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Trac J, Balas M, Gee D, Hutter MM, Jung JJ. Does routine upper gastrointestinal swallow study after metabolic and bariatric surgery lead to earlier diagnosis of leak? Surg Obes Relat Dis 2024:S1550-7289(24)00077-7. [PMID: 38570283 DOI: 10.1016/j.soard.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/14/2024] [Accepted: 02/17/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND It is unclear whether routine upper gastrointestinal swallow study (SS) in the immediate postoperative period is associated with earlier diagnosis of gastrointestinal leak after bariatric surgery. OBJECTIVE To investigate the relationship between routine SS and time to diagnosis of postoperative gastrointestinal leak. SETTING MBSAQIP-accredited hospitals in the United States and Canada. METHODS We conducted an observational cohort study of adults who underwent laparoscopic primary Roux-en-Y gastric bypass (RYGB) (n = 82,510) and sleeve gastrectomy (SG) (n = 283,520) using the MBSAQIP 2015-2019 database. Propensity scores were used to match patient cohorts who underwent routine versus no routine SS. Primary outcome was time to diagnosis of leak. Median days to diagnosis of leak were compared. The Nelson-Aalen estimator was used to determine the cumulative hazards of leak. RESULTS In our study, 36,280 (23%) RYGB and 135,335 (33%) SG patients received routine SS. Routine SS was not associated with earlier diagnosis of leak (RYGB routine SS median 7 [IQR 3-12] days v. no routine SS 6 [2-11] days, P = .9; SG routine SS 15 [9-22] days v. no routine SS 14 [8-21] days, P = .06) or lower risk of developing leak (RYGB HR 1.0, 95%-CI .8-1.2; SG HR 1.1, 95%-CI 1.0-1.4). More routine SS patients had a length of stay 2 days or greater (RYGB 78.3% v. 61.1%; SG 48.6% v. 40.3%). CONCLUSIONS Routine SS was not associated with earlier diagnosis of leaks compared to the absence of routine SS. Surgeons should consider abandoning the practice of routine SS for the purpose of obtaining earlier diagnosis of postoperative leaks.
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Affiliation(s)
- Jessica Trac
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Balas
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Denise Gee
- Division of General and Oncologic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew M Hutter
- Division of General and Oncologic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - James J Jung
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Duke University, Durham, North Carolina.
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Kermansaravi M, Chiappetta S, Parmar C, Shikora SA, Prager G, LaMasters T, Ponce J, Kow L, Nimeri A, Kothari SN, Aarts E, Abbas SI, Aly A, Aminian A, Bashir A, Behrens E, Billy H, Carbajo MA, Clapp B, Chevallier JM, Cohen RV, Dargent J, Dillemans B, Faria SL, Neto MG, Garneau PY, Gawdat K, Haddad A, ElFawal MH, Higa K, Himpens J, Husain F, Hutter MM, Kasama K, Kassir R, Khan A, Khoursheed M, Kroh M, Kurian MS, Lee WJ, Loi K, Mahawar K, McBride CL, Almomani H, Melissas J, Miller K, Misra M, Musella M, Northup CJ, O'Kane M, Papasavas PK, Palermo M, Peterson RM, Peterli R, Poggi L, Pratt JSA, Alqahtani A, Ramos AC, Rheinwalt K, Ribeiro R, Rogers AM, Safadi B, Salminen P, Santoro S, Sann N, Scott JD, Shabbir A, Sogg S, Stenberg E, Suter M, Torres A, Ugale S, Vilallonga R, Wang C, Weiner R, Zundel N, Angrisani L, De Luca M. Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus. Sci Rep 2024; 14:3445. [PMID: 38341469 PMCID: PMC10858961 DOI: 10.1038/s41598-024-54141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/08/2024] [Indexed: 02/12/2024] Open
Abstract
Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.
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Affiliation(s)
- Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Hazrat-e Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Sonja Chiappetta
- Department of General and Laparoscopic Surgery, Obesity and Metabolic Surgery Unit, Ospedale Evangelico Betania, Naples, Italy.
| | | | - Scott A Shikora
- Department of Surgery, Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | - Teresa LaMasters
- Unitypoint Clinic Weight Loss Specialists, West Des Moines, IA, USA
- Department of Surgery, University of Iowa, Iowa City, IA, USA
| | - Jaime Ponce
- Bariatric Surgery Program, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Lilian Kow
- Adelaide Bariatric Centre, Flinders University of South Australia, Adelaide, Australia
| | - Abdelrahman Nimeri
- Department of Surgery, Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Shanu N Kothari
- Prisma Health, Department of Surgery, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Edo Aarts
- WeightWorks Clinics and Allurion Clinics, Amersfoort, The Netherlands
| | | | - Ahmad Aly
- Austin and Repatriation Medical Centre, University of Melbourne, Heidelberg, VIC, Australia
| | - Ali Aminian
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmad Bashir
- Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Amman, Jordan
| | | | - Helmuth Billy
- Ventura Advanced Surgical Associates, Ventura, CA, USA
| | - Miguel A Carbajo
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| | - Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX, USA
| | | | - Ricardo V Cohen
- Center for the Treatment of Obesity and Diabetes, Hospital Alemão Oswaldo Cruz, Sao Paolo, Brazil
| | | | - Bruno Dillemans
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - Silvia L Faria
- Gastrocirurgia de Brasilia, University of Brasilia, Brasilia, Brazil
| | | | - Pierre Y Garneau
- Division of Bariatric Surgery, CIUSSS-NIM, Montreal, Canada
- Department of Surgery, Université de Montréal, Montréal, Canada
| | - Khaled Gawdat
- Bariatric Surgery Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ashraf Haddad
- Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Amman, Jordan
| | | | - Kelvin Higa
- Fresno Heart and Surgical Hospital, UCSF Fresno, Fresno, CA, USA
| | - Jaques Himpens
- Bariatric Surgery Unit, Delta Chirec Hospital, Brussels, Belgium
| | - Farah Husain
- University of Arizona College of Medicine, Phoenix, USA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Radwan Kassir
- Department of Digestive Surgery, CHU Félix Guyon, Saint Denis, La Réunion, France
| | - Amir Khan
- Walsall Healthcare NHS Trust, Walsall, UK
| | | | - Matthew Kroh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marina S Kurian
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Wei-Jei Lee
- Medical Weight Loss Center, China Medical University Shinchu Hospital, Zhubei City, Taiwan
| | - Ken Loi
- Director of St George Surgery, Sydney, Australia
| | - Kamal Mahawar
- South Tyneside and Sunderland Foundation NHS Trust, Sunderland, UK
| | | | | | - John Melissas
- Bariatric Unit, Heraklion University Hospital, University of Crete, Crete, Greece
| | - Karl Miller
- Diakonissen Wehrle Private Hospital, Salzburg, Austria
| | | | - Mario Musella
- Advanced Biomedical Sciences Department, Federico II" University, Naples, Italy
| | | | - Mary O'Kane
- Department of Nutrition and Dietetics, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Pavlos K Papasavas
- Division of Metabolic and Bariatric Surgery, Hartford Hospital, Hartford, CT, USA
| | - Mariano Palermo
- Department of Surgery, Centro CIEN-Diagnomed, University of Buenos Aires, Buenos Aires, Argentina
| | - Richard M Peterson
- Department of General and Minimally Invasive Surgery, UT Health San Antonio, San Antonio, TX, USA
| | - Ralph Peterli
- Department of Visceral Surgery, Clarunis, University Digestive Health Care Center, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Luis Poggi
- Department of Surgery Clinica Anglo Americana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Janey S A Pratt
- Department of Surgery, Stanford School of Medicine, VA Palo Alto Health Care System, 3801 Miranda Avenue, GS 112, Palo Alto, CA, 94304, USA
| | - Aayad Alqahtani
- New You Medical Center, King Saud University, Obesity Chair, Riyadh, Saudi Arabia
| | - Almino C Ramos
- Medical Director of Gastro-Obeso-Center, Institute for Metabolic Optimization, Sao Paulo, Brazil
| | - Karl Rheinwalt
- Department of Bariatric, Metabolic, and Plastic Surgery, St. Franziskus Hospital, Cologne, Germany
| | - Rui Ribeiro
- Centro Multidisciplinar Do Tratamento da Obesidade, Hospital Lusíadas Amadora e Lisbon, Amadora, Portugal
| | - Ann M Rogers
- Department of Surgery - Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Paulina Salminen
- Division of Digestive Surgery and Urology, Department of Digestive Surgery, Turku University Hospital, Turku, Finland
| | - Sergio Santoro
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, 05652-900, Brazil
| | - Nathaniel Sann
- Advanced Surgical Partners of Virginia, Richmond, VA, USA
| | - John D Scott
- Division of Bariatric and Minimal Access Surgery, Department of Surgery, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Asim Shabbir
- National University of Singapore, Singapore, Singapore
| | - Stephanie Sogg
- Massachusetts General Hospital Weight Center, Boston, MA, USA
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Michel Suter
- Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Antonio Torres
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Calle del Prof Martín Lagos, S/N, 28040, Madrid, Spain
| | - Surendra Ugale
- Kirloskar and Virinchi Hospitals, Hyderabad, Telangana, India
| | - Ramon Vilallonga
- Endocrine, Bariatric, and Metabolic Surgery Department, Universitary Hospital Vall Hebron, Barcelona, Spain
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Rudolf Weiner
- Bariatric Surgery Unit, Sana Clinic Offenbach, Offenbach, Germany
| | - Natan Zundel
- Department of Surgery, University of Buffalo, Buffalo, NY, USA
| | - Luigi Angrisani
- Department of Public Health, Federico II University of Naples, Naples, Italy
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Greene ME, Grieco A, Evans-Labok K, Ko CY, Hutter MM. First report of outcomes from the patient-reported outcome measures program in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program. Surg Obes Relat Dis 2024; 20:173-183. [PMID: 37949691 DOI: 10.1016/j.soard.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/14/2023] [Accepted: 09/04/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Health-related quality-of-life (HRQoL) is one of the most important outcomes to metabolic and bariatric surgery (MBS) patients but was not measured by the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). A patient-reported outcome measures (PROMs) program pilot started in 2016 with MBSAQIP implementation in 2019. OBJECTIVES To measure how MBS impacts patient HRQoL 1 and 2 years after primary laparoscopic Roux-en-Y gastric bypass (bypass) or laparoscopic sleeve gastrectomy (sleeve). SETTING The 82 centers in the United States participating in the MBSAQIP PROMs program. METHODS Preoperative HRQoL scores and satisfaction were compared with postoperative scores 1 and 2 years after surgery with univariate comparisons and adjusted regression models. RESULTS There were 13,901 PROMs responses from 11,146 patients. Patient satisfaction with their MBS decision was 97%. On average, patients had significant improvement in Obesity-related Problem (OP) scores (65.8 preoperatively, 23.0 at 1 yr, and 26.3 at 2 yr; P <.05), Obesity and Weight-Loss Quality-of-Life (OWLQOL) scores (36.7 preoperatively, 77.2 at 1 yr, and 74.6 at 2 yr; P < .05), their physical health (39.2 preoperatively versus 51.7 at 1 yr and 50.0 at 2 yr), and mental health (45.6 preoperatively versus 53.3 at 1 yr and 51.4 at 2 yr). Compared with bypass patients, sleeve patients had significantly lower odds of having low OP scores postoperatively (odds ratio [95% CI) ] .67 [.53, .83]) and lower odds of high OWLQOL (.61 [.48, .77]) at 1 year. CONCLUSION All patients regardless of procedure on average report significant improvement in their scores for OP, OWLQOL, and physical and mental health after MBS. At 1 and 2 years, bypass patients reported greater improvement in their obesity-related PROMs than sleeve patients.
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Affiliation(s)
- Meridith E Greene
- Department of Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois; Department of Surgery, University of California Los Angeles David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Matthew M Hutter
- Department of Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Greene ME, Goldman RE, Hutter MM. Selection of patient-reported outcomes measures for implementation in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program. Surg Obes Relat Dis 2023; 19:897-906. [PMID: 37037688 DOI: 10.1016/j.soard.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/15/2022] [Accepted: 01/29/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND The Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) assesses safety after metabolic and bariatric surgery and the impact on weight and obesity-related diseases. However, changes in quality of life are likely what matters most to patients, and these are not currently assessed. The best way to measure health-related quality of life (HRQoL) is to use validated patient-reported outcomes measures (PROMs), which capture patients' perspectives of their quality of life both before and after surgery. OBJECTIVES Identify the outcomes most important to bariatric surgery patients and identify the most appropriate validated PROMs to implement in a national program for the MBSAQIP. SETTING Five hospitals from a single healthcare system in New England. METHODS A series of 18 focus groups and/or interviews conducted with patients, patients' family members, and bariatric health providers determined the outcomes most important to bariatric patients and which validated PROMs would accurately measure those outcomes. Immersion crystallization was used to analyze focus group data and identify appropriate PROMs. RESULTS Focus group participants ranked health as the most important outcome for metabolic and bariatric surgery. Self-confidence, mobility, and everyday activities were the next highest ranked HRQoL domains. The Patient-Reported Outcomes Measurement Information System 10-Item Global Health Survey was selected as the general health measure. The Obesity-Related Problems scale and the Obesity and Weight-Loss Quality of Life Instrument were the disease-specific measures selected for inclusion in the MBSAQIP PROMs program. CONCLUSION The addition of PROMs to the MBSAQIP provides a unique opportunity to monitor HRQoL at the national level, which can foster improved shared decision-making before surgery.
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Affiliation(s)
- Meridith E Greene
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Grieco A, Greene ME, Ko CY, Cohen ME, Evans-Labok K, Fraker T, Hutter MM. Evaluating agreement between clinic- and patient-reported outcomes for weight and co-morbidities at 1 year after bariatric surgery. Surg Obes Relat Dis 2023; 19:309-317. [PMID: 36400692 DOI: 10.1016/j.soard.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Development of patient-reported outcomes (PROs) to include traditionally clinic-reported data has the potential to decrease the data-collection burden for patients and clinicians and increase follow-up rates. However, replacing clinic report by patient report requires that the data reasonably agree. OBJECTIVE To assess agreement between PROs and clinical registry data at 1 year after bariatric surgery. SETTING Not-for-profit organization, bariatric surgery data registry, PROs platform. METHODS Patient- and clinic-reported 1-year postoperative weight and co-morbidities were compared for matched PROs and registry records. The co-morbidities evaluated were diabetes, sleep apnea, hypertension, gastroesophageal reflux disease, and hyperlipidemia. Weight difference in pounds and nominal groupings (binary, 4-level) for co-morbidities were assessed for agreement between data sources using descriptive statistics, Bland-Altman plots, multiple regression, and kappa coefficients. Sensitivity analyses and follow-up by response method were examined. RESULTS Among 1130 patients with both 1-year PROs and registry weights, 95% of patient-reported weights were within 13 lb of the registry-recorded weight, and patients underreported their weight by ∼2 lb, on average. Percent agreement and kappa coefficients were highest for diabetes (n = 999; binary: 94%, κ = .72; 4-level: 86%, κ = .71) and lowest for gastroesophageal reflux disease (n = 1032; binary: 75%, κ = .40; 4-level: 57%, κ = .35). Of patients eligible for both PROs and registry 1-year follow-up, 21% had PROs only. CONCLUSIONS One-year patient- and clinic-reported weights and disease status for patients with diabetes and hypertension showed high agreement. The degree of bias from patient report was low. Patient report is a viable alternative to clinic report for certain objective measurements and may increase follow-up.
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Affiliation(s)
| | - Meridith E Greene
- Codman Center for Clinical Effectiveness in Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois; Department of Surgery, University of California Los Angeles David Geffen School of Medicine and Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California
| | | | | | | | - Matthew M Hutter
- Codman Center for Clinical Effectiveness in Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Yang AZ, Jung JJ, Hutter MM. Black-versus-White racial disparities in 30-day outcomes at Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited centers: a needed quality indicator. Surg Obes Relat Dis 2023; 19:273-281. [PMID: 36759274 DOI: 10.1016/j.soard.2022.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/28/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Creating a metric in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to assess Black-versus-White disparities is critical if we are to ensure equitable care for all. OBJECTIVE To investigate Black-versus-White disparities while replicating MBSAQIP methodology with regard to covariates and modeling so that the results can serve as the foundation to create a benchmarked site-level Disparities Metric for MBSAQIP. SETTING United States and Canada. METHODS Across the 2015-2019 MBSAQIP cohorts, 543,976 adults underwent primary or revision sleeve gastrectomy or Roux-en-Y gastric bypass and were reported as either White or Black. Using a set of covariates derived from published MBSAQIP performance models, we performed multivariable logistic modeling with 10-fold cross-validation for the 11 outcomes evaluated in MBSAQIP Semiannual Reports, plus venous thromboembolism (VTE) and death. We analyzed primary and revision cases separately. RESULTS After risk adjustment, Black patients experienced higher odds of all-occurrence morbidity (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19-1.25; P < .001), serious events (OR, 1.08; 95% CI, 1.04-1.13; P < .001), all-cause intervention (OR, 1.31; 95% CI, 1.24-1.37; P < .001), related intervention (OR, 1.29; 95% CI, 1.22-1.37; P < .001), all-cause readmission (OR, 1.37; 95% CI, 1.33-1.41; P < .001), related readmission (OR, 1.41; 95% CI, 1.36-1.46; P < .001), venous thromboembolism (OR, 1.49; 95% CI, 1.34-1.65; P < .001), and death (OR, 1.59; 95% CI, 1.34-1.89; P < .001) after primary procedures. Black patients experienced lower odds of morbidity (OR, .94; 95% CI, .91-.98; P = .004) and surgical-site infection (OR, .72; 95% CI, .66-.78; P < .001). CONCLUSIONS Black patients experienced a higher risk for serious complications and required more readmissions, reoperations, and postoperative interventions. This study supports the creation of a site-level Disparities Metric for the MBSAQIP and provides the framework to do so.
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Affiliation(s)
- Alan Z Yang
- Harvard Medical School, Boston, Massachusetts
| | - James J Jung
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Spence RT, Guidolin K, Quereshy FA, Chadi SA, Chang DC, Hutter MM. External validation of the Codman score in colorectal surgery: a pragmatic tool to drive quality improvement. Colorectal Dis 2023. [PMID: 36965098 DOI: 10.1111/codi.16547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/23/2022] [Accepted: 01/23/2023] [Indexed: 03/27/2023]
Abstract
AIM The simple six-variable Codman score is a tool designed to reduce the complexity of contemporary risk-adjusted postoperative mortality rate predictions. We sought to externally validate the Codman score in colorectal surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file and colectomy targeted dataset of 2020 were merged. A Codman score (composed of six variables: age, American Society of Anesthesiologists score, emergency status, degree of sepsis, functional status and preoperative blood transfusion) was assigned to every patient. The primary outcome was in-hospital mortality and secondary outcome was morbidity at 30 days. Logistic regression analyses were performed using the Codman score and the ACS NSQIP mortality and morbidity algorithms as independent variables for the primary and secondary outcomes. The predictive performance of discrimination area under receiver operating curve (AUC) and calibration of the Codman score and these algorithms were compared. RESULTS A total of 40 589 patients were included and a Codman score was generated for 40 557 (99.02%) patients. The median Codman score was 3 (interquartile range 1-4). To predict mortality, the Codman score had an AUC of 0.92 (95% CI 0.91-0.93) compared to the NSQIP mortality score 0.93 (95% CI 0.92-0.94). To predict morbidity, the Codman score had an AUC of 0.68 (95% CI 0.66-0.68) compared to the NSQIP morbidity score 0.72 (95% CI 0.71-0.73). When body mass index and surgical approach was added to the Codman score, the performance was no different to the NSQIP morbidity score. The calibration of observed versus expected predictions was almost perfect for both the morbidity and mortality NSQIP predictions, and only well fitted for Codman scores of less than 4 and greater than 7. CONCLUSION We propose that the six-variable Codman score is an efficient and actionable method for generating validated risk-adjusted outcome predictions and comparative benchmarks to drive quality improvement in colorectal surgery.
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Affiliation(s)
- Richard T Spence
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Keegan Guidolin
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Fayez A Quereshy
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network and Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Sami A Chadi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network and Princess Margaret Hospital, Toronto, Ontario, Canada
| | - David C Chang
- Department of General Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew M Hutter
- Department of General Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Jung JJ, Park AK, Hutter MM. The United States Experience with One Anastomosis Gastric Bypass at MBSAQIP-Accredited Centers. Obes Surg 2022; 32:3239-3247. [PMID: 36008649 DOI: 10.1007/s11695-022-06002-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE One anastomosis gastric bypass (OAGB) has emerged as a potentially safe and effective weight-loss procedure. Worldwide, OAGB is the third most commonly performed primary bariatric procedure, comprising 4% of the annual volume. In the USA, OAGB has yet to be endorsed as a primary bariatric procedure and can only be performed under research protocols or as a revision procedure. MATERIALS AND METHODS We performed an observational cohort study to describe the preoperative, intraoperative, and postoperative characteristics of adult patients who underwent primary or revision OAGB from 2015 to 2019 at MBSAQIP centers. Exclusion criteria included emergent surgery, incomplete 30-day follow-up, and non-laparoscopic- or robotic approach. RESULTS During the study period, 803,906 bariatric procedures were performed and 645 (0.08%) were OAGB. Among these, 436 (67.6%) were primary and 209 (32.4%) were revision OAGB. The mean operation time was 89 min (SD, 59) and 8% were performed using a robotic approach. The overall complication rate was 7.4% and there was one death (0.2%). The post-operative complication rates were generally higher than the early complication rate (3.4%) reported in the YOMEGA trial, an RCT from France. Revision OAGB had a longer mean operation time of 141 min (SD, 85, p < 0.001). CONCLUSION Primary OAGB was a rarely performed bariatric procedure at MBSAQIP-accredited centers comprising only 0.05% compared to 4% worldwide. Future studies should compare safety of OAGB to that of established bariatric procedures like Roux-en-Y gastric bypass and sleeve gastrectomy.
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Affiliation(s)
- James J Jung
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Division of General Surgery, Department of Surgery, University of Toronto, 30 Bond Street, 16CC-043, Toronto, ON, M5B 1W8, Canada.
| | - Albert K Park
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Matthew M Hutter
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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9
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Corey KE, Pitts R, Lai M, Loureiro J, Masia R, Osganian SA, Gustafson JL, Hutter MM, Gee DW, Meireles OR, Witkowski ER, Richards SM, Jacob J, Finkel N, Ngo D, Wang TJ, Gerszten RE, Ukomadu C, Jennings LL. ADAMTSL2 protein and a soluble biomarker signature identify at-risk non-alcoholic steatohepatitis and fibrosis in adults with NAFLD. J Hepatol 2022; 76:25-33. [PMID: 34600973 PMCID: PMC8688231 DOI: 10.1016/j.jhep.2021.09.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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: 10/22/2020] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Identifying fibrosis in non-alcoholic fatty liver disease (NAFLD) is essential to predict liver-related outcomes and guide treatment decisions. A protein-based signature of fibrosis could serve as a valuable, non-invasive diagnostic tool. This study sought to identify circulating proteins associated with fibrosis in NAFLD. METHODS We used aptamer-based proteomics to measure 4,783 proteins in 2 cohorts (Cohort A and B). Targeted, quantitative assays coupling aptamer-based protein pull down and mass spectrometry (SPMS) validated the profiling results in a bariatric and NAFLD cohort (Cohort C and D, respectively). Generalized linear modeling-logistic regression assessed the ability of candidate proteins to classify fibrosis. RESULTS From the multiplex profiling, 16 proteins differed significantly by fibrosis in cohorts A (n = 62) and B (n = 98). Quantitative and robust SPMS assays were developed for 8 proteins and validated in Cohorts C (n = 71) and D (n = 84). The A disintegrin and metalloproteinase with thrombospondin motifs like 2 (ADAMTSL2) protein accurately distinguished non-alcoholic fatty liver (NAFL)/non-alcoholic steatohepatitis (NASH) with fibrosis stage 0-1 (F0-1) from at-risk NASH with fibrosis stage 2-4, with AUROCs of 0.83 and 0.86 in Cohorts C and D, respectively, and from NASH with significant fibrosis (F2-3), with AUROCs of 0.80 and 0.83 in Cohorts C and D, respectively. An 8-protein panel distinguished NAFL/NASH F0-1 from at-risk NASH (AUROCs 0.90 and 0.87 in Cohort C and D, respectively) and NASH F2-3 (AUROCs 0.89 and 0.83 in Cohorts C and D, respectively). The 8-protein panel and ADAMTSL2 protein had superior performance to the NAFLD fibrosis score and fibrosis-4 score. CONCLUSION The ADAMTSL2 protein and an 8-protein soluble biomarker panel are highly associated with at-risk NASH and significant fibrosis; they exhibited superior diagnostic performance compared to standard of care fibrosis scores. LAY SUMMARY Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease worldwide. Diagnosing NAFLD and identifying fibrosis (scarring of the liver) currently requires a liver biopsy. Our study identified novel proteins found in the blood which may identify fibrosis without the need for a liver biopsy.
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Affiliation(s)
- Kathleen E. Corey
- Division of Gastroenterology, Massachusetts General Hospital (MGH) and Harvard Medical School (HMS), Boston, MA, USA
| | - Rebecca Pitts
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Michelle Lai
- Division of Hepatology, Beth Israel Deaconess Hospital (BIDMC) and HMS, Boston, MA, USA
| | - Joseph Loureiro
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Ricard Masia
- Department of Pathology, MGH and HMS, Boston, MA, USA
| | - Stephanie A. Osganian
- Division of Gastroenterology, Massachusetts General Hospital (MGH) and Harvard Medical School (HMS), Boston, MA, USA
| | - Jenna L. Gustafson
- Division of Gastroenterology, Massachusetts General Hospital (MGH) and Harvard Medical School (HMS), Boston, MA, USA
| | | | | | | | | | | | - Jaison Jacob
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Nancy Finkel
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Debby Ngo
- Department of Pulmonary/Critical Care, Cardiovascular Institute, BIDMC and HMS, Boston, MA, USA
| | - Thomas J Wang
- Department of Cardiology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Robert E. Gerszten
- Division of Cardiovascular Medicine and Cardiovascular Institute, BIDMC and HMS, Boston, MA, USA
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10
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Jung JJ, Park AK, Witkowski ER, Hutter MM. Comparison of Short-term Safety of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in the United States: 341 cases from MBSAQIP-accredited Centers. Surg Obes Relat Dis 2021; 18:326-334. [PMID: 34896012 DOI: 10.1016/j.soard.2021.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/22/2021] [Accepted: 11/07/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND One anastomosis gastric bypass (OAGB) is the third most common (4%) primary bariatric procedure worldwide but is seldom performed in the United States and is currently under consideration for endorsement by the American Society for Metabolic and Bariatric Surgery. Evidence from the United States on safety of OAGB compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is limited. OBJECTIVE To compare the short-term safety outcomes of the three primary bariatric procedures. SETTING Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited hospitals in the United States and Canada. METHODS Using the 2015-2019 MBSAQIP database, we compared the safety outcomes of adult patients who underwent primary laparoscopic OAGB, RYGB, and SG. Exclusion criteria included age over 80 years, emergency operation, conversion, and incomplete follow-up. The primary outcome was 30-day overall complication. Secondary outcomes were 30-day surgical and medical complications and hospitalization length. RESULTS A total of 341 patients underwent primary OAGB. Using propensity scores, we matched the OAGB cohort 1:1 with two cohorts of similar baseline characteristics who underwent RYGB and SG, respectively. The OAGB cohort had a lower overall complication rate than the RYGB cohort (6.7% versus12.3%, P = .02) and a similar rate to the SG cohort (5.0%, P = .43). The OAGB cohort had a similar rate of surgical complication to the RYGB cohort (5.0% versus 8.5%, P = .1) and a higher rate than the SG group (1.2%, P = .009). The OAGB cohort had a shorter median hospitalization than the RYGB cohort (1 d [interquartile range (IQR) 1-2 d] versus 2 d [IQR 1-2 d], P < .001) and a similar hospitalization length to the SG cohort ([1-2 d], P = .46). CONCLUSION Using the largest and the most current U.S. data, this study demonstrated that the short-term safety profile of primary OAGB is acceptable, but future studies should determine the long-term safety.
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Affiliation(s)
- James J Jung
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Surgery, University of Toronto, Toronto, Canada.
| | - Albert K Park
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Elan R Witkowski
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Matthew M Hutter
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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11
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Subudhi S, Drescher HK, Dichtel LE, Bartsch LM, Chung RT, Hutter MM, Gee DW, Meireles OR, Witkowski ER, Gelrud L, Masia R, Osganian SA, Gustafson JL, Rwema S, Bredella MA, Bhatia SN, Warren A, Miller KK, Lauer GM, Corey KE. Distinct Hepatic Gene-Expression Patterns of NAFLD in Patients With Obesity. Hepatol Commun 2021; 6:77-89. [PMID: 34558849 PMCID: PMC8710788 DOI: 10.1002/hep4.1789] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/13/2021] [Indexed: 02/06/2023] Open
Abstract
Approaches to manage nonalcoholic fatty liver disease (NAFLD) are limited by an incomplete understanding of disease pathogenesis. The aim of this study was to identify hepatic gene‐expression patterns associated with different patterns of liver injury in a high‐risk cohort of adults with obesity. Using the NanoString Technologies (Seattle, WA) nCounter assay, we quantified expression of 795 genes, hypothesized to be involved in hepatic fibrosis, inflammation, and steatosis, in liver tissue from 318 adults with obesity. Liver specimens were categorized into four distinct NAFLD phenotypes: normal liver histology (NLH), steatosis only (steatosis), nonalcoholic steatohepatitis without fibrosis (NASH F0), and NASH with fibrosis stage 1‐4 (NASH F1‐F4). One hundred twenty‐five genes were significantly increasing or decreasing as NAFLD pathology progressed. Compared with NLH, NASH F0 was characterized by increased inflammatory gene expression, such as gamma‐interferon‐inducible lysosomal thiol reductase (IFI30) and chemokine (C‐X‐C motif) ligand 9 (CXCL9), while complement and coagulation related genes, such as C9 and complement component 4 binding protein beta (C4BPB), were reduced. In the presence of NASH F1‐F4, extracellular matrix degrading proteinases and profibrotic/scar deposition genes, such as collagens and transforming growth factor beta 1 (TGFB1), were simultaneously increased, suggesting a dynamic state of tissue remodeling. Conclusion: In adults with obesity, distinct states of NAFLD are associated with intrahepatic perturbations in genes related to inflammation, complement and coagulation pathways, and tissue remodeling. These data provide insights into the dynamic pathogenesis of NAFLD in high‐risk individuals.
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Affiliation(s)
- Sonu Subudhi
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hannah K Drescher
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura E Dichtel
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lea M Bartsch
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Raymond T Chung
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Denise W Gee
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ozanan R Meireles
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Elan R Witkowski
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Louis Gelrud
- Department of Medicine, St. Mary's Hospital Bon Secours, Richmond, VA, USA
| | - Ricard Masia
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephanie A Osganian
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jenna L Gustafson
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Steve Rwema
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Miriam A Bredella
- Division of Musculoskeletal Radiology and Interventions, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sangeeta N Bhatia
- Ludwig Center for Molecular Oncology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Andrew Warren
- Ludwig Center for Molecular Oncology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Georg M Lauer
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kathleen E Corey
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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12
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Lindeman KG, Rushin CC, Cheney MC, Bouxsein ML, Hutter MM, Yu EW. Bone Density and Trabecular Morphology at Least 10 Years After Gastric Bypass and Gastric Banding. J Bone Miner Res 2020; 35:2132-2142. [PMID: 32663365 DOI: 10.1002/jbmr.4112] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/11/2020] [Accepted: 06/07/2020] [Indexed: 12/20/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) instigates high-turnover bone loss in the initial 5 years after surgery, whereas skeletal changes after adjustable gastric banding (AGB) are less pronounced. Long-term skeletal data are scarce, and the mechanisms of bone loss remain unclear. We sought to examine bone density and microarchitecture in RYGB and AGB patients a decade after surgery and to determine whether prior published reports of bone loss represent an appropriate adaptation to new postsurgical weight. In this cross-sectional study, 25 RYGB and 25 AGB subjects who had bariatric surgery ≥10 years ago were matched 1:1 with nonsurgical controls for age, sex, and current body mass index (BMI). We obtained bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), volumetric BMD and microarchitecture by high-resolution peripheral quantitative computed tomography (HR-pQCT), trabecular morphology by individual trabecular segmentation, and metabolic bone laboratory results. As compared with BMI-matched controls, RYGB subjects had significantly lower hip BMD, and lower total volumetric BMD at the distal radius and tibia. Substantial deficits in cortical and trabecular microarchitecture were observed in the RYGB group compared to controls, with reduced trabecular plate bone volume fraction and estimated failure load at both the radius and tibia, respectively. Bone turnover markers CTX and P1NP were 99% and 77% higher in the RYGB group than controls, respectively, with no differences in serum calcium, 25-hydroxyvitamin D, or parathyroid hormone. In contrast, the AGB group did not differ from their BMI-matched controls in any measured bone density, microarchitecture, or laboratory parameter. Thus, RYGB, but not AGB, is associated with lower than expected hip and peripheral BMD for the new weight setpoint, as well as deleterious changes in bone microarchitecture. These findings suggest that pathophysiologic processes other than mechanical unloading or secondary hyperparathyroidism contribute to bone loss after RYGB, and have important clinical implications for the long-term care of RYGB patients. © 2020 American Society for Bone and Mineral Research.
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Affiliation(s)
| | - Claire C Rushin
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA
| | | | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Matthew M Hutter
- Harvard Medical School, Boston, MA, USA.,Department of Surgery, Weight Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elaine W Yu
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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13
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Udelsman BV, Corey K, Hutter MM, Chang DC, Witkowski ER. Use of noninvasive scores for advanced liver fibrosis can guide the need for hepatic biopsy during bariatric procedures. Surg Obes Relat Dis 2020; 17:292-298. [PMID: 33153965 DOI: 10.1016/j.soard.2020.09.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/22/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with obesity are at increased risk for nonalcoholic fatty liver disease (NAFLD). The effectiveness of noninvasive screening tests for ruling out advanced fibrosis (stage 3-4) is unknown. OBJECTIVES To determine the prevalence of advanced fibrosis in patients undergoing routine liver biopsy during bariatric surgery and assess the effectiveness of existing noninvasive risk calculators. SETTING Academic medical center in the United States. METHODS Routine liver biopsies were obtained during first-time bariatric surgery (January 2001-December 2017). Patient demographic characteristics, co-morbidities, and preoperative laboratory values were compiled. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were compared between 3 noninvasive risk calculators for advanced fibrosis: the fibrosis-4 index, NAFLD fibrosis score, and aminotransferase-to-platelet ratio index (APRI). RESULTS Among 2465 patients, the prevalence of advanced fibrosis (stage 3-4) was 3.4%. The mean age was 45.5 years, and the mean body mass index was 46.8. The sensitivity of noninvasive risk calculators ranged from 85% (NAFLD fibrosis score) to 24% (APRI). The NAFLD fibrosis score performed best in screening out advanced fibrosis, with an NPV of 99%. The PPV ranged from 9% to 65%. In this study cohort, the use of the NALFD fibrosis score correctly ruled out advanced fibrosis in 893 (36%) patients, with 13 false negatives. CONCLUSIONS The prevalence of advanced fibrosis in individuals undergoing routine first-time bariatric procedures is 3.4%. Use of the NALFD fibrosis score can rule out advanced fibrosis in one-third of this population, and guide surgical decision-making.
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Affiliation(s)
- Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Kathleen Corey
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Elan R Witkowski
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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14
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Baughman AW, Hirschberg RE, Lucas LJ, Suarez ED, Stockmann D, Hutton Johnson S, Hutter MM, Murphy DJ, Marsh RH, Thompson RW, Boland GW, Ives Erickson J, Palamara K. Pandemic Care Through Collaboration: Lessons From a COVID-19 Field Hospital. J Am Med Dir Assoc 2020; 21:1563-1567. [PMID: 33138938 PMCID: PMC7832230 DOI: 10.1016/j.jamda.2020.09.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 07/08/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 12/04/2022]
Abstract
During the surge of Coronavirus Disease 2019 (COVID-19) infections in March and April 2020, many skilled-nursing facilities in the Boston area closed to COVID-19 post-acute admissions because of infection control concerns and staffing shortages. Local government and health care leaders collaborated to establish a 1000-bed field hospital for patients with COVID-19, with 500 respite beds for the undomiciled and 500 post-acute care (PAC) beds within 9 days. The PAC hospital provided care for 394 patients over 7 weeks, from April 10 to June 2, 2020. In this report, we describe our implementation strategy, including organization structure, admissions criteria, and clinical services. Partnership with government, military, and local health care organizations was essential for logistical and medical support. In addition, dynamic workflows necessitated clear communication pathways, clinical operations expertise, and highly adaptable staff.
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Affiliation(s)
- Amy W Baughman
- Boston Hope Field Hospital, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA.
| | - Ronald E Hirschberg
- Boston Hope Field Hospital, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA; Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Larissa J Lucas
- Boston Hope Field Hospital, Boston, MA, USA; North Shore Physicians Group, Boston, MA, USA
| | - Elliot D Suarez
- Boston Hope Field Hospital, Boston, MA, USA; Atrius Health, Newton, MA, USA
| | - Deanna Stockmann
- Boston Hope Field Hospital, Boston, MA, USA; Atrius Health, Newton, MA, USA
| | | | - Matthew M Hutter
- Boston Hope Field Hospital, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
| | - Deborah J Murphy
- Boston Hope Field Hospital, Boston, MA, USA; Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Regan H Marsh
- Boston Hope Field Hospital, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | | | - Giles W Boland
- Boston Hope Field Hospital, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Jeanette Ives Erickson
- Boston Hope Field Hospital, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
| | - Kerri Palamara
- Boston Hope Field Hospital, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
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15
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Hutter MM, Kothari SN, LaMasters TL, DeMaria EJ. Open letter to insurance companies regarding mandatory in-office visit weight documentation in an era of COVID-19. Surg Obes Relat Dis 2020; 16:1165-1166. [PMID: 32620376 PMCID: PMC7255233 DOI: 10.1016/j.soard.2020.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Shanu N Kothari
- Department of Surgery, Prisma Health, Greenville, South Carolina.
| | | | - Eric J DeMaria
- Division of General and Bariatric Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
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16
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Hu K, Liu M, Wang AJ, Zhao G, Sun Y, Yang C, Zhang Y, Hutter MM, Feng D, Sun B, Williams Z. Spine surgeon specialty differences in single-level percutaneous kyphoplasty. BMC Surg 2019; 19:163. [PMID: 31694623 PMCID: PMC6833171 DOI: 10.1186/s12893-019-0630-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 10/21/2019] [Indexed: 01/09/2023] Open
Abstract
Background Percutaneous kyphoplasty (PKP) is a procedure performed by a spine surgeon who undergoes either orthopedic or neurosurgical training. The relationship between short-term adverse outcomes and spine specialty is presently unknown. To compare short-term adverse outcomes of single-level PKP when performed by neurosurgeons and orthopedic surgeons in order to develop more concretely preventive strategies for patients under consideration for single-level PKP. Methods We evaluated patients who underwent single-level PKP from 2012 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We used univariate analysis and multivariate logistic regression to assess the association between spine surgeon specialty and short-term adverse events, including postoperative complication and unplanned readmission, and to identify different independent risk predictors between two specialties. Results Of 2248 patients who underwent single-level PKP procedure, 1229 patients (54.7%) had their operations completed by a neurosurgeon. There were no significant differences in the development of the majority of postoperative complications and the occurrence of unplanned readmission between the neurosurgical cohort (NC) and the orthopedic cohort (OC). A difference in the postoperative blood transfusion rate (0.7% NS vs. 1.7% OC, P = 0.039) was noted and may due to the differences in comorbidities between patients. Multivariate regression analysis revealed different independent predictors of postoperative adverse events for the two spine specialties. Conclusions By comparing a large range of demographic feature, preoperative comorbidities, and intraoperative factors, we find that short-term adverse events in single-level PKP patients does not affect by spine surgeon specialty, except that the OC had higher postoperative blood transfusion rate. In addition, the different perioperative predictors of postoperative complications and unplanned readmissions were identified between the two specialties. These findings can lead to better evidence-based patient counseling and provide valuable information for medical evaluation and potentially devise methods to reduce patients’ risk.
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Affiliation(s)
- Kejia Hu
- Center of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China. .,Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA. .,Department of Orthopedics, Wuxi People's Hospital, Nanjing Medical University, Wuxi, 214023, China.
| | - Motao Liu
- Department of Biomedical Engineering, Columbia University, New York, NY, 10027, USA
| | - Amy J Wang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Gexin Zhao
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China
| | - Yuhao Sun
- Center of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Chaoqun Yang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yiwang Zhang
- Department of Neurosurgery, No. 910th Hospital of The People's Liberation Army Joint Logistics Support Force, Quanzhou, China
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Dehong Feng
- Department of Orthopedics, Wuxi People's Hospital, Nanjing Medical University, Wuxi, 214023, China.
| | - Bomin Sun
- Center of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Ziv Williams
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
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17
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Loehrer AP, Chang DC, Scott JW, Hutter MM, Patel VI, Lee JE, Sommers BD. Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions. JAMA Surg 2019; 153:e175568. [PMID: 29365029 DOI: 10.1001/jamasurg.2017.5568] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Andrew P. Loehrer
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - David C. Chang
- Department of Surgery, Massachusetts General Hospital, Boston
| | - John W. Scott
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Virendra I. Patel
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Udelsman BV, Corey KE, Lindvall C, Gee DW, Meireles OR, Hutter MM, Chang DC, Witkowski ER. Risk factors and prevalence of liver disease in review of 2557 routine liver biopsies performed during bariatric surgery. Surg Obes Relat Dis 2019; 15:843-849. [PMID: 31014948 DOI: 10.1016/j.soard.2019.01.035] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/21/2019] [Accepted: 01/30/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Obesity is a known risk factor for nonalcoholic fatty liver disease (NAFLD). However, among individuals undergoing bariatric surgery, the prevalence and risk factors for NAFLD, as well as distinct phenotypes of steatosis, nonalcoholic steatohepatitis (NASH), and fibrosis remain incompletely understood. OBJECTIVES To determine the prevalence and risk factors for steatosis, NASH, and fibrosis in individuals undergoing routine bariatric surgery. SETTING Academic medical center in the United States. METHODS Liver wedge biopsies were performed at the time of surgery between 2001 and 2017. Pathology reports were reviewed, and individuals were grouped by NAFLD phenotype. Covariates including demographic characteristics, co-morbidities, and preoperative laboratory values were compared between groups using Student's t test, Pearson's χ2, and logistic regression. RESULTS Liver biopsies were obtained in 97.7% of first-time bariatric procedures, representing 2557 patients. Mean age was 45.6 years, mean body mass index was 46.7, and most were non-Hispanic white (76.1%) and female (71.6%). On histologic review 61.2% had steatosis and 30.9% NASH. Fibrosis was identified in 29.3% of individuals, and 7.8% had stage ≥2 fibrosis. On logistic regression, elevated aspartate aminotransferase (odds ratio [OR] 1.87; P < .001) and elevated alanine aminotransferase (OR 1.62; P < .001) were independently associated with fibrosis. Elevated hemoglobin A1C of 5.7% to 6.5% (OR 1.29; P < .01) and >6.5% (OR 3.23; P < .001) were also associated with fibrosis. A similar trend was seen for NASH. CONCLUSIONS NASH and/or fibrosis is present in nearly one third of patients undergoing routine bariatric surgery. Risk factors include diabetes, elevated liver enzymes, and diabetes. Risk assessment and aggressive screening should be considered in patients undergoing bariatric surgery.
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Affiliation(s)
- Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Kathleen E Corey
- Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Denise W Gee
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Ozanan R Meireles
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Elan R Witkowski
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Spence RT, Chang DC, Kaafarani HMA, Panieri E, Anderson GA, Hutter MM. Derivation, Validation and Application of a Pragmatic Risk Prediction Index for Benchmarking of Surgical Outcomes. World J Surg 2018; 42:533-540. [PMID: 28795214 DOI: 10.1007/s00268-017-4177-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite the existence of multiple validated risk assessment and quality benchmarking tools in surgery, their utility outside of high-income countries is limited. We sought to derive, validate and apply a scoring system that is both (1) feasible, and (2) reliably predicts mortality in a middle-income country (MIC) context. METHODS A 5-step methodology was used: (1) development of a de novo surgical outcomes database modeled around the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) in South Africa (SA dataset), (2) use of the resultant data to identify all predictors of in-hospital death with more than 90% capture indicating feasibility of collection, (3) use these predictors to derive and validate an integer-based score that reliably predicts in-hospital death in the 2012 ACS-NSQIP, (4) apply the score in the original SA dataset and demonstrate its performance, (5) identify threshold cutoffs of the score to prompt action and drive quality improvement. RESULTS Following step one-three above, the 13 point Codman's score was derived and validated on 211,737 and 109,079 patients, respectively, and includes: age 65 (1), partially or completely dependent functional status (1), preoperative transfusions ≥4 units (1), emergency operation (2), sepsis or septic shock (2) American Society of Anesthesia score ≥3 (3) and operative procedure (1-3). Application of the score to 373 patients in the SA dataset showed good discrimination and calibration to predict an in-hospital death. A Codman Score of 8 is an optimal cutoff point for defining expected and unexpected deaths. CONCLUSION We have designed a novel risk prediction score specific for a MIC context. The Codman Score can prove useful for both (1) preoperative decision-making and (2) benchmarking the quality of surgical care in MIC's.
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Affiliation(s)
- Richard T Spence
- Department of General Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA. .,Department of Surgery, University of Cape Town, Cape Town, South Africa.
| | - David C Chang
- Department of General Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Department of General Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Eugenio Panieri
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | | | - Matthew M Hutter
- Department of General Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Liu JB, Ban KA, Berian JR, Hutter MM, Huffman KM, Liu Y, Hoyt DB, Hall BL, Ko CY. Concurrent bariatric operations and association with perioperative outcomes: registry based cohort study. BMJ 2017; 358:j4244. [PMID: 28951446 PMCID: PMC5613750 DOI: 10.1136/bmj.j4244] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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] [Accepted: 09/01/2017] [Indexed: 12/15/2022]
Abstract
Objective To determine whether perioperative outcomes differ between patients undergoing concurrent compared with non-concurrent bariatric operations in the USA.Design Retrospective, propensity score matched cohort study.Setting Hospitals in the US accredited by the American College of Surgeons' metabolic and bariatric surgery accreditation and quality improvement program.Participants 513 167 patients undergoing bariatric operations between 1 January 2014 and 31 December 2016.Main outcome measures The primary outcome measure was a composite of 30 day death, morbidity, readmission, reoperation, anastomotic or staple line leak, and bleeding events. Operative duration and lengths of stay were also assessed. Operations were defined as concurrent if they overlapped by 60 or more minutes or in their entirety.Results In this study of 513 167 operations, 739 (29.5%) surgeons at 483 (57.8%) hospitals performed 6087 (1.2%) concurrent operations. The most frequently performed concurrent bariatric operations were sleeve gastrectomy (n=3250, 53.4%) and Roux-en-Y gastric bypass (n=1601, 26.3%). Concurrent operations were more often performed at large academic medical centers with higher operative volumes and numbers of trainees and by higher volume surgeons. Compared with non-concurrent operations, concurrent operations lasted a median of 34 minutes longer (P<0.001) and resulted in 0.3 days longer average length of stay (P<0.001). Perioperative adverse events were not observed to more likely occur in concurrent compared with non-concurrent operations (7.5% v 7.4%; relative risk 1.02, 95% confidence interval 0.90 to 1.15; P=0.84).Conclusions Concurrent bariatric operations occurred infrequently, but when they did, there was no observable increased risk for adverse perioperative outcomes compared with non-concurrent operations. These results, however, do not argue against improved and more meaningful disclosure of concurrent surgery practices.
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Affiliation(s)
- Jason B Liu
- American College of Surgeons, 633 N St Clair St, Chicago, IL, 60611, USA
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Kristen A Ban
- American College of Surgeons, 633 N St Clair St, Chicago, IL, 60611, USA
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Julia R Berian
- American College of Surgeons, 633 N St Clair St, Chicago, IL, 60611, USA
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Matthew M Hutter
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | - Yaoming Liu
- American College of Surgeons, 633 N St Clair St, Chicago, IL, 60611, USA
| | - David B Hoyt
- American College of Surgeons, 633 N St Clair St, Chicago, IL, 60611, USA
| | - Bruce L Hall
- American College of Surgeons, 633 N St Clair St, Chicago, IL, 60611, USA
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Olin Business School, Washington University in St Louis, St Louis, MO, USA; BJC Healthcare, St Louis, MO, USA
| | - Clifford Y Ko
- American College of Surgeons, 633 N St Clair St, Chicago, IL, 60611, USA
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Fong ZV, McMillan MT, Marchegiani G, Sahora K, Malleo G, De Pastena M, Loehrer AP, Lee GC, Ferrone CR, Chang DC, Hutter MM, Drebin JA, Bassi C, Lillemoe KD, Vollmer CM, Fernández-Del Castillo C. Discordance Between Perioperative Antibiotic Prophylaxis and Wound Infection Cultures in Patients Undergoing Pancreaticoduodenectomy. JAMA Surg 2017; 151:432-9. [PMID: 26720272 DOI: 10.1001/jamasurg.2015.4510] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Wound infections after pancreaticoduodenectomy (PD) are common. The standard antibiotic prophylaxis given to prevent the infections is often a cephalosporin. However, this decision is rarely guided by microbiology data pertinent to PD, particularly in patients with biliary stents. OBJECTIVE To analyze the microbiology of post-PD wound infection cultures and the effectiveness of institution-based perioperative antibiotic protocols. DESIGN, SETTING, AND PARTICIPANTS The pancreatic resection databases of 3 institutions (designated as institutions A, B, or C) were queried on patients undergoing PD from June 1, 2008, to June 1, 2013, and a total of 1623 patients were identified. Perioperative variables as well as microbiology data for intraoperative bile and postoperative wound cultures were analyzed from June 1, 2008, to June 1, 2013. INTERVENTIONS Perioperative antibiotic administration. MAIN OUTCOMES AND MEASURES Wound infection microbiology analysis and resistance patterns. RESULTS Of the 1623 patients who underwent PD, 133 with wound infections (8.2%) were identified. The wound infection rate did not differ significantly across the 3 institutions. The predominant perioperative antibiotics used at institutions A, B, and C were cefoxitin sodium, cefazolin sodium with metronidazole, and ampicillin sodium-sulbactam sodium, respectively. Of the 133 wound infections, 89 (67.1%) were deep-tissue infection, occurring at a median of 8 (range, 1-57) days after PD. A total of 53 (40.0%) of the wound infections required home visiting nurse services on discharge, and 73 (29.1%) of all PD readmissions were attributed to wound infection. Preoperative biliary stenting was the strongest predictor of postoperative wound infection (odds ratio, 2.5; 95% CI, 1.58-3.88; P = .03). There was marked institutional variation in the type of microorganisms cultured from both the intraoperative bile and wound infection cultures (Streptococcus pneumoniae, 114 cultures [47.9%] in institution A vs 3 [4.5%] in institution B; P = .001) and wound infection cultures (predominant microorganism in institution A: Enterococcus faecalis, 18 cultures [51.4%]; institution B: Staphylococcus aureus, 8 [43.9%]; and institution C: Escherichia coli, 17 [36.2%], P = .001). Similarly, antibiotic resistance patterns varied (resistance pattern in institution A: cefoxitin, 29 cultures [53.1%]; institution B: ampicillin-sulbactam, 9 [69.2%]; and institution C: penicillin, 32 [72.7%], P < .001). Microorganisms isolated in intraoperative bile cultures were similar to those identified in wound cultures in patients with post-PD wound infections. CONCLUSIONS AND RELEVANCE The findings of this large-scale, multi-institutional study indicate that intraoperative bile cultures should be routinely obtained in patients who underwent preoperative endoscopic retrograde cholangiopancreatography since the isolated microorganisms closely correlate with those identified on postoperative wound cultures. Institution-specific internal reviews should amend current protocols for antibiotic prophylaxis to reduce the incidence of wound infections following PD.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | | | - Klaus Sahora
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | | | - Andrew P Loehrer
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jeffrey A Drebin
- Perelman School of Medicine, Hospital of Pennsylvania, Philadelphia
| | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
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Hu K, Moses ZB, Hutter MM, Williams Z. Short-Term Adverse Outcomes After Deep Brain Stimulation Treatment in Patients with Parkinson Disease. World Neurosurg 2016; 98:365-374. [PMID: 27826085 DOI: 10.1016/j.wneu.2016.10.138] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 10/26/2016] [Accepted: 10/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite ongoing progress in our understanding of long-term outcomes after neuromodulation procedures, acute adverse outcomes shortly after deep brain stimulation (DBS) treatment have remained remarkably limited. OBJECTIVE To identify risk factors associated with acute 30-day outcomes after DBS treatment in patients with Parkinson disease (PD). METHODS We evaluated patients who underwent DBS treatment for PD from 2005 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program database. We used bivariate analysis and multivariate logistic regression to identify short-term postoperative outcomes, including 30-day complication, discharge destination, and unplanned readmission. RESULTS Overall, 650 patients with PD underwent DBS procedures and complications were identified in 32 patients (4.9%). Of 481 patients who had complete discharge data, 18 patients (3.7%) were discharged to a facility and 16 patients (3.3%) experienced an unplanned readmission. Patients with PD who were obese (P = 0.045), who had preoperative anemia (P = 0.008), and who experienced longer operative durations (P = 0.01) had increased odds of postoperative complications. Inpatient status (P = 0.001), dependent functional status (P < 0.001), and anemia (P = 0.043) were all associated with discharge to a facility other than home. Longer operative duration (P = 0.013), anemia (P = 0.036), and dependent functional status (P = 0.03) were significantly associated with unplanned readmission. As expected, complications increased the likelihood of unplanned readmission (P < 0.001). CONCLUSIONS This study provides individualized estimates of the risks associated with short-term adverse outcomes based on patient demographics and comorbidities. These data can be used as an adjunct for short-term risk stratification of patients with PD being considered for DBS treatment.
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Affiliation(s)
- Kejia Hu
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Microsurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ziev B Moses
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ziv Williams
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Loehrer AP, Song Z, Haynes AB, Chang DC, Hutter MM, Mullen JT. Impact of Health Insurance Expansion on the Treatment of Colorectal Cancer. J Clin Oncol 2016; 34:4110-4115. [PMID: 27863191 DOI: 10.1200/jco.2016.68.5701] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Purpose Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. Lack of insurance coverage has been associated with more advanced disease at presentation, more emergent admissions at time of colectomy, and lower survival relative to privately insured patients. The 2006 Massachusetts health care reform serves as a unique natural experiment to assess the impact of insurance expansion on colorectal cancer care. Methods We used the Hospital Cost and Utilization Project State Inpatient Databases to identify patients with colorectal cancer with government-subsidized or self-pay (GSSP) or private insurance admitted to a hospital between 2001 and 2011 in Massachusetts (n = 17,499) and three control states (n = 144,253). Difference-in-differences models assessed the impact of the 2006 Massachusetts coverage expansion on resection of colorectal cancer, controlling for confounding factors and secular trends. Results Before the 2006 Massachusetts reform, government-subsidized or self-pay patients had significantly lower rates of resection for colorectal cancer compared with privately insured patients in both Massachusetts and the control states. The Massachusetts insurance expansion was associated with a 44% increased rate of resection (rate ratio = 1.44; 95% CI, 1.23 to 1.68; P < .001), a 6.21 percentage point decreased probability of emergent admission (95% CI, -11.88 to -0.54; P = .032), and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34 to 14.91; P = .019) compared with the control states. Conclusion The 2006 Massachusetts health care reform, a model for the Affordable Care Act, was associated with increased rates of resection and decreased probability of emergent resection for colorectal cancer. Our findings suggest that insurance expansion may help improve access to care for patients with colorectal cancer.
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Affiliation(s)
| | - Zirui Song
- All authors: Massachusetts General Hospital, Boston, MA
| | - Alex B Haynes
- All authors: Massachusetts General Hospital, Boston, MA
| | - David C Chang
- All authors: Massachusetts General Hospital, Boston, MA
| | | | - John T Mullen
- All authors: Massachusetts General Hospital, Boston, MA
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Loehrer AP, Hawkins AT, Auchincloss HG, Song Z, Hutter MM, Patel VI. Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights From Massachusetts. Ann Surg 2016; 263:705-11. [PMID: 26587850 PMCID: PMC4777641 DOI: 10.1097/sla.0000000000001310] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease. BACKGROUND Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act. METHODS We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion. RESULTS Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states. CONCLUSIONS The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.
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Affiliation(s)
- Andrew P. Loehrer
- Department of Surgery, Massachusetts General Hospital, Boston Massachusetts
| | | | | | - Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Matthew M. Hutter
- Department of Surgery, Massachusetts General Hospital, Boston Massachusetts
| | - Virendra I. Patel
- Department of Surgery, Massachusetts General Hospital, Boston Massachusetts
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Loehrer AP, Chang DC, Hutter MM, Song Z, Lillemoe KD, Warshaw AL, Ferrone CR. Health Insurance Expansion and Treatment of Pancreatic Cancer: Does Increased Access Lead to Improved Care? J Am Coll Surg 2015; 221:1015-22. [PMID: 26611798 DOI: 10.1016/j.jamcollsurg.2015.09.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/09/2015] [Accepted: 09/10/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pancreatic cancer is increasingly common and poised to become the second leading cause of cancer deaths by the year 2020. Surgical resection is the only chance for cure, yet significant disparities in resection rates exist by insurance status. The 2006 Massachusetts health care reform serves as natural experiment to evaluate the unknown impact of health insurance expansion on treatment of pancreatic cancer. STUDY DESIGN Using the Agency for Healthcare Research and Quality's State Inpatient Databases, this cohort study examines nonelderly, adult patients with no insurance, private coverage, or government-subsidized insurance plans, who were admitted with pancreatic cancer in Massachusetts and 3 control states. The primary end point was change in pancreatic resection rates. Difference-in-difference models were used to show the impact of Massachusetts health care reform on resection rates for pancreatic cancer, controlling for confounding factors and secular trends. RESULTS Before the Massachusetts reform, government-subsidized and self-pay patients had significantly lower rates of resection than privately insured patients. The 2006 Massachusetts health reform was associated with a 15% increased rate of admission with pancreatic cancer (p = 0.043) and a 67% increased rate of surgical resection (p = 0.043) compared with control states. Measured disparities in likelihood of resection by insurance status decreased in Massachusetts and remained unchanged in control states. CONCLUSIONS The 2006 Massachusetts health care reform was associated with increased resection rates for pancreatic cancer compared with control states. Our findings provide hopeful evidence that increased insurance coverage can help improve equity in pancreatic cancer treatment. Additional studies are needed to evaluate the longevity of these findings and generalizability in other states.
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Affiliation(s)
- Andrew P Loehrer
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Sangji NF, Silvestri S, Abayaah E, Chang DC, Hutter MM, O'Malley C. Sharps Injuries in the Operating Room Sterile Fields of an Academic Tertiary Care Center. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
IMPORTANCE Racial disparities in receipt of minimally invasive surgery (MIS) persist in the United States and have been shown to also be associated with a number of driving factors, including insurance status. However, little is known as to how expanding insurance coverage across a population influences disparities in surgical care. OBJECTIVE To evaluate the impact of Massachusetts health care reform on racial disparities in MIS. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study assessed the probability of undergoing MIS vs an open operation for nonwhite patients in Massachusetts compared with 6 control states. All discharges (n = 167,560) of nonelderly white, black, or Latino patients with government insurance (Medicaid or Commonwealth Care insurance) or no insurance who underwent a procedure for acute appendicitis or acute cholecystitis at inpatient hospitals between January 1, 2001, and December 31, 2009, were assessed. Data are from the Hospital Cost and Utilization Project State Inpatient Databases. INTERVENTION The 2006 Massachusetts health care reform, which expanded insurance coverage for government-subsidized, self-pay, and uninsured individuals in Massachusetts. MAIN OUTCOMES AND MEASURES Adjusted probability of undergoing MIS and difference-in-difference estimates. RESULTS Prior to the 2006 reform, Massachusetts nonwhite patients had a 5.21-percentage point lower probability of MIS relative to white patients (P < .001). Nonwhite patients in control states had a 1.39-percentage point lower probability of MIS (P = .007). After reform, nonwhite patients in Massachusetts had a 3.71-percentage point increase in the probability of MIS relative to concurrent trends in control states (P = .01). After 2006, measured racial disparities in MIS resolved in Massachusetts, with nonwhite patients having equal probability of MIS relative to white patients (0.06 percentage point greater; P = .96). However, nonwhite patients in control states without health care reform have a persistently lower probability of MIS relative to white patients (3.19 percentage points lower; P < .001). CONCLUSIONS AND RELEVANCE The 2006 Massachusetts insurance expansion was associated with an increased probability of nonwhite patients undergoing MIS and resolution of measured racial disparities in MIS.
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Affiliation(s)
| | - Zirui Song
- Francis Weld Peabody Society, Harvard Medical School, Boston, Massachusetts3National Bureau of Economic Research, Cambridge, Massachusetts
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Auchincloss HG, Loehrer A, Hutter MM. Reducing readmissions after complex GI surgery: targeting high-risk patients alone is inadequate. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.246] [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: 11/25/2022]
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Loehrer AP, Auchincloss HG, Song Z, Hutter MM. Massachusetts health care reform is associated with reduced disparities in the management of acute cholecystitis. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.232] [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: 10/26/2022]
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McKenzie TJ, Chen Y, Hodin RA, Shikora SA, Hutter MM, Gaz RD, Moore FD, Lubitz CC. Recalcitrant hypocalcemia after thyroidectomy in patients with previous Roux-en-Y gastric bypass. Surgery 2013; 154:1300-6; discussion 1306. [PMID: 23978591 DOI: 10.1016/j.surg.2013.04.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/18/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hypocalcemia is a potential complication after thyroidectomy. Patients with previous roux-en-Y gastric bypass (RYGBP) may be at increased risk for recalcitrant symptomatic hypocalcemia after thyroidectomy. This complication is poorly described and there is no current consensus on optimal management in this unique population. METHODS All patients from 2000 to 2012 who underwent thyroidectomy with history of preceding RYGBP were identified retrospectively. Each of the 19 patients meeting inclusion criteria were matched 2:1 for age, gender, and body mass index (BMI) to a cohort who underwent thyroidectomy without previous RYGBP. The study cohort and matched controls were compared for incidence of symptomatic postoperative hypocalcemia, requirement of intravenous (IV) calcium supplementation, and duration of hospital stay. RESULTS Age, proportion of female patients, and BMI were equivalent between cases (n = 19) and controls (n = 38). Comparison of primary outcomes demonstrated that the study group had a significantly higher incidence of symptomatic hypocalcemia (42% vs. 0%; P < .01), administration of IV calcium (21% vs. 0%; P < .01), and duration of hospital stay (2.2 vs. 1.2 days, P = .02). CONCLUSION Patients with previous RYGBP have a greater incidence of recalcitrant symptomatic hypocalcemia after thyroidectomy, resulting in prolonged duration of hospital stay. In this patient population, calcium levels should be closely monitored and early calcium and vitamin D supplementation initiated preemptively.
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Affiliation(s)
- Travis J McKenzie
- Massachusetts General Hospital, Department of Surgery, Wang Ambulatory Care Center, Boston, MA.
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Jackson TD, Hutter MM. Morbidity and Effectiveness of Laparoscopic Sleeve Gastrectomy, Adjustable Gastric Band, and Gastric Bypass for Morbid Obesity. Adv Surg 2012; 46:255-68. [DOI: 10.1016/j.yasu.2012.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Loehrer AP, Song Z, Auchincloss HG, Hutter MM. The impact of expanded insurance coverage in massachusetts on acute surgical disease. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Regenbogen SE, Bordeianou L, Hutter MM, Gawande AA. The intraoperative Surgical Apgar Score predicts postdischarge complications after colon and rectal resection. Surgery 2010; 148:559-66. [PMID: 20227100 DOI: 10.1016/j.surg.2010.01.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 01/18/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND We previously developed an intraoperative 10-point Surgical Apgar Score-based on blood loss, lowest heart rate, and lowest mean arterial pressure-to predict major complications after colorectal resection. However, because complications often arise after uncomplicated hospitalizations, we sought to evaluate whether this intraoperative metric would predict postdischarge complications after colectomy. METHODS We linked our institution's National Surgical Quality Improvement Program database with an Anesthesia Intraoperative Management System for all colorectal resections over 4 years. Using Chi-square trend tests and logistic regression, we evaluated the Surgical Apgar Score's prediction for major postoperative complications before and after discharge. RESULTS Among 795 colectomies, there were 230 (29%) major complications within 30 days; 45 (20%) after uncomplicated discharges. Surgical Apgar Scores predicted both inpatient complications and late postdischarge complications (both P < .0001). Late complications occurred from 0 to 27 (median, 11) days after discharge; the most common were surgical site infections (42%), sepsis (24%), and venous thromboembolism (16%). In pairwise comparisons against average-scoring patients (Surgical Apgar Scores, 7-8), the relative risk of postdischarge complications trended lower, to 0.6 (95% confidence interval [CI], 0.2-1.7) for those with the best scores (9-10); and were significantly higher, at 2.6 (95% CI, 1.4-4.9) for scores 5-6, and 4.5 (95% CI, 1.8-11.0) for scores 0-4. CONCLUSION The intraoperative Surgical Apgar Score remained a useful metric for predicting postcolectomy complications arising after uncomplicated discharges. Even late complications may thus be related to intraoperative condition and events. Surgeons could use this intraoperative metric to target low-scoring patients for intensive postdischarge surveillance and mitigation of postdischarge complications after colectomy.
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Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
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Blackburn GL, Hutter MM, Harvey AM, Apovian CM, Boulton HRW, Cummings S, Fallon JA, Greenberg I, Jiser ME, Jones DB, Jones SB, Kaplan LM, Kelly JJ, Kruger RS, Lautz DB, Lenders CM, Lonigro R, Luce H, McNamara A, Mulligan AT, Paasche-Orlow MK, Perna FM, Pratt JSA, Riley SM, Robinson MK, Romanelli JR, Saltzman E, Schumann R, Shikora SA, Snow RL, Sogg S, Sullivan MA, Tarnoff M, Thompson CC, Wee CC, Ridley N, Auerbach J, Hu FB, Kirle L, Buckley RB, Annas CL. Expert panel on weight loss surgery: executive report update. Obesity (Silver Spring) 2009; 17:842-62. [PMID: 19396063 DOI: 10.1038/oby.2008.578] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Rapid shifts in the demographics and techniques of weight loss surgery (WLS) have led to new issues, new data, new concerns, and new challenges. In 2004, this journal published comprehensive evidence-based guidelines on WLS. In this issue, we've updated those guidelines to assure patient safety in this fast-changing field. WLS involves a uniquely vulnerable population in need of specialized resources and ongoing multidisciplinary care. Timely best-practice updates are required to identify new risks, develop strategies to address them, and optimize treatment. Findings in these reports are based on a comprehensive review of the most current literature on WLS; they directly link patient safety to methods for setting evidence-based guidelines developed from peer-reviewed scientific publications. Among other outcomes, these reports show that WLS reduces chronic disease risk factors, improves health, and confers a survival benefit on those who undergo it. The literature also shows that laparoscopy has displaced open surgery as the predominant approach; that government agencies and insurers only reimburse procedures performed at accredited WLS centers; that best practice care requires close collaboration between members of a multidisciplinary team; and that new and existing facilities require wide-ranging changes to accommodate growing numbers of severely obese patients. More than 100 specialists from across the state of Massachusetts and across the many disciplines involved in WLS came together to develop these new standards. We expect them to have far-reaching effects of the development of health care policy and the practice of WLS.
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Affiliation(s)
- George L Blackburn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Affiliation(s)
- George L Blackburn
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Surgery, Center for the Study of Nutrition Medicine, Boston, Massachusetts, USA.
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Abstract
To update evidence-based best practice guidelines for collection of data on weight loss surgery (WLS). Systematic search of English-language literature in MEDLINE and the Cochrane Library on WLS and data collection, registries, risk adjustment, accreditation, benchmarks, and administrative and outcomes databases published between April 2004 and May 2007. Use of key words to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. During our search, we identified 212 papers; the 63 most relevant were reviewed in detail. Most data collection on WLS has relied on administrative data sets, single-institution studies, and other sources that are not WLS specific. A six-center, nationwide study involving data collection has been started by the longitudinal assessment of bariatric surgery, but results are not yet available. Two WLS-specific, longitudinal, national data collection systems are about to be implemented. Key factors in patient safety include data collection for all weight loss procedures; prospective, risk-adjusted, universal, benchmarked, longitudinal data collection systems; and use of WLS-specific data points that track clinical effectiveness and complications following WLS. Data collection will need to include assessments of novel therapies and specific subgroups (e.g., adolescents, the elderly, and individuals who are at the greatest risk or have the most to gain from WLS). Quality indicators, including metrics on processes of care and determination of outliers, need to be established and monitored to advance patient safety and quality improvement.
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Affiliation(s)
- Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Regenbogen SE, Ehrenfeld JM, Lipsitz SR, Greenberg CC, Hutter MM, Gawande AA. Utility of the surgical apgar score: validation in 4119 patients. ACTA ACUST UNITED AC 2009; 144:30-6; discussion 37. [PMID: 19153322 DOI: 10.1001/archsurg.2008.504] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To confirm the utility of a 10-point Surgical Apgar Score to rate surgical outcomes in a large cohort of patients. DESIGN Using electronic intraoperative records, we calculated Surgical Apgar Scores during a period of 2 years (July 1, 2003, through June 30, 2005). SETTING Major academic medical center. PATIENTS Systematic sample of 4119 general and vascular surgery patients enrolled in the National Surgical Quality Improvement Program surgical outcomes database at a major academic medical center. MAIN OUTCOME MEASURES Incidence of major postoperative complications and/or death within 30 days of surgery. RESULTS Of 1441 patients with scores of 9 to 10, 72 (5.0%) developed major complications within 30 days, including 2 deaths (0.1%). By comparison, among 128 patients with scores of 4 or less, 72 developed major complications (56.3%; relative risk, 11.3; 95% confidence interval, 8.6-14.8; P < .001), of whom 25 died (19.5%; relative risk, 140.7; 95% confidence interval, 33.7-587.4; P < .001). The 3-variable score achieves C statistics of 0.73 for major complications and 0.81 for deaths. CONCLUSIONS The Surgical Apgar Score provides a simple, immediate, objective means of measuring and communicating patient outcomes in surgery, using data routinely available in any setting. The score can be effective in identifying patients at higher- and lower-than-average likelihood of major complications and/or death after surgery and may be useful for evaluating interventions to prevent poor outcomes.
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Affiliation(s)
- Scott E Regenbogen
- Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
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Campbell DA, Henderson WG, Englesbe MJ, Hall BL, O'Reilly M, Bratzler D, Dellinger EP, Neumayer L, Bass BL, Hutter MM, Schwartz J, Ko C, Itani K, Steinberg SM, Siperstein A, Sawyer RG, Turner DJ, Khuri SF. Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion—Results of the First American College of Surgeons–National Surgical Quality Improvement Program Best Practices Initiative. J Am Coll Surg 2008; 207:810-20. [DOI: 10.1016/j.jamcollsurg.2008.08.018] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 08/15/2008] [Accepted: 08/18/2008] [Indexed: 10/21/2022]
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Lancaster RT, Hutter MM. Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Surg Endosc 2008; 22:2554-63. [PMID: 18806945 DOI: 10.1007/s00464-008-0074-y] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 06/13/2008] [Accepted: 06/23/2008] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous multi-institution comparisons of open and laparoscopic Roux-en-Y gastric bypass (ORYGB and LRYGB), and laparoscopic adjustable gastric banding (LAGB) have been limited by the lack of unique current procedural terminology (CPT) codes. Specific codes have been available for LRYGB and LAGB since 2005 and 2006, respectively. We compare the short-term safety of these procedures, using risk-adjusted clinical data from a multi-institutional quality improvement program. METHODS The America College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use File (PUF) was used to compare patients undergoing LRYGB with those undergoing ORYGB or LAGB. RESULTS ORYGB versus LRYGB: The 2-year study period (2005-2006) included 5,777 patients (ORYGB = 1,146, LRYGB = 4,631). Patients undergoing ORYGB experienced a higher 30-day incidence of mortality (0.79% vs. 0.17%; p = 0.002), major complications rate (7.42% vs. 3.37%; p < 0.0001), any complication rate (13.18% vs. 6.69%; p < 0.0001), return visits to the OR (4.97% vs. 3.56%; p = 0.032), and longer postoperative length of stay (LOS) (median 3 vs. 2 days; p < 0.0001). After risk adjustment, ORYGB continued to demonstrate higher odds of major complication (OR = 2.04; [1.54, 2.69]). LAGB versus LRYGB: Analysis of 1 year of data from 2006 included 4,756 patients (LRYGB = 3,580, LAGB = 1,176). Those treated with LAGB experienced an equivalent 30-day mortality (0.09% vs. 0.14%; p = 1.0), and a lower rate of major complications (1.0% vs. 3.3%; p < 0.0001), any complication (2.6% vs. 6.7%; p < 0.0001), return visits to the OR (0.94% vs. 3.6%; p < 0.0001), and shorter postoperative LOS (median 1 vs. 2 days; p < 0.0001). Risk adjustment showed that LAGB was associated with a lower major complication odds (OR = 0.29; [0.16, 0.53]). CONCLUSIONS Compared with LRYGB, ORYGB is associated with higher 30-day mortality and higher risk-adjusted major complication rate. While ORYGB may sometimes be indicated, a laparoscopic approach may be safer for RYGB when feasible. LAGB, compared with LRYGB, has a similarly low mortality rate and a small but statistically significant decrease in risk-adjusted 30-day complications. Clinical efficacy and long-term outcomes will need to be evaluated to determine superiority between these procedures.
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Affiliation(s)
- Robert T Lancaster
- Department of Surgery, The Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, 15 Parkman Street-Wang ACC 335, Boston, MA 02114, USA.
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Mullen JT, Davenport DL, Hutter MM, Hosokawa PW, Henderson WG, Khuri SF, Moorman DW. Impact of body mass index on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. Ann Surg Oncol 2008; 15:2164-72. [PMID: 18548313 DOI: 10.1245/s10434-008-9990-2] [Citation(s) in RCA: 256] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 05/05/2008] [Accepted: 05/06/2008] [Indexed: 01/27/2023]
Abstract
BACKGROUND Obesity is an increasingly common serious chronic health condition. We sought to determine the impact of body mass index (BMI) on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. METHODS A prospective, multi-institutional, risk-adjusted cohort study of patients undergoing major intra-abdominal cancer surgery was performed from the 14 university hospitals participating in the Patient Safety in Surgery Study of the National Surgical Quality Improvement Program (NSQIP). Demographic, clinical, and intraoperative variables and 30-day morbidity and mortality were prospectively collected in standardized fashion. Analysis of variance, Bonferroni multiple comparisons of means tests, and multivariable logistic regression analysis were performed. RESULTS We identified 2258 patients who underwent esophagectomy (n = 29), gastrectomy (n = 223), hepatectomy (n = 554), pancreatectomy (n = 699), or low anterior resection/proctectomy (n = 753). Patients were stratified by National Institutes of Health (NIH)-defined BMI obesity class, with 573 (25.4%) patients classified as obese (BMI > 30 kg/m(2)). There were no differences in mean work relative value units, total time of operation, or length of stay amongst the BMI classes. After adjusting for other risk factors, obesity was not a risk factor for death or major complications but was a risk factor for wound complications. The risk of postoperative death was greatest in underweight patients (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.7-16.2). CONCLUSION In patients undergoing major intra-abdominal cancer surgery, obesity is not a risk factor for postoperative mortality or major complications. Importantly, underweight patients have a fivefold increased risk of postoperative mortality, perhaps a consequence of their underlying nutritional status.
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Affiliation(s)
- John T Mullen
- Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Stoneman 912, Boston, MA 02215, USA.
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Regenbogen SE, Lancaster TR, Lipsitz SR, Greenberg CC, Hutter MM, Gawande AA. Does performance matter? Role of intraoperative factors versus preoperative risk in surgical outcomes. J Am Coll Surg 2007. [DOI: 10.1016/j.jamcollsurg.2007.06.183] [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: 11/24/2022]
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Virani S, Michaelson JS, Hutter MM, Lancaster RT, Warshaw AL, Henderson WG, Khuri SF, Tanabe KK. Morbidity and mortality after liver resection: results of the patient safety in surgery study. J Am Coll Surg 2007; 204:1284-92. [PMID: 17544086 DOI: 10.1016/j.jamcollsurg.2007.02.067] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.2] [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: 02/19/2007] [Accepted: 02/26/2007] [Indexed: 12/20/2022]
Abstract
BACKGROUND Liver resection is performed with increasing frequency. Nearly all of the published information on operative mortality and morbidity rates associated with liver resection is derived from studies that rely on retrospective data collection from single centers. The goal of this study is to use audited multiinstitutional data from the private sector of the Patient Safety in Surgery Study to characterize complications after liver resection and to identify variables that are associated with 30-day morbidity and mortality. STUDY DESIGN Prospectively collected data on liver resection patients from 14 hospitals were collected using National Surgical Quality Improvement Program's methodology. Rates of occurrence of 21 defined postoperative complications were measured. Bivariate analyses and stepwise logistic regression were used to identify factors associated with 30-day morbidity and mortality. RESULTS At least one complication occurred in 22.6% of patients within 30 days. Stepwise logistic regression identified several preoperative factors associated with morbidity, including serum albumin, SGOT > 40, previous cardiac operation, operative work relative value unit, and history of severe COPD. Mortality within 30 days was observed in 2.6% of patients. Factors associated with mortality were found to be male gender, American Society of Anesthesiologists class 3 or higher, presence of ascites, dyspnea, and severe COPD. Only 0.7% of patients without any complications died, compared with 9.0% of patients with at least 1 complication (p < 0.0001). CONCLUSIONS Prospective, standardized, audited, multiinstitutional data were analyzed to identify several preoperative and intraoperative factors associated with morbidity and mortality after liver resection. These factors should be considered during patient selection and perioperative management.
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Hutter MM. Quality Improvement and Peer Review. J Am Coll Surg 2007. [DOI: 10.1016/j.jamcollsurg.2007.02.062] [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: 10/23/2022]
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Johnson RG, Wittgen CM, Hutter MM, Henderson WG, Mosca C, Khuri SF. Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Women. J Am Coll Surg 2007; 204:1137-46. [PMID: 17544072 DOI: 10.1016/j.jamcollsurg.2007.02.059] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 02/14/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Women with peripheral vascular disease requiring vascular operations are less well studied than their male counterparts. The surgical outcomes of female vascular patients in the Department of Veterans Affairs (VA) and private sector hospitals have not previously been compared, and their preoperative risk profile, postoperative morbidity, and mortality need to be better elucidated. STUDY DESIGN Patients undergoing vascular operations at 14 private sector and 128 VA hospitals, from October 2001 through September 2004, had their preoperative characteristics, operative data, and 30-day postoperative morbidity and mortality compared, as part of the Patient Safety in Surgery (PSS) Study. Logistic regression analysis was performed to develop predictive models for morbidity and mortality, which allowed for a comparison of risk-adjusted outcomes between the two hospital groups. RESULTS There were 458 vascular surgical operations performed in women in the VA, and 3,535 vascular operations were performed in women in the private sector. Eighteen of 45 preoperative comorbidities and laboratory variables differed considerably between the institutions, and 16 of 18 were adverse among the private sector patients. The unadjusted 30-day mortality rate was higher in the private sector compared with the VA (5.2% versus 2.4%, p=0.008); the unadjusted morbidity rate was higher in the private sector compared with the VA sector (23.4% versus 13.3%, p < 0.0001). After risk adjustment, there was no marked difference between the VA and the private sector in mortality (p=0.12), but the difference in morbidity rates remained pronounced, with an odds ratio of 0.60 for VA versus private sector (95% CI=0.44, 0.81). CONCLUSIONS Compared with their VA counterparts, women undergoing vascular operations at private sector hospitals had a higher incidence of preoperative comorbidities; after risk adjustment, mortality did not differ substantially. Despite risk adjustment, the incidence of postoperative morbidity in the VA patients was considerably lower, suggesting unidentified differences in the hospital populations, their processes of care, or both.
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Affiliation(s)
- Robert G Johnson
- Department of Surgery, Saint Louis University, St Louis, MO 63110, USA
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Lancaster RT, Tanabe KK, Schifftner TL, Warshaw AL, Henderson WG, Khuri SF, Hutter MM. Liver Resection in Veterans Affairs and Selected University Medical Centers: Results of the Patient Safety in Surgery Study. J Am Coll Surg 2007; 204:1242-51. [PMID: 17544082 DOI: 10.1016/j.jamcollsurg.2007.02.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [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: 02/19/2007] [Accepted: 02/26/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND A congressional mandate, which led to the formation of the National Surgical Quality Improvement Program, is now being fulfilled with the publication of general and vascular surgical outcomes comparisons between Veterans Affairs (VA) and university medical centers. A series of National Surgical Quality Improvement Program articles evaluate the effect of hospital type (VA versus university hospitals) on procedure-specific outcomes. This article focuses on liver resections. STUDY DESIGN This is a prospective cohort study of a sample of patients undergoing liver resections at 128 VA medical centers compared with 14 university medical centers from October 1, 2001, to September 30, 2004. Preoperative and intraoperative characteristics were evaluated to identify possible variables related to morbidity and mortality and possible confounders of the hospital effect. These variables were then used to identify the effect that the hospital setting might have on surgical outcomes after liver resections. RESULTS Data from 237 liver resections at VA hospitals were compared with 783 procedures performed at university hospitals. The unadjusted 30-day morbidity rate tended to be higher in the VA (university 22.6% versus VA 27.9%; p = 0.10). After risk adjustment, results were equivalent (odds ratio = 0.94; p = 0.77). Unadjusted 30-day mortality rate was significantly higher in VA hospitals (6.8% versus 2.6%; p = 0.002). After risk adjustment, there was no longer a significant difference in mortality between the two hospital systems (odds ratio = 1.62; p = 0.33). CONCLUSIONS For liver resections, the National Surgical Quality Improvement Program and Patient Safety in Surgery Study data suggest that there is no significant difference in risk-adjusted morbidity or mortality rates between VA and the university medical centers.
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Affiliation(s)
- Robert T Lancaster
- Department of Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA 02114
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Henderson WG, Khuri SF, Mosca C, Fink AS, Hutter MM, Neumayer LA. Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Men. J Am Coll Surg 2007; 204:1103-14. [PMID: 17544069 DOI: 10.1016/j.jamcollsurg.2007.02.068] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [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: 02/19/2007] [Accepted: 02/26/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND We used data from the Patient Safety in Surgery Study to compare patient populations, operative characteristics, and unadjusted and risk-adjusted 30-day postoperative mortality and morbidity between the Veterans Affairs (VA) (n = 94,098) and private (n = 18,399) sectors for general surgery operations in men. STUDY DESIGN This is a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in male patients undergoing major general surgery operations at 128 VA medical centers and 14 university medical centers from October 1, 2001, to September 30, 2004. Multiple logistic regression analysis was used to identify preoperative predictors of postoperative mortality and morbidity. An indicator variable for VA versus private-sector medical center was added to the model to determine if risk-adjusted outcomes were significantly different in the two systems. RESULTS The unadjusted 30-day mortality rate was higher in the VA compared with the private sector (2.62% versus 2.03%, p = 0.0002); unadjusted morbidity rate was lower in the VA compared with the private sector (12.24% versus 13.99%, p < 0.0001). After risk adjustment, odds ratio for mortality for the VA versus private sector was 1.23 (95% CI, 1.08-1.41). For morbidity after risk adjustment, the indicator variable for health-care system just missed statistical significance (p = 0.0585). Thirty-day postoperative mortality was comparable in the VA and private sector for very common operations but was higher in the VA for less common, more complex operations. CONCLUSIONS In general surgery operations in men, the VA appeared to have a higher risk-adjusted mortality rate compared with the private sector, but differences in mortality ascertainment in the two sectors might account for some of this effect. The higher mortality in the VA could be the result of higher mortality in the less common, more complex operations. There is a trend toward lower risk-adjusted morbidity in the VA compared with the private sector.
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Fink AS, Hutter MM, Campbell DC, Henderson WG, Mosca C, Khuri SF. Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Women. J Am Coll Surg 2007; 204:1127-36. [PMID: 17544071 DOI: 10.1016/j.jamcollsurg.2007.02.060] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [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: 02/13/2007] [Accepted: 02/14/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 1985, Congress mandated that the Department of Veterans Affairs (VA) compare its risk-adjusted surgical results with those in the private sector. The National Surgical Quality Improvement Program was developed as a result, in the VA system, and subsequently trialed in 14 university medical centers in the private sector. This report examines the results of the comparison between patient characteristics and outcomes of female general surgical patients in the two health care environments. STUDY DESIGN Preoperative patient characteristics and laboratory variables, operative variables, and unadjusted postoperative outcomes were compared between VA and the private sector populations. In addition, stepwise logistic regression models were developed for 30-day postoperative mortality and morbidity. Finally, the effect of being treated in a VA or private sector hospital was assessed by adding an indicator variable to the models and testing it for statistical significance. RESULTS Data from 5,157 female general surgical VA patients who underwent eligible procedures were compared with those from 27,467 patients in the private sector. Unadjusted 30-day mortality was virtually identical in the two groups (1.3%). The unadjusted morbidity rate was slightly, but notably, higher in the private sector (10.9%) as compared with that observed in the VA (8.5%, p < 0.0001). Predictive models were generated for mortality and morbidity combining both groups; top variables in these models were similar to those described previously in the National Surgical Quality Improvement Program. The indicator variable for system of care (VA versus private sector) was not statistically significant in the mortality model, but substantially favored the VA in the morbidity model (odds ratio=0.80, 95% CI=0.71, 0.90). CONCLUSIONS The data demonstrate that in female general surgical patients, risk-adjusted mortality rates are comparable in the VA and the private sector, but risk-adjusted morbidity is higher in the private sector. Rates of urinary tract infections in the two populations may account for much of the latter difference.
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Affiliation(s)
- Aaron S Fink
- Department of Surgery, Atlanta VAMC, Atlanta, GA 30033, USA
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Rowell KS, Turrentine FE, Hutter MM, Khuri SF, Henderson WG. Use of National Surgical Quality Improvement Program Data as a Catalyst for Quality Improvement. J Am Coll Surg 2007; 204:1293-300. [PMID: 17544087 DOI: 10.1016/j.jamcollsurg.2007.03.024] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Accepted: 03/26/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Semiannually, the National Surgical Quality Improvement Program (NSQIP) provides its participating sites with observed-to-expected (O/E) ratios for 30-day postoperative mortality and morbidity. At each reporting period, there is typically a small group of hospitals with statistically significantly high O/E ratios, meaning that their patients have experienced more adverse events than would be expected on the basis of the population characteristics. An important issue is to determine which actions a surgical service should take in the presence of a high O/E ratio. STUDY DESIGN This article reviews case studies of how some of the Department of Veterans Affairs and private-sector NSQIP participating sites used the clinically rich NSQIP database for local quality improvement efforts. Data on postoperative adverse events before and after these local quality improvement efforts are presented. RESULTS After local quality improvement efforts, wound complication rates were reduced at the Salt Lake City Veterans Affairs medical center by 47%, surgical site infections in patients undergoing intraabdominal surgery were reduced at the University of Virginia by 36%, and urinary tract infections in vascular patients were reduced at the Massachusetts General Hospital by 74%. At some sites participating in the NSQIP, notably the Massachusetts General Hospital and the University of Virginia, the NSQIP has served as the basis for surgical service-wide outcomes research and quality improvement programs. CONCLUSIONS The NSQIP not only provides participating sites with risk-adjusted surgical mortality and morbidity outcomes semiannually, but the clinically rich NSQIP database can also serve as a catalyst for local quality improvement programs to significantly reduce postoperative adverse event rates.
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Hutter MM, Lancaster RT, Henderson WG, Khuri SF, Mosca C, Johnson RG, Abbott WM, Cambria RP. Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men. J Am Coll Surg 2007; 204:1115-26. [PMID: 17544070 DOI: 10.1016/j.jamcollsurg.2007.02.066] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [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: 02/13/2007] [Accepted: 02/26/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND In response to a Congressional mandate to compare risk-adjusted surgical outcomes from Department of Veterans Affairs (VA) hospitals with those from private-sector hospitals, the National Surgical Quality Improvement Program was initiated in the VA system and then was developed in a select group of university medical centers in the private sector. This article analyzes risk-adjusted outcomes after vascular surgical operations in men performed at VA hospitals as compared with private-sector hospitals. STUDY DESIGN This is a prospective cohort study of a sample of vascular surgical operations in men performed at 128 VA medical centers as compared with 14 university medical centers from October 1, 2001 to September 30, 2004. Patient and operative characteristics, and both unadjusted and risk-adjusted 30-day postoperative morbidity and mortality outcomes were compared. RESULTS Data from 30,058 vascular operations in men at VA hospitals were compared with 5,174 cases performed at private-sector hospitals. The unadjusted 30-day mortality rate was notably lower in the VA system as compared with the private-sector group (3.4% versus 4.2%, p = 0.004). After risk-adjustment, there was no marked difference in mortality between the two hospital types. The unadjusted 30-day morbidity rate was also considerably lower in the VA hospitals as compared with the private sector (17.3% versus 22.3%, p < 0.0001). After risk-adjustment, morbidity in the VA system remained considerably lower than in the private sector, with an odds ratio of 0.84 (95% CI, 0.78 to 0.92). CONCLUSIONS In vascular surgical operations in men, the VA hospitals demonstrated a lower risk-adjusted 30-day morbidity rate than the private-sector group. There is no marked difference in adjusted mortality rates between the two types of institutions.
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Affiliation(s)
- Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
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Abstract
This manuscript addresses the question "Does outcomes research affect quality?" using examples from the field of bariatric surgery. The roles that outcomes research has played in each of the four major recent events in bariatric surgery are examined. In the first three major events, which include 1) the National Institutes of Health Consensus Conference on Bariatric Surgery in 1991, 2) the dramatic increase in numbers of bariatric operations performed, and 3) the move toward a laparoscopic approach in bariatric surgery, a multitude of outcomes studies seem to be the result, but not the cause, of these changes in the field of bariatric surgery. However, for the most recent event, the 2006 Centers for Medicare and Medicaid Services National Coverage Determination for bariatric surgery and the introduction of accreditation in general surgery, outcomes research has played a significant role in the determination of policy and, ultimately, quality.
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Affiliation(s)
- Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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