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Fanaroff AC, Dayoub EJ, Yang L, Schultz K, Ramadan OI, Wang GJ, Damrauer SM, Genovese EA, Secemsky EA, Parikh SA, Nathan AS, Kohi MP, Weinberg MD, Jaff MR, Groeneveld PW, Giri JS. Association Between Diagnosis-to-Limb Revascularization Time and Clinical Outcomes in Outpatients With Chronic Limb-Threatening Ischemia: Insights From the CLIPPER Cohort. J Am Heart Assoc 2024:e033898. [PMID: 38639376 DOI: 10.1161/jaha.123.033898] [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: 01/05/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI. METHODS AND RESULTS In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death. CONCLUSIONS A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.
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Affiliation(s)
- Alexander C Fanaroff
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Penn Center for Health Incentives and Behavioral Economics University of Pennsylvania Philadelphia PA
| | - Elias J Dayoub
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Kaitlyn Schultz
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Omar I Ramadan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Grace J Wang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Scott M Damrauer
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Department of Genetics, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Elizabeth A Genovese
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Eric A Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School Harvard University Boston MA
| | - Sahil A Parikh
- Division of Cardiology, Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Ashwin S Nathan
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Maureen P Kohi
- Department of Radiology University of North Carolina Chapel Hill NC
| | | | | | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
- General Internal Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Jay S Giri
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
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Rice JR, Rothenberg KA, Ramadan OI, Savage D, Kalapatapu V, Julien HM, Schneider DB, Wang GJ. Factors Associated with Urgent Amputation Status and Its Impact on Mortality. Ann Vasc Surg 2024:S0890-5096(24)00110-9. [PMID: 38582210 DOI: 10.1016/j.avsg.2023.12.093] [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: 12/11/2023] [Accepted: 12/22/2023] [Indexed: 04/08/2024]
Abstract
OBJECTIVES Thirty-day mortality is higher after urgent major lower extremity amputations compared to elective lower extremity amputations. This study aims to identify factors associated with urgent amputations and to examine their impact on perioperative outcomes and long-term mortality. METHODS Patients undergoing major lower limb amputation from 2013-2020 in the Vascular Quality Initiative (VQI) were included. Urgent amputation was defined as occurring within 72 hours of admission. Associations with sociodemographic characteristics, comorbidities, and outcomes including postoperative complication, inpatient death, and long-term survival were compared using univariable tests and multivariable logistic regression. Long-term survival between groups was compared using Kaplan-Meier analysis. RESULTS Of the 12,874 patients included, 4,850 (37.7%) had urgent and 8,024 (62.3%) had elective amputations. Nonwhite patients required urgent amputation more often than white patients (39.8% vs 37.9%, P=0.03). A higher proportion of Medicaid and self-pay patients presented urgently (Medicaid:13.0% vs 11.0%; self-pay: 3.4% vs 2.5%, P< 0.001). Patients requiring urgent amputation were less often taking aspirin (55.6% vs 60.1%, P<0.001) or statin (62.2% vs 67.2%, P<0.001), had fewer prior revascularization procedures (41.0% vs 48.8%, P<0.001), and were of higher ASA class 4-5 (50.9% vs 40.1%, P<0.001). Urgent amputations were more commonly for uncontrolled infection (48.1% vs 29.4%, P< 0.001) or acute limb ischemia (14.3% vs 6.2%, P<0.001). Post-operative complications were higher after urgent amputations (34.7% vs 16.6%, P<0.001), including need for return to operating room (23.8% vs 8.4%, P< 0.001) and need for higher revision (15.2% vs 4.5%, P<0.001). Inpatient mortality was higher after urgent amputation (8.9% vs 5.4%, P<0.001). Multivariable analysis revealed non-white race, self-pay, homelessness, current smoking, ASA class 4-5, and amputations for uncontrolled infection or acute limb ischemia were associated with urgent status, whereas living in a nursing home or prior revascularization were protective. Further, urgent amputation was associated with an increased odds of postoperative complication or death (OR 1.86 [1.69-2.04], P<0.001) as well as long-term mortality (OR: 1.24 [1.13-1.35], P<0.001). Kaplan-Meier analysis corroborated that elective status was associated with improvement of long-term survival. CONCLUSIONS Patients requiring urgent amputations are more often nonwhite, uninsured, and less frequently had prior revascularization procedures, revealing disparities in access to care. Urgency was associated with a higher post-operative complication rate, as well as increased long-term mortality. Efforts should be directed towards reducing these disparities to improve outcomes following amputation.
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Affiliation(s)
- Jayne R Rice
- Hospital of University of Pennsylvania, Department of Vascular Surgery and Endovascular Therapy.
| | - Kara A Rothenberg
- Hospital of University of Pennsylvania, Department of Vascular Surgery and Endovascular Therapy
| | - Omar I Ramadan
- Hospital of University of Pennsylvania, Department of Vascular Surgery and Endovascular Therapy
| | - Dasha Savage
- Hospital of University of Pennsylvania, Department of Vascular Surgery and Endovascular Therapy
| | - Venkat Kalapatapu
- Hospital of University of Pennsylvania, Department of Vascular Surgery and Endovascular Therapy
| | - Howard M Julien
- Hospital of University of Pennsylvania, Department of Medicine, Division of Cardiovascular Medicine
| | - Darren B Schneider
- Hospital of University of Pennsylvania, Department of Vascular Surgery and Endovascular Therapy
| | - Grace J Wang
- Hospital of University of Pennsylvania, Department of Vascular Surgery and Endovascular Therapy
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Ramadan OI, Rosenbaum PR, Reiter JG, Jain S, Hill AS, Hashemi S, Kelz RR, Fleisher LA, Silber JH. Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes. Ann Surg 2024; 279:631-639. [PMID: 38456279 PMCID: PMC10926994 DOI: 10.1097/sla.0000000000006132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls. SUMMARY BACKGROUND DATA It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients. METHODS Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality. RESULTS We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001]. CONCLUSIONS Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.
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Affiliation(s)
- Omar I. Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Paul R. Rosenbaum
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Siddharth Jain
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sean Hashemi
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Rachel R. Kelz
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Lee A. Fleisher
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey H. Silber
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
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Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Silber JH, Fleisher LA. Assessing the Ambulatory Surgery Center Volume-Outcome Association. JAMA Surg 2024; 159:397-403. [PMID: 38265816 PMCID: PMC10809135 DOI: 10.1001/jamasurg.2023.7161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/01/2023] [Indexed: 01/25/2024]
Abstract
Importance In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US. Objective To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity. Design, Setting, and Participants This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019. Main Outcomes and Measures Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures). Results Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity. Conclusions and Relevance In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.
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Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Statistics and Data Science, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Omar I. Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- The Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Lee A. Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia
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Eisinger EC, Chen AT, Ramadan OI, Morgan AU, Delgado MK, Kaufman EJ. Health Care Use Among Patients Retroactively Insured via a Hospital-Based Insurance Linkage Program. J Gen Intern Med 2024:10.1007/s11606-024-08712-y. [PMID: 38483779 DOI: 10.1007/s11606-024-08712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE Over 25% of the 27 million uninsured individuals in the United States are eligible for Medicaid. Many hospitals have insurance linkage programs that assist eligible patients with enrollment, but little is known about the impact of these programs on care utilization. This research assessed health care utilization and health outcomes among patients enrolled in Medicaid via a hospital-based insurance linkage program. METHODS This retrospective cohort study included adults aged 18-64 admitted to the hospital from 2016 to 2021. Those who obtained insurance retroactively via insurance linkage (RI) were compared with those who presented with Medicaid (MI) or remained uninsured (UI). The primary outcome was the presence of at least one visit with a primary care provider (PCP) in the 12 months following index admission. Secondary outcomes included having an assigned PCP, ED revisits, and hospital readmissions. For patients with diabetes and hypertension, 12-month hemoglobin A1c (HbA1c) and blood pressure (BP) readings were tracked. RESULTS Of 3882 patients admitted with no insurance, 2905 (74.8%) were enrolled in insurance (RI). In multivariable analysis, RI patients were 14% more likely (OR 1.14, p = 0.020) to have completed at least one PCP visit by 12 months after index admission compared to those with preexisting Medicaid (MI), and uninsured patients were 29% less likely (OR 0.71, p = 0.003). MI and RI patients also had more ED revisits (p < 0.001) and greater 12-month reductions in blood pressure (p < 0.001) compared with uninsured patients. CONCLUSION Hospital-based insurance linkage reached three-quarters of uninsured patients and was associated with increased utilization of acute and outpatient health care services. An acute care encounter represents an opportunity to connect patients to insurance, a key step toward improving their health outcomes.
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Affiliation(s)
- Ella C Eisinger
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela T Chen
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Omar I Ramadan
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna U Morgan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Kit Delgado
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Trauma, Surgical Critical Care & Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
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Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Hashemi S, Brown RT, Kelz RR, Fleisher LA, Silber JH. Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates. J Gen Intern Med 2023:10.1007/s11606-023-08415-w. [PMID: 38087179 DOI: 10.1007/s11606-023-08415-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/05/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region. OBJECTIVE To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region. DESIGN A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals. MAIN MEASURES 30-day (primary) and 90-day (secondary) all-cause mortality. KEY RESULTS 30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality. LIMITATIONS The study used claims-based data. CONCLUSIONS In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.
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Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA.
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Statistics and Data Science, The Wharton School of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
| | - Omar I Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
| | - Sean Hashemi
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
| | - Rebecca T Brown
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Rachel R Kelz
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lee A Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation, The University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- The Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School of the University of Pennsylvania, Philadelphia, PA, USA
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Filiberto AC, Ramadan OI, Wang GJ, Cooper MA. Sex disparities in patients with acute aortic dissection: A scoping review. Semin Vasc Surg 2023; 36:492-500. [PMID: 38030323 DOI: 10.1053/j.semvascsurg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 12/01/2023]
Abstract
Disparities in outcomes for patients with cardiovascular disease and those undergoing cardiac or vascular operations are well-established. These disparities often span several dimensions and persist despite advancements in medical and surgical care; sex is among the most pervasive. Specifically, females sex has been implicated as a predictor of poor outcomes in both patients with acute type A aortic dissections (ATAADs) and type B aortic dissections (TBADs). For instance, one study, using the International Registry of Acute Aortic Dissection database, found that females with acute aortic dissection-including ATAAD and TBAD that were either medically or surgically managed-had 40% higher odds of in-hospital mortality than men. Notably, both types of acute aortic dissections affect men more commonly than females and can be life-threatening without prompt, appropriate treatment. The underlying mechanisms for these disparities are unclear but are thought to be multifactorial. The association of sex with patterns of disease and outcomes in patients with ATAAD or TBAD remains unclear, with conflicting reports from different studies. Thus, we sought to review the literature regarding sex disparities in patients with ATAAD and TBAD.
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Affiliation(s)
- Amanda C Filiberto
- Department of Surgery, Division of Vascular Surgery, 1329 SW 16th St., University of Florida, Gainesville, FL, 32610
| | - Omar I Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Michol A Cooper
- Department of Surgery, Division of Vascular Surgery, 1329 SW 16th St., University of Florida, Gainesville, FL, 32610.
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Halada S, Chen AT, Ramadan OI, Li EH, Goldshore M, Morris JB, Morales CZ. Incorporation and Utilization of an Additional Needs Screener by Surgical Trainees for Comprehensive Care of Underserved and Underinsured Surgical Patients. J Surg Educ 2023; 80:1287-1295. [PMID: 37451882 DOI: 10.1016/j.jsurg.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/01/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Comprehensive, socially-minded healthcare has historically been delivered in the primary care setting. For underserved patient populations, however, a surgical care episode may serve as the health care access point. To maximize patient wellbeing during the perioperative period, our surgical center developed the Additional Needs Screener (ANS). Operationalized into practice by GME and UME trainees, this tool screens surgical patients across 3 domains (social, emotional, and immigration needs) and connects patients to partner organizations if appropriate. This study describes the pilot utilization of the ANS among underserved and underinsured surgical patients. DESIGN Clinical quality improvement and retrospective cohort study of patients completing the ANS from implementation in September 2021 to September 2022. SETTING The Hospital of the University of Pennsylvania, PA-a tertiary care center. PARTICIPANTS One hundred and 10 underinsured and/or underserved patients completed at least 1 ANS domain. RESULTS Patients were majority female (55F, 53M, 2 other) and Hispanic/Latinx (72%) with a median age of 38 (IQR = 34-48). Most patients spoke a primary language other than English (77%), and nearly all were either uninsured (82%) or received emergency medical assistance or Medicaid (14%) at referral. Patients demonstrated significant needs; 39% endorsed difficulty affording housing, 32% endorsed difficulty paying for food, 29% endorsed experiencing current life-interfering distress, and 75% had undocumented immigration status. Ultimately, 57% of screened patients accepted referrals to our needs response teams. CONCLUSIONS Underserved and underinsured patients presenting for surgical care face significant challenges relating to social, emotional, and immigration needs. Through adoption of the ANS, trainees gained competency identifying and addressing these barriers in the perioperative period. Future works will focus on categorizing referral outcomes, developing interventions to increase patient trust, and improving screener dissemination.
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Affiliation(s)
- Stephen Halada
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Angela T Chen
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Eric H Li
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Matthew Goldshore
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Jon B Morris
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Carrie Z Morales
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania.
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Ramadan OI, Kelz RR, Sharpe JE, Wirtalla CJ, Keele LJ, Harhay MO, Roberts SE, Wang GJ. Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:648-656.e6. [PMID: 37116595 DOI: 10.1016/j.jvs.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair. METHODS A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type. RESULTS We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients. CONCLUSIONS Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - James E Sharpe
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Luke J Keele
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Michael O Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Ramadan OI, Rosenbaum PR, Reiter JG, Jain S, Hill AS, Hashemi S, Kelz RR, Fleisher LA, Silber JH. Redefining Multimorbidity in Older Surgical Patients. J Am Coll Surg 2023; 236:1011-1022. [PMID: 36919934 DOI: 10.1097/xcs.0000000000000659] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations. STUDY DESIGN We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching. RESULTS Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795). CONCLUSIONS Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.
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Affiliation(s)
- Omar I Ramadan
- From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Ramadan, Kelz)
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
| | - Paul R Rosenbaum
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, PA (Rosenbaum)
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
| | - Siddharth Jain
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
| | - Sean Hashemi
- From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Ramadan, Kelz)
| | - Rachel R Kelz
- From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Ramadan, Kelz)
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
| | - Lee A Fleisher
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Fleisher)
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, PA (Fleisher)
| | - Jeffrey H Silber
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Silber)
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA (Silber)
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Silber JH, Rosenbaum PR, Reiter JG, Jain S, Ramadan OI, Hill AS, Hashemi S, Kelz RR, Fleisher LA. The Safety of Performing Surgery at Ambulatory Surgery Centers Versus Hospital Outpatient Departments in Older Patients With or Without Multimorbidity. Med Care 2023; 61:328-337. [PMID: 36929758 PMCID: PMC10079624 DOI: 10.1097/mlr.0000000000001836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Surgery for older Americans is increasingly being performed at ambulatory surgery centers (ASCs) rather than hospital outpatient departments (HOPDs), while rates of multimorbidity have increased. OBJECTIVE To determine whether there are differential outcomes in older patients undergoing surgical procedures at ASCs versus HOPDs. RESEARCH DESIGN Matched cohort study. SUBJECTS Of Medicare patients, 30,958 were treated in 2018 and 2019 at an ASC undergoing herniorrhaphy, cholecystectomy, or open breast procedures, matched to similar HOPD patients, and another 32,702 matched pairs undergoing higher-risk procedures. MEASURES Seven and 30-day revisit and complication rates. RESULTS For the same procedures, HOPD patients displayed a higher baseline predicted risk of 30-day revisits than ASC patients (13.09% vs 8.47%, P < 0.0001), suggesting the presence of considerable selection on the part of surgeons. In matched Medicare patients with or without multimorbidity, we observed worse outcomes in HOPD patients: 30-day revisit rates were 8.1% in HOPD patients versus 6.2% in ASC patients ( P < 0.0001), and complication rates were 41.3% versus 28.8%, P < 0.0001. Similar patterns were also found for 7-day outcomes and in higher-risk procedures examined in a secondary analysis. Similar patterns were also observed when analyzing patients with and without multimorbidity separately. CONCLUSIONS The rates of revisits and complications for ASC patients were far lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was much higher than the baseline risk for the same procedures performed at the ASC, suggesting that surgeons are appropriately selecting their riskier patients to be treated at the HOPD rather than the ASC.
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Affiliation(s)
- Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- The Department of Pediatrics, The University of
Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Health Care Management, The Wharton School,
The University of Pennsylvania, Philadelphia, PA
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Statistics and Data Science, The Wharton
School, The University of Pennsylvania, Philadelphia, PA
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
| | - Siddharth Jain
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
| | - Omar I. Ramadan
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Surgery, The Perelman School of Medicine, The
University of Pennsylvania
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
| | - Sean Hashemi
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
| | - Rachel R. Kelz
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Surgery, The Perelman School of Medicine, The
University of Pennsylvania
| | - Lee A. Fleisher
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, The
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Perioperative Outcomes Research and
Transformation, The University of Pennsylvania, Philadelphia, PA
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Rosen CB, Roberts SE, Wirtalla CJ, Ramadan OI, Keele LJ, Kaufman EJ, Halpern SD, Kelz RR. Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study. J Am Coll Surg 2022; 235:724-735. [PMID: 36250697 PMCID: PMC9583235 DOI: 10.1097/xcs.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. STUDY DESIGN Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. RESULTS Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001). CONCLUSIONS Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.
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Affiliation(s)
- Claire B Rosen
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Chris J Wirtalla
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
| | - Luke J Keele
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Elinore J Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Scott D Halpern
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
- Department of Medicine, Hospital of the University of Pennsylvania; Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
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Ramadan OI, Dember LM, Wang GJ, Ng JH, Mantell MP, Neuman MD. Association between anaesthesia type and arteriovenous fistula maturation. BJA Open 2022; 3:100031. [PMID: 36267664 PMCID: PMC9581339 DOI: 10.1016/j.bjao.2022.100031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Whereas general anaesthesia is commonly used for haemodialysis fistula creation, regional or local anaesthesia has been posited to lead to better fistula maturation outcomes. We sought to measure the association between anaesthesia type and arteriovenous fistula maturation. METHODS We performed a secondary analysis of data from the Hemodialysis Fistula Maturation study, a multicentre prospective cohort study of advanced chronic kidney disease patients who underwent single-stage upper extremity fistula creation between 2010 and 2013. We evaluated the relationship between anaesthesia type and unassisted (without maturation-facilitating interventions) or overall (unassisted or assisted) fistula maturation using multivariable logistic regression. RESULTS Among 602 participants, 336 (55.8%) received regional/local anaesthesia and 266 (44.2%) received general anaesthesia. Unassisted maturation occurred in 164/309 patients (53.1%) after regional/local vs 91/226 patients (40.3%) after general anaesthesia (P=0.003). After adjustment for patient factors and fistula type, regional/local anaesthesia was associated with greater odds of unassisted maturation than general anaesthesia (odds ratio 1.72, 95% confidence interval 1.24-2.39; P=0.001). However, after further adjustment for clinical centre fixed effects, odds of unassisted maturation did not differ by anaesthesia type (odds ratio 1.03, 95% confidence interval 0.78-1.36; P=0.830). Similar findings were observed for overall maturation and composite endpoints accounting for potential survivorship bias. CONCLUSIONS Regional/local anaesthesia was associated with increased odds of fistula maturation when adjusting for patient factors and fistula type. However, this association did not persist after adjusting for centre fixed effects. Future research is needed to better understand the relationship between anaesthesia type and centre factors to optimise outcomes after fistula surgery.
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Affiliation(s)
- Omar I. Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura M. Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Grace J. Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jia Hwei Ng
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Mark P. Mantell
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D. Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Rice JR, Rothenburg K, Milici J, Ramadan OI, Kalapatapu V, Jackson B, Schneider DB, Wang G. Factors Associated With Urgent Amputation Status and Its Impact on Mortality. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.681] [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: 10/18/2022]
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Ramadan OI, Santos T, Stoecker JB, Belkin N, Jackson BM, Schneider DB, Rice J, Wang GJ. The Differential Impact of Medicaid Expansion on Disparities in Outcomes Following Peripheral Vascular Intervention. Ann Vasc Surg 2022; 86:135-143. [PMID: 35460861 DOI: 10.1016/j.avsg.2022.04.016] [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: 12/19/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Peripheral artery disease (PAD) disproportionately affects nonwhite, Hispanic/Latino, and low socioeconomic status patients, who are less likely to have insurance and routine healthcare visits. Medicaid expansion (ME) has improved insurance rates and access to care, potentially benefitting these patients. We sought to assess the impact of ME on disparities in outcomes after peripheral vascular intervention (PVI) for PAD. METHODS A retrospective analysis of prospectively-collected Vascular Quality Initiative PVI procedures between 2011-2019 was conducted. The sample was restricted to first-record procedures in adults under age 65 in states that expanded Medicaid on 1/1/2014 (ME group) or had not expanded before 1/1/2019 (non-expansion [NE] group). ME and NE groups were compared between pre-expansion (2011-2013) and post-expansion (2014-2019) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors and clinical center and year fixed effects. Our primary outcome was one-year major amputation. Secondary outcomes included trends in presentation, 30-day mortality, one-year mortality, and one-year primary and secondary patency. Outcomes were stratified by race and ethnicity. RESULTS We examined 34,313 PVI procedures, including 20,378 with follow up data. Rates of Medicaid insurance increased post-expansion in ME and NE states (ME 16.7% to 23.0%, p<0.001; NE 10.0% to 11.9%, p=0.013) while rates of self-pay decreased in ME states only (ME 4.6% to 1.8%, p<0.001; NE 8.1% to 8.4%, p=0.620). Adjusted difference-in-differences analysis revealed lower odds of urgent/emergent PVI among all patients and among nonwhite patients in ME states post-expansion compared to NE states (all: odds ratio [OR] 0.53 [95% confidence interval 0.33-0.87], p=0.011; nonwhite: OR 0.41 [0.19-0.88], p=0.023). No differences were observed for one-year major amputation (OR 0.70 [0.43-1.14], p=0.152), primary patency (OR 0.93 [0.63-1.38], p=0.726), or secondary patency (OR 1.29 [0.69-2.41], p=0.431). Odds of one-year mortality were higher in ME states post-expansion compared to NE states (OR 2.50 [1.07-5.87], p=0.035), although 30-day mortality was not different (OR 2.04 [0.60-6.90], p=0.253). Notably, odds of one-year major amputation among Hispanic/Latino patients decreased in ME states post-expansion compared to NE states (OR 0.11 [0.01-0.86], p=0.036). CONCLUSIONS ME was associated with lower odds of one-year major amputation among Hispanic/Latino patients who underwent PVI for PAD. ME was also associated with lower odds of urgent/emergent procedures among patients overall and nonwhite patients specifically. However, one-year mortality increased in the overall cohort. Further study is needed to corroborate our findings that ME may have benefits for certain underserved populations with PAD.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Tatiane Santos
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; The Wharton School at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nathan Belkin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M Jackson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Darren B Schneider
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jayne Rice
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Grace J Wang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Ramadan OI, Dember LM, Ng JH, Mantell MP, Wang GJ, Neuman MD. Association Between Anesthesia Type and Arteriovenous Fistula Maturation: Secondary Analysis of a Multicenter Prospective Cohort Study. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.647] [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: 11/26/2022]
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Ramadan OI, Naji A, Levine MH, Porrett PM, Dunn TB, Weinrieb RM, Kaminski M, Trofe-Clark J, Lorincz IS, Blumberg E, Weikert BC, Bleicher M, Abt PL. Response to letters concerning: "Kidney transplantation and donation in the transgender population: A single-institution case series". Am J Transplant 2020; 20:3695-3696. [PMID: 32594653 DOI: 10.1111/ajt.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/09/2020] [Accepted: 06/18/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ali Naji
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew H Levine
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paige M Porrett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ty B Dunn
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Weinrieb
- Department of Psychiatry, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary Kaminski
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Trofe-Clark
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Nephrology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ilona S Lorincz
- Division of Endocrinology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Blumberg
- Division of Infectious Disease, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Blair C Weikert
- Division of Infectious Disease, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa Bleicher
- Division of Nephrology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ramadan OI, Naji A, Levine MH, Porrett PM, Dunn TB, Nazarian SM, Weinrieb RM, Kaminski M, Johnson D, Trofe-Clark J, Lorincz IS, Blumberg EA, Weikert BC, Bleicher M, Abt PL. Kidney transplantation and donation in the transgender population: A single-institution case series. Am J Transplant 2020; 20:2899-2904. [PMID: 32353210 DOI: 10.1111/ajt.15963] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/03/2020] [Accepted: 04/19/2020] [Indexed: 01/25/2023]
Abstract
The medical needs of the transgender population are increasingly recognized within the US health care system. Hormone therapy and gender-affirming surgery present distinct anatomic, hormonal, infectious, and psychosocial issues among transgender kidney transplant donors and recipients. We present the first reported experience with kidney transplantation and donation in transgender patients. A single-center case series (January 2014-December 2018) comprising 4 transgender kidney transplant recipients and 2 transgender living donors was constructed and analyzed. Experts in transplant surgery, transplant psychiatry, transplant infectious disease, pharmacy, and endocrinology were consulted to discuss aspects of care for these patients. Four transgender patients identified as male-to-female and 2 as female-to-male. Three of 6 had gender-affirming surgeries prior to transplant surgery, 1 of whom had further procedures posttransplant. Additionally, 4 patients were on hormone therapy. All 6 had psychiatric comorbidities. The 4 grafts have done well, with an average serum creatinine of 1.45 mg/dL at 2 years (range 1.01-1.85 mg/dL). However, patients encountered various postoperative complications, 1 of which was attributable to modified anatomy. Thus, transgender kidney transplant patients can present novel challenges in regard to surgical considerations as well as pre- and posttransplant care. Dedicated expertise is needed to optimize outcomes for this population.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ali Naji
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew H Levine
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paige M Porrett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ty B Dunn
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susanna M Nazarian
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Weinrieb
- Department of Psychiatry, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary Kaminski
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Johnson
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Trofe-Clark
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Nephrology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ilona S Lorincz
- Division of Endocrinology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily A Blumberg
- Division of Infectious Disease, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Blair C Weikert
- Division of Infectious Disease, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa Bleicher
- Division of Nephrology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dawkins RL, Miller JH, Menacho ST, Ramadan OI, Lysek MC, Kuhn EN, Tubbs RS, Walker ML, Walters BC, Agee BS, Rozzelle CJ. Thoracolumbar Injury Classification and Severity Score in Children: A Validity Study. Neurosurgery 2019; 84:E362-E367. [PMID: 30189030 DOI: 10.1093/neuros/nyy408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 03/07/2018] [Accepted: 08/02/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a valid tool for assessing the need for surgical intervention in adult patients. There is limited insight into its usefulness in children. OBJECTIVE To assess the validity of the TLICS system in pediatric patients. METHODS The medical records for pediatric patients with acute, traumatic thoracolumbar fractures at two Level 1 trauma centers were reviewed retrospectively. A TLICS score was calculated for each patient using computed tomography and magnetic resonance images, along with the neurological examination recorded in the patient's medical record. TLICS scores were compared with the type of treatment received. Receiver operating characteristic (ROC) curve analysis was employed to quantify the validity of the TLICS scoring system. RESULTS TLICS calculations were completed for 165 patients. The mean TLICS score was 2.9 (standard deviation ± 2.7). Surgery was the treatment of choice for 23% of patients. There was statistically significant agreement between the TLICS suggested treatment and the actual treatment received (P < 0.001). The ROC curve calculated using multivariate logistic regression analysis of the TLICS system's parameters as a tool for predicting treatment demonstrated excellent discriminative ability, with an area under the ROC curve of 0.96, which was also statistically significant (P < 0.001). CONCLUSION The TLICS system demonstrates good validity for selecting appropriate thoracolumbar fracture treatment in pediatric patients.
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Affiliation(s)
- Ross L Dawkins
- Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Sarah T Menacho
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Omar I Ramadan
- Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael C Lysek
- Department of Internal Medicine, Brookwood Baptist Health, Birmingham, Alabama
| | - Elizabeth N Kuhn
- Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Marion L Walker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Beverly C Walters
- Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bonita S Agee
- Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Curtis J Rozzelle
- Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Dawkins RL, Miller JH, Ramadan OI, Lysek MC, Kuhn EN, Rocque BG, Conklin MJ, Tubbs RS, Walters BC, Agee BS, Rozzelle CJ. Thoracolumbar Injury Classification and Severity Score in children: a reliability study. J Neurosurg Pediatr 2018; 21:284-291. [PMID: 29328004 DOI: 10.3171/2017.7.peds1720] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There are many classification systems for injuries of the thoracolumbar spine. The recent Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a reliable tool for adult patients. The aim of this study was to assess the reliability of the TLICS system in pediatric patients. The validity of the TLICS system is assessed in a companion paper. METHODS The medical records of pediatric patients with acute, traumatic thoracolumbar fractures at a single Level 1 trauma center were retrospectively reviewed. A TLICS was calculated for each patient using CT and MRI, along with the neurological examination recorded in the patient's medical record. TLICSs were compared with the type of treatment received. Five raters scored all patients separately to assess interrater reliability. RESULTS TLICS calculations were completed for 81 patients. The mean patient age was 10.9 years. Girls represented 51.8% of the study population, and 80% of the study patients were white. The most common mechanisms of injury were motor vehicle accidents (60.5%), falls (17.3%), and all-terrain vehicle accidents (8.6%). The mean TLICS was 3.7 ± 2.8. Surgery was the treatment of choice for 33.3% of patients. The agreement between the TLICS-suggested treatment and the actual treatment received was statistically significant (p < 0.0001). The interrater reliability of the TLICS system ranged from moderate to very good, with a Fleiss' generalized kappa (κ) value of 0.69 for the TLICS treatment suggestion among all patients; however, interrater reliability decreased when MRI was used to contribute to the TLICS. The κ value decreased from 0.73 to 0.57 for patients with CT only vs patients with CT/MRI or MRI only, respectively (p < 0.0001). Furthermore, the agreement between suggested treatment and actual treatment was worse when MRI was used as part of injury assessment. CONCLUSIONS The TLICS system demonstrates good interrater reliability among physicians assessing thoracolumbar fracture treatment in pediatric patients. Physicians should be cautious when using MRI to aid in the surgical decision-making process.
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Affiliation(s)
- Ross L Dawkins
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
| | | | - Omar I Ramadan
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
| | - Michael C Lysek
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
| | - Elizabeth N Kuhn
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
| | - Brandon G Rocque
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
| | - Michael J Conklin
- 3Division of Orthopedic Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama
| | | | - Beverly C Walters
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
| | - Bonita S Agee
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
| | - Curtis J Rozzelle
- 1Section of Pediatric Neurosurgery, Children's of Alabama, Department of Neurosurgery, and
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Ramadan OI, Wei B, Cerfolio RJ. Robotic surgery for lung resections-total port approach: advantages and disadvantages. J Vis Surg 2017; 3:22. [PMID: 29078585 DOI: 10.21037/jovs.2017.01.06] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/10/2016] [Indexed: 11/06/2022]
Abstract
Minimally invasive thoracic surgery, when compared with open thoracotomy, has been shown to have improved perioperative outcomes as well as comparable long-term survival. Robotic surgery represents a powerful advancement of minimally invasive surgery, with vastly improved visualization and instrument maneuverability, and is increasingly popular for thoracic surgery. However, there remains debate over the best robotic approaches for lung resection, with several different techniques evidenced and described in the literature. We delineate our method for total port approach with four robotic arms and discuss how its advantages outweigh its disadvantages. We conclude that it is preferred to other robotic approaches, such as the robotic assisted approach, due to its enhanced visualization, improved instrument range of motion, and reduced potential for injury.
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Affiliation(s)
- Omar I Ramadan
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Benjamin Wei
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J Cerfolio
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Ramadan OI, Cerfolio RJ, Wei B. Tips and tricks to decrease the duration of operation in robotic surgery for lung cancer. J Vis Surg 2017; 3:11. [PMID: 29078574 DOI: 10.21037/jovs.2017.01.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/10/2016] [Indexed: 11/06/2022]
Abstract
Minimally invasive surgery (MIS) for lung cancer has been associated with decreased perioperative morbidity while maintaining similar long-term survival when compared to open thoracotomy. Robotic thoracic surgery constitutes an evolutionary step in this field, beckoning dramatic advancements both in visualization as well as surgical instrument range of motion and ergonomics. As such, robotic thoracic surgery is growing in adoption worldwide. One of its oft-cited disadvantages, however, is increased operative time, especially for less-experienced surgeons. We describe an assortment of tips and tricks that we conclude can safely reduce robotic operative duration.
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Affiliation(s)
- Omar I Ramadan
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J Cerfolio
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Benjamin Wei
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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