty variables in more than 60,000 patients undergoing operations. Twenty-six medical centers participate from across North America. The variables collect information in the domains of cognition, function, mobility and decision-making. Variables are collected in both the pre- and post-operative settings. It is clear that the quality of surgical care cannot be limited to the immediate hospitalization. The pilot has recently expanded its use of longer-term outcomes and has begun collecting 30-day outcomes of functional status and living location.
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Affiliation(s)
- Emily Finlayson
- University of California San Francisco, San Francisco, California, United States
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39
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Tang V, Zhao S, Boscardin J, Sudore R, Covinsky K, Walter LC, Esserman L, Mukhtar R, Finlayson E. Functional Status and Survival After Breast Cancer Surgery in Nursing Home Residents. JAMA Surg 2019; 153:1090-1096. [PMID: 30167636 DOI: 10.1001/jamasurg.2018.2736] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Breast cancer surgery, the most common cancer operation performed in nursing home residents, is viewed as a low-risk surgical intervention. However, outcomes in patients with high functional dependence and limited life expectancy are poorly understood. Objective To assess the overall survival and functional status changes after breast cancer surgery in female nursing home residents stratified by surgery type. Design, Setting, and Participants This study used Medicare claims from 2003 to 2013 to identify 5969 US nursing home residents who underwent inpatient breast cancer surgery. Using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, this study examined preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs) of mortality. Fine-Gray competing risks regression was used to estimate unadjusted and adjusted subhazard ratios (sHRs) of functional decline. Statistical analysis was performed from January 2016 to January 2018. Main Outcomes and Measures Functional status and death. Results From 2003 to 2013, a total of 5969 female nursing home residents (mean [SD] age, 82 [7] years; 4960 [83.1%] white) underwent breast cancer surgery: 666 (11.2%) underwent lumpectomy, 1642 (27.5%) underwent mastectomy, and 3661 (61.3%) underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND). The 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND. The 1-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND. Among 1-year survivors, the functional decline rate was 56% to 60%. The mean MDS-ADL score increased (signifying greater dependency) by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND. In multivariate analysis, poor baseline MDS-ADL score (range, 20-28) was associated with a higher 1-year mortality risk (lumpectomy: HR, 1.92 [95% CI, 1.23-3.00], P = .004; mastectomy: HR, 1.80 [95% CI, 1.35-2.39], P < .001; and ALND: HR, 1.77 [95% CI, 1.46-2.15], P < .001). After multivariate adjustment, preoperative decline in MDS-ADL score (lumpectomy: sHR, 1.59 [95% CI, 1.25-2.03], P < .001; mastectomy: sHR, 1.79; [95% CI, 1.52-2.09], P < .001; and ALND: sHR, 1.72 [95% CI, 1.56-1.91], P < .001) and cognitive impairment (lumpectomy: sHR, 1.27 [95% CI, 1.03-1.56], P = .02; mastectomy: sHR, 1.26 [95% CI, 1.09-1.45], P = .002; and ALND: sHR, 1.14 [95% CI, 1.04-1.24], P = .003) were significantly associated with 1-year functional decline across all breast cancer surgery groups. Conclusions and Relevance For female nursing home residents who underwent breast cancer surgery, 30-day mortality and survival as well as 1-year mortality and functional decline were high. The 1-year survivors had significant functional decline. This study's findings suggest that this information should be incorporated into collaborative surgical decision-making processes.
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Affiliation(s)
- Victoria Tang
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Shoujun Zhao
- Department of Surgery, University of California, San Francisco
| | - John Boscardin
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Rebecca Sudore
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kenneth Covinsky
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Louise C Walter
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco.,Department of Radiology, University of California, San Francisco.,Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Rita Mukhtar
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco.,Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco
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Kata A, Buffington A, Tucholka JL, Brasel KJ, Cooper Z, Finlayson E, Mosenthal AC, Hanlon BM, Marka NA, Schwarze ML. Effectiveness of a Question Prompt List on Patient-Reported Concerns and Well-Being: A Multisite Randomized Controlled Trial. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.197] [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: 11/30/2022]
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41
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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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42
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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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Kaplan JA, Tang V, Finlayson E. How Did We Get Here? A Broader View of the Postoperative Period. Anesthesiol Clin 2019; 37:411-422. [PMID: 31337475 DOI: 10.1016/j.anclin.2019.04.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The decision to offer surgery to an older adult with medical comorbidities involves candid conversations between the surgeon, patient, and caregivers. Tools are available to physicians that facilitate patient empowerment. Beyond short-term risks, the conversation should include the potential for institutional discharge, functional and cognitive decline, and longer term mortality.
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Affiliation(s)
- Jennifer Anne Kaplan
- Department of Surgery, University of Minnesota, 420 Delaware Street, PWB 11-145E, MMC 195, Minneapolis, MN 55455, USA
| | - Victoria Tang
- Division of Geriatric Medicine, University of California, San Francisco, San Francisco Veterans Affairs Medical Center, 4150 Clement Street 181(G), San Francisco, CA 94121, USA
| | - Emily Finlayson
- Department of Surgery, Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94115, USA; Department of Medicine, Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94115, USA.
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Kata A, Dutt M, Sudore RL, Finlayson E, Broering JM, Tang VL. What Matters? The Valued Life Activities of Older Adults Undergoing Elective Surgery. J Am Geriatr Soc 2019; 67:2305-2310. [PMID: 31400227 DOI: 10.1111/jgs.16102] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 03/18/2019] [Revised: 06/10/2019] [Accepted: 07/05/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Valued life activities are those activities an individual deems particularly important or meaningful. Surgery in older adults can affect their ability to perform valued activities, but data are lacking. We characterized these activities and assessed performance of them following surgery. DESIGN Retrospective observational study. SETTING Preoperative program for older adults undergoing elective surgery at an academic hospital. PARTICIPANTS Older adults (N = 194) in the program from February 2015 to February 2018. MEASUREMENTS A preoperative written questionnaire asked, "What are the activities that are most important to you to be able to do when you return home from surgery?" Participants could list up to three activities. Content analysis was used to develop domains of valued life activities and categorize responses. Postoperative questionnaires and medical records were used to determine ability to perform activities 6 months after surgery. RESULTS Of 194 participants (mean age = 74.9 ± 9.1 y), 57.7% were female; 33.5% had more than two comorbid conditions. We elicited 510 valued activities, with a mean of 2.6 (± .7) activities per participant. Content analysis revealed five categories: (1) recreational activities (28.9%); (2) mobility (24.9%); (3) activities of daily living (ADLs; 17.5%); (4) instrumental activities of daily living (IADLs; 16.9%); and (5) social activities (12.0%). Ultimately, 154 participants had surgery, of which 27.3% were unable to perform one of their valued activities at 6 months. Performance varied between activity categories; 91.9% of mobility activities, 90.8% of ADLs, 80.3% of IADLs, 77.3% of social activities, and 65.5% of recreational activities were able to be performed after surgery. CONCLUSION Older adults expressed a wide range of valued life activities. More than one-quarter were unable to engage in at least one valued life activity after surgery, with recreation the most commonly affected. Assessment of valued life activities should be incorporated into the perioperative management of older adults. J Am Geriatr Soc 67:2305-2310, 2019.
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Affiliation(s)
- Anna Kata
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Meghan Dutt
- California Northstate University, College of Medicine, Elk Grove, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California.,Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | - Emily Finlayson
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California.,Department of Surgery, University of California, San Francisco, California
| | | | - Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California.,Division of Hospital Medicine, Department of Medicine, Veterans Affairs Medical Center, San Francisco, California
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Suskind AM, Kowalik C, Quanstrom K, Boscardin J, Zhao S, Reynolds WS, Mishra K, Finlayson E. The impact of frailty on treatment for overactive bladder in older adults. Neurourol Urodyn 2019; 38:1915-1923. [PMID: 31286561 DOI: 10.1002/nau.24093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 03/27/2019] [Accepted: 06/17/2019] [Indexed: 01/17/2023]
Abstract
AIMS To examine the impact of frailty on treatment outcomes for overactive bladder (OAB) in older adults starting pharmacotherapy, onabotulinumtoxinA, and sacral neuromodulation. METHODS This is a prospective study of men and women age ≥60 years starting pharmacotherapy, onabotulinumtoxinA, or sacral neuromodulation. Subjects were administered questionnaires at baseline and again at 1- and 3-months. Frailty was assessed at baseline using the timed up and go test (TUGT), whereby a TUGT time of ≥12 seconds was considered to be slow, or frail. Response to treatment was assessed using the overactive bladder symptom score (OABSS) and the OAB-q SF (both Bother and HRQOL subscales). Information on side effects/adverse events was also collected. Mixed effects linear modeling was used to model changes in outcomes over time both within and between groups. RESULTS A total of 45 subjects enrolled in the study, 40% (N = 18) of whom had a TUGT ≥12 seconds. Both TUGT groups demonstrated improvement in OAB symptoms over time and there were no statistically significant differences in these responses per group (all P-values >.05). Similar trends were found for both OAB-q SF Bother and OAB-q SF HRQOL questionnaire responses. Side effects and adverse events were not significantly different between groups (all P's >.05). CONCLUSIONS Adults ≥60 years of age starting second- and third-line treatments for OAB, regardless of TUGT time, demonstrated improvement in OAB symptoms at 3 months. These findings suggest that frail older adults may receive comparable benefit and similar rates of side effects compared with less frail older individuals.
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Affiliation(s)
- Anne M Suskind
- Department of Urology, University of California, San Francisco, California
| | - Casey Kowalik
- Department of Urology, University of Kansas Medical Center, Kansas City, Missouri
| | - Kathryn Quanstrom
- Department of Urology, University of California, San Francisco, California
| | - John Boscardin
- Department of Biostatistics, Uinversity of California, San Francisco, California
| | - Shoujun Zhao
- Department of Urology, University of California, San Francisco, California
| | | | - Kavita Mishra
- Department of Obstetrics and Gynecology, Standford University, California
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, California
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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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Washington SL, Porten SP, Quanstrom K, Jin C, Bridge M, Finlayson E, Walter LC, Suskind AM. The Association Between Race and Frailty in Older Adults Presenting to a Nononcologic Urology Practice. Urology 2019; 127:19-23. [PMID: 30822479 DOI: 10.1016/j.urology.2019.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/08/2019] [Accepted: 02/21/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To explore whether there is an association between nonwhite race and frailty among older adults presenting to an academic nononcologic urology practice. MATERIALS AND METHODS This is a prospective study of individuals ages ≥65years presenting to a nononcologic urology practice between December 2015 and November 2016. All individuals had a Timed Up and Go Test (TUGT, where a slower TUGT time of ≥15 seconds is suggestive of frailty. TUGT times, race (white vs nonwhite), and other clinical data were extracted from the electronic medical record using direct queries. Multivariable logistic regression was used to identify the association between race and slower TUGT times while adjusting for age, gender, number of medications, body mass index, and number of urologic diagnoses. RESULTS Among the 1715 individuals in our cohort, 33.9% were of nonwhite race and 15.3% had TUGT ≥15 seconds. A higher percentage of nonwhite individuals had TUGT times ≥15 seconds compared to white individuals (23.6% vs 11.1%, P <.01). TUGT times ≥15 seconds were significantly associated with nonwhite race after adjusting for clinical factors (adjusted odds ratio 2.5, 95% confidence interval 1.8-3.3). CONCLUSION Among older adults presenting to an academic nononcologic urology practice, nonwhite race was associated with increased odds of frailty. A greater understanding of the relationship between race and frailty is needed to better address the needs of this vulnerable population.
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Affiliation(s)
| | - Sima P Porten
- Department of Urology, University of California, San Francisco, CA
| | | | - Chengshi Jin
- Department of Urology, University of California, San Francisco, CA
| | - Mark Bridge
- Department of Urology, University of California, San Francisco, CA
| | - Emily Finlayson
- Department of General Surgery, University of California, San Francisco, CA
| | - Louise C Walter
- Division of Geriatrics, University of California, San Francisco, CA; San Francisco VA Medical Center, San Francisco, CA
| | - Anne M Suskind
- Department of Urology, University of California, San Francisco, CA
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Hornor MA, Tang VL, Berian J, Robinson TN, Coleman J, Katlic MR, Rosenthal RA, Christensen K, Baker T, Finlayson E, Lagoo‐Deenadaayalan SA, Ko CY, Russell MM. Optimizing the Feasibility and Scalability of a Geriatric Surgery Quality Improvement Initiative. J Am Geriatr Soc 2019; 67:1074-1078. [DOI: 10.1111/jgs.15815] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Melissa A. Hornor
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Victoria L. Tang
- Division of Geriatrics, Department of MedicineUniversity of California, San Francisco San Francisco California
| | - Julia Berian
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
- Department of SurgeryUniversity of Chicago Chicago Illinois
| | | | - JoAnn Coleman
- Department of Surgery, Sinai Center for Geriatric SurgerySinai Hospital Baltimore Maryland
| | - Mark R. Katlic
- Department of Surgery, Sinai Center for Geriatric SurgerySinai Hospital Baltimore Maryland
| | | | - Kataryna Christensen
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
| | - Tracey Baker
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
| | - Emily Finlayson
- Department of SurgeryUniversity of California, San Francisco San Francisco California
| | | | - Clifford Y. Ko
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
- Department of SurgeryUniversity of California, Los Angeles Los Angeles California
| | - Marcia M. Russell
- Department of SurgeryUniversity of California, Los Angeles Los Angeles California
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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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