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Ryan JF, Lesniak DM, Cordeiro E, Campbell SM, Rajaee AN. Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist. Ann Surg Oncol 2023; 30:4695-4713. [PMID: 37036590 DOI: 10.1245/s10434-023-13472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist. METHODS A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis. RESULTS A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies). CONCLUSIONS On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - David M Lesniak
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - A Nikoo Rajaee
- Department of Surgery, University of Alberta, Edmonton, Canada.
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2
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Chen B, McAlpine K, Lawson KA, Finelli A, Saarela O. Hierarchical causal variance decomposition for institution and provider comparisons in healthcare. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2023. [DOI: 10.1007/s10742-023-00301-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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3
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Brown-Johnson CG, Spargo T, Kling SMR, Saliba-Gustafsson EA, Lestoquoy AS, Garvert DW, Vilendrer S, Winget M, Asch SM, Maggio P, Nazerali RS. Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery 2021; 170:587-595. [PMID: 33941389 DOI: 10.1016/j.surg.2021.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/01/2021] [Accepted: 03/21/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility. METHODS This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits. RESULTS During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics. CONCLUSION Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.
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Affiliation(s)
- Cati G Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA.
| | - Tavish Spargo
- Division of Plastic and Reconstructive Surgery, Stanford Health Care, Stanford, CA
| | - Samantha M R Kling
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Erika A Saliba-Gustafsson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Anna Sophia Lestoquoy
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Donn W Garvert
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Stacie Vilendrer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Marcy Winget
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Paul Maggio
- Department of Surgery, Stanford Health Care, Stanford, CA
| | - Rahim S Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford Health Care, Stanford, CA
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Ratnayake I, Hebbard P, Feely A, Biswanger N, Decker K. Assessment of Breast Cancer Surgery in Manitoba: A Descriptive Study. ACTA ACUST UNITED AC 2021; 28:581-592. [PMID: 33478040 PMCID: PMC7903285 DOI: 10.3390/curroncol28010058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/12/2020] [Accepted: 01/13/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Variation in breast cancer surgical practice patterns can lead to poor clinical outcomes. It is important to measure and reduce variation to ensure all women diagnosed with breast cancer receive equitable, high-quality care. A population-based assessment of the variation in breast cancer surgery treatment and quality has never been conducted in Manitoba. The objective of this study was to assess the variation in surgical treatment patterns, quality of care, and post-operative outcomes for women diagnosed with invasive breast cancer. METHODS This descriptive study used data from the Manitoba Cancer Registry, Hospital Discharge Abstracts Database, Medical Claims, Manitoba Health Insurance Registry, and Statistics Canada. The study included women in Manitoba aged 20+ and diagnosed with invasive breast cancer between 1 January 2010 and 31 December 2014. RESULTS Axillary lymph node dissection (ALND) for node-negative disease ranged from 11.8% to 33.3%, timeliness (surgery within 30 days of consult) ranged from 33.3% to 60.2%, and re-excision ranged from 14.7% to 24.6% between health authorities. Women who underwent breast-conserving surgery had the shortest median length of stay and women who underwent mastectomy with immediate reconstruction had the longest median length of stay. In-hospital post-operative complications were higher among women who received mastectomy with immediate reconstruction (9.9%). CONCLUSION Variation in surgical treatment, quality, and outcomes exist in Manitoba. The findings from this study can be used to inform cancer service delivery planning, quality improvement efforts, and policy development. Influencing data-driven change at the health system level is paramount to ensuring Manitobans receive the highest quality of care.
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Affiliation(s)
- Iresha Ratnayake
- Department of Epidemiology & Cancer Registry, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada; (A.F.); (K.D.)
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P5, Canada;
- Correspondence: ; Tel.: +1-204-784-2781
| | - Pamela Hebbard
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P5, Canada;
- CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Allison Feely
- Department of Epidemiology & Cancer Registry, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada; (A.F.); (K.D.)
| | - Natalie Biswanger
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P5, Canada;
- Screening Programs, CancerCare Manitoba, Winnipeg, MB R3C 2B1, Canada
| | - Kathleen Decker
- Department of Epidemiology & Cancer Registry, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada; (A.F.); (K.D.)
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P5, Canada;
- Research Institute in Oncology & Hematology, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
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Jacox N, Webb C, Sharma V, Temple-Oberle C. Delivering Breast Reconstruction Information to Patients-Part 2: Women Report on Preferred Information Content. Plast Surg (Oakv) 2020; 28:196-203. [PMID: 33215033 DOI: 10.1177/2292550320925902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose To determine the type of information women want to be provided in order to make an informed decision as to whether, when, and using what technique to proceed with breast reconstruction. Method Using purposeful sampling, 19 patients who had recently undergone various breast reconstruction procedures were recruited to each participate in a 30- to 45-minute semi-structured interview. Participants shared their insights and beliefs regarding the type of breast reconstruction information they most valued prior to undergoing breast reconstruction surgery. Participants were also queried as to perceived information gaps. In some cases, the participants' partners or support persons were also interviewed. Grounded theory and thematic analysis assisted in interview transcript analysis. Results Eight topics were identified relating to women's informational needs around breast reconstruction. Examples include how to weigh the pros and cons of various breast reconstruction options to decide between flap or implant reconstruction, whether there are safety concerns with immediate breast reconstruction or nipple-sparing reconstruction, and expectations and advice on how to manage possibly unexpected intimacy issues after breast reconstruction. Conclusions Using mixed methods research methodology, 19 women reported on preoperative informational gaps relating to their recent breast reconstruction experiences. Patients report that adequate breast reconstruction information prior to breast reconstruction surgery helps them to manage their expectations, prepare for surgery and recovery, and improve postoperative satisfaction.
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Regional differences and trends in breast cancer surgical procedures and their relation to socioeconomic disparities and screening patterns. J Public Health (Oxf) 2020. [DOI: 10.1007/s10389-018-01007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
OBJECTIVE This study evaluates the impact of individual surgeons and institutions on the use of mastectomy or breast conserving surgery (BCS) among elderly women with breast cancer. SUMMARY OF BACKGROUND DATA Current literature characterizes patient clinical and demographic factors that increase likelihood of mastectomy use. However, the impact of the individual provider or institution is not well understood, and could provide key insights to biases in the decision-making process. METHODS A retrospective cohort study of 29,358 women 65 years or older derived from the SEER-Medicare linked database with localized breast cancer diagnosed from 2000 to 2009. Multilevel, multivariable logistic models were employed, with odds ratios (ORs) used to describe the impact of demographic or clinical covariates, and the median OR (MOR) used to describe the relative impact of the surgeon and institution. RESULTS Six thousand five hundred ninety-four women (22.4%) underwent mastectomy. Unadjusted rates of mastectomy ranged from 0% in the bottom quintile of surgeons to 58.0% in the top quintile. On multivariable analysis, the individual surgeon (MOR 1.97) had a greater impact on mastectomy than did the institution (MOR 1.71) or all other clinical and demographic variables except tumor size (OR 3.06) and nodal status (OR 2.95). Surgeons with more years in practice, or those with a lower case volume were more likely to perform mastectomy (P < 0.05). CONCLUSION The individual surgeon influences the likelihood of mastectomy for the treatment of localized breast cancer. Further research should focus on physician-related biases that influence this decision to ensure patient autonomy.
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Billig JI, Speth KA, Nasser JS, Wang L, Chung KC. Assessment of Surgeon Variation in Adherence to Evidence-Based Recommendations for Treatment of Trigger Finger. JAMA Netw Open 2019; 2:e1912960. [PMID: 31603484 PMCID: PMC6804023 DOI: 10.1001/jamanetworkopen.2019.12960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Stenosing tenosynovitis (trigger finger) affects approximately 2% of the population. Given the prevalence of trigger finger and rising health care costs, adherence to the cost-effective and evidence-based treatment algorithm will permit better outcomes and allocation of resources. OBJECTIVES To examine treatment patterns for trigger finger and to determine surgeon-level and patient-level factors that influence adherence to evidence-based treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study examined deidentified claims for treatment of trigger finger from a national insurance provider using the Clinformatics Data Mart database. Patients were included if they were 18 years or older and treated from January 1, 2002, through December 31, 2016 (excluding a washout period from July 1, 2008, until June 30, 2010), with a new diagnosis of single-digit trigger finger. Data were analyzed from December 21, 2018, through April 28, 2019. EXPOSURES Cost-effective and evidence-based research published in July 2009 for the treatment of trigger finger. MAIN OUTCOMES AND MEASURES After excluding the 1-year washout period on either side of July 1, 2009, adherence to the recommended treatment algorithm of 2 corticosteroid injections before surgical release of trigger finger was compared with practice before publication of research supporting this cost-effective and evidence-based approach. RESULTS In this analysis of 83 667 patients with trigger finger, 52 698 (63.0%) were women, and 20 045 (24.0%) had type 1 or 2 diabetes. Mean (SD) age was 61 (13) years. From 2002 to 2016, an overall increasing trend in adherence to the cost-effective and evidence-based approach to treatment was noted, with no significant increase in adherence in the postpublication era (67.5% vs 73.3%; P = .27). Substantial variation in adherence was observed at the surgeon level (intraclass correlation, 33%). Plastic surgeons had no change in adherence over time compared with orthopedic surgeons (odds ratio [OR], 1.00; 95% CI, 0.98-1.02; P = .90), whereas general surgeons had increased adherence (OR, 1.04; 95% CI, 1.02-1.06; P < .001). Higher-volume surgeons were also more adherent to these evidence-based recommendations (OR, 1.59; 95% CI, 1.53-1.65; P < .001). CONCLUSIONS AND RELEVANCE This study found substantial surgeon-level variation in adherence to evidence-based treatment of trigger finger. Surgeon specialty and volume were associated with differences in adherence. Efforts to understand surgeon barriers to implementation, regardless of physician specialty, appear to be necessary, and better implementation strategies may permit increased uptake of evidence-based treatment of trigger finger.
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Affiliation(s)
- Jessica I. Billig
- Veterans Affairs (VA)/National Clinician Scholars Program, VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
| | - Kelly A. Speth
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Jacob S. Nasser
- Comprehensive Hand Center, Section of Plastic Surgery, Michigan Medicine, Ann Arbor
| | - Lu Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Kevin C. Chung
- Comprehensive Hand Center, Section of Plastic Surgery, Michigan Medicine, Ann Arbor
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9
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Feng Y, Flitcroft K, van Leeuwen MT, Elshaug AG, Spillane A, Pearson SA. Patterns of immediate breast reconstruction in New South Wales, Australia: a population-based study. ANZ J Surg 2019; 89:1230-1235. [PMID: 31418524 PMCID: PMC6852512 DOI: 10.1111/ans.15381] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Abstract
Background The rate of immediate breast reconstruction (IBR) following mastectomy for breast cancer in Australia is low and varies between regions. To date, no previous Australian studies have examined IBR rates between all hospitals within a particular jurisdiction, despite hospitals being an important known contributor to variation in IBR rates in other countries. Methods We used cross‐classified random‐effects logistic regression models to examine the inter‐hospital variation in IBR rates by using data on 7961 women who underwent therapeutic mastectomy procedures in New South Wales (NSW) between January 2012 and June 2015. We derived IBR rates by patient‐, residential neighbourhood‐ and hospital‐related factors and investigated the underlying drivers for the variation in IBR. Results We estimated the mean IBR rate across all hospitals performing mastectomy to be 17.1% (95% Bayesian credible interval (CrI) 12.1–23.1%) and observed wide inter‐hospital variation in IBR (variance 4.337, CrI 2.634–6.889). Older women, those born in Asian countries (odds ratio (OR) 0.5, CrI 0.4–0.6), residing in neighbourhoods with lower socioeconomic status (OR 0.7, CrI 0.5–0.8 for the most disadvantaged), and who underwent surgery in public hospitals (OR 0.4, CrI 0.1–1.0) were significantly less likely to have IBR. Women residing in non‐metropolitan areas and attending non‐metropolitan hospitals were significantly less likely to undergo IBR than their metropolitan counterparts attending metropolitan hospitals. Conclusion Wide inter‐hospital variation raises concerns about potential inequities in access to IBR services and unmet demand in certain areas of NSW. Explaining the underlying drivers for IBR variation is the first step in identifying policy solutions to redress the issue.
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Affiliation(s)
- Yingyu Feng
- Menzies Centre for Health Policy, Sydney School of Public Health, Charles Perkins Centre D17, The University of Sydney, Sydney, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kathy Flitcroft
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Breast and Surgical Oncology, The Poche Centre, Sydney, New South Wales, Australia
| | - Marina T van Leeuwen
- Centre for Big Data Research in Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, Charles Perkins Centre D17, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Spillane
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Breast and Surgical Oncology, The Poche Centre, Sydney, New South Wales, Australia.,Breast and Melanoma Surgery Units, The Mater Hospital, Sydney, New South Wales, Australia.,Breast and Melanoma Surgery Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Menzies Centre for Health Policy, Sydney School of Public Health, Charles Perkins Centre D17, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Big Data Research in Health, The University of New South Wales, Sydney, New South Wales, Australia
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Abstract
BACKGROUND The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care. METHODS The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included. RESULTS The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction. CONCLUSIONS Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.
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Racial Differences in Complication Risk Following Emergency General Surgery: Who Your Surgeon Is May Matter. J Surg Res 2019; 235:424-431. [PMID: 30691824 DOI: 10.1016/j.jss.2018.05.086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/23/2018] [Accepted: 05/31/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Understanding the mechanisms that lead to health-care disparities is necessary to create robust solutions that ensure all patients receive the best possible care. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing an emergency general surgery (EGS). MATERIALS AND METHODS Using the Florida State Inpatient Database, we analyzed patients who underwent one or more of seven EGS procedures from 2010 to 2014. The primary outcome was development of a major postoperative complication. To determine the individual surgeon effect on complications, we performed multilevel mixed effects modeling, adjusting for clinical and hospital factors, such as diagnosis, comorbidities, and hospital teaching status and volume. RESULTS 215,745 cases performed by 5816 surgeons at 198 hospitals were included. The overall unadjusted complication rate was 8.6%. Black patients had a higher adjusted risk of having a complication than white patients (odds ratio 1.12, 95% confidence interval 1.03-1.22). Surgeon random effects, when hospital fixed effects were held constant, accounted for 27.2% of the unexplained variation in complication risk among surgeons. This effect was modified by patient race; for white patients, surgeon random effects explained only 12.4% of the variability, compared to 52.5% of the variability in complications among black patients. CONCLUSIONS This multiinstitution analysis within a single large state demonstrates that not only do black patients have a higher risk of developing a complication after undergoing EGS than white patients but also surgeon-level effects account for a larger proportion of the between-surgeon variation. This suggests that the individual surgeon contributes to racial disparities in EGS.
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12
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Surgeon-driven variability in emergency general surgery outcomes: Does it matter who is on call? Surgery 2018; 164:1109-1116. [DOI: 10.1016/j.surg.2018.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/07/2018] [Accepted: 07/09/2018] [Indexed: 11/21/2022]
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Duan L, Kawatkar AA. Comparative Effectiveness of Surgical Options for Patients with Ductal Carcinoma In Situ: An Instrumental Variable Approach. Perm J 2018; 22:17-132. [PMID: 30028673 DOI: 10.7812/tpp/17-132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Many patients with ductal carcinoma in situ (DCIS) receive treatment that is too extensive. OBJECTIVE To take a holistic approach in comparing the effectiveness in cancer prevention between mastectomy and breast-conserving surgery (BCS) for patients with DCIS. DESIGN Female Kaiser Permanente Southern California members who underwent surgery for treatment of single primary DCIS from 2004 to 2014 were identified by the Kaiser Permanente Southern California cancer registry and HealthConnect database. METHOD Two-stage residual inclusion with the surgeon's preference of surgical procedure type as the instrumental variable was used to examine the effect of surgical choice on DCIS recurrence, breast cancer progression, and other cancer progression. Traditional Cox proportional hazards models were used for comparison. RESULTS Of qualified subjects, 72.2% underwent BCS and 27.8% underwent mastectomy. Patients were likelier to receive BCS if their surgeon preferred to perform BCS in the past 5 years (odds ratio = 1.02, 95% confidence interval = 1.02-1.03). Although traditional Cox proportional hazards models suggested an association between BCS and higher risk of DCIS recurrence, no significant effect was observed when we adjusted for endogeneity. Neither model showed significant differences between mastectomy and BCS in progression of any cancer. CONCLUSION No significant benefit was observed with a more aggressive surgical procedure in preventing DCIS recurrence or cancer progression in a diverse population. Many patients with DCIS could benefit from BCS with preservation of their body image. Breast conservation followed-up with cancer surveillance is a rational approach to ensure affordable, effective care for patients with DCIS.
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Affiliation(s)
- Lewei Duan
- Biostatistician in the Department of Research and Evaluation for Kaiser Permanente Southern California in Pasadena.
| | - Aniket A Kawatkar
- Research Scientist in the Department of Research and Evaluation for Kaiser Permanente Southern California in Pasadena.
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14
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Udyavar NR, Salim A, Havens JM, Cooper Z, Cornwell EE, Lipsitz SR, Scott JW, Haider AH. The impact of individual physicians on outcomes after trauma: is it the system or the surgeon? J Surg Res 2018; 229:51-57. [PMID: 29937016 DOI: 10.1016/j.jss.2018.02.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/29/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma. METHODS Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size. RESULTS There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon. CONCLUSIONS At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management.
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Affiliation(s)
- N Rhea Udyavar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Ali Salim
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joaquim M Havens
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward E Cornwell
- Department of Surgery, Howard University Hospital, Washington, District of Columbia
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - John W Scott
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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15
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Shumway DA, McLeod CM, Morrow M, Li Y, Kurian AW, Sabolch A, Hamilton AS, Ward KC, Katz SJ, Hawley ST, Jagsi R. Patient Experiences and Clinician Views on the Role of Radiation Therapy for Ductal Carcinoma In Situ. Int J Radiat Oncol Biol Phys 2018; 100:1237-1245. [PMID: 29439886 PMCID: PMC8603836 DOI: 10.1016/j.ijrobp.2018.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/18/2017] [Accepted: 01/03/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE To evaluate patient experiences with decisions regarding radiation therapy (RT) for ductal carcinoma in situ (DCIS), and to assess clinician views on the role of RT for DCIS with favorable features in the present era. METHODS AND MATERIALS A sample of women with newly diagnosed breast cancer from the population-based Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries were sent surveys approximately 2 months after undergoing breast-conserving surgery (BCS), with a 70% response rate. The analytic sample was limited to 538 respondents with unilateral DCIS. We also surveyed 761 surgeons and radiation oncologists treating breast cancer in those regions, of whom, 539 responded (71%). RESULTS After BCS, 23% of patients omitted RT, with twice the rate of omission in Los Angeles County relative to Georgia (31% vs 16%; P < .001). The most common reasons for omitting RT were advice from a clinician that it was not needed (62%) and concern about side effects (24%). Cost and transportation were not reported as influential considerations. After covariate adjustment, low- and intermediate-grade disease (odds ratio [OR] 5.5, 95% confidence interval [CI] 2.5-12; and OR 3.2, 95% CI 1.7-6.1, respectively) and Los Angeles County SEER site (OR 4.3, 95% CI 2.3-8.2) were significantly associated with greater RT omission. Of the responding clinicians, 62% would discuss RT omission for a patient with DCIS with favorable features. Clinicians in Los Angeles County were more likely to discuss RT omission than were those in Georgia (67% vs 56%; P = .01). Approximately one third of clinicians would obtain the Oncotype DX DCIS score. CONCLUSIONS The heterogeneity in RT omission after BCS for DCIS continues to be substantial, with systematic differences in provider opinions across the 2 regions we studied. Enhanced precision of recurrence estimates, guidance from professional organizations, and better communication are needed to improve the consistency of treatment in this controversial area.
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Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Chandler M McLeod
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yun Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Allison W Kurian
- Department of Medicine, Stanford University, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California
| | - Aaron Sabolch
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ann S Hamilton
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan.
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16
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Larson KE, Grobmyer SR, Reschke MAB, Valente SA. Fifteen-Year Decrease in General Surgery Resident Breast Operative Experience: Are We Training Proficient Breast Surgeons? JOURNAL OF SURGICAL EDUCATION 2018; 75:247-253. [PMID: 28818349 DOI: 10.1016/j.jsurg.2017.07.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The goal of the study was to evaluate trends in general surgery resident breast cases over the past 15 years. STUDY DESIGN The Accreditation Council for Graduate Medical Education (ACGME) Case Logs Statistics Reports from 2000 to 2015 were reviewed for average breast-specific case numbers and trends over time. ACGME data were available for all cases and breast-specific cases including the following: excisional biopsy/lumpectomy, simple mastectomy, modified radical mastectomy, and sentinel lymph node excision. SETTING The study evaluation was conducted at Cleveland Clinic, Cleveland, Ohio. PARTICIPANTS No individuals directly participated in this project. However, all general surgery residents at ACGME-accredited programs are represented in this analysis by virtue of the ACGME Case Logs Statistics Reports. RESULTS Total residency case volume increased by 2% (2000-2015, p = 0.0159), with 2015 graduates logging 985.5 cases. In contrast, breast cases decreased by 17.1%. The largest drops were in modified radical mastectomy (61.5% decrease, p = 0.0001) and excisional biopsy/lumpectomy (25.8% decrease). Simple mastectomy increased from 6.0 to 10.8 cases (p = 0.0001). Sentinel lymph node excision fluctuated, but has been down-trending recently (67.3% decrease from 2010 to 2015, p = 0.0001). Decreased experience is occurring at both junior and senior resident levels. CONCLUSIONS Breast case operative experience for general surgery residents decreased by 17% between 2000 and 2015, despite increase in overall operative volume. Residents have less experience in more advanced cases including axillary management, raising concern about the proficiency of graduating surgeons with respect to these procedures. It is reasonable to set national minimums for resident breast operative experience to ensure that individuals are appropriately trained to perform these cases in practice.
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Affiliation(s)
- Kelsey E Larson
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mika A B Reschke
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
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17
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Hawley ST, Griffith KA, Hamilton AS, Ward KC, Morrow M, Janz NK, Katz SJ, Jagsi R. The association between patient attitudes and values and the strength of consideration for contralateral prophylactic mastectomy in a population-based sample of breast cancer patients. Cancer 2017; 123:4547-4555. [PMID: 28810062 PMCID: PMC5907487 DOI: 10.1002/cncr.30924] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/19/2017] [Accepted: 07/05/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Little is known about how the individual decision styles and values of breast cancer patients at the time of treatment decision making are associated with the consideration of different treatment options and specifically with the consideration of contralateral prophylactic mastectomy (CPM). METHODS Newly diagnosed patients with early-stage breast cancer who were treated in 2013-2014 were identified through the Surveillance, Epidemiology, and End Results registries of Los Angeles and Georgia and were surveyed approximately 7 months after surgery (n = 2578; response rate, 71%). The primary outcome was the consideration of CPM (strong vs less strong). The association between patients' values and decision styles and strong consideration was assessed with multivariate logistic regression. RESULTS Approximately one-quarter of women (25%) reported strong/very strong consideration of CPM, and another 29% considered it moderately/weakly. Decision styles, including a rational-intuitive approach to decision making, varied. The factors most valued by women at the time of treatment decision making were as follows: avoiding worry about recurrence (82%) and reducing the need for more surgery (73%). In a multivariate analysis, patients who preferred to make their own decisions, those who valued avoiding worry about recurrence, and those who valued avoiding radiation significantly more often strongly considered CPM (P < .05), whereas those who reported being more logical and those who valued keeping their breast did so less often. CONCLUSIONS Many patients considered CPM, and the consideration was associated with both decision styles and values. The variability in decision styles and values observed in this study suggests that formally evaluating these characteristics at or before the initial treatment encounter could provide an opportunity for improving patient clinician discussions. Cancer 2017;123:4547-4555. © 2017 American Cancer Society.
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Affiliation(s)
- Sarah T. Hawley
- University of Michigan, Department of Internal Medicine, Division of General Medicine, Veterans Administration Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor, MI
| | - Kent A. Griffith
- University of Michigan, Center for Cancer Biostatistics, School of Public Health, Ann Arbor, MI
| | - Ann S. Hamilton
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kevin C. Ward
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta, GA
| | - Monica Morrow
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, New York, NY
| | - Nancy K. Janz
- University of Michigan, Department of Health Behavior and Health Education, School of Public Health, Ann Arbor, MI
| | - Steven J. Katz
- University of Michigan, Department of Health Management and Policy, School of Public Health, Department of Internal Medicine, Division of General Medicine, Ann Arbor, MI
| | - Reshma Jagsi
- University of Michigan, Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI
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18
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Flitcroft KL, Brennan ME, Costa DSJ, Spillane AJ. Regional variation in immediate breast reconstruction in Australia. BJS Open 2017; 1:114-121. [PMID: 29951613 PMCID: PMC5989981 DOI: 10.1002/bjs5.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/24/2017] [Indexed: 11/09/2022] Open
Abstract
Background Breast reconstruction following mastectomy has proven benefits and is the standard of care in many high‐income countries. This audit documented regional variation in immediate breast reconstruction rates across Australia. Methods The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit database and geospatial software were used to model the distribution of breast reconstructions performed on women having mastectomy in Australia in 2013. Geospatial mapping identified the distribution of these procedures in relation to the Greater Capital City Statistical Areas (GCCSAs) of the five largest states. Data were analysed using χ2 tests of independence and an independent‐samples t test. Results Of 3786 patients having a mastectomy, 692 underwent breast reconstruction of which 679 (98·1 per cent) were immediate reconstructions. Rates of reconstruction differed significantly between jurisdictions (χ2 = 164·90), and were significantly higher in GCCSAs (χ2 = 144·60) and private hospitals (χ2 = 50·72) (all P < 0·001). Immediate breast reconstruction was not reported for 43·8 per cent of hospitals where mastectomy was conducted by members of BreastSurgANZ, including 29·8 per cent of hospitals within GCCSAs. A wider age range of women appeared to have had immediate reconstructions at hospitals within GCCSAs, although the difference in mean age between regions was not significant. Immediate breast reconstruction was considerably less likely to be performed in women who lived in areas of lower to mid socioeconomic status. Conclusion Variations in the rate of immediate breast reconstruction may not be purely resource‐driven.
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Affiliation(s)
- K L Flitcroft
- Breast and Surgical Oncology at the Poche Centre University of Sydney Sydney Australia.,Northern Clinical School University of Sydney Sydney Australia
| | - M E Brennan
- Breast and Surgical Oncology at the Poche Centre University of Sydney Sydney Australia.,Northern Clinical School University of Sydney Sydney Australia
| | - D S J Costa
- Pain Management Research Unit University of Sydney at Royal North Shore Hospital St Leonards, New South Wales Australia
| | - A J Spillane
- Breast and Surgical Oncology at the Poche Centre University of Sydney Sydney Australia.,Northern Clinical School University of Sydney Sydney Australia.,Surgical Oncology, Breast and Endocrine Surgery Department, Mater Hospital Sydney Australia.,Surgical Oncology, Breast and Endocrine Surgery Department, Royal North Shore Hospital St Leonards, New South Wales Australia
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19
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Cornelissen AJM, Beugels J, van Kuijk SMJ, Heuts EM, Rozen SM, Spiegel AJ, van der Hulst RRWJ, Tuinder SMH. Sensation of the autologous reconstructed breast improves quality of life: a pilot study. Breast Cancer Res Treat 2017; 167:687-695. [PMID: 29071492 PMCID: PMC5807496 DOI: 10.1007/s10549-017-4547-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/16/2017] [Indexed: 11/04/2022]
Abstract
Purpose The number of breast cancer survivors continues to grow. Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. Impaired sensation remains a debilitating side effect with a significant impact on the quality of life. Microsurgical nerve coaptation of a sensory nerve has the potential to improve sensation of the reconstructed breast. This study investigates the effect of improved sensation of the reconstructed breast on the quality of life in breast cancer survivors. Methods A retrospective cohort study was performed in the Maastricht University Medical Center. Patients undergoing a DIEP flap breast reconstruction between January 2015 and January 2016 were included. The primary outcome was quality of life (BREAST-Q domain ‘physical well-being of the chest’). The Semmes–Weinstein monofilaments were used for objective sensation measurement of the reconstructed breast(s). Results Eighteen patients with and 14 patients without nerve coaptation responded. Nipple reconstruction was the only characteristic that differed statistically significant between both groups (p = 0.04). The BREAST-Q score for the domain physical well-being of the chest was 77.89 ± 18.89 on average in patients with nerve coaptation and 66.21 ± 18.26 in patients without nerve coaptation (p = 0.09). Linear regression showed a statistically significant relation between objectively measured sensation and BREAST-Q score for the domain physical well-being of the chest with a regression coefficient of − 13.17 ± 3.61 (p < 0.01). Conclusions Improved sensation in the autologous reconstructed breast, with the addition of microsurgical nerve coaptation, has a statistical significant positive impact on the quality of life in breast cancer survivors according to the BREAST-Q.
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Affiliation(s)
- Anouk J M Cornelissen
- Department of Plastic Surgery, Maastricht University Medical Center +, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Jop Beugels
- Department of Plastic Surgery, Maastricht University Medical Center +, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center +, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Esther M Heuts
- Department of Surgery, Maastricht University Medical Center +, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Shai M Rozen
- Department of Plastic and Reconstructive Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX, 75390, USA
| | - Aldona J Spiegel
- Division of Plastic Surgery, Houston Methodist Hospital, 6565 Fannin St, Houston, TX, 77030, USA
| | - René R W J van der Hulst
- Department of Plastic Surgery, Maastricht University Medical Center +, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Stefania M H Tuinder
- Department of Plastic Surgery, Maastricht University Medical Center +, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
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20
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Cheng HM, McMillan C, Lipa JE, Snell L. A Qualitative Assessment of the Journey to Delayed Breast Reconstruction. Plast Surg (Oakv) 2017; 25:157-162. [PMID: 29026820 DOI: 10.1177/2292550317716124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Canada has low immediate breast reconstruction (IBR) rates compared to the United States and Europe. Breast cancer survivors live with mastectomy defects sometimes for years, and this represents an area for improvement in cancer care. PURPOSE This study qualitatively assessed (1) information provided about breast reconstruction at the time of cancer diagnosis among women seeking delayed breast reconstruction (DBR) and (2) referral practices for plastic surgery consultation for DBR. METHODS Fifty-two consecutive patients seen in consultation for DBR at a single Canadian tertiary care centre completed questionnaires regarding their experience in seeking breast reconstruction. Seven semi-structured interviews were conducted to further explore themes identified through questionnaires. Questionnaire responses and interview transcripts were analyzed for recurring themes using standard qualitative techniques. RESULTS A significant portion of women (43%) was interested in reconstruction prior to mastectomy, yet IBR was infrequently discussed (14%) or discouraged by their oncologic surgeons (33%). Common patient reasons for not pursuing IBR were referring physician objection and not having adequate knowledge. Women expressed wanting to discuss reconstruction at the time of cancer diagnosis. Half of the patients had attended another consultation, but the initial plastic surgeon either did not offer procedures for which these women were candidates or had prohibitively long surgical wait times. CONCLUSION Lack of information about reconstructive options at the time of cancer diagnosis and perceived access barriers to plastic surgeons may contribute to underutilization of IBR in Canada. Access to breast reconstruction can be improved by reducing inefficiencies in plastic surgery referrals.
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Affiliation(s)
- Ho Man Cheng
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Joan E Lipa
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laura Snell
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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21
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Shumway DA, Griffith KA, Sabel MS, Jones RD, Forstner JM, Bott-Kothari TL, Hawley ST, Jeruss J, Jagsi R. Surgeon and Radiation Oncologist Views on Omission of Adjuvant Radiotherapy for Older Women with Early-Stage Breast Cancer. Ann Surg Oncol 2017; 24:3518-3526. [DOI: 10.1245/s10434-017-6013-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Indexed: 12/16/2022]
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22
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Sim N, Soh S, Ang CH, Hing CH, Lee HJ, Nallathamby V, Yap YL, Ong WC, Lim TC, Lim J. Breast reconstruction rate and profile in a Singapore patient population: a National University Hospital experience. Singapore Med J 2017; 59:300-304. [PMID: 28503698 DOI: 10.11622/smedj.2017035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Breast reconstruction is an integral part of breast cancer management with the aim of restoring a breast to its natural form. There is increasing awareness among women that it is a safe procedure and its benefits extend beyond aesthetics. Our aim was to establish the rate of breast reconstruction and provide an overview of the patients who underwent breast reconstruction at National University Hospital (NUH), Singapore. METHODS We evaluated factors that impact a patient's decision to proceed with breast reconstruction, such as ethnicity, age, time and type of implant. We retrospectively reviewed the medical records of women who had breast cancer and underwent breast surgery at NUH between 2001 and 2010. RESULTS The breast reconstruction rate in this study was 24.3%. There were 241 patients who underwent breast reconstruction surgeries (including delayed and immediate procedures) among 993 patients for whom mastectomies were done for breast cancer. Chinese patients were the largest ethnic group who underwent breast reconstruction after mastectomy (74.3%). Within a single ethnic patient group, Malay women had the largest proportion of women undergoing breast reconstruction (60.0%). The youngest woman in whom cancer was detected in our study was aged 20 years. Malay women showed the greatest preference for autologous tissue breast reconstruction (92.3%). The median age at cancer diagnosis of our cohort was 46 years. CONCLUSION We noted increases in the age of patients undergoing breast reconstruction and the proportion of breast reconstruction cases over the ten-year study period.
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Affiliation(s)
- Nadia Sim
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sharon Soh
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chuan Han Ang
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Chor Hoong Hing
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Surgery, National University Health System, Singapore
| | - Han Jing Lee
- Department of Surgery, National University Health System, Singapore.,Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Vigneswaran Nallathamby
- Department of Surgery, National University Health System, Singapore.,Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Yan Lin Yap
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Wei Chen Ong
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Thiam Chye Lim
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Jane Lim
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
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23
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Dodgion CM, Lipsitz SR, Decker MR, Hu YY, Quamme SRP, Karcz A, D'Avolio L, Greenberg CC. Institutional variation in surgical care for early-stage breast cancer at community hospitals. J Surg Res 2017; 211:196-205. [PMID: 28501117 DOI: 10.1016/j.jss.2016.11.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/12/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is significant institutional variation in the surgical care of breast cancer, and this may reflect access to services and resultant physician practice patterns. In previous studies, specialty care has been associated with variation in the operative treatment of breast cancer but has not been evaluated in a community setting. This study investigates these issues in a cohort of 59 community hospitals in the United States. MATERIALS AND METHODS Data on patients receiving an operation for breast cancer (2006-2009) in a large, geographically diverse cohort of hospitals were obtained. Administrative data, autoabstracted cancer-specific variables from free text, and multiple other data sets were combined. Polymotous logistic regression with multilevel outcomes identified associations between these variables and surgical treatment. RESULTS At 59 community hospitals, 4766 patients underwent breast conserving surgery (BCS), mastectomy, or mastectomy with reconstruction. The older patients were most likely to receive mastectomy alone, whereas the younger age group underwent more reconstruction (age <50), and BCS was most likely in patients aged 50-65. Surgical procedure also varied according to tumor characteristics. BCS was more likely at smaller hospitals, those with ambulatory surgery centers, and those located in nonmetropolitan areas. The likelihood of reconstruction doubled when there were more reconstructive surgeons in the health services area (P = 0.02). BCS was more likely when radiation oncology services were available within the hospital or network (P = 0.04). CONCLUSIONS Interpretation of these results for practice redesign is not straightforward. Although access to specialty care is statistically associated with type of breast surgical procedure, clinical impact is limited. It may be more effective to target other aspects of care to ensure each patient receives treatment consistent with her individual preferences.
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Affiliation(s)
- Christopher M Dodgion
- Department of Surgery, Wisconsin Surgical Outcomes Research (WiSOR) Program, University of Wisconsin Hospitals & Clinics, Madison, Wisconsin; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marquita R Decker
- Department of Surgery, Wisconsin Surgical Outcomes Research (WiSOR) Program, University of Wisconsin Hospitals & Clinics, Madison, Wisconsin
| | - Yue-Yung Hu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sudha R Pavuluri Quamme
- Department of Surgery, Wisconsin Surgical Outcomes Research (WiSOR) Program, University of Wisconsin Hospitals & Clinics, Madison, Wisconsin
| | - Anita Karcz
- Institute for Health Metrics, Burlington, Massachusetts
| | - Leonard D'Avolio
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, Massachusetts; Ariadne Labs: Brigham and Women's Hospital and Harvard School of Public Health, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Caprice C Greenberg
- Department of Surgery, Wisconsin Surgical Outcomes Research (WiSOR) Program, University of Wisconsin Hospitals & Clinics, Madison, Wisconsin.
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24
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Boero IJ, Gillespie EF, Hou J, Paravati AJ, Kim E, Einck JP, Yashar C, Mell LK, Murphy JD. The Impact of Radiation Oncologists on the Early Adoption of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 97:571-580. [PMID: 28126306 DOI: 10.1016/j.ijrobp.2016.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/19/2016] [Accepted: 11/08/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Despite multiple randomized trials showing the efficacy of hypofractionated radiation therapy in early-stage breast cancer, the United States has been slow to adopt this treatment. The goal of this study was to evaluate the impact of individual radiation oncologists on the early adoption of hypofractionated radiation therapy for early-stage breast cancer. METHODS We identified 22,233 Medicare beneficiaries with localized breast cancer that was diagnosed from 2004 to 2011 who underwent breast-conserving surgery with adjuvant radiation. Multilevel, multivariable logistic models clustered by radiation oncologist and geographic practice area were used to determine the impact of the provider and geographic region on the likelihood of receiving hypofractionated compared with standard fractionated radiation therapy while controlling for a patient's clinical and demographic covariates. Odds ratios (OR) describe the impact of demographic or clinical covariates, and the median OR (MOR) describes the relative impact of the individual radiation oncologist and geographic region on the likelihood of undergoing hypofractionated radiation therapy. RESULTS Among the entire cohort, 2333 women (10.4%) were treated with hypofractionated radiation therapy, with unadjusted rates ranging from 0.0% in the bottom quintile of radiation oncologists to 30.4% in the top quintile. Multivariable analysis found that the individual radiation oncologist (MOR 3.08) had a greater impact on the use of hypofractionation than did geographic region (MOR 2.10) or clinical and demographic variables. The impact of the provider increased from the year 2004 to 2005 (MOR 2.82) to the year 2010 to 2011 (MOR 3.16) despite the publication of long-term randomized trial results in early 2010. Male physician and radiation oncologists treating the highest volume of breast cancer patients were less likely to perform hypofractionation (P<.05). CONCLUSIONS The individual radiation oncologist strongly influenced the likelihood of a patient's receiving hypofractionated radiation therapy, and this trend increased despite the publication of long-term data showing equivalence to standard fractionation. Future research should focus on physician-related factors that influence this decision.
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Affiliation(s)
- Isabel J Boero
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Erin F Gillespie
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Jiayi Hou
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Anthony J Paravati
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Ellen Kim
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - John P Einck
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California.
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25
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Sineshaw HM, Wu XC, Flanders WD, Osarogiagbon RU, Jemal A. Variations in Receipt of Curative-Intent Surgery for Early-Stage Non-Small Cell Lung Cancer (NSCLC) by State. J Thorac Oncol 2016; 11:880-9. [PMID: 26980472 DOI: 10.1016/j.jtho.2016.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous studies reported racial and socioeconomic disparities in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) in the United States. We examined variation in receipt of surgery and whether the racial disparity varies by state. METHODS Patients in whom stage I or II NSCLC was diagnosed from 2007 to 2011 were identified from 38 state and the District of Columbia population-based cancer registries compiled by the North American Association of Central Cancer Registries. Percentage of patients receiving curative-intent surgery was calculated for each registry. Adjusted risk ratios were generated by using modified Poisson regression to control for sociodemographic (e.g., age, sex, race, insurance) and clinical (e.g., grade, stage) factors. Non-Hispanic (NH) whites and Massachusetts were used as references for comparisons because they had the lowest uninsured rates. RESULTS In all registries combined, 66.4% of patients with early-stage NSCLC (73,475 of 110,711) received curative-intent surgery. Receipt of curative-intent surgery for early-stage NSCLC varied substantially by state, ranging from 52.2% to 56.1% in Wyoming, Louisiana, and New Mexico to 75.2% to 77.2% in Massachusetts, New Jersey, and Utah. In a multivariable analysis, the likelihood of receiving curative-intent surgery was significantly lower in all but nine states/registries compared with Massachusetts, ranging from 7% lower in California to 25% lower in Wyoming. Receipt of curative-intent surgery for early-stage NSCLC was lower for NH blacks than for NH whites in every state, although statistically significant in Florida and Texas. CONCLUSIONS Receipt of curative-intent surgery for early-stage NSCLC varies substantially across states in the United States, with northeastern states generally showing the highest rates. Further, receipt of treatment appeared to be lower in NH blacks than in NH whites in every state, although statistically significant in Florida and Texas.
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Affiliation(s)
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - W Dana Flanders
- American Cancer Society, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia
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Fisher S, Yasui Y, Dabbs K, Winget M. Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer. Ann Surg Oncol 2016; 23:1845-51. [PMID: 26842490 DOI: 10.1245/s10434-016-5118-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada. METHODS All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals. RESULTS Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated. CONCLUSIONS Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.
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Affiliation(s)
- Stacey Fisher
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Yutaka Yasui
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Kelly Dabbs
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Marcy Winget
- School of Public Health, University of Alberta, Edmonton, AB, Canada. .,Department of Medicine, Stanford University, Stanford, CA, USA.
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Advanced Age Does Not Worsen Recovery or Long-Term Morbidity After Postmastectomy Breast Reconstruction. Ann Plast Surg 2016; 76:164-9. [DOI: 10.1097/sap.0000000000000512] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Conway RG, Bartlett EK, Hoffman RL, Czerniecki BJ, Karakousis GC, Kelz RR. Residents' Experience in Breast Cancer Care. JOURNAL OF SURGICAL EDUCATION 2015; 72:1233-1239. [PMID: 26119094 DOI: 10.1016/j.jsurg.2015.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/23/2015] [Accepted: 04/29/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE General surgeons commonly treat breast cancer (BC), hence necessitating adequate training during residency. We examined surgery residents' exposure to these conditions across postgraduate years (PGYs) to assess the proximity of involvement to commencement. STUDY DESIGN We examined the BC operative profile by PGY using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, 2008-2011). Operations were classified using the Surgical Council on Resident Education curriculum complexity categories. Univariate analysis was performed using chi-square, Fisher exact, analysis of variance, and Kruskal-Wallis tests, as appropriate. RESULTS Of 58,413 BC operations, 23,996 involved PGY1 to PGY5 residents. A Surgical Council on Resident Education complexity was assigned to 97.7% of operations studied (n = 23,432). PGY was inversely proportional to the number of operations performed. PGY1 to PGY3 residents covered most essential-common operations (PGY1-3, 72% vs PGY4-5, 28%; p < 0.001). PGY1 and PGY2 residents covered more than half of the complex operations (PGY1-2, 55% [n = 359] vs PGY3-5, 45% [n = 288]; p = 0.033). CONCLUSIONS Although junior residents perform most of the BC cases in surgical residency, residents do participate in operations for BC across the continuum of the training years. Program directors should consider trainees' career aspirations to ensure adequate exposure to the operative and nonoperative management of this common disease before the transition to independent practice.
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Affiliation(s)
- R Gregory Conway
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edmund K Bartlett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca L Hoffman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian J Czerniecki
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Lebo PB, Quehenberger F, Kamolz LP, Lumenta DB. The Angelina effect revisited: Exploring a media-related impact on public awareness. Cancer 2015; 121:3959-64. [PMID: 26414603 DOI: 10.1002/cncr.29461] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/12/2015] [Accepted: 04/20/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND In 2013, Angelina Jolie's double mastectomy and publication of her personal treatment choice for BRCA1 positivity generated considerable media attention. To the authors' knowledge, the current study is the first prospective survey conducted among the general public to measure a quantifiable media-related effect on public awareness. METHODS The authors analyzed the changes in the general public's awareness of reconstructive options in breast cancer among 2 female population-matched cohorts aged 18 to 65 years (1000 participants in each cohort) before (March 2013; poll 1) and after (June 2013; poll 2) the announcement of Ms. Jolie's mastectomy in May 2013. RESULTS There was an observed increase in public awareness: significantly more women from poll 2 were aware of reconstructive breast surgery being possible after breast cancer-related mastectomy, notably with regard to autologous tissue and single-stage reconstructions. Approximately 20% of the women in poll 2 (205 women) indicated that media coverage regarding Ms. Jolie affected their interest in breast cancer. A question that was exclusive to poll 2 revealed a preference for autologous (66.2%) versus implant-based (8.2%) reconstructions, with the remainder indicating no preference (25.6%). None of the stratification variables were found to be associated with the above findings. CONCLUSIONS To the best of the authors' knowledge, this is the first prospective study to demonstrate a statistically significant impact of a celebrity announcement on public awareness regarding breast cancer treatment. The results underscore the importance of a media-related impact for professionals in the health care sector, which can serve as a tipping point for raising awareness and improving knowledge concerning a specific disease among the general public.
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Affiliation(s)
- Patricia Beatrice Lebo
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Franz Quehenberger
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Lars-Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - David Benjamin Lumenta
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Churilla TM, Donnelly PE, Leatherman ER, Adonizio CS, Peters CA. Total Mastectomy or Breast Conservation Therapy? How Radiation Oncologist Accessibility Determines Treatment Choice and Quality: A SEER Data-base Analysis. Breast J 2015; 21:473-80. [PMID: 26133235 DOI: 10.1111/tbj.12449] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Mastectomy and breast conservation therapy (BCT) are equivalent in survival for treatment of early stage breast cancer. This study evaluated the impact of radiation oncologist accessibility on choice of breast conserving surgery (BCS) versus mastectomy, and the appropriate receipt of radiotherapy after BCS. In the National Cancer Institute Survival, Epidemiology, and End Results data base, the authors selected breast cancer cases from 2004 to 2008 with the following criteria: T2N1M0 or less, lobular or ductal histology, and treatment with simple or partial mastectomy. We combined the Health Resources and Services Administration Area Resource File to define average radiation oncologist density (ROD) by county over the same time period. We evaluated tumor characteristics, demographic information, and ROD with respect to BCS rates and receipt of radiation therapy after BCS in univariable and multivariable analyses. In 118,773 cases analyzed, mastectomy was performed 33.2% of the time relative to BCS. After adjustment for demographic and tumor variables, the odds of having BCS versus mastectomy were directly associated with ROD (multiplicative change in odds for a single unit increase in ROD [95% CI] = 1.02 [1.01-1.03]; p < 0.001). Adjuvant radiation therapy was not administered in 28.2% of BCS cases. When adjusting for demographic and tumor variables, the odds of having BCS without adjuvant radiation were inversely associated with ROD (0.95 [0.94-0.97]; p < 0.001). We observed a direct relationship between ROD and BCS rates independent of demographic and tumor variables, and an inverse trend for omission of radiotherapy after BCS. Access to radiation oncologists may represent an important factor in surgical choice and receiving appropriate BCT in early stage breast cancer.
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Affiliation(s)
| | | | - Erin R Leatherman
- Department of Statistics, West Virginia University, Morgantown, West Virginia
| | | | - Christopher A Peters
- The Commonwealth Medical College, Scranton, Pennsylvania.,Northeast Radiation Oncology Center, Dunmore, Pennsylvania
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Shumway DA, Griffith KA, Pierce LJ, Feng M, Moran JM, Stenmark MH, Jagsi R, Hayman JA. Wide Variation in the Diffusion of a New Technology: Practice-Based Trends in Intensity-Modulated Radiation Therapy (IMRT) Use in the State of Michigan, With Implications for IMRT Use Nationally. J Oncol Pract 2015; 11:e373-9. [DOI: 10.1200/jop.2014.002568] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMRT use grew significantly across the state of Michigan over time, with four-fold variability among centers, which was related to facility characteristics.
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Affiliation(s)
| | | | | | - Mary Feng
- University of Michigan, Ann Arbor, MI
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Anderson RT, Morris CR, Kimmick G, Trentham-Dietz A, Camacho F, Wu XC, Sabatino SA, Fleming ST, Lipscomb J. Patterns of locoregional treatment for nonmetastatic breast cancer by patient and health system factors. Cancer 2014; 121:790-9. [PMID: 25369150 DOI: 10.1002/cncr.29092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/24/2014] [Accepted: 09/02/2014] [Indexed: 11/05/2022]
Abstract
BACKGROUND The purpose of this study was to examine local definitive therapy for nonmetastatic breast cancer with the Patterns of Care Breast and Prostate Cancer (POCBP) study of the National Program of Cancer Registries (Centers for Disease Control and Prevention). METHODS POCBP medical record data were re-abstracted in 7 state/regional registry systems (Georgia, North Carolina, Kentucky, Louisiana, Wisconsin, Minnesota, and California) to verify data quality and assess treatment patterns in the population. National Comprehensive Cancer Network clinical practice treatment guidelines were aligned with American Joint Committee on Cancer staging at diagnosis to appraise care. RESULTS Six thousand five hundred five of 9142 patients with registry-confirmed breast cancer were coded as having primary disease with stage 0 to IIIA tumors and were included in the study. Approximately 88% received guideline-concordant locoregional treatment. However, this outcome varied by age group: 92% of women < age 50 versus 80% of women ≥ age 70 years old received guideline care (P < 0.01). Characteristics that best discriminated receipt (no/yes) of guideline-concordant care in receiver operating curve analyses were the receipt of breast-conserving surgery (BCS) versus mastectomy (C = 0.70), patient age (C = 0.62), a greater tumor stage (C = 0.60), public insurance (C = 0.58), and the presence of at least mild comorbidity (C = 0.55). Radiation therapy (RT) after BCS was the most omitted treatment component causing nonconcordance in the study population. In multivariate regression, the effects of the treatment facility, ductal carcinoma in situ, race, and comorbidity on nonconcordant care differed by age group. CONCLUSIONS Patterns of underuse of standard therapies for breast cancer vary by age group and BCS use, with which there is a risk of omission of RT.
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Affiliation(s)
- Roger T Anderson
- University of Virginia School of Medicine, Charlottesville, Virginia
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Logic regression for provider effects on kidney cancer treatment delivery. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2014; 2014:316935. [PMID: 24795774 PMCID: PMC3985159 DOI: 10.1155/2014/316935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 02/28/2014] [Indexed: 11/18/2022]
Abstract
In the delivery of medical and surgical care, often times complex interactions between patient, physician, and hospital factors influence practice patterns. This paper presents a novel application of logic regression in the context of kidney cancer treatment delivery. Using linked data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program and Medicare we identified patients diagnosed with kidney cancer from 1995 to 2005. The primary endpoints in the study were use of innovative treatment modalities, namely, partial nephrectomy and laparoscopy. Logic regression allowed us to uncover the interplay between patient, provider, and practice environment variables, which would not be possible using standard regression approaches. We found that surgeons who graduated in or prior to 1980 despite having some academic affiliation, low volume surgeons in a non-NCI hospital, or surgeons in rural environment were significantly less likely to use laparoscopy. Surgeons with major academic affiliation and practising in HMO, hospital, or medical school based setting were significantly more likely to use partial nephrectomy. Results from our study can show efforts towards dismantling the barriers to adoption of innovative treatment modalities, ultimately improving the quality of care provided to patients with kidney cancer.
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Nathan H, Herlong HF, Gurakar A, Li Z, Koteish AA, Bridges JF, Pawlik TM. Clinical Decision-Making by Gastroenterologists and Hepatologists for Patients with Early Hepatocellular Carcinoma. Ann Surg Oncol 2014; 21:1844-51. [DOI: 10.1245/s10434-014-3536-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Indexed: 12/15/2022]
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Showalter SL, Grover S, Sharma S, Lin L, Czerniecki BJ. Factors Influencing Surgical and Adjuvant Therapy in Stage I Breast Cancer: A SEER 18 Database Analysis. Ann Surg Oncol 2012; 20:1287-94. [DOI: 10.1245/s10434-012-2693-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Indexed: 11/18/2022]
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Hawley ST, Lillie SE, Morris A, Graff JJ, Hamilton A, Katz SJ. Surgeon-level variation in patients' appraisals of their breast cancer treatment experiences. Ann Surg Oncol 2012; 20:7-14. [PMID: 23054105 DOI: 10.1245/s10434-012-2582-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences. METHODS Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes. RESULTS Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction. CONCLUSIONS Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.
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Affiliation(s)
- Sarah T Hawley
- Division of General Medicine, University of Michigan Health System, Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, MI, USA.
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Mandelblatt JS, Faul LA, Luta G, Makgoeng SB, Isaacs C, Taylor K, Sheppard VB, Tallarico M, Barry WT, Cohen HJ. Patient and physician decision styles and breast cancer chemotherapy use in older women: Cancer and Leukemia Group B protocol 369901. J Clin Oncol 2012; 30:2609-14. [PMID: 22614985 PMCID: PMC3413274 DOI: 10.1200/jco.2011.40.2909] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 03/27/2012] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Physician and patient decision styles may influence breast cancer care for patients ≥ 65 years ("older") because there is uncertainty about chemotherapy benefits in this group. We evaluate associations between decision-making styles and actual treatment. METHODS Data were collected from women treated outside of clinical trials for newly diagnosed stage I to III breast cancer (83% response) from January 2004 through April 2011 in 75 cooperative group sites. Physicians completed a one-time mailed survey (91% response), and clinical data were abstracted from charts. Patient decision style was measured on a five-point scale. Oncologists' preference for prescribing chemotherapy was based on standardized vignettes. Regression and multiple imputation were used to assess associations between chemotherapy and other variables. Results There were 1,174 women seen by 212 oncologists; 43% of women received chemotherapy. One-third of women preferred to make their own treatment decision. Patient and physician decision styles were independently associated with chemotherapy. Women who preferred less physician input had lower odds of chemotherapy than women who preferred more input (odds ratio [OR] = 0.79 per 1-point change; 95% CI, 0.65 to 0.97; P = .02) after considering covariates. Patients whose oncologists had a high chemotherapy preference had higher odds of receiving chemotherapy (OR = 2.65; 95% CI, 1.80 to 3.89; P < .001) than those who saw oncologists with a low preference. CONCLUSION Physicians' and older patients' decision styles are each associated with breast cancer chemotherapy use. It will be important to re-evaluate the impact of decision styles when there is greater empirical evidence about the benefits and risks of chemotherapy in older patients.
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Affiliation(s)
- Jeanne S Mandelblatt
- Lombardi Comprehensive Cancer Center, 3300 Whitehaven Blvd, Washington, DC 20007, USA.
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Preminger BA, Trencheva K, Chang CS, Chiang A, El-Tamer M, Ascherman J, Rohde C. Improving access to care: breast surgeons, the gatekeepers to breast reconstruction. J Am Coll Surg 2012; 214:270-6. [PMID: 22225646 DOI: 10.1016/j.jamcollsurg.2011.11.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 11/15/2011] [Accepted: 11/29/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Fewer than half of patients undergo reconstruction after breast cancer treatment, despite its quality of life benefits. Earlier studies demonstrated that most general surgeons do not discuss reconstructive options with patients. The aim of this study was to examine the likelihood of reconstruction within a cohort of mastectomy patients and compare rates of reconstruction between those referred and not referred for plastic surgery evaluation. STUDY DESIGN Retrospective review of the records of 471 consecutive patients between the ages of 19 and 94 years who underwent mastectomy between 2003 and 2007. Variables evaluated were age, body mass index, diabetes, laterality (unilateral vs bilateral), TNM staging, history of radiation, smoking history, insurance type, and race. RESULTS Of 471 patients, 313 were referred for consultation with a plastic surgeon and 158 were not; 91.7% of those referred were reconstructed and 100% of those not referred were not reconstructed. The 2 groups differed considerably in terms of age (mean age 61.84 years in the nonreferred group vs 51.83 years in the referred group), body mass index (25.9 in referred group, 27 in nonreferred group), diabetes (15% in nonreferred group vs 3.5% in referred group), and laterality (14% of nonreferred group underwent bilateral mastectomies vs 26% of those referred). The groups did not differ significantly in terms of race or tobacco use. Those with private insurance were more likely to be reconstructed, but no independent effect of insurance type was seen on multivariate analysis. CONCLUSIONS The breast surgeon's decision to refer a patient for reconstruction significantly affects whether the patient will receive breast reconstruction. Factors that appear to influence the referral decision are age, diabetes, body mass index, and laterality of mastectomy (bilateral more than unilateral).
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Dooley WC, Bong J, Parker J. Mechanisms of improved outcomes for breast cancer between surgical oncologists and general surgeons. Ann Surg Oncol 2011; 18:3248-51. [PMID: 21584834 DOI: 10.1245/s10434-011-1771-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Prior multi-institutional studies have reported a survival benefit of breast cancer treatment by surgical oncologists (SO) over general surgeons (GS). METHODS Retrospective review tumor registry data of all breast cancer patients receiving primary treatment at a single institution from January 1, 1995, to December 31, 2008. RESULTS During the time period, there were 2192 patients who received primary breast cancer treatment at this institution. The mean age was 57 years and the mean follow-up was >55 months. Stage distribution was similar between GS and SO. Overall survival (SO 83.8% vs. GS 75.6%) and disease-free survival (SO 80.7% vs. GS 72.0%) was highly statistically significant (P<0.0001). For stages 1, 2a, 2b, 3a, and 3b there were statistically significant (P<0.05) differences for overall and disease-free survival. Overall, the use of breast conservation was more likely by SO-52.6 vs. 38.3% all stages and 65.8 vs. 54.0% for stage 0-2. The compliance with all systemic therapies (chemotherapy and hormone therapy) was more likely if being treated by SO-77.3 vs. 68.5% (P<0.02). The use of radiotherapy for breast conservation and in stage 3 mastectomy patients was higher for SO (P<0.001). Participation in clinical trials was far higher for SO patients-56.2 vs. GS 7.0% (P<0.001). CONCLUSIONS The value added by having primary breast cancer treatment by a SO seems to arise from the more successful completion of multidisciplinary care in a timely fashion and higher rates of clinical trial involvement.
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Affiliation(s)
- William C Dooley
- OU Breast Institute, University of Oklahoma, Oklahoma City, OK, USA.
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Veiga DF, Veiga-Filho J, Ribeiro LM, Archangelo-Junior I, Mendes DA, Andrade VO, Caetano LV, Campos FS, Juliano Y, Ferreira LM. Evaluations of aesthetic outcomes of oncoplastic surgery by surgeons of different gender and specialty: A prospective controlled study. Breast 2011; 20:407-12. [DOI: 10.1016/j.breast.2011.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 08/25/2010] [Accepted: 04/06/2011] [Indexed: 01/11/2023] Open
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41
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Greenberg CC, Lipsitz SR, Hughes ME, Edge SB, Theriault R, Wilson JL, Carter WB, Blayney DW, Niland J, Weeks JC. Institutional variation in the surgical treatment of breast cancer: a study of the NCCN. Ann Surg 2011; 254:339-45. [PMID: 21725233 PMCID: PMC3428030 DOI: 10.1097/sla.0b013e3182263bb0] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer. BACKGROUND Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON. METHODS Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care. RESULTS Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = -0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction. CONCLUSIONS Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.
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MESH Headings
- Academic Medical Centers/supply & distribution
- Adult
- Age Factors
- Aged
- Breast Neoplasms/epidemiology
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/epidemiology
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Combined Modality Therapy
- Female
- Guideline Adherence/statistics & numerical data
- Health Services Accessibility/statistics & numerical data
- Humans
- Mammaplasty/statistics & numerical data
- Mastectomy/statistics & numerical data
- Mastectomy, Segmental/statistics & numerical data
- Middle Aged
- Multivariate Analysis
- Neoplasm Staging
- Patient Care Team/statistics & numerical data
- Practice Patterns, Physicians'
- Radiotherapy, Adjuvant/statistics & numerical data
- Retrospective Studies
- United States
- Utilization Review/statistics & numerical data
- Workforce
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Affiliation(s)
- Caprice C Greenberg
- Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Filson CP, Banerjee M, Wolf JS, Ye Z, Wei JT, Miller DC. Surgeon characteristics and long-term trends in the adoption of laparoscopic radical nephrectomy. J Urol 2011; 185:2072-7. [PMID: 21496845 DOI: 10.1016/j.juro.2011.02.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE We describe longitudinal trends in surgeon adoption of laparoscopic radical nephrectomy. We assessed whether this technique is associated with specific surgeon and/or practice setting characteristics. METHODS AND MATERIALS We used Surveillance, Epidemiology and End Results-Medicare data to identify patients who underwent laparoscopic or open radical nephrectomy for early stage kidney cancer from 1995 through 2005. We assessed long-term trends in surgeon adoption of laparoscopic radical nephrectomy and fit multilevel logistic regression models to estimate the association between surgeon or practice setting characteristics and patient receipt of laparoscopic radical nephrectomy. RESULTS The annual proportion of patients receiving laparoscopic radical nephrectomy increased from 1.4% in 1995 to 44.9% in 2005 (p <0.001). In patients treated by recent medical school graduates (graduation year 1991 or thereafter) the likelihood of undergoing laparoscopic radical nephrectomy was more than 2-fold higher when urologists practiced at National Cancer Institute designated Cancer Centers (OR 2.37, 95% CI 1.11-5.06) or in urban settings (OR 2.92, 95% CI 1.10-7.75). Patients treated by urologists who graduated before 1991 and had a major academic affiliation (OR 1.78, 95% CI 1.34-2.38) or were in a group practice (OR 1.99, 95% CI 1.51-2.63) were significantly more likely to be treated with a minimally invasive surgical approach than those treated in nonacademic and solo practices, respectively. CONCLUSIONS Urologist adoption of laparoscopic radical nephrectomy increased progressively from 1995 through 2005 and was influenced by urologist proximity to training, academic affiliation and rural/urban status. These data clarify residual barriers to surgeon adoption of laparoscopic radical nephrectomy and potentially of other innovative surgical therapies.
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Affiliation(s)
- Christopher P Filson
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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Dick AW, Sorbero MS, Ahrendt GM, Hayman JA, Gold HT, Schiffhauer L, Stark A, Griggs JJ. Comparative effectiveness of ductal carcinoma in situ management and the roles of margins and surgeons. J Natl Cancer Inst 2011; 103:92-104. [PMID: 21200025 PMCID: PMC3022620 DOI: 10.1093/jnci/djq499] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 03/31/2010] [Accepted: 11/09/2010] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The high incidence of ductal carcinoma in situ (DCIS) and variations in its treatment motivate inquiry into the comparative effectiveness of treatment options. Few such comparative effectiveness studies of DCIS, however, have been performed with detailed information on clinical and treatment attributes. METHODS We collected detailed clinical, nonclinical, pathological, treatment, and long-term outcomes data from multiple medical records of 994 women who were diagnosed with DCIS from 1985 through 2000 in Monroe County (New York) and the Henry Ford Health System (Detroit, MI). We used ipsilateral disease-free survival models to characterize the role of treatments (surgery and radiation therapy) and margin status (positive, close [<2 mm], or negative [≥2 mm]) and logistic regression models to characterize the determinants of treatments and margin status, including the role of surgeons. All statistical tests were two-sided. RESULTS Treatments and margin status were statistically significant and strong predictors of long-term disease-free survival, but results varied substantially by surgeon. This variation by surgeon accounted for 15%-35% of subsequent ipsilateral 5-year recurrence rates and for 13%-30% of 10-year recurrence rates. The overall differences in predicted 5-year disease-free survival rates for mastectomy (0.993), breast-conserving surgery with radiation therapy (0.945), and breast-conserving surgery without radiation therapy (0.824) were statistically significant (P(diff) < .001 for each of the differences). Similarly, each of the differences at 10 years was statistically significant (P < .001). CONCLUSIONS Our work demonstrates the contributions of treatments and margin status to long-term ipsilateral disease-free survival and the link between surgeons and these key measures of care. Although variation by surgeon could be generated by patients' preferences, the extent of variation and its contribution to long-term health outcomes are troubling. Further work is required to determine why women with positive margins receive no additional treatment and why margin status and receipt of radiation therapy vary by surgeon.
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MESH Headings
- Adult
- Aged
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Comparative Effectiveness Research
- Disease-Free Survival
- Female
- Humans
- Kaplan-Meier Estimate
- Logistic Models
- Mastectomy/methods
- Mastectomy, Modified Radical
- Mastectomy, Segmental
- Middle Aged
- Multivariate Analysis
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm, Residual/radiotherapy
- Odds Ratio
- Physician's Role
- Radiotherapy, Adjuvant
- Retrospective Studies
- Treatment Outcome
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Funkhouser E, Houston TK, Levine DA, Richman J, Allison JJ, Kiefe CI. Physician and patient influences on provider performance: β-blockers in postmyocardial infarction management in the MI-Plus study. Circ Cardiovasc Qual Outcomes 2010; 4:99-106. [PMID: 21139090 DOI: 10.1161/circoutcomes.110.942318] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Efforts to improve the quality of care for patients with cardiovascular disease frequently target the decrease of physician-level performance variability. We assessed how variability in providing β-blockers to ambulatory postmyocardial infarction (MI) patients was influenced by physician and patient level characteristics. METHODS AND RESULTS β-Blocker prescription and patient characteristics were abstracted from charts of post-MI patients treated by 133 primary care physicians between 2003 and 2007 and linked to physician and practice characteristics. Associations of β-blocker prescription with physician- and patient-level characteristics were examined using mixed-effects models, with physician-level effects as random. Mean physician-specific predicted probabilities and the intraclass correlations, which assessed the proportion of variance explainable at the physician level, were estimated. Of 1901 patients without major contraindication, 69.1% (range across physicians, 20% to 100%) were prescribed β-blockers. Prescription varied with comorbidity from 78.3% in patients with chronic kidney disease to 54.7% for patients with stroke. Although physician characteristics such as older physician age, group practice, and rural location were each positively associated with β-blocker prescription, physician factors accounted for only 5% to 8% of the variance in β-blocker prescription; the preponderance of the variance, 92% to 95%, was at the patient level. The mean physician-specific probability of β-blocker prescription (95% confidence interval) in the fully adjusted model was 63% (61% to 65%). CONCLUSIONS β-Blocker prescription rates were surprisingly low. The contribution of physician factors to overall variability in β-blocker prescription, however, was limited. Increasing evidence-based use of β-blockers may not be accomplished by focusing mostly on differential performance across physicians.
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Affiliation(s)
- Ellen Funkhouser
- Division of Preventive Medicine, School of Medicine, University of Alabama-Birmingham, 1717 11th Ave S., Birmingham, AL 35205, USA.
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Does it matter where you go for breast surgery?: attending surgeon's influence on variation in receipt of mastectomy for breast cancer. Med Care 2010; 48:892-9. [PMID: 20808256 DOI: 10.1097/mlr.0b013e3181ef97df] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeon's influence on the variation in receipt of these procedures. OBJECTIVES To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer. METHODS Attending surgeons (n = 419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during June 2005 to February 2007 (n = 2290) were surveyed. Respondent surgeons (n = 291) and patients (n = 1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment. RESULTS Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median, 29%; 5th-95th percentile, 9%-65%) then for mastectomy (median, 18%; 5th-95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, 1 surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%). CONCLUSION Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.
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Lee CN, Dominik R, Levin CA, Barry MJ, Cosenza C, O'Connor AM, Mulley AG, Sepucha KR. Development of instruments to measure the quality of breast cancer treatment decisions. Health Expect 2010; 13:258-72. [PMID: 20550591 DOI: 10.1111/j.1369-7625.2010.00600.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Women with early-stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients' knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality. OBJECTIVE To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them. METHODS Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross-sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined. RESULTS Thirty-eight facts (11-14 per decision) and 27 goals (8-10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals. CONCLUSIONS Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients' and providers' perspectives are different, it is vital that instrument development should include items reflecting both views.
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Affiliation(s)
- Clara N Lee
- Division of Plastic and Reconstructive Surgery, University of North Carolina, School of Medicine, Chapel Hill, NC 27599-7195, USA.
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Abstract
The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.
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Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer. Med Care 2010; 48:45-51. [PMID: 19956081 DOI: 10.1097/mlr.0b013e3181bd49ca] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions. METHODS We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%). RESULTS Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes. CONCLUSION Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.
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Dodgion CM, Greenberg CC. Using population-based registries to study variations in health care. J Oncol Pract 2009; 5:319-20. [PMID: 21479073 PMCID: PMC2869186 DOI: 10.1200/jop.091041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2009] [Indexed: 11/20/2022] Open
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