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George EL, Jacobs MA, Reitz KM, Massarweh NN, Youk AO, Arya S, Hall DE. Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings. JAMA Surg 2024; 159:501-509. [PMID: 38416481 PMCID: PMC10902781 DOI: 10.1001/jamasurg.2023.8081] [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: 06/25/2023] [Accepted: 11/25/2023] [Indexed: 02/29/2024]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking. Objective To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals. Design, Setting, and Participants This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older. Exposures Surgical care in VA or private-sector hospitals. Main Outcomes and Measures Postoperative 30-day mortality and failure to rescue (FTR). Results Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures. Conclusions and Relevance Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
| | | | - Nader N Massarweh
- Perioperative and Surgical Care Service, Atlanta Veterans Affairs Healthcare System, Decatur, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Ada O Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pennsylvania
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Yu J, Khamzina Y, Kennedy J, Liang NL, Hall DE, Arya S, Tzeng E, Reitz KM. The Association Between Frailty and Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair. J Vasc Surg 2024:S0741-5214(24)00983-2. [PMID: 38614142 DOI: 10.1016/j.jvs.2024.04.021] [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: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysm (AAA). Early postoperative outcomes are associated with both patients' physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAA (rAAA). STUDY DESIGN Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI; robust≤20, normal 21-29, frail 30-39, very frail≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHR) with 95% confidence intervals (95%CI). Interaction terms evaluated the association's moderation. RESULTS We identified 5,806 patients (age 72±9 years; 77% male; EVAR 65%; robust 6%; normal 48%; frail 36%; very frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR [aHR = 1.43 (95%CI 1.19-1.73)] was associated with increased 1-year mortality when compared to EVAR. Increasing frailty status [frail aHR = 1.26 (95%CI 1.00-1.59); very frail aHR =1.64 (95%CI 1.26-2.13)] was associated with increased 1-year mortality, which was moderated by repair type (P-interaction<.05). OSR was associated with increased 1-year mortality in normal [aHR = 1.49 (95%CI 1.20-1.87)] and frail [aHR = 1.51 (95%CI 1.20-1.89)], but not among robust [aHR = 0.88 (95%CI 0.59-1.32)] and very frail [aHR = 1.29 (95%CI 0.97-1.72)] patients. CONCLUSION Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared to EVAR. However, there was no difference between OSR and EVAR among robust patients who can well-tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.
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Affiliation(s)
- Jia Yu
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Jason Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Surgery Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Wolff Center, UPMC, Pittsburgh, PA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
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Hadlandsmyth K, Lund BC, Gao Y, Strayer AL, Davila H, Hausmann LRM, Schmidt S, Shireman PK, Jacobs MA, Mader MJ, Tessler RA, Duncan CA, Hall DE, Sarrazin MV. Social Determinants of Long-Term Opioid Use Following Total Knee Arthroplasty. J Knee Surg 2024. [PMID: 38599604 DOI: 10.1055/s-0044-1786021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Total knee arthroplasty (TKA) risks persistent pain and long-term opioid use (LTO). The role of social determinants of health (SDoH) in LTO is not well established. We hypothesized that SDoH would be associated with postsurgical LTO after controlling for relevant demographic and clinical variables. This study utilized data from the Veterans Affairs Surgical Quality Improvement Program, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services, including Veterans aged ≥ 65 who underwent elective TKA between 2013 and 2019 with no postsurgical complications or history of significant opioid use. LTO was defined as > 90 days of opioid use beginning within 90 days postsurgery. SDoH variables included the Area Deprivation Index, rurality, and housing instability in the last 12 months identified via medical record screener or International Classification of Diseases, Tenth Revision codes. Multivariable risk adjustment models controlled for demographic and clinical characteristics. Of the 9,064 Veterans, 97% were male, 84.2% white, mean age was 70.6 years, 46.3% rural, 11.2% living in highly deprived areas, and 0.9% with a history of homelessness/housing instability. Only 3.7% (n = 336) developed LTO following TKA. In a logistic regression model of only SDoH variables, housing instability (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.09-5.22) and rurality conferred significant risk for LTO. After adjusting for demographic and clinical variables, LTO was only associated with increasing days of opioid supply in the year prior to surgery (OR = 1.52, 95% CI: 1.43-1.63 per 30 days) and the initial opioid fill (OR = 1.07; 95% CI: 1.06-1.08 per day). Our primary hypothesis was not supported; however, our findings do suggest that patients with housing instability may present unique challenges for postoperative pain management and be at higher risk for LTO.
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Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Andrea L Strayer
- College of Nursing, University of Iowa, Iowa City, Iowa
- Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations VA Quality Scholars Advanced Fellowship Program, Iowa City, Iowa
| | - Heather Davila
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Paula K Shireman
- Department of Primary Care and Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Michael J Mader
- Research Service, South Texas Veterans Healthcare System, San Antonio, Texas
| | - Robert A Tessler
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carly A Duncan
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Schmidt S, Jacobs MA, Kim J, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods. JAMA Surg 2024; 159:411-419. [PMID: 38324306 PMCID: PMC10851138 DOI: 10.1001/jamasurg.2023.7468] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/14/2023] [Indexed: 02/08/2024]
Abstract
Importance Insurance coverage expansion has been proposed as a solution to improving health disparities, but insurance expansion alone may be insufficient to alleviate care access barriers. Objective To assess the association of Area Deprivation Index (ADI) with postsurgical textbook outcomes (TO) and presentation acuity for individuals with private insurance or Medicare. Design, Setting, and Participants This cohort study used data from the National Surgical Quality Improvement Program (2013-2019) merged with electronic health record data from 3 academic health care systems. Data were analyzed from June 2022 to August 2023. Exposure Living in a neighborhood with an ADI greater than 85. Main Outcomes and Measures TO, defined as absence of unplanned reoperations, Clavien-Dindo grade 4 complications, mortality, emergency department visits/observation stays, and readmissions, and presentation acuity, defined as having preoperative acute serious conditions (PASC) and urgent or emergent cases. Results Among a cohort of 29 924 patients, the mean (SD) age was 60.6 (15.6) years; 16 424 (54.9%) were female, and 13 500 (45.1) were male. A total of 14 306 patients had private insurance and 15 618 had Medicare. Patients in highly deprived neighborhoods (5536 patients [18.5%]), with an ADI greater than 85, had lower/worse odds of TO in both the private insurance group (adjusted odds ratio [aOR], 0.87; 95% CI, 0.76-0.99; P = .04) and Medicare group (aOR, 0.90; 95% CI, 0.82-1.00; P = .04) and higher odds of PASC and urgent or emergent cases. The association of ADIs greater than 85 with TO lost significance after adjusting for PASC and urgent/emergent cases. Differences in the probability of TO between the lowest-risk (ADI ≤85, no PASC, and elective surgery) and highest-risk (ADI >85, PASC, and urgent/emergent surgery) scenarios stratified by frailty were highest for very frail patients (Risk Analysis Index ≥40) with differences of 40.2% and 43.1% for those with private insurance and Medicare, respectively. Conclusions and Relevance This study found that patients living in highly deprived neighborhoods had lower/worse odds of TO and higher presentation acuity despite having private insurance or Medicare. These findings suggest that insurance coverage expansion alone is insufficient to overcome health care disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
- Department of Primary Care and Rural Medicine, School of Medicine, Texas A&M University, Bryan
- Department of Medical Physiology, School of Medicine, Texas A&M University, Bryan
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Covell MM, Roy JM, Rumalla K, Dicpinigaitis AJ, Kazim SF, Hall DE, Schmidt MH, Bowers CA. The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review. Neurosurgery 2024; 94:251-262. [PMID: 37695046 DOI: 10.1227/neu.0000000000002668] [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: 06/14/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Hospital Frailty Risk Score (HFRS) is an International Classification of Disease 10th Revision-based scale that was originally designed for, and validated in, the assessment of patients 75 years or older presenting in an acute care setting. This study highlights central tenets inherent to the concept of frailty; questions the logic behind, and utility of, HFRS' recent implementation in the neurosurgical literature; and discusses why there is no useful role for HFRS as a frailty-based neurosurgical risk assessment (FBNRA) tool. METHODS The authors performed a systematic review of the literature per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all cranial and spinal studies that used HFRS as their primary frailty tool. Seventeen (N = 17) studies used HFRS to assess frailty's impact on neurosurgical outcomes. Thirteen total journals, 10 of which were neurosurgical journals, including the highest impact factor journals, published the 17 papers. RESULTS Increasing HFRS score was associated with adverse outcomes, including prolonged length of stay (11 of 17 studies), nonroutine discharge (10 of 17 studies), and increased hospital costs (9 of 17 studies). Four different HFRS studies, of the 17, predicted one of the following 4 adverse outcomes: worse quality of life, worse functional outcomes, reoperation, or in-hospital mortality. CONCLUSION Despite its rapid acceptance and widespread proliferation through the leading neurosurgical journals, HFRS lacks any conceptual relationship to the frailty syndrome or FBNRA for individual patients. HFRS measures acute conditions using International Classification of Disease 10th Revision codes and awards "frailty" points for symptoms and examination findings unrelated to the impaired baseline physiological reserve inherent to the very definition of frailty. HFRS lacks clinical utility as it cannot be deployed point-of-care at the bedside to risk stratify patients. HFRS has never been validated in any patient population younger than 75 years or in any nonacute care setting. We recommend HFRS be discontinued as an individual FBNRA tool.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington , District of Columbia , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Joanna Mary Roy
- Topiwala National Medical College, Mumbai , India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Alis J Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla , New York , USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
- Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh , Pennsylvania , USA
- Wolff Center at UPMC, Pittsburgh , Pennsylvania , USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
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Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships Between Race/Ethnicity, Insurance Type, and Neighborhood Deprivation. Ann Surg 2024; 279:246-257. [PMID: 37450703 PMCID: PMC10787813 DOI: 10.1097/sla.0000000000005994] [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] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health. BACKGROUND Studies focused on single or binary composite outcomes may not detect health disparities. METHODS Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO). RESULTS Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P <0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P <0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P <0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases. CONCLUSIONS DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.
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Affiliation(s)
- Michael A. Jacobs
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and
Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh
Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh,
Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel
Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The
University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University
of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- UT Health Physicians Business Intelligence and Data
Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of
Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Paula K. Shireman
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and
Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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Flinn SJ, Silver DS, Hodges J, Bilderback AL, Buchanan D, Ludwig JM, Schuster J, Hall DE. Association of Frailty with Healthcare Utilization for Patients over One Year Following Surgical Evaluation. Ann Surg 2024:00000658-990000000-00760. [PMID: 38264904 DOI: 10.1097/sla.0000000000006218] [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: 01/25/2024]
Abstract
OBJECTIVE Characterize the distribution of healthcare utilization associated with pre-operative frailty in the year following evaluation by a surgeon. SUMMARY BACKGROUND DATA Frailty is associated with increased morbidity, mortality, and costs for surgical patients. However, the total financial burden for frail patients beyond the index surgery and inpatient stay remains unknown. METHODS Prospective cohort assembled from February 2016 to December 2020 within a multi-hospital integrated healthcare delivery and finance system (IDFS), from patients evaluated with the Risk Analysis Index (RAI) of frailty. Inclusion criteria: age greater than 18, valid RAI, membership in the IDFS Health Plan. Data were stratified by frailty and surgical status. RESULTS The mean (SD) age was 54.7 (16.1) and 58.2% female of the cohort (n=86,572). For all patients with reimbursement for surgery (n=53,856), frail and very frail patients incurred respective increases of 8% ( P =0.027) and 29% ( P <0.001) on utilization relative to the normal group. Robust patients saw a 52% ( P <0.001) decrease. This pattern was more pronounced in the cohort without surgery (n=32,716). The increase over normal utilization for frail and very frail patients increased to 23% ( P =0.004) and 68% ( P <0.001), respectively. Utilization among robust patients decreased 62% ( P <0.001). Increases among the frail were primarily due to increased inpatient medical and post-acute care services (all P <0.001). CONCLUSIONS Patient frailty is associated with increased total healthcare utilization, primarily via increased inpatient medical and post-acute care following surgery. Quantifying these frailty-related financial burdens may inform clinical decision making as well as the design of value-based reimbursement strategies.
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Affiliation(s)
- Stephen J Flinn
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David S Silver
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jacob Hodges
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew L Bilderback
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dan Buchanan
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Daniel E Hall
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Estock JL, Pandalai PK, Johanning JM, Youk AO, Varley PR, Arya S, Massarweh NN, Hall DE. A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty. J Surg Res 2023; 292:130-136. [PMID: 37619497 DOI: 10.1016/j.jss.2023.07.034] [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: 04/12/2023] [Revised: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers. METHODS We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality. RESULTS Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality. CONCLUSIONS While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.
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Affiliation(s)
- Jamie L Estock
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania.
| | | | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania; Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick R Varley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | | | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh, Pittsburg, Pennsylvania; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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9
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Varley PR, Buchanan D, Hall DE. Concerns About a Frailty Screening Initiative and Postoperative Mortality-Reply. JAMA Surg 2023; 158:1353-1354. [PMID: 37466936 DOI: 10.1001/jamasurg.2023.2858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Patrick R Varley
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Memorial VA, Madison, Wisconsin
- Wisconsin Surgical Outcomes Research Program (WiSOR), Madison
| | | | - Daniel E Hall
- Wolff Center at UPMC, Pittsburgh, Pennsylvania
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Orkaby AR, Huan T, Intrator O, Cai S, Schwartz AW, Wieland D, Hall DE, Figueroa JF, Strom JB, Kim DH, Driver JA, Kinosian B. Comparison of Claims-Based Frailty Indices in U.S. Veterans 65 and Older for Prediction of Long-Term Institutionalization and Mortality. J Gerontol A Biol Sci Med Sci 2023; 78:2136-2144. [PMID: 37395654 PMCID: PMC10613003 DOI: 10.1093/gerona/glad157] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Frailty is increasingly recognized as a useful measure of vulnerability in older adults. Multiple claims-based frailty indices (CFIs) can readily identify individuals with frailty, but whether 1 CFI improves prediction over another is unknown. We sought to assess the ability of 5 distinct CFIs to predict long-term institutionalization (LTI) and mortality in older Veterans. METHODS Retrospective study conducted in U.S. Veterans ≥65 years without prior LTI or hospice use in 2014. Five CFIs were compared: Kim, Orkaby (Veteran Affairs Frailty Index [VAFI]), Segal, Figueroa, and the JEN-FI, grounded in different theories of frailty: Rockwood cumulative deficit (Kim and VAFI), Fried physical phenotype (Segal), or expert opinion (Figueroa and JFI). The prevalence of frailty according to each CFI was compared. CFI performance for the coprimary outcomes of any LTI or mortality from 2015 to 2017 was examined. Because Segal and Kim include age, sex, or prior utilization, these variables were added to regression models to compare all 5 CFIs. Logistic regression was used to calculate model discrimination and calibration for both outcomes. RESULTS A total of 3 million Veterans were included (mean age 75, 98% male participants, 80% White, and 9% Black). Frailty was identified for between 6.8% and 25.7% of the cohort with 2.6% identified as frail by all 5 CFIs. There was no meaningful difference between CFIs in the area under the receiver operating characteristic curve for LTI (0.78-0.80) or mortality (0.77-0.79). CONCLUSIONS Based on different frailty constructs, and identifying different subsets of the population, all 5 CFIs similarly predicted LTI or death, suggesting each could be used for prediction or analytics.
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Affiliation(s)
- Ariela R Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tianwen Huan
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Shubing Cai
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Andrea W Schwartz
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Darryl Wieland
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Biodemography of Aging Research Unit, Duke University, Durham, North Carolina, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion; and Pittsburgh GRECC, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dae H Kim
- The Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane A Driver
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center and Center for Health Equity Research and Promotion, Cpl. Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Dicpinigaitis AJ, Kazim SF, Al-Mufti F, Hall DE, Reitz KE, Rumalla K, McIntyre MK, Arthur AS, Srinivasan VM, Burkhardt JK, Schmidt MH, Gandhi CD, Bowers CA. Frailty in aneurysmal subarachnoid hemorrhage: the risk analysis index. J Neurol 2023; 270:4820-4826. [PMID: 37329347 DOI: 10.1007/s00415-023-11805-z] [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: 04/29/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Few studies have evaluated frailty in the setting of aneurysmal subarachnoid hemorrhage (aSAH) using large-scale data. The risk analysis index (RAI) may be implemented at the bedside or assessed retrospectively, differentiating it from other indices used in administrative registry-based research. METHODS Adult aSAH hospitalizations were identified in the National Inpatient Sample (NIS) from 2015 to 2019. Complex samples statistical methods were performed to evaluate the comparative effect size and discriminative ability of the RAI, the modified frailty index (mFI), and the Hospital Frailty Risk Score (HFRS). Poor functional outcome was determined by the NIS-SAH Outcome Measure (NIS-SOM), shown to have high concordance with modified Rankin Scale scores > 2. RESULTS 42,300 aSAH hospitalizations were identified in the NIS during the study period. By both ordinal [adjusted odds ratio (aOR) 3.20, 95% confidence interval (CI) 3.05, 3.36, p < 0.001] and categorical stratification [frail aOR 3.59, 95% CI 3.39, 3.80, p < 0.001; severely frail aOR 6.67, 95% CI 5.78, 7.69, p < 0.001], the RAI achieved the largest effect sizes for NIS-SOM in comparison with the mFI and HFRS. Discrimination of the RAI for NIS-SOM in high-grade aSAH was significantly greater than that of the HFRS (c-statistic 0.651 vs. 0.615). The mFI demonstrated the lowest discrimination in both high-grade and normal-grade patients. A combined Hunt and Hess-RAI model (c-statistic 0.837, 95% CI 0.828, 0.845) for NIS-SOM achieved significantly greater discrimination than both the combined models for mFI and HFRS (p < 0.001). CONCLUSION The RAI was robustly associated with poor functional outcomes in aSAH independent of established risk factors.
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Affiliation(s)
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY, 10595, USA
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, 10595, USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Katherine E Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA
| | - Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, 97239, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Sciences Center/Semmes-Murphy Clinic, Memphis, TN, 38120, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA
| | - Chirag D Gandhi
- School of Medicine, New York Medical College, Valhalla, NY, 10595, USA
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, 10595, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA.
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12
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Bowers CA, Varela S, Naftchi AF, Kazim SF, Hall DE, Ng C, Rawanduzy C, Spirollari E, Vazquez S, Das A, Graifman G, Asserson DB, Dominguez JF, Kinon MD, Schmidt MH. Superior discrimination of the Risk Analysis Index compared with the 5-item modified frailty index in 30-day outcome prediction after anterior cervical discectomy and fusion. J Neurosurg Spine 2023; 39:509-519. [PMID: 37439459 DOI: 10.3171/2023.5.spine221020] [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: 09/09/2022] [Accepted: 05/04/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE The objective of this paper was to compare the predictive ability of the recalibrated Risk Analysis Index (RAI-rev) with the 5-item modified frailty index-5 (mFI-5) for postoperative outcomes of anterior cervical discectomy and fusion (ACDF). METHODS This study was performed using data of adult (age > 18 years) ACDF patients obtained from the National Surgical Quality Improvement Program database during the years 2015-2019. Multivariate modeling and receiver operating characteristic (ROC) curve analysis, including area under the curve/C-statistic calculation with the DeLong test, were performed to evaluate the comparative discriminative ability of the RAI-rev and mFI-5 for 5 postoperative outcomes. RESULTS Both the RAI-rev and mFI-5 were independent predictors of increased postoperative mortality and morbidity in a cohort of 61,441 ACDF patients. In the ROC analysis for 30-day mortality prediction, C-statistics indicated a significantly better performance of the RAI-rev (C-statistic = 0.855, 95% CI 0.852-0.858) compared with the mFI-5 (C-statistic = 0.684, 95% CI 0.680-0.688) (p < 0.001, DeLong test). The results were similar for postoperative ACDF morbidity, Clavien-Dindo grade IV complications, nonhome discharge, and reoperation, demonstrating the superior discriminative ability of the RAI-rev compared with the mFI-5. CONCLUSIONS The RAI-rev demonstrates superior discrimination to the mFI-5 in predicting postoperative ACDF mortality and morbidity. To the authors' knowledge, this is the first study to document frailty as an independent risk factor for postoperative mortality after ACDF. The RAI-rev has conceptual fidelity to the frailty phenotype and may be more useful than the mFI-5 in preoperative ACDF risk stratification. Prospective validation of these findings is necessary, but patients with high RAI-rev scores may benefit from knowing that they might have an increased surgical risk for ACDF morbidity and mortality.
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Affiliation(s)
- Christian A Bowers
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque
| | - Samantha Varela
- 2School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | | | - Syed Faraz Kazim
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque
| | - Daniel E Hall
- 4Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh
- 5Wolff Center at UPMC, Pittsburgh
- 6Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh
- 7Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Christina Ng
- 3School of Medicine, New York Medical College, Valhalla, New York
| | | | - Eris Spirollari
- 3School of Medicine, New York Medical College, Valhalla, New York
| | - Sima Vazquez
- 3School of Medicine, New York Medical College, Valhalla, New York
| | - Ankita Das
- 3School of Medicine, New York Medical College, Valhalla, New York
| | - Gillian Graifman
- 3School of Medicine, New York Medical College, Valhalla, New York
| | - Derek B Asserson
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque
| | - Jose F Dominguez
- 8Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Merritt D Kinon
- 8Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Meic H Schmidt
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque
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Mady LJ, De Ravin E, Vohra V, Lu J, Newman JG, Hall DE, Dalton PH, Rowan NR. Exploring Olfactory Dysfunction as a Marker of Frailty and Postoperative Outcomes in Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2023; 149:828-836. [PMID: 37498617 PMCID: PMC10375382 DOI: 10.1001/jamaoto.2023.1935] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/05/2023] [Indexed: 07/28/2023]
Abstract
Importance Olfactory dysfunction (OD) is increasingly recognized as a robust marker of frailty and mortality. Despite broad recognition of frailty as a critical component of head and neck cancer (HNC) care, there is no standardized frailty assessment. Objective To assess the prevalence of OD and its association with frailty and postoperative outcomes in HNC. Design, Setting, and Participants In this prospective cohort study with enrollment between February 17, 2021, to September 29, 2021, at a tertiary academic medical center, 85 eligible adult patients with primary, treatment-naive HNC of mucosal or cutaneous origin were included. Patients with a history of COVID-19, neurocognitive, or primary smell/taste disorders were excluded. Exposures Prospective olfactory assessments (self-reported, visual analog scale [VAS] and psychophysical, University of Pennsylvania Smell Identification Test [UPSIT]) with concurrent frailty assessment (Risk Analysis Index [RAI]) were used. Olfactory-specific quality of life (QOL) was examined with brief Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS). Main Outcome(s) and Measure(s) The primary outcome was the prevalence of OD as assessed by VAS (0-10, no to normal smell) and UPSIT (0-40, higher scores reflect better olfaction) and its association with frailty (RAI, 0-81, higher scores indicate greater frailty). For surgical patients, secondary outcomes were associations between OD and postoperative length of stay (LOS), 30-day postoperative outcomes, and QOD-NS (0-21, higher scores indicate worse QOL). Results Among 51 patients with HNC (mean [SD] age, 63 [10] years; 39 [77%] male participants; 41 [80%] White participants), 24 (47%) were frail, and 4 (8%) were very frail. Despite median (IQR) self-reported olfaction by VAS of 9 (8-10), 30 (59%) patients demonstrated measured OD with psychophysical testing. No meaningful association was found between self-reported and psychophysical testing (Hodges-Lehmann, <0.001; 95% CI, -2 to 1); a total of 46 (90%) patients did not report decreased olfaction-specific QOL. Median UPSIT scores were lower in frail patients (Hodges-Lehmann, 6; 95% CI, 2-12). Multivariate modeling demonstrated severe microsmia/anosmia was associated with 1.75 (95% CI, 1.09-2.80) times odds of being frail/very frail and approximately 3 days increased LOS (β, 2.96; 95% CI, 0.29-5.62). Conclusions and Relevance Although patients with HNC are unaware of olfactory changes, OD is common and may serve as a bellwether of frailty. In this prospective cohort study, a dose-dependent association was demonstrated between increasing degrees of OD and frailty, and the potential utility of olfaction was highlighted as a touchstone in the assessment of HNC frailty.
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Affiliation(s)
- Leila J. Mady
- Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emma De Ravin
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Varun Vohra
- Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Lu
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jason G. Newman
- MUSC Hollings Cancer Center, Charleston, South Carolina
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Daniel E. Hall
- Wolff Center at UPMC, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Nicholas R. Rowan
- Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Kochar A, Deo SV, Charest B, Peterman-Rocha F, Elgudin Y, Chu D, Yeh RW, Rao SV, Kim DH, Driver JA, Hall DE, Orkaby AR. Preoperative frailty and adverse outcomes following coronary artery bypass grafting surgery in US veterans. J Am Geriatr Soc 2023; 71:2736-2747. [PMID: 37083188 PMCID: PMC10524307 DOI: 10.1111/jgs.18390] [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: 12/11/2022] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Contemporary guidelines emphasize the value of incorporating frailty into clinical decision-making regarding revascularization strategies for coronary artery disease. Yet, there are limited data describing the association between frailty and longer-term mortality among coronary artery bypass grafting (CABG) patients. METHODS We conducted a retrospective cohort study (2016-2020, 40 VA medical centers) of US veterans nationwide that underwent coronary artery bypass grafting (CABG). Frailty was quantified by the Veterans Administration Frailty Index (VA-FI), which applies the cumulative deficit method to render a proportion of 30 pertinent diagnosis codes. Patients were classified as non-frail (VA-FI ≤ 0.1), pre-frail (0.1 < VA-FI ≤ 0.2), or frail (VA-FI > 0.2). We used Cox proportional hazards models to ascertain the association of frailty with all-cause mortality. Our primary study outcome was 5-year all-cause mortality; the co-primary outcome was days alive and out of the hospital within the first postoperative year. RESULTS There were 13,554 CABG patients (median 69 years, 79% White, 1.5% women). The mean pre-operative VA-FI was 0.21 (SD: 0.11); 31% were pre-frail (VA-FI: 0.17) and 47% were frail (VA-FI: 0.31). Frail patients were older and had higher co-morbidity burdens than pre-frail and non-frail patients. Compared with non-frail patients (13.0% [11.4, 14.7]), there was a significant association between frail and pre-frail patients and increased cumulative 5-year all-cause mortality (frail: 24.8% [23.3, 26.1]; HR: 1.75 [95% CI 1.54, 2.00]; pre-frail 16.8% [95% CI 15.3, 18.4]; HR 1.2 [1.08,1.34]). Compared with non-frail patients (mean 362[SD 12]), pre-frail (mean 361 [SD 14]; p < 0.01) and frail patients (mean 358[SD 18]; p < 0.01) spent fewer days alive and out of the hospital in the first postoperative year. CONCLUSIONS Pre-frailty and frailty were prevalent among US veterans undergoing CABG and associated with worse mid-term outcomes. Given the high prevalence of frailty with attendant adverse outcomes, there may be an opportunity to improve outcomes by identifying and mitigating frailty before surgery.
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Affiliation(s)
- Ajar Kochar
- Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston USA
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston USA
| | - Salil V Deo
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland USA
- Case School of Medicine, Case Western Reserve University, Cleveland USA
| | - Brian Charest
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston USA
| | | | - Yakov Elgudin
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland USA
- Case School of Medicine, Case Western Reserve University, Cleveland USA
| | - Danny Chu
- Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh USA
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston USA
| | - Sunil V Rao
- The Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Dae H. Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston USA
| | - Jane A. Driver
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston USA
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare system, Boston USA
| | - Daniel E Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh USA
- Center for Health Equity Research and Promotion, Veteran Affairs Pittsburgh Healthcare System, Pittsburgh USA
| | - Ariela R. Orkaby
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston USA
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare system, Boston USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston USA
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15
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Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Wang CP, Manuel LS, Shireman PK. Differentiating Urgent from Elective Cases Matters in Minority Populations: Developing an Ordinal "Desirability of Outcome Ranking" to Increase Granularity and Sensitivity of Surgical Outcomes Assessment. J Am Coll Surg 2023; 237:545-555. [PMID: 37288840 PMCID: PMC10417256 DOI: 10.1097/xcs.0000000000000776] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Surgical analyses often focus on single or binary outcomes; we developed an ordinal Desirability of Outcome Ranking (DOOR) for surgery to increase granularity and sensitivity of surgical outcome assessments. Many studies also combine elective and urgent procedures for risk adjustment. We used DOOR to examine complex associations of race/ethnicity and presentation acuity. STUDY DESIGN NSQIP (2013 to 2019) cohort study assessing DOOR outcomes across race/ethnicity groups risk-adjusted for frailty, operative stress, preoperative acute serious conditions, and elective, urgent, and emergent cases. RESULTS The cohort included 1,597,199 elective, 340,350 urgent, and 185,073 emergent cases with patient mean age of 60.0 ± 15.8, and 56.4% of the surgeries were performed on female patients. Minority race/ethnicity groups had increased odds of presenting with preoperative acute serious conditions (adjusted odds ratio [aORs] range 1.22 to 1.74), urgent (aOR range 1.04 to 2.21), and emergent (aOR range 1.15 to 2.18) surgeries vs the White group. Black (aOR range 1.23 to 1.34) and Native (aOR range 1.07 to 1.17) groups had increased odds of higher/worse DOOR outcomes; however, the Hispanic group had increased odds of higher/worse DOOR (aOR 1.11, CI 1.10 to 1.13), but decreased odds (aORs range 0.94 to 0.96) after adjusting for case status; the Asian group had better outcomes vs the White group. DOOR outcomes improved in minority groups when using elective vs elective/urgent cases as the reference group. CONCLUSIONS NSQIP surgical DOOR is a new method to assess outcomes and reveals a complex interplay between race/ethnicity and presentation acuity. Combining elective and urgent cases in risk adjustment may penalize hospitals serving a higher proportion of minority populations. DOOR can be used to improve detection of health disparities and serves as a roadmap for the development of other ordinal surgical outcomes measures. Improving surgical outcomes should focus on decreasing preoperative acute serious conditions and urgent and emergent surgeries, possibly by improving access to care, especially for minority populations.
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Affiliation(s)
- Michael A Jacobs
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX (Jacobs, Shireman)
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX (Schmidt, Wang)
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA (Hall)
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA (Hall)
- Wolff Center, UPMC, Pittsburgh, PA (Hall)
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC (Stitzenberg)
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Kao)
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX (Schmidt, Wang)
| | - Laura S Manuel
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio, TX (Manuel)
| | - Paula K Shireman
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX (Jacobs, Shireman)
- University Health, San Antonio, TX (Shireman)
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX (Shireman)
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Allen MB, Orkaby AR, Justice S, Hall DE, Hu FY, Cooper Z, Bernacki RE, Bader AM. Frailty and Outcomes Following Cardiopulmonary Resuscitation for Perioperative Cardiac Arrest. JAMA Netw Open 2023; 6:e2321465. [PMID: 37399014 DOI: 10.1001/jamanetworkopen.2023.21465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Importance Frailty is associated with mortality following surgery and cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. Despite the growing focus on frailty as a basis for preoperative risk stratification and concern that CPR in patients with frailty may border on futility, the association between frailty and outcomes following perioperative CPR is unknown. Objective To determine the association between frailty and outcomes following perioperative CPR. Design, Setting, and Participants This longitudinal cohort study of patients used the American College of Surgeons National Surgical Quality Improvement Program, including more than 700 participating hospitals in the US, from January 1, 2015, through December 31, 2020. Follow-up duration was 30 days. Patients 50 years or older undergoing noncardiac surgery who received CPR on postoperative day 0 were included; patients were excluded if data required to determine frailty, establish outcome, or perform multivariable analyses were missing. Data were analyzed from September 1, 2022, through January 30, 2023. Exposures Frailty defined as Risk Analysis Index (RAI) of 40 or greater vs less than 40. Outcomes and Measures Thirty-day mortality and nonhome discharge. Results Among the 3149 patients included in the analysis, the median age was 71 (IQR, 63-79) years, 1709 (55.9%) were men, and 2117 (69.2%) were White. Mean (SD) RAI was 37.73 (6.18), and 792 patients (25.9%) had an RAI of 40 or greater, of whom 534 (67.4%) died within 30 days of surgery. Multivariable logistic regression adjusting for race, American Society of Anesthesiologists physical status, sepsis, and emergency surgery demonstrated a positive association between frailty and mortality (adjusted odds ratio [AOR], 1.35 [95% CI, 1.11-1.65]; P = .003). Spline regression analysis demonstrated steadily increasing probability of mortality and nonhome discharge with increasing RAI above 37 and 36, respectively. Association between frailty and mortality following CPR varied by procedure urgency (AOR for nonemergent procedures, 1.55 [95% CI, 1.23-1.97]; AOR for emergent procedures, 0.97 [95% CI, 0.68-1.37]; P = .03 for interaction). An RAI of 40 or greater was associated with increased odds of nonhome discharge compared with an RAI of less than 40 (AOR, 1.85 [95% CI, 1.31-2.62]; P < .001). Conclusions and Relevance The findings of this cohort study suggest that although roughly 1 in 3 patients with an RAI of 40 or greater survived at least 30 days following perioperative CPR, higher frailty burden was associated with increased mortality and greater risk of nonhome discharge among survivors. Identifying patients who are undergoing surgery and have frailty may inform primary prevention strategies, guide shared decision-making regarding perioperative CPR, and promote goal-concordant surgical care.
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Affiliation(s)
- Matthew B Allen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ariela R Orkaby
- New England Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Justice
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel E Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- GRECC, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Frances Y Hu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachelle E Bernacki
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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17
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Bowers CA, Varela S, Conlon M, Kazim SF, Thommen R, Roster K, Hall DE, Schmidt MH. Comparison of the Risk Analysis Index and the modified 5-factor frailty index in predicting 30-day morbidity and mortality after spine surgery. J Neurosurg Spine 2023; 39:136-145. [PMID: 37029672 DOI: 10.3171/2023.2.spine221019] [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: 09/09/2022] [Accepted: 02/28/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE Frailty's role in preoperative risk assessment in spine surgery has increased in association with the increasing size of the aging population. However, previous frailty assessment tools have significant limitations. The aim of this study was to compare the predictive ability of the Risk Analysis Index (RAI) with the 5-factor modified frailty index (mFI-5) for postoperative spine surgery morbidity and mortality. METHODS Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database for adults > 18 years who underwent spine surgery between 2015 and 2019. Multivariate modeling and receiver operating characteristic curve analysis, including area under the curve/C-statistic calculations, were performed to evaluate the comparative discriminative ability of RAI and mFI-5 on postoperative outcomes. RESULTS In a cohort of 292,225 spine surgery patients, multivariate modeling showed that increasing RAI scores, and not increasing mFI-5 scores, were independent predictors of increased postoperative mortality for the trauma, tumor, and infection subcohorts. In the overall spine cohort, both increasing RAI and increasing mFI-5 scores were associated with increased mortality, but C-statistics indicated that the RAI (C-statistic 0.802 [95% CI 0.800-0.803], p < 0.0001, DeLong test) had superior discrimination compared with the mFI-5 (C-statistic 0.677 [95% CI 0.675-0.679], p < 0.0001, DeLong test). In subgroup analyses, the RAI had superior discriminative ability to mFI-5 for mortality in the trauma and infection groups (p < 0.001 and p = 0.039, respectively). CONCLUSIONS The RAI demonstrates superior discrimination to the mFI-5 for predicting postoperative mortality and morbidity after spine surgery and the RAI maintains conceptual fidelity to the frailty phenotype. Patients with high RAI scores may benefit from knowing the possibility of increased surgical risk with potential spine surgery.
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Affiliation(s)
- Christian A Bowers
- 1Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque
| | - Samantha Varela
- 2School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Matthew Conlon
- 3School of Medicine, New York Medical College, Valhalla, New York
| | - Syed Faraz Kazim
- 1Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque
| | - Rachel Thommen
- 3School of Medicine, New York Medical College, Valhalla, New York
| | - Katie Roster
- 3School of Medicine, New York Medical College, Valhalla, New York
| | - Daniel E Hall
- 4Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh
- 7Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Meic H Schmidt
- 1Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque
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Piazza KM, Ashcraft LE, Rose L, Hall DE, Brown RT, Bowen MEL, Mavandadi S, Brecher AC, Keddem S, Kiosian B, Long JA, Werner RM, Burke RE. Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults. Implement Sci Commun 2023; 4:57. [PMID: 37231459 PMCID: PMC10209584 DOI: 10.1186/s43058-023-00431-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/23/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults. METHODS We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions. DISCUSSION To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities. TRIAL REGISTRATION Registered 05 May 2021, at ISRCTN #60,657,985. REPORTING GUIDELINES Standards for Reporting Implementation Studies (see attached).
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Affiliation(s)
- Kirstin Manges Piazza
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA.
| | - Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Liam Rose
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA, USA
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rebecca T Brown
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Mary Elizabeth Libbey Bowen
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Education, and Clinical Center, VISN4 Mental Illness Research, Corporal Michael JCrescenz VA Medical Center, Philadelphia, PA, USA
| | - Shahrzad Mavandadi
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- School of Nursing, University of Delaware, Newark, DE, USA
| | | | - Shimrit Keddem
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine & Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bruce Kiosian
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Judith A Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Estock JL, Schlegel C, Shinall MC, Varley P, Youk AO, Hoehn R, Hall DE. Interpreting the risk analysis index of frailty in the context of surgical oncology. J Surg Oncol 2023; 127:1062-1070. [PMID: 36881022 PMCID: PMC10079577 DOI: 10.1002/jso.27218] [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] [Received: 10/20/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND AND OBJECTIVES The Risk Analysis Index (RAI) accurately predicts adverse postoperative outcomes but the inclusion of cancer status in the RAI has raised two key concerns about its suitability for use in surgical oncology: (1) the potential over classification of cancer patients as frail, and (2) the potential overestimation of postoperative mortality for patients with surgically curable cancers. METHODS We performed a retrospective cohort analysis to assess the RAI's power to appropriately identify frailty and predict postoperative mortality in cancer patients. We assessed discrimination for mortality and calibration across five RAI models-the complete RAI and four variants that removed different cancer-related variables. RESULTS We found that the presence of disseminated cancer was a key variable driving the RAI's power to predict postoperative mortality. The model including only this variable [RAI (disseminated cancer)] was similar to the complete RAI in the overall sample (c = 0.842 vs. 0.840) and outperformed the complete RAI in the cancer subgroup (c = 0.736 vs 0.704, respectively, p < 0.0001, Max R2 = 19.3% vs. 15.1%, respectively). CONCLUSION The RAI demonstrates somewhat less discrimination when applied exclusively to cancer patients, but remains a strong predictor of postoperative mortality, especially in the setting of disseminated cancer.
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Affiliation(s)
- Jamie L Estock
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Cameron Schlegel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick Varley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Richard Hoehn
- Department of Surgery, University Hospitals, Cleveland, Ohio, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- GRECC, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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20
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Varley PR, Buchanan D, Bilderback A, Wisniewski MK, Johanning J, Nelson JB, Johnson JT, Minnier T, Hall DE. Association of Routine Preoperative Frailty Assessment With 1-Year Postoperative Mortality. JAMA Surg 2023; 158:475-483. [PMID: 36811872 PMCID: PMC9947800 DOI: 10.1001/jamasurg.2022.8341] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 06/24/2022] [Accepted: 10/15/2022] [Indexed: 02/24/2023]
Abstract
Importance Patient frailty is a known risk factor for adverse outcomes following surgery, but data are limited regarding whether systemwide interventions related to frailty are associated with improved patient outcomes. Objective To evaluate whether a frailty screening initiative (FSI) is associated with reduced late-term mortality after elective surgery. Design, Setting, and Participants This quality improvement study with an interrupted time series analysis used data from a longitudinal cohort of patients in a multihospital, integrated health care system in the US. Beginning in July 2016, surgeons were incentivized to measure frailty with the Risk Analysis Index (RAI) for all patients considering elective surgery. Implementation of the BPA occurred in February 2018. The cutoff for data collection was May 31, 2019. Analyses were conducted between January and September 2022. Exposures The exposure of interest was an Epic Best Practice Alert (BPA) used to identify patients with frailty (RAI ≥42) and prompt surgeons to document a frailty-informed shared decision-making process and consider additional evaluation by a multidisciplinary presurgical care clinic or the primary care physician. Main Outcomes and Measures The primary outcome was 365-day mortality after the elective surgical procedure. Secondary outcomes included 30-day and 180-day mortality as well as the proportion of patients referred for additional evaluation based on documented frailty. Results A total of 50 463 patients with at least 1 year of postsurgical follow-up (22 722 before intervention implementation and 27 741 after) were included (mean [SD] age, 56.7 [16.0] y; 57.6% women). Demographic characteristics, RAI score, and operative case mix, as defined by Operative Stress Score, were similar between time periods. After BPA implementation, the proportion of frail patients referred to a primary care physician and presurgical care clinic increased significantly (9.8% vs 24.6% and 1.3% vs 11.4%, respectively; both P < .001). Multivariable regression analysis demonstrated an 18% reduction in the odds of 1-year mortality (0.82; 95% CI, 0.72-0.92; P < .001). Interrupted time series models demonstrated a significant slope change in the rate of 365-day mortality from 0.12% in the preintervention period to -0.04% in the postintervention period. Among patients triggering the BPA, estimated 1-year mortality changed by -4.2% (95% CI, -6.0% to -2.4%). Conclusions and Relevance This quality improvement study found that implementation of an RAI-based FSI was associated with increased referrals of frail patients for enhanced presurgical evaluation. These referrals translated to a survival advantage among frail patients of similar magnitude to those observed in a Veterans Affairs health care setting, providing further evidence for both the effectiveness and generalizability of FSIs incorporating the RAI.
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Affiliation(s)
- Patrick R. Varley
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Dan Buchanan
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Kay Wisniewski
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
- Nebraska–Western Iowa Veterans Affairs (VA) Health System, Omaha, Nebraska
| | - Joel B. Nelson
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonas T. Johnson
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tamra Minnier
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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21
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Oyekan AA, Lee JY, Hodges JC, Chen SR, Wilson AE, Fourman MS, Clayton EO, Njoku-Austin C, Crasto JA, Wisniewski MK, Bilderback A, Gunn SR, Levin WI, Arnold RM, Hinrichsen KL, Mensah C, Hogan MV, Hall DE. Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program. JB JS Open Access 2023; 8:JBJSOA-D-22-00107. [PMID: 37101601 PMCID: PMC10125643 DOI: 10.2106/jbjs.oa.22.00107] [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: 04/28/2023] Open
Abstract
Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anthony A. Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Email for corresponding author:
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen R. Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan E. Wilson
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mitchell S. Fourman
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Elizabeth O. Clayton
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jared A. Crasto
- Department of Orthopaedic Surgery, The Spine Institute of Arizona, Scottsdale, Arizona
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Scott R. Gunn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William I. Levin
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie L. Hinrichsen
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Mensah
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - MaCalus V. Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Schmidt S, Kim J, Jacobs MA, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Independent Associations of Neighborhood Deprivation and Patient-level Social Determinants of Health with Textbook Outcomes after Inpatient Surgery. Ann Surg Open 2023; 4:e237. [PMID: 37588414 PMCID: PMC10427124 DOI: 10.1097/as9.0000000000000237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Objective Assess associations of Social Determinants of Health (SDoH) using Area Deprivation Index (ADI), race/ethnicity and insurance type with Textbook Outcomes (TO). Summary Background Data Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. Methods Three healthcare system cohort study using National Surgical Quality Improvement Program (2013-2019) linked with ADI risk-adjusted for frailty, case status and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, Emergency Department/Observation Stays and readmissions). Results Cohort (34,251 cases) mean age 58.3 [SD=16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI>85, and 81.8% TO. Racial and ethnic minorities, non-Private insurance, and ADI>85 patients had increased odds of urgent/emergent surgeries (aORs range: 1.17-2.83, all P<.001). Non-Hispanic Black patients, ADI>85 and non-Private insurances had lower TO odds (aORs range: 0.55-0.93, all P<.04), but ADI>85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR=0.51, P<.001). ADI>85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (CI=7.2%-12.6%) for urgent/emergent cases, 7.0% (CI=4.6%-9.3%) for Medicaid, and 1.6% (CI=0.2%-3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI≤85-elective) to highest-risk (Black-Medicaid-ADI>85-urgent/emergent) was 29.8% for very frail patients. Conclusion Multi-level SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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23
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Yan Q, Kim J, Hall DE, Shinall MC, Reitz KM, Stitzenberg KB, Kao LS, George EL, Youk A, Wang CP, Silverstein JC, Bernstam EV, Shireman PK. Association of Frailty and the Expanded Operative Stress Score with Preoperative Acute Serious Conditions, Complications, and Mortality in Males Compared to Females: A Retrospective Observational Study. Ann Surg 2023; 277:e294-e304. [PMID: 34183515 PMCID: PMC8709872 DOI: 10.1097/sla.0000000000005027] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The aim of this study was to expand Operative Stress Score (OSS) increasing procedural coverage and assessing OSS and frailty association with Preoperative Acute Serious Conditions (PASC), complications and mortality in females versus males. SUMMARY BACKGROUND DATA Veterans Affairs male-dominated study showed high mortality in frail veterans even after very low stress surgeries (OSS1). METHODS Retrospective cohort using NSQIP data (2013-2019) merged with 180-day postoperative mortality from multiple hospitals to evaluate PASC, 30-day complications and 30-, 90-, and 180-day mortality. RESULTS OSS expansion resulted in 98.2% case coverage versus 87.0% using the original. Of 82,269 patients (43.8% male), 7.9% were frail/very frail. Males had higher odds of PASC [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) = 1.21-1.41, P < 0.001] and severe/life-threatening Clavien-Dindo IV (CDIV) complications (aOR = 1.18, 95% CI = 1.09-1.28, P < 0.001). Although mortality rates were higher (all time-points, P < 0.001) in males versus females, mortality was similar after adjusting for frailty, OSS, and case status primarily due to increased male frailty scores. Additional adjustments for PASC and CDIV resulted in a lower odds of mortality in males (30-day, aOR = 0.81, 95% CI = 0.71-0.92, P = 0.002) that was most pronounced for males with PASC compared to females with PASC (30-day, aOR = 0.75, 95% CI = 0.56-0.99, P = 0.04). CONCLUSIONS Similar to the male-dominated Veteran population, private sector, frail patients have high likelihood of postoperative mortality, even after low-stress surgeries. Preoperative frailty screening should be performed regardless of magnitude of the procedure. Despite males experiencing higher adjusted odds of PASC and CDIV complications, females with PASC had higher odds of mortality compared to males, suggesting differences in the aggressiveness of care provided to men and women.
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Affiliation(s)
- Qi Yan
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Care Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Myrick C. Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Elizabeth L. George
- Department of Surgery, Stanford University School of Medicine, Stanford, California
- Division of Health Services Research and Development, VA Palo Alto Healthcare System, Palo Alto, California
| | - Ada Youk
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Care Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, San Antonio, Texas
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | | | - Elmer V Bernstam
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, TX, United States
- Division of General Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, United States
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, San Antonio, Texas
- University Health, San Antonio, Texas
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24
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Reitz KM, Althouse AD, Forman DE, Zuckerbraun BS, Vodovotz Y, Zamora R, Raffai RL, Hall DE, Tzeng E. MetfOrmin BenefIts Lower Extremities with Intermittent Claudication (MOBILE IC): randomized clinical trial protocol. BMC Cardiovasc Disord 2023; 23:38. [PMID: 36681798 PMCID: PMC9862509 DOI: 10.1186/s12872-023-03047-8] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) affects over 230 million people worldwide and is due to systemic atherosclerosis with etiology linked to chronic inflammation, hypertension, and smoking status. PAD is associated with walking impairment and mobility loss as well as a high prevalence of coronary and cerebrovascular disease. Intermittent claudication (IC) is the classic presenting symptom for PAD, although many patients are asymptomatic or have atypical presentations. Few effective medical therapies are available, while surgical and exercise therapies lack durability. Metformin, the most frequently prescribed oral medication for Type 2 diabetes, has salient anti-inflammatory and promitochondrial properties. We hypothesize that metformin will improve function, retard the progression of PAD, and improve systemic inflammation and mitochondrial function in non-diabetic patients with IC. METHODS 200 non-diabetic Veterans with IC will be randomized 1:1 to 180-day treatment with metformin extended release (1000 mg/day) or placebo to evaluate the effect of metformin on functional status, PAD progression, cardiovascular disease events, and systemic inflammation. The primary outcome is 180-day maximum walking distance on the 6-min walk test (6MWT). Secondary outcomes include additional assessments of functional status (cardiopulmonary exercise testing, grip strength, Walking Impairment Questionnaires), health related quality of life (SF-36, VascuQoL), macro- and micro-vascular assessment of lower extremity blood flow (ankle brachial indices, pulse volume recording, EndoPAT), cardiovascular events (amputations, interventions, major adverse cardiac events, all-cause mortality), and measures of systemic inflammation. All outcomes will be assessed at baseline, 90 and 180 days of study drug exposure, and 180 days following cessation of study drug. We will evaluate the primary outcome with linear mixed-effects model analysis with covariate adjustment for baseline 6MWT, age, baseline ankle brachial indices, and smoking status following an intention to treat protocol. DISCUSSION MOBILE IC is uniquely suited to evaluate the use of metformin to improve both systematic inflammatory responses, cellular energetics, and functional outcomes in patients with PAD and IC. TRIAL REGISTRATION The prospective MOBILE IC trial was publicly registered (NCT05132439) November 24, 2021.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
- Center for Systems Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | | | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Wolff Center, UPMC, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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25
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Hall DE, Youk A, Allsup K, Kennedy K, Byard TD, Dhupar R, Chu D, Rahman AM, Wilson M, Cahalin LP, Afilalo J, Forman DE. Preoperative Rehabilitation Is Feasible in the Weeks Prior to Surgery and Significantly Improves Functional Performance. J Frailty Aging 2023; 12:267-276. [PMID: 38008976 PMCID: PMC10683858 DOI: 10.14283/jfa.2022.42] [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: 11/28/2023]
Abstract
BACKGROUND Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that rehabilitation strategies deployed after surgery improve outcomes by building strength. OBJECTIVES Examine the feasibility and impact of a novel, multi-faceted prehabilitation intervention for frail patients before surgery. DESIGN Single arm clinical trial. SETTING Veterans Affairs hospital. PARTICIPANTS Patients preparing for major abdominal, urological, thoracic, or cardiac surgery with frailty identified as a Risk Analysis Index≥30. INTERVENTION Prehabilitation started in a supervised setting to establish safety and then transitioned to home-based exercise with weekly telephone coaching by exercise physiologists. Prehabilitation included (a)strength and coordination training; (b)respiratory muscle training (IMT); (c)aerobic conditioning; and (d)nutritional coaching and supplementation. Prehabilitation length was tailored to the 4-6 week time lag typically preceding each participant's normally scheduled surgery. MEASUREMENTS Functional performance and patient surveys were assessed at baseline, every other week during prehabilitation, and then 30 and 90 days after surgery. Within-person changes were estimated using linear mixed models. RESULTS 43 patients completed baseline assessments; 36(84%) completed a median 5(range 3-10) weeks of prehabilitation before surgery; 32(74%) were retained through 90-day follow-up. Baseline function was relatively low. Exercise logs show participants completed 94% of supervised exercise, 78% of prescribed IMT and 74% of home-based exercise. Between baseline and day of surgery, timed-up-and-go decreased 2.3 seconds, gait speed increased 0.1 meters/second, six-minute walk test increased 41.7 meters, and the time to complete 5 chair rises decreased 1.6 seconds(all P≤0.007). Maximum and mean inspiratory and expiratory pressures increased 4.5, 7.3, 14.1 and 13.5 centimeters of water, respectively(all P≤0.041). CONCLUSIONS Prehabilitation is feasible before major surgery and achieves clinically meaningful improvements in functional performance that may impact postoperative outcomes and recovery. These data support rationale for a larger trial powered to detect differences in postoperative outcomes.
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Affiliation(s)
- D E Hall
- Daniel E Hall, UPMC Presbyterian Hospital, Suite F12, 200 Lothrop St, Pittsburgh, PA 15213, P:412.647.0421|F:412.647.1448,
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Thommen R, Kazim SF, Rumalla K, Kassicieh AJ, Kalakoti P, Schmidt MH, McKee RG, Hall DE, Miskimins RJ, Bowers CA. Correction to: Preoperative frailty measured by risk analysis index predicts complications and poor discharge outcomes after Brain Tumor Resection in a large multi-center analysis. J Neurooncol 2022; 160:763. [DOI: 10.1007/s11060-022-04212-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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27
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Murphy AC, Schultz KC, Gao S, Morales AM, Barnato AE, Fanning JB, Hall DE. Prudence in end-of-life decision making: A virtue-based analysis of physician communication with patients and surrogates. SSM Qual Res Health 2022; 2:100182. [PMID: 36582622 PMCID: PMC9797053 DOI: 10.1016/j.ssmqr.2022.100182] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite significant improvements in end-of-life care over several decades, belated hospice referrals and hospital staffing patterns make challenging end-of-life conversations between strangers unsurprising, especially when the interaction is time-sensitive. Understanding how physicians perform under these circumstances is relevant to patient quality and medical education. This study is a secondary analysis of transcripts from a simulation that placed 88 intensivists, hospitalists, and ED physicians in the setting of responding to a nurse's call to evaluate a floor patient for impending respiratory collapse. A philosophical account of prudence guided the analytical approach and was operationalized through behavior-based and exemplar-based qualitative coding strategies. Exemplary performances and specific behaviors were then compared with preferred outcomes. Results indicate that exemplary performance correlated with a cluster of 3 behaviors that predicted the desired outcomes, but did not determine them: (1) directly affirming the likelihood that the patient will die in the near term; (2) explicitly soliciting the patient's preferences for care; and (3) asking what other family and friends should be involved. The current study implies that educational initiatives aimed at improving end-of-life conversations should expose clinicians both to technical competencies and to the virtues required to employ these competencies well.
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Affiliation(s)
- Alan C. Murphy
- Kaiser Permanente Baldwin Park, 1011 Baldwin Park Blvd, Baldwin Park, CA 91706, USA,Corresponding author. (A.C. Murphy)
| | - Kevan C. Schultz
- Center for Social and Urban Research, University of Pittsburgh, 3343 Forbes Avenue, Pittsburgh, PA, 15260, USA
| | - ShaSha Gao
- VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA, 15240, USA
| | - Andre M. Morales
- Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, 1313 21st Ave South, Nashville, TN, 37203, USA
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, 1 Medical Center Drive, Lebanon, NH, 03766, USA
| | - Joseph B. Fanning
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 400, Nashville, TN, 37203, USA
| | - Daniel E. Hall
- General Surgery, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA, 15240, USA,General Surgery, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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28
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Thommen R, Kazim SF, Rumalla K, Kassicieh AJ, Kalakoti P, Schmidt MH, McKee RG, Hall DE, Miskimins RJ, Bowers CA. Preoperative frailty measured by risk analysis index predicts complications and poor discharge outcomes after Brain Tumor Resection in a large multi-center analysis. J Neurooncol 2022; 160:285-297. [PMID: 36316568 DOI: 10.1007/s11060-022-04135-z] [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: 08/23/2022] [Accepted: 09/14/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the independent effect of frailty, as measured by the Risk Analysis Index-Administrative (RAI-A) for postoperative complications and discharge outcomes following brain tumor resection (BTR) in a large multi-center analysis. METHODS Patients undergoing BTR were queried from the National Surgical Quality Improvement Program (NSIQP) for the years 2015 to 2019. Multivariable logistic regression was performed to evaluate the independent associations between frailty tools (age, 5-factor modified frailty score [mFI-5], and RAI-A) on postoperative complications and discharge outcomes. RESULTS We identified 30,951 patients who underwent craniotomy for BTR; the median age of our study sample was 59 (IQR 47-68) years old and 47.8% of patients were male. Overall, increasing RAI-A score, in an overall stepwise fashion, was associated with increasing risk of adverse outcomes including in-hospital mortality, non-routine discharge, major complications, Clavien-Dindo Grade IV complication, and extended length of stay. Multivariable regression analysis (adjusting for age, sex, BMI, non-elective surgery status, race, and ethnicity) demonstrated that RAI-A was an independent predictor for worse BTR outcomes. The RAI-A tiers 41-45 (1.2% cohort) and > 45 (0.3% cohort) were ~ 4 (Odds Ratio [OR]: 4.3, 95% CI: 2.1-8.9) and ~ 9 (OR: 9.5, 95% CI: 3.9-22.9) times more likely to have in-hospital mortality compared to RAI-A 0-20 (34% cohort). CONCLUSIONS AND RELEVANCE Increasing preoperative frailty as measured by the RAI-A score is independently associated with increased risk of complications and adverse discharge outcomes after BTR. The RAI-A may help providers present better preoperative risk assessment for patients and families weighing the risks and benefits of potential BTR.
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Affiliation(s)
- Rachel Thommen
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM 87131, USA
| | - Syed Faraz Kazim
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM 87131, USA
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87131, USA
| | - Kavelin Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM 87131, USA
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87131, USA
| | - Alexander J Kassicieh
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM 87131, USA
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87131, USA
| | - Piyush Kalakoti
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Meic H Schmidt
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM 87131, USA
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87131, USA
| | - Rohini G McKee
- Department of Surgery, University of New Mexico Hospital (UNMH), Albuquerque, NM 87131, USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Wolff Center at UPMC, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Richard J Miskimins
- Department of Surgery, University of New Mexico Hospital (UNMH), Albuquerque, NM 87131, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM 87131, USA.
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87131, USA.
- Department of Neurosurgery MSC10 5615, University of New Mexico, Albuquerque, NM 81731, USA.
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29
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Reitz KM, Arya S, Hall DE. Quantifying Frailty Requires a Conceptual Model Before a Statistical Model. JAMA Surg 2022; 157:1065. [PMID: 35947376 PMCID: PMC10074604 DOI: 10.1001/jamasurg.2022.3110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Katherine M Reitz
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
- Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center at UPMC, Pittsburgh, Pennsylvania
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30
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Reitz KM, Kennedy J, Li SR, Handzel R, Tonetti DA, Neal MD, Zuckerbraun BS, Hall DE, Sperry JL, Angus DC, Tzeng E, Seymour CW. Association Between Time to Source Control in Sepsis and 90-Day Mortality. JAMA Surg 2022; 157:817-826. [PMID: 35830181 PMCID: PMC9280613 DOI: 10.1001/jamasurg.2022.2761] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance Rapid source control is recommended to improve patient outcomes in sepsis. Yet there are few data to guide how rapidly source control is required. Objective To determine the association between time to source control and patient outcomes in community-acquired sepsis. Design, Setting, and Particpants Multihospital integrated health care system cohort study of hospitalized adults (January 1, 2013, to December 31, 2017) with community-acquired sepsis as defined by Sepsis-3 who underwent source control procedures. Follow-up continued through January 1, 2019, and data analyses were completed March 17, 2022. Exposures Early (<6 hours) compared with late (6-36 hours) source control as well as each hour of source control delay (1-36 hours) from sepsis onset. Main Outcomes and Measures Multivariable models were clustered at the level of hospital with adjustment for patient factors, sepsis severity, resource availability, and the physiologic stress of procedures generating adjusted odds ratios (aOR) and 95% CI. Results Of 4962 patients with sepsis (mean [SD] age, 62 [16] years; 52% male; 85% White; mean [SD] Sequential Organ Failure Assessment score, 3.8 [2.5]), source control occurred at a median (IQR) of 15.4 hours (5.5-21.7) after sepsis onset, with 1315 patients (27%) undergoing source control within 6 hours. The crude 90-day mortality was similar for early and late source control (n = 177 [14%] vs n = 529 [15%]; P = .35). In multivariable models, early source control was associated with decreased risk-adjusted odds of 90-day mortality (aOR, 0.71; 95% CI, 0.63-0.80). This association was greater among gastrointestinal and abdominal (aOR, 0.56; 95% CI, 0.43-0.80) and soft tissue interventions (aOR, 0.72; 95% CI, 0.55-0.95) compared with orthopedic and cranial interventions (aOR, 1.33; 95% CI, 0.96-1.83; P < .001 for interaction). Conclusions and Relevance Source control within 6 hours of community-acquired sepsis onset was associated with a reduced risk-adjusted odds of 90-day mortality. Prioritizing the rapid identification of septic foci and initiation of source control interventions can reduce the number of avoidable deaths among patients with sepsis.
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Affiliation(s)
- Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Division of Vascular Surgery, UPMC, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shimena R. Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Handzel
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel A. Tonetti
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania,Center for Health Equity Research and Promotion, Veterans Affairs, Pittsburgh, Pennsylvania,Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Division of Vascular Surgery, UPMC, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Burke RE, Ashcraft LE, Manges K, Kinosian B, Lamberton CM, Bowen ME, Brown RT, Mavandadi S, Hall DE, Werner RM. What matters when it comes to measuring
Age‐Friendly
Health System transformation. J Am Geriatr Soc 2022; 70:2775-2785. [DOI: 10.1111/jgs.18002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/21/2022] [Accepted: 07/24/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Robert E. Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
| | - Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Kirstin Manges
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Division of Geriatric Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Geriatrics and Extended Care Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Cait M. Lamberton
- Wharton School at the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Mary E. Bowen
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- School of Nursing University of Delaware Newark Delaware USA
| | - Rebecca T. Brown
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Division of Geriatric Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Geriatrics and Extended Care Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Shahrzad Mavandadi
- Mental Illness Research, Education, and Clinical Center Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion VA Pittsburgh Healthcare System Pittsburgh Pennsylvania USA
- Department of Surgery, School of Medicine University of Pittsburgh Medical Center (UPMC) Pittsburgh Pennsylvania USA
- Geriatrics Research Education and Clinical Center VA Pittsburgh Healthcare System Pittsburgh Pennsylvania USA
- Wolff Center at University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA
| | - Rachel M. Werner
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
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Weill SR, Layden AJ, Nabozny MJ, Leahy J, Claxton R, Zelenski AB, Zimmermann C, Childers J, Arnold R, Hall DE. Applying VitalTalk TM Techniques to Best Case/Worst Case Training to Increase Scalability and Improve Surgeon Confidence in Shared Decision-making. J Surg Educ 2022; 79:983-992. [PMID: 35246401 DOI: 10.1016/j.jsurg.2022.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 10/22/2021] [Revised: 01/03/2022] [Accepted: 01/22/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Best Case/Worst Case (BC/WC) is a communication tool designed to promote shared decision-making for high-risk procedures near the end of life. This study aimed to increase scalability of a BC/WC training program and measure its impact on surgeon confidence in and perceived importance of the methodology. DESIGN A prospective cohort pre-post study; December 2018 to January 2019. SETTING Multi-center tertiary care teaching hospital. PARTICIPANTS Forty-eight resident surgeons from general surgery and otolaryngology. RESULTS Learners were 24 to 37 years old with 52% in post graduate year 1 to 2. Although learners encountered high-stakes communication (HSC) frequently (3.6 [0.7] on 5-point Likert scale), most reported no HSC training in medical school (74.5%) or residency (87.5%). BC/WC training was accomplished with an instructor to learner ratio of 1-to-5.3. After training, learner confidence improved on all measured communication skills on a 5-point scale (e.g., exploring patient's values increased from 3.6 [0.8] to 4.1 [0.6], p = <0.0001); average within-person improvement was 0.72 (0.6) points across all skills. Perceived importance improved across all skills (e.g., basing a recommendation on patient's values increased from 4.4 [0.8] to 4.8 [0.5], p = 0.0009); average within-person improvement was 0.46 (0.5) points across all skills. Learners reported this training would likely help them in future interactions (4.4 [0.73] on 5-point scale) and 95.2% recommended it be offered to resident physicians in other residency programs and to attending surgeons. CONCLUSIONS Formal training in BC/WC increases learners' perception of both the importance of HSC skills and their confidence in exercising those skills in clinical practice. VitalTalkTM methodology permitted scaling training to 5.3 learners per instructor and was highly recommended for other surgeons. Ongoing training, such as this, may support more patient-centered decision-making and care.
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Affiliation(s)
- Sydney R Weill
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Alexander J Layden
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Janet Leahy
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Rene Claxton
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Amy B Zelenski
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris Zimmermann
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Julie Childers
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania; The Wolff Center at UPMC, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Butler CR, Appelbaum PS, Ascani H, Aulisio M, Campbell CE, de Boer IH, Dighe AL, Hall DE, Himmelfarb J, Knight R, Mehl K, Murugan R, Rosas SE, Sedor JR, O'Toole JF, Tuttle KR, Waikar SS, Freeman M. A Participant-Centered Approach to Understanding Risks and Benefits of Participation in Research Informed by the Kidney Precision Medicine Project. Am J Kidney Dis 2022; 80:132-138. [PMID: 34871700 PMCID: PMC9166631 DOI: 10.1053/j.ajkd.2021.10.006] [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: 06/30/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
An understanding of the ethical underpinnings of human subjects research that involves some risk to participants without anticipated direct clinical benefit-such as the kidney biopsy procedure as part of the Kidney Precision Medicine Project (KPMP)-requires a critical examination of the risks as well as the diverse set of countervailing potential benefits to participants. This kind of deliberation has been foundational to the development and conduct of the KPMP. Herein, we use illustrative features of this research paradigm to develop a more comprehensive conceptualization of the types of benefits that may be important to research participants, including respecting pluralistic values, supporting the opportunity to act altruistically, and enhancing benefits to a participant's community. This approach may serve as a model to help researchers, ethicists, and regulators to identify opportunities to better respect and support participants in future research that entails some risk to these participants as well as to improve the quality of research for people with kidney disease.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington; Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
| | - Paul S Appelbaum
- Department of Psychiatry, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York; New York State Psychiatric Institute, New York, New York
| | - Heather Ascani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mark Aulisio
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Center for Biomedical Ethics, MetroHealth System, Cleveland, Ohio
| | - Catherine E Campbell
- Kidney Precision Medicine Project Patient Partner, American Association of Kidney Patients, Tampa, Florida; Sigma Theta Tau International Honor Society, Case Management Society of America, AARP Volunteer Nursing Leadership Board
| | - Ian H de Boer
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Ashveena L Dighe
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Daniel E Hall
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Wolff Center at UPMC, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion and Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Jonathan Himmelfarb
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Richard Knight
- Kidney Precision Medicine Project Patient Partner, American Association of Kidney Patients, Tampa, Florida; American Association of Kidney Patients, Pittsburgh, Pennsylvania
| | - Karla Mehl
- Division of Nephrology, Irving Medical Center, Columbia University, New York, New York
| | - Raghavan Murugan
- Center for Critical Care Nephrology, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - John R Sedor
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Nephrology and Hypertension, Glickman Urological and Kidney and Lerner Research Institutes, Cleveland Clinic Foundation, Cleveland, Ohio
| | - John F O'Toole
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Nephrology and Hypertension, Glickman Urological and Kidney and Lerner Research Institutes, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Katherine R Tuttle
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts; Renal Division, Brigham & Women's Hospital, Boston, Massachusetts
| | - Michael Freeman
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics and Humanities, Penn State College of Medicine, Hershey, Pennsylvania
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Li SR, Handzel RM, Tonetti D, Kennedy J, Shapiro K, Rosengart MR, Hall DE, Seymour C, Tzeng E, Reitz KM. Consensus Current Procedural Terminology Code Definition of Source Control for Sepsis. J Surg Res 2022; 275:327-335. [PMID: 35325636 DOI: 10.1016/j.jss.2022.02.036] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/13/2022] [Accepted: 02/13/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Unlike antibiotic and perfusion support, guidelines for sepsis source control lack high-quality evidence and are ungraded. Internally valid administrative data methods are needed to identify cases representing source control procedures to evaluate outcomes. METHODS Over five modified Delphi rounds, two independent reviewers identified Current Procedural Terminology (CPT) codes pertinent to source control. In each round, codes with perfect agreement were retained or excluded, whereas disagreements were reviewed by the panelists. Manual review of 400 patient records meeting Sepsis-3 criteria (2010-2017) clinically adjudicated which encounters included source control procedures (gold standard). The performance of consensus codes was compared with the gold standard to assess sensitivity, specificity, predictive values, and likelihood ratios. RESULTS Of 5752 CPT codes, 609 consensus codes represented source control procedures. Of 400 hospitalizations for sepsis, 39 (9.8%; 95% confidence interval [CI] 7.0%-13.1%) underwent gold standard source control procedures and 29 (7.3%; 95% CI 4.9-10.3%) consensus code-defined source control procedures. Thirty consensus codes were identified (20.0% gastrointestinal/intraabdominal, 10.0% genitourinary, 13.3% hepatopancreatobiliary, 23.3% orthopedic/cranial, 23.3% soft tissue, and 10.0% intrathoracic), which had 61.5% (95% CI 44.6%-76.6%) sensitivity, 98.6% (95% CI 96.8%-99.6%) specificity, 83.2% (95% CI 66.6%-92.4%) positive, and 95.9% (95% CI 93.9%-97.2%) negative predictive values. With pretest probability at sample prevalence, an identified consensus code had a posttest probability of 83.0% (95% CI 66.0%-92.0%), whereas consensus code absence had a probability of 4.0% (95% CI 3.0-6.0) for undergoing a source control procedure. CONCLUSIONS Using modified Delphi methodology, we created and validated CPT codes identifying source control procedures, providing a framework for evaluation of the surgical care of patients with sepsis.
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Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Robert M Handzel
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel Tonetti
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine Shapiro
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Seymour
- Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Mady LJ, Baddour K, Hodges JC, Magaña LC, Schwarzbach HL, Borrebach JD, Nilsen ML, Johnson JT, Hall DE. The impact of frailty on mortality in non-surgical head and neck cancer treatment: Shifting the clinical paradigm. Oral Oncol 2022; 126:105766. [PMID: 35168191 PMCID: PMC9642850 DOI: 10.1016/j.oraloncology.2022.105766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/06/2021] [Revised: 01/11/2022] [Accepted: 02/06/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Compare survival of head and neck cancer (HNC) patients treated with surgical or non-surgical management according to frailty, quantify frailty with the Risk Analysis Index (RAI), a validated 14-item instrument. MATERIALS AND METHODS Prospective cohort study of newly diagnosed HNC patients (≥18 years) who had frailty assessment from April 13, 2016 to September 30, 2016. Primary outcome was overall survival at 1- and 3-years. Cox proportional hazard models were utilized to examine mortality with predictor variables. Adjusted and unadjusted (Kaplan-Meier) survival curves stratified by either RAI scores or treatment modality were plotted. Kruskal-Wallis and likelihood ratio chi-square tests were used for comparing clinicodemographic variables. RESULTS Of 165 patients, 54 (32.7%) were managed non-surgically, 49 (29.7%) were treated with definitive surgery only, and 62 (37.6%) were treated with multimodality (surgery + adjuvant) therapy. Among the full cohort and subgroup analysis of the frail/very frail (RAI ≥ 37), non-surgical patients had worse or similar 3-year survival than those treated with surgery +/- adjuvant therapy. Multivariable Cox proportional hazard models demonstrate that frail patients treated non-surgically experienced worse survival than their counterparts treated with surgery (HR = 2.50, p = 0.015, 95% CI: 1.19, 5.23) or multimodality therapy (HR = 3.91, p < 0.001, 95% CI: 1.94-7.89). CONCLUSION Across all levels of frailty, long term survival of HNC patients treated without surgery is either worse than or like those treated with surgery. These findings (1) challenge current practices of steering patients "too frail for surgery" towards non-surgical, "non-invasive" therapy, and (2) suggest equipoise warranting randomized trials to clarify treatment of frail patients.
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Affiliation(s)
- Leila J. Mady
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Linda C. Magaña
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hannah L. Schwarzbach
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Marci L. Nilsen
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jonas T. Johnson
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel E. Hall
- Wolff Center at UPMC, Pittsburgh, PA, USA,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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George EL, Massarweh NN, Youk A, Reitz KM, Shinall MC, Chen R, Trickey AW, Varley PR, Johanning J, Shireman PK, Arya S, Hall DE. Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery. JAMA Surg 2022; 157:231-239. [PMID: 34964818 PMCID: PMC8717209 DOI: 10.1001/jamasurg.2021.6488] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. Objective To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. Design, Setting, and Participants This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Exposures Surgical care in either a VA or private sector setting. Main Outcomes and Measures Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Results Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. Conclusions and Relevance VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.
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Affiliation(s)
- Elizabeth L. George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California,Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Nader N. Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Myrick C. Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rui Chen
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | | | - Jason Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha,Nebraska Western Iowa Veterans Affairs Health System, Omaha
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio,South Texas Veterans Health Care System, San Antonio
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California,Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California,Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania,Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Reitz KM, Hall DE, Shinall MC, Shireman PK, Silverstein JC. Using the Unified Medical Language System to Expand the Operative Stress Score - First Use Case. J Surg Res 2021; 268:552-561. [PMID: 34464893 PMCID: PMC8678140 DOI: 10.1016/j.jss.2021.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/01/2021] [Accepted: 07/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Unified Medical Language System (UMLS) maps relationships between and within >100 biomedical vocabularies, including Current Procedural Terminology (CPT) codes, creating a powerful knowledge resource which can accelerate clinical research. METHODS We used synonymy and concepts relating hierarchical structure of CPT codes within the UMLS, (1) guiding surgical experts in expanding the Operative Stress Score (OSS) from 565 originally rated CPT codes to additional, 1,853 related procedures; (2) establishing validity of the association between the added OSS ratings and 30-day outcomes in VASQIP (2015-2018). RESULTS The UMLS Metathesaurus and Semantic Network was converted into an interactive graph database (https://github.com/dbmi-pitt/UMLS-Graph) delineating ontology relatedness. From this UMLS-graph, the CPT hierarchy was queried obtaining all paths from each code to the hierarchical apex. Of 1,853 added ratings, 43% and 76% were siblings and cousins of original OSS CPT codes. Of 857,577 VASQIP cases (mean age, 64±11years; 91% male; 75% white), 786,122 (92%) and 71,455 (8%) were rated in the original and added OSS. Compared to original, added OSS cases included more females (14% versus 9%) and frail patients (25% versus 19%) undergoing high stress procedures (11% versus 8%; all P <.001). Postoperative mortality consistently increased with OSS. Very low stress procedures had <0.5% (original, 0.4% [95%CI, 0.4%-0.5%] versus added, 0.9% [95%CI, 0.6%-1.2%]) and very high 3.8% (original, 3.5% [95%CI, 3.0%-4.0%] versus added, 5.8% [95%CI, 4.6-7.3%]) mortality rates. CONCLUSIONS The synonymy and concepts relating biomedical data within the UMLS can be abstracted and efficiently used to expand the utility of existing clinical research tools.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Taxas; Department of Surgery, South Texas Veterans Health Care System, San Antonio, Taxas; University Health, San Antonio, Taxas
| | - Jonathan C Silverstein
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Varley PR, Borrebach JD, Arya S, Massarweh NN, Bilderback AL, Wisniewski MK, Nelson JB, Johnson JT, Johanning JM, Hall DE. Clinical Utility of the Risk Analysis Index as a Prospective Frailty Screening Tool within a Multi-practice, Multi-hospital Integrated Healthcare System. Ann Surg 2021; 274:e1230-e1237. [PMID: 32118596 DOI: 10.1097/sla.0000000000003808] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The goal of this project was to first address barriers to implementation of the Risk Analysis Index (RAI) within a large, multi-hospital, integrated healthcare delivery system, and to subsequently demonstrate its utility for identifying at-risk surgical patients. BACKGROUND Prior studies demonstrate the validity of the RAI for evaluating preoperative frailty, but they have not demonstrated the feasibility of its implementation within routine clinical practice. METHODS Implementation of the RAI as a frailty screening instrument began as a quality improvement initiative at the University of Pittsburgh Medical Center in July 2016. RAI scores were collected within a REDCap survey instrument integrated into the outpatient electronic health record and then linked to information from additional clinical datasets. NSQIP-eligible procedures were queried within 90 days following the RAI, and the association between RAI and postoperative mortality was evaluated using logistic regression and Cox proportional hazards models. Secondary outcomes such as inpatient length of stay and readmissions were also assessed. RESULTS RAI assessments were completed on 36,261 unique patients presenting to surgical clinics across five hospitals from July 1 to December 31, 2016, and 8,172 of these underwent NSQIP-eligible surgical procedures. The mean RAI score was 23.6 (SD 11.2), the overall 30-day and 180-day mortality after surgery was 0.7% and 2.6%, respectively, and the median time required to collect the RAI was 33 [IQR 23-53] seconds. Overall clinic compliance with the recommendation for RAI assessment increased from 58% in the first month of the study period to 84% in the sixth and final month. RAI score was significantly associated with risk of death (HR=1.099 [95% C.I.: 1.091 - 1.106], p < 0.001). At an RAI cutoff of ≥37, the positive predictive values for 30- and 90-day readmission were 14.8% and 26.2%, respectively, and negative predictive values were 91.6% and 86.4%, respectively. CONCLUSIONS The RAI frailty screening tool can be efficiently implemented within multi-specialty, multi-hospital healthcare systems. In the context of our findings and given the value of the RAI in predicting adverse postoperative outcomes, health systems should consider implementing frailty screening within surgical clinics.
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Affiliation(s)
| | - Jeffrey D Borrebach
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Surgical Service Line VA Palo Alto Healthcare System, Palo Alto, CA
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX; Division of Surgical Oncology, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Andrew L Bilderback
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mary Kay Wisniewski
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonas T Johnson
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE; Nebraska Western Iowa VA Health System, Omaha, NE
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA.,Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
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Agarwal N, Goldschmidt E, Taylor T, Roy S, Altieri Dunn SC, Bilderback A, Friedlander RM, Kanter AS, Okonkwo DO, Gerszten PC, Hamilton DK, Hall DE. Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa468_s103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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40
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Reitz KM, Hall DE, Makaroun MS, Tzeng E, Liang NL. Early Postoperative Mortality Among US Veterans With a Robust Physiologic Reserve Undergoing Open or Endovascular Abdominal Aortic Aneurysm Repair. JAMA Netw Open 2021; 4:e2137245. [PMID: 34812851 PMCID: PMC8611481 DOI: 10.1001/jamanetworkopen.2021.37245] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This cohort study uses data from the Veterans Affairs Surgical Quality Improvement Program database to examine the risk of early postoperative mortality among US veterans with a robust physiologic reserve undergoing open or endovascular abdominal aortic aneurysm repair.
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Affiliation(s)
- Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs, Pittsburgh, Pennsylvania
| | - Michel S. Makaroun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Nathan L. Liang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
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Yan Q, Kim J, Reitz KM, Hall DE, Shinall MC, Stitzenberg KB, Kao LS, George E, Wang CP, Shireman PK. Sex Differences in Postoperative Complications and Mortality. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reitz KM, Althouse AD, Meyer J, Arya S, Goodney PP, Shireman PK, Hall DE, Tzeng E. Association of Smoking With Postprocedural Complications Following Open and Endovascular Interventions for Intermittent Claudication. JAMA Cardiol 2021; 7:45-54. [PMID: 34613348 DOI: 10.1001/jamacardio.2021.3979] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 11/14/2022]
Abstract
Importance Smoking is a key modifiable risk factor in the development and progression of peripheral artery disease, which often manifests as intermittent claudication (IC). Smoking cessation is a first-line therapy for IC, yet a minority of patients quit smoking prior to elective revascularization. Objective To assess if preprocedural smoking is associated with an increased risk of early postprocedural complications following elective open and endovascular revascularization. Design, Setting, and Participants This retrospective cohort study used nearest-neighbor (1:1) propensity score matching of 2011 to 2019 data from the Veterans Affairs Surgical Quality Improvement Program, including all cases with a primary diagnosis of IC and excluding emergent cases, primary procedures that were not lower extremity revascularization, and patients with chronic limb-threatening ischemia within 30 days of the intervention. All data were abstracted June 18, 2020, and analyzed from July 26, 2020, to June 30, 2021. Exposures Preprocedural cigarette smoking. Main Outcomes and Measures Any and organ system-specific (ie, wound, respiratory, thrombosis, kidney, cardiac, sepsis, and neurological) 30-day complications and mortality, overall and in prespecified subgroups. Results Of 14 350 included cases of revascularization, 14 090 patients (98.2%) were male, and the mean (SD) age was 65.7 (7.0) years. A total of 7820 patients (54.5%) were smoking within the preprocedural year. There were a total of 4417 endovascular revascularizations (30.8%), 4319 hybrid revascularizations (30.1%), and 5614 open revascularizations (39.1%). A total of 1594 patients (11.1%) had complications, and 57 (0.4%) died. Among 7710 propensity score-matched cases (including 3855 smokers and 3855 nonsmokers), 484 smokers (12.6%) and 34 nonsmokers (8.9%) experienced complications, an absolute risk difference (ARD) of 3.68% (95% CI, 2.31-5.06; P < .001). Compared with nonsmokers, any complication was higher for smokers following endovascular revascularization (26 [4.3%] vs 52 [2.1%]; ARD, 2.19%; 95% CI, 0.77-3.60; P = .003), hybrid revascularization (204 [17.3%] vs 163 [14.1%]; ARD, 3.18%; 95% CI, 0.23-6.13; P = .04), and open revascularization (228 [15.4%] vs 153 [10.3%]; ARD, 5.18%; 95% CI, 2.78-7.58; P < .001). Compared with nonsmokers, respiratory complications were higher for smokers following endovascular revascularization (20 [1.7%] vs 6 [0.5%]; ARD, 1.17%; 95% CI, 0.35-2.00; P = .009), hybrid revascularization (33 [2.8%] vs 10 [0.9%]; ARD, 1.93%; 95% CI, 0.85-3.02; P = .001), and open revascularization (32 [2.2%] vs 19 [1.3%]; ARD, 0.89%; 95% CI, 0-1.80; P = .06). Wound complications and graft failure were higher for smokers compared with nonsmokers following open interventions (wound complications: 146 [9.9%] vs 87 [5.8%]; ARD, 4.05%; 95% CI, 2.12-5.99; P < .001; graft failure: 33 [2.2%] vs 11 [0.7%]; ARD, 1.50%; 95% CI, 0.63-2.37; P = .001). In a sensitivity analysis, compared with active smokers (n = 5173; smoking within 2 weeks before the procedure), the risk of any complication was decreased by 65% for never smokers (n = 1197; adjusted odds ratio, 0.45; 95% CI, 0.34-0.59) and 29% for former smokers (n = 4755; cessation more than 1 year before the procedure; adjusted odds ratio, 0.71; 95% CI, 0.61-0.83; P = .001 for interaction). Conclusions and Relevance In this cohort study, more than half of patients with IC were smoking prior to elective revascularization, and complication risks were higher across all modalities of revascularization. These findings stress the importance of smoking cessation to optimize revascularization outcomes.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Andrew D Althouse
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joseph Meyer
- Department of Cardiology, Johns Hopkins, Baltimore, Maryland
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Paula K Shireman
- Department of Surgery, UT Health San Antonio, University of Texas, San Antonio.,Department of Surgery, South Texas Veterans Health Care System, San Antonio
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Wolff Center at UPMC, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Reitz KM, Varley PR, Liang NL, Youk A, George EL, Shinall MC, Shireman PK, Arya S, Tzeng E, Hall DE. The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study. Ann Surg 2021; 274:637-645. [PMID: 34506319 PMCID: PMC8433485 DOI: 10.1097/sla.0000000000005068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions. SUMMARY OF BACKGROUND DATA Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity. METHODS Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score). RESULTS Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases. CONCLUSIONS Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan L Liang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- Department of Surgery, South Texas Veterans Health Care System, San Antonio, Texas
- University Health System, San Antonio, Texas
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
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Arya S, George EL, Hall DE. To Perform or Not to Perform Surgery for Frail Patients?-Reply. JAMA Surg 2021; 156:891-892. [PMID: 34009294 DOI: 10.1001/jamasurg.2021.1531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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)
- Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Sigler LE, Reitschuler-Cross E, Arnold RM, Hall DE. Preoperative Frailty Assessment #407. J Palliat Med 2021; 24:285-286. [PMID: 33522858 DOI: 10.1089/jpm.2020.0629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Agarwal N, Goldschmidt E, Taylor T, Roy S, Dunn SCA, Bilderback A, Friedlander RM, Kanter AS, Okonkwo DO, Gerszten PC, Hamilton DK, Hall DE. Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients. Neurosurgery 2021; 88:552-557. [PMID: 33372214 DOI: 10.1093/neuros/nyaa468] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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: 10/25/2019] [Accepted: 08/10/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With an aging population, elderly patients with multiple comorbidities are more frequently undergoing spine surgery and may be at increased risk for complications. Objective measurement of frailty may predict the incidence of postoperative adverse events. OBJECTIVE To investigate the associations between preoperative frailty and postoperative spine surgery outcomes including mortality, length of stay, readmission, surgical site infection, and venous thromboembolic disease. METHODS As part of a system-wide quality improvement initiative, frailty assessment was added to the routine assessment of patients considering spine surgery beginning in July 2016. Frailty was assessed with the Risk Analysis Index (RAI), and patients were categorized as nonfrail (RAI 0-29) or prefrail/frail (RAI ≥ 30). Comparisons between nonfrail and prefrail/frail patients were analyzed using Fisher's exact test for categorical data or by Wilcoxon rank sum tests for continuous data. RESULTS From August 2016 through September 2018, 668 patients (age of 59.5 ± 13.3 yr) had a preoperative RAI score recorded and underwent scheduled spine surgery. Prefrail and frail patients suffered comparatively higher rates of mortality at 90 d (1.9% vs 0.2%, P < .05) and 1 yr (5.1% vs 1.2%, P < .01) from the procedure date. They also had longer in-hospital length of stay (LOS) (3.9 d ± 3.6 vs 3.1 d ± 2.8, P < .001) and higher rates of 60 d (14.6% vs 8.2%, P < .05) and 90 d (15.8% vs 9.8%, P < .05) readmissions. CONCLUSION Preoperative frailty, as measured by the RAI, was associated with an increased risk of readmission and 90-d and 1-yr mortality following spine surgery. The RAI can be used to stratify spine patients and inform preoperative surgical decision making.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tavis Taylor
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Souvik Roy
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Andrew Bilderback
- The Wolff Center at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter C Gerszten
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- The Wolff Center at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Tuttle KR, Knight R, Appelbaum PS, Arora T, Bansal S, Bebiak J, Brown K, Campbell C, Cooperman L, Corona-Villalobos CP, Dighe A, de Boer IH, Hall DE, Jefferson N, Jolly S, Kermani A, Lee SC, Mehl K, Murugan R, Roberts GV, Rosas SE, Himmelfarb J, Miller RT. Integrating Patient Priorities with Science by Community Engagement in the Kidney Precision Medicine Project. Clin J Am Soc Nephrol 2021; 16:660-668. [PMID: 33257411 PMCID: PMC8092068 DOI: 10.2215/cjn.10270620] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 01/21/2023]
Abstract
The Kidney Precision Medicine Project (KPMP) is a multisite study designed to improve understanding of CKD attributed to diabetes or hypertension and AKI by performing protocol-driven kidney biopsies. Study participants and their kidney tissue samples undergo state-of-the-art deep phenotyping using advanced molecular, imaging, and data analytical methods. Few patients participate in research design or concepts for discovery science. A major goal of the KPMP is to include patients as equal partners to inform the research for clinically relevant benefit. The purpose of this report is to describe patient and community engagement and the value they bring to the KPMP. Patients with CKD and AKI and clinicians from the study sites are members of the Community Engagement Committee, with representation on other KPMP committees. They participate in KPMP deliberations to address scientific, clinical, logistic, analytic, ethical, and community engagement issues. The Community Engagement Committee guides KPMP research priorities from perspectives of patients and clinicians. Patients led development of essential study components, including the informed consent process, no-fault harm insurance coverage, the ethics statement, return of results plan, a "Patient Primer" for scientists and the public, and Community Advisory Boards. As members across other KPMP committees, the Community Engagement Committee assures that the science is developed and conducted in a manner relevant to study participants and the clinical community. Patients have guided the KPMP to produce research aligned with their priorities. The Community Engagement Committee partnership has set new benchmarks for patient leadership in precision medicine research.
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Affiliation(s)
- Katherine R. Tuttle
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington
| | - Richard Knight
- Kidney Precision Medicine Project Patient Partner, Washington, DC,American Association of Kidney Patients, Tampa, Florida
| | - Paul S. Appelbaum
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Tanima Arora
- Division of Nephrology, Yale University, New Haven, Connecticut
| | - Shweta Bansal
- Division of Nephrology, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Jack Bebiak
- Kidney Precision Medicine Project Patient Partner, Indianapolis, Indiana
| | - Keith Brown
- Kidney Precision Medicine Project Patient Partner, Post Falls, Idaho
| | | | - Leslie Cooperman
- Kidney Precision Medicine Project Patient Partner, Indianapolis, Indiana
| | | | - Ashveena Dighe
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington
| | - Ian H. de Boer
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington
| | - Daniel E. Hall
- Kidney Precision Medicine Project Patient Partner, Dallas, Texas
| | | | - Stacey Jolly
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Asra Kermani
- Division of Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Simon C. Lee
- Department of Population and Data Sciences, University of Texas Southwestern Medical School, Dallas, Texas
| | - Karla Mehl
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | - Raghavan Murugan
- Division of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Glenda V. Roberts
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington,Kidney Precision Medicine Project Patient Partner, Seattle, Washington
| | - Sylvia E. Rosas
- Division of Nephrology, Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Jonathan Himmelfarb
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington
| | - R. Tyler Miller
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Division of Nephrology, University of Texas Southwestern Medical School, Dallas, Texas
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Cashion W, Gellad WF, Sileanu FE, Mor MK, Fine MJ, Hale J, Hall DE, Rogal S, Switzer G, Ramkumar M, Wang V, Bronson DA, Wilson M, Gunnar W, Weisbord SD. Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare. Clin J Am Soc Nephrol 2021; 16:437-445. [PMID: 33602753 PMCID: PMC8011004 DOI: 10.2215/cjn.10020620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/19/2020] [Accepted: 12/21/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation. RESULTS Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1). CONCLUSIONS Most dually enrolled veterans underwent transplantation at a non-Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration-only post-transplant care had the lowest 5-year mortality.
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Affiliation(s)
- Winn Cashion
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Hale
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Departments of Surgery, Anesthesia and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shari Rogal
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Galen Switzer
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mohan Ramkumar
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina,Department of Population Health Sciences and Department of Medicine, Duke University, Durham, North Carolina
| | - Douglas A. Bronson
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C
| | - Mark Wilson
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C
| | - William Gunnar
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C.,Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven D. Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Morales A, Schultz KC, Gao S, Murphy A, Barnato AE, Fanning JB, Hall DE. Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations. Palliat Med Rep 2021; 2:71-83. [PMID: 33860283 PMCID: PMC8043084 DOI: 10.1089/pmr.2020.0054] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.
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Affiliation(s)
- Andre Morales
- Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevan C. Schultz
- University Center for Social and Urban Research (UCSUR), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shasha Gao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | | | - Amber E. Barnato
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Joseph B. Fanning
- Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E. Hall
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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50
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Altieri Dunn SC, Bellon JE, Bilderback A, Borrebach JD, Hodges JC, Wisniewski MK, Harinstein ME, Minnier TE, Nelson JB, Hall DE. SafeNET: Initial development and validation of a real-time tool for predicting mortality risk at the time of hospital transfer to a higher level of care. PLoS One 2021; 16:e0246669. [PMID: 33556123 PMCID: PMC7870086 DOI: 10.1371/journal.pone.0246669] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/24/2021] [Indexed: 01/31/2023] Open
Abstract
Background Processes for transferring patients to higher acuity facilities lack a standardized approach to prognostication, increasing the risk for low value care that imposes significant burdens on patients and their families with unclear benefits. We sought to develop a rapid and feasible tool for predicting mortality using variables readily available at the time of hospital transfer. Methods and findings All work was carried out at a single, large, multi-hospital integrated healthcare system. We used a retrospective cohort for model development consisting of patients aged 18 years or older transferred into the healthcare system from another hospital, hospice, skilled nursing or other healthcare facility with an admission priority of direct emergency admit. The cohort was randomly divided into training and test sets to develop first a 54-variable, and then a 14-variable gradient boosting model to predict the primary outcome of all cause in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and transition to comfort measures only or hospice care. For model validation, we used a prospective cohort consisting of all patients transferred to a single, tertiary care hospital from one of the 3 referring hospitals, excluding patients transferred for myocardial infarction or maternal labor and delivery. Prospective validation was performed by using a web-based tool to calculate the risk of mortality at the time of transfer. Observed outcomes were compared to predicted outcomes to assess model performance. The development cohort included 20,985 patients with 1,937 (9.2%) in-hospital mortalities, 2,884 (13.7%) 30-day mortalities, and 3,899 (18.6%) 90-day mortalities. The 14-variable gradient boosting model effectively predicted in-hospital, 30-day and 90-day mortality (c = 0.903 [95% CI:0.891–0.916]), c = 0.877 [95% CI:0.864–0.890]), and c = 0.869 [95% CI:0.857–0.881], respectively). The tool was proven feasible and valid for bedside implementation in a prospective cohort of 679 sequentially transferred patients for whom the bedside nurse calculated a SafeNET score at the time of transfer, taking only 4–5 minutes per patient with discrimination consistent with the development sample for in-hospital, 30-day and 90-day mortality (c = 0.836 [95%CI: 0.751–0.921], 0.815 [95% CI: 0.730–0.900], and 0.794 [95% CI: 0.725–0.864], respectively). Conclusions The SafeNET algorithm is feasible and valid for real-time, bedside mortality risk prediction at the time of hospital transfer. Work is ongoing to build pathways triggered by this score that direct needed resources to the patients at greatest risk of poor outcomes.
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Affiliation(s)
| | - Johanna E. Bellon
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Andrew Bilderback
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | | | - Jacob C. Hodges
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Mary Kay Wisniewski
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Matthew E. Harinstein
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Tamra E. Minnier
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Joel B. Nelson
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Daniel E. Hall
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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