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Poultsides GA, Kebebew E, Hawn MT. Festschrift for Dr. Jeffrey A. Norton, 12-13 October 2023, Stanford, CA, USA. Ann Surg Oncol 2024; 31:3591-3594. [PMID: 38488895 DOI: 10.1245/s10434-024-15160-9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/17/2024]
Affiliation(s)
- George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Dixit AA, Bateman BT, Hawn MT, Odden MC, Sun EC. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA 2024:2817853. [PMID: 38648036 PMCID: PMC11036309 DOI: 10.1001/jama.2024.5003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/08/2024] [Indexed: 04/25/2024]
Abstract
This cohort study evaluates the risk of postoperative respiratory complications among patients with diabetes undergoing surgery who had vs those who had not a prescription fill for glucagon-like peptide 1 receptor agonists.
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Affiliation(s)
- Anjali A. Dixit
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Mary T. Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Michelle C. Odden
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Eric C. Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Hawn MT. Philanthropic support of academic programs. Surgery 2024; 175:1250-1251. [PMID: 38281853 DOI: 10.1016/j.surg.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024]
Abstract
Academic surgical departments must subsidize the research mission, as most funded research does not fully support the faculty effort and true costs of the investigation. Most departments support their research program with the margin from clinical revenue; however, increased pressure on clinical income poses a challenge to this strategy. Philanthropy is an increasingly important revenue source to fund academic missions. The opportunities and challenges of this funding source are discussed in this article.
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Affiliation(s)
- Mary T Hawn
- Stanford University School of Medicine, Stanford, CA.
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Graham LA, Illarmo S, Gray CP, Harris AHS, Wagner TH, Hawn MT, Iannuzzi JC, Wren SM. Mapping the Discharge Process After Surgery. JAMA Surg 2024; 159:438-444. [PMID: 38381415 PMCID: PMC10882508 DOI: 10.1001/jamasurg.2023.7539] [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: 08/17/2023] [Accepted: 10/28/2023] [Indexed: 02/22/2024]
Abstract
Importance Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. Objective To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. Design, Setting, and Participants This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Exposure Postoperative hospital discharge. Main Outcomes and Measures Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. Results At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. Conclusions and Relevance These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Caroline P. Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Alex H. S. Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T. Hawn
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - James C. Iannuzzi
- Department of Surgery, San Francisco VA Medical Center, San Francisco, California
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco
| | - Sherry M. Wren
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
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Decker HC, Graham LA, Titan A, Hawn MT, Kanzaria HK, Wick E, Kushel MB. Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans. Health Aff (Millwood) 2024; 43:234-241. [PMID: 38315919 DOI: 10.1377/hlthaff.2023.01003] [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] [Indexed: 02/07/2024]
Abstract
Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.
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Affiliation(s)
- Hannah C Decker
- Hannah C. Decker , University of California San Francisco, San Francisco, California
| | - Laura A Graham
- Laura A. Graham, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Ashley Titan
- Ashley Titan, Stanford University, Stanford, California
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Graham LA, Hawn MT. Managing Competing Risks for Surgical Patients With Complex Medical Problems-Considering Confounding. JAMA Surg 2024; 159:149-150. [PMID: 37991777 DOI: 10.1001/jamasurg.2023.5952] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Laura A Graham
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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Decker HC, Graham LA, Titan A, Kanzaria HK, Hawn MT, Kushel M, Wick E. Housing Status, Cancer Care, and Associated Outcomes Among US Veterans. JAMA Netw Open 2023; 6:e2349143. [PMID: 38127343 PMCID: PMC10739065 DOI: 10.1001/jamanetworkopen.2023.49143] [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] [Received: 06/25/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. Objective To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. Design, Setting, and Participants This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Exposures Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. Main Outcomes and Measures The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. Results This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. Conclusions and Relevance In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.
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Affiliation(s)
| | - Laura A. Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- S-SPIRE, Stanford University, Stanford, California
| | - Ashley Titan
- Department of Surgery, Stanford University, Stanford, California
| | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Mary T. Hawn
- Department of Surgery, Stanford University, Stanford, California
| | - Margot Kushel
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Division of General Internal Medicine, Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
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Affiliation(s)
- Laura A Graham
- Stanford University, School of Medicine, Stanford, California
- VA Palo Alto Healthcare System, Palo Alto, California
| | - Yvonne A Maldonado
- Stanford University, School of Medicine, Stanford, California
- Stanford Health Care and Lucile Packard Children's Hospital, Stanford, California
| | - Lucy S Tompkins
- Stanford University, School of Medicine, Stanford, California
| | - Samuel H Wald
- Stanford University, School of Medicine, Stanford, California
| | - Amanda Chawla
- Stanford Health Care and Lucile Packard Children's Hospital, Stanford, California
| | - Mary T Hawn
- Stanford University, School of Medicine, Stanford, California
- VA Palo Alto Healthcare System, Palo Alto, California
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Boland CR, Koi M, Hawn MT, Carethers JM, Yurgelun MB. Serendipity Strikes: How Pursuing Novel Hypotheses Shifted the Paradigm Regarding the Genetic Basis of Colorectal Cancer and Changed Cancer Therapy. Dig Dis Sci 2023; 68:3504-3513. [PMID: 37402979 DOI: 10.1007/s10620-023-08006-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 07/06/2023]
Abstract
In this installment of the "Paradigm Shifts in Perspective" series, the authors, all scientists who have been involved in colorectal cancer (CRC) research for most or all of their careers, have watched the field develop from early pathological descriptions of tumor formation to the current understanding of tumor pathogenesis that informs personalized therapies. We outline how our understanding of the pathogenetic basis of CRC began with seemingly isolated discoveries-initially with the mutations in RAS and the APC gene, the latter of which was initially found in the context of intestinal polyposis, to the more complex process of multistep carcinogenesis, to the chase for tumor suppressor genes, which led to the unexpected discovery of microsatellite instability (MSI). These discoveries enabled the authors to better understand how the DNA mismatch repair (MMR) system not only recognizes DNA damage but also responds to damage by DNA repair or by triggering apoptosis in the injured cell. This work served, in part, to link the earlier findings on the pathogenesis of CRC to the development of immune checkpoint inhibitors, which has been transformative-and curative-for certain types of CRCs and other cancers as well. These discoveries also highlight the circuitous routes that scientific progress takes, which can include thoughtful hypothesis testing and at other times recognizing the importance of seemingly serendipitous observations that substantially change the flow and direction of the discovery process. What has happened over the past 37 years was not predictable when this journey began, but it does speak to the power of careful scientific experimentation, following the facts, perseverance in the face of opposition, and the willingness to think outside of established paradigms.
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Affiliation(s)
| | | | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, CJ Huang Bldg, Palo Alto, CA, 94306, USA
| | | | - Matthew B Yurgelun
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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Graham LA, Gray C, Wagner TH, Illarmo S, Hawn MT, Wren SM, Iannuzzi J, Harris AHS. Applying cognitive task analysis to health services research. Health Serv Res 2023; 58:415-422. [PMID: 36421922 PMCID: PMC10012243 DOI: 10.1111/1475-6773.14106] [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] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study. DATA SOURCES AND STUDY SETTING Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration. STUDY DESIGN Qualitative study of discharge planning using CTA. DATA COLLECTION/EXTRACTION METHODS Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis. PRINCIPAL FINDINGS We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task. CONCLUSIONS A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Department of SurgeryStanford‐Surgery Policy Improvement Research and Education Center (S‐SPIRE), Stanford UniversityStanfordCaliforniaUSA
| | - Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Department of SurgeryStanford‐Surgery Policy Improvement Research and Education Center (S‐SPIRE), Stanford UniversityStanfordCaliforniaUSA
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Mary T. Hawn
- Department of General SurgeryVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
- Department of SurgeryStanford UniversityStanfordCaliforniaUSA
| | - Sherry M. Wren
- Department of General SurgeryVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
- Department of SurgeryStanford UniversityStanfordCaliforniaUSA
| | - James Iannuzzi
- Department of SurgerySan Francisco Veterans Affairs Healthcare SystemSan FranciscoCaliforniaUSA
- Division of Vascular Surgery, Department of SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Alex H. S. Harris
- Department of SurgeryStanford‐Surgery Policy Improvement Research and Education Center (S‐SPIRE), Stanford UniversityStanfordCaliforniaUSA
- Center for Innovation to Implementation, VA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
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Pugh CM, Kirton OC, Tuttle JEB, Maier RV, Hu YY, Stewart JH, Freischlag JA, Sosa JA, Vickers SM, Hawn MT, Eberlein TJ, Farmer DL, Higgins RS, Pellegrini CA, Roman SA, Crandall ML, De Virgilio CM, Tsung A, Britt LD. Addressing the Surgical Workplace: An Opportunity to Create a Culture of Belonging. Ann Surg 2023; 277:551-556. [PMID: 36575980 DOI: 10.1097/sla.0000000000005773] [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] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Carla M Pugh
- Department of Surgery, Stanford Medicine, Stanford California
| | - Orlando C Kirton
- Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - J E Betsy Tuttle
- Department of Surgery, E. Carolina University/Brody School of Medicine, Greenville, North Carolina
| | - Ronald V Maier
- Department of Surgery, University of Washington Medicine, Seattle, Washington
| | - Yue-Yung Hu
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Evanston, Illinois
| | - John H Stewart
- Department of Surgery, LSU Health New Orleans, Shreveport, Louisiana
| | - Julie Ann Freischlag
- Department of Vascular and Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Selwyn M Vickers
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary T Hawn
- Department of Surgery, Stanford Medicine, Stanford California
| | - Timothy J Eberlein
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Diana L Farmer
- Department of Surgery, University of California Davis Health, Davis, California
| | - Robert S Higgins
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Sanziana A Roman
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Marie L Crandall
- Department of Surgery, University of Florida at Jacksonville, Jacksonville, Florida
| | | | - Allan Tsung
- Department of Surgery, University of Virginia Health, Charlottesville, Virginia
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Shapiro LM, Graham LA, Hawn MT, Kamal RN. Quality Reporting Windows May Not Capture the Effects of Surgical Site Infections After Orthopaedic Surgery. J Bone Joint Surg Am 2022; 104:1281-1291. [PMID: 35856929 DOI: 10.2106/jbjs.21.01278] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative surgical site infections (SSIs) and the associated complications impact morbidity and mortality and result in substantial burden to the health-care system. These complications are typically reported during the 90-day surveillance period, with implications for reimbursement and quality measurement; however, the long-term effects of SSI are not routinely assessed. We evaluated the long-term effects of SSI on health-care utilization and cost following orthopaedic surgery in an observational cohort study. METHODS Patients in the Veterans Affairs health-care system who underwent an orthopaedic surgical procedure were included. The exposure of interest was an SSI within 90 days after the index procedure. The primary outcome was health-care utilization in the 2 years after discharge. Data for inpatient admission, inpatient days, outpatient visits, emergency room visits, total costs, and subsequent surgeries were also obtained. After adjusting for factors affecting SSI, we examined differences in each health-care utilization outcome by postoperative SSI occurrence and across time with use of differences-in-differences analysis. Cost differences were modeled with use of a gamma distribution with a log link. RESULTS A total of 96,983 patients were included, of whom 4,056 (4.2%) had an SSI within 90 days of surgery. After adjusting for factors known to impact SSI and preoperative health-care utilization, SSI was associated with a greater risk of outpatient visits (relative risk [RR], 1.29; 95% confidence interval [CI], 1.26 to 1.32), emergency room visits (RR, 1.18; 95% CI, 1.15 to 1.21), and inpatient admission (RR, 1.35; 95% CI, 1.32 to 1.38) at 2 years postoperatively. The average cost among patients with an SSI was $148,824 ± $268,358 compared with $42,125 ± $124,914 among those without an SSI (p < 0.001). In the adjusted analysis, costs for patients with an SSI were 64% greater at 2 years compared with those without an SSI (RR, 1.64; 95% CI, 1.57 to 1.70). Overall, of all subsequent surgeries conducted within the 2-year postoperative period, 37% occurred within the first 90 days. CONCLUSIONS The reported effects of a postoperative SSI on health-care utilization and cost are sustained at 2 years post-surgery-a long-term impact that is not recognized in quality-measurement models. Efforts, including preoperative care pathways and optimization, and policies, including reimbursement models and risk-adjustment, should be made to reduce SSI and to account for these long-term effects. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, California
| | - Laura A Graham
- Stanford University School of Medicine, Stanford, California
| | - Mary T Hawn
- Stanford University School of Medicine, Stanford, California
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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Buyske J, Hawn MT. Delivering Better Solutions for Women Physicians Who Experience Pregnancy, Childbirth, and Childrearing. Acad Med 2022; 97:955-957. [PMID: 35234718 DOI: 10.1097/acm.0000000000004642] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
As the number of women physicians entering the field of medicine has increased over the past decades, pregnancy and maternity leave are becoming common place during both training and independent practice. However, the current system is not designed for extended leaves of absence from the clinical environment. In this commentary, the authors review recent changes in regulatory requirements impacting women physicians in postgraduate training who experience pregnancy, childbirth, and childrearing and identify solutions that may result in more optimal work environments for women physicians in practice who experience pregnancy, childbirth, and childrearing.
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Affiliation(s)
- Jo Buyske
- J. Buyske is president and chief executive officer, American Board of Surgery, Philadelphia, Pennsylvania
| | - Mary T Hawn
- M.T. Hawn is the Emile Holman Professor of Surgery and chair, Department of Surgery, Stanford University School of Medicine, Stanford, California, and vice chair, American Board of Surgery, Philadelphia, Pennsylvania
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Abstract
IMPORTANCE The association between physician fatigue and patient outcomes is important to understand but has been difficult to examine given methodological and data limitations. Surgeons frequently perform urgent procedures overnight and perform additional procedures the following day, which could adversely affect outcomes for those daytime operations. OBJECTIVE To examine the association between an attending surgeon operating overnight and outcomes for operations performed by that surgeon the next day. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, a retrospective analysis of a large multicenter registry of surgical procedures was done using a within-surgeon analysis to address confounding, with data from 20 high-volume US institutions. This study included 498 234 patients who underwent a surgical procedure during the day (between 7 am and 5 pm) between January 1, 2010, and August 30, 2020. EXPOSURES Whether the attending surgeon for the current day's procedures operated between 11 pm and 7 am the previous night. Two exposure measures were examined: whether the surgeon operated at all the previous night and the number of hours spent operating the previous night (including having performed no work at all). MAIN OUTCOMES AND MEASURES The primary composite outcome was in-hospital death or major complication (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke). Secondary outcomes included operation length and individual outcomes of death, major complications, and minor complications (surgical site infection or urinary tract infection). RESULTS Among 498 234 daytime operations performed by 1131 surgeons, 13 098 (2.6%) involved an attending surgeon who operated the night before. The mean (SD) age of the patients who underwent an operation was 55.3 (16.4) years, and 264 740 (53.1%) were female. After adjusting for operation type, surgeon fixed effects, and observable patient characteristics (ie, age and comorbidities), the adjusted incidence of in-hospital death or major complications was 5.89% (95% CI, 5.41%-6.36%) among daytime operations when the attending surgeon operated the night before compared with 5.87% (95% CI, 5.85%-5.89%) among daytime operations when the same surgeon did not (absolute adjusted difference, 0.02%; 95% CI, -0.47% to 0.51%; P = .93). No significant associations were found between overnight work and secondary outcomes except for operation length. Operating the previous night was associated with a statistically significant decrease in length of daytime operations (adjusted length, 112.7 vs 117.4 minutes; adjusted difference, -4.7 minutes; 95% CI, -8.7 to -0.8, P = .02), although this difference is unlikely to be meaningful. CONCLUSIONS AND RELEVANCE The findings of this cross-sectional study suggest that operating overnight was not associated with worse outcomes for operations performed by surgeons the subsequent day. These results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform operations the following morning.
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Affiliation(s)
- Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,Department of Health Policy, Stanford University School of Medicine, Stanford, California
| | - Michelle M Mello
- Department of Health Policy, Stanford University School of Medicine, Stanford, California.,Stanford Law School, Stanford, California.,Freeman Spogli Institute for International Studies, Stanford University, Stanford, California
| | - Michelle T Vaughn
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Massachusetts General Hospital, Boston.,National Bureau of Economic Research, Cambridge, Massachusetts
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15
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Alimi YR, Esquivel MM, Hawn MT. Laparoscopic Heller Myotomy and Toupet Fundoplication. World J Surg 2022; 46:1535-1541. [DOI: 10.1007/s00268-022-06471-7] [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] [Accepted: 01/16/2022] [Indexed: 10/19/2022]
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16
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Ma IT, Dayani F, Yesantharao P, Chang J, Hawn MT, Wald S, Lee GK, Nazerali R. Single Institution's Plastic Surgery Case Trends and Considerations in the Midst of COVID-19. Plast Reconstr Surg 2022; 149:169e-171e. [PMID: 34878421 PMCID: PMC8691162 DOI: 10.1097/prs.0000000000008657] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text.
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Affiliation(s)
- Irene T Ma
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Fara Dayani
- University of California, San Francisco School of Medicine
| | | | - James Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Mary T Hawn
- Division of General Surgery, Department of Surgery, Stanford University
| | - Samuel Wald
- Department of Anesthesia, Stanford University
| | - Gordon K Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
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17
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Abstract
BACKGROUND More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING This study was conducted at a Veterans Affairs medical center. SETTING Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL ANTECEDENTES:Más del 50% de complicaciones postoperatorias de la herida ocurren después del alta. Es la complicación postoperatoria más común y el motivo más frecuente de reingreso después del procedimiento quirúrgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida después del alta quirúrgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las características de las complicaciones de la herida, identificadas después del alta hospitalaria, en pacientes sometidos a cirugía colorrectal, en comparación con las complicaciones intrahospitalarias.DISEÑO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirúrgica de la Administración de Salud de Veteranos.ENTORNO CLÍNICO:Administración de Veteranos.PACIENTES:Pacientes sometidos a resección colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACIÓN:Costos de atención ajustados al alta, 30 días y 90 días después de la cirugía.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicación de la herida dentro de los 30 días de la cirugía. (49,2% índice hospitalario, 50,8% después del alta). En comparación con los pacientes, del índice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), más infecciones de órganos/espacios quirúrgicos (14,3% frente a 10,1%, p <0,01), tasas más altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberían de haber tenido un abordaje laparoscópico para su cirugía (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugía a los 30 días, fue de $ 37,315 (desviación estándar = $ 29,319). En comparación con el índice de complicaciones de las herida hospitalaria, las complicaciones de la herida después del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 días y $ 9,736 (15%, p<0,001) y menor costo a los 90 días. Los pacientes con índice de complicación de la herida hospitalaria, tenían un 40% menos de probabilidades de requerir reingreso a los 30 días, pero sus reingresos eran $ 12,518 más costosos que los reingresos entre los pacientes presentando complicación de la herida recién identificada después del alta (p <0,001).LIMITACIONES:Limitado a las características del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 días, que aquellos con complicaciones de la herida identificadas durante su índice de hospitalización y aproximadamente la mitad fueron tratados de forma ambulatoria.
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Affiliation(s)
- Laura A Graham
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Todd H Wagner
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Tanmaya D Sambare
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T Hawn
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
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Rajasingh CM, Graham LA, Richman J, Mell MW, Morris MS, Hawn MT. Challenging weekend discharges associated with excess length of stay in surgical patients at Veterans Affairs hospitals. Surgery 2021; 171:405-410. [PMID: 34736786 DOI: 10.1016/j.surg.2021.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Challenging discharges can lead to prolonged hospital stays. We hypothesized that surgical patients discharged from Veterans Affairs hospitals on weekdays have longer hospital stays and greater excess length of stay. METHODS We identified inpatient general and vascular procedures at Veterans Affairs hospitals from 2007 to 2014. Expected length of stay was calculated using a stratified negative binomial model adjusted for patient/operative characteristics. Excess length of stay was defined as the difference between observed and expected length of stay. RESULTS We identified 135,875 patients (80.4% weekday discharges, 19.6% weekend discharges). The average length of stay was 7.5 days. Patients with weekday discharges spent on average 2.5 more days in the hospital compared with patients discharged on weekends (8.0 vs. 5.5 days, P < .001); 28.5% of patients with weekday discharges had an observed length of stay at least 1 day longer than expected, compared with 16.4% of patients with weekend discharges (P < .001). CONCLUSION Surgical patients are less frequently discharged from Veterans Affairs hospitals on the weekends than during the week, and this corresponds to an increased excess length of stay for patients ultimately discharged on weekdays. Exploring the opportunity to coordinate safe weekend discharges may improve efficiency of post-surgery hospital care and reduce healthcare costs.
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Affiliation(s)
| | - Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, CA; S-SPIRE Center, Department of Surgery, Stanford University, CA
| | - Joshua Richman
- Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, AL
| | - Matthew W Mell
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Melanie S Morris
- Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, AL
| | - Mary T Hawn
- Department of Surgery, Stanford University, CA
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Graham LA, Hawn MT, Dasinger EA, Baker SJ, Oriel BS, Wahl TS, Richman JS, Copeland LA, Itani KM, Burns EA, Whittle J, Morris MS. Psychosocial Determinants of Readmission After Surgery. Med Care 2021; 59:864-871. [PMID: 34149017 PMCID: PMC8425630 DOI: 10.1097/mlr.0000000000001600] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood. OBJECTIVE We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population. RESEARCH DESIGN This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital. SUBJECTS We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015-June 30, 2017). MEASURES We assessed unplanned readmission to any medical facility within 30 days of hospital discharge. RESULTS A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score <31 as the most important psychosocial determinant of readmission after surgery. CONCLUSIONS Mental health concerns, inadequate health literacy, and lower social support after hospital discharge are significant predictors of increased unplanned readmissions after major general, vascular, or thoracic surgery. These elements should be incorporated into routinely collected electronic health record data. Also, discharge plans should accommodate varying levels of health literacy and consider how the patient's mental health and social support needs will affect recovery.
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Affiliation(s)
- Laura A. Graham
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System
- Department of Surgery, Stanford-Surgery Policy, Improvement Research, and Education (S-SPIRE) Center, Stanford University School of Medicine, Palo Alto, CA
| | - Mary T. Hawn
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System
- Department of Surgery, Stanford-Surgery Policy, Improvement Research, and Education (S-SPIRE) Center, Stanford University School of Medicine, Palo Alto, CA
| | - Elise A. Dasinger
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Samantha J. Baker
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Brad S. Oriel
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston
| | - Tyler S. Wahl
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Joshua S. Richman
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Laurel A. Copeland
- VA Central Western Massachusetts Healthcare System, Leeds
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Kamal M.F. Itani
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston
- Department of Medicine, Harvard University School of Medicine, Boston, MA
| | - Edith A. Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI
- Zucker School of Medicine at Hofstra Northwell, Manhasset, NY
| | - Jeffrey Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Melanie S. Morris
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
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20
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Farber ON, Gomez GI, Titan AL, Fisher AT, Puntasecca CJ, Arana VT, Kempinsky A, Wise CE, Bessoff KE, Hawn MT, Korndorffer JR, Forrester JD, Esquivel MM. Impact of COVID-19 on presentation, management, and outcomes of acute care surgery for gallbladder disease and acute appendicitis. World J Gastrointest Surg 2021; 13:859-870. [PMID: 34512909 PMCID: PMC8394376 DOI: 10.4240/wjgs.v13.i8.859] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/31/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management.
AIM To examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.
METHODS A retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson’s r correlation coefficient. Variables were compared using the Welch’s t-Test, Chi-squared tests, and Fisher’s exact test as appropriate.
RESULTS Patients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01].
CONCLUSION During the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.
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Affiliation(s)
- Orly Nadell Farber
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Giselle I Gomez
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Ashley L Titan
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Andrea T Fisher
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Christopher J Puntasecca
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Veronica Toro Arana
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Arielle Kempinsky
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Clare E Wise
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Kovi E Bessoff
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - James R Korndorffer Jr
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Joseph D Forrester
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
| | - Micaela M Esquivel
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, United States
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21
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Ahmed SM, Hawn MT. Steps to a Culturally Conscious Workspace in the Modern Surgical Era. J Am Coll Surg 2021; 233:327-328. [PMID: 34304824 DOI: 10.1016/j.jamcollsurg.2021.05.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022]
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22
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Wise CE, Bereknyei Merrell S, Sasnal M, Forrester JD, Hawn MT, Lau JN, Lin DT, Schmiederer IS, Spain DA, Nassar AK, Knowlton LM. COVID-19 Impact on Surgical Resident Education and Coping. J Surg Res 2021; 264:534-543. [PMID: 33862581 PMCID: PMC7877215 DOI: 10.1016/j.jss.2021.01.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19. MATERIALS AND METHODS We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic. RESULTS Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19. CONCLUSIONS Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.
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Affiliation(s)
| | - Sylvia Bereknyei Merrell
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California
| | - Marzena Sasnal
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California
| | - Joseph D Forrester
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Mary T Hawn
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - James N Lau
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Dana T Lin
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Ingrid S Schmiederer
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - David A Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Aussama K Nassar
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Lisa Marie Knowlton
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California.
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23
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George EL, Fox P, Hawn MT. Life Happens, Even to Surgical Trainees. JAMA Surg 2021; 156:653. [PMID: 34009251 DOI: 10.1001/jamasurg.2021.1811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Department of Surgery Stanford University, Stanford, California
| | - Paige Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Mary T Hawn
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
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24
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Mudumbai SC, Pershing S, Bowe T, Kamal RN, Sears ED, Hawn MT, Eisenberg D, Finlay AK, Hagedorn H, Harris AHS. Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration. JAMA Netw Open 2021; 4:e217470. [PMID: 33956131 PMCID: PMC8103225 DOI: 10.1001/jamanetworkopen.2021.7470] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. OBJECTIVE To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. EXPOSURES A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. MAIN OUTCOMES AND MEASURES Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). RESULTS A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. CONCLUSIONS AND RELEVANCE Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.
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Affiliation(s)
- Seshadri C. Mudumbai
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California
| | - Suzann Pershing
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Department of Ophthalmology, Byers Eye Institute at Stanford, Stanford University School of Medicine, Stanford, California
| | - Tom Bowe
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
| | - Robin N. Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Erika D. Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Surgery, Michigan Medicine, Ann Arbor
| | - Mary T. Hawn
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Stanford–Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Dan Eisenberg
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Stanford–Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Andrea K. Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
| | - Hildi Hagedorn
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Alex H. S. Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Stanford–Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Sambare TD, Graham LA, Itani KMF, Morris MS, Moshrefi S, Hawn MT. Impact of Gastrointestinal Surgical Site Wound Complications on Long-term Healthcare Utilization. J Gastrointest Surg 2021; 25:503-511. [PMID: 31993964 DOI: 10.1007/s11605-019-04489-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/30/2019] [Accepted: 11/23/2019] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Wound complication following gastrointestinal surgery substantially impacts the quality and costs of surgical care. The impact of wound complication on subsequent long-term healthcare utilization has not been fully studied. OBJECTIVE We assessed the impact of surgical wound complication on inpatient and outpatient healthcare utilization in the 2 years after gastrointestinal (GI) surgery. DESIGN An observational retrospective cohort study was conducted on Veterans Affairs health system patients who underwent an inpatient GI surgical procedure, were assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP), and were discharged alive from Veterans Affairs (VA) hospitals between October 1, 2007 and September 30, 2014. SETTING Population-based PARTICIPANTS: A total of 64,351 patients underwent a GI surgical procedure in the VA system between 2007 and 2014. The cohort was 93.5% male, with a median age of 63.0 years (interquartile range (IQR) 57.0-70.0). A total of 7880 patients (12.2%) had at least one reported wound complication, 5460 of which had their postoperative wound complication classified by a VASQIP nurse. EXPOSURE VASQIP-assessed or ICD-9-coded wound complication in the 30 days after surgery MAIN OUTCOME MEASUREMENTS: Inpatient visits, total inpatient days, outpatient visits, and emergency department visits, and operative interventions up to 2 years after discharge from index admission RESULTS: Patients with a postoperative wound complication had greater inpatient healthcare utilization compared with no-wound complication for up to 2 years after surgery: inpatient admissions (mean number 3.5 vs. 2.8; P < .001), inpatient bed days (mean 41.0 vs. 25.0; P < .001). Patients with a postoperative wound complication also had greater 2-year outpatient utilization than the no-wound complication cohort: outpatient visits (mean number 92.7 vs. 75.9; P < .001) and emergency department visits (mean 3.5 vs. 2.7; P < .001). The same relationship held for wound-related parameters; inpatient admissions (2.2 vs. 0.4; P < .001); inpatient bed days (21.4 vs. 3.7; P < .001); and outpatient visits (56.2 vs. 9.7; P < .001). A greater proportion of patients in the wound complication cohort had an operative intervention for all time intervals examined (P < .001). CONCLUSIONS Surgical wound complications impact healthcare utilization patterns for up to 2 years after the index procedure including hospital readmissions and operative interventions; efforts to reduce postoperative wound complications will have substantial effects on patient outcomes and healthcare expenditures well beyond the 30-day postoperative period.
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Affiliation(s)
- Tanmaya D Sambare
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA
| | - Laura A Graham
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA
| | | | | | - Shawn Moshrefi
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA
| | - Mary T Hawn
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA.
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Parker SG, Halligan S, Liang MK, Muysoms FE, Adrales GL, Boutall A, de Beaux AC, Dietz UA, Divino CM, Hawn MT, Heniford TB, Hong JP, Ibrahim N, Itani KMF, Jorgensen LN, Montgomery A, Morales-Conde S, Renard Y, Sanders DL, Smart NJ, Torkington JJ, Windsor ACJ. Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons. World J Surg 2021; 44:1070-1078. [PMID: 31848677 DOI: 10.1007/s00268-019-05317-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. METHODS A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. RESULTS Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. CONCLUSIONS Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.
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Affiliation(s)
- Samuel G Parker
- The Abdominal Wall Unit, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK.
| | - Steve Halligan
- UCL Centre for Medical Imaging, 2nd floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Mike K Liang
- Department of Surgery, McGovern Medical Center, University of Texas Health Science Center, 5656 Kelley Street, Houston, TX, 77026, USA
| | - Filip E Muysoms
- Department of Surgery, Maria Middelares Hospital, Buitenring-Sint-Denijs 30, 9000, Ghent, Belgium
| | - Gina L Adrales
- Division of Minimally Invasive Surgery, The John Hopkins Hospital, 600 North Wolfe Street Blalock 618, Baltimore, MD, 21287, USA
| | - Adam Boutall
- The Colorectal Unit, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Andrew C de Beaux
- Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Ulrich A Dietz
- Department of Visceral, Vascular and Thoracic Surgery, Kantonal Hospital of Olten, Baselstrasse 150, Olten, 4600, Switzerland
| | - Celia M Divino
- Department of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, NY, 10029, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94304, USA
| | - Todd B Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
| | - Joon P Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 88 Oympicro, 43gil Songpagu, Seoul, 05505, South Korea
| | - Nabeel Ibrahim
- Department of General Surgery, Macquarie University Hospital, 3 Technology Pl, Macquarie University, Sydney, NSW, 2109, Australia
| | - Kamal M F Itani
- Department of General Surgery, Veterans Affairs Boston Health Care System, Boston and Harvard Universities, 1400 VFW Parkway, West Roxbury, MA, 02132, USA
| | - Lars N Jorgensen
- Digestive Disease Center, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Agneta Montgomery
- Department of Surgery, Skane University Hospital Malmo, 202 05, Malmo, Sweden
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital ''Virgen del Rocio'', Betis-65, 1, 41010, Seville, Spain
| | - Yohann Renard
- Department of General, Digestive and Endocrine Surgery, Robert-Debre´ University Hospital, University of Reims Champagne-Ardenne, Rue Cognacq-Jay, 51092, Reims Cedex, France
| | - David L Sanders
- Department of General and Upper GI Surgery, North Devon, District Hospital, Raleigh Park, Barnstaple, Devon, EX31 4JB, UK
| | - Neil J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, England, UK
| | - Jared J Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Alastair C J Windsor
- The Abdominal Wall Unit, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
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Forrester JD, Hawn MT. Concerns about Proposed Update to COVID-19 Screening Protocols before Surgery: In Reply to Yenigun and Colleagues. J Am Coll Surg 2020; 231:789-790. [PMID: 32951984 PMCID: PMC7499146 DOI: 10.1016/j.jamcollsurg.2020.08.757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/27/2020] [Indexed: 12/02/2022]
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Prigoff JG, Titan AL, Fields AC, Shwaartz C, Melnitchouk N, Bleday R, Hawn MT, Wiechmann L. The Effect of Surgical Trainee Education on Opioid Prescribing: An International Evaluation. J Surg Educ 2020; 77:1490-1495. [PMID: 32446768 DOI: 10.1016/j.jsurg.2020.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/16/2020] [Revised: 03/29/2020] [Accepted: 04/15/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Up to 6% of opioid naive patients who undergo surgery become chronic opioid users. The aim of this study was to determine if formal opioid prescribing education of general surgery residents is associated with decreased opioid prescribing postoperatively. METHODS We surveyed surgery residents at 3 general surgery programs in the United States and 1 in Israel. Residents were divided into 2 groups based on whether or not they received formal opioid prescribing education. RESULTS Of those surveyed, 107 (50%) responded. 45% of residents had formal opioid prescribing education, which included instructional videos, current literature, and hospital guidelines. For the 4 operations analyzed, residents who received no formal teaching prescribed a higher number of opioids (lumpectomy p = 0.001, open inguinal hernia repair p = 0.004, laparoscopic appendectomy p = 0.007, thyroidectomy p = 0.002). The largest difference in opioid prescribing was seen in "high prescribers," defined as residents prescribing 15 or more opioid pills. For thyroidectomy, 24.4% of residents without formal education prescribed 20 or more oxycodone 5mg pills compared to 0% of residents with formal education. The Israeli cohort was less likely to receive a pain focused education and was also less likely to prescribe opioids to their patients for all 4 procedures evaluated. CONCLUSIONS Although a minority of general surgery residents are receiving an opioid prescribing education, a formal educational program was associated with significantly decreased opioid prescribing. There is a need for a generalizable educational opioid program for surgery residents.
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Affiliation(s)
- Jake G Prigoff
- Department of Surgery, Columbia University Medical Center, New York, New York.
| | - Ashley L Titan
- Department of Surgery, Stanford University, Stanford, California
| | - Adam C Fields
- Department of Surgery, Brigham and Women's Hospital Boston, Massachusetts
| | - Chaya Shwaartz
- Department of Surgery, Sheba University Hospital, Tel Aviv, Israel
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital Boston, Massachusetts
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital Boston, Massachusetts
| | - Mary T Hawn
- Department of Surgery, Stanford University, Stanford, California
| | - Lisa Wiechmann
- Department of Surgery, Columbia University Medical Center, New York, New York
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Cao D, Chandiramani R, Capodanno D, Berger JS, Levin MA, Hawn MT, Angiolillo DJ, Mehran R. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 2020; 18:37-57. [PMID: 32759962 DOI: 10.1038/s41569-020-0410-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/18/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.
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Affiliation(s)
- Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Jeffrey S Berger
- Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Tabata MM, Rosenthal EL, Arbaugh CJ, Kin C, Kim E, Graham LA, Hawn MT. Trends in the Inclusion of Black and Female Surgeons in Invited Visiting Professorships. JAMA Surg 2020; 154:878-879. [PMID: 31290945 DOI: 10.1001/jamasurg.2019.2137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mika M Tabata
- School of Medicine, Stanford University, Stanford, California
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | | | - Cindy Kin
- Department of Surgery, Stanford University, Stanford, California
| | - Emiley Kim
- Wellesley College, Wellesley, Massachusetts
| | - Laura A Graham
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, California
| | - Mary T Hawn
- Department of Surgery, Stanford University, Stanford, California
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Abstract
Management of antiplatelet therapy in patients with cardiac stents who need subsequent surgery is complex. Current guidelines recommend delaying elective surgery or, if surgery is emergent, proceeding without aspirin cessation. This study assessed provider knowledge, attitudes, and practices for patients with cardiac stents needing subsequent surgery. A national survey was administered to Veterans Administration surgeons, anesthesiologists, and cardiologists. Questions examined guideline awareness and agreement, perceptions of bleeding risk and stent thrombosis, practice patterns for antiplatelet therapy management, and experience with perioperative stent thrombosis. Chi-square tests and generalized estimating equations were used to examine differences in reported practices. Among 295 respondents, guideline awareness (92%) and agreement (93%) were high but higher among cardiologists and anesthesiologists than surgeons. Guideline agreement and personal experience with stent thrombosis were also associated with reported practice patterns. In adjusted models for early surgeries, cardiologists and anesthesiologists were more likely to report continuation of dual therapy as compared with surgeons regardless of stent type (drug-eluting P = 0.03; bare metal P < 0.01). Despite successful guideline adoption, significant variations in practice patterns by provider type were found. Understanding reasons behind the variation and outcomes of various antiplatelet management strategies are important steps in optimizing care of patients with coronary stents undergoing noncardiac surgery.
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Affiliation(s)
- Laura A. Graham
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, Alabama; the
| | - Thomas M. Maddox
- VA Eastern Colorado Health Care System, University of Colorado Denver, Denver, Colorado
| | - Kamal M. F. Itani
- VA Eastern Colorado Health Care System, University of Colorado Denver, Denver, Colorado
| | - Mary T. Hawn
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, Alabama; the
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
BACKGROUND The novel coronavirus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE). STUDY DESIGN An interventional platform (operating room, interventional suite, and endoscopy) PPE taskforce was convened by the hospital and medical school leadership and tasked with developing a common algorithm for PPE use, to be used throughout the interventional platform. In conjunction with our infectious disease experts, we developed our guidelines based on potential patterns of spread, risk of exposure, and conservation of PPE. RESULTS A decision tree algorithm describing our institutional guidelines for precautions for operating room team members was created. This algorithm is based on urgency of operation, anticipated viral burden at the surgical site, opportunity for a procedure to aerosolize virus, and likelihood a patient could be infected based on symptoms and testing. CONCLUSIONS Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision tree algorithm for the interventional platform teams, we can ensure optimal health care worker safety.
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Affiliation(s)
| | | | - Paul M Maggio
- Department of Surgery, Stanford University, Stanford, CA
| | - Mary T Hawn
- Department of Surgery, Stanford University, Stanford, CA
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33
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Hernandez-Boussard T, Graham LA, Carroll I, Dasinger EA, Titan AL, Morris MS, Hawn MT. Perioperative opioid use and pain-related outcomes in the Veterans Health Administration. Am J Surg 2020; 219:969-975. [PMID: 31280840 PMCID: PMC10163865 DOI: 10.1016/j.amjsurg.2019.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/17/2019] [Accepted: 06/21/2019] [Indexed: 11/18/2022]
Abstract
Understanding variation in perioperative opioid exposure and its effect on patients' outcomes is critical for pain management. This study characterized perioperative exposure to morphine and its association with postoperative pain and 30-day readmissions. We utilized nationwide Veterans Healthcare Administration (VHA) data on four high-volume surgical procedures, 2007-2014. We identified 235,239 Veterans undergoing orthopedic, general, or vascular surgery; 5.4% high trajectories (116.1 OME/Day), 53.2% medium trajectories (39.7 OME/Day), and 41.4% low trajectories (19.1 OME/Day). Modeled estimates suggest that patients in the high OME group had higher risk of a pain-related readmission (OR: 1.59; CI: 1.39, 1.83) compared to the low OME trajectory. Yet when stratified by pain trajectory, patients with high pain and high OME had lower risk of a pain-related readmission compared to patients in the high pain low OME group (OR: 0.76, CI: 0.62, 0.94). In conclusion, patients receiving high perioperative OME are more likely to return to care for pain-related problems. This study highlights opportunities to reduce the amount of prescriptions opioids in the communities.
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Affiliation(s)
- Tina Hernandez-Boussard
- Department of Medicine, Stanford University, Stanford, CA, USA; Department of Surgery, Stanford University, Stanford, CA, USA; Department of Biomedical Data Science, Stanford University, Stanford, CA, USA.
| | - Laura A Graham
- Department of Surgery, Stanford University, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ian Carroll
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Elise A Dasinger
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley L Titan
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Melanie S Morris
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Maggio PM, Hawn MT. Mandatory Use of Perioperative Disposable Jackets-Things We Do for No Good Reason. JAMA Surg 2020; 155:21. [PMID: 31642892 DOI: 10.1001/jamasurg.2019.4086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Paul M Maggio
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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35
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Parker SG, Halligan S, Liang MK, Muysoms FE, Adrales GL, Boutall A, de Beaux AC, Dietz UA, Divino CM, Hawn MT, Heniford TB, Hong JP, Ibrahim N, Itani KMF, Jorgensen LN, Montgomery A, Morales-Conde S, Renard Y, Sanders DL, Smart NJ, Torkington JJ, Windsor ACJ. International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair. Br J Surg 2019; 107:209-217. [PMID: 31875954 DOI: 10.1002/bjs.11400] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/25/2019] [Accepted: 09/18/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. METHODS A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. RESULTS Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. CONCLUSION Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.
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Affiliation(s)
- S G Parker
- Abdominal Wall Unit, University College London Hospital, London, UK
| | - S Halligan
- UCL Centre for Medical Imaging, London, UK
| | - M K Liang
- Department of Surgery, McGovern Medical Center, University of Texas Health Science Center, Houston, Texas, USA
| | - F E Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | - G L Adrales
- Division of Minimally Invasive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - A Boutall
- Colorectal Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - A C de Beaux
- Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - U A Dietz
- Department of Visceral, Vascular and Thoracic Surgery, Kantonal Hospital of Olten, Olten, Switzerland
| | - C M Divino
- Department of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, USA
| | - M T Hawn
- Department of Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - T B Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - J P Hong
- Department of Plastic Surgery, Asan Medical Centre, University of Ulsan, Seoul, South Korea
| | - N Ibrahim
- Department of General Surgery, Macquarie University Hospital, Macquarie University, Sydney, New South Wales, Australia
| | - K M F Itani
- Department of General Surgery, Veterans Affairs Boston Health Care System, Boston and Harvard Universities, West Roxbury, Massachusetts, USA
| | - L N Jorgensen
- Digestive Disease Centre, Bispebjerg University Hospital, Copenhagen, Denmark
| | - A Montgomery
- Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden
| | - S Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital 'Virgen del Rocio', Seville, Spain
| | - Y Renard
- Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims Cedex, France
| | - D L Sanders
- Department of General and Upper Gastrointestinal Surgery, North Devon District Hospital, Barnstaple, UK
| | - N J Smart
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Exeter, UK
| | - J J Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - A C J Windsor
- Abdominal Wall Unit, University College London Hospital, London, UK
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36
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Mudumbai SC, Pershing S, Bowe T, Kamal RN, Sears ED, Finlay AK, Eisenberg D, Hawn MT, Weng Y, Trickey AW, Mariano ER, Harris AHS. Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC Health Serv Res 2019; 19:859. [PMID: 31752856 PMCID: PMC6868867 DOI: 10.1186/s12913-019-4640-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/15/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes. METHODS Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator. RESULTS Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.
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Affiliation(s)
- Seshadri C Mudumbai
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94402, USA. .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA. .,Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.
| | - Suzann Pershing
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Ophthalmology, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Thomas Bowe
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA
| | - Robin N Kamal
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Orthopaedic Surgery, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Erika D Sears
- Department of Surgery, Section of Plastic Surgery at the University of Michigan, 2101 Taubman Center 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA
| | - Dan Eisenberg
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Mary T Hawn
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Yingjie Weng
- Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Amber W Trickey
- Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94402, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Alex H S Harris
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.,Department of Surgery Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
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Mull HJ, Graham LA, Morris MS, Rosen AK, Richman JS, Whittle J, Burns E, Wagner TH, Copeland LA, Wahl T, Jones C, Hollis RH, Itani KMF, Hawn MT. Association of Postoperative Readmissions With Surgical Quality Using a Delphi Consensus Process to Identify Relevant Diagnosis Codes. JAMA Surg 2019; 153:728-737. [PMID: 29710234 DOI: 10.1001/jamasurg.2018.0592] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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 Postoperative readmission data are used to measure hospital performance, yet the extent to which these readmissions reflect surgical quality is unknown. Objective To establish expert consensus on whether reasons for postoperative readmission are associated with the quality of surgery in the index admission. Design, Setting, and Participants In a modified Delphi process, a panel of 14 experts in medical and surgical readmissions comprising physicians and nonphysicians from Veterans Affairs (VA) and private-sector institutions reviewed 30-day postoperative readmissions from fiscal years 2008 through 2014 associated with inpatient surgical procedures performed at a VA medical center between October 1, 2007, and September 30, 2014. The consensus process was conducted from January through May 2017. Reasons for readmission were grouped into categories based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Panelists were given the proportion of readmissions coded by each reason and median (interquartile range) days to readmission. They answered the question, "Does the readmission reason reflect possible surgical quality of care problems in the index admission?" on a scale of 1 (never related) to 5 (directly related) in 3 rounds of consensus building. The consensus process was completed in May 2017 and data were analyzed in June 2017. Main Outcomes and Measures Consensus on proportion of ICD-9-coded readmission reasons that reflected quality of surgical procedure. Results In 3 Delphi rounds, the 14 panelists achieved consensus on 50 reasons for readmission; 12 panelists also completed group telephone calls between rounds 1 and 2. Readmissions with diagnoses of infection, sepsis, pneumonia, hemorrhage/hematoma, anemia, ostomy complications, acute renal failure, fluid/electrolyte disorders, or venous thromboembolism were considered associated with surgical quality and accounted for 25 521 of 39 664 readmissions (64% of readmissions; 7.5% of 340 858 index surgical procedures). The proportion of readmissions considered to be not associated with surgical quality varied by procedure, ranging from to 21% (613 of 2331) of readmissions after lower-extremity amputations to 47% (745 of 1598) of readmissions after cholecystectomy. Conclusions and Relevance One-third of postoperative readmissions are unlikely to reflect problems with surgical quality. Future studies should test whether restricting readmissions to those with specific ICD-9 codes might yield a more useful quality measure.
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Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Laura A Graham
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Melanie S Morris
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Joshua S Richman
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Jeffery Whittle
- Medicine Division, Milwaukee VA Medical Center, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Edith Burns
- Medicine Division, Milwaukee VA Medical Center, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Todd H Wagner
- VA Palo Alto Medical Center, Palo Alto, California.,Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds.,University of Massachusetts Medical School, Worcester.,Baylor Scott & White Health, Center for Applied Health Research, Temple, Texas
| | - Tyler Wahl
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Caroline Jones
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Robert H Hollis
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Kamal M F Itani
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,Harvard University School of Medicine, Boston, Massachusetts
| | - Mary T Hawn
- VA Palo Alto Medical Center, Palo Alto, California.,Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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Affiliation(s)
- Laura A Graham
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
| | - Mary T Hawn
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Anderson TN, Lee EW, Korndorffer JR, Hawn MT, Lau JN. Decade in Surgical Education and Simulation Fellowship: A New Pathway for the Surgical Education Leader. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.520] [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: 11/28/2022]
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Prigoff JG, Fields AC, Titan AL, Hawn MT, Jambhekar A, Melnitchouk N, Bleday R, Wiechmann L. Reducing Postoperative Opioid Prescribing Through Education: A Multicenter Survey of Surgical Residents. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.547] [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: 11/17/2022]
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Graham LA, Wagner TH, Sambare TD, Hawn MT. Association between Timing and Cost of Postoperative Wound Complication. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.315] [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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Affiliation(s)
- Mary T. Hawn
- Department of Surgery, Stanford University, Stanford, California
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Rothenberg KA, Stern JR, George EL, Trickey AW, Morris AM, Hall DE, Johanning JM, Hawn MT, Arya S. Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA Netw Open 2019; 2:e194330. [PMID: 31125103 PMCID: PMC6632151 DOI: 10.1001/jamanetworkopen.2019.4330] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures. OBJECTIVE To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS = 0) and those with a LOS of 1 or more days (LOS ≥ 1). Statistical analysis was performed from June 1, 2018, to March 31, 2019. EXPOSURE Frailty, as measured by the Risk Analysis Index. MAIN OUTCOMES AND MEASURES The main outcome was 30-day unplanned readmission. RESULTS Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS = 0, 2.0%; LOS ≥ 1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS = 0, 8.3% vs 1.9%; LOS ≥ 1, 8.5% vs 3.2%; P < .001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS = 0, 6.9% vs 2.5%; LOS ≥ 1, 9.8% vs 4.6%; P < .001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS = 0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS ≥ 1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS = 0, 22.8%; LOS ≥ 1, 29.3%). CONCLUSIONS AND RELEVANCE These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.
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Affiliation(s)
- Kara A. Rothenberg
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jordan R. Stern
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
- Surgical Service, Veterans Affairs Palo Alto Health System, Palo Alto, California
| | - Elizabeth L. George
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Arden M. Morris
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel E. Hall
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolffe Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason M. Johanning
- Department of Surgery, University of Nebraska College of Medicine, Omaha
| | - Mary T. Hawn
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Shipra Arya
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
- Surgical Service, Veterans Affairs Palo Alto Health System, Palo Alto, California
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Graham LA, Mull HJ, Wagner TH, Morris MS, Rosen AK, Richman JS, Whittle J, Burns E, Copeland LA, Itani KMF, Hawn MT. Comparison of a Potential Hospital Quality Metric With Existing Metrics for Surgical Quality-Associated Readmission. JAMA Netw Open 2019; 2:e191313. [PMID: 31002316 PMCID: PMC6481441 DOI: 10.1001/jamanetworkopen.2019.1313] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/29/2019] [Indexed: 11/16/2022] Open
Abstract
Importance The existing readmission quality metric does not meaningfully distinguish readmissions associated with surgical quality from those that are not associated with surgical quality and thus may not reflect the quality of surgical care. Objective To compare a quality metric that classifies readmissions associated with surgical quality with the existing metric of any unplanned readmission in a surgical population. Design, Setting, and Participants Cohort study using US nationwide administrative data collected on 4 high-volume surgical procedures performed at 103 Veterans Affairs hospitals from October 1, 2007, through September 30, 2014. Data analysis was conducted from October 1, 2017, to January 24, 2019. Main Outcomes and Measures Hospital-level rates of unplanned readmission (existing metric) and surgical readmissions associated with surgical quality (new metric) in the 30 days following hospital discharge for an inpatient surgical procedure. Results The study population included 109 258 patients who underwent surgery at 103 hospitals. Patients were majority male (94.1%) and white (78.2%) with a mean (SD) age of 64.0 (10.0) years at the time of surgery. After case-mix adjustment, 30-day surgical readmissions ranged from 4.6% (95% CI, 4.5%-4.8%) among knee arthroplasties to 11.1% (95% CI, 10.9%-11.3%) among colorectal resections. The new surgical readmission metric was significantly correlated with facility-level postdischarge complications for all procedures, with ρ coefficients ranging from 0.33 (95% CI, 0.13-0.51) for cholecystectomy to 0.52 (95% CI, 0.38-0.68) for colorectal resection. Correlations between postdischarge complications and the new surgical readmission metric were higher than correlations between complications and the existing readmission metric for all procedures examined (knee arthroplasty: 0.50 vs 0.48; hip replacement: 0.44 vs 0.18; colorectal resection: 0.52 vs 0.42; and cholecystectomy: 0.33 vs 0.10). When compared with using the existing readmission metric, using the new surgical readmission metric could change hip replacement-associated payment penalty determinations in 28.4% of hospitals and knee arthroplasty-associated penalties in 26.0% of hospitals. Conclusions and Relevance In this study, surgical quality-associated readmissions were more correlated with postdischarge complications at a higher rate than were unplanned readmissions. Thus, a metric based on such readmissions may be a better measure of surgical care quality. This work provides an important step in the development of future value-based payments and promotes evidence-based quality metrics targeting the quality of surgical care.
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Affiliation(s)
- Laura A. Graham
- Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Hillary J. Mull
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Todd H. Wagner
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Melanie S. Morris
- Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Joshua S. Richman
- Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Jeffery Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Edith Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Laurel A. Copeland
- Veterans Affairs Central Western Massachusetts Healthcare System, Leeds
- University of Massachusetts Medical School, Worcester
| | - Kamal M. F. Itani
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
- Harvard University School of Medicine, Boston, Massachusetts
| | - Mary T. Hawn
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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Branch-Elliman W, Pizer SD, Dasinger EA, Gold HS, Abdulkerim H, Rosen AK, Charns MP, Hawn MT, Itani KMF, Mull HJ. Facility type and surgical specialty are associated with suboptimal surgical antimicrobial prophylaxis practice patterns: a multi-center, retrospective cohort study. Antimicrob Resist Infect Control 2019; 8:49. [PMID: 30886702 PMCID: PMC6404270 DOI: 10.1186/s13756-019-0503-9] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/27/2019] [Indexed: 12/13/2022] Open
Abstract
Background Guidelines recommend discontinuation of antimicrobial prophylaxis within 24 h after incision closure in uninfected patients. However, how facility and surgical specialty factors affect the implementation of these evidence-based surgical prophylaxis guidelines in outpatient surgery is unknown. Thus, we sought to measure how facility complexity, including ambulatory surgical center (ASC) status and availability of ancillary services, impact adherence to guidelines for timely discontinuation of antimicrobial prophylaxis after outpatient surgery. A secondary aim was to measure the association between surgical specialty and guideline compliance. Methods A multi-center, national Veterans Health Administration retrospective cohort from 10/1/2015-9/30/2017 including any Veteran undergoing an outpatient surgical procedure in any of five specialties (general surgery, urology, ophthalmology, ENT, orthopedics) was created. The primary outcome was the association between facility complexity and proportion of surgeries not compliant with discontinuation of antimicrobials within 24 h of incision closure. Data were analyzed using logistic regression with adjustments for patient and procedural factors. Results Among 153,097 outpatient surgeries, 7712 (5.0%) received antimicrobial prophylaxis lasting > 24 h after surgery; rates ranged from 0.4% (eye surgeries) to 13.7% (genitourinary surgeries). Cystoscopies and cystoureteroscopy with lithotripsy procedures had the highest rates (16 and 20%), while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest (0.2-0.3%). In an adjusted logistic regression model, lower complexity ASC and hospital outpatient departments had higher odds of prolonged antimicrobial prophylaxis compared to complex hospitals (OR ASC, 1.3, 95% CI: 1.2-1.5). Patient factors associated with higher odds of noncompliance with antimicrobial discontinuation included younger age, female sex, and white race. Genitourinary and ear/nose/throat surgeries were associated with the highest odds of prolonged antimicrobial prophylaxis. Conclusions Facility complexity appears to play a role in adherence to surgical infection prevention guidelines. Lower complexity facilities with limited infection prevention and antimicrobial stewardship resources may be important targets for quality improvement. Such interventions may be especially useful for genitourinary and ear/nose/throat surgical subspecialties. Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ambulatory surgery centers and hospital outpatient departments in their efforts to improve this facet of patient safety.
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Affiliation(s)
- Westyn Branch-Elliman
- 1Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, MA 1400 VFW Parkway West Roxbury, Boston, MA 02132 USA.,2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA
| | - Steven D Pizer
- 4Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, 150 South Huntington Avenue Boston, Boston, MA 02130 USA.,5Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA
| | - Elise A Dasinger
- VA Quality Scholars Program, Birmingham VA Medical Center, Birmingham, 700 19th Street S, AL 35233 England
| | - Howard S Gold
- 3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA.,7Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis Street, Boston, MA 02115 USA
| | - Hassen Abdulkerim
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Amy K Rosen
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
| | - Martin P Charns
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Mary T Hawn
- 9Palo Alto VA Medical Center, 3801 Miranda Ave, Palo Alto, CA 95010 USA.,10Stanford University School of Medicine, 291 Campus Drive Stanford, Stanford, CA 94305 USA
| | - Kamal M F Itani
- 11Department of Surgery, VA Boston Healthcare System, 1400 VFW Parkway West Roxbury, Boston, MA 02132 USA.,3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
| | - Hillary J Mull
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
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Dasinger EA, Graham LA, Wahl TS, Richman JS, Baker SJ, Hawn MT, Hernandez-Boussard T, Rosen AK, Mull HJ, Copeland LA, Whittle JC, Burns EA, Morris MS. Preoperative opioid use and postoperative pain associated with surgical readmissions. Am J Surg 2019; 218:828-835. [PMID: 30879796 DOI: 10.1016/j.amjsurg.2019.02.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 11/20/2018] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The extent of preoperative opioid utilization and the relationship with pain-related readmissions are not well understood. METHODS VA Surgical Quality Improvement Program data on general, vascular, and orthopedic surgeries (2007-2014) were merged with pharmacy data to evaluate preoperative opioid use and pain-related readmissions. Opioid use in the 6-month preoperative period was categorized as none, infrequent, frequent, and daily. RESULTS In the six-month preoperative period, 65.7% had no opioid use, 16.7% had infrequent use, 6.3% frequent use, and 11.4% were daily opioid users. Adjusted odds of pain-related readmission were higher for opioid-exposed groups vs the opioid-naïve group: infrequent (OR 1.17; 95% CI:1.04-1.31), frequent (OR 1.28; 95% CI:1.08-1.52), and daily (OR 1.49; 95% CI:1.27-1.74). Among preoperative opioid users, those with a pain-related readmission had higher daily preoperative oral morphine equivalents (mean 44.5 vs. 36.1, p < 0.001). CONCLUSIONS Patients using opioids preoperatively experienced higher rates of pain-related readmissions, which increased with frequency and dosage of opioid exposure.
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Affiliation(s)
- Elise A Dasinger
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Laura A Graham
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, CA, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tyler S Wahl
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua S Richman
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Samantha J Baker
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary T Hawn
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, CA, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA; University of Massachusetts Medical School, Worcester, MA, USA
| | - Jeffrey C Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Edith A Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melanie S Morris
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Sheckter CC, Jopling J, Ding Q, Trickey AW, Wagner T, Morris AM, Hawn MT. Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing. J Am Coll Surg 2019; 228:798-806.e2. [PMID: 30660819 DOI: 10.1016/j.jamcollsurg.2018.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 12/16/2018] [Accepted: 12/16/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Health care value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation. STUDY DESIGN Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014 to 2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared with median use, accounting for case, patient, and attending-level variables. RESULTS There were 111,055 laboratory orders and 7,360 imaging orders linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% CIs > 1, p < 0.05). Compared with the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% CI >1, p < 0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders. CONCLUSIONS Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared with imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high users and could be used to educate residents on their ordering patterns.
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Affiliation(s)
- Clifford C Sheckter
- Department of Surgery, Stanford University, Stanford, CA; Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, CA
| | - Jeffrey Jopling
- Department of Surgery, Stanford University, Stanford, CA; Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, CA
| | - Qian Ding
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, CA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, CA
| | - Todd Wagner
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, CA
| | - Arden M Morris
- Department of Surgery, Stanford University, Stanford, CA; Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, CA
| | - Mary T Hawn
- Department of Surgery, Stanford University, Stanford, CA; Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, CA.
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Dasinger EA, Branch-Elliman W, Pizer SD, Abdulkerim H, Rosen AK, Charns MP, Hawn MT, Itani KMF, Mull HJ. Association between postoperative opioid use and outpatient surgical adverse events. Am J Surg 2019; 217:605-612. [PMID: 30639132 DOI: 10.1016/j.amjsurg.2018.12.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 10/23/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Opioid-related adverse drug events are common following inpatient surgical procedures. Little is known about opioid prescribing after outpatient surgical procedures and if opioid use is associated with short term risks of outpatient surgical adverse events (AEs). METHODS VA Corporate Data Warehouse was used to identify opioid use within 48 h for FY2012-14 chart-reviewed cases from a larger VA study of AEs in outpatient surgeries. We estimated a multilevel logistic regression model to determine the effect of opioid exposure on risk of AEs between 2 and 30 days postoperatively. RESULTS Of the 1730 outpatient surgical cases, 628 (36%) had postoperative opioid use and 12% had an AE. Opioid use following outpatient surgery was not significantly associated with higher surgical AE rates after controlling for relevant covariates (OR = 1.1 95% CI 0.79-1.54). Only procedure RVUs were associated with higher odds of postoperative AEs. CONCLUSIONS Postoperative opioid use following outpatient surgery is not a significant driver of postoperative AEs.
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Affiliation(s)
- Elise A Dasinger
- VA Quality Scholars Program, Birmingham VA Medical Center, Birmingham, AL, United States.
| | - Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Medicine, VA Boston Healthcare System, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Steven D Pizer
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, MA, United States; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Hassen Abdulkerim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States
| | - Martin P Charns
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Mary T Hawn
- Palo Alto VA Medical Center, Palo Alto, CA, United States; Stanford University School of Medicine, Stanford, CA, United States
| | - Kamal M F Itani
- Harvard Medical School, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States; Department of Surgery, VA Boston Healthcare System, Boston, MA, United States
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States
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Graham LA, Wagner TH, Richman JS, Morris MS, Copeland LA, Harris AH, Itani KM, Hawn MT. Exploring Trajectories of Health Care Utilization Before and After Surgery. J Am Coll Surg 2018; 228:116-128. [PMID: 30359825 DOI: 10.1016/j.jamcollsurg.2018.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term trajectories of health care utilization in the context of surgery have not been well characterized. The objective of this study was to examine health care utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated after surgical admissions. STUDY DESIGN Hospital medical and surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (October 1, 2007 to September 30, 2014) were identified. Group-based trajectory analysis identified 5 distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression. RESULTS Of 280,681 surgery inpatients, most underwent orthopaedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of health care utilization were identified, with 5.2% of patients among consistently high inpatient users accounting for 34.0% of inpatient days. Male (95.4% vs 93.5%, p < 0.01), African-American (21.6% vs 17.3%, p < 0.01), or unmarried patients (61.6% vs 52.5%, p < 0.01) were more likely to be high health care users as compared with other trajectories. High users also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs 16.3%; bipolar disorder: 5.3% vs 2.1%, p < 0.01), social/behavioral risk factors (smoker: 41.1% vs 33.6%, p < 0.01; alcohol use disorder: 28.9% vs 12.9%, p < 0.01), and chronic pain (6.4% vs 2.8%, p < 0.01). CONCLUSIONS Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative health care utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.
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Affiliation(s)
- Laura A Graham
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL
| | - Todd H Wagner
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA
| | - Joshua S Richman
- Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Melanie S Morris
- Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA; University of Massachusetts Medical School, Worcester, MA
| | - Alex Hs Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA
| | - Kamal Mf Itani
- VA Boston Health Care System, Boston University and Harvard Medical School, Boston, MA
| | - Mary T Hawn
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA.
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