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Vu JV, Kurowski JA, Achkar JP, Hull TL, Lipman J, Holubar SD, Steele SR, Lightner AL. Long-term Outcomes of Perianal Fistulas in Pediatric Crohn's Disease. Dis Colon Rectum 2023; 66:816-822. [PMID: 36856689 DOI: 10.1097/dcr.0000000000002690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Approximately 30% of Crohn's disease-related perianal fistulas heal in the adult population with conventional medical and surgical interventions. This healing rate remains unknown in pediatric patients. OBJECTIVE This study aimed to determine the healing rate of pediatric perianal Crohn's fistulas and identify factors associated with healing. DESIGN Retrospective case series. SETTING A quaternary referral center. PATIENTS Patients aged <18 years with a Crohn's perianal fistula, seen between January 1, 1991, and August 1, 2021, were included in the study. INTERVENTIONS Multivariable logistic regression to identify factors independently associated with perianal fistula healing. MAIN OUTCOME MEASURES Healing of Crohn's perianal fistula at the date of last clinical encounter, defined as the clinical note reporting a healed fistula or normal perianal examination. RESULTS A total of 91 patients aged <18 years with a Crohn's disease-related perianal fistula were identified (59% female, 76% white). The mean (SD) age at Crohn's diagnosis was 12 (±4) years. The mean follow-up after Crohn's diagnosis was 10 (±7) years. Overall, 89% of patients had a perianal fistula, 2% had an anovaginal fistula, and 10% had an ileal pouch-associated fistula. Patients underwent a median (interquartile range) of 2 (1-5) operations. A seton was placed in 60% of patients, 47% underwent abscess drainage, and 44% underwent fistulotomy or fistulectomy. Fistula healing occurred in 71% of patients over a median of 1.3 (0.4-2.5) years. Seven patients (7%) underwent proctectomy, and 3 (3%) underwent ileal pouch excision. After multivariable adjustment, younger age at diagnosis of perianal fistula was associated with an increased likelihood of healing (OR 0.56 for each increased year; 95% CI, 0.34-0.92). LIMITATIONS Retrospective, single institution. CONCLUSIONS Over two-thirds of fistulas heal in pediatric Crohn's disease patients with conventional surgical and medical intervention. Younger age at fistula development is associated with an increased likelihood of healing. See Video Abstract at http://links.lww.com/DCR/C185 . RESULTADOS A LARGO PLAZO DE LAS FSTULAS PERIANALES EN LA ENFERMEDAD DE CROHN EN PACIENTES PEDITRICOS ANTECEDENTES:Aproximadamente el 30% de las fístulas perianales relacionadas con la enfermedad de Crohn se curan en la población adulta con intervenciones médicas y quirúrgicas convencionales. Esta tasa de curación sigue siendo desconocida en pacientes pediátricos.OBJETIVO:Determinar la tasa de curación de las fístulas de Crohn perianales en población pediátrica e identificar los factores asociados con la curación.DISEÑO:Serie de casos retrospectiva.ESCENARIO:Un centro de referencia cuaternario.PACIENTES:Pacientes menores de 18 años con fístula(s) perianal(es) por enfermedad de Crohn, atendidos entre el 1 de enero de 1991 y el 1 de agosto de 2021.INTERVENCIONES:Regresión logística multivariable para identificar factores asociados de forma independiente con la cicatrización de la fístula perianal.PRINCIPALES MEDIDAS DE RESULTADO:Curación de la fístula perianal de Crohn en la fecha del último encuentro clínico, definida como la nota clínica que informa una fístula curada o un examen perianal normal.RESULTADOS:Se identificó un total de 91 pacientes <18 años de edad con una fístula perianal relacionada con la enfermedad de Crohn (59% mujeres, 76% blancos). La edad media (DE) al diagnóstico de Crohn fue de 12 (±4) años. El seguimiento medio tras el diagnóstico de Crohn fue de 10 (±7) años. En general, el 89 % de los pacientes tenía fístula perianal, el 2 % tenía fístula anovaginal y el 10 % de los pacientes tenía fístula asociada a reservorio ileal. Los pacientes fueron sometidos a una mediana (RIC) de 2 (1-5) operaciones. En el 60% de los pacientes se colocó sedal, en el 47% se drenó el absceso y en el 44% se realizó fistulotomía o fistulectomía. La curación de la fístula se produjo en el 71% de los pacientes durante una mediana de 1,3 (0,4-2,5) años. Siete pacientes (7%) se sometieron a proctectomía y 3 (3%) se sometieron a escisión del reservorio ileal. Después del ajuste multivariable, la edad más joven en el momento del diagnóstico de la fístula perianal se asoció con una mayor probabilidad de curación (OR 0,56 por cada año de aumento, IC del 95%, 0,34-0,92).LIMITACIONES:Retrospectivo, institución única.CONCLUSIONES:Más de dos tercios de las fístulas se curan en pacientes pediátricos con enfermedad de Crohn con intervención médica y quirúrgica convencional. Una edad más joven en el momento del desarrollo de la fístula se asocia con una mayor probabilidad de curación. Consulte Video Resumen en http://links.lww.com/DCR/C185 . (Traducción--Dr. Felipe Bellolio ).
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Affiliation(s)
- Joceline V Vu
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jacob A Kurowski
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jean-Paul Achkar
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeremy Lipman
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Vu JV, Lussiez A. Smoking Cessation for Preoperative Optimization. Clin Colon Rectal Surg 2023; 36:175-183. [PMID: 37113283 PMCID: PMC10125302 DOI: 10.1055/s-0043-1760870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.
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Affiliation(s)
- Joceline V. Vu
- Department of Surgery, Temple University Hospital System, Philadelphia, Pennsylvania
| | - Alisha Lussiez
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
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Cheong JY, Vu JV, Connelly TM, Tabbaa J, Gunter R, Liska D, Gorgun E, Steele SR, Valente MA. The impact of race and socioeconomic status on stage IV colorectal cancer survival. Am J Surg 2023; 225:523-526. [PMID: 36586755 DOI: 10.1016/j.amjsurg.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/01/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aims of this study were to determine the impact of race and socioeconomics on survival in patients with stage IV colorectal cancer. METHODS A prospective database of stage IV colorectal cancer patients treated at a multi-hospital health system from 2015 to 2019 was retrospectively analyzed. Univariate and multivariate survival analysis using log-rank Mantel-Cox test and Cox proportional hazard model were performed to determine the impact of race, socioeconomic factors, presentation, and treatment on overall survival. RESULTS 4012 patients were diagnosed with colorectal cancer, of which 803 patients were stage IV. There were 677 (84.3%) White, and 108 (13.4%) Black patients. Black patients have worse 5-year overall survival than white patients (HR 1.43 (1.09-1.87)). Patients who received chemotherapy had significantly better survival than patients who did not receive chemotherapy (HR 0.58 (0.47-0.71)). Black patients have significantly lower rates of receiving chemotherapy as compared to white patients (61.1% vs 75.37%, p = 0.0018). CONCLUSION Patients with Stage IV colorectal cancer have worse survival if they are black, older age, and did not receive chemotherapy.
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Affiliation(s)
- Ju Yong Cheong
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joceline V Vu
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tara M Connelly
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jenna Tabbaa
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Gunter
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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Abstract
OBJECTIVE To evaluate the association between postoperative opioid prescription size and patient-reported satisfaction among surgical patients. SUMMARY BACKGROUND DATA Opioids are overprescribed after surgery, which negatively impacts patient outcomes. The assumption that larger prescriptions increase patient satisfaction has been suggested as an important driver of excessive prescribing. METHODS This prospective cohort study evaluated opioid-naive adult patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, and minor hernia repair between January 1 and May 31, 2018. The primary outcome was patient satisfaction, collected via a 30-day postoperative survey. Satisfaction was measured on a scale of 0 to 10 and dichotomized into "highly satisfied" (9-10) and "not highly satisfied" (0-8). The explanatory variable of interest was size of opioid prescription at discharge from surgery, converted into milligrams of oral morphine equivalents (OME). Hierarchical logistic regression was performed to evaluate the association between prescription size and satisfaction while adjusting for clinical covariates. RESULTS One thousand five hundred twenty patients met the inclusion criteria. Mean age was 53 years and 43% of patients were female. One thousand two hundred seventy-nine (84.1%) patients were highly satisfied and 241 (15.9%) were not highly satisfied. After multivariable adjustment, there was no significant association between opioid prescription size and satisfaction (OR 1.00, 95% CI 0.99-1.00). The predicted probability of being highly satisfied ranged from 83% for the smallest prescription (25 mg OME) to 85% for the largest prescription (750 mg OME). CONCLUSIONS In a large cohort of patients undergoing common surgical procedures, there was no association between opioid prescription size at discharge after surgery and patient satisfaction. This implies that surgeons can provide significantly smaller opioid prescriptions after surgery without negatively affecting patient satisfaction.
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Affiliation(s)
- Brian T Fry
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Ryan A Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Jay S Lee
- Department of Surgery, Memorial Sloan Kettering, New York, NY
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
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Rivard SJ, Vu JV, Kanters AE, Park J, Berho M, Hendren S. Interactive Training Program Improves Surgeon and Pathologist Comfort Level With Total Mesorectal Excision Grading for Rectal Cancer. Dis Colon Rectum 2022; 65:238-245. [PMID: 34759249 DOI: 10.1097/dcr.0000000000002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total mesorectal excision for rectal cancer has been shown to decrease local recurrence and improve survival, and specimen grading is recommended as a best practice. However, specimen grading remains underutilized in the United States potentially because of the lack of surgeon and pathologist training in the technique. OBJECTIVE This study aimed to determine whether an interactive webinar improves physician comfort with mesorectal grading. DESIGN To test the effect of the program, participants completed a survey before and after participating. SETTINGS Twelve Michigan Surgical Quality Collaborative hospitals volunteered to participate in a Total Mesorectal Excision Project. PARTICIPANTS Total mesorectal excision grading training program participants were surgeons, surgery residents, pathologists, and pathology assistants from 12 hospitals. MAIN OUTCOME MEASURES Comfort with grading total mesorectal excision specimens was our main outcome measure. Prewebinar surveys also measured familiarity, previous experience, and training in grade assignment, as well as interest in the training program. Postwebinar surveys measured webinar relevance and effectiveness as well as participant intention to use content in practice. RESULTS A total of 34 participants completed the prewebinar survey and 28 participants completed the postwebinar survey. The postwebinar overall median comfort level with specimen grading of 3.64 was significantly higher than the prewebinar overall median comfort level of 2.94 (95% CI, 3.32-3.96 versus 95% CI 2.56-3.32; p = 0.007). When evaluated separately, both surgeons and pathologists reported significantly higher comfort levels with total mesorectal excision grading after the webinar. LIMITATIONS Six participants did not complete the postwebinar survey. Surgery residents and pathology assistants were analyzed with practicing surgeons and pathologists. The pre- and postwebinar surveys were deidentified, so paired analysis was not possible. CONCLUSIONS Our total mesorectal excision grading training program improved the comfort level of both surgeons and pathologists with specimen grading. Survey results also demonstrate that providers are interested in receiving training in rectal cancer specimen grading. See Video Abstract at http://links.lww.com/DCR/B766.PROGRAMA DE ENTRENAMIENTO INTERACTIVO MEJORA EL NIVEL DE COMODIDAD DEL CIRUJANO Y DEL PATÓLOGO CON LA CLASIFICACIÓN DE LA ESCISIÓN TOTAL DEL MESORRECTO PARA EL CÁNCER DE RECTO. ANTECEDENTES Se ha demostrado que la escisión total del mesorrecto para el cáncer de recto disminuye la recurrencia local y mejora la supervivencia, y se recomienda la clasificación de la muestra como buena práctica de rutina. Sin embargo, sigue siendo poco utilizado en los Estados Unidos debido principalmente a la falta de formación en la técnica de cirujanos y patólogos. OBJETIVO Determinar si un seminario interactivo en línea mejora la comodidad del médico con la clasificación mesorrectal. DISEO Para probar el efecto del programa, los participantes completaron una encuesta antes y después de haber participado de la misma. MARCO Doce hospitales en cooperación sobre la calidad quirúrgica de Michigan se ofrecieron como voluntarios para participar en el proyecto de Escisión Total de Mesorrecto. PARTICIPANTES Los participantes del programa de entrenamiento en la clasificación de escisión total de mesorrecto fueron cirujanos, residentes de cirugía, patólogos y asistentes de patología de doce hospitales. PRINCIPALES RESULTADOS MEDIDOS La comodidad con la clasificación de las muestras de escisión total de mesorrecto fue nuestro principal resultado de medición. Las encuestas previas al seminario en línea también midieron la familiaridad, la experiencia y entrenamiento previo en la clasificación, así como el interés en el programa de entrenamiento. Las encuestas posteriores midieron la relevancia y la eficacia del seminario web, así como la intención de los participantes de utilizar en la practica el contenido. RESULTADOS Un total de 34 participantes completaron la encuesta previa, y 28 de ellos la completaron con posterioridad al seminario en línea.La mediana del nivel de comodidad general, posterior al seminario en línea, con respecto a la clasificación de la pieza de 3,64 fue significativamente mayor con respecto al valor de 2,94 previo al seminario (IC del 95%: 3,32 - 3,96 versus IC 2,56 - 3,32, respectivamente; valor de p = 0,007).Cuando fueron evaluados de manera separada, tanto los cirujanos como los patólogos reportaron niveles de comodidad significativamente más altos con la clasificación de escisión total de mesorrecto (TME) después del seminario en línea. LIMITACIONES Seis participantes no completaron la encuesta posterior al seminario en línea. Los residentes de cirugía y los asistentes de patología fueron analizados conjuntamente con los cirujanos y patólogos en ejercicio, respectivamente. Las encuestas previas y posteriores al seminario en línea fueron anónimas, anulándose la identificación, por lo que no fue posible realizar un análisis por pares. CONCLUSIONES Nuestro programa de entrenamiento en la clasificación de escisión total de mesorrecto mejoró el nivel de comodidad tanto de los cirujanos como de los patólogos con la clasificación de las muestras. Los resultados de la encuesta también demuestran que el personal involucrado está interesado en recibir capacitación en la clasificación de muestras de cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B766. (Traducción-Dr Osvaldo Gauto).
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Affiliation(s)
| | | | | | | | - Mariana Berho
- Department of Pathology and Laboratory Medicine Institute, Cleveland Clinic Florida, Weston, Florida
| | - Samantha Hendren
- Department of Colorectal Surgery, Michigan Medicine, Ann Arbor, Michigan
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Abstract
OBJECTIVE The aim of this study was to determine whether older adults are at higher risk of lasting functional and cognitive decline after surgery, and the impact of decline on survival and healthcare use. SUMMARY BACKGROUND DATA Patient-centered outcomes after surgery are poorly characterized. METHODS Using data from the Health and Retirement Study linked with Medicare, we matched older adults (≥65 years) who underwent one of 163 high-risk elective operations (ie, inpatient mortality of ≥1%) with nonsurgical controls between 1992 and 2012. Functional decline was defined as an increase in the number of activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) requiring assistance from baseline. Cognitive decline was defined by worse response to a test of memory and mental processing from baseline. Using logistic regression, we examined whether surgery was associated with functional and cognitive decline, and whether declines were associated with poorer survival and increased healthcare use. RESULTS The matched cohort of patients who did not undergo surgery consisted of 3591 (75%) participants compared to 1197 (25%) who underwent surgery. Patients who underwent surgery were at higher risk of functional and cognitive declines [adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI): 1.23-1.87 and aOR 1.32, 95% CI: 1.03-1.71]. Declines were associated with poorer long-term survival [hazard ratio (HR) 1.67, 95% CI: 1.43-1.94 and HR 1.35, 95% CI: 1.15-1.58], and were significantly associated with nearly all measures of increased healthcare utilization (P < 0.001). CONCLUSION Older adults undergoing high-risk surgery are at increased risk of developing lasting functional and cognitive declines.
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Affiliation(s)
| | - Yun Li
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Paul Abrahamse
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | | | | | - Maria J. Silveira
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System
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Abstract
OBJECTIVE To assess the association between preoperative opioid exposure and readmissions following common surgery. SUMMARY BACKGROUND DATA Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown. METHODS We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type. RESULTS Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29). CONCLUSIONS Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.
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Affiliation(s)
- Ruiqi Tang
- Medical Student, University of Michigan Medical School
| | - Katherine B. Santosa
- House Officer, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
| | | | - Lewei A. Lin
- Assistant Professor, Department of Psychiatry, Michigan Medicine Medicine and Research Investigator, VA Ann Arbor Healthcare System
| | - Yen-Ling Lai
- Analyst, Michigan Opioid Prescribing Engagement Network (Michigan OPEN)
| | - Michael J. Englesbe
- Darling Professor of Surgery, Section of Transplantation, Department of Surgery, Michigan Medicine
| | - Chad M. Brummett
- Associate Professor, Division of Pain Medicine, Department of Anesthesiology, Michigan Medicine
| | - Jennifer F. Waljee
- Associate Professor, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
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Abbott KL, George BC, Sandhu G, Harbaugh CM, Gauger PG, Ötleş E, Matusko N, Vu JV. Natural Language Processing to Estimate Clinical Competency Committee Ratings. J Surg Educ 2021; 78:2046-2051. [PMID: 34266789 DOI: 10.1016/j.jsurg.2021.06.013] [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: 03/05/2021] [Revised: 05/21/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Residency program faculty participate in clinical competency committee (CCC) meetings, which are designed to evaluate residents' performance and aid in the development of individualized learning plans. In preparation for the CCC meetings, faculty members synthesize performance information from a variety of sources. Natural language processing (NLP), a form of artificial intelligence, might facilitate these complex holistic reviews. However, there is little research involving the application of this technology to resident performance assessments. With this study, we examine whether NLP can be used to estimate CCC ratings. DESIGN We analyzed end-of-rotation assessments and CCC assessments for all surgical residents who trained at one institution between 2014 and 2018. We created models of end-of-rotation assessment ratings and text to predict dichotomized CCC assessment ratings for 16 Accreditation Council for Graduate Medical Education (ACGME) Milestones. We compared the performance of models with and without predictors derived from NLP of end-of-rotation assessment text. RESULTS We analyzed 594 end-of-rotation assessments and 97 CCC assessments for 24 general surgery residents. The mean (standard deviation) for area under the receiver operating characteristic curve (AUC) was 0.84 (0.05) for models with only non-NLP predictors, 0.83 (0.06) for models with only NLP predictors, and 0.87 (0.05) for models with both NLP and non-NLP predictors. CONCLUSIONS NLP can identify language correlated with specific ACGME Milestone ratings. In preparation for CCC meetings, faculty could use information automatically extracted from text to focus attention on residents who might benefit from additional support and guide the development of educational interventions.
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Affiliation(s)
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Paul G Gauger
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Erkin Ötleş
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Katzman C, Harker EC, Ahmed R, Keilin CA, Vu JV, Cron DC, Gunaseelan V, Lai YL, Brummett CM, Englesbe MJ, Waljee JF. The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use. Ann Surg 2021; 274:e410-e416. [PMID: 32427764 DOI: 10.1097/sla.0000000000003723] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery. BACKGROUND Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use. METHODS We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates. RESULTS In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89-2.03; remote intermittent: OR 4.7, 95% CI 4.46-4.93; recent intermittent: OR 12.2, 95% CI 11.49-12.90]. CONCLUSIONS Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery.
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Affiliation(s)
- Charles Katzman
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Emily C Harker
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Rizwan Ahmed
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Charles A Keilin
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Joceline V Vu
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Vidhya Gunaseelan
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Yen-Ling Lai
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- University of Michigan, Department of Anesthesiology, Ann Arbor, Michigan
| | - Michael J Englesbe
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Jennifer F Waljee
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
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10
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Vu JV, George BC, Clark M, Rivard SJ, Regenbogen SE, Kwakye G. Readiness of Graduating General Surgery Residents to Perform Colorectal Procedures. J Surg Educ 2021; 78:1127-1135. [PMID: 33431299 PMCID: PMC8217079 DOI: 10.1016/j.jsurg.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/19/2020] [Accepted: 12/16/2020] [Indexed: 05/11/2023]
Abstract
OBJECTIVE In the United States, the majority of colorectal procedures are performed primarily by nonfellowship trained general surgeons. Given that surgical technique and experience affect patient outcomes, it is important that general surgeons are well-trained to perform colorectal surgery operations. In this study, we evaluated how prepared general surgery residents were to perform colorectal procedures upon graduating residency. DESIGN This was a retrospective observational cohort study. Attending ratings of residents' intraoperative performance were collected with the System for Improving and Measuring Procedural Learning application from 9/2015 to 9/2018. Descriptive analyses and Bayesian mixed models were used to determine a resident's probability of being deemed competent upon graduating residency, controlling for core vs. advanced procedure, case complexity, and rater and resident effects. SETTING Faculty and residents within 30 teaching institutions within the Procedural Learning and Safety Collaborative (PLSC). PATIENTS We sampled colorectal procedures and categorized them as core or advanced based on American Board of Surgery designations. RESULTS A total of 564 residents were rated after 2102 operations (82% core, 18% advanced). A resident in their fifth year of clinical training had a 93% (95% CI 85-97%) adjusted probability of competent performance after a core procedure and 75% (95% CI 55-89%) after an advanced procedure. CONCLUSIONS General surgery residents were not universally deemed competent to perform colorectal procedures even at the end of residency. These gaps were more pronounced for advanced colorectal procedures. Current graduation requirements should be carefully reviewed to ensure residents are appropriately trained to meet the needs of their communities. Additionally, advanced training remains a critical resource for surgeons who will perform complex colorectal procedures in practice.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michiagn.
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, Michiagn
| | - Michael Clark
- Consulting for Statistics, Computing, and Analytics Research (CSCAR), University of Michigan, Ann Arbor, Michigan
| | | | | | - Gifty Kwakye
- Department of Surgery, University of Michigan, Ann Arbor, Michiagn
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11
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Kemp MT, Rivard SJ, Anderson S, Audu CO, Barrett M, Fry BT, Lane M, Vu JV, Young BAC, Englesbe M, Sandhu G, Coleman DM. Trainee Wellness and Safety in the Context of COVID-19: The Experience of One Institution. Acad Med 2021; 96:655-660. [PMID: 33208674 DOI: 10.1097/acm.0000000000003853] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The COVID-19 pandemic has had significant ramifications for provider well-being. During these unprecedented and challenging times, one institution's Department of Surgery put in place several important initiatives for promoting the well-being of trainees as they were redeployed to provide care to COVID-19 patients. In this article, the authors describe these initiatives, which fall into 3 broad categories: redeploying faculty and trainees, ensuring provider safety, and promoting trainee wellness. The redeployment initiatives are the following: reframing the team mindset, creating a culture of grace and forgiveness, establishing a multidisciplinary wellness committee, promoting centralized leadership, providing clear communication, coordinating between departments and programs, implementing phased restructuring of the department's services, establishing scheduling flexibility and redundancy, adhering to training regulations, designating a trainee ombudsperson, assessing physical health risks for high-risk individuals, and planning for structured deimplementation. Initiatives specific to promoting provider safety are appointing a trainee safety advocate, guaranteeing personal protective equipment and relevant information about these materials, providing guidance regarding safe practices at home, and offering alternative housing options when necessary. Finally, the initiatives put in place to directly promote trainee wellness are establishing an environment of psychological safety, providing mental health resources, maintaining the educational missions, solidifying a sense of community by showing appreciation, being attentive to childcare, and using social media to promote community morale. The initiatives to carry out the department's strategy presented in this article, which were well received by both faculty and trainee members of the authors' community, may be employed in other departments and even outside the context of COVID-19. The authors hope that colleagues at other institutions and departments, independent of specialty, will find the initiatives described here helpful during, and perhaps after, the pandemic as they develop their own institution-specific strategies to promote trainee wellness.
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Affiliation(s)
- Michael T Kemp
- M.T. Kemp is a general surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0001-8287-9984
| | - Samantha J Rivard
- S.J. Rivard is a general surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0003-1274-1183
| | - Sara Anderson
- S. Anderson is an oral and maxillofacial surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christopher O Audu
- C.O. Audu is a vascular surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0002-4183-8825
| | - Meredith Barrett
- M. Barrett is a transplant surgery fellow, Department of Surgery, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0001-5476-0118
| | - Brian T Fry
- B.T. Fry is a general surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0002-7185-8579
| | - Megan Lane
- M. Lane is a plastic surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joceline V Vu
- J.V. Vu is a general surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bree Ann C Young
- B.A.C. Young is a thoracic surgery resident, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Englesbe
- M. Englesbe is professor of surgery, Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0001-8691-9111
| | - Gurjit Sandhu
- G. Sandhu is associate professor of surgery and learning health sciences and vice chair of resident professional development, Department of Surgery, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0003-0258-7899
| | - Dawn M Coleman
- D.M. Coleman is associate professor of surgery, Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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12
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Brescia AA, Vu JV, He C, Li J, Harrington SD, Thompson MP, Norton EC, Regenbogen SE, Syrjamaki JD, Prager RL, Likosky DS. Determinants of Value in Coronary Artery Bypass Grafting. Circ Cardiovasc Qual Outcomes 2020; 13:e006374. [PMID: 33176461 DOI: 10.1161/circoutcomes.119.006374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to $10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation >24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay >14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P<0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with $45 526 at high-value hospitals (P<0.001), driven by higher readmission ($3675 versus $2177, P=0.005), professional ($7462 versus $6090, P<0.001), postacute care ($7315 versus $5947, P=0.031), and index hospitalization payments ($33 474 versus $30 800, P<0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus $752, P<0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P<0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services.
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Affiliation(s)
- Alexander A Brescia
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor
| | - Joceline V Vu
- Department of Surgery (J.V.V., S.E.R., J.D.S.), School of Public Health, University of Michigan, Ann Arbor
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.)
| | - Jun Li
- Department of Epidemiology (J.L.), School of Public Health, University of Michigan, Ann Arbor
| | | | - Michael P Thompson
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.).,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Department of Economics (E.C.N.), School of Public Health, University of Michigan, Ann Arbor.,Department of Health Management and Policy (E.C.N.), School of Public Health, University of Michigan, Ann Arbor.,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Department of Surgery (J.V.V., S.E.R., J.D.S.), School of Public Health, University of Michigan, Ann Arbor.,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - John D Syrjamaki
- Department of Surgery (J.V.V., S.E.R., J.D.S.), School of Public Health, University of Michigan, Ann Arbor.,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - Richard L Prager
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.)
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.)
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13
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Brown CS, Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee J, Englesbe M. Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system. BMJ Qual Saf 2020; 30:251-259. [PMID: 32938775 DOI: 10.1136/bmjqs-2020-011295] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system. METHODS We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time. RESULTS We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: -0.7 tablets of 5 mg oxycodone/month, 95% CI -1.0 to -0.5 tablets, p<0.001). After the first guideline release, prescription size declined by -1.4 tablets/month (95% CI -1.8 to -1.0 tablets, p<0.001). The difference between these slopes was significant (p=0.006). The second guideline release resulted in a relative increase in slope (-0.3 tablets/month, 95% CI -0.1 to -0.6, p<0.001). The third guideline release resulted in no change (p=0.563 for the intervention). Overall, mean (SD) prescription size decreased from 25 (17) tablets of 5 mg oxycodone to 12 (8) tablets. Opioid consumption also decreased from 11 (16) to 5 (7) tablets (p<0.001), while satisfaction and postoperative pain remained unchanged. CONCLUSIONS The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.
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Affiliation(s)
- Craig S Brown
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA .,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Ryan A Howard
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
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14
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Vu JV, Morris AM, Maguire LH, De Roo AC, Mukkamala A, Krauss JC, Regenbogen SE, Hendren S, Hardiman KM. Development and characteristics of a multidisciplinary colorectal cancer clinic. Am J Surg 2020; 221:826-831. [PMID: 32943178 DOI: 10.1016/j.amjsurg.2020.08.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/09/2020] [Accepted: 08/23/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Multidisciplinary cancer clinics deliver streamlined care and facilitate collaboration between specialties. We described patient volume and specialty service utilization, including surgery, of a multidisciplinary colorectal cancer clinic established at a tertiary care academic institution. METHODS We conducted a retrospective observational cohort study of adult patients with colorectal adenocarcinoma from 2012 to 2017. We performed a descriptive analysis of patient volume, percentage of rectal cancer patients, and the number of patients who saw and received surgery, chemotherapy, and radiation each year. RESULTS Over 5 years, 1711 patients were served at the multidisciplinary clinic. Patient volume increased 37%, from n = 228 (annualized) to n = 312. The percentage of rectal cancer patients increased from 29% in 2013 to 42% in 2017. The highest rate of utilization was for surgery; 792 (46%) patients had surgery at the multidisciplinary clinic institution, and 510 (30%) received chemotherapy there. Out of 635 rectal cancer patients, 114 (18%) received radiation there. CONCLUSIONS Over the five-year experience of a colorectal cancer-focused multidisciplinary clinic, overall patient volume increased by 37%. Over the study period, 63% of patients seen at the multidisciplinary clinic ultimately received at least one treatment modality at the clinic institution. Overall, the clinic's establishment resulted in the increased referral of complex patients.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, United States.
| | - Arden M Morris
- S-SPIRE Center, Department of Surgery, Stanford University, United States
| | | | - Ana C De Roo
- Department of Surgery, University of Michigan, United States
| | | | - John C Krauss
- Division of Hematology/Oncology, Department of Internal Medicine, and Department of Learning Health Sciences, University of Michigan, United States
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15
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Krapohl GL, Hemmila MR, Hendren S, Bishop K, Rogers R, Rocker C, Fasbinder L, Englesbe MJ, Vu JV, Campbell DA. Building, scaling, and sustaining a learning health system for surgical quality improvement: A toolkit. Learn Health Syst 2020; 4:e10215. [PMID: 32685683 PMCID: PMC7362672 DOI: 10.1002/lrh2.10215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 12/25/2022] Open
Abstract
This article describes how to start, replicate, scale, and sustain a learning health system for quality improvement, based on the experience of the Michigan Surgical Quality Collaborative (MSQC). The key components to operationalize a successful collaborative improvement infrastructure and the features of a learning health system are explained. This information is designed to guide others who desire to implement quality improvement interventions across a regional network of hospitals using a collaborative approach. A toolkit is provided (under Supporting Information) with practical information for implementation.
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Affiliation(s)
- Greta L. Krapohl
- Michigan Surgical Quality CollaborativeAnn ArborMichigan
- Department of SurgeryUniversity of MichiganAnn ArborMichigan
| | - Mark R. Hemmila
- Department of SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Kathy Bishop
- Michigan Surgical Quality CollaborativeAnn ArborMichigan
| | - Rhonda Rogers
- Michigan Surgical Quality CollaborativeAnn ArborMichigan
| | - Cheryl Rocker
- Michigan Surgical Quality CollaborativeAnn ArborMichigan
| | | | - Michael J. Englesbe
- Michigan Surgical Quality CollaborativeAnn ArborMichigan
- Department of SurgeryUniversity of MichiganAnn ArborMichigan
| | - Joceline V. Vu
- Department of SurgeryUniversity of MichiganAnn ArborMichigan
| | - Darrell A. Campbell
- Michigan Surgical Quality CollaborativeAnn ArborMichigan
- Department of SurgeryUniversity of MichiganAnn ArborMichigan
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Abstract
OBJECTIVE We sought to describe the differences in health care spending and utilization among patients who develop persistent postoperative opioid use. SUMMARY OF BACKGROUND DATA Although persistent opioid use following surgery has garnered concern, its impact on health care costs and utilization remains unknown. METHODS We examined insurance claims among 133,439 opioid-naive adults undergoing surgery. Outcomes included 6-month postoperative health care spending; proportion of spending attributable to admission, readmission, ambulatory or emergency care; monthly spending 6 months before and following surgery. We defined persistent opioid use as continued opioid fills beyond 3 months postoperatively. We used linear regression to estimate outcomes adjusting for clinical covariates. RESULTS In this cohort, 8103 patients developed persistent opioid use. For patients who underwent inpatient procedures, new persistent opioid use was associated with health care spending (+$2700 per patient, P < 0.001) compared with patients who did not develop new persistent use. For patients who underwent outpatient procedures, new persistent opioid use was similarly correlated with higher health care spending (+$1500 per patient, P < 0.001) compared with patients who did not develop new persistent use. Patients without persistent opioid use returned to baseline health care spending within 6 months, regardless of other complications. However, patients with persistent opioid use had sustained increases in spending by approximately $200 per month. CONCLUSION Unlike other postoperative complications, persistent opioid use is associated with sustained increases in spending due to greater readmissions and ambulatory care visits. Early identification of patients vulnerable to persistent use may enhance the value of surgical care.
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Affiliation(s)
- Jay S. Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Joceline V. Vu
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | | | | | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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17
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Harbaugh CM, Vu JV, DeJonckheere M, Kim N, Nichols LP, Chang T. Youth Perspectives of Prescription Pain Medication in the Opioid Crisis. J Pediatr 2020; 221:159-164. [PMID: 32143929 DOI: 10.1016/j.jpeds.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To characterize current youth perspectives of prescription pain medication. STUDY DESIGN In total, 1047 youths aged 14-24 years were recruited by targeted social media advertisements to match national demographic benchmarks. Youths were queried by open-ended text message prompts about exposure and access to prescription pain medication, perceived safety of prescribed and nonprescribed medication, and associations with the word "opioid." Responses were analyzed inductively for emerging themes and frequencies. RESULTS Among 745 respondents (71.2% response rate), 439 identified as female (59.3%), 561 as white (75.8%), and mean age was 18.3 ± 3.2 years. Previous exposure to prescription pain medication was reported by 377 respondents (52.0%), most commonly related to dentistry (32.8%), surgery (19.2%), and injury (12.0%). Nonmedical sources of access to prescription pain medication were identified by 256 respondents (36.9%) and medical sources other than their doctor by an additional 111 respondents (16.0%). Three additional themes emerged from youth responses: (1) prescribed medication was thought to be safer than nonprescribed medication, based on trust in doctors; (2) risks of addiction and overdose were thought to be greater for nonprescribed medication; (3) respondents had a widely ranging understanding of the word "opioid," from historical to current events, medical to illicit substances, and personal to public associations. CONCLUSIONS Although youths are aware of the opioid crisis, they perceive less risk of prescription pain medication prescribed by a doctor, than from other sources. Policies should target education to youth in clinical and nonclinical settings, highlighting the risks of addiction and overdose with all opioids.
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Affiliation(s)
| | - Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Noa Kim
- Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Lauren P Nichols
- Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Tammy Chang
- Department of Family Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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Abstract
OBJECTIVE We characterized patterns of preoperative opioid use in patients undergoing elective surgery to identify the relationship between preoperative use and subsequent opioid fill after surgery. BACKGROUND Preoperative opioid use is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use. METHODS We analyzed claims data from Clinformatics DataMart Database for patients aged 18 to 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative use was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of use. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid use group. We used logistic regression to examine likelihood of second fill by opioid use group. RESULTS Out of 267,252 patients, 102,748 (38%) filled an opioid prescription in the 12 months before surgery. Cluster analysis yielded 6 groups of preoperative opioid use, ranging from minimal (27.6%) to intermittent (7.7%) to chronic use (2.7%). Preoperative opioid use was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid use. Increasing preoperative use was associated with risk-adjusted likelihood of requiring a second opioid fill compared with naive patients [minimal use: odds ratio (OR) 1.49, 95% confidence interval (95% CI) 1.45-1.53; recent intermittent use: OR 6.51, 95% CI 6.16-6.88; high chronic use: OR 60.79, 95% CI 27.81-132.92, all P values <0.001). CONCLUSION Preoperative opioid use is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids before surgery, even minimal use increases the probability of needing additional postoperative prescriptions in the 30 days after surgery when compared with opioid-naive patients. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jay S Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Pooja Lagisetty
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Center for Clinical Management and Research, Ann Arbor VA
| | - Matthew Wixson
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
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19
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Vu JV, Sheetz KH, De Roo AC, Hiatt T, Hendren S. Variation in colectomy rates for benign polyp and colorectal cancer. Surg Endosc 2020; 35:802-808. [PMID: 32076864 DOI: 10.1007/s00464-020-07451-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Removal of pre-cancerous polyps on screening colonoscopy is a mainstay of colorectal cancer (CRC) prevention. Complex polyps may require surgical removal with colectomy, an operation with a 17% morbidity and 1.5% mortality rate. Recently, advanced endoscopic techniques have allowed some patients with complex polyps to avoid the morbidity of colectomy. However, the rate of colectomy for benign polyp in the United States is unclear, and variation in this rate across geographic regions has not been studied. We compared regional variation in colectomy rates for CRC versus benign polyp. METHODS We performed a retrospective population-based study of Medicare beneficiaries undergoing colectomy for CRC or benign polyp, using the 100% Medicare Provider Analysis and Review files from 2010 to 2015. We used multivariable linear regression to obtain population-based colectomy rates for CRC and benign polyp at the hospital referral region (HRR) level, adjusted for age, sex, and race. RESULTS Of 280,815 patients, 157,802 (65.8%) underwent colectomy for CRC compared to 81,937 (34.2%) for benign polyp. Across HRRs, colectomy rates varied 5.8-fold for cancer (0.32-1.84 per 1000 beneficiaries). However, there was a 69-fold variation for benign polyp (0.01-0.69). While the rate of colectomy for CRC was correlated with the rate of colectomy for benign polyp (slope = 0.61, 95% CI 0.48-0.75), HRRs with the lowest or highest rates of colectomy for CRC did not necessarily have similarly low or high rates for benign polyp. CONCLUSIONS The use of colectomy for benign polyp is much more variable compared to CRC, suggesting overuse of colectomy for benign polyp in some regions. This variation may stem from provider-level differences, such as endoscopists' referral practice or skill or surgeons' decision to perform colectomy, or from limited access to advanced endoscopists. Interventions to increase endoscopic resection of benign polyps may spare some patients the morbidity and cost of surgery.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
| | - Ana C De Roo
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
| | - Tadd Hiatt
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, 48103, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
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Vu JV, Harbaugh CM, De Roo AC, Biesterveld BE, Gauger PG, Dimick JB, Sandhu G. Leadership-Specific Feedback Practices in Surgical Residency: A Qualitative Study. J Surg Educ 2020; 77:45-53. [PMID: 31492642 PMCID: PMC6944744 DOI: 10.1016/j.jsurg.2019.08.020] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/02/2019] [Accepted: 08/19/2019] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The importance of feedback is well recognized in surgical training. Although there is increased focus on leadership as an essential competency in surgical training, it is unclear whether surgical residents receive effective feedback on leadership performance. We performed an exploratory qualitative study with surgical residents to understand current leadership-specific feedback practices in one surgical training program. DESIGN We conducted semistructured interviews with surgical residents. Using line-by-line coding in an iterative process, we focused on feedback on leadership performance to capture both semantic and conceptual data. SETTING The general surgery residency program at the University of Michigan, a tertiary care, academic institution. PARTICIPANTS Residents were purposively selected to include key informants and comprise a balanced sample with respect to postgraduate year, gender, and race. RESULTS Four major themes were identified during the thematic analysis: (1) the importance of feedback for leadership development in residency; (2) inadequacy of current feedback mechanisms; (3) barriers to giving and receiving leadership-specific feedback; and (4) resident-driven recommendations for better leadership feedback. CONCLUSIONS Many surgical residents do not receive effective leadership feedback, although they express strong desire for formal evaluation of leadership skills. Establishing avenues for feedback on leadership performance will help bridge this gap. Additionally, training to give and receive leadership-specific feedback may improve the quality and incorporation of delivered feedback for developing surgeon-leaders.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan.
| | - Calista M Harbaugh
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Ana C De Roo
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | | | - Paul G Gauger
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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De Roo AC, Vu JV, Regenbogen SE. Statewide Utilization of Multimodal Analgesia and Length of Stay After Colectomy. J Surg Res 2019; 247:264-270. [PMID: 31706540 DOI: 10.1016/j.jss.2019.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/23/2019] [Accepted: 10/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Both enhanced recovery and anesthesia literature recommend multimodal perioperative analgesia to hasten recovery, prevent adverse events, and reduce opioid use after surgery. However, adherence to, and outcomes of, these recommendations are unknown. We sought to characterize use of multimodal analgesia and its association with length of stay after colectomy. MATERIALS AND METHODS Within a statewide, 72-hospital collaborative quality initiative, we evaluated postoperative analgesia regimens among adult patients undergoing elective colectomy between 2012 and 2015. We used logistic regression to identify factors associated with the use of multimodal analgesia and performed multivariable linear regression to evaluate its association with postoperative length of stay (LOS). RESULTS Among 7265 patients who underwent elective colectomy in the study period, 4660 (64.1%) received multimodal analgesia, 2405 (33.1%) received opioids alone, and 200 (2.8%) received one nonopioid pain medication alone. Multimodal analgesia was independently associated with shorter adjusted postoperative LOS, compared with opioids alone (5.60 d [95% CI 5.38-5.81] versus 5.96 d [5.68-6.24], P = 0.016). CONCLUSIONS Multimodal analgesia is associated with shorter LOS, yet one-third of patients statewide received opioids alone after colectomy. As surgeons increasingly focus on our role in the opioid crisis, particularly in postdischarge opioid prescribing, we must also focus on inpatient postoperative pain management to limit opioid exposure. At the hospital level, this may have the added benefit of decreasing LOS and hastening recovery.
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Affiliation(s)
- Ana C De Roo
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
| | - Joceline V Vu
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Scott E Regenbogen
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
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Kanters AE, Vu JV, Schuman AD, Van Wieren I, Duby A, Hardiman KM, Hendren SK. Completeness of operative reports for rectal cancer surgery. Am J Surg 2019; 220:165-169. [PMID: 31630821 DOI: 10.1016/j.amjsurg.2019.09.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/20/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation. We sought to determine whether operative reports contain the key elements recommended by the National Accreditation Program for Rectal Cancer. METHODS Rectal cancer operative reports from June-December 2018 were submitted from ten hospitals in Michigan. These reports were analyzed to identify key elements in the synoptic operative template and assessed for completeness. RESULTS In total, 110 operative reports were reviewed. Thirty-one (28%) reports contained all 24 elements; all of these reports used a synoptic template. Overall, 62 (56%) reports used a synoptic template and 48 (44%) did not. Using a synoptic template significantly improved documentation, as these reports contained 92% of required elements, compared to 39% for narrative reports (p < 0.001). CONCLUSIONS/DISCUSSION Narrative operative reports inconsistently document rectal cancer resection. This study provides evidence that synoptic reporting will improve quality of documentation for rectal cancer surgery.
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Affiliation(s)
- Arielle E Kanters
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA.
| | - Joceline V Vu
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Ari D Schuman
- Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Inga Van Wieren
- Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Ashley Duby
- Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Karin M Hardiman
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA
| | - Samantha K Hendren
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
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Affiliation(s)
- Joceline V. Vu
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Calista M. Harbaugh
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
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Vu JV, Gunaseelan V, Dimick JB, Englesbe MJ, Campbell DA, Telem DA. Mechanisms of age and race differences in receiving minimally invasive inguinal hernia repair. Surg Endosc 2019; 33:4032-4037. [PMID: 30767140 DOI: 10.1007/s00464-019-06695-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/06/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Black patients and older adults are less likely to receive minimally invasive hernia repair. These differences by race and age may be influenced by surgeon-specific utilization rate of minimally invasive repair. In this study, we explored the association between race, age, and surgeon utilization of minimally invasive surgery (MIS) with the likelihood of receiving MIS inguinal hernia repair. METHODS A retrospective cohort study was performed in patients undergoing elective primary inguinal hernia repair from 2012 to 2016, using data from the Michigan Surgical Quality Collaborative, a 72-hospital clinical registry. Surgeons were stratified by proportion of MIS performed. Using hierarchical logistic regression models, we investigated the association between receiving MIS repair and race, age, and surgeon MIS utilization rate. RESULTS Out of 4667 patients, 1253 (27%) received MIS repair. Out of 190 surgeons, 81 (43%) performed only open repair. Controlling for surgeon MIS utilization, race was not associated with MIS receipt (OR 0.93, p = 0.775), but older patients were less likely to receive MIS repair (OR 0.41, p < 0.001). CONCLUSIONS Race differences were explained by surgeon MIS utilization, implicating access to MIS-performing surgeon as a mediator. Conversely, age disparity was independent of MIS utilization, even after adjusting for comorbidities, indicating some degree of provider bias against performing MIS repair in older patients. Interventions to address disparities should include systematic efforts to improve access, as well as provider and patient education for older adults.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA. .,Center for Health Outcomes and Policy, Ann Arbor, MI, 48109, USA.
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, 48109, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Center for Health Outcomes and Policy, Ann Arbor, MI, 48109, USA
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, 48109, USA
| | - Darrell A Campbell
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, 48109, USA
| | - Dana A Telem
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Center for Health Outcomes and Policy, Ann Arbor, MI, 48109, USA
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Vu JV, De Roo A, Hardiman KM. Can ZEB2 Be Used as a Molecular Marker for Risk Stratification of Patients With Colorectal Cancer? JAMA Netw Open 2018; 1:e183133. [PMID: 30646215 DOI: 10.1001/jamanetworkopen.2018.3133] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Ana De Roo
- Department of Surgery, Michigan Medicine, Ann Arbor
| | - Karin M Hardiman
- Division of Colorectal Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
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Fry BT, Lee JS, Howard R, Campbell DA, Brummett C, Waljee JF, Englesbe MJ, Vu JV. Opioid Prescribing and Patient Satisfaction after General Surgery. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Harbaugh CM, Vu JV, Barrett M, Englesbe MJ, Sandhu G, Dimick JB. Falling Through the Cracks: A Qualitative Analysis of Leadership Development in Surgical Residency. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Vu JV, Gunaseelan V, Krapohl GL, Englesbe MJ, Campbell DA, Dimick JB, Telem DA. Surgeon utilization of minimally invasive techniques for inguinal hernia repair: a population-based study. Surg Endosc 2018; 33:486-493. [PMID: 29987572 DOI: 10.1007/s00464-018-6322-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/29/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND MIS utilization for inguinal hernia repair is low compared to in other procedures. The impact of low adoption in surgeons is unclear, but may affect regional access to minimally invasive surgery (MIS). We explored the impact of surgeon MIS utilization in inguinal hernia repair across a statewide population. METHODS We analyzed 6723 patients undergoing elective inguinal hernia repair from 2012 to 2016 in the Michigan Surgical Quality Collaborative. The primary outcome was surgeon MIS utilization. The geographic distribution of high MIS-utilizing surgeons was compared across Hospital Referral Regions using Pearson's Chi-squared test. Hierarchical logistic regression was used to identify patient and hospital factors associated with MIS utilization. RESULTS Surgeon MIS utilization varied, with 58% of 540 surgeons performing no MIS repair. For the remaining surgeons, MIS utilization was bimodally distributed. High-utilization surgeons were unevenly distributed across region, with corresponding differences in regional MIS rate ranging from 10 to 48% (p < 0.001). MIS was used in 41% of bilateral and 38% of recurrent hernia. MIS repair was more likely with higher hospital volume and less likely for patients aged 65+ (OR 0.68, p = 0.003), black patients (OR 0.75, p = 0.045), patients with COPD (OR 0.57, p < 0.001), and patients in ASA class > 3 (OR 0.79 p < 0.001). CONCLUSIONS MIS utilization varies between surgeons, likely driving differences in regional MIS rates and leading to guideline-discordant care for patients with bilateral or recurrent hernia. Interventions to reduce this practice gap could include training programs in MIS repair, or regionalization of care to improve MIS access.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA. .,Center for Healthcare Outcomes and Policy, Ann Arbor, MI, 48109, USA.
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, 48109, USA
| | - Greta L Krapohl
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, 48109, USA
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, 48109, USA
| | - Darrell A Campbell
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, 48109, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI, 48109, USA
| | - Dana A Telem
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI, 48109, USA
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Lee JS, Parashar V, Miller JB, Bremmer SM, Vu JV, Waljee JF, Dossett LA. Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework. Ann Surg Oncol 2018; 25:1843-1851. [PMID: 29637436 PMCID: PMC5976533 DOI: 10.1245/s10434-018-6466-x] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Excessive opioid prescribing is common after curative-intent surgery, but little is known about what factors influence prescribing behaviors among surgeons. To identify targets for intervention, we performed a qualitative study of opioid prescribing after curative-intent surgery using the Theoretical Domains Framework, a well-established implementation science method for identifying factors influencing healthcare provider behavior. METHODS Prior to data collection, we constructed a semi-structured interview guide to explore decision making for opioid prescribing. We then conducted interviews with surgical oncology providers at a single comprehensive cancer center. Interviews were recorded, transcribed verbatim, then independently coded by two investigators using the Theoretical Domains Framework to identify theoretical domains relevant to opioid prescribing. Relevant domains were then linked to behavior models to select targeted interventions likely to improve opioid prescribing. RESULTS Twenty-one subjects were interviewed from November 2016 to May 2017, including attending surgeons, resident surgeons, physician assistants, and nurses. Five theoretical domains emerged as relevant to opioid prescribing: environmental context and resources; social influences; beliefs about consequences; social/professional role and identity; and goals. Using these domains, three interventions were identified as likely to change opioid prescribing behavior: (1) enablement (deploy nurses during preoperative visits to counsel patients on opioid use); (2) environmental restructuring (provide on-screen prompts with normative data on the quantity of opioid prescribed); and (3) education (provide prescribing guidelines). CONCLUSIONS Key determinants of opioid prescribing behavior after curative-intent surgery include environmental and social factors. Interventions targeting these factors are likely to improve opioid prescribing in surgical oncology.
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Affiliation(s)
- Jay S Lee
- Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Vartika Parashar
- Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Jacquelyn B Miller
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samantha M Bremmer
- Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Joceline V Vu
- Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA.
- Division of Surgical Oncology, University of Michigan Comprehensive Cancer Center, 3303 Cancer Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5932, USA.
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Vu JV, Englesbe MJ, Sheetz KH. Invited commentary: databases for surgical health services research: collaborative quality improvement programs. Surgery 2018; 164:S0039-6060(17)30883-8. [PMID: 29398032 DOI: 10.1016/j.surg.2017.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Michigan Surgical Quality Collaborative (MSQC), Ann Arbor, MI.
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Michigan Surgical Quality Collaborative (MSQC), Ann Arbor, MI
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Michigan Surgical Quality Collaborative (MSQC), Ann Arbor, MI
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Vu JV, Collins SD, Seese E, Hendren S, Englesbe MJ, Campbell DA, Krapohl GL. Evidence that a Regional Surgical Collaborative Can Transform Care: Surgical Site Infection Prevention Practices for Colectomy in Michigan. J Am Coll Surg 2017; 226:91-99. [PMID: 29111416 DOI: 10.1016/j.jamcollsurg.2017.10.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Surgical site infections (SSI) after colectomy are associated with increased morbidity and health care use. Since 2012, the Michigan Surgical Quality Collaborative (MSQC) has promoted a "bundle" of care processes associated with lower SSI risk, using an audit-and-feedback system for adherence, face-to-face meetings, and support for quality improvement projects at participating hospitals. The purpose of this study was to determine whether practices changed over time. STUDY DESIGN We previously found 6 processes of care independently associated with SSI in colectomy. From 2012 to 2016, we promoted a bundle of 3 care measures (cefazolin/metronidazole, oral antibiotics after mechanical bowel preparation, and normoglycemia) in 52 hospitals. Primary outcome was change in use of the 3-item SSI bundle. We also used a hierarchical logistic regression model to assess the association between 6-item compliance and SSI rate, morbidity, and health care use. RESULTS The use of cefazolin/metronidazole increased from 18.6% to 32.3% (p < 0.001), oral antibiotic preparation increased from 42.9% to 62.0% (p < 0.001). The increase in normoglycemia was not significant. Concurrently, the SSI rate fell from 6.7% to 3.9% in the 52 hospitals (p = 0.012). Patients receiving more bundle measures had decreased rates of SSI, sepsis, and pneumonia. Morbidity and health care use significantly decreased with increased bundle compliance. CONCLUSIONS These data show a significant increase in use of process measures promoted by a regional quality improvement collaborative, and an associated decrease in SSI after elective colectomy. These results highlight the promise of regional collaboratives to accelerate practice change and improve outcomes.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Stacey D Collins
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | - Elizabeth Seese
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | | | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI; Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | - Darrell A Campbell
- Department of Surgery, University of Michigan, Ann Arbor, MI; Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | - Greta L Krapohl
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI.
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Vu JV, Llarena NC, Estevez SL, Moravek MB, Jeruss JS. Oncofertility program implementation increases access to fertility preservation options and assisted reproductive procedures for breast cancer patients. J Surg Oncol 2016; 115:116-121. [PMID: 27966219 DOI: 10.1002/jso.24418] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [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: 03/22/2016] [Accepted: 08/02/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Breast cancer treatment can cause premature ovarian failure, yet the majority of young cancer patients do not receive adequate education about treatment effects before initiating chemotherapy. We studied the impact of an oncofertility program on access to fertility preservation. METHODS An oncofertility program was initiated to foster collaboration between oncologists and reproductive endocrinologists, and to help increase access to fertility preservation. Documented conversations about fertility concerns, specialist referrals, appointments, and fertility preservation procedures were compared between breast cancer patients from 2004 to 2006, before oncofertility program initiation, and 2007-2012, after program initiation. The study included women <45, stages 0-III, diagnosed before (n = 278) and after (n = 515) program initiation. RESULTS Demographics for the cohorts were similar. Fertility discussions (P < 0.0001), patients interested in maintaining fertility at diagnosis (P = 0.0041), referrals to reproductive endocrinologists (P < 0.0001), appointments (P < 0.0001), and fertility preservation procedures (P < 0.0183) increased significantly after programmatic implementation. CONCLUSIONS An oncofertility program increased discussions about fertility preservation and access to assisted reproductive procedures. This program positively impacted compliance with national guidelines advising reproductive-age cancer patients to be offered fertility preservation counseling as an initial component of the multidisciplinary care plan. J. Surg. Oncol. 2017;115:116-121. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Natalia C Llarena
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Molly B Moravek
- Department of Obstetrics and Gynecology, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Jacqueline S Jeruss
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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