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Adams D, McDonald PL, Mader M, Holland S, Nunez T, van der Wees P. Gaining consensus on a protocol for general surgery physician assistants in the management of non-compressible abdominal haemorrhage in military austere environments: a Delphi study. BMJ Open 2024; 14:e088159. [PMID: 39322592 PMCID: PMC11426011 DOI: 10.1136/bmjopen-2024-088159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Non-compressible abdominal haemorrhage (NCAH) is a potentially preventable cause of death due to injury. Limited exploratory laparotomy by a non-surgeon is a temporary intervention to sustain life until definitive surgical intervention by trauma surgeons can be obtained. This study aims to establish consensus on a protocol for general surgery physician assistants performing limited exploratory laparotomy to manage NCAH in an austere environment. METHOD This study included anonymised trauma surgeons and general surgery physician assistants from military and civilian backgrounds. Participants were recruited from various professional surgical organisations, including direct interaction with trauma surgeons and surgical physician assistants. Participants used a modified Delphi survey with a 9-point Likert scale in two rounds. The two surveys were categorised into three parts: protocol for NCAH (part A), the potential role of general surgery physician assistants (part B) and measures of success (part C). A total of 24 statements were voted on and assessed. Votes were divided into three zones: agreement (median 7-9), uncertain (median 4-6) and disagreement (median 1-3). To reach a consensus, 70% agreement was required within a zone. If more than 30% of the votes fell outside of a specific zone, consensus was not achieved. After consensus, the original protocol was revised in an online meeting with experts. RESULTS The initial analysis involved 29 participants. After 2 survey rounds, 19 out of 24 statements reached a consensus. Part A: 10 statements gained consensus, including in austere environments, controlling NCAH can be challenging. A qualified general surgery physician assistant should intervene. A focused assessment with sonography for trauma examination can be used for screening. Bleeding can be managed with packing and pressure. After managing the haemorrhage, the abdominal wall should be left open with a temporary closure technique. Part B: nine statements gained consensus, including in austere locations, a licensed general surgery physician assistant with a minimum of 3 years of experience working under the supervision of a trauma/general surgeon can perform interventions for limited exploratory laparotomy for patients with NCAH. Part C: general surgery physician assistants will be required to have the same success rates as any qualified surgeon. CONCLUSION Gaining consensus and implementing a revised protocol for managing NCAH by general surgery physician assistants is attainable. General surgery physician assistants will need formal training to manage NCAH. With the support of trauma surgeons who provide direct and indirect supervision, general surgery physician assistants can develop a comprehensive understanding of the necessary skills and make sound decisions when treating patients with this condition. This teamwork can also increase surgical capacity and potentially decrease mortality rates for patients with NCAH in austere environments.
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Affiliation(s)
- Donald Adams
- Translational Health Science, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Paige L McDonald
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Michael Mader
- Research Services, VA South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Seth Holland
- United States Acute Care Solutions, New Braunfels, Texas, USA
| | - Timothy Nunez
- Trauma and Acute Care Surgery, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, Texas, USA
| | - Philip van der Wees
- Department of Clinical Research and Leadership, PhD program in Translational Health Sciences, George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Berian JR, Schwarze ML, Werner NE, Mahoney JE, Shah MN. Using Systems Engineering and Implementation Science to Design an Implementation Package for Preoperative Comprehensive Geriatric Assessment Among Older Adults Having Major Abdominal Surgery: Protocol for a 3-Phase Study. JMIR Res Protoc 2024; 13:e59428. [PMID: 39250779 PMCID: PMC11420609 DOI: 10.2196/59428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Older Americans, a growing segment of the population, have an increasing need for surgical services, and they experience a disproportionate burden of postoperative complications compared to their younger counterparts. A preoperative comprehensive geriatric assessment (pCGA) is recommended to reduce risk and improve surgical care delivery for this population, which has been identified as vulnerable. The pCGA optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social and environmental support. The pCGA has been shown to decrease postoperative morbidity, mortality, and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of the pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic medical centers. By applying implementation science and human factors engineering methods, this study will provide the necessary evidence to optimize the implementation of the pCGA in a variety of health care settings. OBJECTIVE The purpose of this paper is to describe the study protocol to design an adaptable, user-centered pCGA implementation package for use among older adults before major abdominal surgery. METHODS This protocol uses systems engineering methods to develop, tailor, and pilot-test a user-centered pCGA implementation package, which can be adapted to community-based hospitals in preparation for a multisite implementation trial. The protocol is based upon the National Institutes of Health Stage Model for Behavioral Intervention Development and aligns with the goal to develop behavioral interventions with an eye to real-world implementation. In phase 1, we will use observation and interviews to map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery. In phase 2, we will apply user-centered design methods, engaging health care providers, patients, and caregivers to co-design a pCGA implementation package. This package will be applicable to a diverse population of older patients undergoing major abdominal surgery at a large academic hospital and an affiliate community site. In phase 3, we will pilot-test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. We anticipate that this study will take approximately 60 months (April 2023-March 2028). RESULTS This study protocol will generate (1) a detailed process map of the pCGA; (2) an adaptable, user-centered pCGA implementation package ready for feasibility testing in a pilot trial; and (3) preliminary pilot data on the implementation and effectiveness of the package. We anticipate that these data will serve as the basis for future multisite hybrid implementation-effectiveness clinical trials of the pCGA in older adults undergoing major abdominal surgery. CONCLUSIONS The expected results of this study will contribute to improving perioperative care processes for older adults before major abdominal surgery. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/59428.
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Affiliation(s)
- Julia R Berian
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Margaret L Schwarze
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Nicole E Werner
- Department of Health and Wellness Design, School of Public Health, Indiana University-Bloomington, Bloomington, IN, United States
| | - Jane E Mahoney
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Manish N Shah
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
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Bansal N, Campbell SM, Lin CY, Ashcroft DM, Chen LC. Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care-a modified e-Delphi study. BMC Med 2024; 22:5. [PMID: 38167142 PMCID: PMC10763174 DOI: 10.1186/s12916-023-03213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Long-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care. METHODS Scenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1-9 scale from inappropriate to appropriate. The score's median, 30th and 70th percentiles, and disagreement index were calculated. RESULTS The panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery. CONCLUSIONS The high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.
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Affiliation(s)
- Neetu Bansal
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
| | - Stephen M Campbell
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria, 0208, South Africa
- Centre for Epidemiology and Public Health, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Chiu-Yi Lin
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Darren M Ashcroft
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, M13 9PL, UK
| | - Li-Chia Chen
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
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Correia RH, Siu HYH, Vanstone M, Jones A, Gopaul A, Costa AP. Development of practice-based quality indicators for the primary care of older adults: a RAND/UCLA Appropriateness Method study protocol. BMJ Open 2023; 13:e072232. [PMID: 37699633 PMCID: PMC10503316 DOI: 10.1136/bmjopen-2023-072232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/25/2023] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION Older adults have high rates of primary care utilisation, and quality primary care has the potential to address their complex medical needs. Family physicians have different levels of knowledge and skills in caring for older patients, which may influence the quality of care delivery and resulting health outcomes. In this study, we aim to establish consensus on practice-based metrics that characterise quality of care for older primary care patients and can be examined using secondary, administrative data. METHODS AND ANALYSIS We describe a two-round RAND/UCLA Appropriateness Method (RAM) study to assess the consensus of a technical expert panel. We will recruit pan-Canadian experts who demonstrate excellence in clinical practice or scholarship related to the primary care of older adults. A literature review will generate a candidate list of practice-based quality indicators. The first round aims to evaluate the appropriateness and importance of candidate indicators through an online questionnaire. We will then develop technical definitions for each endorsed indicator using ICES data holdings. Panellists will offer feedback on the technical definitions in a virtual synchronous meeting and provide ratings on the same criteria in a second questionnaire. ETHICS AND DISSEMINATION Our study has been approved by the Hamilton Integrated Research Ethics Board (Project ID #15545). Findings will be disseminated via manuscripts, presentations and the lead author's thesis. TRIAL REGISTRATION NUMBER ISRCTN17074347.
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Affiliation(s)
- Rebecca H Correia
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Henry Yu-Hin Siu
- Department of Family Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Aquila Gopaul
- Department of Family Medicine, Western University, London, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
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Irajpour A, Maleki F, Shati M, Najafii MR. Home health care of Iranian elderly with dementia: Study protocol for guideline adaptation. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:8. [PMID: 37034851 PMCID: PMC10079205 DOI: 10.4103/jehp.jehp_1706_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/09/2022] [Indexed: 06/19/2023]
Abstract
BACKGROUND Advanced stages of dementia interfere with elderly self-care. Consequently, they need caregivers who take responsibility for their care in the long-term. Restrictions to the caregiver's access to information, resources, and organizational support have created problems in their caregiver role, which is why the World Health Organization (WHO) emphasizes caring for caregivers by providing evidence-based information and training programs. As there is no clinical practice guideline for home care in the Islamic Republic of Iran, this study aims to develop a home health care guideline for the elderly with dementia. MATERIALS AND METHODS The ADAPTE process provided by the Guidelines International Network was considered as the basis. In order to identify the care needs of Iranian patients with dementia, semi-structured interviews were added to this guideline. DISCUSSION The identification and implementation of the perspectives of patients and caregivers during the process of guidelines adaptation increase the applicability of the guidelines. Improved quality of life for the patients in their place of residence is one of the expected consequences of this guideline's implementation. The developed guidelines will be used at home health care centers, and dementia and Alzheimer's associations in Iran.
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Affiliation(s)
- Alireza Irajpour
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Maleki
- Student Research Committee, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Shati
- Mental Health Research Center, School of Behavioral Sciences and Mental Health, Tehran Institute of Psychiatry, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mohamad R. Najafii
- Department of Neurology, School of Medicine, Isfahan University of Medical Science, Isfahan, Iran
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Shahkolahi Z, Irajpour A, Jafari-Mianaei S, Heidarzadeh M. Developing patient safety standards for health-care quality promotion in neonatal intensive care units: A mixed-methods Protocol. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:291. [PMID: 36439017 PMCID: PMC9683434 DOI: 10.4103/jehp.jehp_1409_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/29/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Neonatal intensive care unit (NICU) is one of the accident-prone settings in the health-care system. There is a series of structural and process threats to the safety of infants hospitalized in this unit, which can be prevented by taking the right actions. For this purpose, developing standards based on current knowledge, available resources, and the context that provides care can determine patient injury prevention requirements. Likewise, it can be a source for national development and application of related guidelines and protocols. This study aims to develop patient safety standards in the NICUs of Iran. MATERIALS AND METHODS This mixed-methods study will apply the exploration, preparation, implementation, and sustainment framework to develop patient safety standards. In each phase of this framework, a set of activities take place. Exploration is based on the world health organization model to develop standards. Determining the validity and applicability of standards will be done in Phase 2 (Preparation) and Phase 3 (Implementation), respectively. Since the long-term effects are not desired, the fourth phase (Sustainment) will not be considered. DISCUSSION Patient safety standards from this study will contribute to efficient and effective, equitable, and high-quality health-care delivery. The application of them will further promote patient safety and the quality of medical care in Iranian NICUs.
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Affiliation(s)
- Zahra Shahkolahi
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Irajpour
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Soheila Jafari-Mianaei
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Heidarzadeh
- Pediatric Health Research Center, Faculty of Medicine, Tabriz University of Medical Science, Tabriz, Iran
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Ma M, Zhang L, Rosenthal R, Finlayson E, Russell MM. The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon. SEMINARS IN COLON AND RECTAL SURGERY 2020; 31:100779. [PMID: 33041604 PMCID: PMC7531280 DOI: 10.1016/j.scrs.2020.100779] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons’ (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.
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Affiliation(s)
- Meixi Ma
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL USA.,Department of Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL USA
| | - Lindsey Zhang
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL USA.,Department of Surgery, University of Chicago, Chicago, IL USA
| | | | - Emily Finlayson
- Department of Surgery, University of California San Francisco, San Francisco, CA USA
| | - Marcia M Russell
- Department of Surgery, University of California Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
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Byrne M, O’Malley L, Glenny AM, Campbell S, Tickle M. A RAND/UCLA appropriateness method study to identify the dimensions of quality in primary dental care and quality measurement indicators. Br Dent J 2020; 228:83-88. [DOI: 10.1038/s41415-020-1200-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Hornor MA, Tang VL, Berian J, Robinson TN, Coleman J, Katlic MR, Rosenthal RA, Christensen K, Baker T, Finlayson E, Lagoo‐Deenadaayalan SA, Ko CY, Russell MM. Optimizing the Feasibility and Scalability of a Geriatric Surgery Quality Improvement Initiative. J Am Geriatr Soc 2019; 67:1074-1078. [DOI: 10.1111/jgs.15815] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Melissa A. Hornor
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Victoria L. Tang
- Division of Geriatrics, Department of MedicineUniversity of California, San Francisco San Francisco California
| | - Julia Berian
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
- Department of SurgeryUniversity of Chicago Chicago Illinois
| | | | - JoAnn Coleman
- Department of Surgery, Sinai Center for Geriatric SurgerySinai Hospital Baltimore Maryland
| | - Mark R. Katlic
- Department of Surgery, Sinai Center for Geriatric SurgerySinai Hospital Baltimore Maryland
| | | | - Kataryna Christensen
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
| | - Tracey Baker
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
| | - Emily Finlayson
- Department of SurgeryUniversity of California, San Francisco San Francisco California
| | | | - Clifford Y. Ko
- Division of Research and Optimal Patient CareAmerican College of Surgeons Chicago Illinois
- Department of SurgeryUniversity of California, Los Angeles Los Angeles California
| | - Marcia M. Russell
- Department of SurgeryUniversity of California, Los Angeles Los Angeles California
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