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Hashmi SA, Martins RS, Ishtiaq A, Rizvi NA, Mustafa MA, Pervez A, Siddiqui A, Shariq SF, Nadeem S, Haider AH, Waqar MA. Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan. BMC Palliat Care 2024; 23:112. [PMID: 38693518 PMCID: PMC11061908 DOI: 10.1186/s12904-024-01438-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 04/19/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.
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Affiliation(s)
- Syeda Amrah Hashmi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Russell Seth Martins
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Annum Ishtiaq
- Section of Palliative Medicine, Department of Oncology, Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Nashia Ali Rizvi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Mohsin Ali Mustafa
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Alina Pervez
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Ayra Siddiqui
- Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | | | - Sarah Nadeem
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
- Section of Endocrinology, Department of Medicine, Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Adil H Haider
- Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Muhammad Atif Waqar
- Section of Palliative Medicine, Department of Oncology, Aga Khan University Hospital, Karachi, 74800, Pakistan.
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Ayub F, Afzal N, Ali W, Asif F, Ul Hassan SS, Haque G, Ahmed FA, Ajani K, Tharani Z, Jaffer M, Haider AH, Aboumatar HJ, Latif A. Exploring medical and nursing students' perceptions about a patient safety course: a qualitative study. BMC Med Educ 2024; 24:452. [PMID: 38664699 PMCID: PMC11044541 DOI: 10.1186/s12909-024-05348-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/25/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Educating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students. METHODS A dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021-2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo. RESULTS The findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety. CONCLUSIONS Student perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.
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Affiliation(s)
- Farwa Ayub
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | - Noreen Afzal
- Dean's Office, Aga Khan University Medical College, Karachi, Pakistan
| | - Wajid Ali
- Dean's Office, Aga Khan University Medical College, Karachi, Pakistan
| | - Fozia Asif
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | | | - Ghazal Haque
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | - Fasih Ali Ahmed
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
- Division of Surgical Oncology, University Hospitals, Cleveland, OH, USA
| | | | - Zahra Tharani
- School of Nursing & Midwifery, Aga Khan University, Karachi, Pakistan
| | - Mehtab Jaffer
- School of Nursing & Midwifery, Aga Khan University, Karachi, Pakistan
| | - Adil H Haider
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Hanan J Aboumatar
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Asad Latif
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan.
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA.
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan.
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Vaqar M, Tariq M, Khan MR, Khan S, Riaz Q, Mahmood S, Ali N, Haider AH. A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan. Postgrad Med J 2024; 100:350-357. [PMID: 38648192 DOI: 10.1093/postmj/qgad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/20/2023] [Accepted: 12/09/2023] [Indexed: 04/25/2024]
Abstract
This article presents an overview of Aga Khan University's (AKU) pioneering medical education initiatives over the past 40 years, exploring its impact on healthcare in the region and its commitment to advancing medical education and research in the developing world. Established in 1983 as the first private university in Pakistan, AKU has evolved into a global institution with a focus on improving healthcare standards and addressing healthcare needs in the developing world. The article also discusses the undergraduate and postgraduate medical education programs at AKU Medical College, Pakistan, highlighting their unique features and pioneering approaches to medical education. The institution's journey highlights its ability to adapt to the evolving healthcare landscape while maintaining a focus on quality and excellence, offering a model for other institutions striving to meet healthcare needs in low- and middle-income countries.
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Affiliation(s)
- Maham Vaqar
- Research Fellow, Dean's Office, Aga Khan University, Karachi 74800, Pakistan
| | - Muhammad Tariq
- Vice Dean, Medical College, Aga Khan University, Karachi 74800, Pakistan
| | - Muhammad Rizwan Khan
- Associate Dean, Postgraduate Medical Education, Aga Khan University, Karachi 74800, Pakistan
| | - Sadaf Khan
- Associate Dean, Undergraduate Medical Education, Aga Khan University, Karachi 74800, Pakistan
| | - Qamar Riaz
- Assistant Dean, Postgraduate Medical Education, Aga Khan University, Karachi 74800, Pakistan
| | - Sana Mahmood
- Director, Strategy and Advancement, Medical College, Karachi 74800, Pakistan
| | - Natasha Ali
- Associate Dean, Department of Continuing Professional Education, Aga Khan University, Karachi 74800, Pakistan
| | - Adil H Haider
- Dean, Medical College, Aga Khan University, Karachi 74800, Pakistan
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Abdul Rahim K, Shaikh NQ, Lakhdir MPA, Afzal N, Merchant AAH, Mahmood SBZ, Bakhshi SK, Ali M, Samad Z, Haider AH. No healthcare coverage, big problem: lack of insurance for older population associated with worse emergency general surgery outcomes. Trauma Surg Acute Care Open 2024; 9:e001165. [PMID: 38616789 PMCID: PMC11015297 DOI: 10.1136/tsaco-2023-001165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 03/20/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Older populations, being a unique subset of patients, have poor outcomes for emergency general surgery (EGS). In regions lacking specialized medical coverage for older patients, disparities in healthcare provision lead to poor clinical outcomes. We aimed to identify factors predicting index admission inpatient mortality from EGS among sexagenarians, septuagenarians, and octogenarians. Methods Data of patients aged >60 years with EGS conditions defined by the American Association for the Surgery of Trauma at primary index admission from 2010 to 2019 operated and non-operated at a large South Asian tertiary care hospital were analyzed. The primary outcome was primary index admission inpatient 30-day mortality. Parametric survival regression using Weibull distribution was performed. Factors such as patients' insurance status and surgical intervention were assessed using adjusted HR and 95% CI with a p-value of <0.05 considered statistically significant. Results We included 9551 primary index admissions of patients diagnosed with the nine most common primary EGS conditions. The mean patient age was 69.55±7.59 years. Overall mortality and complication rates were 3.94% and 42.29%, respectively. Primary index admission inpatient mortality was associated with complications including cardiac arrest and septic shock. Multivariable survival analysis showed that insurance status was not associated with mortality (HR 1.13; 95% CI 0.79, 1.61) after adjusting for other variables. The odds of developing complications among self-paid individuals were higher (adjusted OR 1.17; 95% CI 1.02, 1.35). Conclusion Lack of healthcare coverage for older adults can result in delayed presentation, leading to increased morbidity. Close attention should be paid to such patients for timely provision of treatment. There is a need to expand primary care access and proper management of comorbidities for overall patient well-being. Government initiatives for expanding insurance coverage for older population can further enhance their healthcare access, mitigating the risk of essential treatments being withheld due to financial limitations. Level of evidence III.
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Affiliation(s)
| | | | - Maryam Pyar Ali Lakhdir
- Department of Community Health Sciences, The Aga Khan University Medical College, Karachi, Pakistan
| | - Noreen Afzal
- Medical College, The Aga Khan University, Karachi, Pakistan
| | | | | | - Saqib Kamran Bakhshi
- Section of Neurosurgery, Department of Surgery, The Aga Khan University, Medical College, Karachi, Pakistan
| | - Mushyada Ali
- Department of Medicine, The Aga Khan University Medical College, Karachi, Pakistan
| | - Zainab Samad
- Department of Medicine, The Aga Khan University Medical College, Karachi, Pakistan
| | - Adil H Haider
- Department of Community Health Sciences, The Aga Khan University Medical College, Karachi, Pakistan
- Department of Surgery, The Aga Khan University, Medical College, Karachi, Pakistan
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Pervez A, Bukhari MM, Chhapra R, Baig MI, Martins RS, Pirzada S, Rizvi NA, Aamdani SS, Ayub B, Rehman AA, Mustafa MA, Nadeem S, Asad N, Haider AH, Nadeem T. Adolopment of clinical practice guidelines and creation of referral pathways for psychiatric conditions in Pakistan. Lancet Reg Health Southeast Asia 2024; 23:100387. [PMID: 38486880 PMCID: PMC10938165 DOI: 10.1016/j.lansea.2024.100387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 06/07/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024]
Abstract
Psychiatric disorders are highly prevalent in Pakistan and burdens the scarce number of psychiatrists present in the country. The establishment of evidence-based clinical practice guidelines (EBCPGs) and primary-care referral pathways within the local context is imperative to make the process efficient. In this Health Policy, we aimed to develop EBCPGs and primary-care referral pathways that are specific to Pakistan's primary-care setting, with the aim of facilitating the management of psychiatric conditions. Ten EBCPGs were created through the GRADE-ADOLOPMENT process; two recommendations were adopted with minor changes, 43 were excluded, and all others were adopted without any changes. Ten primary-care referral pathways for managing ten psychiatric disorders were created and 23 recommendations were added which will help to bridge the gap in care provision. These psychiatric referral pathways and EBCPGs will bring Pakistan's healthcare system a step closer to achieving optimal health outcomes for patients.
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Affiliation(s)
- Alina Pervez
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | | | | | | | - Russell Seth Martins
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | - Sonia Pirzada
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Nashia Ali Rizvi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | | | - Bushra Ayub
- Learning Research Centre, Patel Hospital, Karachi, Pakistan
| | - Alina Abdul Rehman
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | - Mohsin Ali Mustafa
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | - Sarah Nadeem
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Nargis Asad
- Department of Psychiatry, Aga Khan University, Karachi, Pakistan
| | | | - Tania Nadeem
- Department of Psychiatry, Aga Khan University, Karachi, Pakistan
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Ortega G, Dacier BM, Zárate Rodriguez J, Chun MBJ, Udyavar NR, Allar BG, Green AR, Haider AH, Smink DS. Teaching cultural dexterity in surgical care: As essential to a surgeon's skill set as tying a knot. Am J Surg 2024:S0002-9610(24)00161-2. [PMID: 38531750 DOI: 10.1016/j.amjsurg.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Gezzer Ortega
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Brittany M Dacier
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Maria B J Chun
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - N Rhea Udyavar
- Division of General Surgery, University of Washington, University of Washington School of Medicine, Seattle, WA, USA
| | - Benjamin G Allar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander R Green
- Division of General Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adil H Haider
- Aga Khan University Medical College, Karachi, Pakistan; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Douglas S Smink
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Bakhshi SK, Afzal N, Merchant AAH, Abdul Rahim K, Shaikh NQ, Noorali AA, Lakhdir MPA, Tariq M, Haider AH. Undergraduate Medical Education Curriculum Reforms in Pakistan: A Mixed Methods Study of Academic Leadership Perspectives. Acad Med 2024:00001888-990000000-00783. [PMID: 38442198 DOI: 10.1097/acm.0000000000005683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
PURPOSE Periodic revision of undergraduate medical education (UGME) curricula is an essential part of evidence-based educational practices. Pakistan's national UGME curriculum, last updated in 2005, was reviewed, and recommended updates were made in 2022. The authors explore academic medical school leaders' perspectives about the proposed reforms, gaps within the existing curriculum, and how to ensure the reform implementation is effective, collaborative, and feedback-driven. METHOD Using a mixed methods approach, data were collected from April-July 2022. Academic leadership (principals, who could designate vice principals or medical educators) at all medical schools across Pakistan (n = 117) were invited. Agreement with each of 20 proposed reforms was measured via a survey employing a Likert scale. A semi-structured interview guide expanded on the survey questions with probes. RESULTS Eighty-eight survey responses, from private (59; 67.0%) and public (29; 33.0%) institutions, were obtained (75.2% response rate). Participants recommended most of the proposed reforms. The 3 reforms that received the highest agreement were teaching professionalism as an integral part of the curriculum (83; 94.3%), mandating bedside procedural skills training (80; 90.9%), and including patient safety in the UGME curriculum (79; 89.8%). Including multidisciplinary tumor boards and surgical oncology had the lowest agreement (26; 29.5%). Fifteen interviews were conducted, which revealed 3 major themes: perceptions about changes to the curricular content; limitation of human and financial resources as barriers to reform implementation; and recommendations for effective implementation of an updated curriculum. CONCLUSIONS The findings reflect an overall positive attitude of academic medical school leadership toward the 20 proposed UGME curriculum reforms, which could aid with on-the-ground implementation. However, major limitations, such as a lack of trained faculty and financial resources, must be addressed. The authors propose future research on the resources required for implementing UGME reforms and the reforms' impact after national implementation.
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Affiliation(s)
- Saqib Kamran Bakhshi
- S.K. Bakhshi is assistant professor, Department of Surgery, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Noreen Afzal
- N. Afzal is instructor of research, Department of Surgery, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Asma Altaf Hussain Merchant
- A.A.H. Merchant is clinical research fellow, Dean's Office, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Komal Abdul Rahim
- K.A. Rahim is research associate, Dean's Office, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Namra Qadeer Shaikh
- N.Q. Shaikh is a clinical research fellow, Dean's Office, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Ali Aahil Noorali
- A.A. Noorali is research associate, Department of Medicine, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Maryam Pyar Ali Lakhdir
- M.P.A. Lakhdir is senior instructor, Department of Community Health Sciences, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Muhammad Tariq
- M. Tariq is professor of medicine and vice dean of the medical college, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Adil H Haider
- A.H. Haider is professor, Departments of Surgery and Community Health Sciences, and dean of the medical college, Aga Khan University, Karachi City, Sindh, Pakistan
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Inam M, Sheikh S, Minhas AMK, Vaughan EM, Krittanawong C, Samad Z, Lavie CJ, Khoja A, D'Cruze M, Slipczuk L, Alarakhiya F, Naseem A, Haider AH, Virani SS. A review of top cardiology and cardiovascular medicine journal guidelines regarding the use of generative artificial intelligence tools in scientific writing. Curr Probl Cardiol 2024; 49:102387. [PMID: 38185435 DOI: 10.1016/j.cpcardiol.2024.102387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024]
Abstract
BACKGROUND Generative Artificial Intelligence (AI) tools have experienced rapid development over the last decade and are gaining increasing popularity as assistive models in academic writing. However, the ability of AI to generate reliable and accurate research articles is a topic of debate. Major scientific journals have issued policies regarding the contribution of AI tools in scientific writing. METHODS We conducted a review of the author and peer reviewer guidelines of the top 25 Cardiology and Cardiovascular Medicine journals as per the 2023 SCImago rankings. Data were obtained though reviewing journal websites and directly emailing the editorial office. Descriptive data regarding journal characteristics were coded on SPSS. Subgroup analyses of the journal guidelines were conducted based on the publishing company policies. RESULTS Our analysis revealed that all scientific journals in our study permitted the documented use of AI in scientific writing with certain limitations as per ICMJE recommendations. We found that AI tools cannot be included in the authorship or be used for image generation, and that all authors are required to assume full responsibility of their submitted and published work. The use of generative AI tools in the peer review process is strictly prohibited. CONCLUSION Guidelines regarding the use of generative AI in scientific writing are standardized, detailed, and unanimously followed by all journals in our study according to the recommendations set forth by international forums. It is imperative to ensure that these policies are carefully followed and updated to maintain scientific integrity.
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Affiliation(s)
- Maha Inam
- Office of the Vice Provost, Research, Aga Khan University, Karachi, Pakistan
| | - Sana Sheikh
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Abdul Mannan Khan Minhas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Elizabeth M Vaughan
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Department of Internal Medicine, UTMB, Galveston, TX, United States
| | - Chayakrit Krittanawong
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, United States
| | - Zainab Samad
- Section of Cardiology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, United States
| | - Adeel Khoja
- Department of Medicine, Aga Khan University, Karachi, Pakistan; Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Melaine D'Cruze
- Institute for Educational Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Leandro Slipczuk
- Cardiology Division, Montefiore Medical Center, Bronx, NY, United States; Albert Einstein College of Medicine, Bronx, NY, United States
| | | | - Azra Naseem
- Institute for Educational Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Adil H Haider
- Dean's Office, Medical College, Aga Khan University Hospital, Karachi, Pakistan
| | - Salim S Virani
- Office of the Vice Provost, Research, Aga Khan University, Karachi, Pakistan; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Section of Cardiology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan; The Texas Heart Institute, Houston, TX, United States.
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Allar BG, Ortega G, Chun MBJ, Rodriguez JGZ, Mullen JT, Lynch KA, Harrington DT, Green AR, Lipsett PA, Britt LD, Haider AH, Smink DS, Kent TS. Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial. J Surg Educ 2024; 81:330-334. [PMID: 38142149 PMCID: PMC10922754 DOI: 10.1016/j.jsurg.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/27/2023] [Accepted: 11/24/2023] [Indexed: 12/25/2023]
Abstract
The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.
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Affiliation(s)
- Benjamin G Allar
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Gezzer Ortega
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maria B J Chun
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | | | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kenneth A Lynch
- Rhode Island Hospital Department of Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David T Harrington
- Rhode Island Hospital Department of Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Pamela A Lipsett
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Adil H Haider
- Aga Khan University Medical College, Karachi, Pakistan
| | - Douglas S Smink
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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de Jager E, Levine AA, Sidey-Gibbons CJ, Udyavar NR, Liu C, Lamaina M, Maggard Gibbons MA, Ko CY, Burstin HR, Haider AH, Hoyt DB, Schoenfeld AJ, Weissman JS, Britt LD. Development and Validation of a Novel Literature-Based Method to Identify Disparity-Sensitive Surgical Quality Metrics. J Am Coll Surg 2023; 237:856-861. [PMID: 37703495 DOI: 10.1097/xcs.0000000000000859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Disparity in surgical care impedes the delivery of uniformly high-quality care. Metrics that quantify disparity in care can help identify areas for needed intervention. A literature-based Disparity-Sensitive Score (DSS) system for surgical care was adapted by the Metrics for Equitable Access and Care in Surgery (MEASUR) group. The alignment between the MEASUR DSS and Delphi ratings of an expert advisory panel (EAP) regarding the disparity sensitivity of surgical quality metrics was assessed. STUDY DESIGN Using DSS criteria MEASUR co-investigators scored 534 surgical metrics which were subsequently rated by the EAP. All scores were converted to a 9-point scale. Agreement between the new measurement technique (ie DSS) and an established subjective technique (ie importance and validity ratings) were assessed using the Bland-Altman method, adjusting for the linear relationship between the paired difference and the paired average. The limit of agreement (LOA) was set at 1.96 SD (95%). RESULTS The percentage of DSS scores inside the LOA was 96.8% (LOA, 0.02 points) for the importance rating and 94.6% (LOA, 1.5 points) for the validity rating. In comparison, 94.4% of the 2 subjective EAP ratings were inside the LOA (0.7 points). CONCLUSIONS Applying the MEASUR DSS criteria using available literature allowed for identification of disparity-sensitive surgical metrics. The results suggest that this literature-based method of selecting quality metrics may be comparable to more complex consensus-based Delphi methods. In fields with robust literature, literature-based composite scores may be used to select quality metrics rather than assembling consensus panels.
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Affiliation(s)
- Elzerie de Jager
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Adele A Levine
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Chris J Sidey-Gibbons
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - N Rhea Udyavar
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Charles Liu
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Margherita Lamaina
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Melinda A Maggard Gibbons
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Clifford Y Ko
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Helen R Burstin
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Adil H Haider
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - David B Hoyt
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Andrew J Schoenfeld
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - Joel S Weissman
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
| | - L D Britt
- From the Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, MA (de Jager, Levine, Udyavar, Haider, Schoenfeld, Weissman)
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Merchant AAH, Shaukat N, Ashraf N, Hassan S, Jarrar Z, Abbasi A, Ahmed T, Atiq H, Khan UR, Khan NU, Mushtaq S, Rasul S, Hyder AA, Razzak J, Haider AH. Which curve is better? A comparative analysis of trauma scoring systems in a South Asian country. Trauma Surg Acute Care Open 2023; 8:e001171. [PMID: 38020857 PMCID: PMC10668242 DOI: 10.1136/tsaco-2023-001171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives A diverse set of trauma scoring systems are used globally to predict outcomes and benchmark trauma systems. There is a significant potential benefit of using these scores in low and middle-income countries (LMICs); however, its standardized use based on type of injury is still limited. Our objective is to compare trauma scoring systems between neurotrauma and polytrauma patients to identify the better predictor of mortality in low-resource settings. Methods Data were extracted from a digital, multicenter trauma registry implemented in South Asia for a secondary analysis. Adult patients (≥18 years) presenting with a traumatic injury from December 2021 to December 2022 were included in this study. Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), Mechanism/GCS/Age/Pressure score and GCS/Age/Pressure score were calculated for each patient to predict in-hospital mortality. We used receiver operating characteristic curves to derive sensitivity, specificity and area under the curve (AUC) for each score, including Glasgow Coma Scale (GCS). Results The mean age of 2007 patients included in this study was 41.2±17.8 years, with 49.1% patients presenting with neurotrauma. The overall in-hospital mortality rate was 17.2%. GCS and RTS proved to be the best predictors of in-hospital mortality for neurotrauma (AUC: 0.885 and 0.874, respectively), while TRISS and ISS were better predictors for polytrauma patients (AUC: 0.729 and 0.722, respectively). Conclusion Trauma scoring systems show differing predictability for in-hospital mortality depending on the type of trauma. Therefore, it is vital to take into account the region of body injury for provision of quality trauma care. Furthermore, context-specific and injury-specific use of these scores in LMICs can enable strengthening of their trauma systems. Level of evidence Level III.
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Affiliation(s)
| | - Natasha Shaukat
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Naela Ashraf
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Sheza Hassan
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Zeerak Jarrar
- Department of Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Ayesha Abbasi
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Tanveer Ahmed
- Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Sindh, Pakistan
| | - Huba Atiq
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
- Department of Emergency Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Uzma Rahim Khan
- Department of Emergency Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Nadeem Ullah Khan
- Department of Emergency Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Saima Mushtaq
- Department of Emergency Medicine, Jinnah Postgraduate Medical Centre, Karachi, Sindh, Pakistan
| | - Shahid Rasul
- Department of Surgery, Jinnah Postgraduate Medical Centre, Karachi, Sindh, Pakistan
| | - Adnan A Hyder
- Center on Commercial Determinants of Health and Department of Global Health, George Washington University School of Public Health and Health Services, Washington, DC, USA
| | - Junaid Razzak
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Adil H. Haider
- Dean's Office, The Aga Khan University, Karachi, Sindh, Pakistan
- Department of Surgery and Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
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12
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Merchant AAH, Hassan S, Baig N, Atiq H, Mahmood S, Doll A, Naseer R, Haq ZU, Shehnaz D, Haider AH, Razzak J. Methodological analysis of a community-based training initiative using the EPIS framework: an ongoing initiative to empower 10 million bystanders in CPR and bleeding control. Trauma Surg Acute Care Open 2023; 8:e001132. [PMID: 38020852 PMCID: PMC10649812 DOI: 10.1136/tsaco-2023-001132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background Out-of-hospital cardiac arrest (OHCA) and life-threatening bleeding from trauma are leading causes of preventable mortality globally. Early intervention from bystanders can play a pivotal role in increasing the survival rate of victims. While great efforts for bystander training have yielded positive results in high-income countries, the same has not been replicated in low and middle-income countries (LMICs) due to resources constraints. This article describes a replicable implementation model of a nationwide program, aimed at empowering 10 million bystanders with basic knowledge and skills of hands-only cardiopulmonary resuscitation (CPR) and bleeding control in a resource-limited setting. Methods Using the EPIS (Exploration, Preparation, Implementation and Sustainment) framework, we describe the application of a national bystander training program, named 'Pakistan Life Savers Programme (PLSP)', in an LMIC. We discuss the opportunities and challenges faced during each phase of the program's implementation and identify feasible and sustainable actions to make them reproducible in similar low-resource settings. Results A high mortality rate owing to OHCA and traumatic life-threatening bleeding was identified as a national issue in Pakistan. After intensive discussions during the exploration phase, PLSP was chosen as a potential solution. The preparation phase oversaw the logistical administration of the program and highlighted avenues using minimal resources to attain maximum outreach. National implementation of bystander training started as a pilot in suburban schools and expanded to other institutions, with 127 833 bystanders trained to date. Sustainability of the program was targeted through its addition in a single national curriculum taught in schools and the development of a cohesive collaborative network with entities sharing similar goals. Conclusion This article provides a methodological framework of implementing a national intervention based on bystander response. Such programs can increase bystander willingness and confidence in performing CPR and bleeding control, decreasing preventable deaths in countries having a high mortality burden. Level of evidence Level VI.
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Affiliation(s)
| | - Sheza Hassan
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Noor Baig
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
- Department of Emergency Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Huba Atiq
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
- Department of Emergency Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Sana Mahmood
- CITRIC Health Data Science Center, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Ann Doll
- Resuscitation Academy Foundation, Seattle, Washington, USA
| | | | - Zia Ul Haq
- Department of Public Health, Khyber Medical University, Peshawar, Pakistan
| | | | - Adil H. Haider
- Dean's Office, The Aga Khan University, Karachi, Sindh, Pakistan
- Department of Surgery and Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Junaid Razzak
- Centre of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Sindh, Pakistan
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
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13
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Merchant AAH, Shaikh NQ, Afzal N, Noorali AA, Abdul Rahim K, Ahmad R, Ahmer A, Khan AA, Bakhshi SK, Mahmood SBZ, Lakhdir MPA, Khan MR, Tariq M, Haider AH. Disparities in patient-resident physician communication and counseling: A multi-perspective exploratory qualitative study. PLoS One 2023; 18:e0288549. [PMID: 37871016 PMCID: PMC10593213 DOI: 10.1371/journal.pone.0288549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 06/29/2023] [Indexed: 10/25/2023] Open
Abstract
Effective communication between physicians and patients plays an integral role in clinical care. Gaps in a physician's ability to ensure effective communication, especially with patients from diverse backgrounds, are known causes of medical errors. This study explores the potential biases and disparities in patient-resident communication, which may influence a patient's quality of care. This exploratory qualitative study was conducted at the largest academic medical center in Pakistan. Purposive sampling was used to approach participants from surgery, medicine, obstetrics and gynecology, pediatrics and family medicine. Faculty, fellows and residents working in these departments and medical students in their fourth and fifth years of undergraduate education with prior experience of at least one month in these specialties during their clinical rotations were included. Focus group discussions (FGDs) lasting 45-60 minutes were conducted with each cohort of healthcare professionals separately, using a semi-structured interview guide. Sixty participants (19 males and 41 females, mean age: 32.9, SD: 10.9) took part in the study. Thematic analysis revealed five major themes. Four themes focused on residents' biases and patient disparities hindering patient-resident communication: (1) patient-resident gender discordance (2) ethnicity and language barriers, (3) differing social class of the patient, and (4) challenging patient-resident interactions (patients resistant to treatment, exceedingly inquisitive and those with multiple attendants, etc.). The fifth theme identified the need for a communication skills curriculum in postgraduate medical education. Opposite gender and discordant socioeconomic/cultural backgrounds of patients pose a challenge to effective patient-physician communication. Self-identification and awareness of residents' biases when interacting with patients can ensure their active elimination and improve their communication skills. Integrating these components in a standardized curriculum within postgraduate programs can enable resident-physicians to provide the same level of care and communicate more efficiently with patients of all backgrounds.
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Affiliation(s)
| | | | - Noreen Afzal
- Dean’s Office, Aga Khan University, Karachi, Pakistan
| | | | - Komal Abdul Rahim
- Dean’s Office, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Rida Ahmad
- Dean’s Office, Aga Khan University, Karachi, Pakistan
| | - Areesha Ahmer
- Medical College, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | | - Muhammad Tariq
- Dean’s Office, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Adil H. Haider
- Dean’s Office, Aga Khan University, Karachi, Pakistan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
- Department of Surgery, Aga Khan University, Karachi, Pakistan
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14
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Bakhshi SK, Abdul Rahim K, Merchant AAH, Afzal N, Qadeer Shaikh N, Noorali AA, Lakhdir MPA, Mahmood SBZ, Tariq M, Haider AH. Barriers to research productivity amongst postgraduate trainees: results from a survey of 333 medical and surgical residents. Postgrad Med J 2023; 99:1182-1188. [PMID: 37544657 DOI: 10.1093/postmj/qgad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE We aimed to determine the perceptions of, barriers to, and predictors of research engagement amongst residents at a national level in Pakistan. METHODS This cross-sectional study used REDCap for online survey dissemination to residents from 12 institutes accredited by the national accreditation body (College of Physicians and Surgeons Pakistan) for core medical and surgical specialties. Logistic regression was used to estimate associations between likelihood of publications and participant characteristics. RESULTS The response rate was 79% (333/423), with 171 (51%) medical and 162 (49%) surgical residents. The mean ± standard deviation age was 28.8 ± 2.7 years; 137 (41%) were males and 195 (59%) females. More than half the residents, 202 (61%), had received research training, but 189 (57%) scored <33% on basic research knowledge. While most residents agreed on the positive impact of research on their careers (P = .012) and realized that they should be involved in it (P = .33), they also strongly believed that it was difficult to engage in research during training (P < .01). Only 60 (18%) trainees had published a paper in local and 37 (11%) in international journals, respectively. The most significant barriers to conducting research included time limitation due to clinical work, lack of financial support, and unavailability of data (P < .01). CONCLUSION Residents have a positive attitude towards research. However, research engagement among residents is low. Improving research mentorship and creating systems that enable protected time and institutional access to data are needed to increase research output of postgraduate trainees. Key messages What is already known on this topic Postgraduate trainees benefit academically from research conducted during residency training. However, in low- and middle-income countries like Pakistan, research output among residents has remained low over the years. The nation has consistently produced very little research. What this study adds The current study helped shed light on the reasons for low research productivity amongst medical and surgical residents in Pakistan. How this study might affect research, practice, or policy The potential predictors for low research involvement highlighted in this study necessitate modification of the existing national residency curriculum to increase research engagement and productivity among residents. Not only can the potential factors be improved, but the study also helps in bringing stakeholders' attention to increasing research opportunities in Pakistan.
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Affiliation(s)
- Saqib K Bakhshi
- Section of Neurosurgery, Department of Surgery, Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Komal Abdul Rahim
- Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
- Dean's Office, Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Asma A H Merchant
- Dean's Office, Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Noreen Afzal
- Dean's Office, Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Namra Qadeer Shaikh
- Dean's Office, Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Ali A Noorali
- Department of Community Health Sciences, Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | | | - Saad B Z Mahmood
- Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
| | - Muhammad Tariq
- Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
| | - Adil H Haider
- Dean's Office, Medical College, Aga Khan University, Karachi, 74800, Pakistan
- Department of Community Health Sciences, Medical College, Aga Khan University, Karachi, 74800, Pakistan
- Department of Surgery, Medical College, Aga Khan University, Karachi, 74800, Pakistan
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15
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Nadeem S, Pervez A, Abid MA, Khalid RN, Rizvi NA, Aamdani SS, Ayub B, Mustafa MA, Ahmed S, Riaz M, Irfan K, Noordin S, Jafri L, Majid H, Umer M, Zehra N, Sheikh A, Haider AH, Khan AH. GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context. Arch Osteoporos 2023; 18:71. [PMID: 37204537 DOI: 10.1007/s11657-023-01258-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/25/2023] [Indexed: 05/20/2023]
Abstract
Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis. PURPOSE Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan. METHODS The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE). RESULTS The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age. CONCLUSION The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.
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Affiliation(s)
- Sarah Nadeem
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Alina Pervez
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | - Muhammad Abbas Abid
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan
| | | | - Nashia Ali Rizvi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | | | - Bushra Ayub
- Learning Research Centre, Patel Hospital, Karachi, Pakistan
| | - Mohsin Ali Mustafa
- Center for Clinical Best Practices, Clinical and Translational Research Incubator, Aga Khan University, Karachi, Pakistan
| | - Sibtain Ahmed
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan
| | - Mehmood Riaz
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Khadija Irfan
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | | | - Lena Jafri
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan
| | - Hafsa Majid
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan
| | - Masood Umer
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Nawazish Zehra
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan
| | - Aisha Sheikh
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Adil H Haider
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Aysha Habib Khan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan.
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Martins RS, Hussain H, Chaudry M, Rizvi NA, Mustafa MA, Ayub B, Aamdani SS, Rehman AA, Pervez A, Nadeem S, Khalid R, Ali AS, Shahid S, Zubairi ABS, Haider AH, Irfan M. GRADE-ADOLOPMENT of clinical practice guidelines and creation of clinical pathways for the primary care management of chronic respiratory conditions in Pakistan. BMC Pulm Med 2023; 23:123. [PMID: 37069600 PMCID: PMC10111762 DOI: 10.1186/s12890-023-02409-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/31/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION In Pakistan, chronic respiratory conditions contribute a large burden of morbidity and mortality. A major reason for this is the lack of availability of local evidence-based clinical practice guidelines (EBCPGs) in Pakistan, particularly at the primary care level. Thus, we developed EBCPGs and created clinical diagnosis and referral pathways for the primary care management of chronic respiratory conditions in Pakistan. METHODS The source guidelines were selected by two local expert pulmonologists after a thorough literature review on PubMed and Google Scholar from 2010 to December 2021. The source guidelines covered idiopathic pulmonary fibrosis, asthma, chronic obstructive pulmonary disorders, and bronchiectasis. The GRADE-ADOLOPMENT process consists of three key elements: adoption (using recommendations as is or with minor changes), adaptation (effective context-specific changes to recommendations) or additions (including new recommendations to fill a gap in the EBCPG). We employed the GRADE-ADOLOPMENT process to adopt, adapt, adopt with minor changes, or exclude recommendations from a source guideline. Additional recommendations were added to the clinical pathways based on a best-evidence review process. RESULTS 46 recommendations were excluded mainly due to the unavailability of recommended management in Pakistan and scope beyond the practice of general physicians. Clinical diagnosis and referral pathways were designed for the four chronic respiratory conditions, explicitly delineating the role of primary care practitioners in the diagnosis, basic management, and timely referral of patients. Across the four conditions, 18 recommendations were added (seven for IPF, three for bronchiectasis, four for COPD, and four for asthma). CONCLUSION The widespread use of the newly created EBCPGs and clinical pathways in the primary healthcare system of Pakistan can help alleviate the morbidity and mortality related to chronic respiratory conditions disease in the country.
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Affiliation(s)
- Russell Seth Martins
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan
| | - Hawra Hussain
- Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Maryam Chaudry
- Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Nashia Ali Rizvi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan
| | - Mohsin Ali Mustafa
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan
| | - Bushra Ayub
- Learning Research Centre, Patel Hospital, Karachi, 75300, Pakistan
| | | | - Alina Abdul Rehman
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan
| | - Alina Pervez
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan
| | - Sarah Nadeem
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
| | - Rameesha Khalid
- Section of Pulmonology, Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
| | - Akbar Shoukat Ali
- Section of Pulmonology, Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
| | - Shayan Shahid
- Section of Pulmonology, Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
| | - Ali Bin Sarwar Zubairi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, 74800, Pakistan
- Section of Pulmonology, Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan
| | - Adil H Haider
- Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Muhammad Irfan
- Section of Pulmonology, Department of Medicine, Aga Khan University, Karachi, 74800, Pakistan.
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Rahim KA, Lakhdir MPA, Afzal N, Merchant AAH, Shaikh NQ, Noorali AA, Tariq U, Ahmad R, Bakhshi SK, Mahmood SBZ, Khan MR, Tariq M, Haider AH. Leveraging the vantage point - exploring nurses' perception of residents' communication skills: a mixed-methods study. BMC Med Educ 2023; 23:148. [PMID: 36869344 PMCID: PMC9985286 DOI: 10.1186/s12909-023-04114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/17/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Effective communication is key to a successful patient-doctor interaction and improved healthcare outcomes. However, communication skills training in residency is often subpar, leading to inadequate patient-physician communication. There is a dearth of studies exploring the observations of nurses - key members of healthcare teams with a special vantage point to observe the impact of residents' communication with patients. Thus, we aimed to gauge the perceptions of nurses regarding residents' communication skills expertise. METHODS This study employed a sequential mixed-methods design, and was conducted at an academic medical center in South Asia. Quantitative data was collected via a REDCap survey using a structured validated questionnaire. Ordinal logistic regression was applied. For qualitative data, In-depth interviews were conducted with nurses using a semi-structured interview guide. RESULTS A total of 193 survey responses were obtained from nurses hailing from various specialties including Family Medicine (n = 16), Surgery (n = 27), Internal Medicine (n = 22), Pediatrics (n = 27), and Obstetrics/Gynecology (n = 93). Nurses rated long working hours, infrastructural deficits, and human failings as the main barriers to effective patient-resident communication. Residents working in in-patient settings were more likely to have inadequate communication skills (P-value = 0.160). Qualitative data analysis of nine in-depth interviews revealed two major themes: existing status-quo of residents' communication skills (including deficient verbal and non-verbal communication, bias in patient counselling and challenging patients) and recommendations for improving patient-resident communication. CONCLUSION The findings from this study highlight significant gaps in patient-resident communication from the perception of nurses and identify the need for creating a holistic curriculum for residents to improve patient-physician interaction.
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Affiliation(s)
- Komal Abdul Rahim
- Dean's Office, Medical College, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan.
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan.
- Internal Medicine, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan.
| | - Maryam Pyar Ali Lakhdir
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Noreen Afzal
- Dean's Office, Medical College, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | | | - Namra Qadeer Shaikh
- Dean's Office, Medical College, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Ali Aahil Noorali
- Dean's Office, Medical College, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Umar Tariq
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Rida Ahmad
- Dean's Office, Medical College, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Saqib Kamran Bakhshi
- Dean's Office, Medical College, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Saad Bin Zafar Mahmood
- Dean's Office, Medical College, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | | | | | - Adil H Haider
- Medical College, Aga Khan University, Karachi, Pakistan
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Martins RS, Masood MQ, Mahmud O, Rizvi NA, Sheikh A, Islam N, Khowaja ANA, Ram N, Furqan S, Mustafa MA, Aamdani SS, Pervez A, Haider AH, Nadeem S. Adolopment of adult diabetes mellitus management guidelines for a Pakistani context: Methodology and challenges. Front Endocrinol (Lausanne) 2023; 13:1081361. [PMID: 36686436 PMCID: PMC9849674 DOI: 10.3389/fendo.2022.1081361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/16/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Pakistan has the highest national prevalence of type 2 diabetes mellitus (T2DM) in the world. Most high-quality T2DM clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local T2DM CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of adult DM in Pakistan. Methods We employed the GRADE-ADOLOPMENT approach utilizing the T2DM CPG of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes - 2021 as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context. Results The source document contained 243 recommendations, 219 of which were adopted without change, 5 with minor changes, and 18 of which were excluded in the newly created Pakistani guidelines. One recommendation was adapted: the recommended age to begin screening all individuals for T2DM/pre-diabetes was lowered from 45 to 30 years, due to the higher prevalence of T2DM in younger Pakistanis. Exclusion of recommendations were primarily due to differences in the healthcare systems of Pakistan and the US, or the unavailability of certain drugs in Pakistan. Conclusion A CPG for the management of T2DM in Pakistan was created. Our newly developed guideline recommends earlier screening for T2DM in Pakistan, primarily due to the higher prevalence of T2DM amongst younger individuals in Pakistan. Moreover, the systematic methodology used is a significant improvement on pre-existing T2DM CPGs in Pakistan. Once these evidence based CGPs are officially published, their nationwide uptake should be top priority. Our findings also highlight the need for rigorous expanded research exploring the effectiveness of earlier screening for T2DM in Pakistan.
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Affiliation(s)
- Russell Seth Martins
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | - Muhammad Qamar Masood
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Omar Mahmud
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Nashia Ali Rizvi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | - Aisha Sheikh
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Najmul Islam
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Nanik Ram
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Saira Furqan
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Mohsin Ali Mustafa
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | | | - Alina Pervez
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | | | - Sarah Nadeem
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
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Zogg CK, Metcalfe D, Sokas CM, Dalton MK, Hirji SA, Davis KA, Haider AH, Cooper Z, Lichtman JH. Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes. Ann Surg 2023; 277:e204-e211. [PMID: 33914485 PMCID: PMC8384940 DOI: 10.1097/sla.0000000000004805] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes. SUMMARY BACKGROUND DATA The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression. RESULTS A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions. CONCLUSION The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, CT
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
- Yale School of Public Health, New Haven, CT
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Claire M. Sokas
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Michael K. Dalton
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sameer A. Hirji
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Adil H. Haider
- The Aga Khan University Medical College, Karachi, Pakistan
| | - Zara Cooper
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
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de Jager E, Osman SY, Levine AA, Liu C, Maggard Gibbons MA, Ko CY, Burstin HR, Haider AH, Hoyt DB, Schoenfeld AJ, Britt LD, Weissman JS. Disparity-Sensitive Measures in Surgical Care: A Delphi Panel Consensus. J Am Coll Surg 2023; 236:135-143. [PMID: 36111798 PMCID: PMC9771907 DOI: 10.1097/xcs.0000000000000420] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care. STUDY DESIGN An environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used. RESULTS We identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature. CONCLUSION There are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.
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Affiliation(s)
- Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, AUS
| | - Samia Y Osman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Adele A Levine
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Charles Liu
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | | | - Clifford Y Ko
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
- American College of Surgeons, Chicago, IL
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | | | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA
| | - LD Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA
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Herrera-Escobar JP, Reidy E, Phuong J, Brasel KJ, Cuschieri J, Fallat M, Potter BK, Price MA, Bulger EM, Haider AH, Bonne S, Brasel KJ, Cuschieri J, de Roon-Cassini T, Dicker RA, Fallat M, Ficke JR, Gabbe B, Gibran NS, Heinemann AW, Ho V, Kao LS, Kellam JF, Kurowski BG, Levy-Carrick NC, Livingston D, Mandell SP, Manley GT, Michetti CP, Miller AN, Newcomb A, Okonkwo D, Potter BK, Seamon M, Stein D, Wagner AK, Whyte J, Yonclas P, Zatzick D, Zielinski MD. Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey. J Trauma Acute Care Surg 2022; 93:854-862. [PMID: 35972140 DOI: 10.1097/ta.0000000000003747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes. METHODS Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions. CONCLUSION This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research. LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level IV.
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Affiliation(s)
- Juan P Herrera-Escobar
- From the Center for Surgery and Public Health (J.P.H.-E., E.R., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Biomedical Informatics and Medical Education (J.P.), University of Washington, Seattle, Washington; Division of Trauma, Critical Care and Acute Care Surgery (K.J.B.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (J.C.), University of San Francisco California, San Francisco, California; Department of Surgery (M.F.), University of Louisville, Louisville, Kentucky; Walter Reed Department of Surgery (B.K.P.), Uniformed Services University, Bethesda, Maryland; Coalition for National Trauma Research (M.A.P.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; Office of the Dean, Aga Khan University Medical College (A.H.H.), Karachi, Pakistan
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22
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Shahbaz H, Noorali AA, Inam M, Qadeer N, Merchant AAH, Khan AA, Afzal N, Abdul Rahim K, Munaf I, Ahmad R, Tariq M, Haider AH. Developing a communication-skills training curriculum for resident-physicians to enhance patient outcomes at an academic medical centre: an ongoing mixed-methods study protocol. BMJ Open 2022; 12:e056840. [PMID: 35981768 PMCID: PMC9394207 DOI: 10.1136/bmjopen-2021-056840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Effective physician-patient communication is directly linked to enhanced patient safety, improved healthcare quality and health outcomes. Numerous studies have been done to implement and reinforce communication skills as core competencies to be acquired during residency training for providing culturally competent care. Pakistan has an ethnically diverse culture with people from varying diasporas. Hence there is a need to develop a curriculum that teaches cultural competency to residents. Thus, the aim of this study is (1) the identification of existing problems of communication skills among residents across various specialties, and (2) to strategise a communication skills curriculum by organising a conference of experts based on the Delphi method/estimate-talk-estimate method. METHODS AND ANALYSIS This study is divided into two phases. The first phase will employ a mixed-methods approach whereby the perceptions of attendings, residents, fellows, nurses, medical students and patients about resident-patient communication will be assessed via validated surveys, focused group discussions and in-depth interviews. Quantitative and qualitative data will be analysed using Stata and NVivo, respectively. The second phase is the development of a communication skills curriculum for residents based on results from phase one and a Delphi consensus involving medical education experts. Both phases will be conducted at a tertiary care hospital in Karachi, Pakistan. ETHICS AND DISSEMINATION This study has received ethical approval from the Ethical Review Committee at the Aga Khan University (2021-6041-17126). All participants will be mandated to provide informed consent and their confidentiality will be maintained by using de-identifiers and limiting access of the data to the research team only. The findings from this study will be presented in the form of original research papers.
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Affiliation(s)
- Hamna Shahbaz
- Dean's Office, The Aga Khan University, Karachi, Pakistan
| | | | - Maha Inam
- The Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | - Namra Qadeer
- Dean's Office, The Aga Khan University, Karachi, Pakistan
| | | | - Adnan Ali Khan
- The Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | - Noreen Afzal
- Dean's Office, The Aga Khan University, Karachi, Pakistan
| | - Komal Abdul Rahim
- Dean's Office, The Aga Khan University, Karachi, Pakistan
- Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Rida Ahmad
- Dean's Office, The Aga Khan University, Karachi, Pakistan
| | - Muhammad Tariq
- Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Adil H Haider
- Department of Surgery and Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
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Herrera-Escobar JP, Price MA, Reidy E, Bixby PJ, Hau K, Bulger EM, Haider AH. Core outcome measures for research in traumatic injury survivors: The National Trauma Research Action Plan modified Delphi consensus study. J Trauma Acute Care Surg 2022; 92:916-923. [PMID: 35081596 DOI: 10.1097/ta.0000000000003546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Until recently, survival has been the main outcome measure for injury research. Given the impact of injury on quality of life, the National Academies of Science, Engineering, and Medicine has called for advancing the science of research evaluating the long-term outcomes of trauma survivors. This is necessary so that treatments and interventions can be assessed for their impact on a trauma patients' long-term functional and psychosocial outcomes. We sought to propose a set of core domains and measurement instruments that are best suited to evaluate long-term outcomes after traumatic injury with a goal for these measures to be adopted as a national standard. METHODS As part of the development of a National Trauma Research Action Plan, we conducted a two-stage, five-round modified online Delphi consensus process with a diverse panel of 50 key stakeholders including clinicians, researchers, and trauma survivors from more than 9 professional areas across the United States. Before voting, panelists reviewed the results of a scoping review on patient-reported outcomes after injury and standardized information on measurement instruments following the Consensus-based Standards for the Selection of Health Measurement Instruments guidelines. RESULTS The panel considered a preliminary list of 74 outcome domains (patient-reported outcomes) and ultimately reached the a priori consensus criteria for 29 core domains that encompass aspects of physical, mental, social, and cognitive health. Among these 29 core domains, the panel considered a preliminary list of 199 patient-reported outcome measures and reached the a priori consensus criteria for 14 measures across 13 core domains. Participation of panelists ranged from 65% to 98% across the five Delphi rounds. CONCLUSION We developed a core outcome measurement set that will facilitate the synthesis, comparison, and interpretation of long-term trauma outcomes research. These measures should be prioritized in all future studies in which researchers elect to evaluate long-term outcomes of traumatic injury survivors. LEVEL OF EVIDENCE Diagnostic Test or Criteria, Level IV.
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Affiliation(s)
- Juan Pablo Herrera-Escobar
- From the Center for Surgery and Public Health (J.P.H.-E., E.R., K.H., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Coalition for National Trauma Research (M.A.P., P.J.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; Aga Khan University Medical College (A.H.H.), Karachi, Pakistan
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Lotfi AL, Haider AH, Pervaiz AP, Kadado AJK, Bachman MB, Rodriguez Arciniega JRA, Visintainer PV. Impact of wire sensor location on coronary physiological measurement. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The location of the wire sensor to measure FFR and dPR has not been systemically studied. Therefore, we hypothesize that the coronary physiological measurements will vary with the location of the sensor. This exploratory study is to assess whole cycle pressure distal/pressure aorta (Pd/Pa) ratio, FFR, and dPR at different sensor position within the vessel to evaluate the impact of pressure drop and measurements based on sensor position.
Methods
54 patients who had an indication for coronary angiography were screened and 30 consecutive patients were enrolled. The OptoWire 2 or 3 generation fiberoptic pressure wire was used to assess Pd/Pa, dPR, and FFR. Our primary goal is to test if those measurements vary with the FFR wire sensor placed at 10mm (proximal), 35–45mm (mid), and greater than or equal 60–70mm (distal) distal to the target lesion respectively. We used a multilevel linear regression approach.
Results
Of 30 patients enrolled, 23 (76.6%) were males, mean age was 64.7 years (± 11.0 yrs), and mean stenosis was 61.6% (±13.4%). Adjusting for age, gender, and severity of stenosis, results showed that for all three measures (Pd/Pa, DPR, and FFR) (Figure 1), pressure decreased in a linear fashion the further the sensor was from the target lesion (p values <0.001). Further, pairwise comparisons of the measurements at adjacent locations similarly showed significant declines in pressure (p values <0.001).
Conclusions
This is first study to demonstrate that the location of the pressure wire can impact the results of both resting and hyperemic pressures which can cause a false negative result. This is especially important where the values are near the cut-off.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A L Lotfi
- University of Massachusetts Medical School-Baystate Campus, Cardiology, Springfield, United States of America
| | - A H Haider
- University of Massachusetts Medical School-Baystate Campus, Cardiology, Springfield, United States of America
| | - A P Pervaiz
- University of Massachusetts Medical School-Baystate Campus, Cardiology, Springfield, United States of America
| | - A J K Kadado
- University of Massachusetts Medical School-Baystate Campus, Cardiology, Springfield, United States of America
| | - M B Bachman
- University of Massachusetts Medical School-Baystate Campus, Cardiology, Springfield, United States of America
| | - J R A Rodriguez Arciniega
- University of Massachusetts Medical School-Baystate Campus, Cardiology, Springfield, United States of America
| | - P V Visintainer
- University of Massachusetts Medical School-Baystate Campus, Epidemiology and Biostatistics, Springfield, United States of America
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Castillo-Angeles M, Herrera-Escobar JP, Toppo A, Sanchez SE, Kaafarani HM, Salim A, Haider AH, Nehra D. Patient reported outcomes 6 to 12 months after interpersonal violence: A multicenter cohort study. J Trauma Acute Care Surg 2021; 91:260-264. [PMID: 34397950 DOI: 10.1097/ta.0000000000003272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Violence continues to be a significant public health burden, but little is known about the long-term outcomes of these patients. Our goal was to determine the impact of violence-related trauma on long-term functional and psychosocial outcomes. METHODS We identified trauma patients with moderate to severe injuries (Injury Severity Score, ≥9) treated at one of three level 1 trauma centers. These patients were asked to complete a survey over the phone between 6 and 12 months after injury evaluating both functional and psychosocial outcomes (12-item Short Form Survey, Trauma Quality of Life, posttraumatic stress disorder [PTSD] screen, chronic pain, return to work). Patients were classified as having suffered a violent injury if the mechanism of injury was a stab, gunshot, or assault. Self-inflicted wounds were excluded. Adjusted logistic regression models were built to determine the association between a violent mechanism of injury and long-term outcomes. RESULTS A total of 1,050 moderate to severely injured patients were successfully followed, of whom 176 (16.8%) were victims of violence. For the victims of violence, mean age was 34.4 years (SD, 12.5 years), 85% were male, and 57.5% were Black; 30.7% reported newly needing help with at least one activity of daily living after the violence-related event. Fifty-nine (49.2%) of 120 patients who were working before their injury had not yet returned to work; 47.1% screened positive for PTSD, and 52.3% reported chronic pain. On multivariate analysis, a violent mechanism was significantly associated with PTSD (odds ratio, 2.57; 95% confidence interval, 1.59-4.17; p < 0.001) but not associated with chronic pain, return to work, or functional outcomes. CONCLUSION The physical and mental health burden after violence-related trauma is not insignificant. Further work is needed to identify intervention strategies and social support systems that may be beneficial to reduce this burden. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Manuel Castillo-Angeles
- From the Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, (M.C.-A., J.P.H.-E., A.S., A.H.H., D.N.), Center for Surgery and Public Health, Department of Surgery (M.C.-A., J.P.H.-E., A.T., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School; Harvard T. H. Chan School of Public Health (M.C.-A., J.P.H.-E., A.T., A.S., A.H.H.); Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (S.E.S.), Boston University School of Medicine; and Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (H.M.K.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Jarman MP, Weaver MJ, Haider AH, Salim A, Harris MB. Geographic Distribution of Orthopaedic Trauma Resources and Service Use in the United States: A Cross Sectional Analysis. J Surg Res 2021; 267:328-335. [PMID: 34186309 DOI: 10.1016/j.jss.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/15/2021] [Accepted: 05/26/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Management of orthopaedic injury is an essential component of comprehensive trauma care, and availability of orthopaedic surgeons impacts trauma system capacity and accessibility of care. We sought to estimate the geographic distribution of orthopaedic injury in the United States and identify regions needing additional orthopaedic trauma resources. METHODS In this retrospective cross-sectional study using 2014 Agency for Healthcare Research and Quality State Inpatient Datasets from 26 states and the District of Columbia, administrative data were used to determine hospital referral region (HRR)-level incidence of orthopaedic trauma and surgical care. Factors associated with HRR-level orthopaedic trauma volume were identified using negative binomial regression, and model parameters were used to estimate injury incidence and operative volume in unobserved HRRs. The primary outcomes of interest were HRR-level incidence of orthopaedic injury, polytrauma, and emergency orthopaedic surgery, as well and the number of emergency orthopaedic surgery patients per orthopaedic surgeon. RESULTS Orthopaedic injury incidence and operative patients per orthopaedic surgeon were associated with HRR-level volume of medical service use, population characteristics, geographic characteristics, and existing trauma care resources. Orthopaedic injury incidence ranged from 20 patients/HRR to 33,260 patients/HRR. Polytrauma incidence ranged from < 10 patients/HRR to 12,140 patients/HRR. Emergency orthopaedic surgery incidence ranged from < 10 patients/HRR to 18,759 patients/HRR. The volume of operative orthopaedic trauma patients per orthopaedic surgeon ranged from < 10 patients/surgeon to 224 patients and/or surgeon. DISCUSSION The incidence of orthopaedic injury and volume of injury patients per orthopaedic surgeon varies substantially across HRRs in the United States. Regions with high patient volume and moderate patient-to-provider ratios may be ideal settings for orthopaedic trauma training programs or post-fellowship professional opportunities. Future research should examine the impact of high volume orthopaedic trauma volume and high patient-to-provider ratios on health outcomes.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; College of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Salim
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Malik MA, Inam H, Martins RS, Janjua MBN, Zahid N, Khan S, Sattar AK, Khan S, Haider AH, Enam SA. Workplace mistreatment and mental health in female surgeons in Pakistan. BJS Open 2021; 5:6284043. [PMID: 34037208 PMCID: PMC8152181 DOI: 10.1093/bjsopen/zrab041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background Despite workplace mistreatment, which includes harassment, bullying and gender discrimination(GD)/bias, being serious problems for female surgeons, there are limited data from lower–middle-income countries like Pakistan. This study explored harassment and GD/bias experienced by female surgeons in Pakistan, and the effects of these experiences on mental health and well-being. Methods A nationwide survey was conducted between July and September 2019 in collaboration with the Association of Women Surgeons of Pakistan, an organization consisting of female surgeons and trainees in Pakistan. An anonymous online survey was emailed directly, disseminated via social media platforms (such as Facebook, Twitter and Instagram), and sent to surgical programmes in Pakistan. Results A total of 146 women surgeons responded to the survey; 67.1 per cent were trainees and the rest attending surgeons. Overall, 57.5 per cent of surgeons reported experiencing harassment, most common being verbal (64.0 per cent) and mental (45.9 per cent), but this mostly went unreported (91.5 per cent). On multivariable analysis adjusted for age and specialty, workplace harassment (odds ratio 2.02 (95 per cent c.i. 1.09 to 4.45)) and bullying (odds ratio 5.14 (95 per cent c.i. 2.00–13.17)) were significantly associated with severe self-perceived burnout, while having a support system was protective against feelings of depression (odds ratio 0.35 (95 per cent c.i. 0.16 to 0.74)). The overwhelming majority (91.3 per cent) believed that more institutional support groups were needed to help surgeons with stress reduction (78.8 per cent), receiving mentorship (74.7 per cent) and work–life balance (67.8 per cent). Conclusion Workplace mistreatment, in particular harassment and bullying, has a damaging impact on the mental well-being of female surgeons, particularly trainees. The absence of support groups in Pakistan should be urgently addressed so that surgeons, especially trainees, may cope better with potentially harmful workplace stressors.
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Affiliation(s)
- M A Malik
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - H Inam
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - R S Martins
- Medical College, Aga Khan University Hospital, Karachi, Pakistan
| | - M B N Janjua
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - N Zahid
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - S Khan
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - A K Sattar
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - S Khan
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - A H Haider
- Medical College, Aga Khan University Hospital, Karachi, Pakistan
| | - S A Enam
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Herrera-Escobar JP, Osman SY, Das S, Toppo A, Orlas CP, Castillo-Angeles M, Rosario A, Janjua MB, Arain MA, Reidy E, Jarman MP, Nehra D, Price MA, Bulger EM, Haider AH. Long-term patient-reported outcomes and patient-reported outcome measures after injury: the National Trauma Research Action Plan (NTRAP) scoping review. J Trauma Acute Care Surg 2021; 90:891-900. [PMID: 33605698 PMCID: PMC8081443 DOI: 10.1097/ta.0000000000003108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of this scoping review is to identify and summarize patient-reported outcome measures (PROMs) that are being used to track long-term patient-reported outcomes (PROs) after injury and can potentially be included in trauma registries. METHODS Online databases were used to identify studies published between 2013 and 2019, from which we selected 747 articles that involved survivors of acute physical traumatic injury aged 18 years or older at time of injury and used PROMs to evaluate recovery between 6 months and 10 years postinjury. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results. RESULTS Most studies were observational, with relatively small sample sizes, and predominantly on traumatic brain injury or orthopedic patients. The number of PROs assessed per study varied from one to 12, for a total of 2052 PROs extracted, yielding 74 unique constructs (physical health, 25 [34%]; mental health, 27 [37%]; social health, 12 [16%]; cognitive health, 7 [10%]; and quality of life, 3 [4%]). These 74 constructs were assessed using 355 different PROMs. Mental health was the most frequently examined outcome domain followed by physical health. Health-related quality of life, which appeared in more than half of the studies (n = 401), was the most common PRO evaluated, followed by depressive symptoms. Physical health was the domain with the highest number of PROMs used (n = 157), and lower-extremity functionality was the PRO that contributed most PROMs (n = 33). CONCLUSION We identified a wide variety of PROMs available to track long-term PROs after injury in five different health domains: physical, mental, social, cognitive, and quality of life. However, efforts to fully understand the health outcomes of trauma patients remain inconsistent and insufficient. Defining PROs that should be prioritized and standardizing the PROMs to measure them will facilitate the incorporation of long-term outcomes in national registries to improve research and quality of care. LEVEL OF EVIDENCE Systematic Reviews & Meta-analyses, Level IV.
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Lee GJ, Ortega G, Reidy E, Atkinson RB, Pichardo MS, Reich AJ, Ladin K, Chun MBJ, Demko C, Barreiro-Rosado JA, Udyavar NR, Kent TS, Green AR, Haider AH, Smink DS. A Qualitative Analysis of Surgical Faculty and Surgical Resident Perceptions of Potential Barriers to Implementing a Novel Surgical Education Curriculum. J Surg Educ 2021; 78:896-904. [PMID: 33041253 PMCID: PMC8026762 DOI: 10.1016/j.jsurg.2020.09.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum. DESIGN, SETTING, AND PARTICIPANTS Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method. RESULTS Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors. CONCLUSIONS Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program.
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Affiliation(s)
- Gillian J Lee
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Howard University College of Medicine, Washington, District of Columbia
| | - Gezzer Ortega
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Emma Reidy
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel B Atkinson
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Margaret S Pichardo
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Howard University College of Medicine, Washington, District of Columbia; Yale School of Public Health, New Haven, Connecticut
| | - Amanda J Reich
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keren Ladin
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Occupational Therapy, Tufts University Department of Public Health and Community Medicine, Medford, Massachusetts
| | - Maria B J Chun
- Department of Surgery, University of Hawaii at Mānoa, Honolulu, Hawaii
| | - Caroline Demko
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeenn A Barreiro-Rosado
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - N Rhea Udyavar
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexander R Green
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Douglas S Smink
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Hashmi ZG, Jarman MP, Havens JM, Scott JW, Goralnick E, Cooper Z, Salim A, Haider AH. Quantifying lives lost due to variability in emergency general surgery outcomes: Why we need a national emergency general surgery quality improvement program. J Trauma Acute Care Surg 2021; 90:685-693. [PMID: 33443987 DOI: 10.1097/ta.0000000000003074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nearly 4 million Americans present to hospitals with conditions requiring emergency general surgery (EGS) annually, facing significant morbidity and mortality. Unlike elective surgery and trauma, there is no dedicated national quality improvement program to improve EGS outcomes. Our objective was to estimate the number of excess deaths that could potentially be averted through EGS quality improvement in the United States. METHODS Adults with the American Association for the Surgery of Trauma-defined EGS diagnoses were identified in the Nationwide Emergency Department Sample 2006 to 2014. Hierarchical logistic regression was performed to benchmark treating hospitals into reliability adjusted mortality quintiles. Weighted generalized linear modeling was used to calculate the relative risk of mortality at each hospital quintile, relative to best-performing quintile. We then calculated the number of excess deaths at each hospital quintile versus the best-performing quintile using techniques previously used to quantify potentially preventable trauma deaths. RESULTS Twenty-six million EGS patients were admitted, and 6.5 million (25%) underwent an operation. In-hospital mortality varied from 0.3% to 4.1% across the treating hospitals. Relative to the best-performing hospital quintile, an estimated 158,177 (153,509-162,736) excess EGS deaths occurred at lower-performing hospital quintiles. Overall, 47% of excess deaths occurred at the worst-performing hospitals, while 27% of all excess deaths occurred among the operative cohort. CONCLUSION Nearly 200,000 excess EGS deaths occur across the United States each decade. A national initiative to enable structures and processes of care associated with optimal EGS outcomes is urgently needed to achieve "Zero Preventable Deaths after Emergency General Surgery." LEVEL OF EVIDENCE Care management, level IV.
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Affiliation(s)
- Zain G Hashmi
- From the Department of Surgery (Z.G.H., M.P.J., J.M.H., E.G., Z.C., A.S., A.H.H.), Brigham and Women's Hospital, Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (J.W.S.), University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine (E.G.), Brigham and Women's Hospital, Boston, Massachusetts; and The Dean's Office, Medical College (A.H.H.), Aga Khan University, Karachi, Pakistan
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Hashmi ZG, Dalton MK, Sheikh SS, McCarty JC, Salim A, Haider AH. National estimates of intestinal ostomy creation and reversal for trauma. J Trauma Acute Care Surg 2021; 90:459-465. [PMID: 33617196 DOI: 10.1097/ta.0000000000003022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal. METHODS Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal. RESULTS A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal. CONCLUSION The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal. LEVEL OF EVIDENCE Epidemiology, level III.
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Affiliation(s)
- Zain G Hashmi
- From the Center for Surgery and Public Health, Department of Surgery (Z.G.H., M.K.D., J.C.M., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (Z.G.H.), Sinai Hospital of Baltimore, Baltimore, Maryland; Department of Surgery (S.S.S.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (J.C.M.), St. Elizabeth's Medical Center, Boston, Massachusetts; and Medical College (A.H.H.), Aga Khan University, Karachi, Pakistan
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Khan MR, Samad Z, Haider AH. Supporting front-line postgraduate medical trainees during the COVID-19 pandemic: a checklist for organisations. Postgrad Med J 2021; 98:e82-e83. [PMID: 33563715 DOI: 10.1136/postgradmedj-2020-139441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2020] [Indexed: 11/03/2022]
Affiliation(s)
| | - Zainab Samad
- Medicine, Aga Khan University, Karachi, Pakistan
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Herrera-Escobar JP, El Moheb M, Ranjit A, Weed C, Brasel K, Kasotakis G, Kaafarani HMA, Velmahos G, Nehra D, Haider AH, Jarman M, Salim A. Sex differences in long-term outcomes after traumatic injury: A mediation analysis. Am J Surg 2021; 222:842-848. [PMID: 33541687 DOI: 10.1016/j.amjsurg.2021.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND We sought to examine the association and potential mediators between sex and long-term trauma outcomes. METHODS Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis. RESULTS 2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes. CONCLUSIONS There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.
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Affiliation(s)
- Juan P Herrera-Escobar
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mohamad El Moheb
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anju Ranjit
- Department of Obstetrics and Gynecology, Howard University Hospital, Washington, D.C, USA
| | - Christina Weed
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Haytham M A Kaafarani
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Velmahos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepika Nehra
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Adil H Haider
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Aga Khan University School of Medicine, Karachi, Pakistan
| | - Molly Jarman
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Salim
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Atkinson RB, Ortega G, Green AR, Chun MBJ, Harrington DT, Lipsett PA, Mullen JT, Petrusa E, Reidy E, Haider AH, Smink DS. Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills. J Surg Educ 2020; 77:e138-e145. [PMID: 32739444 PMCID: PMC7704898 DOI: 10.1016/j.jsurg.2020.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/02/2020] [Accepted: 07/10/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills. METHODS Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16. RESULTS A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05). CONCLUSIONS At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.
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Affiliation(s)
- Rachel B Atkinson
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Gezzer Ortega
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Maria B J Chun
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | - David T Harrington
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Pamela A Lipsett
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John T Mullen
- Massachusetts General Hospital, Boston, Massachusetts
| | - Emil Petrusa
- Massachusetts General Hospital, Boston, Massachusetts
| | - Emma Reidy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Aga Khan University Medical College, Karachi, Pakistan
| | - Douglas S Smink
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
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Malik M, Inam H, Janjua MBN, Martins RS, Zahid N, Khan S, Sattar AK, Haider AH, Enam SA. Factors Affecting Women Surgeons' Careers in Low-Middle-Income Countries: An International Survey. World J Surg 2020; 45:362-368. [PMID: 33040193 DOI: 10.1007/s00268-020-05811-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite increasing numbers of women surgeons globally, barriers to career advancement persist. While these barriers have been extensively discussed in high-income countries (HICs), the topic has received minimal attention in lower-middle-income countries (LMICs) like Pakistan. METHODS The Association of Women Surgeons of Pakistan (AWSP)-an organization in Pakistan consisting of female surgeons and trainees-carried out this international cross-sectional study over July-Sept 2019. An anonymous online survey was disseminated via social media platforms and various institutions across Pakistan and internationally. RESULTS A total of 218 female surgeons responded to the survey, with 146 (67%) from Pakistan and 72 (33%) from HICs. While HIC surgeons were more likely to report gender discrimination/bias (GD/bias) during residency (29.2% vs 11.6%; p = 0.001), more Pakistani surgeons reported that GD/bias negatively affected their job satisfaction (80.7% vs. 64.9%; p = 0.024). GD/bias manifested most commonly as differences in mentoring relationships (72%). A higher percentage Pakistani surgeons reported having experienced a family-related interruption in their career (24.7% vs. 11.1%; p = 0.019). The vast majority (95%) felt that surgery was perceived as a masculine field, and the majority (56.4%) of respondents reported having been told that they could not be a surgeon because of their gender. CONCLUSION Our study highlights keys factors that must be addressed to provide equal career opportunities to women surgeons. It is the responsibility of surgical educators, policy makers, and healthcare organizations to facilitate women surgeons' career progression by developing systems that support equitable career growth for women surgeons.
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Affiliation(s)
- Mahim Malik
- Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan.
| | - Hina Inam
- Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
| | | | - Russell S Martins
- Medical Student, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Nida Zahid
- Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Sadaf Khan
- Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Abida K Sattar
- Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Adil H Haider
- Medical College, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Syed Ather Enam
- Department of Surgery, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
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Alber DA, Dalton MK, Uribe-Leitz T, Ortega G, Salim A, Haider AH, Jarman MP. A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care. J Surg Res 2020; 257:486-492. [PMID: 32916501 DOI: 10.1016/j.jss.2020.08.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/01/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are well-documented disparities in outcomes for injured Black and Hispanic patients in the United States. However, patient level characteristics cannot fully explain the differences in outcomes and system-level factors, including the trauma center designation of the hospital to which a patient presents, may contribute to their worse outcomes. We aim to determine if Black and Hispanic patients are more likely to be undertriaged, compared with white patients. METHODS This is a retrospective, cross-sectional, population-based study that uses data from the 2014 Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases. We included data from all states with available State Inpatient Databases data that included both race and hospital characteristics needed for analysis (n = 18). Logistic regression was used to identify predictors of severely injured (Injury Severity Score ≥16) patients being brought to a trauma center. RESULTS We identified 70,970 severely injured trauma patients with complete data. Non-Hispanic White represented 74.1% of the study population, 9.8% were non-Hispanic Black, and 9.7% were Hispanic. After adjustment for other demographic and injury characteristics, Non-Hispanic Black and Hispanic patients were more likely to be undertriaged, compared with white patients (odds ratio, 1.20; 95% confidence interval, 1.12-1.29 and odds ratio, 1.39; 95% confidence interval, 1.29-1.48, respectively). Male sex and older age were associated with higher odds of undertriage, whereas urban residence, high injury severity, and penetrating injury were associated with lower odds of undertriage. CONCLUSIONS Severely injured Black and Hispanic trauma patients are more likely to be undertriaged than otherwise similar white patients. The factors that contribute to racial and ethnic disparities in receiving trauma center care need to be identified and addressed to provide equitable trauma care.
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Affiliation(s)
- Daniel A Alber
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; The College of Brown University, Providence, Rhode Island
| | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Tarsicio Uribe-Leitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Gezzer Ortega
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ali Salim
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
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Cole AP, Lu C, Krimphove MJ, Szymaniak J, Sun M, Fletcher SA, Lipsitz SR, Mahal BA, Nguyen PL, Choueiri TK, Kibel AS, Haider AH, Trinh QD. Comparing the Association Between Insurance and Mortality in Ovarian, Pancreatic, Lung, Colorectal, Prostate, and Breast Cancers. J Natl Compr Canc Netw 2020; 17:1049-1058. [PMID: 31487683 DOI: 10.6004/jnccn.2019.7296] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 03/15/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Insurance coverage is associated with better cancer outcomes; however, the relative importance of insurance coverage may differ between cancers. This study compared the association between insurance coverage at diagnosis and cancer-specific mortality (CSM; insurance sensitivity) in 6 cancers. PATIENTS AND METHODS Using the SEER cancer registry, data were abstracted for individuals diagnosed with ovarian, pancreatic, lung, colorectal, prostate, or breast cancer in 2007 through 2010. The association between insurance coverage at diagnosis and CSM was modeled using a Fine and Gray competing-risks regression adjusted for demographics. An interaction term combining insurance status and cancer type was used to test whether insurance sensitivity differed between cancers. Separate models were fit for each cancer. To control for lead-time bias and to assess whether insurance sensitivity may be mediated by earlier diagnosis and treatment, additional models were fit adjusting for disease stage and treatment. RESULTS Lack of insurance was associated with an increased hazard of CSM in all cancers (P<.01). The magnitude of the effect differed significantly between cancers (Pinteraction=.04), ranging from an adjusted hazard ratio of 1.13 (95% CI, 1.01-1.28) in ovarian and 1.19 (95% CI, 1.11-1.29) in pancreatic cancer to 2.19 (95% CI, 2.02-2.37) in breast and 2.98 (95% CI, 2.54-3.49) in prostate cancer. The benefit of insurance was attenuated after adjusting for stage and treatment (eg, screening/early treatment effect), with the largest reductions in prostate, breast, and colorectal cancers. CONCLUSIONS Greater insurance sensitivity was seen in screening-detected malignancies with effective treatments for early-stage disease (eg, prostate, breast, and colorectal cancers). Given that this differential is significantly reduced after adjusting for stage and treatment, our results suggest that a significant portion (but not all) of the benefit of insurance coverage is due to detection and treatment of certain curable early-stage cancers.
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Affiliation(s)
- Alexander P Cole
- Division of Urological Surgery, and.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chang Lu
- Division of Urological Surgery, and.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marieke J Krimphove
- Department of Urology, Frankfurt University Hospital, Frankfurt, Germany; and
| | | | - Maxine Sun
- Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School
| | - Sean A Fletcher
- Division of Urological Surgery, and.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital
| | - Brandon A Mahal
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, and
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, and
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School
| | | | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Division of Urological Surgery, and.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Janjua MB, Inam H, Martins RS, Zahid N, Sattar AK, Khan SM, Khan S, Darbar A, Faruqui N, Akram S, Enam SA, Haider AH, Malik MA. Gender discrimination against female surgeons: A cross-sectional study in a lower-middle-income country. Ann Med Surg (Lond) 2020; 57:157-162. [PMID: 32774847 PMCID: PMC7394833 DOI: 10.1016/j.amsu.2020.07.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/10/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction Although gender discrimination and bias (GD/bias) experienced by female surgeons in the developed world has received much attention, GD/bias in lower-middle-income countries like Pakistan remains unexplored. Thus, our study explores how GD/bias is perceived and reported by surgeons in Pakistan. Method A single-center cross-sectional anonymous online survey was sent to all surgeons practicing/training at a tertiary care hospital in Pakistan. The survey explored the frequency, source and impact of GD/bias among surgeons. Results 98/194 surgeons (52.4%) responded to the survey, of which 68.4% were males and 66.3% were trainees. Only 19.4% of women surgeons reported 'significant' frequency of GD/bias during residency. A higher percentage of women reported 'insignificant' frequency of GD/bias during residency, as compared to males (61.3% vs. 32.8%; p = 0.004). However, more women surgeons reported facing GD/bias in various aspects of their career/training, including differences in mentorship (80.6% vs. 26.9%; p < 0.005) and differences in operating room opportunities (77.4% vs. 32.8%; p < 0.005). The source was most frequently reported to be co-residents of the opposite gender. Additionally, a high percentage of female surgeons reported that their experience of GD/bias had had a significant negative impact on their career/training progression, respect/value in the surgical team, job satisfaction and selection of specialty. Conclusion Although GD/bias has widespread impacts on the training/career of female surgeons in Pakistan, most females fail to recognize this GD/bias as "significant". Our results highlight a worrying lack of recognition of GD/bias by female surgeons, representing a major barrier to gender equity in surgery in Pakistan and emphasizing the need for future research.
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McClintock TR, Gondi S, Wang Y, Friedlander DF, Cole AP, Sun M, Melnitchouk N, Chang SL, Haider AH, Weissman JS, Trinh QD. Association of Affordable Care Act-related Medicaid expansion with variation in utilization of surgical services. Am J Surg 2020; 220:441-447. [DOI: 10.1016/j.amjsurg.2019.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 01/11/2023]
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40
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Jarman MP, Sturgeon D, Mathews I, Uribe-Leitz T, Haider AH. Validation of Zip Code-Based Estimates of Ambulance Driving Distance to Control for Access to Care in Emergency Surgery Research. JAMA Surg 2020; 154:970-971. [PMID: 31339529 DOI: 10.1001/jamasurg.2019.2179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel Sturgeon
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Tarsicio Uribe-Leitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Deputy Editor
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Haider AH, Figura RH, Ladha K, Johnston M, Noll KM, Heptinstall SR, Haut ER, Efron DT. Can We Decrease the Number of Trauma Patients ‘Missing in Action'? A Prospective Pilot Intervention to Improve Trauma Patient Compliance with Outpatient Follow-up at an Urban Level I Trauma Center. Am Surg 2020. [DOI: 10.1177/000313481408000134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adil H. Haider
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
| | - Ronald H. Figura
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
| | - Karim Ladha
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
| | - Marla Johnston
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
| | - Kathy M. Noll
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
| | - Suzette R. Heptinstall
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
| | - Elliott R. Haut
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
| | - David T. Efron
- Center for Surgical Trials and Outcomes Research Department of Surgery Johns Hopkins School of Medicine Baltimore, Maryland
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42
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Oyetunji TA, Haider AH, Obirieze AC, Fisher M, Cornwell EE, Qureshi FG, Abdullah F, Nwomeh BC. Epidemiology of 577 Pediatric Firearm Fatalities: A 2-year Review of the National Trauma Data Bank. Am Surg 2020. [DOI: 10.1177/000313481408000418] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to delineate the epidemiology of pediatric firearm injuries, including ethno-demographic patterns with impact on years of potential life lost (YPLL). A 2-year review of the National Trauma Data Bank (2007 to 2008) was conducted. Firearm fatalities in records of patients younger than 18 years were identified. Data were analyzed by demographic and injury characteristics and YPLL was calculated by ethnicity. A total of 577 deaths were identified in the pediatric group. Blacks accounted for 49.7 per cent of the fatalities; Hispanics, 19.2 per cent; whites, 17.7 per cent, and other ethnicity, 13.4 per cent. Median Injury Severity Score was 25 with a median Glasgow Coma Scale score of 3. Traumatic brain injury was present in 84.2 per cent of the records. Assault accounted for 72.8 per cent, self-inflicted injury 12.7 per cent, and unintentional injuries were 8.2 per cent. Most firearm fatalities occurred at home (33.6%). By emergency department (ED) disposition, 29.3 per cent died in the ED, 32.9 per cent were admitted to the intensive care unit, and 30.0 per cent taken to the operating room. Blacks had a total of 17,446 YPLL, Hispanics 6,776 YPLL, and whites 6,718 YPLL. Pediatric firearm fatalities still remain an important public health concern. Inclusive gun control policies focused on primary prevention of accidental injuries may be more effective in mitigating its impact.
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Affiliation(s)
- Tolulope A. Oyetunji
- Department of Surgery, Howard University College of Medicine, Washington, DC; the
| | | | | | - Michael Fisher
- Department of Surgery, Howard University College of Medicine, Washington, DC; the
| | - Edward E. Cornwell
- Department of Surgery, Howard University College of Medicine, Washington, DC; the
| | - Faisal G. Qureshi
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; the
| | - Fizan Abdullah
- Department of General and Thoracic Surgery, Children's National Medical Center, Washington, DC
| | - Benedict C. Nwomeh
- Division of Pediatric Surgery, Ohio State University College of Medicine, Columbus, Ohio
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Herrera-Escobar JP, Castillo-Angeles MA, Osman SY, Orlas CP, Janjua MB, Abdullah-Arain M, Reidy E, Jarman MP, Price MA, Bulger EM, Nehra D, Haider AH. Long-term patient-reported outcome measures after injury: National Trauma Research Action Plan (NTRAP) scoping review protocol. Trauma Surg Acute Care Open 2020; 5:e000512. [PMID: 32537519 PMCID: PMC7264830 DOI: 10.1136/tsaco-2020-000512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022] Open
Abstract
Background A significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics. Objectives To describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury. Methods A systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Dissemination This scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals.
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Affiliation(s)
- Juan Pablo Herrera-Escobar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Manuel A Castillo-Angeles
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Samia Y Osman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Claudia P Orlas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Emma Reidy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Deepika Nehra
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Aga Khan University Medical College, Karachi, Pakistan
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Herrera-Escobar JP, Blake D, Toppo A, Han K, Kasotakis G, Kaafarani HM, Velmahos G, Haider AH, Salim A, Nehra D. Reduced chronic pain: Another benefit of recovery at an inpatient rehabilitation facility over a skilled nursing facility? Am J Surg 2020; 221:216-221. [PMID: 32560920 DOI: 10.1016/j.amjsurg.2020.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF). METHODS Trauma patients admitted to 3 Level-I trauma centers were interviewed to evaluate the presence of daily pain requiring medication, functional outcomes, and physical and mental health-related quality-of-life at 6-12 months post-injury. Inverse-probability-of-treatment-weighting (IPTW)-adjusted analyses were performed to compare outcomes between patients who were discharged to IRF vs SNF. RESULTS A total of 519 patients were included: 389 discharged to IRFs and 130 to SNFs. In adjusted analyses, IRF was associated with a significant reduction in the likelihood of chronic pain after injury (28.3% vs. 44.7%; OR:0.49; 95% CI, 0.26-0.91; P = .02). However, there were no significant differences in functional outcome or SF-12 composite scores between groups. CONCLUSION Our findings suggest that injured patients discharged to an IRF as compared to a SNF had less chronic pain and analgesic use.
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Affiliation(s)
- Juan P Herrera-Escobar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H Chan School of Public Health, Boston, MA, USA; Department of Surgery, Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - David Blake
- Department of Surgery, Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston University School of Medicine, Boston, MA, USA
| | - Alexander Toppo
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Kelsey Han
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Kasotakis
- Department of Surgery, Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston University School of Medicine, Boston, MA, USA
| | - Haytham Ma Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Ali Salim
- Department of Surgery, Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepika Nehra
- Department of Surgery, Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Blair KJ, Monroy A, Rook JM, Wood E, Foianini JE, Haider AH, Swaroop M, Boeck MA. What is trauma? Qualitatively assessing stakeholder perceptions in Santa Cruz de la Sierra, Bolivia. Glob Public Health 2020; 15:1364-1379. [PMID: 32379009 DOI: 10.1080/17441692.2020.1761424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Addressing the burden of injury in low-resource settings requires development of trauma systems. This study aimed to describe perceptions of trauma in Santa Cruz, Bolivia to better inform strategies for trauma system development. In 2015-2016, we conducted 16 individual and 11 group interviews with key stakeholders involved with or exposed to trauma. A pile sorting activity showed participants pictures of injury mechanisms to explore perceptions of trauma. Responses were analysed for themes using content and discourse analysis. Among 27 interviews, six were with physicians, seven with first responders, three with community members, and 11 with trauma patients. Pictures commonly categorised as trauma depicted a road traffic incident (92.6%), fall (88.9%), gunshot wound (88.9%), and burn (85.2%). Fewer respondents stated intoxication (51.9%) or drowning (40.7%) were trauma. Coding of responses revealed five themes: trauma definition, mechanism, physical injury, management, and psychological trauma. Medical personnel focused more on trauma as mechanism, physical injury, and management, whereas laypersons commonly described trauma as psychological. Varied understanding of what represents trauma could influence trauma registry data collection. Laypersons' focus on psychological trauma may affect use of designated trauma care hospitals. These viewpoints must be considered when designing policies and interventions for trauma system strengthening.
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Affiliation(s)
- Kevin J Blair
- Department of Surgery, Division of Trauma & Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Alexa Monroy
- Department of Surgery, Division of Trauma & Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jordan M Rook
- Department of Surgery, Division of Trauma & Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ethan Wood
- Department of Surgery, Division of Trauma & Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Sinai Icahn School of Medicine, New York, NY, USA
| | - J Esteban Foianini
- Department of Surgery Clínica Foianini, Santa Cruz de la Sierra, Santa Cruz, Bolivia
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.,Aga Khan University Medical College, Karachi, Pakistan
| | - Mamta Swaroop
- Department of Surgery, Division of Trauma & Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Marissa A Boeck
- Department of Surgery, Division of Trauma & Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.,Department of Surgery, New York-Presbyterian Hospital/Columbia University, New York, NY, USA.,Department of Surgery, Zuckerberg San Francisco General Hospital, UCSF, San Francisco, CA, USA
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46
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Affiliation(s)
- Amir A Ghaferi
- Institute for Healthcare Policy and Innovation, Department of Surgery, University of Michigan, Ann Arbor
| | - Adil H Haider
- Aga Khan University, Karachi, Pakistan.,Deputy Editor
| | - Melina R Kibbe
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill.,Editor
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Zogg CK, Scott JW, Metcalfe D, Gluck AR, Curfman GD, Davis KA, Dimick JB, Haider AH. Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients. JAMA Surg 2020; 154:402-411. [PMID: 30601888 DOI: 10.1001/jamasurg.2018.5177] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. Design, Setting, and Participants Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. Interventions/Exposure Policy implementation in January 2014. Main Outcomes and Measures Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. Results A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation. Conclusions and relevance This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | - John W Scott
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - David Metcalfe
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Abbe R Gluck
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | - Gregory D Curfman
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | | | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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48
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Pak LM, Kwon NK, Baldini EH, Learn PA, Koehlmoos T, Haider AH, Raut CP. Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population. J Surg Res 2020; 250:125-134. [PMID: 32044509 DOI: 10.1016/j.jss.2020.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 11/05/2019] [Accepted: 01/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system. METHODS Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation. RESULTS Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011). CONCLUSIONS In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.
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Affiliation(s)
- Linda M Pak
- Department of Surgery, Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Nicollette K Kwon
- Department of Surgery, Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts; Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Peter A Learn
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Tracey Koehlmoos
- Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chandrajit P Raut
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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49
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Gezzer Ortega
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Aga Khan University Medical College, Karachi, Pakistan.,Deputy Editor
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50
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Jarman MP, Weaver MJ, Haider AH, Salim A, Harris MB. The National Burden of Orthopedic Injury: Cross-Sectional Estimates for Trauma System Planning and Optimization. J Surg Res 2020; 249:197-204. [PMID: 31991329 DOI: 10.1016/j.jss.2019.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/26/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Management of orthopedic injuries is a critical component of comprehensive trauma care. As patterns of injury incidence and recovery change in the face of emerging injury prevention efforts and technologies and an aging US population, assessment of the burden of orthopedic injury is essential to optimize trauma system planning. We sought to estimate the incidence of orthopedic injury requiring emergency orthopedic surgery in the United States. METHODS Using nationally representative samples from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, we estimated the incidence of orthopedic injury, polytrauma with orthopedic injury, and emergency operative orthopedic procedures performed for the management of traumatic injury. We used multivariable logistic regression to identify patient, injury, and hospital characteristics associated with odds of emergency orthopedic surgery. RESULTS A total of 7,214,915 patients were diagnosed with orthopedic injury in 2013-2014, resulting in 1,167,656 emergency orthopedic surgical procedures. Fall-related injuries accounted for 51% of health care encounters and 61% of emergency orthopedic surgical procedures. Odds of emergency orthopedic surgery were 2.04 times greater for patients with polytrauma, compared with isolated orthopedic injury (P < 0.001). CONCLUSIONS The total burden or orthopedic injury in the United States is substantial, and there is considerable heterogeneity in demand for care and practice patterns in the orthopedic trauma community. Population-based trauma system planning and tailored care delivery models would likely optimize initial treatment, recovery, and health outcomes for orthopedic trauma patients.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; College of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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