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Khalil M, Woldesenbet S, Munir MM, Katayama E, Mehdi Khan MM, Altaf A, Rashid Z, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery. World J Surg 2024; 48:1075-1083. [PMID: 38436547 DOI: 10.1002/wjs.12106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/09/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. METHODS A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. RESULTS Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p < 0.001). CONCLUSION Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.
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Affiliation(s)
- Mujtaba Khalil
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Zayed Rashid
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Susan Tsai
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Ali K, Sakowitz S, Chervu NL, Verma A, Bakhtiyar SS, Curry J, Cho NY, Benharash P. Association of dementia with clinical and financial outcomes following lobectomy for lung cancer. JTCVS OPEN 2023; 16:965-975. [PMID: 38204693 PMCID: PMC10775042 DOI: 10.1016/j.xjon.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 01/12/2024]
Abstract
Objective The number of adults with dementia is rising worldwide. Although dementia has been linked with inferior outcomes following various operations, this phenomenon has not been fully elucidated among patients undergoing elective lung resection. Using a national cohort, we evaluated the association of dementia with clinical and financial outcomes following lobectomy for cancer. Methods Adults undergoing lobectomy for lung cancer were identified within the 2010-2020 Nationwide Readmissions Database. Patients with a comorbid diagnosis of dementia were considered the Dementia cohort (others: Non-Dementia). Multivariable regressions were developed to evaluate the association between dementia and key outcomes. Results Of ∼314,436 patients, 2863 (0.9%) comprised the Dementia cohort. Compared with Non-Dementia, the Dementia cohort was older (75 vs 68 years, P < .001), less commonly female (49.4 vs 53.9%, P = .01), and had a greater burden of comorbid conditions. After adjustment, dementia remained associated with similar odds of in-hospital mortality (adjusted odds ratio [aOR], 0.86; 95% confidence interval [CI], 0.54-1.38) but greater likelihood of pneumonia (aOR, 1.31; CI, 1.04-1.65) and infectious complications (aOR, 1.37; CI, 1.01-1.87). Further, dementia was associated with longer length of stay (β +0.96 days; CI, 0.51-1.41), but no difference in hospitalization cost (β $1528; CI, -92 to 3148). Conclusions Patients with dementia faced similar odds of mortality, but greater complications and resource use following lobectomy for lung cancer. Novel interventions are needed to improve care coordination and develop standardized recovery pathways for this growing cohort.
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Affiliation(s)
- Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Nikhil L. Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
- Department of Surgery, University of California, Los Angeles, Calif
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
- Department of Surgery, University of Colorado, Aurora, Colo
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
- Department of Surgery, University of California, Los Angeles, Calif
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Kodadek LM, Moore MS, Canner JK, Schneider EB. Diverticulitis in Older Adults: Is Cognitive Impairment Associated With Outcomes? J Surg Res 2023; 291:359-366. [PMID: 37506436 DOI: 10.1016/j.jss.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/25/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Older age is associated with increased prevalence of both diverticulitis and cognitive impairment. The association between cognitive impairment and outcomes among older adults presenting to the emergency department (ED) for diverticulitis is unknown. METHODS Adults aged ≥65 y presenting to an ED with a primary diagnosis of colonic diverticulitis were identified using the Nationwide Emergency Department Sample (2016-2019) and stratified by cognitive impairment status in this retrospective cohort study. Multivariable Poisson regression models adjusted for patient age, sex, Elixhauser Comorbidity Index, primary payer status, and presence of complicated diverticulitis quantified relative risk of a) inpatient admission, b) operative intervention, and c) in-hospital mortality comparing patients with or without a diagnosis code suggestive of cognitive impairment. RESULTS Among 683,444 older adults with an ED encounter for diverticulitis from 2016 to 2019, there were 468,226 patients with isolated colonic diverticulitis and 26,388 (5.6%) with comorbid cognitive impairment. After adjustment, the risk of inpatient admission for those with cognitive impairment was 18% higher than for those without cognitive impairment (adjusted relative risks [aRR]: 1.18, 95% confidence interval [CI]: 1.17-1.20). Those with cognitive impairment were 34% more likely to undergo colectomy than those without cognitive impairment (aRR: 1.34, 95% CI: 1.24-1.44). Older adults with cognitive impairment had a 32% greater mortality than those without cognitive impairment (aRR: 1.32, 95% CI: 1.05-1.67). CONCLUSIONS Among older adults presenting for ED care with a primary diagnosis of colonic diverticulitis, individuals with cognitive impairment had higher rates of hospitalization, operative intervention, and in-hospital mortality than those without cognitive impairment.
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Affiliation(s)
- Lisa M Kodadek
- Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Miranda S Moore
- Department of Surgery, Center for Health Services and Outcomes Research, Yale School of Medicine, New Haven, Connecticut
| | - Joseph K Canner
- Department of Surgery, Center for Health Services and Outcomes Research, Yale School of Medicine, New Haven, Connecticut
| | - Eric B Schneider
- Department of Surgery, Center for Health Services and Outcomes Research, Yale School of Medicine, New Haven, Connecticut
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Clark CJ, Adler R, Xiang L, Shah SK, Cooper Z, Kim DH, Lin KJ, Hsu J, Lipsitz S, Weissman JS. Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study. Am J Surg 2023; 226:108-114. [PMID: 37031040 PMCID: PMC10330079 DOI: 10.1016/j.amjsurg.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/22/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery. METHODS Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes. RESULTS 5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001). CONCLUSIONS The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.
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Affiliation(s)
- Clancy J Clark
- Division of Surgical Oncology, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
| | - Rachel Adler
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Samir K Shah
- Division of Vascular Surgery, Department of General Surgery, University of Florida, Gainesville, FL, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John Hsu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
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David-Bercholz J, Acker L, Caceres AI, Wu PY, Goenka S, Franklin NO, Rodriguiz RM, Wetsel WC, Devinney M, Wright MC, Zetterberg H, Yang T, Berger M, Terrando N. Conserved YKL-40 changes in mice and humans after postoperative delirium. Brain Behav Immun Health 2022; 26:100555. [PMID: 36457825 PMCID: PMC9706140 DOI: 10.1016/j.bbih.2022.100555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022] Open
Abstract
Delirium is a common postoperative neurologic complication among older adults. Despite its prevalence (14%-50%) and likely association with inflammation, the exact mechanisms that underpin postoperative delirium are unclear. This project aimed to characterize systemic and central nervous system (CNS) inflammatory changes following surgery in mice and humans. Matched plasma and cerebrospinal fluid (CSF) samples from the "Investigating Neuroinflammation Underlying Postoperative Brain Connectivity Changes, Postoperative Cognitive Dysfunction, Delirium in Older Adults" (INTUIT; NCT03273335) study were compared to murine endpoints. Delirium-like behavior was evaluated in aged mice using the 5-Choice Serial Reaction Time Test (5-CSRTT). Using a well established orthopedic surgical model in the FosTRAP reporter mouse we detected neuronal changes in the prefrontal cortex, an area implicated in attention, but notably not in the hippocampus. In aged mice, plasma interleukin-6 (IL-6), chitinase-3-like protein 1 (YKL-40), and neurofilament light chain (NfL) levels increased after orthopedic surgery, but hippocampal YKL-40 expression was decreased. Given the growing evidence for a YKL-40 role in delirium and other neurodegenerative conditions, we assayed human plasma and CSF samples. Plasma YKL-40 levels were similarly increased after surgery, with a trend toward a greater postoperative plasma YKL-40 increase in patients with delirium. However, YKL-40 levels in CSF decreased following surgery, which paralleled the findings in the mouse brain. Finally, we confirmed changes in the blood-brain barrier (BBB) as early as 9 h after surgery in mice, which warrants more detailed and acute evaluations of BBB integrity following surgery in humans. Together, these results provide a nuanced understanding of neuroimmune interactions underlying postoperative delirium in mice and humans, and highlight translational biomarkers to test potential cellular targets and mechanisms.
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Key Words
- 4-OHT, 4-hydroxytamoxifen
- 5-CSRTT, 5-Choice Serial Reaction Time Test
- AD, Alzheimer’s disease
- Aging
- Attention
- BBB, blood-brain barrier
- Biomarkers
- CAM, Confusion AssessmentMethod
- CNS, central nervous system
- CSF, cerebrospinal fluid
- Delirium
- ELISA, enzyme-linked immunosorbent assay
- GFAP, glial fibrillary acidic protein
- IHC, immunohistochemistry
- IL-6, interleukin-6
- MMSE, mini-mental status exam
- NfL, neurofilament light chain
- PBS, phosphate-buffered saline
- PFA, paraformaldehyde
- PLC, prelimbic cortex
- ROI, regions of interest
- SIMOA, single molecule array
- Surgery
- TRAP, Targeted Recombination in Active Populations
- YKL-40
- YKL-40, chitinase-3-like protein 1
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Affiliation(s)
| | - Leah Acker
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Ana I. Caceres
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Pau Yen Wu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Saanvi Goenka
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Nathan O. Franklin
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
| | - Ramona M. Rodriguiz
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
| | - William C. Wetsel
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
- Department of Neurobiology, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
| | - Michael Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Mary Cooter Wright
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Ting Yang
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
- Department of Immunology, Duke University Medical Center, Durham, NC, United States
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Liu VY, Pawar A, Weissman JS, Kim DH. Clinical outcomes of cardiovascular procedures in older patients with dementia. J Am Geriatr Soc 2022; 70:3315-3317. [PMID: 35770876 PMCID: PMC9669092 DOI: 10.1111/jgs.17936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Victor Y. Liu
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel S. Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Dae Hyun Kim
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA
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Shah SK, Adler RR, Xiang L, Clark CJ, Cooper Z, Finlayson E, Kim DH, Lin KJ, Lipsitz SR, Weissman JS. Patients living with dementia have worse outcomes when undergoing high-risk procedures. J Am Geriatr Soc 2022; 70:2838-2846. [PMID: 35637607 PMCID: PMC9588582 DOI: 10.1111/jgs.17893] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/18/2022] [Accepted: 05/03/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with Alzheimer's Disease and Related Dementias (ADRD) undergoing inpatient procedures represent a population at elevated risk for adverse outcomes including postoperative complications, mortality, and discharge to a higher level of care. Outcomes may be particularly poor in patients with ADRD undergoing high-risk procedures. We sought to determine traditional (e.g., 30-day mortality) and patient-centered (e.g., discharge disposition) outcomes in patients with ADRD undergoing high-risk inpatient procedures. METHODS This retrospective cohort study analyzed electronic health records linked to fee-for-service Medicare claims data at a tertiary care academic health system. All patients from a large multi-hospital health system undergoing high-risk inpatient procedures from October 1, 2015 to September 30, 2017 with continuous Medicare Parts A and B enrollment in the 12 months prior to and 90 days following the procedure were included. RESULTS This study included 6779 patients. 536 (7.9%) had ADRD. A multivariable analysis of outcomes demonstrated higher risks for postoperative complications (OR 1.49, 95% CI 1.23-1.81) and 90-day mortality (OR 1.44 [95% CI 1.09-1.91]) in patients with ADRD compared to those without. Patients with ADRD were more likely to be discharged to a higher level of care (OR 1.70, 95% CI 1.32-2.18) and only 37.3% of patients admitted from home were discharged to home. CONCLUSIONS Compared to those without ADRD, patients living with ADRD undergoing high-risk procedures have poor traditional and patient-centered outcomes including increased risks for 90-day mortality, postoperative complications, longer hospital lengths of stay, and discharge to a higher level of care. These data may be used by patients, their surrogates, and their physicians to help align surgical decision-making with health care goals.
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Affiliation(s)
- Samir K Shah
- Division of Vascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Rachel R Adler
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Clancy J Clark
- Division of Surgical Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily Finlayson
- Department of Surgery, Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
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