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Bhatti UF, Shen AS, Melo N, Barmparas G, Wang AS, Margulies DR, Alban RF. Don't Let the Sun Rise on Small Bowel Obstruction Without Surgical Consultation-Redefining Nonoperative Management Pathways. Am Surg 2024:31348241248797. [PMID: 38644162 DOI: 10.1177/00031348241248797] [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] [Indexed: 04/23/2024]
Abstract
Introduction: Small bowel obstruction (SBO) is a common cause of hospital admission leading to resource utilization. The majority of these patients require non-operative management (NOM) which can lead to increased length of stay (LOS), readmissions, resource utilization, and throughput delays. Early surgical consultation (SC) for SBO may improve efficiency and outcomes. Methods: We implemented an institution-wide intervention (INT) to encourage early SC (<1 day of diagnosis) for SBO patients in July 2022. A retrospective analysis was performed on all patients with SBO requiring NOM from January 2021 to June 2023, categorized into pre- and post-INT groups. The primary outcome was the number of SC's and secondary outcomes were early SC (<1 day of diagnosis), utilization of SBFT, LOS, 30-day readmission, and costs of admission. Results: A total of 670 patients were included, 438 in the pre-INT and 232 in the post-INT group. Overall, SBFT utilization was significantly higher in cases with SC (17.2% vs 41.4%, P < .001). Post-INT patients were more likely to receive SC (94.0% vs 83.3%, P < .001) and increased SBFT utilization (47.0% vs 33.6%, P = .001). Additionally, early SC improved significantly in the post-INT group (74.3% vs 65.7%, P = .03). There was no difference in LOS between groups (4.0 vs 3.8 days, P = .48). There was a trend toward decreased readmission rates in the INT group at 30 days (7.3% vs 11.0%, P = .13) and reduced direct costs in the INT group (US$/admission = 8467 vs 8708, P = .1). Conclusion: Hospital-wide interventions to increase early surgical involvement proved effective by improving early SC, increased SBFT utilization, and showed a trend towards decreased readmission rates and direct costs.
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Affiliation(s)
- Umar F Bhatti
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Aricia S Shen
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Nicolas Melo
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew S Wang
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rodrigo F Alban
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
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Childers CP, Ettner SL, Hays RD, Kominski G, Maggard-Gibbons M, Alban RF. Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures. Ann Surg 2021; 274:107-113. [PMID: 31460881 PMCID: PMC7035992 DOI: 10.1097/sla.0000000000003571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. SUMMARY BACKGROUND DATA Reducing surgical costs is paramount to the viability of hospitals. METHODS Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons. RESULTS The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy. CONCLUSIONS Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.
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Affiliation(s)
| | - Susan L. Ettner
- Division of General Internal Medicine and Health Services
Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los
Angeles, CA
- Department of Health Policy & Management, UCLA
Fielding School of Public Health, Los Angeles, CA
| | - Ron D. Hays
- Division of General Internal Medicine and Health Services
Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los
Angeles, CA
- Department of Health Policy & Management, UCLA
Fielding School of Public Health, Los Angeles, CA
| | - Gerald Kominski
- Department of Health Policy & Management, UCLA
Fielding School of Public Health, Los Angeles, CA
- UCLA Center for Health Policy Research, Fielding School of
Public Health, Los Angeles, California
| | | | - Rodrigo F. Alban
- Department of Surgery, Cedars Sinai Medical Center, Los
Angeles, CA
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3
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Tseng J, Alban RF, Siegel E, Chung A, Giuliano AE, Amersi FF. Changes in utilization of axillary dissection in women with invasive breast cancer and sentinel node metastasis after the ACOSOG Z0011 trial. Breast J 2021; 27:216-221. [PMID: 33586201 DOI: 10.1111/tbj.14191] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/16/2022]
Abstract
The American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial demonstrated no survival advantage for women with clinical T1-T2 invasive breast cancer with 1-2 positive sentinel lymph nodes (SLN) who received whole-breast radiation, and no further axillary surgery when compared to women who did undergo axillary lymph node dissection (ALND). We used the National Cancer Database (NCDB) to study changes in utilization of ALND after the publication of this trial. NCDB was queried for female patients from 2012 to 2015 who met Z0011 criteria. Patients were divided into four groups based on Commission on Cancer facility accreditation. Outcome measures include the rate of ALND (nonadherence to Z0011) and the average number of nodes retrieved with ALND. 27,635 patients were identified, with no significant differences in T stage and receptor profiles between groups. Overall rate of ALND decreased from 34.0% in 2012 to 22.7% in 2015. Nonadherence was lowest in Academic Programs (decreasing from 30.1% in 2012 to 20.5% in 2015) and was highest in Community Cancer Programs (41.2% in 2012 to 29.1% in 2015). Median number of positive SLN did not differ between groups (p = .563). Median number of nodes retrieved on ALND decreased from 9 (IQR 5-14) in 2012 to 7 (IQR 4-12) in 2015 (p < .001). In patients who met the ACOSOG Z11 trial guidelines, rates of ALND have decreased over time. However, rates of nonadherence to Z0011 are significantly higher in Community Cancer Programs compared to Academic Programs.
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rodrigo F Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Emily Siegel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alice Chung
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Farin F Amersi
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Huang R, Ryu RC, Kim TT, Alban RF, Margulies DR, Ley EJ, Barmparas G. Is magnetic resonance imaging becoming the new computed tomography for cervical spine clearance? Trends in magnetic resonance imaging utilization at a Level I trauma center. J Trauma Acute Care Surg 2020; 89:365-370. [PMID: 32744833 DOI: 10.1097/ta.0000000000002752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Increasing evidence supports the limited use of magnetic resonance imaging (MRI) for cervical spine (C-spine) clearance following blunt trauma. We sought to characterize the utilization of MRI of the C-spine at a Level I trauma center. METHODS All blunt trauma patients undergoing a computed tomography (CT) of the C-spine between January 2009 and December 2018 were reviewed. The CT and MRI results, demographics, clinical presentation, subspecialty consultations, and interventions were recorded. The MRI results were considered clinically significant if they resulted in cervical thoracic orthosis/halo placement or surgical intervention. Linear regression models were utilized to identify trends. RESULTS There were 9,101 patients that underwent a CT of the C-spine, with 513 (5.6%) being positive for an acute injury. MRI was obtained for 375 (4.1%) of patients. A linear increase in the proportion of patients undergoing an MRI was noted, from 0.9% in 2009 to 5.6% in 2018 (p < 0.01). Of the 513 patients with a positive CT, 290 (56.5%) had an MRI. In 40 (13.8%) of them, the CT demonstrated a minor injury. Clinically significant MRI findings were noted only in two (5.0%) of the 40 patients, and both had a neurologic deficit on initial examination. Of the 8,588 patients with a negative CT, 85 (1.0%) underwent an MRI. Of those, 9 (10.6%) had a clinically significant MRI with all but one presenting with a neurological deficit. CONCLUSION MRI is increasingly utilized for C-spine clearance following blunt trauma. MRI was exceedingly unlikely to demonstrate a clinically significant finding in the absence of a neurological deficit, when the CT was negative or included minor injuries. Trauma centers are encouraged to constantly evaluate their own practices and intervene with education and collaboration to limit the excessive use of unnecessary resources. LEVEL OF EVIDENCE Therapeutic/Care Management Study, Level III or IV. Diagnostic test, level IV.
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Affiliation(s)
- Raymond Huang
- From the Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery (R.H., R.F.A., D.R.M., E.J.L., G.B.), and Department of Orthopedics (R.C.R., T.T.K.), Cedars-Sinai Medical Center, Los Angeles, California
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5
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Abstract
Surgeons are often unfamiliar with the costs of surgical instrumentation and supplies. We hypothesized that surgeon cost feedback would be associated with a reduction in cost. A multidisciplinary team evaluated surgical supply costs for laparoscopic appendectomies of 7 surgeons (surgeons A-G) at a single-center academic institution. In the intervention, each surgeon was debriefed with their average supply cost per case, their partner's average supply cost per case, the cost of each surgical instrument/supply, and the cost of alternatives. In addition, the laparoscopic appendectomy tray was standardized to remove extraneous instruments. Pre-intervention (March 2017-February 2018) and post-intervention (March 2018-October 2018) costs were compared. Pre-intervention, the surgeons' average supply cost per case ranged from $754-$1189; when ranked from most to least expensive, surgeon A > B > C > D > E > F > G. Post-intervention, the surgeons' average supply cost per case ranged from $676 to $846, and ranked from surgeon G > D > F > C > E > B > A. Overall, the average cost per case was lower in the post-intervention group ($854.35 vs. $731.11, P < .001). This resulted in savings per case of $123.24 (14.4%), to a total annualized savings of $29 151.
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Affiliation(s)
- Joshua Tseng
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harry C Sax
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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6
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Zhao B, Childers CP, Hays RD, Ettner SL, Alban RF, Maggard-Gibbons M, Clary BM. Surgeon Awareness of the Relative Costs of Common Surgical Instruments. JAMA Surg 2020; 154:877-878. [PMID: 31241725 DOI: 10.1001/jamasurg.2019.1746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Beiqun Zhao
- Department of Surgery, University of California, San Diego, La Jolla
| | | | - Ron D Hays
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| | - Rodrigo F Alban
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | | | - Bryan M Clary
- Department of Surgery, University of California, San Diego, La Jolla
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Abstract
Recent studies have suggested improved outcomes in surgical patients with healthcare insurance, whereas several others have noted disparities in access to health care, the care provided, and the aftercare of uninsured patients. Several different strategies exist in the management and prevention of the open abdomen secondary to abdominal compartment syndrome. To date, no study has evaluated the effects of race and insurance in patients with an open abdomen (OA). A retrospective review from our OA database was queried. All patients with an OA from January 2002 to December 2010 were included for analysis. Data analyzed included patients’ demographics, race, insurance status, hospital charges, Injury Severity Scores, and outcomes. Insured patients were identified and compared with their uninsured counterparts. A total of 720 patients were treated for an OA during the study period. Of these, 273 (37.9%) died within their hospital stay. Patients who died were noted to be older and sicker with higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiologic Scores (27.6 vs 18.2, P < 0.001 and 54.6 vs 38.5, P < 0.001, respectively). Logistic regression analysis revealed that age, APACHE II, and Injury Severity Scores were independently associated with mortality. From our categorical variables, race was not associated with worse outcomes. In addition, being uninsured was significantly associated with increased mortality (odds ratio, 1.67; 95% confidence interval, 1.1 to 2.6; P = 0.05). “Self-pay” status was associated with increased mortality even after adjusting for severity of illness. Further studies incorporating baseline comorbidities need to be undertaken to further assess the reasons for these disparities.
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Affiliation(s)
- Jason M. Clark
- From Orlando Health–Surgical Education, Orlando, Florida
| | | | - Karen Safcsak
- From Orlando Health–Surgical Education, Orlando, Florida
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8
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Manguso N, Barmparas G, Dhillon NK, Ley EJ, Huang R, Melo N, Alban RF, Margulies DR. New cars on the highways: Trends in injuries and outcomes following ejection. Surg Open Sci 2019; 2:22-26. [PMID: 32754704 PMCID: PMC7391881 DOI: 10.1016/j.sopen.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 07/18/2019] [Accepted: 08/30/2019] [Indexed: 11/28/2022] Open
Abstract
Background Although ejections from motor vehicles are considered a marker of a significant mechanism and a predictor of severe injuries and mortality, scant recent data exist to validate these outcomes. This study investigates whether ejections increase the mortality risk following a motor vehicle crash using data that reflect the introduction of new vehicles to the streets of a large city in the United States. Methods The Trauma and Emergency Medicine Information System of Los Angeles County was queried for patients ≥ 16 years old admitted following a motor vehicle crash between 2002 and 2012. Ejected patients were compared to nonejected. Primary outcome was mortality. A logistic regression model was used to identify predictors of mortality and severe trauma. Results A total of 9,742 (6.8%) met inclusion criteria. Of these, 449 (4.6%) were ejected; 368 (82.0%) were passengers and 81 (18.0%) were drivers. The rate of ejection decreased linearly (6.1% in 2002 to 3.4% in 2012). Compared to nonejected patients, ejected patients were more likely to require intensive care unit admission (43.7% vs 22.1%, P < .01), have critical injuries (Injury Severity Score > 25) (24.2% vs 7.3%, P <.01), require emergent surgery (16.3% vs 8.0%, P <.01), and expire in the emergency department (3.6% vs 1.2%, P <.01). Overall mortality was 3.6%: 9.6% for ejected and 3.3% for nonejected patients (P <.01). In a logistic regression model, ejection and extrication both predicted mortality (adjusted odds ratio: 1.83, P <.01 and 1.87, P <.01, respectively). Ejection also predicted critical injuries (Injury Severity Score > 25) with adjusted odds ratio of 2.48 (P <.01). Conclusion Ejections following motor vehicle crash have decreased throughout the years; however, they remain a marker of critical injuries and predictive of mortality. The rate of ejection during a motor vehicle crash has decreased since 2002. Ejected patients had a significantly higher mortality compared to nonejected. Ejection was a predictor of both critical injuries and mortality.
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Affiliation(s)
| | | | | | | | | | | | | | - Daniel R. Margulies
- Corresponding author at: Division of Acute Care Surgery, Department of Surgery, Cedars-Sinai Medical Center. Tel.: + 1 310 423 4349; fax: + 1 310 423 0139.
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Dhillon NK, Barmparas G, Lin TL, Alban RF, Melo N, Yang AR, Margulies DR, Ley EJ. Unexpected complicated appendicitis in the elderly diagnosed with acute appendicitis. Am J Surg 2019; 218:1219-1222. [PMID: 31481154 DOI: 10.1016/j.amjsurg.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 03/15/2019] [Revised: 07/10/2019] [Accepted: 08/16/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND This study determined the prevalence of complicated appendicitis in elderly patients diagnosed preoperatively with uncomplicated appendicitis. METHODS Patients with a preoperative diagnosis of uncomplicated appendicitis at an academic hospital from 11/2013 to 05/2017 were reviewed. Patients ≥65 years were compared to those younger. Pathology reports were categorized as either uncomplicated or complicated (COMP). The primary outcome was the prevalence of COMP appendicitis. RESULTS The prevalence of COMP appendicitis increased with age after 20 years with an abrupt increase after 65 years. Patients ≥65 years were more likely to have COMP appendicitis (48.1% vs. 15.5%; OR: 5.1; p < 0.01) and prolonged stays (3.8 vs. 2.3 days; p < 0.01). CONCLUSION Nearly half of elderly patients had pathologic confirmation of complicated appendicitis despite no preoperative clinical or radiographic suspicion for complicated appendicitis. Nonoperative management of acute appendicitis in the elderly may not be appropriate due to the high rate of unexpected complicated appendicitis.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ting-Lung Lin
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Rodrigo F Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Nicolas Melo
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Audrey R Yang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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10
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Srour MK, Tseng J, Luu M, Alban RF, Giuliano AE, Chung A. Patterns in the Use of Axillary Operations for Patients with Node-Positive Breast Cancer After Neoadjuvant Chemotherapy: A National Cancer Database (NCDB) Analysis. Ann Surg Oncol 2019; 26:3305-3311. [DOI: 10.1245/s10434-019-07540-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 11/18/2022]
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Alban RF, Anania EC, Cohen TN, Fabri PJ, Gewertz BL, Jain M, Jopling JK, Maggio PM, Sanchez JA, Sax HC. Performance improvement in surgery. Curr Probl Surg 2019; 56:211-246. [PMID: 31155033 DOI: 10.1067/j.cpsurg.2019.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/06/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Rodrigo F Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Monica Jain
- University of California San Francisco Medical Center, San Francisco, CA
| | | | | | - Juan A Sanchez
- St. Agnes Hospital, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harry C Sax
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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Alban RF, Anania EC, Cohen TN, Fabri PJ, Gewertz BL, Jain M, Jopling JK, Maggio PM, Sanchez JA, Sax HC. Performance improvement in surgery. Curr Probl Surg 2019; 56:204-208. [PMID: 31155032 DOI: 10.1067/j.cpsurg.2019.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Rodrigo F Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Monica Jain
- University of California San Francisco Medical Center, San Francisco, CA
| | | | | | - Juan A Sanchez
- St. Agnes Hospital, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harry C Sax
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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13
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Tseng J, Cohen T, Melo N, Alban RF. Imaging utilization affects negative appendectomy rates in appendicitis: An ACS-NSQIP study. Am J Surg 2019; 217:1094-1098. [DOI: 10.1016/j.amjsurg.2018.12.072] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 10/17/2018] [Accepted: 12/29/2018] [Indexed: 12/29/2022]
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Espinoza-Mercado F, Borgella JD, Berz D, Alban RF, Sarkissian A, Imai HTA, Soukiasian HJ. Disparities in Compliance With National Guidelines for the Treatment of Malignant Pleural Mesothelioma. Ann Thorac Surg 2019; 108:889-896. [PMID: 31004585 DOI: 10.1016/j.athoracsur.2019.03.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/08/2019] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Current guidelines support cancer-directed surgery, chemotherapy, or active surveillance for clinical stages 1 to 3 of epithelial malignant pleural mesothelioma (MPM). Definitive chemotherapy is recommended for sarcomatoid/biphasic histologies. Our objective is to assess compliance with recommendations, measuring their impact on overall survival. METHODS The National Cancer Database participant user file (2004 to 2014) was queried for patients diagnosed with MPM clinical stages 1 to 3. Multivariable logistic regression model identified factors independently associated with guideline compliance. Kaplan-Meier analysis and Cox proportional hazards were used for overall survival comparison with histologic subgroup analysis. RESULTS A total of 3419 patients with clinical stages 1 to 3 met criteria for analysis and comprised epithelial (68.5%), sarcomatoid (17.2%), and biphasic subtypes (14.3%). Cancer-directed surgery was significantly underutilized in epithelial MPM, with 29.3% having no treatment. On multivariable analysis, insurance status and facility type were the strongest predictors of guideline compliance. High-volume hospitals were the most compliant with guidelines (odds ratio 3.58, 95% confidence interval (CI), 2.34 to 5.49, P < .001). Median survival estimates for no treatment, chemotherapy alone, surgery plus chemotherapy, and trimodal therapy were 10.2, 15.4, 21.1, and 21.7 months, respectively (log rank P < .001). In epithelial MPM, a significant increase in overall survival was observed in surgery plus chemotherapy (hazard ratio 0.62, 95% CI, 0.53 to 0.73, P < .001) and trimodality (hazard ratio 0.61, 95% CI, 0.49 to 0.76, P < .001; reference: no treatment). CONCLUSIONS There is a suboptimal compliance with national guidelines for the treatment of MPM, particularly in low-volume nonacademic settings. Adherence to recommended surgery-based multimodal therapy is associated with an overall survival improvement.
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Affiliation(s)
- Fernando Espinoza-Mercado
- Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jerald D Borgella
- Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Berz
- Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F Alban
- Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ariella Sarkissian
- Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hsdg Taryne A Imai
- Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harmik J Soukiasian
- Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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15
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Tseng J, Sax HC, Alban RF. Variability in Critical Care-Related Charge Markups in Medicare Patients. Am Surg 2018; 84:1622-1625. [PMID: 30747682] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care-related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60-6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts (P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care-related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Borgella J, EspinozaMercado F, Alban RF, Imai TA, Soukiasian HJ. Does Location Matter? Regional Variations in Outcomes of Minimally Invasive Esophagectomy Using the National Cancer Database. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.079] [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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Tseng J, Alban RF, Siegel E, Giuliano AE, Amersi F. Changes in Utilization of Axillary Dissection in Women with Invasive Breast Cancer and Sentinel Node Metastasis after American College of Surgeons Oncology Group (ACOSOG) Z0011 Trial. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care–related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60–6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts ( P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care–related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harry C. Sax
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Siegel E, Tseng J, Giuliano AE, Amersi F, Alban RF. Breast Cancer Treatment at Academic Centers Increases Likelihood of Reconstruction after Mastectomy. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.048] [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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20
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Tseng J, Nuño M, Lewis AV, Srour M, Margulies DR, Alban RF. Firearm legislation, gun violence, and mortality in children and young adults: A retrospective cohort study of 27,566 children in the USA. Int J Surg 2018; 57:30-34. [PMID: 30071359 DOI: 10.1016/j.ijsu.2018.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 04/04/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Firearm violence results in the death of thousands of children in the US annually. The effects of firearm legislation on gun violence are published but widely contested. MATERIALS AND METHODS The Kid's Inpatient Database from 2000 to 2009 were queried to capture hospitalizations of children diagnosed with a firearm-related injury. Cases were categorized into five levels of firearm legislation strictness by Brady State Scorecard. Trends of injuries were explored in terms of legislative strength, age, and race. RESULTS 27,566 children analyzed in the study. Most were adolescents aged 15-19 (87.3%), male (89.7%), and black (53.7%). The proportion of accidental injuries increased relative to state law leniency (R2 = 0.90), with highest percentage in lenient states (33.2%) compared to strict (16.7%). The proportion of suicide attempts were higher in states with lenient laws (4.4%) compared to strict (1.3%). Accidents were inversely related to age (59.3% in ages 0-4 compared to 22.0% in adolescents), while assaults were positively related to age (31.6% in ages 0-4 compared to 66.6% in adolescents). Whites were most likely to present with accidental injuries (44.6%), and Blacks and Hispanics with assaults (68.2% and 75.6%). Race (p = 0.009), age (p < 0.001), and firearm injury type (p = 0.001) were associated with mortality; Hispanics (OR 1.36, 95% CI: 1.03-1.78), children age 5-9 (2.03, 1.30-3.17) and suicide attempts (15.6, 11.6-20.9) had higher odds of in-hospital mortality. CONCLUSIONS Firearm-related injuries types in hospitalized children are associated with age, race, and state level legislation. Accidents are most prevalent in young children, Whites, and states with lenient gun laws, while suicide attempts are more common in adolescents, Whites, and states with lenient gun laws. Suicide attempts are also associated with the greatest odds of in-hospital mortality. To address firearm violence, consideration should be given to legislation that promote safe gun storage behaviors and restrict firearm accessibility to children.
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Davis, CA, USA.
| | - Azaria V Lewis
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Marissa Srour
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Rodrigo F Alban
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
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Alban RF, Tseng J, Rodriguez H. Standardization of Continuous Renal Replacement Therapy-Reply. JAMA Intern Med 2018; 178:1003. [PMID: 29971369 DOI: 10.1001/jamainternmed.2018.2676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Joshua Tseng
- Cedars-Sinai Medical Center, Los Angeles, California
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Tseng J, Halbert RJ, Minissian N, Rodriguez H, Barathan S, Hain P, Alban RF. Association of Standardization of Continuous Renal Replacement Therapy and High-Value Care: An Evidence-Based Approach. JAMA Intern Med 2018; 178:572-573. [PMID: 29482214 PMCID: PMC5876928 DOI: 10.1001/jamainternmed.2017.8732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cohort study assesses utilization patterns of continuous renal replacement therapy and attempts to establish evidence-based guidelines to standardize the process flow and to promote meaningful use.
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Affiliation(s)
- Joshua Tseng
- Cedars Sinai Medical Center, Los Angeles, California
| | | | | | | | | | - Patricia Hain
- Cedars Sinai Medical Center, Los Angeles, California
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Vora H, Chung A, Lewis A, Mirocha J, Amersi F, Giuliano A, Alban RF. Reconstruction among patients undergoing mastectomy: the effect of surgical deserts. J Surg Res 2018; 223:237-242. [DOI: 10.1016/j.jss.2017.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 10/24/2017] [Accepted: 11/03/2017] [Indexed: 01/22/2023]
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Liou DZ, Serna-Gallegos D, Mirocha J, Bairamian V, Alban RF, Soukiasian HJ. Predictors of Failure to Rescue After Esophagectomy. Ann Thorac Surg 2018; 105:871-878. [PMID: 29397102 DOI: 10.1016/j.athoracsur.2017.10.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/17/2017] [Accepted: 10/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Failure to rescue (FTR), defined as death after a major complication, is a metric increasingly being used to assess quality of care. Risk factors associated with FTR after esophagectomy have not been previously studied. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent esophagectomy with gastric conduit between 2010 and 2014. Patients with at least one major postoperative complication were grouped according to inhospital mortality (FTR group) and survival to discharge (SUR group). A stepwise logistic regression model was used to identify predictors of FTR. RESULTS A total of 1,730 patients comprised the study group, with 102 (5.9%) in the FTR group and 1,628 (94.1%) in the SUR group. The FTR patients were older (69.0 versus 64.0 years, p < 0.0001) compared with the SUR patients. There were no differences in sex, body mass index, preoperative weight loss, smoking status, operation type, or surgeon specialty between the two groups. Age greater than 75 years (adjusted odds ratio 2.68, p < 0.0001), black race (adjusted odds ratio 2.75, p = 0.001), American Society of Anesthesiologists class 4 or 5 (adjusted odds ratio 1.82, p = 0.02), and the occurrence of pneumonia, respiratory failure, acute renal failure, sepsis, or acute myocardial infarction were predictive of FTR based on multivariable logistic regression. CONCLUSIONS Nearly 6% of patients who have a major complication after esophagectomy do not survive to discharge. Age greater than 75 years, black race, American Society of Anesthesiologists class 4 or 5, and complications related to major infection or organ failure predict FTR. Further research is necessary to investigate how these factors affect survival after complications in order to improve rescue efforts.
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Affiliation(s)
- Douglas Z Liou
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Derek Serna-Gallegos
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vahak Bairamian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F Alban
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harmik J Soukiasian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Aquino L, Kang CY, Harada MY, Ko A, Do-Nguyen A, Ley EJ, Margulies DR, Alban RF. Is Routine Continuous EEG for Traumatic Brain Injury Beneficial? Am Surg 2017; 83:1433-1437. [PMID: 29336768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and subclinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of "routine" cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.
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Abstract
Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and sub-clinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of “routine” cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.
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Affiliation(s)
- Lia Aquino
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christopher Y. Kang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y. Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Amy Do-nguyen
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Tseng J, Loper B, Jain M, Lewis AV, Margulies DR, Alban RF. Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study. Trauma Surg Acute Care Open 2017; 2:e000126. [PMID: 29766117 PMCID: PMC5887781 DOI: 10.1136/tsaco-2017-000126] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/09/2023] Open
Abstract
Background Surgical intervention for ischemic colitis is associated with significant postoperative morbidity and mortality. Predictive factors of adverse outcomes have been reported in the literature, but are based on small sample populations. We sought to identify risk factors for mortality after emergent colectomy for ischemic colitis using a clinical outcomes database. Methods The American College of Surgeons National Surgical Quality Improvement Project database was queried from 2010 to 2015 to identify emergent colectomies performed for ischemic colitis using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Univariate and multivariate logistic regression analysis was used to identify independent risk factors associated with increased risk of mortality. Results A total of 4548 patients undergoing emergent colectomies for ischemic colitis were identified. Overall, 30-day postoperative mortality was 25.3%. On univariate analysis, preoperative risk factors associated with a higher rate of mortality include dyspnea, functional status, ventilator dependency, history of chronic obstructive pulmonary disease, ascites, congestive heart failure exacerbation, hypertension, dialysis dependency, cancer, open wounds, chronic steroids, weight loss >10%, transfusions within 72 hours before surgery, septic shock and duration from hospital admission to surgery. Factors that were significant for mortality on logistic regression analysis include elderly age, poor functional status, multiple comorbidities, septic shock, blood transfusion, acute renal failure and the duration of time from hospital admission to surgery. Conclusions Postoperative morbidity and mortality rates for ischemic colitis remain significantly high. Identification of risk factors may help patient selection for surgical interventions, and make informed decisions with patients and family members. Although it is certainly challenging, early diagnosis and prompt surgical intervention for patients with ischemic colitis may improve outcomes. Study type and level of evidence Therapeutic/care management, level II
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brandi Loper
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Monica Jain
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Azaria V Lewis
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rodrigo F Alban
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Vora H, Alban RF, Li Q, Amersi F, Giuliano AE, Chung AP. Comparison of Surgical Outcomes after Breast Reconstruction in Patients Younger and Older than Age 65 Years: A NSQIP Analysis. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.025] [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: 11/16/2022]
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Alban RF, Nuño M, Ko A, Barmparas G, Lewis AV, Margulies DR. Weaker gun state laws are associated with higher rates of suicide secondary to firearms. J Surg Res 2017; 221:135-142. [PMID: 29229119 DOI: 10.1016/j.jss.2017.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 01/10/2017] [Revised: 06/20/2017] [Accepted: 08/14/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Firearm-related suicides comprise over two-thirds of gun-related violence in the United States, and gun laws and policies remain under scrutiny, with many advocating for revision of the regulatory map for lawful gun ownership, aiming at restricting access and distribution of these weapons. However, the quantitative relationship between how strict gun laws are and the incidence of firearm violence with their associated mortality is largely unknown. We therefore, sought to explore the impact of firearm law patterns among states on the incidence and outcomes of firearm-related suicide attempts, utilizing established objective criteria. METHODS The National Inpatient Sample for the years 1998-2011 was queried for all firearm-related suicides. Discharge facilities were stratified into five categories (A, B, C, D, and F, with A representing states with the most strict and F representing states with the least strict laws) based on the Brady Campaign to prevent Gun Violence that assigns scorecards for every state. The primary outcomes were suicide attempts and in-hospital mortality per 100,000 populations by Brady state grade. RESULTS During the 14-year study period, 34,994 subjects met inclusion criteria. The mean age was 42.0 years and 80.1% were male. A handgun was utilized by 51.8% of patients. The overall mortality was 33.3%. Overall, 22.0% had reported psychoses and 19.3% reported depression. After adjusting for confounding factors and using group A as reference, there were higher adjusted odds for suicide attempts for patients admitted in group C, D, and F category states (1.73, 2.09, and 1.65, respectively, all P < 0.001). CONCLUSIONS Firearm-related suicide attempt injuries are more common in states with less strict gun laws, and these injuries tend to be associated with a higher mortality. Efforts aimed at nationwide standardization of firearm state laws are warranted, particularly for young adults and suicide-prone populations. LEVEL OF EVIDENCE III. STUDY TYPE Trauma Outcomes study.
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Affiliation(s)
- Rodrigo F Alban
- Division of Acute Care Surgery, Department of Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Miriam Nuño
- Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Division of Acute Care Surgery, Department of Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Acute Care Surgery, Department of Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Azaria V Lewis
- Division of Acute Care Surgery, Department of Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R Margulies
- Division of Acute Care Surgery, Department of Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Tatum JM, White T, Kang C, Ley EJ, Melo N, Bloom M, Alban RF. Prospective Trial of House Staff Time to Response and Intervention in a Surgical Intensive Care Unit: Pager vs. Smartphone. J Surg Educ 2017; 74:851-856. [PMID: 28347663 DOI: 10.1016/j.jsurg.2017.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/01/2017] [Accepted: 03/06/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The objective of the study was to characterize house staff time to response and intervention when notified of a patient care issue by pager vs. smartphone. We hypothesized that smartphones would reduce house staff time to response and intervention. DESIGN Prospective study of all electronic communications was conducted between nurses and house staff between September 2015 and October 2015. The 4-week study period was randomly divided into two 2-week study periods where all electronic communications between intensive care unit nurses and intensive care unit house staff were exclusively by smartphone or by pager, respectively. Time of communication initiation, time of house staff response, and time from response to clinical intervention for each communication were recorded. Outcomes are time from nurse contact to house staff response and intervention. SETTING Single-center surgical intensive care unit of Cedars-Sinai Medical Center in Los Angeles, California, an academic tertiary care and level I trauma center. PARTICIPANTS All electronic communications occurring between nurses and house staff in the study unit during the study period were considered. During the study period, 205 nurse-house staff electronic communications occurred, 100 in the phone group and 105 in the pager group. RESULTS House staff response to communication time was significantly shorter in the phone group (0.5 [interquartile range = 1.7] vs. 2 [3]min, p < 0.001). Time to house staff intervention after response was also significantly more rapid in the phone group (0.8 [1.7] vs. 1 [2]min, p = 0.003). CONCLUSIONS Dedicated clinical smartphones significantly decrease time to house staff response after electronic nursing communications compared with pagers.
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Affiliation(s)
- James M Tatum
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Terris White
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christopher Kang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicolas Melo
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew Bloom
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Abstract
BACKGROUND Organ availability is a consistently limiting factor in transplant surgery. A primary driver of this limitation is donor conversion rate, which is defined as the percentage of eligible donors for whom procurement is actually performed. An alternative way to increase organ availability is through improved utilization of organs from donors after cardiac death (DCD). Recently, a concerted, multidisciplinary effort has been made within our system to improve conversion rates and DCD utilization, thus increasing organ availability. STUDY DESIGN Retrospective analysis of a prospectively collected database from TransLife, our local organ procurement organization (OPO), as well as the Orlando Regional Medical Center (ORMC) trauma registry, from 2009-2012 (up to 2013 for DCD). During which time, this organization implemented best practice guidelines to improve conversions and DCD utilization. We analyzed yearly conversion rates, DCD donations and population demographics before and after implementation of these policies. RESULTS During the study period, donor conversion rates significantly improved from 58% in 2009 to 82% percent in 2012 hospital-wide (P<0.05); and from 50% in 2009 to 81% in 2012 among trauma patients alone (P<0.05). In addition, total organs transplanted increased from 13 to 31 organs (P<0.05) after implementation of best practice guidelines. No significant differences in trauma population demographics were noted during the study period. CONCLUSIONS Based on our experience, the establishment of best practice policies for referral of potential donors, coupled with programs to educate hospital staff on the existence and importance of these policies, leads to significant improvement in donor conversion rates and increased utilization of DCD donors.
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Affiliation(s)
| | - Bobby L Gibbons
- Department of Surgical Education, Orlando Regional Medical Center
| | - Vanessa L Bershad
- TransLife Organ Procurement Organization, Orlando Regional Medical Center
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Abstract
Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.
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Affiliation(s)
- Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y. Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J.T. Smith
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Scheipe
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicolas Melo
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Ko A, Do-Nguyen A, Aquino L, Harada M, Melo N, Margulies DR, Alban RF. Surgical Management of Appendicitis and Cholecystitis during Pregnancy: A National Analysis. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Alban RF, Ko A, Stanford W, Sax HC. Involvement of Physician Advocates in Progression of Care Rounds Improves Hospital Throughout with an Acute Care Surgery Model. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jain M, Phillips EH, Burch MA, Shouhed D, Alban RF. Laparoscopic and Open Adrenalectomy Performed for Malignant Adrenal Tumors: An Analysis of the American College of Surgeons NSQIP Database. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.245] [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: 10/20/2022]
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Ko A, Harada MY, Smith EJT, Scheipe M, Alban RF, Melo N, Margulies DR, Ley EJ. Pain Assessment and Control in the Injured Elderly. Am Surg 2016; 82:867-871. [PMID: 27779962] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.
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Affiliation(s)
- Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Vora H, Chung AP, Alban RF. Reconstruction Outcomes among Patients with Breast Cancer Undergoing Mastectomy in California: Disparities and Surgical Deserts. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.133] [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: 10/20/2022]
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Ko A, Aquino L, Melo N, Alban RF. Surgical outcomes and failure-to-rescue events after colectomy in teaching hospitals: a nationwide analysis. Am J Surg 2016; 212:1133-1139. [PMID: 27765178 DOI: 10.1016/j.amjsurg.2016.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 08/29/2016] [Accepted: 08/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The relationship between failure-to-rescue (FTR) after colectomy is not well understood, particularly in teaching institutions. We sought to examine this relationship using a large national database. METHODS Patients undergoing colectomy from 2010 to 2012 were identified in the Nationwide Inpatient Sample database. FTR events were defined as deaths following deep vein thrombosis or pulmonary embolism, sepsis, gastrointestinal bleed, acute myocardial infarction, acute kidney injury, pneumonia, respiratory failure, shock. We compared outcomes between teaching hospitals (TH) and nonteaching hospitals (NTH). RESULTS A total of 220,369 patients underwent colectomy; 50.2% were performed at TH. Overall mortality was 3.7% with 96% of deaths attributed to at least one FTR event. More complications occurred in NTH, but there was no difference in mortality or FTR rates. However, TH had higher incidences of deep vein thrombosis or pulmonary embolism and sepsis leading to postoperative mortality, whereas NTH had higher rates of acute myocardial infarction and gastrointestinal bleed. CONCLUSIONS A substantial proportion of mortality is attributed to FTR events after colectomy in both TH and NTH. Further investigation targeting specific complications is warranted.
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Affiliation(s)
- Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA 90048, USA
| | - Lia Aquino
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA 90048, USA
| | - Nicolas Melo
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA 90048, USA
| | - Rodrigo F Alban
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA 90048, USA.
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Bloom MB, Zaw AA, Hoang DM, Mason R, Alban RF, Chung R, Melo N, Volod O, Ley EJ, Margulies DR. Body mass index strongly impacts the diagnosis and incidence of heparin-induced thrombocytopenia in the surgical intensive care unit. J Trauma Acute Care Surg 2016; 80:398-403; discussion 403-4. [PMID: 26906645 DOI: 10.1097/ta.0000000000000952] [Citation(s) in RCA: 16] [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] [Indexed: 12/21/2022]
Abstract
BACKGROUND The obese state has been linked to several immune-mediated conditions. Our objective was to examine the association of body mass index (BMI) with the diagnosis of heparin-induced thrombocytopenia (HIT). METHODS Prospectively collected data on patients in the surgical and cardiac intensive care unit suspected of having HIT between January 2007 and August 2014 were analyzed. Patients were categorized into five discrete BMI (kg/m) groups and compared. Data collected included Warkentin 4-T scores, antiplatelet factor 4 (anti-PF4OD) values, serotonin release assay values, and thromboembolic diseases. HIT positivity was defined as serotonin release assay value greater than 20%. RESULTS Of 304 patients meeting inclusion criteria, mean (SD) age was 62.1 (16.5) years, 59% were male, and mean (SD) BMI was 27 (6) kg/m. Thirty-six (12%) were positive for HIT. Incidence of HIT increased progressively with BMI (0%, 8%, 11%, 19%, 36%; p < 0.001). Compared with patients with normal BMI, patients with a BMI of 30 kg/m to 39.9 kg/m had a 200% increase in the odds for HIT (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.20-7.54; p = 0.019), while patients with a BMI of 40 kg/m or greater had a 600% increase (OR, 6.98; 95% CI, 1.59-28.2; p = 0.012). After regression analysis, BMI remained an independent predictor of the development of HIT (adjusted OR per kg/m, 1.08; 95% CI, 1.02-1.14; p = 0.010). Anti-PF4OD values greater than or equal to 2.0 also increased with BMI (p < 0.001). In-hospital mortality increased significantly with BMI above normal (p = 0.026). Warkentin 4-T scores, deep venous thrombosis, pulmonary embolism, and stroke incidence did not correlate with changes in BMI. CONCLUSION Increasing BMI seems to be strongly associated with increased rates of HIT in intensive care unit patients. Obesity is an important new clinical variable for estimating the pretest probability of HIT, and patient "thickness" could be considered a fifth "T" of the 4-T scoring system. Additional biochemical work is indicated to decipher the role of obesity in this immune-mediated condition. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Affiliation(s)
- Matthew B Bloom
- From the Division of Trauma and Critical Care (M.B.B., A.A.Z., D.M.H., R.F.A., R.C., N.M., E.J.L., D.R.M.), Department of Surgery, Department of Pharmacy (R.M.), and Division of Coagulation Service (O.V.), Department of Hematology, Cedars-Sinai Medical Center, Los Angeles, California
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Ko A, Murry JS, Hoang DM, Harada MY, Aquino L, Coffey C, Sax HC, Alban RF. High-value care in the surgical intensive care unit: effect on ancillary resources. J Surg Res 2016; 202:455-60. [PMID: 27041599 DOI: 10.1016/j.jss.2016.01.040] [Citation(s) in RCA: 13] [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: 12/04/2015] [Revised: 01/05/2016] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Changes in health care policies have influenced transformations in hospital systems to be cost-efficient while maintaining robust outcomes. This is particularly important in intensive care units where significant resources are used to care for critically ill patients. We sought to determine whether high-value care processes (HVCp) implemented in a surgical intensive care unit (SICU) have an impact on commonly used ancillary tests. MATERIALS AND METHODS An implementation phase using a Lean Six Sigma approach was performed in October 2014 at a 24-bed large academic center SICU with aims to decrease orders of excessive daily laboratory tests and X-rays. The HVCp implemented included use of daily checklists, staff education, and visual reminders emphasizing the importance of appropriate laboratory tests and chest X-rays. Preintervention (July 2014-October 2014) and post-intervention (November 2014-June 2015) phases were compared. RESULTS Average SICU census, case mix index (4.3 versus 4.4, P = 0.57), all patient refined severity of illness (3.2 versus 3.2, P = 0.91), and SICU mortality (7.1% versus 5.1%, P = 0.18) were similar in both phases. A significant reduction of excessive laboratory tests was evident after the implementation period. Eight hundred sixty-five arterial blood gases/mo were obtained in the preintervention phase compared with 420 arterial blood gases/mo after intervention (P = 0.004), representing a 51.4% reduction. Similar results were obtained with complete blood counts, basic metabolic profiles, coagulation profiles, and chest X-rays (12%, 17.8%, 30.2%, and 20.3% reductions, respectively), a total estimated cost savings of $59,137/mo and prevention of excess phlebotomy of approximately 4 L of blood/mo. CONCLUSIONS By implementing an HVCp including a checklist, visual reminders, and provider education, we significantly reduced the use of commonly ordered ancillary tests in the SICU without affecting outcomes, resulting in an annual cost savings of $710,000.
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Affiliation(s)
- Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jason S Murry
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - David M Hoang
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y Harada
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lia Aquino
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Charles Coffey
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harry C Sax
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F Alban
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Giancarelli A, Birrer KL, Alban RF, Hobbs BP, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res 2015; 202:182-7. [PMID: 27083965 DOI: 10.1016/j.jss.2015.12.036] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [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: 09/10/2015] [Revised: 11/11/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium is vital for coagulation, but hypocalcemia commonly occurs during massive transfusion due to citrate and serum calcium chelation. This study was conducted to determine the incidence of hypocalcemia and severe hypocalcemia in trauma patients who receive massive transfusion and to compare characteristics of patients with severe versus nonsevere hypocalcemia. MATERIALS AND METHODS This was a retrospective study of trauma patients who received massive transfusion between January 2009 and November 2013. The primary outcome was the incidence of hypocalcemia (ionized calcium [iCa] < 1.12 mmol/L) and severe hypocalcemia (iCa < 0.90 mmol/L). Secondary outcomes included calcium monitoring, calcium replacement, and correction of coagulopathy. RESULTS There were 156 patients included; 152 (97%) experienced hypocalcemia, and 111 (71%) had severe hypocalcemia. Patients were stratified into iCa ≥ 0.90 (n = 45) and iCa < 0.90 (n = 111). There were no differences in demographics or baseline laboratories except the severe hypocalcemia group had higher baseline activated partial thromboplastin time (29.7 [23.7-50.9] versus 25.8 [22.3-35.9], P = 0.003), higher lactic acid (5.8 [4.1-9.8] versus 4.0 [3.1-7.8], P = 0.019), lower platelets (176 [108-237] versus 208 [169-272], P = 0.003), and lower pH (7.14 [6.98-7.28] versus 7.23 [7.14-7.33], P = 0.019). Mortality was higher in the severe hypocalcemia group (49% versus 24%, P = 0.007). Patients in the iCa < 0.90 group received more blood products (34 [23-58] versus 22 [18-30] units, P < 0.001), and calcium chloride (4 [2-7] versus 3 [1-4] g, P = 0.002), but there was no difference in duration of MTP or final iCa. Neither group reached a median iCa > 1.12. CONCLUSIONS Hypocalcemia is common during MTP, and vigilant monitoring is warranted. Research is needed to effectively manage hypocalcemia during massive transfusion.
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Affiliation(s)
- Amanda Giancarelli
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida.
| | - Kara L Birrer
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
| | - Rodrigo F Alban
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Brandon P Hobbs
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
| | - Xi Liu-DeRyke
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida.
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Ko A, Zaw A, Sun BJ, Harada M, Barmparas G, Alban RF, Bloom MB, Margulies DR, Ley EJ. Limit Crystalloid Resuscitation in Elderly Trauma Patients. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.393] [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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Murry JS, Hoang DM, Ashragian S, Liou DZ, Barmparas G, Chung R, Alban RF, Margulies DR, Ley EJ. Selective Nonoperative Management of Abdominal Stab Wounds. Am Surg 2015; 81:1034-1038. [PMID: 26463303] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (ED-OR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure ≤110 mm Hg, or blood transfusion. NON-THER was defined as abdominal exploration without identification of intra-abdominal injury requiring repair. Of 142 patients included, 104 were ED-OR and 38 were ADMIT. When ED-OR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1; P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days; P = 0.04). Incidence of NON-THER was higher in ED-OR cohort (71% vs 13%; P ≤ 0.001). In a regression model, ED-OR was a predictor of NON-THER (adjusted odds ratio 16.6; P < 0.001). One patient from ED-OR expired after complications from NON-THER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure ≥110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.
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Affiliation(s)
- Jason S Murry
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Murry JS, Hoang DM, Ashragian S, Liou DZ, Barmparas G, Chung R, Alban RF, Margulies DR, Ley EJ. Selective Nonoperative Management of Abdominal Stab Wounds. Am Surg 2015. [DOI: 10.1177/000313481508101024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (ED-OR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure ≤110 mm Hg, or blood transfusion. NON-THER was defined as abdominal exploration without identification of intra-abdominal injury requiring repair. Of 142 patients included, 104 were ED-OR and 38 were ADMIT. When ED-OR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1; P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days; P = 0.04). Incidence of NON-THER was higher in ED-OR cohort (71% vs 13%; P ≤ 0.001). In a regression model, ED-OR was a predictor of NON-THER (adjusted odds ratio 16.6; P < 0.001). One patient from ED-OR expired after complications from NON-THER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure ≥110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.
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Affiliation(s)
- Jason S. Murry
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - David M. Hoang
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sogol Ashragian
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Doug Z. Liou
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rex Chung
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Zaw AA, Murry J, Hoang D, Chen K, Louy C, Bloom MB, Melo N, Alban RF, Margulies DR, Ley EJ. Epidural Analgesia after Rib Fractures. Am Surg 2015; 81:950-954. [PMID: 26463287] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. The purpose of this study was to determine how epidural catheters alter mortality and complications in trauma patients. We performed a retrospective study involving adult blunt trauma patients with moderate-to-severe injuries from January 1, 2004 to December 31, 2013. During the 10-year period, 526 patients met the inclusion criteria; 43/526 (8%) patients had a catheter placed. Mean age of patients with epidural catheter (CATH) was higher compared with patients without epidural catheter (NOCATH) (54 vs 48 years, P = 0.021), Injury Severity Score was similar (26 CATH vs 27 NOCATH, P = 0.84), and CATH had higher mean rib fractures (7.4 vs 4.1, P < 0.001). Mortality was lower in CATH (0% vs 13%, P = 0.006). Deep vein thrombosis (DVT) rate was higher in CATH (12% vs. 5%, P = 0.036). After regression analysis, we found catheter placement to be a predictor for DVT (adjusted odds ratios 2.80, P = 0.036). Our center noted increased use of epidural catheters in patients who present with moderate-to-severe injuries. Patients with catheters were older and had a mean of 7.4 ribs fractured. The epidural cohort had longer hospital LOS and decreased mortality. In contrast to other studies, DVT rates were increased in patients who received epidural catheters.
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Affiliation(s)
- Andrea A Zaw
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Abstract
Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. The purpose of this study was to determine how epidural catheters alter mortality and complications in trauma patients. We performed a retrospective study involving adult blunt trauma patients with moderate-to-severe injuries from January 1, 2004 to December 31, 2013. During the 10-year period, 526 patients met the inclusion criteria; 43/526 (8%) patients had a catheter placed. Mean age of patients with epidural catheter (CATH) was higher compared with patients without epidural catheter (NOCATH) (54 vs 48 years, P = 0.021), Injury Severity Score was similar (26 CATH vs 27 NOCATH, P = 0.84), and CATH had higher mean rib fractures (7.4 vs 4.1, P < 0.001). Mortality was lower in CATH (0% vs 13%, P = 0.006). Deep vein thrombosis (DVT) rate was higher in CATH (12% vs. 5%, P = 0.036). After regression analysis, we found catheter placement to be a predictor for DVT (adjusted odds ratios 2.80, P = 0.036). Our center noted increased use of epidural catheters in patients who present with moderate-to-severe injuries. Patients with catheters were older and had a mean of 7.4 ribs fractured. The epidural cohort had longer hospital LOS and decreased mortality. In contrast to other studies, DVT rates were increased in patients who received epidural catheters.
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Affiliation(s)
- Andrea A. Zaw
- Division of Trauma and Critical Care, Department of Surgery
| | - Jason Murry
- Division of Trauma and Critical Care, Department of Surgery
| | - David Hoang
- Division of Trauma and Critical Care, Department of Surgery
| | - Kevin Chen
- Division of Trauma and Critical Care, Department of Surgery
| | - Charles Louy
- Department of Anesthesia, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Nicolas Melo
- Division of Trauma and Critical Care, Department of Surgery
| | | | | | - Eric J. Ley
- Division of Trauma and Critical Care, Department of Surgery
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Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Certain patients appear to benefit when they receive immune enhancing additives, such as glutamine, arginine, and omega-3 fatty acids. We hypothesized that TBI patients given enteral feedings containing these supplements may have improved nutrition measures and infection rates when compared to standard tube feedings. This is a retrospective review of patients from a Level-One trauma center from July 2009 to July 2013. A total of 240 TBI patients received either an immune enhancing nutrition (IEN) formula (n = 126), or a standard formula (SF) (n = 114) based on the attending surgeon's preference. Data collected included demographic information, infection information and outcome measures. Patients were similar in terms of age, ISS, head AIS, and initial prealbumin level. Patients receiving IEN were found to have lower rates of blood stream infections (10.3% vs 19.3%, p < 0.05), whereas pneumonia and UTI rates were similar between groups. In addition, both groups had similar rates of all-cause mortality and hospital length of stay, however IEN patients spent longer in the ICU and on ventilators. In TBI patients receiving IEN, prealbumin levels were higher at the second, third, and fourth week of admission (week 2 - 22.2 vs 17.4, p = 0.006; week 3 - 24.6 vs 20.1, p = 0.04; week 4 - 26.3 vs 22.1, p = 0.19; week 5 - 25.8 vs 20.3, p = 0.21). This study suggests that patients with traumatic brain injury who receive IEN are more likely to have increased prealbumin levels perhaps reflecting improved nutrition throughout their hospital stay and may show some benefit in rates of infections, particularly in bacteremia.
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Affiliation(s)
- Thomas J Painter
- Orlando Health, Department of Surgical Education, 86 W. Underwood Street, Suite 201, Orlando, FL 32806, USA.
| | | | - Rodrigo F Alban
- Department of Surgery Cedars-Sinai Medical Center, 8635 W 3rd St Suite 650-W, Los Angeles, CA 90048, USA.
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48
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Corsa JG, Alban RF, Promes JT. Prehospital intubation adversely affects outcomes in patients receiving massive transfusion. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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49
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Clark JM, Cheatham ML, Safcsak K, Alban RF. Effects of race and insurance on outcomes of the open abdomen. Am Surg 2013; 79:928-932. [PMID: 24069993] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Recent studies have suggested improved outcomes in surgical patients with healthcare insurance, whereas several others have noted disparities in access to health care, the care provided, and the aftercare of uninsured patients. Several different strategies exist in the management and prevention of the open abdomen secondary to abdominal compartment syndrome. To date, no study has evaluated the effects of race and insurance in patients with an open abdomen (OA). A retrospective review from our OA database was queried. All patients with an OA from January 2002 to December 2010 were included for analysis. Data analyzed included patients' demographics, race, insurance status, hospital charges, Injury Severity Scores, and outcomes. Insured patients were identified and compared with their uninsured counterparts. A total of 720 patients were treated for an OA during the study period. Of these, 273 (37.9%) died within their hospital stay. Patients who died were noted to be older and sicker with higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiologic Scores (27.6 vs. 18.2, P < 0.001 and 54.6 vs. 38.5, P < 0.001, respectively). Logistic regression analysis revealed that age, APACHE II, and Injury Severity Scores were independently associated with mortality. From our categorical variables, race was not associated with worse outcomes. In addition, being uninsured was significantly associated with increased mortality (odds ratio, 1.67; 95% confidence interval, 1.1 to 2.6; P = 0.05). "Self-pay" status was associated with increased mortality even after adjusting for severity of illness. Further studies incorporating baseline comorbidities need to be undertaken to further assess the reasons for these disparities.
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Affiliation(s)
- Jason M Clark
- Orlando Health-Surgical Education, Orlando, Florida, USA
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Alban RF, Berry C, Ley E, Mirocha J, Margulies DR, Tillou A, Salim A. Does Health Care Insurance Affect Outcomes after Traumatic Brain Injury? Analysis of the National Trauma Databank. Am Surg 2010. [DOI: 10.1177/000313481007601019] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 ± 22.4 vs 37.3 ± 16.3 years, P < 0.0001), more severely injured (ISS > 16: 78.4% vs 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 ± 9.4 vs 5.1 ± 7.6, P < 0.0001) and had higher mortality (9.3% vs 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.
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Affiliation(s)
- Rodrigo F. Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cherisse Berry
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Areti Tillou
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ali Salim
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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