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Alagoz O, Zhang Y, Arroyo N, Fernandes-Taylor S, Yang DY, Krebsbach C, Venkatesh M, Hsiao V, Davies L, Francis DO. Modeling Thyroid Cancer Epidemiology in the United States Using Papillary Thyroid Carcinoma Microsimulation Model. Value Health 2024; 27:367-375. [PMID: 38141816 PMCID: PMC10922958 DOI: 10.1016/j.jval.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVES Thyroid cancer incidence increased over 200% from 1992 to 2018, whereas mortality rates had not increased proportionately. The increased incidence has been attributed primarily to the detection of subclinical disease, raising important questions related to thyroid cancer control. We developed the Papillary Thyroid Carcinoma Microsimulation model (PATCAM) to answer them, including the impact of overdiagnosis on thyroid cancer incidence. METHODS PATCAM simulates individuals from age 15 until death in birth cohorts starting from 1975 using 4 inter-related components, including natural history, detection, post-diagnosis, and other-cause mortality. PATCAM was built using high-quality data and calibrated against observed age-, sex-, and stage-specific incidence in the United States as reported by the Surveillance, Epidemiology, and End Results database. PATCAM was validated against US thyroid cancer mortality and 3 active surveillance studies, including the largest and longest running thyroid cancer active surveillance cohort in the world (from Japan) and 2 from the United States. RESULTS PATCAM successfully replicated age- and stage-specific papillary thyroid cancers (PTC) incidence and mean tumor size at diagnosis and PTC mortality in the United States between 1975 and 2015. PATCAM accurately predicted the proportion of tumors that grew more than 3 mm and 5 mm in 5 years and 10 years, aligning with the 95% confidence intervals of the reported rates from active surveillance studies in most cases. CONCLUSIONS PATCAM successfully reproduced observed US thyroid cancer incidence and mortality over time and was externally validated. PATCAM can be used to identify factors that influence the detection of subclinical PTCs.
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Affiliation(s)
- Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA.
| | - Yichi Zhang
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Craig Krebsbach
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Manasa Venkatesh
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Vivian Hsiao
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Louise Davies
- Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, NH, USA; Department of Veterans Affairs Medical Center, White River Junction, VT, USA
| | - David O Francis
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
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Damico Smith C, Nanda N, Bonnet K, Schlundt D, Anderson C, Fernandes-Taylor S, Gelbard A, Francis DO. Navigating Pathways to Diagnosis in Idiopathic Subglottic Stenosis: A Qualitative Study. Laryngoscope 2024; 134:815-824. [PMID: 37740907 DOI: 10.1002/lary.31023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE Idiopathic subglottic stenosis is a rare disease, and time to diagnosis is often prolonged. In the United States, some estimate it takes an average of 9 years for patients with similar rare disease to be diagnosed. Patient experience during this period is termed the diagnostic odyssey. The aim of this study is to use qualitative methods grounded in behavioral-ecological conceptual frameworks to identify drivers of diagnostic odyssey length that can help inform efforts to improve health care for iSGS patients. METHODS Qualitative study using semi-structured interviews. Setting consisted of participants who were recruited from those enrolled in a large, prospective multicenter trial. We use directed content analysis to analyze qualitative semi-structured interviews with iSGS patients focusing on their pathways to diagnosis. RESULTS Overall, 30 patients with iSGS underwent semi-structured interviews. The patient-reported median time to diagnosis was 21 months. On average, the participants visited four different health care providers. Specialists were most likely to make an appropriate referral to otolaryngology that ended in diagnosis. However, when primary care providers referred to otolaryngology, patients experienced a shorter diagnostic odyssey. The most important behavioral-ecological factors in accelerating diagnosis were strong social support for the patient and providers' willingness to refer. CONCLUSION Several factors affected time to diagnosis for iSGS patients. Patient social capital was a catalyst in decreasing time to diagnosis. Patient-reported medical paternalism and gatekeeping limited specialty care referrals extended diagnostic odysseys. Additional research is needed to understand the effect of patient-provider and provider-provider relationships on time to diagnosis for patients with iSGS. LEVEL OF EVIDENCE 4 Laryngoscope, 134:815-824, 2024.
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Affiliation(s)
- Cara Damico Smith
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Nainika Nanda
- Division of Otolaryngology, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, U.S.A
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, U.S.A
| | | | | | - Alexander Gelbard
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University
| | - David O Francis
- Division of Otolaryngology, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
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Kennedy E, Zhang Y, Qadadha Y, Cheng C, Adil A, Bach K, Smith D, Arroyo N, Fernandes-Taylor S, Gettle LM, Mayer AM, Francis DO, Chiu AS. Rates of Detecting Thyroid Nodules Recommended for Biopsy with Ultrasound: Are All Indications Equal? Thyroid 2023; 33:1434-1440. [PMID: 37981778 PMCID: PMC10714116 DOI: 10.1089/thy.2023.0234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Background: The use of thyroid ultrasound increases yearly, adding to costs and overdetection of clinically irrelevant nodules. We investigated which indications most commonly prompt referral for thyroid ultrasound and the diagnostic utility by indication. Methods: We performed a retrospective observational cohort study of adults (≥18 years) undergoing an initial dedicated thyroid ultrasound between 2017 and 2019 at a tertiary academic center. Indicated reasons for referral were categorized into suspected palpable nodule (SPN), compressive symptoms (CS), metabolic symptoms (MS), screening due to high-risk factors, follow-up of incidental finding on other imaging, and combination of factors. Percentage of ultrasounds with an identifiable nodule and with a nodule recommended for biopsy was compared by indication. Separate logistic regression models were used to identify factors associated with finding any nodule and a biopsy-recommended nodule. Results: Among the 1739 patients included, the most common indication for thyroid ultrasound was SPN (40%), followed by incidental imaging (28%), CS (13%), combination (11%), MS (6%), and high-risk factors (2%). Overall, 62% of ultrasounds identified a nodule. Ultrasounds performed for incidental findings had the highest rate of nodule identification (94%), compared with 55%, 39%, and 43%, for SPN, CS, and MS, respectively (p < 0.05). Only 27% of ultrasounds identified a biopsy-recommended nodule. Nodules found incidentally had the highest rate of biopsy-recommended nodules at 55%. Rates of biopsy-recommended nodules for SPN, CS, and MS were 21%, 6%, and 10%, respectively. Logistic regression demonstrated that compared with patients referred for an SPN, those with incidental nodules were 10 times more likely to have a nodule found on ultrasound (odds ratio [OR] = 10.6 [CI 7.0-16.0]), while those referred for CS were half as likely to have a nodule (OR = 0.5 [CI 0.4-0.7]). Similar factors were associated with identification of biopsy-recommended nodules. Conclusions: Of all new dedicated thyroid ultrasounds, only a quarter find biopsy-recommended nodules, and nearly 40% do not identify a nodule at all. Notably, only 55% of ultrasounds done for SPN found a nodule. Ultrasound for CS and MS had the lowest rates of detecting nodules. Providing clear guidance on when to order thyroid ultrasounds can help reduce unnecessary health care utilization and potential overtreatment.
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Affiliation(s)
- Elena Kennedy
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yanchen Zhang
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yazeed Qadadha
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Christie Cheng
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Abdullah Adil
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kathy Bach
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dave Smith
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lori Mankowski Gettle
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ann Marie Mayer
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David O. Francis
- Section of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alexander S. Chiu
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Anagnostopoulos PV, Cartmill RS, Yang Q, Schumacher JR, Fernandes-Taylor S, Hermsen JL, DeCamp MM. Systems of Care Factors Should Be Considered in Regionalization of Congenital Cardiac Surgery. Ann Thorac Surg 2023; 116:517-523. [PMID: 36379268 DOI: 10.1016/j.athoracsur.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Regionalization of care has been proposed to optimize outcomes in congenital cardiac surgery (CCS). We hypothesized that hospital infrastructure and systems of care factors could also be considered in regionalization efforts. METHODS Observed-to-expected (O/E) mortality ratio and hospital volumes were obtained between 2015 and 2018 from public reporting data. Using a resource dependence framework, we examined factors obtained from American Hospital Association, Children's Hospital Association, and hospital websites. Linear regression models were estimated with volume only, then with hospital factors, stratified by procedural complexity. Robust regression models were reestimated to assess the impact of outliers. RESULTS We found wide variation in the volume of congenital cardiac surgeries performed (89-3920) and in the surgical outcomes (O/E ratio range, 0.3-3.1). Six outlier hospitals performed few high-complexity cases with high mortality. Univariate analysis including all cases indicated that higher volume predicted lower O/E ratio (β = -0.02; SE = 0.008; P = .011). However, this effect was driven by the most complex cases. Models stratified by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category show that volume is a significant predictor only in category 5 cases (β = -1.707; SE = 0.663; P = .012). Robust univariate regression accounting for outliers found no effect of volume on O/E ratio (β = 0.005; SE = 0.002; P = .975). Elimination of outliers through robust multivariate regression decreased the volume-outcome relationship and found a modest relationship between health plan ownership and outcomes. CONCLUSIONS Systems of care factors should be considered in addition to volume in designing regionalization in CCS. Patient-level data sets will better define these factors.
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Affiliation(s)
- Petros V Anagnostopoulos
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin.
| | - Randi S Cartmill
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Jessica R Schumacher
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Joshua L Hermsen
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Malcolm M DeCamp
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
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Hsiao V, Fernandes-Taylor S, Francis DO. Concerns Over Diagnostic Accuracy of Fine-Needle Biopsy in Thyroid Nodule Diagnosis-Reply. JAMA Surg 2023; 158:889-890. [PMID: 37043230 DOI: 10.1001/jamasurg.2023.0569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Affiliation(s)
- Vivian Hsiao
- University of Wisconsin-Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin-Madison, Madison
| | - Sara Fernandes-Taylor
- University of Wisconsin-Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin-Madison, Madison
| | - David O Francis
- University of Wisconsin-Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin-Madison, Madison
- Department of Otolaryngology, University of Wisconsin-Madison, Madison
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Fernandes-Taylor S, Yang Q, Yang DY, Hanlon BM, Schumacher JR, Ingraham AM. Greater patient sharing between hospitals is associated with better outcomes for transferred emergency general surgery patients. J Trauma Acute Care Surg 2023; 94:592-598. [PMID: 36730565 PMCID: PMC10038852 DOI: 10.1097/ta.0000000000003789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Access to emergency surgical care has declined as the rural workforce has decreased. Interhospital transfers of patients are increasingly necessary, and care coordination across settings is critical to quality care. We characterize the role of repeated hospital patient sharing in outcomes of transfers for emergency general surgery (EGS) patients. METHODS A multicenter study of Wisconsin inpatient acute care hospital stays that involved transfer of EGS patients using data from the Wisconsin Hospital Association, a statewide hospital discharge census for 2016 to 2018. We hypothesized that higher proportion of patients transferred between hospitals would result in better outcomes. We examined the association between the proportion of EGS patients transferred between hospitals and patient outcomes, including in-hospital morbidity, mortality, and length of stay. Additional variables included hospital organizational characteristics and patient sociodemographic and clinical characteristics. RESULTS One hundred eighteen hospitals transferred 3,197 emergency general surgery patients over the 2-year study period; 1,131 experienced in-hospital morbidity, mortality, or extended length of stay (>75th percentile). Patients were 62 years old on average, 50% were female, and 5% were non-White. In the mixed-effects model, hospitals' proportion of patients shared was associated with lower odds of an in-hospital complication; specifically, when the proportion of patients shared between two hospitals doubled, the relative odds of any outcome changed by 0.85. CONCLUSION Our results suggest the importance of emergent relationships between hospital dyads that share patients in quality outcomes. Transfer protocols should account for established efficiencies, familiarity, and coordination between hospitals. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Sara Fernandes-Taylor
- Corresponding Author: , Wisconsin Surgical Outcomes Research Program, University of Wisconsin Department of Surgery, 600 Highland Ave, CSC, Madison, WI 53792-7375, 608-265-9159
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin-Madison
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison
| | - Bret M. Hanlon
- Departments of Biostatistics and Medical Informatics, University of Wisconsin-Madison
| | | | - Angela M. Ingraham
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin-Madison
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Fernandes-Taylor S, Zhao J, Francis DO. New Directions for Improving the Minimal Clinically Important Difference in Patient-Reported Outcome Measures for Use in Clinical Care and Research. JAMA Otolaryngol Head Neck Surg 2023; 149:276-277. [PMID: 36729483 DOI: 10.1001/jamaoto.2022.4733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison
| | - Jiwei Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison
| | - David O Francis
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison.,Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison
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Saucke MC, Alagoz E, Arroyo N, Gutierrez-Meza DE, Fernandes-Taylor S, Ingraham AM. The invisible work of transfer centre nurses: A qualitative study of strategies to overcome communication challenges. J Adv Nurs 2023. [PMID: 36843245 DOI: 10.1111/jan.15603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/12/2023] [Accepted: 02/05/2023] [Indexed: 02/28/2023]
Abstract
AIMS To explore the role of transfer centre nurses and how they facilitate communication between referring and accepting providers during calls about interhospital transfers, including their strategies to overcome communication challenges. DESIGN A qualitative interview study. METHODS We conducted semi-structured interviews with 17 transfer centre nurses at one tertiary medical centre from March to August 2019, asking participants to describe their work. We performed content analysis, applying codes based on the Relational Coordination Framework and generating emergent codes, then organized codes in higher-order concepts. We followed the COREQ checklist. RESULTS Transfer centre nurses employed multiple strategies to mitigate communication challenges. When referring providers had misconceptions about the transfer centre nurse's role and the accepting hospital's processes, the nurses informed referring providers why sharing information with them was necessary. If providers expressed frustrations or lacked understanding about their counterpart's caseload, the nurses managed providers' emotions by letting them "vent," explaining the other provider's situational context and describing the hospital's capabilities. Some nurses also mediated conflict and sought to break the tension if providers debated about the best course of action. When providers struggled to share complete and accurate information, the nurses hunted down details and 'filled in the blanks'. CONCLUSION Transfer centre nurses perform invisible work throughout the lifespan of interhospital transfers. Nurses' expert knowledge of the transfer process and hospitals' capabilities can enhance provider communication. Meanwhile, providers' lack of knowledge of the nurse's role can impede respectful and efficient transfer conversations. Interventions to support and optimize the transfer centre nurses' critical work are needed. IMPACT This study describes how transfer centre nurses facilitate communication and overcome challenges during calls about interhospital transfers. An intervention that supports this critical work has the potential to benefit nurses, providers and patients by ensuring accurate and complete information exchange in an effective, efficient manner that respects all parties. PATIENT OR PUBLIC CONTRIBUTION This study was designed to capture the perspectives and experiences of transfer centre nurses themselves through interviews. Therefore, it was not conducted using input or suggestions from the public or the patient population served by the organization.
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Affiliation(s)
- Megan C Saucke
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Esra Alagoz
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | - Angela M Ingraham
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Hsiao V, Fernandes-Taylor S, Francis DO. Questions About Study Selection, Data Extraction, and Synthesis in the Meta-analysis Comparing Total Thyroidectomy vs Hemithyroidectomy for Treatment of Papillary Thyroid Microcarcinoma-Reply. JAMA Otolaryngol Head Neck Surg 2023; 149:186-188. [PMID: 36547949 DOI: 10.1001/jamaoto.2022.4217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Vivian Hsiao
- Department of Surgery, University of Wisconsin, Madison
| | | | - David O Francis
- Department of Otolaryngology, University of Wisconsin, Madison
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10
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Hsiao V, Massoud E, Jensen C, Zhang Y, Hanlon BM, Hitchcock M, Arroyo N, Chiu AS, Fernandes-Taylor S, Alagoz O, Sundling K, LiVolsi V, Francis DO. Diagnostic Accuracy of Fine-Needle Biopsy in the Detection of Thyroid Malignancy: A Systematic Review and Meta-analysis. JAMA Surg 2022; 157:1105-1113. [PMID: 36223097 PMCID: PMC9558056 DOI: 10.1001/jamasurg.2022.4989] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/16/2022] [Indexed: 01/22/2023]
Abstract
Importance Fine-needle biopsy (FNB) became a critical part of thyroid nodule evaluation in the 1970s. It is not clear how diagnostic accuracy of FNB has changed over time. Objective To conduct a systematic review and meta-analysis estimating the accuracy of thyroid FNB for diagnosis of malignancy in adults with a newly diagnosed thyroid nodule and to characterize changes in accuracy over time. Data Sources PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched from 1975 to 2020 using search terms related to FNB accuracy in the thyroid. Study Selection English-language reports of cohort studies or randomized trials of adult patients undergoing thyroid FNB with sample size of 20 or greater and using a reference standard of surgical histopathology or clinical follow-up were included. Articles that examined only patients with known thyroid disease or focused on accuracy of novel adjuncts, such as molecular tests, were excluded. Two investigators screened each article and resolved conflicts by consensus. A total of 36 of 1023 studies met selection criteria. Data Extraction and Synthesis The MOOSE guidelines were used for data abstraction and assessing data quality and validity. Two investigators abstracted data using a standard form. Studies were grouped into epochs by median data collection year (1975 to 1990, 1990 to 2000, 2000 to 2010, and 2010 to 2020). Data were pooled using a bivariate mixed-effects model. Main Outcomes and Measures The primary outcome was accuracy of FNB for diagnosis of malignancy. Accuracy was hypothesized to increase in later time periods, a hypothesis formulated prior to data collection. Results Of 16 597 included patients, 12 974 (79.2%) were female, and the mean (SD) age was 47.3 (12.9) years. The sensitivity of FNB was 85.6% (95% CI, 79.9-89.5), the specificity was 71.4% (95% CI, 61.1-79.8), the positive likelihood ratio was 3.0 (95% CI, 2.3-4.1), and the negative likelihood ratio was 0.2 (95% CI, 0.2-0.3). The area under the receiver operating characteristic curve was 86.1%. Epoch was not significantly associated with accuracy. None of the available covariates could explain observed heterogeneity. Conclusions and Relevance Accuracy of thyroid FNB has not significantly changed over time. Important developments in technique, preparation, and interpretation may have occurred too heterogeneously to capture a consistent uptrend over time. FNB remains a reliable test for thyroid cancer diagnosis.
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Affiliation(s)
- Vivian Hsiao
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin–Madison, Madison
| | - Elian Massoud
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin–Madison, Madison
| | - Catherine Jensen
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin–Madison, Madison
| | - Yanchen Zhang
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Otolaryngology, University of Wisconsin–Madison, Madison
| | - Bret M. Hanlon
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison, Madison
| | - Mary Hitchcock
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Ebling Library for the Health Sciences, University of Wisconsin–Madison
| | - Natalia Arroyo
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin–Madison, Madison
| | - Alexander S. Chiu
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin–Madison, Madison
- Division of Endocrine Surgery, University of Wisconsin–Madison, Madison
| | - Sara Fernandes-Taylor
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin–Madison, Madison
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin–Madison, Madison
| | - Kaitlin Sundling
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Pathology, University of Wisconsin–Madison, Madison
- Wisconsin State Laboratory of Hygiene, University of Wisconsin–Madison, Madison
| | - Virginia LiVolsi
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia
| | - David O. Francis
- University of Wisconsin–Madison School of Medicine and Public Health, Madison
- Department of Surgery, University of Wisconsin–Madison, Madison
- Department of Otolaryngology, University of Wisconsin–Madison, Madison
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11
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Arroyo N, Bell KJL, Hsiao V, Fernandes-Taylor S, Alagoz O, Zhang Y, Davies L, Francis DO. Prevalence of Subclinical Papillary Thyroid Cancer by Age: Meta-analysis of Autopsy Studies. J Clin Endocrinol Metab 2022; 107:2945-2952. [PMID: 35947867 PMCID: PMC9516102 DOI: 10.1210/clinem/dgac468] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT It is not known how underlying subclinical papillary thyroid cancer (PTC) differs by age. This meta-analysis of autopsy studies investigates how subclinical PTC prevalence changes over the lifetime. METHODS We searched PubMed, Embase, and Web of Science databases from inception to May 2021 for studies that reported the prevalence of PTC found at autopsy. Two investigators extracted the number of subclinical PTCs detected in selected age groups and extent of examination. A quality assessment tool was used to assess bias. Logistic regression models with random intercepts were used to pool the age-specific subclinical PTC prevalence estimates. RESULTS Of 1773 studies screened, 16 studies with age-specific data met the inclusion criteria (n = 6286 autopsies). The pooled subclinical PTC prevalence was 12.9% (95% CI 7.8-16.8) in whole gland and 4.6% (2.5- 6.6) in partial gland examination. Age-specific prevalence estimates were ≤40 years, 11.5% (6.8-16.1); 41-60 years, 12.1% (7.6-16.5); 61-80 years, 12.7% (8-17.5); and 81+ years, 13.4% (7.9-18.9). Sex did not affect age-specific prevalence and there was no difference in prevalence between men and women in any age group. In the regression model, the OR of prevalence increasing by age group was 1.06 (0.92-1.2, P = .37). CONCLUSION This meta-analysis shows the prevalence of subclinical PTC is stable across the lifespan. There is not a higher subclinical PTC prevalence in middle age, in contrast to higher observed incidence rates in this age group. These findings offer unique insights into the prevalence of subclinical PTC and its relationship to age.
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Affiliation(s)
- Natalia Arroyo
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Katy J L Bell
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown NSW 2050, Sydney, New South Wales, Australia
| | - Vivian Hsiao
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Yichi Zhang
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Louise Davies
- The VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA
- Section of Otolaryngology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - David O Francis
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
- Division of Otolaryngology, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
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Fernandes-Taylor S, Damico-Smith C, Arroyo N, Wichmann M, Zhao J, Feurer ID, Francis DO. Multicenter Development and Validation of the Vocal Cord Paralysis Experience (CoPE), a Patient-Reported Outcome Measure for Unilateral Vocal Fold Paralysis-Specific Disability. JAMA Otolaryngol Head Neck Surg 2022; 148:756-763. [PMID: 35797026 DOI: 10.1001/jamaoto.2022.1545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Unilateral vocal fold paralysis (UVFP) is a common and life-changing complication of cancer, trauma, and an estimated 500 000 head, neck, and chest surgeries performed annually in the US, among other causes (eg, idiopathic). Consequent disabilities are profound and often permanent and can include severe voice, swallowing, and breathing dysfunction and concomitant anxiety, isolation, and fear. Physiological measures often correlate poorly with patient-reported disability. The measure described herein was designed to be a comprehensive, psychometrically sound UVFP-specific patient-reported outcome measure (PROM) for use in clinical trials or at point of care. Objective To evaluate the reliability and validity of the CoPE (vocal Cord Paralysis Experience) PROM in a nationally representative sample for both clinical and research use. Design, Setting, and Participants This survey validation study was performed at 34 tertiary care centers across the US and included English-speaking adults with unilateral vocal fold immobility confirmed via laryngoscopy. Main Outcomes and Measures Reliability (internal consistency, alternate form, and test-retest) and validity (convergent and known-group). Results In total, 613 patients (mean [SD] age, 58 [15.3] years; 394 [64.5%] women) were recruited, and 555 (92.3%) completed surveys for all time points. Internal consistency was high in the overall 22-item PROM and psychosocial, swallow, and voice subscales (Cronbach α > 0.91). Intraclass correlations for individuals between the baseline and 2-week administrations were moderate for the overall score and subscales (intraclass correlations range, 0.66-0.80). There were significant differences between the online and 2-week paper administrations for the overall score and voice and psychosocial subscales (overall scale mean: 54.4 [95% CI, 49.7-59.1] vs 48.9 [95% CI, 43.7-54.0] at 2 weeks). The confirmatory model was found to be suitably fitted based on average r2 values 0.5 or greater for subscale and overall scores. Correlations between subscales and existing PROMs (Voice-Related Quality of Life, Eating Assessment Tool, and Communication Participation Item Bank) were all greater than 0.69, and mean PROM subscale scores were significantly different across known quartiles of existing PROMs. Conclusions and Relevance The findings of this survey validation study suggest that the CoPE PROM could serve as a psychometrically sound, comprehensive measure of UVFP-attributed disability suitable for use in clinical and research settings to assess within-person changes. The results will inform a user manual to facilitate use in clinical trials comparing the effectiveness and durability of treatments including behavioral (speech therapy), temporary (eg, injection augmentation), and permanent surgical treatments for UVFP.
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Affiliation(s)
| | | | | | | | - Jiwei Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison
| | - Irene D Feurer
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David O Francis
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison.,Endoscopy and Laryngology Section Editor, JAMA Otolaryngology-Head & Neck Surgery
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13
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Hsiao V, Light TJ, Adil AA, Tao M, Chiu AS, Hitchcock M, Arroyo N, Fernandes-Taylor S, Francis DO. Complication Rates of Total Thyroidectomy vs Hemithyroidectomy for Treatment of Papillary Thyroid Microcarcinoma: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2022; 148:531-539. [PMID: 35511129 PMCID: PMC9073663 DOI: 10.1001/jamaoto.2022.0621] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Papillary thyroid microcarcinomas (PTMCs) have been associated with increased thyroid cancer incidence in recent decades. Total thyroidectomy (TT) has historically been the primary treatment, but current guidelines recommend hemithyroidectomy (HT) for select low-risk cancers; however, the risk-benefit ratio of the 2 operations is incompletely characterized. Objective To compare surgical complication rates between TT and HT for PTMC treatment. Data Sources SCOPUS, Medline via the PubMed interface, and the Cochrane Central Register of Controlled Trials (CENTRAL); through January 1, 2021, with no starting date restriction. Terms related to papillary thyroid carcinoma and its treatment were used for article retrieval. This meta-analysis used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline and was written according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) proposal. Study Selection Original investigations of adults reporting primary surgical treatment outcomes in PTMC and at least 1 complication of interest were included. Articles evaluating only secondary operations or non-open surgical approaches were excluded. Study selection, data extraction, and risk of bias assessment were performed by 2 independent reviewers and conflicts resolved by a senior reviewer. Data Extraction and Synthesis Pooled effect estimates were calculated using a random-effects inverse-variance weighting model. Main Outcomes and Measures Cancer recurrence and site, mortality (all-cause and disease-specific), vocal fold paralysis, hypoparathyroidism, and hemorrhage/hematoma. Risk of bias was assessed using the McMaster Quality Assessment Scale of Harms scale. Results In this systematic review and meta-analysis, 17 studies were analyzed and included 1416 patients undergoing HT and 2411 patients undergoing TT (HT: pooled mean [SD] age, 47.0 [10.0] years; 1139 [84.6%] were female; and TT: pooled mean [SD] age, 48.8 [10.0] years; 1671 [77.4%] were female). Patients undergoing HT had significantly lower risk of temporary vocal fold paralysis compared with patients undergoing TT (3.3% vs 4.5%) (weighted risk ratio [RR], 0.4; 95% CI, 0.2-0.7), temporary hypoparathyroidism (2.2% vs 21.3%) (weighted RR, 0.1; 95% CI, 0.0-0.4), and permanent hypoparathyroidism (0% vs 1.8%) (weighted RR, 0.2; 95% CI, 0.0-0.8). Contralateral lobe malignant neoplasm recurrence was 2.3% in the HT group, while no such events occurred in the TT group. Hemithyroidectomy was associated with a higher overall recurrence rate (3.8% vs 1.0%) (weighted RR, 2.6; 95% CI, 1.3-5.4), but there was no difference in recurrence in the thyroid bed or neck. Conclusions and Relevance The results of this systematic review and meta-analysis help characterize current knowledge of the risk-benefit ratio of HT vs TT for treatment of PTMC and provide data that may have utility for patient counseling surrounding treatment decisions.
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Affiliation(s)
- Vivian Hsiao
- Department of Surgery, University of Wisconsin-Madison, Madison
| | - Tyler J. Light
- Department of Surgery, University of Wisconsin-Madison, Madison,Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison
| | | | - Michael Tao
- Department of Otolaryngology, State University of New York, Syracuse, New York
| | - Alexander S. Chiu
- Department of Surgery, University of Wisconsin-Madison, Madison,Department of Surgery, Division of Endocrine Surgery, University of Wisconsin-Madison, Madison
| | - Mary Hitchcock
- Ebling Library for the Health Sciences, University of Wisconsin-Madison, Madison
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin-Madison, Madison,Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison
| | - Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison,Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison
| | - David O. Francis
- Department of Surgery, University of Wisconsin-Madison, Madison,Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison,Division of Otolaryngology, University of Wisconsin-Madison, Madison
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Hsiao V, Arroyo N, Fernandes-Taylor S, Chiu AS, Davies L, Francis DO. Letter to the Editor: Sensitivity of Palpation for Detection of Thyroid Nodules with Attention to Size. Thyroid 2022; 32:599-601. [PMID: 35216527 PMCID: PMC9145258 DOI: 10.1089/thy.2021.0692] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Vivian Hsiao
- Department of Surgery, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin—Madison, Madison, Wisconsin, USA
- Wisconsin Surgical Outcomes Research, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin—Madison, Madison, Wisconsin, USA
- Wisconsin Surgical Outcomes Research, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Alexander S. Chiu
- Department of Surgery, University of Wisconsin—Madison, Madison, Wisconsin, USA
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Louise Davies
- Section of Otolaryngology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- The VA Outcomes Group, US Department of Veterans Affairs Medical Center, Windsor County, Vermont, USA
| | - David O. Francis
- Department of Surgery, University of Wisconsin—Madison, Madison, Wisconsin, USA
- Wisconsin Surgical Outcomes Research, University of Wisconsin—Madison, Madison, Wisconsin, USA
- Division of Otolaryngology, Department of Surgery, University of Wisconsin—Madison, Madison, Wisconsin, USA
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Ingraham A, Schumacher J, Fernandes-Taylor S, Yang DY, Godat L, Smith A, Barbosa R, Cribari C, Salim A, Schroeppel T, Staudenmayer K, Crandall M, Utter G. General surgeon involvement in the care of patients designated with an American Association for the Surgery of Trauma-endorsed ICD-10-CM emergency general surgery diagnosis code in Wisconsin. J Trauma Acute Care Surg 2022; 92:117-125. [PMID: 34446657 PMCID: PMC8692334 DOI: 10.1097/ta.0000000000003387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The current national burden of emergency general surgery (EGS) illnesses and the extent of surgeon involvement in the care of these patients remain largely unknown. To inform needs assessments, research, and education, we sought to: (1) translate previously developed International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes representing EGS conditions to ICD 10th Revision, CM (ICD-10-CM) codes and (2) determine the national burden of and assess surgeon involvement across EGS conditions. METHODS We converted ICD-9-CM codes to candidate ICD-10-CM codes using General Equivalence Mappings then iteratively refined the code list. We used National Inpatient Sample 2016 to 2017 data to develop a national estimate of the burden of EGS disease. To evaluate surgeon involvement, using Wisconsin Hospital Association discharge data (January 1, 2016 to June 30, 2018), we selected adult urgent/emergent encounters with an EGS condition as the principal diagnosis. Surgeon involvement was defined as a surgeon being either the attending provider or procedural physician. RESULTS Four hundred and eighty-five ICD-9-CM codes mapped to 1,696 ICD-10-CM codes. The final list contained 985 ICD-10-CM codes. Nationally, there were 2,977,843 adult patient encounters with an ICD-10-CM EGS diagnosis. Of 94,903 EGS patients in the Wisconsin Hospital Association data set, most encounters were inpatient as compared with observation (75,878 [80.0%] vs. 19,025 [20.0%]). There were 57,780 patients (60.9%) that underwent any procedure. Among all Wisconsin EGS patients, most had no surgeon involvement (64.9% [n = 61,616]). Of the seven most common EGS diagnoses, surgeon involvement was highest for appendicitis (96.0%) and biliary tract disease (77.1%). For the other five most common conditions (skin/soft tissue infections, gastrointestinal hemorrhage, intestinal obstruction/ileus, pancreatitis, diverticular disease), surgeons were involved in roughly 20% of patient care episodes. CONCLUSION Surgeon involvement for EGS conditions ranges from highly likely (appendicitis) to relatively unlikely (skin/soft tissue infections). The wide range in surgeon involvement underscores the importance of multidisciplinary collaboration in the care of EGS patients. LEVEL OF EVIDENCE Prognostic/epidemiological, Level III.
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Affiliation(s)
- Angela Ingraham
- From the Department of Surgery (A.I., J.S., S.F.-T., D.-Y.Y.), University of Wisconsin-Madison, Madison, Wisconsin; Department of Surgery (L.G., A.S.), University of California-San Diego, San Diego, California; Department of Surgery (R.B.), Legacy Health, Portland, Oregon; Department of Surgery (C.C.), University of Colorado Health, Loveland, Colorado; Department of Surgery (A.S.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (T.S.), University of Colorado Health, Colorado Springs, Colorado; Department of Surgery (K.S.), Stanford University, Palo Alto, California; Department of Surgery (M.C.), University of Florida, Jacksonville, Florida; and Department of Surgery (G.U.), University of California-Davis, Sacramento, California
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16
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Powers B, Smith CD, Arroyo N, Francis DO, Fernandes-Taylor S. How Do Academic Otolaryngologists Decide to Implement New Procedures Into Practice? Otolaryngol Head Neck Surg 2021; 167:253-261. [PMID: 34546818 DOI: 10.1177/01945998211047434] [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: 11/16/2022]
Abstract
OBJECTIVE To identify barriers and facilitators to adoption of a new surgical procedure via an implementation science framework to characterize associated socioemotional, clinical, and decision-making processes. STUDY DESIGN Qualitative study with a semistructured interview approach. SETTING Large tertiary care referral center. METHODS Academic otolaryngologists with at least 2 years of practice were identified and interviewed. Transcripts were thematically coded and separated into steps in the clinical pathway. Synthesis of major themes characterized facilitators and barriers to uptake of a new surgical technique. RESULTS Of 22 otolaryngologists, 19 were interviewed (85% male). They had a median 18 years of practice (interquartile range, 7.8-26.3), and 65% were subspecialty trained. In the decision to implement a new procedure, improving patient outcomes and addressing unmet clinical needs facilitated adoption, whereas costs and adopting profit-driven technologies without improved outcomes were barriers. In patient consults, establishing trust facilitated implementation of new techniques; barriers included participants' hesitation to communicate about the unknowns of a new procedure. Intraoperatively, little change to existing workflow or improved efficiency facilitated adoption, while a substantial learning curve for the new procedure was a barrier. Achieving favorable outcomes and patient satisfaction sustained implementation of new procedures. Too few referrals or indications for the new procedure hindered implementation. CONCLUSION Our study demonstrates that innovation in otolaryngology is often an individual iterative process that providers pursue to improve patients' outcomes. Although models for the oversight of surgical innovation emphasize the need for evidence, obtaining sufficient numbers of providers and patients to generate evidence remains a challenge in specialty surgical practice.
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Affiliation(s)
- Bethany Powers
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Cara Damico Smith
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David O Francis
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Arroyo NA, Gessert T, Hitchcock M, Tao M, Smith CD, Greenberg C, Fernandes-Taylor S, Francis DO. What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice. Ann Surg 2021; 273:474-482. [PMID: 33055590 PMCID: PMC10777662 DOI: 10.1097/sla.0000000000004355] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations. BACKGROUND In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework. METHODS A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model. RESULTS Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement). CONCLUSIONS Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.
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Affiliation(s)
- Natalia A. Arroyo
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Thomas Gessert
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mary Hitchcock
- Ebling Library for the Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael Tao
- Department of Otolaryngology, The State University of New York, Syracuse, New York
| | - Cara Damico Smith
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Caprice Greenberg
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Sara Fernandes-Taylor
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - David O. Francis
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
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Gelbard A, Anderson C, Berry LD, Amin MR, Benninger MS, Blumin JH, Bock JM, Bryson PC, Castellanos PF, Chen SC, Clary MS, Cohen SM, Crawley BK, Dailey SH, Daniero JJ, de Alarcon A, Donovan DT, Edell ES, Ekbom DC, Fernandes-Taylor S, Fink DS, Franco RA, Garrett CG, Guardiani EA, Hillel AT, Hoffman HT, Hogikyan ND, Howell RJ, Huang LC, Hussain LK, Johns MM, Kasperbauer JL, Khosla SM, Kinnard C, Kupfer RA, Langerman AJ, Lentz RJ, Lorenz RR, Lott DG, Lowery AS, Makani SS, Maldonado F, Mannion K, Matrka L, McWhorter AJ, Merati AL, Mori MC, Netterville JL, O'Dell K, Ongkasuwan J, Postma GN, Reder LS, Rohde SL, Richardson BE, Rickman OB, Rosen CA, Rutter MJ, Sandhu GS, Schindler JS, Schneider GT, Shah RN, Sikora AG, Sinard RJ, Smith ME, Smith LJ, Soliman AMS, Sveinsdóttir S, Van Daele DJ, Veivers D, Verma SP, Weinberger PM, Weissbrod PA, Wootten CT, Shyr Y, Francis DO. Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis. JAMA Otolaryngol Head Neck Surg 2021; 146:20-29. [PMID: 31670805 PMCID: PMC6824232 DOI: 10.1001/jamaoto.2019.3022] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Question What are the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS)? Findings In this cohort study of 810 patients with iSGS who underwent 1 of the 3 most common surgical treatments, 23% of patients underwent a recurrent surgical procedure during the 3-year study period, but recurrence differed by modality (cricotracheal resection, 1%; endoscopic resection with adjuvant medical therapy, 12%; and endoscopic dilation, 28%). Among successfully treated patients, those who underwent cricotracheal resection reported the highest quality of life but the greatest perioperative risk and worst long-term voice outcomes. Meaning These results show the feasibility of integrating an engaged rare disease community with a network of surgeons to facilitate rapid and nuanced treatment comparisons; findings may help inform treatment decision-making in iSGS. Importance Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score–matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.
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Affiliation(s)
- Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Catherine Anderson
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynne D Berry
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Milan R Amin
- New York University Voice Center, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York
| | - Michael S Benninger
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joel H Blumin
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - Jonathan M Bock
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - Paul C Bryson
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul F Castellanos
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Sheau-Chiann Chen
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Matthew S Clary
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Denver
| | - Seth M Cohen
- Duke Voice Care Center, Division of Otolaryngology-Head and Neck Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brianna K Crawley
- Department of Otolaryngology-Head & Neck Surgery, Loma Linda University Health, Loma Linda, California
| | - Seth H Dailey
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison
| | - James J Daniero
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
| | - Alessandro de Alarcon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Donald T Donovan
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dale C Ekbom
- Department of Otolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | | | - Daniel S Fink
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Denver
| | - Ramon A Franco
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
| | - C Gaelyn Garrett
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth A Guardiani
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institution, Baltimore, Maryland
| | - Henry T Hoffman
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - Norman D Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor
| | - Rebecca J Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Li-Ching Huang
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Lena K Hussain
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Michael M Johns
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles
| | - Jan L Kasperbauer
- Department of Otolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Sid M Khosla
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Cheryl Kinnard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robbi A Kupfer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor
| | - Alexander J Langerman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert J Lentz
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert R Lorenz
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - David G Lott
- Department of Otorhinolaryngology, Mayo Clinic Scottsdale, Scottsdale, Arizona
| | - Anne S Lowery
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samir S Makani
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Laura Matrka
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Medical Center, Columbus
| | - Andrew J McWhorter
- Department of Otolaryngology, Louisiana State University Health Sciences Center-New Orleans, New Orleans
| | - Albert L Merati
- Department of Otolaryngology-Head & Neck Surgery, University of Washington Medical Center, Seattle
| | - Matthew C Mori
- Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York
| | - James L Netterville
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karla O'Dell
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles
| | - Julina Ongkasuwan
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Gregory N Postma
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta
| | - Lindsay S Reder
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Otis B Rickman
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco
| | - Michael J Rutter
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Guri S Sandhu
- National Centre for Airway Reconstruction, Charing Cross Hospital, Imperial College Healthcare National Health System Trust, London, United Kingdom
| | - Joshua S Schindler
- Department of Otolaryngology-Head & Neck Surgery, Northwest Clinic for Voice and Swallowing, Oregon Health and Science University, Portland
| | - G Todd Schneider
- Department of Otolaryngology, University of Rochester, Rochester, New York
| | - Rupali N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Andrew G Sikora
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Robert J Sinard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marshall E Smith
- Division of Otolaryngology-Head & Neck Surgery, The University of Utah, Salt Lake City
| | - Libby J Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head and Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | | | - Douglas J Van Daele
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - David Veivers
- Department of Otolaryngology-Head and Neck Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Sunil P Verma
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine
| | - Paul M Weinberger
- Departments of Otolaryngology, Molecular and Cellular Physiology, Feist-Weiller Cancer Center, Louisiana State University, Shreveport
| | - Philip A Weissbrod
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Christopher T Wootten
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yu Shyr
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - David O Francis
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
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Fernandes-Taylor S, Yang DY, Schumacher J, Ljumani F, Fertel BS, Ingraham A. Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments. Am J Emerg Med 2020; 40:83-88. [PMID: 33360394 DOI: 10.1016/j.ajem.2020.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States. METHOD We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital. RESULTS Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals. CONCLUSION Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.
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Affiliation(s)
- Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Jessica Schumacher
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Fiona Ljumani
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Baruch S Fertel
- Emergency Services Institute & Enterprise Quality and Safety Cleveland Clinic, Cleveland OH, United States of America
| | - Angela Ingraham
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
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Kohler JE, Cartmill RS, Yang DY, Fernandes-Taylor S, Greenberg CC. Age-Dependent Costs and Complications in Pediatric Umbilical Hernia Repair. J Pediatr 2020; 226:236-239. [PMID: 32629008 DOI: 10.1016/j.jpeds.2020.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/08/2020] [Accepted: 07/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To characterize regional variation in the age of patients undergoing umbilical hernia repair to determine costs and subsequent care. STUDY DESIGN We performed a cross-sectional descriptive study using a large convenience sample of US employer-based insurance claims from July 2012 to December 2015. We identified children younger than 18 years of age undergoing uncomplicated (not strangulated, incarcerated, or gangrenous) umbilical hernia repair as an isolated procedure (International Classification of Diseases, Ninth Revision procedure codes 53.41, 53.42, 53.43, or 53.49, International Classification of Diseases, Tenth Revision procedure code 0WQF0ZZ, or Current Procedural Terminology procedure codes 49580 or 49585). RESULTS In all, 5212 children met criteria for inclusion. Children younger than age 2 years accounted for 9.7% of repairs, with significant variation by census region (6% to 14%, P < .001). Total payments for surgery varied by age; children younger than 2 years averaged $8219 and payments for older children were $6137. Postoperative admissions occurred at a rate of 73.1 per 1000 for children younger than age 2 years and 7.43 for older children; emergency department visits were 41.5 per 1000 for children younger than age 2 years vs 15.9 for older children (P < .001). CONCLUSIONS Umbilical hernias continue to be repaired at early ages with large regional variation. Umbilical hernia repair younger than age 2 years is associated with greater costs and greater frequency of postoperative hospitalization and emergency department visits.
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Affiliation(s)
- Jonathan E Kohler
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Randi S Cartmill
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
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Ingraham A, Saucke M, Fernandes-Taylor S, Ljumani F, Alagoz E. Working Behind the Scenes: How Transfer Center Nurses Facilitate Interactions and Communication between Providers Regarding Transfers of Emergency General Surgery Patients. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Philip JL, Yang DY, Wang X, Fernandes-Taylor S, Hanlon BM, Schumacher J, Saucke MC, Havlena J, Santry HP, Ingraham AM. Effect of Transfer Status on Outcomes of Emergency General Surgery Patients. Surgery 2020; 168:280-286. [PMID: 32456785 DOI: 10.1016/j.surg.2020.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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] [Received: 11/01/2019] [Revised: 01/02/2020] [Accepted: 01/10/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database. METHODS We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design. RESULTS We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay. CONCLUSIONS EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.
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Affiliation(s)
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Xing Wang
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Bret M Hanlon
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Megan C Saucke
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Heena P Santry
- Department of Surgery, Ohio State University, Columbus, OH
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Fisher AV, Hanlon B, Fernandes-Taylor S, Schumacher JR, Lawson EH, Ronnekleiv-Kelly SM, Minter RM, Weber SM, Abbott DE. Natural history and cost analysis of surgical bypass versus endoscopic stenting for the palliative management of malignant gastric outlet obstruction. HPB (Oxford) 2020; 22:529-536. [PMID: 31519358 DOI: 10.1016/j.hpb.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/13/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes. METHODS Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured. RESULTS A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028). CONCLUSION In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention.
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Affiliation(s)
- Alexander V Fisher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Bret Hanlon
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Sara Fernandes-Taylor
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Jessica R Schumacher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Elise H Lawson
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Sean M Ronnekleiv-Kelly
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Rebecca M Minter
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Sharon M Weber
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Daniel E Abbott
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States.
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Fernandes-Taylor S, Damico Smith C, Arroyo N, Bonnet K, Schlundt D, Wichmann M, Feurer I, Francis DO. Study protocol to develop a patient-reported outcome measuring disability associated with unilateral vocal fold paralysis: a mixed-methods approach with the CoPE collaborative. BMJ Open 2019; 9:e030151. [PMID: 31666263 PMCID: PMC6830693 DOI: 10.1136/bmjopen-2019-030151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Patient-reported outcome (PRO) measures are increasingly developed with multisite, representative patient populations so that they can serve as a primary endpoint in clinical trials and longitudinal studies. Creating multisite infrastructure during PRO measure development can facilitate future comparative effectiveness trials. We describe our protocol to simultaneously develop a PRO measure and create a collaborative of tertiary care centres to address the needs of patients with unilateral vocal fold paralysis (UVFP). We describe the stakeholder engagement, information technology and regulatory foundations for PRO measure development and how the process enables plans for multisite trials comparing treatments for this largely iatrogenic condition. METHODS AND ANALYSIS The study has three phases: systematic review, measure development and measure validation. Systematic reviews and qualitative interviews (n=75) will inform the development of a conceptual framework. Qualitative interviews with patients with UVFP will characterise the lived experience of the condition. Candidate PRO measure items will be derived verbatim from patient interviews and refined using cognitive interviews and expert input. The PRO measure will be administered to a large, multisite cohort of adult patients with UVFP via the CoPE (vocal Cord Paralysis Experience) Collaborative. We will establish CoPE to facilitate measure development and to create preliminary infrastructure for future trials, including online data capture, stakeholder engagement, and the identification of barriers and facilitators to participation. Classical test theory psychometrics and grounded theory characterise our approach, and validation includes assessment of latent structure, reliability and validity. ETHICS AND DISSEMINATION Our study is approved by the University of Wisconsin Health Sciences Institutional Review Board. Findings from this project will be published in open-access journals and presented at international conferences. Subsequent use of the PRO measure will include comparative effectiveness trials of treatments for UVFP at CoPE Collaborative sites.
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Affiliation(s)
| | - Cara Damico Smith
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Margarete Wichmann
- University of Wisconsin Survey Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Irene Feurer
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - David O Francis
- Division of Otolaryngology, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Vande Walle K, Yang DYY, Stankowski-Drengler TJ, Livingston-Rosanoff D, Fernandes-Taylor S, Schumacher JR, Wilke LG, Greenberg CC, Neuman HB. Breast Cancer Found Incidentally After Reduction Mammaplasty in Young Insured Women. Ann Surg Oncol 2019; 26:4310-4316. [PMID: 31538286 DOI: 10.1245/s10434-019-07726-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Reduction mammaplasty is a common operation performed for healthy women. The estimated incidence of breast cancer diagnosed at the time of reduction mammaplasty varies from 0.06 to 4.5%, and information on the care of these patients is limited. This study aimed to determine the incidence of breast cancer identified incidentally during reduction mammaplasty and to characterize preoperative imaging. METHODS Women 18 years of age or older who underwent reduction mammaplasty from 2013 to 2015 were identified from the Truven Health MarketScan® Research Databases. Patients with prior breast cancer were excluded. Descriptive statistics were calculated for patient characteristics, incidental breast cancer, preoperative breast imaging, and postoperative treatment. RESULTS Reduction mammaplasty was performed for 18,969 women with a mean age of 42.5 years. Of these patients, 186 (0.98%) were incidentally found to have breast cancer, with 134 (0.71%) having invasive breast cancer and 52 (0.27%) having carcinoma in situ. The patients with incidentally found cancer were older than the patients without cancer (50.8 vs. 42.5 years; p < 0.001). Overall, 58.2% of the patients had undergone mammography before reduction mammoplasty. The rates were higher (> 80%) for the patients older than 40 years. Preoperative mammography was performed for 76.3% of those with a diagnosis of breast cancer at time of reduction mammoplasty. CONCLUSIONS Breast cancer diagnosed incidentally at the time of reduction mammaplasty is uncommon and often radiographically occult. The majority of women older than 50 years appropriately received preoperative mammography. These data can be used to manage patient expectations about the potential for the incidental diagnosis of breast cancer at reduction mammaplasty, even with a negative preoperative mammography.
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Affiliation(s)
- Kara Vande Walle
- Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Dou-Yan Y Yang
- Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA
| | | | | | - Sara Fernandes-Taylor
- Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Jessica R Schumacher
- Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Lee G Wilke
- Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Caprice C Greenberg
- Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Heather B Neuman
- Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA.
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Zens TJ, Cartmill R, Muldowney BL, Fernandes-Taylor S, Nichol P, Kohler JE. Practice Variation in Umbilical Hernia Repair Demonstrates a Need for Best Practice Guidelines. J Pediatr 2019; 206:172-177. [PMID: 30448274 PMCID: PMC6389373 DOI: 10.1016/j.jpeds.2018.10.049] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/08/2018] [Accepted: 10/24/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate and better understand variations in practice patterns, we analyzed ambulatory surgery claims data from 3 demographically diverse states to assess the relationship between age at umbilical hernia repair and patient, hospital, and geographic characteristics. STUDY DESIGN We performed a cross-sectional descriptive study of uncomplicated hernia repairs performed as a single procedure in 2012-2014, using the State Ambulatory Surgery and Services Database for Wisconsin, New York, and Florida. Age and demographic characteristics of umbilical hernia repair patients are described. RESULTS The State Ambulatory Surgery and Services Database analysis included 6551 patients. Across 3 states, 8.2% of hernia repairs were performed in children <2 years, 18.7% in children age 2-3 years, and 73.0% in children age ≥4 years, but there was significant variability (P < .001) in practice patterns by state. In regression analysis, race, Medicaid insurance and rural residence were predictive of early repair, with African American patients less likely to have a repair before age 2 (OR 0.62, P = .046) and rural children (OR 1.53, P = .009) and Medicaid patients (OR 2.01, P < .001) more likely to do so. State of residence predicted early repair even when holding these variables constant. CONCLUSIONS The age of pediatric umbilical hernia repair varies widely. As hernias may resolve over time and can be safely monitored with watchful waiting, formal guidelines are needed to support delayed repair and prevent unnecessary operations.
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Affiliation(s)
- Tiffany J Zens
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Randi Cartmill
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Bridget L Muldowney
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Peter Nichol
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Philip JL, Saucke MC, Schumacher JR, Fernandes-Taylor S, Havlena J, Greenberg CC, Ingraham AM. Characteristics and Timing of Interhospital Transfers of Emergency General Surgery Patients. J Surg Res 2019; 233:8-19. [PMID: 30502291 DOI: 10.1016/j.jss.2018.06.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/01/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
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Fisher AV, Fernandes-Taylor S, Schumacher JR, Havlena JA, Wang X, Lawson EH, Ronnekleiv-Kelly SM, Winslow ER, Weber SM, Abbott DE. Analysis of 90-day cost for open versus minimally invasive distal pancreatectomy. HPB (Oxford) 2019; 21:60-66. [PMID: 30076011 DOI: 10.1016/j.hpb.2018.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 01/23/2018] [Revised: 04/19/2018] [Accepted: 07/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear. METHODS Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments. RESULTS 693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p<0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p<0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p<0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000. CONCLUSION MIDP is associated with >$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP.
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Affiliation(s)
- Alexander V Fisher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Sara Fernandes-Taylor
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Jessica R Schumacher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Jeffrey A Havlena
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Xing Wang
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Elise H Lawson
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Sean M Ronnekleiv-Kelly
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Emily R Winslow
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Sharon M Weber
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Daniel E Abbott
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States.
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Fisher AV, Campbell-Flohr SA, Sell L, Osterhaus E, Acher AW, Leahy-Gross K, Brenny-Fitzpatrick M, Kind AJH, Carayon P, Abbott DE, Winslow ER, Greenberg CC, Fernandes-Taylor S, Weber SM. Adaptation and Implementation of a Transitional Care Protocol for Patients Undergoing Complex Abdominal Surgery. Jt Comm J Qual Patient Saf 2018; 44:741-750. [PMID: 30097384 DOI: 10.1016/j.jcjq.2018.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery. APPROACH The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC). Adaptation was accomplished using a modification of the Replicating Effective Programs (REP) model, which has four phases: (1) preconditions, (2) preimplementation, (3) implementation, and (4) maintenance and evolution. A random sample of five patients each month was selected to complete a phone survey regarding patient satisfaction. Preimplementation planning allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. The adapted protocol specifically addressed surgical issues such as nutrition, fever, ostomy output, dehydration, drain character/output, and wound appearance. After protocol launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions. OUTCOMES Survey responders reported 100% overall satisfaction with the transitional care program. KEY INSIGHTS The adaptable nature of sC-TraC may allow for low-resource hospitals, such as rural or inner-city medical centers, to use the methodology provided in this study for implementation of local phone-based transitional care protocols. In addition, as the C-TraC program has begun to disseminate nationally across US Department of Veterans Affairs (VA) hospitals and rural health settings, sC-TraC may be implemented using the existing transitional care infrastructure in place at these hospitals.
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DuGoff EH, Fernandes-Taylor S, Weissman GE, Huntley JH, Pollack CE. A scoping review of patient-sharing network studies using administrative data. Transl Behav Med 2018; 8:598-625. [PMID: 30016521 PMCID: PMC6086089 DOI: 10.1093/tbm/ibx015] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
There is a robust literature examining social networks and health, which draws on the network traditions in sociology and statistics. However, the application of social network approaches to understand the organization of health care is less well understood. The objective of this work was to examine approaches to conceptualizing, measuring, and analyzing provider patient-sharing networks. These networks are constructed using administrative data in which pairs of physicians are considered connected if they both deliver care to the same patient. A scoping review of English language peer-reviewed articles in PubMed and Embase was conducted from inception to June 2017. Two reviewers evaluated article eligibility based upon inclusion criteria and abstracted relevant data into a database. The literature search identified 10,855 titles, of which 63 full-text articles were examined. Nine additional papers identified by reviewing article references and authors were examined. Of the 49 papers that met criteria for study inclusion, 39 used a cross-sectional study design, 6 used a cohort design, and 4 were longitudinal. We found that studies most commonly theorized that networks reflected aspects of collaboration or coordination. Less commonly, studies drew on the strength of weak ties or diffusion of innovation frameworks. A total of 180 social network measures were used to describe the networks of individual providers, provider pairs and triads, the network as a whole, and patients. The literature on patient-sharing relationships between providers is marked by a diversity of measures and approaches. We highlight key considerations in network identification including the definition of network ties, setting geographic boundaries, and identifying clusters of providers, and discuss gaps for future study.
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Affiliation(s)
- Eva H DuGoff
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, USA
| | - Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Gary E Weissman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Hospital of the University of Pennsylvania, Pulmonary, Allergy, and Critical Care Division, Philadelphia, PA, USA
| | - Joseph H Huntley
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig Evan Pollack
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Gunter RL, Fernandes-Taylor S, Rahman S, Awoyinka L, Bennett KM, Weber SM, Greenberg CC, Kent KC. Feasibility of an Image-Based Mobile Health Protocol for Postoperative Wound Monitoring. J Am Coll Surg 2018; 226:277-286. [PMID: 29366555 DOI: 10.1016/j.jamcollsurg.2017.12.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Surgical site infection (SSI) is the most common nosocomial infection and the leading cause of readmission among surgical patients. Many SSIs develop in the postdischarge period and are inadequately recognized by patients. To address this, we developed a mobile health protocol of remote wound monitoring using smartphone technology. The current study aims to establish its feasibility among patients and providers. STUDY DESIGN We enrolled vascular surgery patients during their inpatient stay. They were trained to use our mobile health application, which allowed them to transmit digital images of their surgical wound and answer a survey about their recovery. After hospital discharge, participants completed the application daily for 2 weeks. Providers on the inpatient team reviewed submissions daily and contacted patients for concerning findings. RESULTS Forty participants were enrolled. Forty-five percent of participants submitted data every day for 2 weeks, with an overall submission rate of 90.2%. Submissions were reviewed within an average of 9.7 hours of submission, with 91.9% of submissions reviewed within 24 hours. We detected 7 wound complications with 1 false negative. Participant and provider satisfaction was universally high. CONCLUSIONS Patients and their caregivers are willing to participate in a mobile health program aimed at remote monitoring of postoperative recovery, and they are able to complete it with a high level of fidelity and satisfaction. Preliminary results indicate the ability to detect and intervene on wound complications.
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Affiliation(s)
- Rebecca L Gunter
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI.
| | - Sara Fernandes-Taylor
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI
| | - Shahrose Rahman
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI
| | - Lola Awoyinka
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI
| | - Kyla M Bennett
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI
| | - Sharon M Weber
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI
| | - Caprice C Greenberg
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI
| | - K Craig Kent
- Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI
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Lawson EH, Schumacher JR, Yang DY, Havlena JA, Fernandes-Taylor S, Greenberg CC. Underuse of Post-Discharge Venous Thromboembolism Prophylaxis for Patients Undergoing Major Surgery for Colorectal Cancer. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Fernandes-Taylor S, Berg S, Gunter R, Bennett K, Smith MA, Rathouz PJ, Greenberg CC, Kent KC. Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery. J Surg Res 2017; 221:196-203. [PMID: 29229128 DOI: 10.1016/j.jss.2017.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/26/2017] [Accepted: 08/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Readmission within 30 d of an acute hospital stay is frequent, costly, and increasingly subject to penalties. Early readmission is most common after vascular surgery; these patients are often discharged to skilled nursing facilities (SNFs), making postacute care an essential partner in reducing readmissions. We characterize 30-day readmissions among vascular surgery patients discharged to SNF to provide evidence for this understudied segment of readmission after specialty surgery. METHODS We utilize the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries to study 30-day readmission or death after discharge to SNF following abdominal aortic aneurysm repair or lower extremity revascularization from 2005-2009. Descriptive statistics and logistic regression with Least Adaptive Shrinkage and Selection Operator were used for analysis. RESULTS Two thousand one hundred ninety-seven patients underwent an abdominal aortic aneurysm procedure or lower extremity revascularization at 686 hospitals and discharged to 1714 SNFs. Eight hundred (36%) were readmitted or had died at 30 d. In adjusted analysis, predictors of readmission or death at 30 d included SNF for-profit status (OR [odds ratio] = 1.2; P = 0.032), number of hospitalizations in the previous year (OR = 1.06; P = 0.011), number of comorbidities (OR = 1.06; P = 0.004), emergent procedure (OR = 1.69; P < 0.001), renal complication (OR = 1.38; P = 0.003), respiratory complication (OR = 1.45; P < 0.001), thromboembolic complication (OR = 1.57; P = 0.019), and wound complication (OR = 0.70; P = 0.017). CONCLUSIONS Patients discharged to SNF following vascular surgery have exceptionally high rates of readmission or death at 30 d. Many factors predicting readmission or death potentially modify decision-making around discharge, making early detection, discharge planning, and matching patient needs to SNF capabilities essential to improving outcomes.
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Affiliation(s)
- Sara Fernandes-Taylor
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Stephen Berg
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rebecca Gunter
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kyla Bennett
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maureen A Smith
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - K Craig Kent
- The Ohio State University College of Medicine, Columbus, Ohio
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Acher AW, Campbell-Flohr SA, Brenny-Fitzpatrick M, Leahy-Gross KM, Fernandes-Taylor S, Fisher AV, Agarwal S, Kind AJ, Greenberg CC, Carayon P, Weber SM. Improving Patient-Centered Transitional Care after Complex Abdominal Surgery. J Am Coll Surg 2017; 225:259-265. [PMID: 28549765 DOI: 10.1016/j.jamcollsurg.2017.04.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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] [Received: 02/27/2017] [Revised: 04/06/2017] [Accepted: 04/06/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol. STUDY DESIGN The intervention includes in-person enrollment of patients. Follow-up protocolized phone calls by specially trained surgical C-TraC nurses addressed medication management, clinic appointments, operation-specific concerns, and identification of red-flag symptoms. Enrollment criteria included pancreatectomy, gastrectomy, operative small bowel obstruction or perforation, ostomy, discharge with a drain, in-hospital complication, and clinician discretion. Engaged patients participated in the first phone call, which was within 48 to 72 hours of discharge and continued every 3 to 4 days. Patients completed the program once they and surgical C-TraC nurse agreed that no additional follow-up was needed or the patient was readmitted. RESULTS Two hundred and twelve patients were enrolled, October 2015 through April 2016, with a mean age of 56 years (range 19 to 89 years); 33% of patients were 65 years or older. Surgery sites included colon (46%), small bowel (16%), pancreas (12%), multivisceral (9%), liver (4.5%), retroperitoneum/soft tissue (4.5%), gastric (4%), biliary (2%), and appendix (1.5%). Refusal rate was 1% and engagement was 95%. At initial call, 47% of patients had at least 1 medication discrepancy (range 0 to 6). Mean number of calls from provider to patient was 3.2 (range 0 to 20, median 3). CONCLUSIONS A phone-based transitional care protocol for surgical patients is feasible, with <1% refusals and 95% engagement. Medication management is a prominent issue. Future studies are needed to assess the impact of surgical C-TraC on post-discharge healthcare use.
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Affiliation(s)
- Alexandra W Acher
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Stephanie A Campbell-Flohr
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Maria Brenny-Fitzpatrick
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kristine M Leahy-Gross
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alexander V Fisher
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Suresh Agarwal
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Amy J Kind
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S Middleton Memorial Veterans Hospital, Shorewood Hills, WI
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Center for Quality and Productivity Improvement, College of Engineering, University of Wisconsin, Madison, WI; Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin, Madison, WI
| | - Pascale Carayon
- Center for Quality and Productivity Improvement, College of Engineering, University of Wisconsin, Madison, WI; Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin, Madison, WI
| | - Sharon M Weber
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S Middleton Memorial Veterans Hospital, Shorewood Hills, WI.
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Fernandes-Taylor S, Gunter RL, Bennett KM, Awoyinka L, Rahman S, Greenberg CC, Kent KC. Feasibility of Implementing a Patient-Centered Postoperative Wound Monitoring Program Using Smartphone Images: A Pilot Protocol. JMIR Res Protoc 2017; 6:e26. [PMID: 28228369 PMCID: PMC5343214 DOI: 10.2196/resprot.6819] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/01/2016] [Accepted: 02/08/2017] [Indexed: 12/21/2022] Open
Abstract
Background Surgical site infections (SSI) represent a significant public health problem as the most common nosocomial infection and a leading cause of unplanned hospital readmissions among surgical patients. Many develop following hospital discharge and often go unrecognized by patients. Telemedicine offers the opportunity to leverage the mobile technology to remotely monitor wound recovery in the transitional period between hospital discharge and routine clinic follow-up. However, many existing telemedicine platforms are episodic, replacing routine follow-up, rather than equipped for continued monitoring; they include only low-risk patient populations and those who already have access to and comfort with the necessary technology; and transmit no visual information. Objective Drawing upon the Coleman model for care transitions and the Proctor model for implementation, we propose a protocol of postoperative wound monitoring using smartphone digital images. In this study, we will establish the feasibility of such a program, both for patients and for the clinical care team. Methods We will recruit 40 patients or patient/caregiver pairs from our inpatient vascular surgery service. Eligible patients will be English-speaking, 18 years of age or older, and have an incision at least 3 cm in length. Participants will receive a training session, during which they will learn to use the device and the wound monitoring smartphone app. Following hospital discharge, they will submit digital images of their wound and responses to a survey about their recovery for 14 days. Experienced health care providers on the vascular surgery inpatient service will review transmitted data daily and contact patients for any concerning findings. Results Primary outcomes will include participant adherence to the protocol, time required for providers to review submissions, time from submission to provider review, and participant satisfaction. Secondary outcomes will include SSI detection and hospital readmission. Conclusions Health systems are increasingly dedicating efforts to transitional care improvement programs. This feasibility trial will confirm whether patients and their caregivers can learn to use a postdischarge wound monitoring smartphone app and will assess patient and provider satisfaction. This protocol will provide preliminary evidence for a shift in the delivery of postdischarge care in a patient-centered and cost-effective manner. Trial Registration Clinicaltrials.gov NCT02735525; https://clinicaltrials.gov/ct2/show/NCT02735525 (Archived by WebCite at http://www.webcitation.org/6oIvN4Mab)
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Affiliation(s)
- Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States
| | - Rebecca L Gunter
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States
| | - Kyla M Bennett
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States
| | - Lola Awoyinka
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States
| | - Shahrose Rahman
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States
| | - K Craig Kent
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States
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Abstract
OBJECTIVE The aim of this study was to determine whether endovascular or open revascularization provides an advantageous approach to symptomatic peripheral arterial disease (PAD) over the longer term. SUMMARY OF BACKGROUND DATA The optimal revascularization strategy for symptomatic lower extremity PAD is not established. METHODS We evaluated amputation-free survival, overall survival, and relative rate of subsequent vascular intervention after endovascular or open lower extremity revascularization for propensity-score matched cohorts of Medicare beneficiaries with PAD from 2006 through 2009. RESULTS Among 14,685 eligible patients, 5928 endovascular and 5928 open revascularization patients were included in matched analysis. Patients undergoing endovascular repair had improved amputation-free survival compared with open repair at 30 days (7.4 vs 8.9%, P = 0.002). This benefit persisted over the long term: At 4 years, 49% of endovascular patients had died or received major amputation compared with 54% of open patients (P < 0.001). An endovascular procedure was associated with a risk-adjusted 16% decreased risk of amputation or death compared with open over the study period (hazard ratio: 0.84; 95% confidence interval, 0.79-0.89; P < 0.001). The amputation-free survival benefit associated with an endovascular revascularization was more pronounced in patients with congestive heart failure or ischemic heart disease than in those without (P = 0.021 for interaction term). The rate of subsequent intervention at 30 days was 7.4% greater for the endovascular vs the open revascularization cohort. At 4 years, this difference remained stable at 8.6%. CONCLUSIONS Using population-based data, we demonstrate that an endovascular approach is associated with improved amputation-free survival over the long term with only a modest relative increased risk of subsequent intervention.
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Affiliation(s)
- Jason T Wiseman
- *Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine & Public Health, Madison, WI †Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine & Public Health, Madison, WI ‡Departments of Population Health Sciences and Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Gunter R, Fernandes-Taylor S, Mahnke A, Awoyinka L, Schroeder CR, Sullivan S, Wiseman JT, Greenberg CC, Kent CK. Evaluating Patient Usability of an Image-Based Mobile Health Platform for Postoperative Wound Monitoring. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.022] [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: 11/15/2022]
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Acher AW, Campbell SA, Brenny-Fitzpatrick M, Leahy-Gross KM, Fernandes-Taylor S, Agarwal S, Kind AJ, Greenberg CC, Carayon P, Weber SM. Improving Patient-Centered Transitional Care after Complex Abdominal Surgery. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gunter R, Fernandes-Taylor S, Mahnke A, Awoyinka L, Schroeder C, Wiseman J, Sullivan S, Bennett K, Greenberg C, Kent KC. Evaluating Patient Usability of an Image-Based Mobile Health Platform for Postoperative Wound Monitoring. JMIR Mhealth Uhealth 2016; 4:e113. [PMID: 27683059 PMCID: PMC5062001 DOI: 10.2196/mhealth.6023] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/02/2016] [Accepted: 08/21/2016] [Indexed: 12/26/2022] Open
Abstract
Background Surgical patients are increasingly using mobile health (mHealth) platforms to monitor recovery and communicate with their providers in the postdischarge period. Despite widespread enthusiasm for mHealth, few studies evaluate the usability or user experience of these platforms. Objective Our objectives were to (1) develop a novel image-based smartphone app for postdischarge surgical wound monitoring, and (2) rigorously user test it with a representative population of vascular and general surgery patients. Methods A total of 9 vascular and general surgery inpatients undertook usability testing of an internally developed smartphone app that allows patients to take digital images of their wound and answer a survey about their recovery. We followed the International Organization for Standardization (ISO) 9241-11 guidelines, focusing on effectiveness, efficiency, and user satisfaction. An accompanying training module was developed by applying tenets of adult learning. Sessions were audio-recorded, and the smartphone screen was mirrored onto a study computer. Digital image quality was evaluated by a physician panel to determine usefulness for clinical decision making. Results The mean length of time spent was 4.7 (2.1-12.8) minutes on the training session and 5.0 (1.4-16.6) minutes on app completion. 55.5% (5/9) of patients were able to complete the app independently with the most difficulty experienced in taking digital images of surgical wounds. Novice patients who were older, obese, or had groin wounds had the most difficulty. 81.8% of images were sufficient for diagnostic purposes. User satisfaction was high, with an average usability score of 83.3 out of 100. Conclusion Surgical patients can learn to use a smartphone app for postoperative wound monitoring with high user satisfaction. We identified design features and training approaches that can facilitate ease of use. This protocol illustrates an important, often overlooked, aspect of mHealth development to improve surgical care.
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Affiliation(s)
- Rebecca Gunter
- Wisconsin Institute of Surgical Outcomes Research, University of Wisconsin, Madison, WI, United States.
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Wiseman JT, Fernandes-Taylor S, Gunter R, Barnes ML, Saunders RS, Rathouz PJ, Yamanouchi D, Kent KC. Inter-rater agreement and checklist validation for postoperative wound assessment using smartphone images in vascular surgery. J Vasc Surg Venous Lymphat Disord 2016; 4:320-328.e2. [PMID: 27318052 DOI: 10.1016/j.jvsv.2016.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/02/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) is the most common nosocomial infection, in vascular surgery patients, who experience a high rate of readmission. Facilitating transition from hospital to outpatient care with digital image-based wound monitoring has the potential to detect and to enable treatment of SSI at an early stage. In this study, we evaluated whether smartphone digital images can supplant in-person evaluation of postoperative vascular surgery wounds. METHODS We developed a wound assessment checklist using previously validated criteria. We recruited adults who underwent a vascular surgical procedure between 2014 and 2015, involving an incision of at least 3 cm, from a high-volume academic vascular surgery service. Vascular surgery care providers evaluated wounds in person using the assessment checklist; a different group of providers evaluated wounds by a smartphone digital image. Inter-rater agreement coefficients for wound characteristics and treatment plan were calculated within and between the in-person group and the digital image group; the sensitivity and specificity of digital images relative to in-person evaluation were determined. RESULTS We assessed a total of 80 wounds. Regardless of modality, inter-rater agreement was poor when wounds were evaluated for the presence of ecchymosis and redness; moderate for cellulitis; and high for the presence of a drain, necrosis, or dehiscence. As expected, the presence of drainage was more readily observed in person. Inter-rater agreement was high for both in-person and image-based assessment with respect to course of treatment, with near-perfect agreement for treatments ranging from antibiotics to surgical débridement to hospital readmission. No difference in agreement emerged when raters evaluated poor-quality compared with high-quality images. For most parameters, specificity was higher than sensitivity for image-based compared with "gold standard" in-person assessment. CONCLUSIONS Using smartphone digital images is a valid method for evaluating postoperative vascular surgery wounds and is comparable to in-person evaluation with regard to most wound characteristics. The inter-rater reliability for determining treatment recommendations was universally high. Remote wound monitoring and assessment may play an integral role in future transitional care models to decrease readmission for SSI in vascular or other surgical patients. These findings will inform smartphone implementation in the clinical care setting as wound images transition from informal clinical communication to becoming part of the care standard.
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Affiliation(s)
- Jason T Wiseman
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Rebecca Gunter
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Maggie L Barnes
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Richard Scott Saunders
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Dai Yamanouchi
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - K Craig Kent
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
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Gunter RL, Chouinard S, Fernandes-Taylor S, Wiseman JT, Clarkson S, Bennett K, Greenberg CC, Kent KC. Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review. J Am Coll Surg 2016; 222:915-27. [PMID: 27016900 DOI: 10.1016/j.jamcollsurg.2016.01.062] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Rebecca L Gunter
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | - Skyler Chouinard
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | | | - Jason T Wiseman
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | - Sam Clarkson
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | - Kyla Bennett
- Wisconsin Institute for Surgical Outcomes Research (WiSOR), Madison, WI
| | | | - K Craig Kent
- Department of Surgery, University of Wisconsin School of Medicine & Public Health, Madison, WI.
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Broman KK, Poulose B, Evans H, Fernandes-Taylor S. Apps incorporating clinical photography offer the potential to improve care. Bull Am Coll Surg 2016; 101:44. [PMID: 26995865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Wiseman JT, Fernandes-Taylor S, Barnes ML, Saunders RS, Saha S, Havlena J, Rathouz PJ, Kent KC. Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery. J Vasc Surg 2015; 62:1023-1031.e5. [PMID: 26143662 PMCID: PMC4586313 DOI: 10.1016/j.jvs.2015.04.453] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/30/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) is one of the most common postoperative complications after vascular reconstruction, producing significant morbidity and hospital readmission. In contrast to SSI that develops while patients are still hospitalized, little is known about the cohort of patients who develop SSI after discharge. In this study, we explore the factors that lead to postdischarge SSI, investigate the differences between risk factors for in-hospital vs postdischarge SSI, and develop a scoring system to identify patients who might benefit from postdischarge monitoring of their wounds. METHODS Patients who underwent major vascular surgery from 2005 to 2012 for aneurysm and lower extremity occlusive disease were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, in-hospital SSI, or SSI after hospital discharge. Predictors of postdischarge SSI were determined by multivariable logistic regression and internally validated by bootstrap resampling. Risk scores were assigned to all significant variables in the model. Summative risk scores were collapsed into quartile-based ordinal categories and defined as low, low/moderate, moderate/high, and high risk. Multivariable logistic regression was used to determine predictors of in-hospital SSI. RESULTS Of the 49,817 patients who underwent major vascular surgery, 4449 (8.9%) were diagnosed with SSI (2.1% in-hospital SSI; 6.9% postdischarge SSI). By multivariable analysis, factors significantly associated with increased odds of postdischarge SSI include female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, neurologic disease, prolonged operative time >4 hours, American Society of Anesthesiology class 4 or 5, lower extremity revascularization or aortoiliac procedure, and groin anastomosis. The model exhibited moderate discrimination (bias-corrected C statistic, 0.691) and excellent internal calibration. The postdischarge SSI rate was 2.1% for low-risk patients, 5.1% for low/moderate-risk patients, 7.8% for moderate/high-risk patients, and 14% for high-risk patients. In a comparative analysis, comorbidities were the primary driver of postdischarge SSI, whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI. CONCLUSIONS The majority of SSIs after major vascular surgery develop following hospital discharge. We have created a scoring system that can select a cohort of patients at high risk for SSI after discharge. These patients can be targeted for transitional care efforts focused on early detection and treatment with the goal of reducing morbidity and preventing readmission secondary to SSI.
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Affiliation(s)
- Jason T Wiseman
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Maggie L Barnes
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - R Scott Saunders
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Sandeep Saha
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Jeffrey Havlena
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - K Craig Kent
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
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Wiseman JT, Fernandes-Taylor S, Barnes ML, Tomsejova A, Saunders RS, Kent KC. Conceptualizing smartphone use in outpatient wound assessment: patients' and caregivers' willingness to use technology. J Surg Res 2015; 198:245-51. [PMID: 26025626 PMCID: PMC4530044 DOI: 10.1016/j.jss.2015.05.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 05/05/2015] [Accepted: 05/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Information technology is transforming health care communication. Using smartphones to remotely monitor incisional wounds via digital photos as well as collect postoperative symptom information has the potential to improve patient outcomes and transitional care. We surveyed a vulnerable patient population to evaluate smartphone capability and willingness to adopt this technology. METHODS We surveyed 53 patients over a 9-mo period on the vascular surgery service at a tertiary care institution. Descriptive statistics were calculated to describe survey item response. RESULTS A total of 94% of recruited patients (50 of 53) participated. The cohort was 50% female, and the mean age was age 70 y (range: 41-87). The majority of patients owned cell phones (80%) and 23% of these cell phones were smartphones. Ninety percent of patients had a friend or family member that could help take and send photos with a smartphone. Ninety-two percent of patients reported they would be willing to take a digital photo of their wound via a smartphone (68% daily, 22% every other day, 2% less than every other day, and 8% not at all). All patients reported they would be willing to answer questions related to their health via a smartphone. Patients identified several potential difficulties with regard to adopting a smartphone wound-monitoring protocol including logistics related to taking photos, health-related questions, and coordination with caretakers. CONCLUSIONS Our survey demonstrates that an older patient cohort with significant comorbidity is able and willing to adopt a smartphone-based postoperative monitoring program. Patient training and caregiver participation will be essential to the success of this intervention.
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Affiliation(s)
- Jason T Wiseman
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Maggie L Barnes
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Adela Tomsejova
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - R Scott Saunders
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - K Craig Kent
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Fernandes-Taylor S, Adesoye T, Bloom JR. Managing psychosocial issues faced by young women with breast cancer at the time of diagnosis and during active treatment. Curr Opin Support Palliat Care 2015; 9:279-84. [PMID: 26164840 PMCID: PMC5787858 DOI: 10.1097/spc.0000000000000161] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW This review examines recent literature on the psychosocial needs of and interventions for young women. We focus on the active treatment period given the toxicity of treatment, the incidence of anxiety, and depressive symptoms in these women during treatment. This review summarizes research relevant to addressing their social and emotional concerns. RECENT FINDINGS Young women undergoing treatment for breast cancer remain understudied despite unique needs. Psychoeducational interventions help to relieve symptoms and emotional distress during treatment, but effects do not appear to persist over the longer term. In the clinical context, the performance of prognostic-risk prediction models in this population is poor. Surgical decision-making is often driven by fear of recurrence and body image rather than prognosis, and decision aids may help young women to synthesize information to preserve their role in the treatment process. SUMMARY First, shared decision-making, second, balancing body image, fear of recurrence, and recommended treatment, and third, palliative care for metastasis are essential research priorities for the clinical setting. In the larger social context, unique family/partner dynamics as well as financial and insurance concerns warrant particular attention in this population.
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Affiliation(s)
- Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Taiwo Adesoye
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Joan R. Bloom
- School of Public Health, University of California at Berkeley, Berkeley, California, USA
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Wiseman JT, Fernandes-Taylor S, Barnes ML, Saunders RS, Saha S, Havlena J, Rathouz PJ, Kent KC. PC62. Predictors of Surgical Site Infection After Hospital Discharge in Patients Undergoing Major Vascular Surgery. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.04.257] [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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Fernandes-Taylor S, Bloom JR. A Psychosocial Perspective on Socioeconomic Disparities in Cancer. Psychooncology 2015. [DOI: 10.1093/med/9780199363315.003.0005] [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: 11/12/2022]
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Wiseman JT, Fernandes-Taylor S, Tomsejova A, Saunders SR, Engelbert TL, Kent CK. Conceptualizing Smartphone Use in Outpatient Wound Assessment: Patients and Caregivers Willingness to Utilize Technology. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.149] [Citation(s) in RCA: 2] [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: 11/17/2022]
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Wiseman J, Fernandes-Taylor S, Engelbert T, Saunders R, Kent K. A Novel Approach to Postoperative Wound Surveillance: Using Available Smartphone Technology to Improve Transitional Care. J Surg Res 2014. [DOI: 10.1016/j.jss.2013.11.080] [Citation(s) in RCA: 2] [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: 11/27/2022]
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Soma G, Greenblatt DY, Nelson MT, Rajamanickam V, Havlena J, Fernandes-Taylor S, Greenberg CC, Kent KC. Early graft failure after infrainguinal arterial bypass. Surgery 2014; 155:300-10. [DOI: 10.1016/j.surg.2013.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
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