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Chiu AS, Schears M, Hitchcock M, Sippel R, Kind A. Disparities in the treatment of primary hyperparathyroidism: A scoping review and conceptual model. Am J Surg 2024:S0002-9610(24)00227-7. [PMID: 38653710 DOI: 10.1016/j.amjsurg.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/13/2024] [Accepted: 04/05/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Primary hyperparathyroidism is underdiagnosed and surgical treatment is underutilized and inequitably distributed. We present a review of the current literature on disparities in the treatment of hyperparathyroidism, with a focus on gaps in knowledge and paths forward. METHODS We searched PubMed and Scopus for abstracts related to disparities in hyperparathyroidism. RESULTS 16 articles (of 1541) met inclusion criteria. The most commonly examined disparity was race. Notably, Black, Hispanic, and Asian patients were less likely to undergo surgery after diagnosis, face delays in obtaining treatment, and less likely to see a high-volume surgeon. Similar disparities in care were noted among those without insurance, older patients, and patients with limited English proficiency. CONCLUSION There are clear inequities in the treatment of hyperparathyroidism. Current research is in an early "identification" phase of disparities research; a new conceptual model based on established socioecological frameworks is provided to help move the field forward to "understanding" and "intervening" in surgical disparities.
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Affiliation(s)
- Alexander S Chiu
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Markayle Schears
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mary Hitchcock
- Ebling Library for the Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Rebecca Sippel
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amy Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Freedman-Weiss MR, Coppersmith NA, Chiu AS, Heller DR, Cutler AS, Longo WE, Oliveira K, Yoo PS. Sexual Harassment in Surgery-Is Operating Room Culture the Culprit? Am Surg 2023; 89:6121-6126. [PMID: 37489517 DOI: 10.1177/00031348231189832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Sexual harassment is a known problem in surgical training and a focus of growing attention in recent years. However, the environments where sexual harassment in surgical training most commonly takes place are not yet described. METHODS An anonymous, voluntary, electronic survey was distributed to surgical trainees, and all programs nationally were invited to participate. RESULTS Sixteen general surgery training programs elected to participate, and the survey achieved a response rate of 30%. 48.9% of respondents reported experiencing sexual harassment. The most common location for harassment was in the operating room (OR) (74% of harassed respondents). The second most common location for harassment was the wards (67.4% of harassed respondents). In the OR, attendings and nurses were the most common harassers. The most common harassment in the OR was being called a sexist slur or intimate nickname. DISCUSSION Surgical trainees report that the OR was the most common location for trainee harassment. Given that harassment is most commonly perpetrated by both attendings and nurses, harassment in surgical training may not entirely be due to hierarchies but may also be attributed to a flawed and permissive OR culture. Surgical training programs should vigilantly eliminate the circumstances that permit sexual harassment in the OR.
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Affiliation(s)
| | | | - Alexander S Chiu
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Danielle R Heller
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Abigail S Cutler
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Walter E Longo
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Kristen Oliveira
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Peter S Yoo
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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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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Guerra ME, Chiu AS, Chilakamarry S, Jean R, Brandt WS, Ruangvoravat L, Davis KA. Risk Factors for the Failure of Non-operative Management Among Patients Admitted for Colonic Diverticulitis. Am Surg 2023; 89:4552-4558. [PMID: 35986004 DOI: 10.1177/00031348221121546] [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] [Indexed: 12/06/2023]
Abstract
BACKGROUND Diverticulitis is one of the most diagnosed gastrointestinal diseases in the country, and its incidence has risen over time, especially among younger populations, with increasing attempts at non-operative management. We elected to look at acute diverticular disease from the lens of a failure analysis, where we could estimate the hazard of requiring operative intervention based upon several clinical factors. MATERIALS AND METHODS The National Inpatient Sample (NIS) was queried between 2010 and 2015 for unplanned admissions among adults with a primary diagnosis of diverticulitis. We used a proportional hazards regression to estimate the hazard of failed non-operative management from multiple clinical covariates, measured as the number of inpatient days from admission until colonic resection. We also evaluated patients who received percutaneous drainage, to investigate whether this was associated with decreasing the failure rate of non-operative management. RESULTS A total of 830,993 discharges over the study period, of whom 83,628 (10.1%) underwent operative resection during the hospitalization, and 35,796 (4.3%) patients underwent percutaneous drainage. Half of all operations occurred by hospital day 1. Among patients treated with percutaneous drainage, 11% went on to require operative intervention. The presence of a peritoneal abscess (HR 3.20, P < .01) and sepsis (HR 4.16, P < .01) were the strongest predictors of failing non-operative management. Among the subset of patients with percutaneous drains, the mean time from admission to drain placement was 2.3 days. CONCLUSION Overall 10.1% of unplanned admissions for diverticulitis result in inpatient operative resection, most of which occurred on the day of admission. Percutaneous drainage was associated with an 11% operative rate.
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Affiliation(s)
| | - Alexander S Chiu
- Department of Surgery,University of Wisconsin--Madison, Madison, WI, USA
| | | | - Raymond Jean
- Department of Surgery, Harborview Medical Center, Seattle, WA, USA
| | - Whitney S Brandt
- Department of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Lucy Ruangvoravat
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of General Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kimberly A Davis
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of General Surgery, Yale School of Medicine, New Haven, CT, USA
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Chiu AS, Saucke MC, Bushaw K, Voils CI, Sydnor J, Haymart M, Pitt SC. The relative importance of treatment outcomes to surgeons' recommendations for low-risk thyroid cancer. Surgery 2023; 173:183-188. [PMID: 36182602 DOI: 10.1016/j.surg.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The treatment of low-risk thyroid cancer is controversial. We evaluated the importance of treatment outcomes to surgeons' recommendations. METHODS A cross-sectional survey asked thyroid surgeons for their treatment recommendations for a healthy 45-year-old patient with a solitary, low-risk, 2-cm papillary thyroid cancer. The importance of the 10 treatment outcomes (survival, recurrence, etc.) to their recommendation was evaluated using constant sum scaling, a method where 100 points are allocated among the treatment outcomes; more points indicate higher importance. The distribution of points was compared between surgeons recommending total thyroidectomy and surgeons recommending lobectomy using Hottelling's T2 test. RESULTS Of 165 respondents (74.3% response rate), 35.8% (n = 59) recommended total thyroidectomy and 64.2% (n = 106) lobectomy. The importance of the 10 treatment outcomes was significantly different between groups (P < .05). Surgeons recommending total thyroidectomy were most influenced by the risk of recurrence (19.1 points; standard deviation 16.5) and rated this 1.6-times more important than those recommending lobectomy. Conversely, surgeons recommending lobectomy placed high emphasis on need for hormone replacement (14.3 points; standard deviation 15.4), rating this 3.1-times more important than those recommending total thyroidectomy. CONCLUSION Surgeons who recommend total thyroidectomy and those who recommend lobectomy differently prioritize the importance of cancer recurrence and thyroid hormone replacement. Understanding how surgeons' beliefs influence their recommendations is important for ensuring patients receive treatment aligned with their values.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kyle Bushaw
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Corrine I Voils
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin Sydnor
- University of Wisconsin School of Business, Madison, WI
| | - Megan Haymart
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Susan C Pitt
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI
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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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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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Einarsson A, Chiu AS, Mori M, Kahler-Quesada A, Assi R, Vallabhajosyula P, Geirsson A. Changing the default option in electronic medical records reduced postoperative opioid prescriptions after cardiac surgery. JTCVS Open 2021; 8:467-474. [PMID: 36004108 PMCID: PMC9390380 DOI: 10.1016/j.xjon.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/22/2022]
Abstract
Objective Overprescribing of opioids has contributed to the opioid epidemic. Electronic medical records systems can auto-populate a default number of opioid pills that are prescribed at time of discharge. The aim of this study was to examine the association between lowered default pill counts with changed prescribing practices after cardiac surgery. Methods On May 18, 2017, the default number of pills prescribers see in electronic medical records in the Yale New Haven Health System was lowered from 30 to 12. Patients undergoing coronary artery grafts, valve surgeries, and thoracic aortic aneurysm surgeries were included in this study. Data were gathered and stratified into 2 groups: 1 year before and 1 year following the default change. The amount of opioid prescribed was compared between the 2 groups. Results A total of 1741 patient charts were reviewed, 832 before the change and 909 after the change. Significant changes were seen in prescribing practices, where the average amount of opioid prescribed was about 25% lower after the change. This amounted to about 15 fewer pills of 5 mg morphine for each patient. A linear regression model adjusting for other factors determined a prescribing difference of 75.2 morphine milligram equivalents per prescription (P < .01). In addition, a significant decrease in opioids prescribed was found for each type of procedure. Conclusions Lowering the default opioid pill count in electronic medical record systems is a simple intervention that may modify prescribing behavior to promote judicious prescribing of opioids after cardiac surgery.
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Daniels J, Wadekar S, DeCubellis K, Jackson GW, Chiu AS, Pagneux Q, Saada H, Engelmann I, Ogiez J, Loze-Warot D, Boukherroub R, Szunerits S. A mask-based diagnostic platform for point-of-care screening of Covid-19. Biosens Bioelectron 2021; 192:113486. [PMID: 34260968 PMCID: PMC8264268 DOI: 10.1016/j.bios.2021.113486] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/02/2021] [Indexed: 12/29/2022]
Abstract
Diagnostics of SARS-CoV-2 infection using real-time reverse-transcription polymerase chain reaction (RT-PCR) on nasopharyngeal swabs is now well-established, with saliva-based testing being lately more widely implemented for being more adapted for self-testing approaches. In this study, we introduce a different concept based on exhaled breath condensate (EBC), readily collected by a mask-based sampling device, and detection with an electrochemical biosensor with a modular architecture that enables fast and specific detection and quantification of COVID-19. The face mask forms an exhaled breath vapor containment volume to hold the exhaled breath vapor in proximity to the EBC collector to enable a condensate-forming surface, cooled by a thermal mass, to coalesce the exhaled breath into a 200-500 μL fluid sample in 2 min. EBC RT-PCR for SARS-CoV-2 genes (E, ORF1ab) on samples collected from 7 SARS-CoV-2 positive and 7 SARS-CoV-2 negative patients were performed. The presence of SARS-CoV-2 could be detected in 5 out of 7 SARS-CoV-2 positive patients. Furthermore, the EBC samples were screened on an electrochemical aptamer biosensor, which detects SARS-CoV-2 viral particles down to 10 pfu mL-1 in cultured SARS-CoV-2 suspensions. Using a "turn off" assay via ferrocenemethanol redox mediator, results about the infectivity state of the patient are obtained in 10 min.
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Affiliation(s)
- John Daniels
- Diagmetrics Inc., 30 Renees Way Madison, Connecticut, 06443, USA
| | - Shekhar Wadekar
- Diagmetrics Inc., 30 Renees Way Madison, Connecticut, 06443, USA
| | - Ken DeCubellis
- Diagmetrics Inc., 30 Renees Way Madison, Connecticut, 06443, USA
| | - George W Jackson
- Base Pair Biotechnologies, Inc., 8619 Broadway St., Suite 100, Pearland, TX, USA
| | - Alexander S Chiu
- Base Pair Biotechnologies, Inc., 8619 Broadway St., Suite 100, Pearland, TX, USA
| | - Quentin Pagneux
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520 - IEMN, F-59000, Lille, France
| | - Hiba Saada
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520 - IEMN, F-59000, Lille, France
| | - Ilka Engelmann
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520 - IEMN, F-59000, Lille, France
| | - Judith Ogiez
- Univ Lille, CHU Lille, Laboratoire de Virologie ULR3610, F-59000, Lille, France
| | - Delphine Loze-Warot
- CerbaHealthCare Biomedical Laboratory, CERBALLIANCE Lille, 17/24 Rue de La Digue, 59000, Lille, France
| | - Rabah Boukherroub
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520 - IEMN, F-59000, Lille, France
| | - Sabine Szunerits
- Univ. Lille, CNRS, Centrale Lille, Univ. Polytechnique Hauts-de-France, UMR 8520 - IEMN, F-59000, Lille, France.
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11
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Resio BJ, Chiu AS, Zhang Y, Pei KY. Characterization of High Mortality Probability Operations at National Surgical Quality Improvement Program Hospitals. JAMA Surg 2021; 155:85-88. [PMID: 31664436 DOI: 10.1001/jamasurg.2019.3750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin J Resio
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Texas Tech University Health System, Lubbock
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Freedman-Weiss MR, Heller DR, White EM, Chiu AS, Jean RA, Yoo PS. Driving Safety Among Surgical Residents in the Era of Duty Hour Restrictions. J Surg Educ 2021; 78:770-776. [PMID: 32948507 DOI: 10.1016/j.jsurg.2020.08.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/18/2020] [Accepted: 08/23/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Fatigued driving is a known contributor to adverse motor vehicle events (AMVEs), defined as crashes and near misses. Surgical trainees work long and irregular hours; the safety of work-related driving since the introduction of work hour regulations has not yet been studied in this population. We aimed to assess the impact of fatigue on driving safety and explore perceptions of a funded rideshare program. DESIGN An electronic survey was delivered and inquired in retrospective fashion about fatigue and sleepiness while driving, occurrences of AMVEs, and projected use of a funded rideshare program as a potential solution to unsafe driving. Chi-square testing determined categorical differences between response choices. SETTING Yale University School of Medicine, Department of Surgery, New Haven, CT-a general surgery program with 4 urban clinical sites positioned along a roughly twenty mile stretch of interstate highway in Southeastern Connecticut. PARTICIPANTS General Surgery residents at the Yale University School of Medicine. RESULTS Of 58 respondents (81% response rate), 97% reported that fatigue compromised their safety while driving to or from work. Eighty-three percent reported falling nearly or completely asleep, and 22% reported AMVEs during work-related driving. Junior residents were more likely than Seniors to drive fatigued on a daily-to-weekly basis (69% vs 47%, p = 0.02) and twice as likely to fall asleep on a weekly-to-monthly basis (67% vs 33%, p = 0.02). Despite this, only 7% of residents had ever hired a ride service when fatigued, though 88%, would use a free rideshare service if provided. CONCLUSIONS Work-related fatigue impairs the driving safety of nearly all residents, contributing to frequent AMVEs. Currently, few residents hire rideshare services. Eliminating the cost barrier by funding a rideshare and encouraging its routine use may protect surgical trainees and other drivers.
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Affiliation(s)
| | - Danielle R Heller
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Erin M White
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Raymond A Jean
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Peter S Yoo
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
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Chao GF, Emlaw J, Chiu AS, Yang J, Thumma J, Brackett A, Pei KY. Asian American Pacific Islander Representation in Outcomes Research: NSQIP Scoping Review. J Am Coll Surg 2021; 232:682-689.e5. [PMID: 33705984 DOI: 10.1016/j.jamcollsurg.2021.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research. STUDY DESIGN Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion. RESULTS In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p < 0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001). CONCLUSIONS Our study is the first to examine AAPI representation in surgical outcomes research. We found < 75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research.
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Affiliation(s)
- Grace F Chao
- National Clinician Scholars Program, Veterans Affairs Ann Arbor, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Surgery, New Haven, CT.
| | - Jonel Emlaw
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Jie Yang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Jyothi Thumma
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Houston Methodist Hospital, Houston, TX
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Abstract
BACKGROUND In academic hospitals, surgical residents write most of the postoperative prescriptions; yet, few residents are trained on postoperative analgesia. This leads to wide variability in practices and often excess opioid prescribing. We sought to create an opioid guideline pocket card for surgical residents to access when prescribing opioids postoperatively and to evaluate the impact of this initiative. METHODS A comprehensive literature review was conducted to generate evidence-based procedure-specific opioid recommendations; additional recommendations were formulated via consensus opinion from surgical divisions at an academic institution. A pocket-sized guideline card was developed to include these procedure-specific recommendations as well as opioid guidelines for discharges after inpatient stays, non-opioid analgesic recommendations, access to opioid safety and disposal instructions for patients discharge, an equianalgesic dosing chart, and instructions for naloxone use. The card was distributed to all General Surgery house staff at a university-affiliated hospital in the spring of 2018. Following the distribution, trainees were surveyed on their use of the card. Descriptive statistics were used to analyze the survey. RESULTS Of 85 trainees, 62 (72.9%) responded to the survey in full; 58% use the card regularly. Of the 27 junior resident respondents, 70.4% use the card at least monthly including 48.1% who use the card daily-to-weekly. Overall, 81.6% of residents changed their opioid-prescribing practices because of this initiative and 89.8% believe the card should continue to be distributed and used. DISCUSSION An evidence-based guideline card for postoperative analgesia is highly valued and utilized by surgical trainees, especially those most junior in their training.
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Affiliation(s)
| | - Alexander S Chiu
- 12228 Department of Surgery, Yale School of Medicinex, New Haven, CT, USA
| | - Erin M White
- 12228 Department of Surgery, Yale School of Medicinex, New Haven, CT, USA
| | - Peter S Yoo
- 12228 Department of Surgery, Yale School of Medicinex, New Haven, CT, USA
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15
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Maduka RC, Gibson CE, Chiu AS, Jean RA, Wills-Johnson N, Azar SA, Oliveira K, Ahuja V. Racial disparities in surgical outcomes for benign thyroid disease. Am J Surg 2020; 220:1219-1224. [DOI: 10.1016/j.amjsurg.2020.06.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/22/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
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16
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Miller SM, Jean RA, Chiu AS, Oliveira K, Yoo PS. Earlier Is Better: Evaluating the Timing of Tracheostomy After Liver Transplantation. Respir Care 2020; 65:1883-1888. [PMID: 32788317 DOI: 10.4187/respcare.07519] [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: 11/05/2022]
Abstract
BACKGROUND Respiratory failure after orthotopic liver transplantation is associated with increased mortality and prolonged hospitalization. METHODS A retrospective analysis was conducted through the query of the National In-patient Sample for subjects who underwent orthotopic liver transplantation and tracheostomy after transplantation from 2000 to 2011. Tracheostomies by post-transplantation day 14 were considered "early," whereas those after day 14 were "routine." A Cox proportional hazards model was used to evaluate the impact of early tracheostomy on post-tracheostomy length of stay. RESULTS There were 2,149 weighted discharges. Of these, 783 (36.4%) had early tracheostomy after transplantation. The subjects who received an early tracheostomy after transplantation were more likely to have a Charlson Comorbidity index22 score of ≥3 (early 71.1% vs late 60.0%; P = .038). Early tracheostomy after transplantation had lower in-hospital mortality (early 26.4% vs late 36.7%; P = .01). Unadjusted median post-tracheostomy length of stay was 31 d for early tracheostomy after transplantation versus 39 d for late tracheostomy after transplantation (P = .034). Early tracheostomy after transplantation was associated with 20% decreased odds of in-hospital mortality (hazard ratio 0.80; P = .01). Early tracheostomy had 41% higher daily rate of discharge alive (hazard ratio 1.41; P < .001). CONCLUSIONS Early tracheostomy after transplantation was associated with lower in-hospital mortality, shorter post-tracheostomy length of stay, and quicker discharge alive. These results supported our hypothesis that, among subjects with respiratory failure after orthotopic liver transplantation, early tracheostomy after transplantation may be associated with more favorable outcomes than a delayed approach.
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Affiliation(s)
- Samuel M Miller
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Raymond A Jean
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kristin Oliveira
- Section of Trauma and Surgical Critical Care, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Peter S Yoo
- Section of Transplantation Surgery and Immunology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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17
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Oliveira K, Jean RA, Gonsai R, Maduka RC, Gibson CE, Chiu AS, Ahuja V. The Unintended Consequences of Nonoperative Management of Acute Appendicitis. J Surg Res 2020; 255:436-441. [PMID: 32619858 DOI: 10.1016/j.jss.2020.05.018] [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] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/01/2020] [Accepted: 05/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Appendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. METHODS National Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. RESULTS We identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). CONCLUSIONS This study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.
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Affiliation(s)
- Kristin Oliveira
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Raymond A Jean
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Radha Gonsai
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Richard C Maduka
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Courtney E Gibson
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Vanita Ahuja
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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18
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Guerra ME, Jean RA, Chiu AS, Johnson DC. The effect of sociodemographic factors on outcomes and time to discharge after bariatric operations. Am J Surg 2020; 219:571-577. [PMID: 32147020 DOI: 10.1016/j.amjsurg.2020.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Bariatric surgery is an effective treatment for obesity resulting in both sustained weight loss and reduction in obesity-related comorbidities. It is uncertain how sociodemographic factors affect postoperative outcomes. METHODS The National Inpatient Sample was queried for patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2005 to 2014. Factors associated with selection of SG over RYGB, increased postoperative length of stay (LOS) greater than 3 days, and inpatient mortality were compared by race, insurance status, and other clinical and hospital factors. RESULTS The database captured 781,413 patients, of which 525,986 had a RYGB and 255,428 had SG. There was an increase in the incidence of SG over RYGB over time. Among the self-pay/uninsured, the increased incidence began several years earlier than other groups. Black patients had greater odds of increased postoperative LOS (OR 1.40) and in-hospital mortality (OR 2.11). CONCLUSION Sociodemographic factors are associated with differences in temporal trends in the adoption of SG versus RYGB for surgical weight loss.
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Affiliation(s)
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Dirk C Johnson
- Section of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, USA
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Freedman-Weiss MR, Chiu AS, Worhunsky D, Manchisi A, Torres-Maldonado I, Sagnella L, Caty MG, Cowles RA, Ozgediz DE, Christison-Lagay ER, Solomon DG, Stitelman DH. An Evidence-Based Guideline Supporting Restricted Opioid Prescription after Pediatric Appendectomy. J Pediatr Surg 2020; 55:106-111. [PMID: 31699433 DOI: 10.1016/j.jpedsurg.2019.09.063] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/29/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND/PURPOSE Surgeon overprescription of opioids is a modifiable contributor to the opioid epidemic. No clear guidelines exist for prescribing opioids to younger patients after surgery. We sought to determine postoperative opioid needs in pediatric/young adult patients after laparoscopic appendectomy. METHODS Patients 5-20 years old who underwent laparoscopic appendectomy were included for study. All consented patients underwent chart review and were additionally called for an attempted interview. Caregivers were queried on analgesic use and adequacy of pain relief. The main outcome measures were: quantity of opioid used, desire for an opioid, presence of pain ≥4/10, and need for follow-up/call owing to pain. All opioids were converted into morphine milligram equivalents (MME). RESULTS Seventy-three patients qualified for the study, 49 of whom completed a postoperative telephone interview. Of the interviewees, 83% did not use or desire an opioid and reported pain <4/10 after discharge. Five patients used an opioid upon discharge, and the average MME consumed was 23 (equivalent to 3 pills of 5 mg oxycodone). No zero-opioid patients had unanticipated follow-up for pain concerns. CONCLUSIONS After hospital discharge following laparoscopic appendectomy, most patients have adequate analgesia without opioids. Opioid prescriptions should be offered sparingly and for no more than 25 MME. LEVEL OF EVIDENCE Level II. TYPE OF STUDY Prognosis study.
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Resio BJ, Jean R, Chiu AS, Pei KY. Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis. JAMA Surg 2019; 154:218-224. [PMID: 30476948 DOI: 10.1001/jamasurg.2018.4359] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown. Objective To investigate the association of the timing of colostomy reversal with operative outcomes. Design, Setting, and Participants This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018. Exposures Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing. Main Outcomes and Measures Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age. Results In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups. Conclusions and Relevance Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.
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Affiliation(s)
- Benjamin J Resio
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Raymond Jean
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Chiu AS, Freedman-Weiss MR, Jean RA, Cohen E, Yoo PS. No refills: The durable impact of a multifaceted effort by surgical trainees to minimize the prescription of postoperative opioids. Surgery 2019; 166:758-763. [DOI: 10.1016/j.surg.2019.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/18/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
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22
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Chiu AS, Jean RA, Resio B, Pei KY. Reply to: "Early postoperative death in extreme risk patients: A perspective on surgical futility". Surgery 2019; 167:518. [PMID: 31629540 DOI: 10.1016/j.surg.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 11/18/2022]
Affiliation(s)
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Benjamin Resio
- Department of Surgery, Yale School of Medicine, New Haven, CT
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Chiu AS, Jean RA, Hoag JR, Freedman-Weiss M, Healy JM, Pei KY. Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing. JAMA Surg 2019; 153:1012-1019. [PMID: 30027289 DOI: 10.1001/jamasurg.2018.2083] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Importance Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. Objective To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures. Design, Setting, and Participants A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1. Intervention The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12. Main Outcomes and Measures Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated. Results There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (P < .001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (P < .001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (P < .001). Regression analysis demonstrated a decrease of 5.22 (95% CI, -6.12 to -4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, -41.36 to -27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, P = .41). Conclusions and Relevance Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.,National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - James M Healy
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Chiu AS, Resio B, Hoag JR, Monsalve AF, Blasberg JD, White MA, Boffa DJ. US Public Perceptions About Cancer Care Provided by Smaller Hospitals Associated With Large Hospitals Recognized for Specializing in Cancer Care. JAMA Oncol 2019; 4:1008-1009. [PMID: 29852033 DOI: 10.1001/jamaoncol.2018.1400] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin Resio
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
| | - Andres F Monsalve
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Marney A White
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Daniel J Boffa
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.,Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Resio BJ, Hoag JR, Chiu AS, Monsalve A, Sathe T, Xu X, Boffa DJ. Variations in Surgical Safety According to Affiliation Status With a Top-Ranked Cancer Hospital. JAMA Oncol 2019; 5:1359-1362. [PMID: 31294746 DOI: 10.1001/jamaoncol.2019.1808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R Hoag
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andres Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Tejas Sathe
- Yale School of Medicine, New Haven, Connecticut
| | - Xiao Xu
- Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Chiu AS, Jean RA, Resio B, Pei KY. Early postoperative death in extreme-risk patients: A perspective on surgical futility. Surgery 2019; 166:380-385. [DOI: 10.1016/j.surg.2019.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/22/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
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Jean RA, Bongiovanni T, Soulos PR, Chiu AS, Herrin J, Kim N, Xu X, Kim AW, Gross CP. Hospital Variation in Spending for Lung Cancer Resection in Medicare Beneficiaries. Ann Thorac Surg 2019; 108:1710-1716. [PMID: 31400321 DOI: 10.1016/j.athoracsur.2019.06.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 06/01/2019] [Accepted: 06/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND As cancer payment models transition from fee for service toward payment "bundles" based on episodes of care, a deeper understanding of the costs associated with stage I lung cancer treatment becomes increasingly relevant. To better understand costs in early lung cancer care, we sought to characterize hospital-level variation in Medicare expenditure after lobectomy for stage I non-small cell lung carcinoma. METHODS Patients who were diagnosed with stage I non-small cell lung carcinoma from 2006 through 2011 and undergoing lobectomy were selected from the Surveillance, Epidemiology and End Results-Medicare linked database. We used Medicare claims to estimate costs of care in the 90 days after initial surgical hospitalization. Hospitals were grouped into quintiles of mean excess cost, calculated as the mean difference between observed costs and risk-adjusted predicted costs. The association between hospital factors and mean excess cost were compared across hospitals, including complication rates and hospital volume. RESULTS A total of 3530 patients underwent lobectomy at 156 hospitals. Hospitals in the lowest cost quintile had index hospitalizations $6226 less costly than predicted. Conversely, the most expensive hospital quintile had index hospital costs that were $6151 costlier than predicted. Increased costs were positively associated with the number of complications per patient (P < .001), but not hospital volume (P = .85). CONCLUSIONS Among Medicare beneficiaries undergoing lobectomy for stage I non-small cell lung carcinoma, the cost of perioperative care varied substantially across hospitals and was strongly associated with complication rate, but not hospital volume.
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Affiliation(s)
- Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, New Haven, Connecticut; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jeph Herrin
- Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, New Haven, Connecticut; Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut; Health Research and Educational Trust, Chicago, Illinois
| | - Nancy Kim
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Xiao Xu
- Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, New Haven, Connecticut; Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Cary P Gross
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, New Haven, Connecticut; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University Cancer Center, New Haven, Connecticut.
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Freedman-Weiss MR, Chiu AS, Caty MG, Solomon DG. Delay in operation for Hirschsprung Disease is associated with decreased length of stay: a 5-Year NSQIP-Peds analysis. J Perinatol 2019; 39:1105-1110. [PMID: 31209278 DOI: 10.1038/s41372-019-0405-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 12/27/2018] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The optimal timing of a pull-through procedure for Hirschsprung Disease is unknown. We, therefore, compared outcomes of pull-throughs performed in the first 30 days of age to 31-120 days. STUDY DESIGN Retrospective review of 282 patients in the NSQIP-Peds database from 2012-2016 of infants ≤120-days old and >36-weeks gestational age with Hirschsprung Disease who underwent primary pull-through. Primary outcome was postoperative and total length of stay (LOS). Operative morbidity and readmissions were also compared. RESULTS Postoperative LOS in <31-day group was 8.3 days (SD- 8.3) vs. 4.3 days (SD- 5.5) in 31-120-day group (p < 0.001). This finding was maintained on multivariate linear regression. Complication and readmission rates did not differ between groups (readmission: 15.6 vs 13% p = 0.51; complication: 5.5 vs 10% p = 0.16). CONCLUSION For appropriately selected patients with Hirschsprung Disease, delaying pull-through until the second month of life is associated with lower total and postoperative stays without increased readmissions or complications.
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Affiliation(s)
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Michael G Caty
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Daniel G Solomon
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
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Heller DR, Jean RA, Luo J, Kurbatov V, Grisotti G, Jacobs D, Chiu AS, Zhang Y, Khan SA. Practice Patterns and Guideline Non-Adherence in Surgical Management of Appendiceal Carcinoid Tumors. J Am Coll Surg 2019; 228:839-851. [PMID: 30898583 PMCID: PMC6751559 DOI: 10.1016/j.jamcollsurg.2019.02.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 10/10/2018] [Revised: 02/21/2019] [Accepted: 02/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Surgical management of appendiceal carcinoid tumors is heavily debated, despite National Comprehensive Cancer Network guidelines recommending aggressive resection of tumors >2 cm. We investigated national practice patterns and the predictors and impact of guideline non-adherence. STUDY DESIGN The National Cancer Database was queried for cases of appendiceal carcinoids diagnosed from 2004 to 2015 treated with either appendectomy or hemicolectomy. Multivariable logistic regression, adjusted for demographic and clinical factors, identified associations with the procedure type among patients stratified by tumor size ≤2 cm and >2 cm. Cox Proportional Hazards then identified associations with overall survival among stratified patient groups. RESULTS Of 3,198 cases of appendiceal carcinoids, 1,893 appendectomies and 1,305 hemicolectomies were identified. Contrary to National Comprehensive Cancer Network guidelines, 32.4% of tumors ≤2 cm were treated with hemicolectomy and 31.3% of tumors >2 cm were treated with definitive appendectomy. Hemicolectomy for small tumors was associated with age 65 years and older (odds ratio [OR] 2.4; 95% CI 1.7 to 3.3; reference group age 18 to 39 years), history of malignancy (OR 2.0; 95% CI 1.6 to 2.6), tumor size 1.1 to 2 cm (OR 2.8; 95% CI 2.3 to 3.4; reference group size ≤1 cm), and lymphovascular invasion (OR 2.2; 95% CI 1.6 to 3.2); appendectomy for large tumors was associated with age 65 years and older only (OR 2.2; 95% CI 1.1 to 4.2). Procedure type was not associated with survival for small or large tumors (hazard ratio 1.0; 95% CI 0.7 to 1.4 and hazard ratio 1.1; 95% CI 0.6 to 2.0, respectively). CONCLUSIONS Despite well-known size-based treatment guidelines for appendiceal carcinoids, one-third of patients in the US undergo hemicolectomy for small tumors and appendectomy for large tumors. Guideline non-adherence, however, is not associated with overall survival. Reasons for these practice patterns should be explored, and guidelines revisited.
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Affiliation(s)
| | - Raymond A Jean
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jiajun Luo
- Department of Surgery, Yale School of Medicine, New Haven, CT; Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Vadim Kurbatov
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Daniel Jacobs
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, CT; Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Sajid A Khan
- Department of Surgery, Yale School of Medicine, New Haven, CT; Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT.
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Heller DR, Chiu AS, Farrell K, Killelea BK, Lannin DR. Why Has Breast Cancer Screening Failed to Decrease the Incidence of de Novo Stage IV Disease? Cancers (Basel) 2019; 11:cancers11040500. [PMID: 30965658 PMCID: PMC6521320 DOI: 10.3390/cancers11040500] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/31/2019] [Accepted: 04/03/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Despite screening mammography, the incidence of Stage IV breast cancer (BC) at diagnosis has not decreased over the past four decades. We previously found that many BCs are small due to favorable biology rather than early detection. This study compared the biology of Stage IV cancers with that of small cancers typically found by screening. Methods: Trends in the incidence of localized, regional, and distant female BC were compared using SEER*Stat. The National Cancer Database (NCDB) was then queried for invasive cancers from 2010 to 2015, and patient/disease variables were compared across stages. Biological variables including estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (Her2), grade, and lymphovascular invasion were sorted into 48 combinations, from which three biological subtypes emerged: indolent, intermediate, and aggressive. The distributions of the subtypes were compared across disease stages. Multivariable regression assessed the association between Stage IV disease and biology. Results: SEER*Stat confirmed that the incidence of distant BC increased between 1973 and 2015 (annual percent change [APC] = 0.46). NCDB data on roughly 993,000 individuals showed that Stage IV disease at presentation is more common in young, black, uninsured women with low income/education and large, biologically aggressive tumors. The distribution of tumor biology varied by stage, with Stage IV disease including 37.6% aggressive and 6.0% indolent tumors, versus sub-centimeter Stage I disease that included 5.1% aggressive and 40.6% indolent tumors (p < 0.001). The odds of Stage IV disease presentation more than tripled for patients with aggressive tumors (OR3.2, 95% CI 3.0–3.5). Conclusions: Stage I and Stage IV breast cancers represent very different populations of biologic tumor types. This may explain why the incidence of Stage IV cancer has not decreased with screening.
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Affiliation(s)
- Danielle R Heller
- Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kaitlin Farrell
- The Breast Center/Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Brigid K Killelea
- The Breast Center/Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Donald R Lannin
- The Breast Center/Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
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Hoag JR, Resio BJ, Monsalve AF, Chiu AS, Brown LB, Herrin J, Blasberg JD, Kim AW, Boffa DJ. Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery. JAMA Netw Open 2019; 2:e191912. [PMID: 30977848 PMCID: PMC6481444 DOI: 10.1001/jamanetworkopen.2019.1912] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Leading cancer hospitals have increasingly shared their brands with other hospitals through growing networks of affiliations. However, the brand of top-ranked cancer hospitals may evoke distinct reputations for safety and quality that do not extend to all hospitals within these networks. OBJECTIVE To assess perioperative mortality of Medicare beneficiaries after complex cancer surgery across hospitals participating in networks with top-ranked cancer hospitals. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was performed of the Centers for Medicare & Medicaid Services 100% Medicare Provider and Analysis Review file from January 1, 2013, to December 31, 2016, for top-ranked cancer hospitals (as assessed by U.S. News and World Report) and affiliated hospitals that share their brand. Participants were 29 228 Medicare beneficiaries older than 65 years who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between January 1, 2013, and October 1, 2016. EXPOSURES Undergoing complex cancer surgery at a top-ranked cancer hospital vs an affiliated hospital. MAIN OUTCOMES AND MEASURES Risk-adjusted 90-day mortality estimated using hierarchical logistic regression and comparison of the relative safety of hospitals within each cancer network estimated using standardized mortality ratios. RESULTS A total of 17 300 patients (59.2%; 8612 women and 8688 men; mean [SD] age, 74.7 [6.2] years) underwent complex cancer surgery at 59 top-ranked hospitals and 11 928 patients (40.8%; 6287 women and 5641 men; mean [SD] age, 76.2 [6.9] years) underwent complex cancer surgery at 343 affiliated hospitals. Overall, surgery performed at affiliated hospitals was associated with higher 90-day mortality (odds ratio, 1.40; 95% CI, 1.23-1.59; P < .001), with odds ratios that ranged from 1.32 (95% CI, 1.12-1.56; P = .001) for colectomy to 2.04 (95% CI, 1.41-2.95; P < .001) for gastrectomy. When the relative safety of each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%; 95% CI, 73.1%-93.3%). CONCLUSIONS AND RELEVANCE The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand. Further investigation of performance across trusted cancer networks could enhance informed decision making for complex cancer care.
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Affiliation(s)
- Jessica R. Hoag
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin J. Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andres F. Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S. Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence B. Brown
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Jeph Herrin
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Justin D. Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anthony W. Kim
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles
| | - Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Abstract
BACKGROUND Falls are the leading source of injury and trauma-related hospital admissions for elderly adults in the USA. Elderly patients with a history of a fall have the highest risk of falling again, and the decision on whether to continue anticoagulation after a fall is difficult. To inform this decision, we evaluated the rate of recurrent falls and the impact of anticoagulation on outcomes. METHODS All patients of age ≥ 65 years and hospitalized for a fall in the first 6 months of 2013 and 2014 were identified in the nationwide readmission database, a nationally representative all-payer database tracking patient readmissions. Readmissions for a recurrent fall within 6 months, and mortality and bleeding injuries (intracranial hemorrhage, solid organ bleed, and hemothorax) during readmission were identified. Logistic regression evaluated factors associated with mortality on repeat falls. RESULTS Of the 331,982 patients admitted for a fall, 15,565 (4.7%) were admitted for a recurrent fall within 6 months. The median time to repeat fall was 57 days (IQR 19-111 days), and 9.0% (1406) of repeat fallers were on anticoagulation. The rate of bleeding injury was similar regardless of anticoagulation status (12.8 vs. 12.7% not on anticoagulation, p = 0.97); however, among patients with a bleeding injury, those on anticoagulation had significantly higher mortality (21.5 vs. 6.9% not on anticoagulation, p < 0.01). CONCLUSION Among patients hospitalized for a fall, 4.7% will be hospitalized for a recurrent fall within 6 months. Patients on anticoagulation with repeat falls do not have increased rates of bleeding injury but do have significantly higher rates of death with a bleeding injury. This information is essential to discuss with patients when deciding to restart their anticoagulation.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Matthew Fleming
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Y Pei
- Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB310, New Haven, CT, 06519, USA.
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Jean RA, Chiu AS, Boffa DJ, Detterbeck FC, Kim AW, Blasberg JD. Corrigendum to 'Delayed discharge does not decrease the cost of readmission after pulmonary lobectomy' [Surgery 164/6 (2018) 1294-1299]. Surgery 2019; 165:1058. [PMID: 30678871 DOI: 10.1016/j.surg.2018.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | | | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Frank C Detterbeck
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine at USC, Los Angeles, CA
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT.
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Heller DR, Jean RA, Chiu AS, Feder SI, Kurbatov V, Cha C, Khan SA. Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery. J Gastrointest Surg 2019; 23:153-162. [PMID: 30328071 PMCID: PMC6751557 DOI: 10.1007/s11605-018-3929-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of palliative care (PC) in critical illness are validated across a range of diseases, yet it remains underutilized in surgical patients. This study analyzed patient and hospital factors predictive of PC utilization for elderly patients with colorectal cancer (CRC) requiring emergent surgery. METHODS The National Inpatient Sample was queried for patients aged ≥ 65 years admitted emergently with CRC from 2009 to 2014. Patients undergoing colectomy, enterectomy, or ostomy formation were included and stratified according to documentation of PC consultation during admission. Chi-squared testing identified unadjusted group differences, and multivariable logistic regression identified predictors of PC. RESULTS Of 86,573 discharges meeting inclusion criteria, only 3598 (4.2%) had PC consultation. Colectomy (86.6%) and ostomy formation (30.4%) accounted for the operative majority. PC frequency increased over time (2.9% in 2009 to 6.2% in 2014, P < 0.001) and was nearly twice as likely to occur in the West compared with the Northeast (5.7 vs. 3.3%, P < 0.001) and in not-for-profit compared with proprietary hospitals (4.5 vs. 2.3%, P < 0.001). PC patients were more likely to have metastases (60.1 vs. 39.9%, P < 0.001) and die during admission (41.5 vs. 6.4%, P < 0.001). On multivariable logistic regression, PC predictors (P < 0.05) included region outside the Northeast, increasing age, more recent year, and metastatic disease. CONCLUSIONS In the USA, PC consultation for geriatric patients with surgically managed complicated CRC is low. Regional variation appears to play an important role. With mounting evidence that PC improves quality of life and outcomes, understanding the barriers associated with its provision to surgical patients is paramount.
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Affiliation(s)
- Danielle R Heller
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Shelli I Feder
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
- US Department of Veterans Affairs, 950 Campbell Ave, West Haven, CT, 06516, USA
| | - Vadim Kurbatov
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Charles Cha
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA
| | - Sajid A Khan
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA.
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Chiu AS, Pei KY, Jean RA. Mentoring Sideways-A Model of Resident-to-Resident Research Mentorship. J Surg Educ 2019; 76:1-3. [PMID: 30626526 DOI: 10.1016/j.jsurg.2018.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/21/2018] [Accepted: 05/27/2018] [Indexed: 06/09/2023]
Abstract
The traditional apprenticeship model of research mentorship, where residents pursue research projects directed by attending surgeons, may be ill-suited to optimize research innovation, productivity, and leadership experience. This is particularly true in an era of ever mounting demands of academic attending surgeons, easier availability of powerful clinical databases, and more residents beginning training with prior research experience and advanced degrees. To help makeup the gaps of traditional research mentorship, we propose a complementary peer-focused, "sideways mentorship" approach. This model revolves around a consortium of residents who develop their own research ideas, and obtain feedback and technical input from fellow residents. Such a model provides trainees more opportunities to explore their own ideas, become exposed to a wider range of disciplines, share technical knowledge and prior experience, and practice being mentors themselves. We believe sideways mentoring model can be successful in this changing research era, and is a valuable addition to the traditional research model and encourage educational programs to support efforts in establishing resident-run research collaborative.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven Connecticut.
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven Connecticut
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven Connecticut; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Peprah D, Chiu AS, Jean RA, Pei KY. Comparison of Outcomes Between Total Abdominal and Partial Colectomy for the Management of Severe, Complicated Clostridium Difficile Infection. J Am Coll Surg 2018; 228:925-930. [PMID: 30576799 DOI: 10.1016/j.jamcollsurg.2018.11.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/30/2018] [Accepted: 11/30/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with severe, complicated Clostridium difficile infection (CDI) may ultimately require a colectomy. Although associated with high morbidity and mortality, a total colectomy has been the mainstay of surgical treatment. However, small studies have suggested partial colectomy may provide equivalent outcomes. We compared the outcomes of partial and total colectomy for CDI in a nationwide database. STUDY DESIGN We performed a retrospective study using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). Patients with a primary diagnosis of Clostridium difficile colitis from 2007 to 2015, who underwent a total abdominal or partial colectomy, were analyzed. Postoperative mortality rate, complications, and length of stay were evaluated. Logistic regression controlling for patient and clinical factors evaluated the impact of type of operation performed. RESULTS There were 733 colectomies for CDI, of which 151 (20.6%) were partial colectomies. Patients with a partial colectomy had a slightly higher 30-day mortality rate (37.1%) compared with total abdominal colectomy patients (34.7%, p = 0.58). However, logistic regression controlling for patient factors demonstrated no statistically significant difference for partial colectomy in 30-day mortality (odds ratio [OR] 1.21, 95% CI 0.76 to 1.96) or complication rate (OR 0.92, 95% CI 0.51 to 1.62) compared with total colectomy. There was no difference in days to surgery (4.6 partial vs 5.0 total, p = 0.70). Total abdominal colectomy trended toward a longer postoperative stay (18.0 vs 15.1 days for partial, p = 0.08). CONCLUSIONS In a national database, a significant percentage of operations for CDI are partial colectomies. There were no significant differences found in mortality or complications between partial and total colectomy for severe complicated CDI.
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Affiliation(s)
- David Peprah
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, CT; Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX.
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Jean RA, Chiu AS, Boffa DJ, Detterbeck FC, Kim AW, Blasberg JD. Delayed discharge does not decrease the cost of readmission after pulmonary lobectomy. Surgery 2018; 164:1294-1299. [DOI: 10.1016/j.surg.2018.05.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/15/2018] [Accepted: 05/31/2018] [Indexed: 01/07/2023]
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Monsalve AF, Hoag JR, Resio BJ, Chiu AS, Brown LB, Detterbeck FC, Blasberg JD, Boffa DJ. Variable impact of prior cancer history on the survival of lung cancer patients. Lung Cancer 2018; 127:130-137. [PMID: 30642541 DOI: 10.1016/j.lungcan.2018.11.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Non-Small Cell Lung Cancer (NSCLC) is commonly diagnosed in patients who have survived a prior malignancy. However, it is currently unclear whether NSCLC patient survival is impacted by the potential for previously-treated malignancies to recur. Understanding the impact of a prior cancer history on NSCLC survival could not only enhance decision making but could affect eligibility for NSCLC studies. METHODS The National Cancer Database (NCDB) was queried for NSCLC patients (stage I-IV) diagnosed between 2004-2014. Kaplan-Meier survival curves and multivariable Cox proportional hazards regression models were estimated to analyze overall survival across a variety of treatment approaches and stages in the presence and absence of a prior cancer history. RESULTS A total of 821,323 patients with a newly diagnosed NSCLC were identified including 179,512 (21.9%) with a prior history of cancer. The unadjusted 5-year overall survival of patients with a prior cancer history (9.8%) was slightly better to those without a cancer history (9.5%, 95% CI 11.76-11.84, P < 0.0001). However, adjusted analyses revealed the impact of prior cancer history was extremely heterogenous across stage and treatment approach. Ultimately, 51.4% of patients fell into a subgroup in which prior cancer history appeared to compromise survival, 16.3% in which the difference was not significant, and 32.3% in which prior cancer was associated with increased survival. Patients with earlier-staged tumors were the most negatively NSCLC impacted by prior cancer history. CONCLUSIONS The association between prior cancer history and survival of newly diagnosed NSCLC patients is highly variable and to some degree reflects a patient's potential for cure.
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Affiliation(s)
- Andres F Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar St. BB205, P.O. Box 208062, New Haven, CT, 06510-8020, USA
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510-8020, USA
| | - Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar St. BB205, P.O. Box 208062, New Haven, CT, 06510-8020, USA
| | - Alexander S Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar St. BB205, P.O. Box 208062, New Haven, CT, 06510-8020, USA
| | | | - Frank C Detterbeck
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar St. BB205, P.O. Box 208062, New Haven, CT, 06510-8020, USA
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar St. BB205, P.O. Box 208062, New Haven, CT, 06510-8020, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar St. BB205, P.O. Box 208062, New Haven, CT, 06510-8020, USA.
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Freedman-Weiss MR, Chiu AS, Solomon DG, Christison-Lagay ER, Ozgediz DE, Cowles RA, Caty MG, Stitelman DH. Opioid Prescribing Habits of General Versus Pediatric Surgeons After Uncomplicated Laparoscopic Appendectomy. J Surg Res 2018; 235:404-409. [PMID: 30691822 DOI: 10.1016/j.jss.2018.09.085] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/13/2018] [Accepted: 09/28/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adolescents who use prescription opioids have an increased risk for future drug abuse and overdose, making them a high-risk population. Appendectomy is one of the most common surgical procedures in this age group, often requires opioid analgesia, and is performed by both pediatric and general surgeons. Prescription patterns comparing these two provider groups have not yet been evaluated; we hypothesize that general surgery providers prescribe more opioids for adolescent and young adult patients than do pediatric surgery providers. METHODS A retrospective chart review was conducted across a single health system consisting of four hospitals. All uncomplicated laparoscopic appendectomies performed between January 1, 2016 and August 14, 2017 on patients aged 7-20 were included for analysis. Any case coded for multiple procedures, identified as converted to open, or had a length of stay >48 h were excluded. The primary outcome measure was amount of opioid prescribed postoperatively. To standardize different formulations and types of analgesia prescribed, prescriptions were converted into oral morphine equivalents (OMEs). For reference, one 5 mg pill of oxycodone equals 7.5 OME. Linear regression was performed controlling for patient weight, gender, race, insurance status, provider type (pediatric versus general surgery), and provider level (resident, advanced practice provider, and attending). RESULTS A total of 336 pediatric laparoscopic appendectomies were analyzed, 148 by general surgeons and 188 by pediatric surgeons. Pediatric surgeons prescribed less opioid than general surgeons overall (59 OME versus 90 OME, P < 0.0001). For patients aged <13 y, there was no significant difference between pediatric (26 OME) and general (37 OME, P = 0.8921) surgeons. However, for the age group 13-20 y, pediatric surgeons prescribed 25% less opioid than general surgeons (90 OME versus 112.5 OME, P < 0.0001). Regression analysis demonstrated that being cared for by a general surgery service (+24.1 OME [95% confidence interval 9.8-38.3]) was associated with high prescribing, whereas having Medicaid was associated with lower prescription amounts (-16.4 OME [95% confidence interval -32.5 to -0.3]). CONCLUSIONS After an uncomplicated laparoscopic appendectomy, general surgeons prescribe significantly more opioid to adolescent patients than do pediatric surgeons, even when controlling for age and weight. One substantial and modifiable contributor of the opioid epidemic is the amount of opioid prescribed. The variability of prescribing habits to adolescents and young adults demonstrates a clear need for increased education and guidelines on this topic, especially for surgeons who do not frequently treat the younger and more vulnerable population.
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Affiliation(s)
| | - Alexander S Chiu
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel G Solomon
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | | | - Doruk E Ozgediz
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Robert A Cowles
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael G Caty
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - David H Stitelman
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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Resio BJ, Chiu AS, Hoag JR, Brown LB, White M, Omar A, Monsalve A, Dhanasopon AP, Blasberg JD, Boffa DJ. Motivators, Barriers, and Facilitators to Traveling to the Safest Hospitals in the United States for Complex Cancer Surgery. JAMA Netw Open 2018; 1:e184595. [PMID: 30646367 PMCID: PMC6324377 DOI: 10.1001/jamanetworkopen.2018.4595] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Directing patients to safer hospitals for complex cancer surgery (regionalization) may prevent thousands of mortalities in the United States. OBJECTIVE To understand the potential for individuals to move to safer hospitals: what would inspire them to travel (motivators), what challenges would they face (barriers), and what would enable them to travel (facilitators). DESIGN, SETTING, AND PARTICIPANTS This nationally representative online survey study asked respondents to consider complex cancer surgery at their local hospital or a hospital specializing in cancer an hour farther away. Completed surveys were weighted across sociodemographics to be nationally representative and outcomes were reported as weighted percentages. In January 2018, a panel of 1817 US adults recruited by address- and telephone-based sampling to be nationally representative were invited to take the survey. Data analysis was conducted from January 24, 2018, to September 19, 2018. MAIN OUTCOMES AND MEASURES Proportion of respondents motivated to travel by specific quality and safety indicators (motivators), magnitude in difference that would be necessary, proportion facing specific barriers, and proportion enabled to move by facilitators. Resistant individuals were identified as people who would not travel except for the largest (top quartile) outcomes differences. RESULTS There were 1016 completed surveys (response rate of 55.9%). The weighted median age was 48 years, 52% were female, median annual income was between $60 000 and $75 000, and 85% lived in a metropolitan area. Nonresponders were more likely than responders to be female, younger, nonwhite, less educated, and lower income (female: 54.4% vs 48.3%; P = .01; younger [aged <45 years]: 56.3% vs 37.1%; P < .001; nonwhite: 41.6% vs 30.0%; P < .001; less than college education: 43.8% vs 32.4%; P < .001; income <$30 000: 22.1% vs 17.1%; P = .01). Superior safety or oncologic outcomes, presented separately, motivated an average of 92% of respondents (95% CI, 90%-94%) to travel. One-third were easily motivated, requiring less than 1% advantage in safety or quality, while 12% were particularly resistant across outcomes. Respondents with lower income (income <$25 000: odds ratio, 2.01; 95% CI, 1.19-3.39) and nonwhite race (odds ratio, 1.60; 95% CI, 1.05-2.42) were more resistant to travel. At least 1 barrier was identified by 74% of respondents (95% CI, 72%-77%), most commonly financial (costs/insurance). However, 94% of respondents (95% CI, 92%-96%) with barriers would travel if provided facilitators, many of which were relatively low cost (transportation, parking, and hotel). CONCLUSIONS AND RELEVANCE It appears that most of the US public could be motivated to travel to safer hospitals for complex cancer surgery, yet most would require some support to move. Further efforts to ensure that benefits from regionalization are equitable across sociodemographic strata are indicated.
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Affiliation(s)
- Benjamin J. Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S. Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R. Hoag
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Marney White
- Yale School of Public Health, New Haven, Connecticut
| | - Audry Omar
- Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Andres Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andrew P. Dhanasopon
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Justin D. Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Jean RA, Chiu AS, Hoag JR, Blasberg JD, Boffa DJ, Detterbeck FC, Kim AW. Identifying Drivers of Multiple Readmissions After Pulmonary Lobectomy. Ann Thorac Surg 2018; 107:947-953. [PMID: 30336117 DOI: 10.1016/j.athoracsur.2018.08.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 08/08/2018] [Accepted: 08/28/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Readmissions after pulmonary lobectomy for lung cancer are important markers of healthcare quality for surgeons and hospitals. The implications on resources and quality are magnified when examining patients who require multiple readmissions within the perioperative period. METHODS The Nationwide Readmission Database between 2013 and 2014 was investigated for patients with a primary diagnosis of lung cancer who underwent pulmonary lobectomy. Using adjusted hierarchical regression models, demographic and clinical factors during the index hospitalization were investigated for associations with single and multiple readmissions during the 90-day postoperative period. First and second readmissions during this period were compared for the primary diagnosis at the time of readmission using Clinical Classification Software codes. RESULTS Of the 41,576 lobectomies during the study period 7,030 patients (16.9%) were readmitted. Among this group 1,554 patients (3.7%) had at least two readmissions. After adjustment for other factors, postoperative arrhythmia (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.25-1.83; p < 0.0001), postoperative infection (OR, 1.55; 95% CI, 1.11-2.17; p = 0.01), and postoperative sepsis (OR, 1.70; 95% CI, 1.08-2.67; p = 0.02) during the index hospitalization were associated with an increased risk of at least two readmissions. The most frequent Clinical Classification Software diagnosis for first readmissions was "postoperative complications" (892, 12.7%) and for second readmissions was heart disease (173, 11.2%). CONCLUSIONS Approximately one-fifth of patients readmitted after pulmonary lobectomy would go on to be readmitted two or more times within 90 days. Although first readmissions were most likely to present with postoperative infection or complication, second readmissions were most likely to present with heart disease.
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Affiliation(s)
- Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Frank C Detterbeck
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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Chiu AS, Resio B, Hoag JR, Monsalve AF, Blasberg JD, Brown L, Omar A, White MA, Boffa DJ. Why Travel for Complex Cancer Surgery? Americans React to 'Brand-Sharing' Between Specialty Cancer Hospitals and Their Affiliates. Ann Surg Oncol 2018; 26:732-738. [PMID: 30311158 DOI: 10.1245/s10434-018-6868-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Leading cancer hospitals have increasingly shared their 'brand' with smaller hospitals through affiliations. Because each brand evokes a distinct reputation for the care provided, 'brand-sharing' has the potential to impact the public's ability to differentiate the safety and quality within hospital networks. The general public was surveyed to determine the perceived similarities and differences in the safety and quality of complex cancer surgery performed at top cancer hospitals and their smaller affiliate hospitals. METHODS A national, web-based KnowledgePanel (GfK) survey of American adults was conducted. Respondents were asked about their beliefs regarding the quality and safety of complex cancer surgery at a large, top-ranked cancer hospital and a smaller, local hospital, both in the presence and absence of an affiliation between the hospitals. RESULTS A total of 1010 surveys were completed (58.1% response rate). Overall, 85% of respondents felt 'motivated' to travel an hour for complex surgery at a larger hospital specializing in cancer, over a smaller local hospital. However, if the smaller hospital was affiliated with a top-ranked cancer hospital, 31% of the motivated respondents changed their preference to the smaller hospital. When asked to compare leading cancer hospitals and their smaller affiliates, 47% of respondents felt that surgical safety, 66% felt guideline compliance, and 53% felt cure rates would be the same at both hospitals. CONCLUSIONS Approximately half of surveyed Americans did not distinguish the quality and safety of surgical care at top-ranked cancer hospitals from their smaller affiliates, potentially decreasing their motivation to travel to top centers for complex surgical care.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin Resio
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | | | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence Brown
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Audrey Omar
- Yale Center for Analytic Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Marney A White
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA. .,Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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Heller DR, Jean RA, Kurbatov V, Chiu AS, Khan SA. Practice Patterns and Guideline Non-Adherence in Surgical Management of Appendiceal Carcinoid Tumors. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Chiu AS, Ahle SL, Freedman-Weiss MR, Yoo PS, Pei KY. The impact of a curriculum on postoperative opioid prescribing for novice surgical trainees. Am J Surg 2018; 217:228-232. [PMID: 30180937 DOI: 10.1016/j.amjsurg.2018.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 04/17/2018] [Revised: 06/22/2018] [Accepted: 08/11/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Surgical residents are frequently responsible for prescribing postoperative analgesia, yet the vast majority are never formally educated on the subject. METHODS A resident-led educational presentation on postoperative analgesia prescribing was provided to incoming surgical interns at a tertiary academic center. Pre- and post-surveys assessed comfort in prescribing postoperative analgesia. Following the educational intervention, opioid prescriptions during the interns' first two months were compared to that of the prior year's interns. RESULTS Education was provided to 31 interns. Prior to the session, few interns felt comfortable prescribing opioids (20%) or non-opioid analgesia (32%). After the session, 96% felt more comfortable prescribing opioids and 91% more comfortable prescribing multi-modal analgesia. Interns who received education prescribed an average of 127.8 Morphine Milligram Equivalents (MME) per prescription, compared to 208.5 MME by the prior year's interns (p < 0.01). CONCLUSION Education on postoperative analgesia targeting interns can be effective in preparing trainees in effective and judicious analgesic prescribing.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Samantha L Ahle
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Peter S Yoo
- Section of Transplant Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Y Pei
- Section of Trauma, Critical Care, and Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Jean RA, Chiu AS, O'Neill KM, Lin Z, Pei KY. The influence of sociodemographic factors on operative decision-making in small bowel obstruction. J Surg Res 2018; 227:137-144. [DOI: 10.1016/j.jss.2018.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/22/2018] [Accepted: 02/14/2018] [Indexed: 11/25/2022]
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Jean RA, Chiu AS, Boffa DJ, Detterbeck FC, Blasberg JD, Kim AW. When good operations go bad: The additive effect of comorbidity and postoperative complications on readmission after pulmonary lobectomy. Surgery 2018; 164:294-299. [PMID: 29801731 DOI: 10.1016/j.surg.2018.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/27/2018] [Accepted: 03/12/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hospital readmission after major thoracic surgery has a marked effect on health care delivery, particularly in the era of value-based reimbursement. We sought to investigate the additive impact of comorbidity and postoperative complications on the risk of readmission after thoracic lobectomy. METHODS We queried the Nationwide Readmission Database of the Healthcare Cost and Utilization Project between 2010 and 2014 for discharges after pulmonary lobectomy with a primary diagnosis of lung cancer. We compared 90-day all-cause readmission rates across the presence of Elixhauser comorbidities and postoperative complications. Adjusted logistic and linear regression, accounting for patient and hospital factors were used to calculate the mean change in readmission rate by the number of comorbidities and postoperative complications. RESULTS A total of 87,894 patients undergoing pulmonary lobectomies were identified during the study period, of whom 15,858 (18.0%) were readmitted for any cause within 90 days of discharge. After adjusting for other factors, each additional comorbidity and postoperative complication were associated with a 2.0% and 2.7% increased probability of readmission, respectively (both P < .0001). Patients with a low burden of low comorbidities were readmitted more frequently for postoperative complications, while those with a high burden of comorbidities were readmitted more frequently for chronic disease. CONCLUSION Among patients with the lowest risk profile, there was an 11.7% readmission rate. Adjusting for other factors, each additional comorbidity and complication increased this rate by approximately 2.0% and 2.7%, respectively. These results demonstrate that the avoidance of postoperative complications may represent an effective mechanism for decreasing readmissions after thoracic surgery.
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Affiliation(s)
- Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | | | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Frank C Detterbeck
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA.
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Arnold BN, Chiu AS, Hoag JR, Kim CH, Salazar MC, Blasberg JD, Boffa DJ. Spontaneous regionalization of esophageal cancer surgery: an analysis of the National Cancer Database. J Thorac Dis 2018; 10:1721-1731. [PMID: 29707326 DOI: 10.21037/jtd.2018.02.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Esophagectomy patients are up to three times more likely to die after surgery when cared for at low-volume hospitals (LVHs). Increased awareness by patients and clinicians of the hazards of esophagectomy at LVHs, may inspire a "spontaneous regionalization" away from LVHs, yet the extent to which this has taken place is unclear. Methods Retrospective analysis of patients undergoing esophagectomy for esophageal cancer in the National Cancer Database (NCDB) across two eras: 2004-2006 (Era 1) and 2010-2012 (Era 2). Primary outcomes included the proportion of patients at high-volume hospitals (HVHs) (≥13/year per Leapfrog Group), adjusted, and unadjusted 90-day mortality. Results The NCDB captured 5,968 esophagectomy patients in Era 1 and 5,580 in Era 2, a 6.5% decrease (P<0.001). Fewer hospitals performed esophagectomies in Era 2 (756 vs. 663, P=0.014), yet the proportion of patients treated at LVHs declined slightly between eras (73% vs. 70%, P<0.001). Patients with high-risk attributes (e.g., advanced age, multiple comorbidities, etc.) were disproportionately treated at LVHs in both eras (77% Era 1, P<0.001, 73% Era 2, P=0.017). However, the 90-day mortality rate for patients with high-risk attributes decreased considerably between Eras at LVHs (19.3% to 12.3%, P<0.001). Conclusions Spontaneous regionalization of esophageal cancer surgery has not occurred on a large scale, yet for high-risk patients, the hazards of being cared for at LVHs have dissipated. Further study is needed to optimize alignment of esophagectomy patients and hospitals.
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Affiliation(s)
- Brian N Arnold
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Alexander S Chiu
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica R Hoag
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT, USA
| | - Clara H Kim
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michelle C Salazar
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Justin D Blasberg
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Chiu AS, Healy JM, DeWane MP, Longo WE, Yoo PS. Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents. J Surg Educ 2018; 75:65-71. [PMID: 28705485 DOI: 10.1016/j.jsurg.2017.06.020] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/12/2017] [Accepted: 06/17/2017] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Opioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience. DESIGN Anonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription. SETTING Accreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital. PARTICIPANTS Categorical and preliminary general surgery residents of all postgraduate years. RESULTS The percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription. CONCLUSION AND RELEVANCE Surgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - James M Healy
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael P DeWane
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Walter E Longo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter S Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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Chiu AS, Jean RA, Davis KA, Pei KY. Impact of Race on the Surgical Management of Adhesive Small Bowel Obstruction. J Am Coll Surg 2017; 226:968-976.e1. [PMID: 29170020 DOI: 10.1016/j.jamcollsurg.2017.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/11/2017] [Accepted: 11/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) represents roughly 15% of admissions by general surgeons. Management of SBO relies heavily on provider judgment, including decisions on how long to try nonsurgical management and whether to use a laparoscopic or open approach when surgery is needed. Given the subjective nature of these decisions, it is unknown if patient race influences management of SBO. STUDY DESIGN The National Surgical Quality Improvement Program was used to identify patients who underwent adhesiolysis or small bowel resection for adhesive SBO between 2010 and 2015 (n = 13,896). Adjusted logistic regression models incorporating patient comorbidity, American Society of Anesthesiologists (ASA) class, and emergency status were used to analyze odds of receiving surgery after 5 days from hospital admission (Eastern Association for the Surgery of Trauma guidelines) and of undergoing an open operation. RESULTS Patients who waited more than 5 days for a procedure had greater adjusted odds of postoperative complication (odds ratio [OR] 1.56 95% CI 1.37 to 1.79) compared with those waiting 5 days or less. Similarly, open procedures had higher odds of complication compared with laparoscopic (OR 2.31 95% CI 2.00 to 2.68). Regression analysis demonstrated that black patients were significantly more likely than white patients to wait more than 5 days for surgery (OR 1.31 95% CI [1.13-1.53]) and undergo open surgery (OR 1.56, 95% CI 1.36 to 1.79). There was no statistical difference for Hispanics patients waiting more than 5 days (OR 0.98, 95% CI 0.73 to 1.31) or receiving open surgery (OR 0.84, 95% CI 0.70 to 1.01) compared with white patients. CONCLUSIONS Clinical decisions regarding SBO management differ based on patient race. Future studies focusing on the surgical decision-making process and the influence of bias are needed.
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Affiliation(s)
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kimberly A Davis
- Department of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, CT.
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Chiu AS, Thomas P, Killelea BK, Horowitz N, Chagpar AB, Lannin DR. Regional variation in breast cancer surgery: Results from the National Cancer Database (NCDB). Am J Surg 2017; 214:907-913. [DOI: 10.1016/j.amjsurg.2017.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 11/16/2022]
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