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Seib CD, Wren SM. AI Imaging Analysis Needs Evaluation Before Implementation. JAMA Surg 2024:2817241. [PMID: 38598188 DOI: 10.1001/jamasurg.2024.0629] [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: 04/11/2024]
Affiliation(s)
- Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
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Graham LA, Illarmo SS, Wren SM, Odden MC, Mudumbai SC. Use of natural language processing method to identify regional anesthesia from clinical notes. Reg Anesth Pain Med 2024:rapm-2024-105340. [PMID: 38580338 DOI: 10.1136/rapm-2024-105340] [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: 01/22/2024] [Accepted: 03/26/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Accurate data capture is integral for research and quality improvement efforts. Unfortunately, limited guidance for defining and documenting regional anesthesia has resulted in wide variation in documentation practices, even within individual hospitals, which can lead to missing and inaccurate data. This cross-sectional study sought to evaluate the performance of a natural language processing (NLP)-based algorithm developed to identify regional anesthesia within unstructured clinical notes. METHODS We obtained postoperative clinical notes for all patients undergoing elective non-cardiac surgery with general anesthesia at one of six Veterans Health Administration hospitals in California between January 1, 2017, and December 31, 2022. After developing and executing our algorithm, we compared our results to a frequently used referent, the Corporate Data Warehouse structured data, to assess the completeness and accuracy of the currently available data. Measures of agreement included sensitivity, positive predictive value, false negative rate, and accuracy. RESULTS We identified 27,713 procedures, of which 9310 (33.6%) received regional anesthesia. 96.6% of all referent regional anesthesia cases were identified in the clinic notes with a very low false negative rate and good accuracy (false negative rate=0.8%, accuracy=82.5%). Surprisingly, the clinic notes documented more than two times the number of regional anesthesia cases that were documented in the referent (algorithm n=9154 vs referent n=4606). DISCUSSION While our algorithm identified nearly all regional anesthesia cases from the referent, it also identified more than two times as many regional anesthesia cases as the referent, raising concerns about the accuracy and completeness of regional anesthesia documentation in administrative and clinical databases. We found that NLP was a promising alternative for identifying clinical information when existing databases lack complete documentation.
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Affiliation(s)
- Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
| | | | - Sherry M Wren
- Department of General Surgery, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Michelle C Odden
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
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Graham LA, Illarmo S, Gray CP, Harris AHS, Wagner TH, Hawn MT, Iannuzzi JC, Wren SM. Mapping the Discharge Process After Surgery. JAMA Surg 2024; 159:438-444. [PMID: 38381415 PMCID: PMC10882508 DOI: 10.1001/jamasurg.2023.7539] [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: 08/17/2023] [Accepted: 10/28/2023] [Indexed: 02/22/2024]
Abstract
Importance Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. Objective To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. Design, Setting, and Participants This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Exposure Postoperative hospital discharge. Main Outcomes and Measures Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. Results At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. Conclusions and Relevance These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Caroline P. Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Alex H. S. Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T. Hawn
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - James C. Iannuzzi
- Department of Surgery, San Francisco VA Medical Center, San Francisco, California
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco
| | - Sherry M. Wren
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
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Hardcastle TC, Gyedu A, Doherty GM, Wren SM. Editorial commentary and call for papers-Humanitarian surgery in conflict zones. World J Surg 2024; 48:507-508. [PMID: 38407321 DOI: 10.1002/wjs.12119] [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: 02/27/2024]
Affiliation(s)
- Timothy C Hardcastle
- Department of Health KwaZulu-Natal and Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University if Science and Technology, Kumasi, Ghana
| | | | - Sherry M Wren
- Stanford University School of Medicine, Stanford, California, USA
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Rajasingh CM, Wren SM. Socioeconomic Status and Postoperative Emergency Department Visits-Reply. JAMA Surg 2024:2815374. [PMID: 38381441 DOI: 10.1001/jamasurg.2023.8010] [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: 02/22/2024]
Affiliation(s)
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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McKnight G, Friebel R, Marks I, Almaqadma A, Youssef Seleem M, Tientcheu TF, Saleh R, Ryan-Coker M, Emodi R, Seida M, Barden J, Redmond A, Amirtharajah M, Wren SM, Leather A, Hargest R. Defining humanitarian surgery: international consensus in global surgery. Br J Surg 2024; 111:znae024. [PMID: 38372664 PMCID: PMC10875721 DOI: 10.1093/bjs/znae024] [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] [Received: 12/15/2023] [Revised: 01/05/2024] [Accepted: 01/12/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Gerard McKnight
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Rocco Friebel
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Isobel Marks
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Urology, Great Ormond Street Hospital for Children, London, UK
| | - Ahmed Almaqadma
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Plastic Surgery Department, Alshifa Medical Complex, Gaza, Palestine
| | - Mohamed Youssef Seleem
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Surgery, Cairo University, Cairo, Egypt
| | - Tim Fabrice Tientcheu
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- General and Digestive Surgical Unit, Central Hospital Yaounde, Yaounde, Cameroon
- Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Raoof Saleh
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Médicins Sans Frontières, Kilo Project, Kilo Hospital, Ibb Governorate, Yemen
| | - Marcella Ryan-Coker
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Surgery, University of Nairobi, Nairobi, Kenya
| | - Rosemary Emodi
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
| | - Mai Seida
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
| | - Jonathan Barden
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
| | - Anthony Redmond
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, University of Manchester, Manchester, UK
| | - Mohana Amirtharajah
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Médicines Sans Frontières Operational Centre Amsterdam, Amsterdam, The Netherlands
| | - Sherry M Wren
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Surgery and Center for Innovation in Global Health, Stanford University, Stanford, California, USA
| | - Andrew Leather
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King’s College London, London, UK
| | - Rachel Hargest
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- School of Medicine, Cardiff University, Cardiff, UK
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Oquendo YA, Coad MM, Wren SM, Lendvay TS, Nisky I, Jarc AM, Okamura AM, Chua Z. Haptic Guidance and Haptic Error Amplification in a Virtual Surgical Robotic Training Environment. IEEE Trans Haptics 2024; PP:1-12. [PMID: 38194379 DOI: 10.1109/toh.2024.3350128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Teleoperated robotic systems have introduced more intuitive control for minimally invasive surgery, but the optimal method for training remains unknown. Recent motor learning studies have demonstrated that exaggeration of errors helps trainees learn to perform tasks with greater speed and accuracy. We hypothesized that training in a force field that pushes the user away from a desired path would improve their performance on a virtual reality ring-on-wire task. Thirty-eight surgical novices trained under a no-force, guidance, or error-amplifying force field over five days. Completion time, translational and rotational path error, and combined errortime were evaluated under no force field on the final day. The groups significantly differed in combined error-time, with the guidance group performing the worst. Error-amplifying field participants did not plateau in their performance during training, suggesting that learning was still ongoing. Guidance field participants had the worst performance on the final day, confirming the guidance hypothesis. Observed trends also suggested that participants who had high initial path error benefited more from guidance. Error-amplifying and error-reducing haptic training for robot-assisted telesurgery benefits trainees of different abilities differently, with our results indicating that participants with high initial combined error-time benefited more from guidance and error-amplifying force field training.
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Rajasingh CM, Wren SM. Emergency Department Visit Rates After Ambulatory Surgery. JAMA Surg 2024; 159:107-109. [PMID: 37910124 PMCID: PMC10620670 DOI: 10.1001/jamasurg.2023.4788] [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: 03/12/2023] [Accepted: 07/27/2023] [Indexed: 11/03/2023]
Abstract
This cohort study compares the rates of emergency department visits after cholecystectomy, transurethral resection of the prostate, and knee arthroplasty at freestanding ambulatory surgery centers vs hospital-owned surgery centers.
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Affiliation(s)
| | - Sherry M. Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Campbell S, Lee SH, Liu Y, Wren SM. A retrospective study of laparoscopic, robotic-assisted, and open emergent/urgent cholecystectomy based on the PINC AI Healthcare Database 2017-2020. World J Emerg Surg 2023; 18:55. [PMID: 38037087 PMCID: PMC10687827 DOI: 10.1186/s13017-023-00521-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Robotic-assisted cholecystectomy (RAC) is becoming increasingly common, but the outcomes of emergent/urgent robotic-assisted cholecystectomies compared to emergent laparoscopic (LC) and open cholecystectomies (OC) remain understudied. METHODS The PINC AI Healthcare Database was queried to identify adults who underwent emergent or urgent (Em-Ur) cholecystectomy between January 1, 2017, and December 31, 2020. Immediate postoperative and 30-day outcomes were identified including intraoperative complications, transfusion, conversion, postoperative complication, and hospital length of stay. Propensity score matching was done to compare outcomes between Em-Ur robotic-assisted, laparoscopic, and open cholecystectomies Subgroup analyses were performed comparing RAC done with and without fluorescent imaging as well as comparing RAC and LC performed for patients with class 3 obesity (BMI ≥ 40 kg/m2). RESULTS RAC Em-Ur cholecystectomies are being performed with increasing frequency and is the most utilized modality for patients with class 3 obesity. There was no difference in intraoperative complications (0.3%), bile duct injury (0.2%), or postoperative outcomes between RAC and LC. LC had significantly shorter operating room times (96 min (75,128)) compared to RAC (120 min (90,150)). There was a significant lower rate of conversion to open in RAC (1.9%) relative to LC (3.2%) in both the overall population and the class 3 obesity sub-analysis (RAC-2.6% vs. LC-4.4%). There was no difference in outcomes in robotic-assisted cholecystectomies done with and without fluorescent imaging. CONCLUSIONS A comparison of propensity score-matched cohorts of emergent/urgent robotic-assisted and laparoscopic cholecystectomy indicates that robotic-assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy, and that both have superior outcomes to open cholecystectomies.
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Affiliation(s)
- Stephen Campbell
- VA Medical Center, Palo Alto Division, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA.
| | | | - Yuki Liu
- Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Sherry M Wren
- VA Medical Center, Palo Alto Division, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA
- Stanford University School of Medicine, Palo Alto, CA, USA
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Rajasingh CM, Baker LC, Wren SM. Freestanding Ambulatory Surgery Centers and Patients Undergoing Outpatient Knee Arthroplasty. JAMA Netw Open 2023; 6:e2328343. [PMID: 37561458 PMCID: PMC10415959 DOI: 10.1001/jamanetworkopen.2023.28343] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 06/30/2023] [Indexed: 08/11/2023] Open
Abstract
Importance In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown. Objectives To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs. Design, Setting, and Participants This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022. Main Outcomes and Measures Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared. Results A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001). Conclusions This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.
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Affiliation(s)
- Charlotte M. Rajasingh
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Laurence C. Baker
- Department of Health Policy, Stanford University, Stanford, California
| | - Sherry M. Wren
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Liebert CA, Melcer EF, Eddington H, Trickey A, Shields S, Lee M, Korndorffer JR, Bekele A, Wren SM, Lin DT. Correlation of Performance on ENTRUST and Traditional Oral Objective Structured Clinical Examination for High-Stakes Assessment in the College of Surgeons of East, Central, and Southern Africa. J Am Coll Surg 2023; 237:117-127. [PMID: 37144790 DOI: 10.1097/xcs.0000000000000740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND To address the global need for accessible evidence-based tools for competency-based education, we developed ENTRUST, an innovative online virtual patient simulation platform to author and securely deploy case scenarios to assess surgical decision-making competence. STUDY DESIGN In partnership with the College of Surgeons of East, Central, and Southern Africa, ENTRUST was piloted during the Membership of the College of Surgeons (MCS) 2021 examination. Examinees (n = 110) completed the traditional 11-station oral objective structured clinical examinations (OSCEs), followed by 3 ENTRUST cases, authored to query similar clinical content of 3 corresponding OSCE cases. ENTRUST scores were analyzed for associations with MCS Examination outcome using independent sample t tests. Correlation of ENTRUST scores to MCS Examination Percentage and OSCE station scores was calculated with Pearson correlations. Bivariate and multivariate analyses were performed to evaluate predictors of performance. RESULTS ENTRUST performance was significantly higher in examinees who passed the MCS examination compared with those who failed (p < 0.001). The ENTRUST score was positively correlated with MCS Examination Percentage (p < 0.001) and combined OSCE station scores (p < 0.001). On multivariate analysis, there was a strong association between MCS Examination Percentage and ENTRUST Grand Total Score (p < 0.001), Simulation Total Score (p = 0.018), and Question Total Score (p < 0.001). Age was a negative predictor for ENTRUST Grand Total and Simulation Total Score, but not for Question Total Score. Sex, native language status, and intended specialty were not associated with performance on ENTRUST. CONCLUSIONS This study demonstrates feasibility and initial validity evidence for the use of ENTRUST in a high-stakes examination context for assessment of surgical decision-making. ENTRUST holds potential as an accessible learning and assessment platform for surgical trainees worldwide.
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Affiliation(s)
- Cara A Liebert
- From the Department of Surgery, Stanford University School of Medicine, Stanford, CA (Liebert, Lee, Korndorffer, Wren, Lin)
- Surgical Services, VA Palo Alto Health Care System, Department of Veterans Affairs, Palo Alto, CA (Liebert, Korndorffer, Wren)
| | - Edward F Melcer
- Department of Computational Media, Baskin School of Engineering, University of California- Santa Cruz, Santa Cruz, CA (Melcer, Shields)
| | - Hyrum Eddington
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford, CA (Eddington, Trickey)
| | - Amber Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford, CA (Eddington, Trickey)
| | - Samuel Shields
- Surgical Services, VA Palo Alto Health Care System, Department of Veterans Affairs, Palo Alto, CA (Liebert, Korndorffer, Wren)
| | - Melissa Lee
- From the Department of Surgery, Stanford University School of Medicine, Stanford, CA (Liebert, Lee, Korndorffer, Wren, Lin)
| | - James R Korndorffer
- From the Department of Surgery, Stanford University School of Medicine, Stanford, CA (Liebert, Lee, Korndorffer, Wren, Lin)
- Surgical Services, VA Palo Alto Health Care System, Department of Veterans Affairs, Palo Alto, CA (Liebert, Korndorffer, Wren)
| | - Abebe Bekele
- School of Medicine, University of Global Health Equity, Kigali, Rwanda (Bekele)
| | - Sherry M Wren
- From the Department of Surgery, Stanford University School of Medicine, Stanford, CA (Liebert, Lee, Korndorffer, Wren, Lin)
- Surgical Services, VA Palo Alto Health Care System, Department of Veterans Affairs, Palo Alto, CA (Liebert, Korndorffer, Wren)
| | - Dana T Lin
- From the Department of Surgery, Stanford University School of Medicine, Stanford, CA (Liebert, Lee, Korndorffer, Wren, Lin)
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Mills J, Liebert C, Wren SM, Pratt JSA, Earley M, Eisenberg D. Robotic General Surgery Trends in the Veterans Health Administration, Community Practice, and Academic Centers From 2013 to 2021. JAMA Surg 2023; 158:552-554. [PMID: 36790771 PMCID: PMC9932937 DOI: 10.1001/jamasurg.2022.7728] [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: 06/24/2022] [Accepted: 09/04/2022] [Indexed: 02/16/2023]
Abstract
This cross-sectional study compares trends in use of robotic surgery for general surgical procedures among the Veterans Health Administration (VHA), community practice, and academic health centers from 2013 to 2021.
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Affiliation(s)
- John Mills
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, California
| | - Cara Liebert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, California
- Department of Surgery, Stanford School of Medicine, Stanford, California
| | - Sherry M. Wren
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, California
- Department of Surgery, Stanford School of Medicine, Stanford, California
| | - Janey S. A. Pratt
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, California
- Department of Surgery, Stanford School of Medicine, Stanford, California
| | - Michelle Earley
- Department of Surgery, Stanford School of Medicine, Stanford, California
| | - Dan Eisenberg
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, California
- Department of Surgery, Stanford School of Medicine, Stanford, California
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Graham LA, Gray C, Wagner TH, Illarmo S, Hawn MT, Wren SM, Iannuzzi J, Harris AHS. Applying cognitive task analysis to health services research. Health Serv Res 2023; 58:415-422. [PMID: 36421922 PMCID: PMC10012243 DOI: 10.1111/1475-6773.14106] [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: 11/25/2022] Open
Abstract
OBJECTIVE Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study. DATA SOURCES AND STUDY SETTING Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration. STUDY DESIGN Qualitative study of discharge planning using CTA. DATA COLLECTION/EXTRACTION METHODS Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis. PRINCIPAL FINDINGS We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task. CONCLUSIONS A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Department of SurgeryStanford‐Surgery Policy Improvement Research and Education Center (S‐SPIRE), Stanford UniversityStanfordCaliforniaUSA
| | - Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Department of SurgeryStanford‐Surgery Policy Improvement Research and Education Center (S‐SPIRE), Stanford UniversityStanfordCaliforniaUSA
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Mary T. Hawn
- Department of General SurgeryVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
- Department of SurgeryStanford UniversityStanfordCaliforniaUSA
| | - Sherry M. Wren
- Department of General SurgeryVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
- Department of SurgeryStanford UniversityStanfordCaliforniaUSA
| | - James Iannuzzi
- Department of SurgerySan Francisco Veterans Affairs Healthcare SystemSan FranciscoCaliforniaUSA
- Division of Vascular Surgery, Department of SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Alex H. S. Harris
- Department of SurgeryStanford‐Surgery Policy Improvement Research and Education Center (S‐SPIRE), Stanford UniversityStanfordCaliforniaUSA
- Center for Innovation to Implementation, VA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
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14
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Wild H, Wren SM. High-Quality Data Collection in Low-Resource Settings: An Imperative to Improving Global Surgical Care. World J Surg 2023; 47:1397-1398. [PMID: 36995398 DOI: 10.1007/s00268-023-06986-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Hannah Wild
- Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA.
| | - Sherry M Wren
- Stanford University School of Medicine, Stanford, CA, USA
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15
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Ryu MY, Martin MJ, Jin AH, Tabor HK, Wren SM. Characterizing Moral Injury and Distress in US Military Surgeons Deployed to Far-Forward Combat Environments in Afghanistan and Iraq. JAMA Netw Open 2023; 6:e230484. [PMID: 36821112 PMCID: PMC9951040 DOI: 10.1001/jamanetworkopen.2023.0484] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE Moral injury and distress (MID), which occurs when individuals have significant dissonance with their belief system and overwhelming feelings of being powerless to do what is believed to be right, has not been explored in the unique population of military surgeons deployed far forward in active combat settings. Deployed military surgeons provide care to both injured soldiers and civilians under command-driven medical rules of engagement (MROE) in variably resourced settings. This practice setting has no civilian corollary for comparison or current specific tool for measurement. OBJECTIVE To characterize MID among military surgeons deployed during periods of high casualty volumes through a mixed-methods approach. DESIGN, SETTING, AND PARTICIPANTS This qualitative study using convergent mixed methods was performed from May 2020 to October 2020. Participants included US military surgeons who had combat deployments to a far-forward role 2 treatment facility during predefined peak casualty periods in Iraq (2003-2008) and Afghanistan (2009-2012), as identified by purposeful snowball sampling. Data analysis was performed from October 2020 to May 2021. MAIN OUTCOMES AND MEASURES Measure of Moral Distress for Healthcare Professionals (MMD-HP) survey and individual, semistructured interviews were conducted to thematic saturation. RESULTS The total cohort included 20 surgeons (mean [SD] age, 38.1 [5.2] years); 16 (80%) were male, and 16 (80%) had 0 or 1 prior deployment. Deployment locations were Afghanistan (11 surgeons [55%]), Iraq (9 surgeons [45%]), or both locations (3 surgeons [15%]). The mean (SD) MMD-HP score for the surgeons was 104.1 (39.3). The primary thematic domains for MID were distressing outcomes (DO) and MROE. The major subdomains of DO were guilt related to witnessing horrific injuries; treating pregnant women, children, and US soldiers; and second-guessing decisions. The major subdomains for MROE were forced transfer of civilian patients, limited capabilities and resources, inexperience in specialty surgical procedures, and communication with command. Postdeployment manifestations of MID were common and affected sleep, medical practice, and interpersonal relationships. CONCLUSIONS AND RELEVANCE In this qualitative study, MID was ubiquitous in deployed military surgeons. Thematic observations about MID, specifically concerning the domains of DO and MROE, may represent targets for further study to develop an evaluation tool of MID in this population and inform possible programs for identification and mitigation of MID.
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Affiliation(s)
- Madeline Y. Ryu
- Stanford University School of Medicine, Stanford, California
| | - Matthew J. Martin
- Division of Trauma and Acute Care Surgery, Department of Surgery, Los Angeles County and USC Medical Center, Los Angeles, California
| | | | - Holly K. Tabor
- Stanford Center for Biomedical Ethics, Department of Medicine, Stanford University, Stanford, California
| | - Sherry M. Wren
- Surgical Service, Palo Alto Veterans Health Care System, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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16
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Ewbank C, Derbew M, Ratnayake A, Gupta S, Hughes MC, Wren SM, Kushner AL. Global Surgery: The Road Less Traveled and How to Get Back on Track. World J Surg 2023; 47:1090-1091. [PMID: 36709216 DOI: 10.1007/s00268-023-06920-x] [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] [Accepted: 01/12/2023] [Indexed: 01/30/2023]
Affiliation(s)
- Clifton Ewbank
- Coast Surgical Group, 786 Third Ave, Chula Vista, CA, USA.
| | - Miliard Derbew
- Department of Surgery, Addis Ababa University, NBH1, 4Killo King George VI St, Addis Ababa, Ethiopia
| | - Amila Ratnayake
- Department of Surgery, Military Hospital Army, 08 Elvitigala Mawatha, Colombo, 00800, Sri Lanka
| | - Shailvi Gupta
- Department of Surgery, University of Maryland, 620 W Lexington St, Baltimore, MD, USA
| | - Melany C Hughes
- Department of Surgery, Stony Brook University, 100 Nicolls Rd, Stony Brook, NY, USA
| | - Sherry M Wren
- Department of Surgery, Stanford University, 780 Welch Rd, 3Rd Floor, Palo Alto, CA, USA
| | - Adam L Kushner
- Surgeons OverSeas, 99 Ave B, Suite 5E, New York, NY, 10009, USA
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17
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Wild H, Stewart BT, LeBoa C, Jewell T, Mehta K, Wren SM. Perioperative Risk Assessment in Humanitarian Settings: A Scoping Review. World J Surg 2023; 47:1092-1113. [PMID: 36631590 DOI: 10.1007/s00268-023-06893-x] [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] [Accepted: 12/25/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND No validated perioperative risk assessment models currently exist for use in humanitarian settings. To inform the development of a perioperative mortality risk assessment model applicable to humanitarian settings, we conducted a scoping review of the literature to identify reports that described perioperative risk assessment in surgical care in humanitarian settings and LMICs. METHODS We conducted a scoping review of the literature to identify records that described perioperative risk assessment in low-resource or humanitarian settings. Searches were conducted in databases including: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, World Health Organization Catalog, and Google Scholar. RESULTS Our search identified 1582 records. After title/abstract and full text screening, 50 reports remained eligible for analysis in quantitative and qualitative synthesis. These reports presented data from over 37 countries from public, NGO, and military facilities. Data reporting was highly inconsistent: fewer than half of reports presented the indication for surgery; less than 25% of reports presented data on injury severity or prehospital data. Most elements of perioperative risk models designed for high-resource settings (e.g., vital signs, laboratory data, and medical comorbidities) were unavailable. CONCLUSION At present, no perioperative mortality risk assessment model exists for use in humanitarian settings. Limitations in consistency and quality of data reporting are a primary barrier, however, can be addressed through data-driven identification of several key variables encompassed by a minimum dataset. The development of such a score is a critical step toward improving the quality of care provided to populations affected by conflict and protracted humanitarian crises.
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Affiliation(s)
- Hannah Wild
- Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA
- Global Injury Control Section, Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Christopher LeBoa
- Department of Environmental Health Sciences, University of California Berkeley, Berkeley, CA, USA
| | - Teresa Jewell
- Health Science Library, University of Washington, Seattle, WA, USA
| | - Kajal Mehta
- Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA
| | - Sherry M Wren
- Stanford University School of Medicine, Stanford, CA, USA
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18
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Mattingly AS, Eddington HS, Rose L, Morris AM, Trickey AW, Cullen MR, Wren SM. Defining Essential Surgery in the US During the COVID-19 Pandemic Response. JAMA Surg 2023; 158:99-100. [PMID: 36260330 PMCID: PMC9582959 DOI: 10.1001/jamasurg.2022.3944] [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: 01/14/2023]
Abstract
This cohort study compares the volume of performed surgical procedures classified as essential, urgent, and nonurgent before and after elective surgeries were restricted during the COVID-19 pandemic in the US.
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Affiliation(s)
| | - Hyrum S. Eddington
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California
| | - Liam Rose
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California,Economics Resource Center, Department of Veterans Affairs, Palo Alto, California
| | - Arden M. Morris
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California,Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California,Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California
| | - Mark R. Cullen
- Center for Population Health Sciences, Stanford Medicine, Stanford, California
| | - Sherry M. Wren
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California,Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California,Department of Surgery, Stanford University School of Medicine, Stanford, California
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19
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Wren SM, Wild H. Armed Conflicts Destroy Civilian Health Systems: Cancer Screening in Ukraine the Newest Casualty of World Conflict. World J Surg 2022; 46:2487-2488. [PMID: 35948827 DOI: 10.1007/s00268-022-06700-z] [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] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Sherry M Wren
- Department of Surgery, Stanford University School of Medicine Stanford, G112 3801 Miranda Avenue, Palo Alto, CA, USA.
| | - Hannah Wild
- Department of Surgery, University of Washington, Seattle, WA, USA
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20
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Bagshaw HP, Arnow KD, Trickey AW, Leppert JT, Wren SM, Morris AM. Assessment of Second Primary Cancer Risk Among Men Receiving Primary Radiotherapy vs Surgery for the Treatment of Prostate Cancer. JAMA Netw Open 2022; 5:e2223025. [PMID: 35900763 PMCID: PMC9335142 DOI: 10.1001/jamanetworkopen.2022.23025] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
IMPORTANCE Shared decision-making is an important part of the treatment selection process among patients with prostate cancer. Updated information is needed regarding the long-term incidence and risk of second primary cancer after radiotherapy vs nonradiotherapy treatments, which may help to inform discussions of risks and benefits for men diagnosed with prostate cancer. OBJECTIVE To assess the current incidence and risk of developing a second primary cancer after receipt of radiotherapy vs nonradiotherapy treatments for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the Veterans Affairs Corporate Data Warehouse to identify 154 514 male veterans 18 years and older who had localized prostate cancer (tumor stages T1-T3) diagnosed between January 1, 2000, and December 31, 2015, and no cancer history. A total of 10 628 patients were excluded because of (1) incomplete treatment information for the year after diagnosis, (2) receipt of both radiotherapy and a surgical procedure in the year after diagnosis, (3) receipt of radiotherapy more than 1 year after diagnosis, (4) occurrence of second primary cancer or death within 1 year or less after diagnosis, (5) prostate-specific antigen value greater than 99 ng/mL within 6 months before diagnosis, or (6) no recorded Veterans Health Administration service after diagnosis. The remaining 143 886 patients included in the study had a median (IQR) follow-up of 9 (6-13) years. Data were analyzed from May 1, 2021, to May 22, 2022. MAIN OUTCOMES AND MEASURES Diagnosis of a second primary cancer more than 1 year after prostate cancer diagnosis. RESULTS Among 143 886 male veterans (median [IQR] age, 65 [60-71] years) with localized prostate cancer, 750 (0.5%) were American Indian or Alaska Native, 389 (0.3%) were Asian, 37 796 (26.3%) were Black or African American, 933 (0.6%) were Native Hawaiian or other Pacific Islander, 91 091 (63.3%) were White, and 12 927 (9.0%) were of unknown race; 7299 patients (5.1%) were Hispanic or Latino, 128 796 (89.5%) were not Hispanic or Latino, and 7791 (5.4%) were of unknown ethnicity. A total of 52 886 patients (36.8%) received primary radiotherapy, and 91 000 (63.2%) did not. A second primary cancer more than 1 year after prostate cancer diagnosis was present in 4257 patients (3.0%), comprising 1955 patients (3.7%) in the radiotherapy cohort and 2302 patients (2.5%) in the nonradiotherapy cohort. In the multivariable analyses, patients in the radiotherapy cohort had a higher risk of second primary cancer compared with those in the nonradiotherapy cohort at years 1 to 5 after diagnosis (hazard ratio [HR], 1.24; 95% CI, 1.13-1.37; P < .001), with higher adjusted HRs in the subsequent 15 years (years 5-10: 1.50 [95% CI, 1.36-1.65; P < .001]; years 10-15: 1.59 [95% CI, 1.37-1.84; P < .001]; years 15-20: 1.47 [95% CI, 1.08-2.01; P = .02). CONCLUSIONS AND RELEVANCE In this cohort study, patients with prostate cancer who received radiotherapy were more likely to develop a second primary cancer than patients who did not receive radiotherapy, with increased risk over time. Although the incidence and risk of developing a second primary cancer were low, it is important to discuss the risk with patients during shared decision-making about prostate cancer treatment options.
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Affiliation(s)
- Hilary P. Bagshaw
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Katherine D. Arnow
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
| | - Amber W. Trickey
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
| | - John T. Leppert
- Department of Urology, Stanford University, Palo Alto, California
- Palo Alto Veterans Health Care System, Palo Alto, California
| | - Sherry M. Wren
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
- Palo Alto Veterans Health Care System, Palo Alto, California
| | - Arden M. Morris
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
- Palo Alto Veterans Health Care System, Palo Alto, California
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21
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Wong BO, Blythe JA, Wu A, Batten JN, Kennedy KM, Kouaho AS, Wren SM. Exploration of Clinician Perspectives on Multidisciplinary Tumor Board Function Beyond Clinical Decision-making. JAMA Oncol 2022; 8:1210-1212. [PMID: 35653129 DOI: 10.1001/jamaoncol.2022.1763] [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)
- Bonnie O Wong
- School of Medicine, Stanford University, Stanford, California
| | - Jacob A Blythe
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Adela Wu
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Jason N Batten
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | | | | | - Sherry M Wren
- Department of Surgery, Stanford University, Stanford, California
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22
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Reid T, Kincaid J, Shrestha R, Strassle PD, Maine R, Charles A, Gallaher J, Manjolo M, Gondwe J, Wren SM. Perceptions of Gender Disparities in Access to Surgical Care in Malawi: A Community Based Survey. Am Surg 2022:31348221101522. [PMID: 35592895 PMCID: PMC9743135 DOI: 10.1177/00031348221101522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gender disparities in surgical care exist but have been minimally studied, particularly in low- and middle-income countries. This study explored perceptions and gender differences in health-seeking behavior and attitudes toward surgical care in Malawi among community members. METHODS A survey tool was administered to adults ≥18 years old at a central hospital, district hospital, and two marketplaces in Malawi from June 2018 to December 2018. Responses from men and women were compared using chi-squared tests. RESULTS Four hundred eighty-five adults participated in the survey, 244 (50.3%) men and 241 (49.7%) women. Women were more likely to state that fear of surgery might prevent them from seeking surgical care (29.1% of men, 43.6% of women, P = .0009). Both genders reported long wait times, medicine/physician shortages, and lack of information about when surgery is needed as potential barriers to seeking surgical care. More men stated that medical preference should be given to sons (17.1% of men, 9.3% of women, P = .01). Men were more likely to report that men should have the final word about household decisions (28.7% of men vs 19.5% of women, P < .0001) and were more likely to spend money independently (68.7% of married men, 37.5% of married women, P < .0001). Few participants reported believing gender equality had been achieved (61% of men and 66.8% of women). CONCLUSIONS A multi-pronged approach is needed to reduce gender disparities in surgical care in Malawi, including addressing paternalistic societal norms, education, and improving health infrastructure.
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Affiliation(s)
- Trista Reid
- Department of Surgery, The University of North Carolina- Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer Kincaid
- Department of Surgery, Jefferson University, Philadelphia, PA, USA
| | - Riju Shrestha
- Gillings School of Global Public Health, The University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Paula D. Strassle
- Division of Intramural Research, National Institutes of Health, National Institute on Minority Health and Health Disparities, Bethesda, MD, USA
| | - Rebecca Maine
- Department of Surgery, The University of North Carolina- Chapel Hill, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, The University of North Carolina- Chapel Hill, Chapel Hill, NC, USA
| | - Jared Gallaher
- Department of Surgery, The University of North Carolina- Chapel Hill, Chapel Hill, NC, USA
| | - Mphatso Manjolo
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Jotham Gondwe
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Sherry M. Wren
- Department of Surgery, Stanford University, Stanford, CA, USA
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23
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Forrester JD, Wren SM. Effectiveness of emergency general surgery - some answers, more questions. Anaesthesia 2022; 77:851-853. [PMID: 35307814 DOI: 10.1111/anae.15719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/27/2022]
Affiliation(s)
- J D Forrester
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - S M Wren
- Department of Surgery, Stanford University, Stanford, CA, USA.,Palo Alto Veterans Healthcare System, Palo Alto, CA, USA
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24
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Liu C, Scannell CA, Kenison T, Wren SM, Saliba D. Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act. J Gen Intern Med 2022; 37:573-581. [PMID: 33959882 PMCID: PMC8101607 DOI: 10.1007/s11606-021-06807-4] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored. OBJECTIVE To evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA. DESIGN Using multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending. PARTICIPANTS Nationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey. INTERVENTION ACA implementation, January 1, 2014. MAIN MEASURES Likelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income. KEY RESULTS Among veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care. CONCLUSIONS ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.
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Affiliation(s)
- Charles Liu
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA.
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Christopher A Scannell
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Tiffany Kenison
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Health Administration, Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Debra Saliba
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Borun Center for Gerontological Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Abstract
This quality improvement study characterizes surgical oncology trials, analyzes growth, identifies associations with early discontinuation or results reporting, and evaluates proportions of trials involving each neoplasm site.
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Affiliation(s)
| | | | - Jolie Z. Shen
- University of Washington School of Medicine, Seattle
| | - Brandon E. Turner
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| | - Henry K. Litt
- Department of Medicine, University of California, San Francisco
| | - Amit Mahipal
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sherry M. Wren
- Department of Surgery, Stanford University, Stanford, California
- Palo Alto Veterans Health Care System, Palo Alto, California
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26
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Mattingly AS, Rose L, Eddington HS, Trickey AW, Cullen MR, Morris AM, Wren SM. Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic. JAMA Netw Open 2021; 4:e2138038. [PMID: 34878546 PMCID: PMC8655602 DOI: 10.1001/jamanetworkopen.2021.38038] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States. OBJECTIVE To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021. EXPOSURES 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19. MAIN OUTCOMES AND MEASURES Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications. RESULTS A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures among patients aged ≥65 years [30.2%]). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P < .001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P < .001) and cataract procedures (IRR, 0.11; 95% CI, -0.11 to 0.32; P = .03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P = .10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P < .001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r = -0.00025; 95% CI, -0.0042 to -0.0009; P = .003), but there was no correlation during the COVID-19 surge (r = -0.00034; 95% CI, -0.0075 to 0.00007; P = .11). CONCLUSIONS AND RELEVANCE This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.
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Affiliation(s)
| | - Liam Rose
- Health Economics Resource Center, Department of Veterans Affairs, Palo Alto, California
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford, California
| | - Hyrum S. Eddington
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford, California
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford, California
| | - Mark R. Cullen
- Stanford Center for Population Health Sciences, Stanford, California
| | - Arden M. Morris
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford, California
- Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Sherry M. Wren
- Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Ko A, Wren SM. Advances in Appropriate Postoperative Triage and the Role of Real-time Machine-Learning Models: The Goldilocks Dilemma. JAMA Netw Open 2021; 4:e2133843. [PMID: 34757414 DOI: 10.1001/jamanetworkopen.2021.33843] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ara Ko
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Sherry M Wren
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
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Chavez JC, Wren SM, Knowlton LM. Disparities in Outcomes after Emergency Surgery in the Rio Grande Valley of Texas. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.249] [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: 11/26/2022]
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Mlambo B, Shih IF, Li Y, Wren SM. The impact of operative approach on postoperative outcomes and healthcare utilization after colectomy. Surgery 2021; 171:320-327. [PMID: 34362589 DOI: 10.1016/j.surg.2021.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 03/16/2021] [Revised: 07/05/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND To evaluate national trends in adoption of different surgical approaches for colectomy and compare clinical outcomes and resource utilization between approaches. METHODS Retrospective study of patients aged ≥18 years who underwent elective inpatient left or right colectomy between 2010 and 2019 from the Premier Healthcare Database. Patients were classified by operative approach: open, minimally invasive: either laparoscopic or robotic. Postoperative outcomes assessed within index hospitalization include operating room time, hospital length of stay, rates of conversion to open surgery, reoperation, and complications. Post-discharge readmission, hospital-based encounters, and costs were collected to 30 days post-discharge. Multivariable regression models were used to compare outcomes between operative approaches adjusted for patient baseline characteristics and clustering within hospitals. RESULTS Among 206,967 patients, the robotic approach rates increased from 2.1%/1.6% (2010) to 32.6%/26.8% (2019) for left/right colectomy, offset by a decrease in both open and laparoscopic approaches. Median length of stay for both left and right colectomies was significantly longer in open (6 days) and laparoscopic (5 days) compared to robotic surgery (4 days; all P values <.001). Robotic surgery compared to open and laparoscopic was associated with a significantly lower conversion rate, development of ileus, overall complications, and 30-day hospital encounters. Robotic surgery further demonstrated lower mortality, reoperations, postoperative bleeding, and readmission rates for left and right colectomies than open. Robotic surgery had significantly longer operating room times and higher costs than either open or laparoscopic. CONCLUSIONS Robotic surgery is increasingly being used in colon surgery, with outcomes equivalent and in some domains superior to laparoscopic.
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Affiliation(s)
- Busisiwe Mlambo
- Department of Surgery, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Yanli Li
- Intuitive Surgical, Inc, Sunnyvale, CA
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.
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Kazaure HS, Truong T, Kuchibhatla M, Lagoo-Deenadayalan S, Wren SM, Johnson KS. Identifying high-risk surgical patients: A study of older adults whose code status changed to Do-Not-Resuscitate. J Am Geriatr Soc 2021; 69:3445-3456. [PMID: 34331702 DOI: 10.1111/jgs.17391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/02/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a paucity of data on older adults (age ≥65 years) undergoing surgery who had an inpatient do-not-resuscitate (DNR) order, and the association between timing of DNR order and outcomes. METHODS This was a retrospective analysis of 1976 older adults in the American College of Surgeons National Surgical Quality Improvement Program geriatric-specific database (2014-2018). Patients were stratified by institution of a DNR order during their surgical admission ("new-DNR" vs. "no-DNR"), and matched by age (±3 years), frailty score (range: 0-1), and procedure. The main outcome of interest was occurrence of death or hospice transition (DoH) ≤30 postoperative days; this was analyzed using bivariate and multivariable methods. RESULTS One in 36 older adults had a new-DNR order. After matching, there were 988 new-DNR and 988 no-DNR patients. Median age and frailty score were 82 years and 0.2, respectively. Most underwent orthopedic (47.6%), general (37.6%), and vascular procedures (8.4%). Overall DoH rate ≤30 days was 44.4% for new-DNR versus 4.0% for no-DNR patients (p < 0.001). DoH rate for patients who had DNR orders placed in the preoperative, day of surgery, and postoperative setting was 16.7%, 23.3%, and 64.6%, respectively (p < 0.001). In multivariable analysis, compared to no-DNR patients, those with a new-DNR order had a 28-fold higher adjusted odds of DoH (odds ratio [OR] 28.1, 95% confidence interval: 13.0-60.1, p < 0.001); however, odds were 10-fold lower if the DNR order was placed preoperatively (OR: 5.8, p = 0.003) versus postoperatively (OR: 52.9, p < 0.001). Traditional markers of poor postoperative outcomes such as American Society of Anesthesiologists class and emergency surgery were not independently associated with DoH. CONCLUSIONS An inpatient DNR order was associated with risk of DoH independent of traditional markers of poor surgical outcomes. Further research is needed to understand factors leading to a DNR order that may aid early recognition of high-risk older adults undergoing surgery.
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Affiliation(s)
- Hadiza S Kazaure
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Sandhya Lagoo-Deenadayalan
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, North Carolina, USA.,Department of Surgery, Durham VA Health Care System, Durham, North Carolina, USA.,Geriatrics Research Education and Clinical and Clinical Center, Durham, Virginia, USA
| | - Sherry M Wren
- Department of General Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kimberly S Johnson
- Department of Surgery, Durham VA Health Care System, Durham, North Carolina, USA.,Geriatrics Research Education and Clinical and Clinical Center, Durham, Virginia, USA.,Division of Geriatrics, Department of Medicine, Center for the Study of Aging and Human Development, Center for Palliative Care, Duke University School of Medicine, Durham, North Carolina, USA
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Mulenga M, Rhodes Z, Wren SM, Parikh PP. Local Staff Perceptions and Expectations of International Visitors in Global Surgery Rotations. JAMA Surg 2021; 156:980-982. [PMID: 34259805 DOI: 10.1001/jamasurg.2021.2861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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)
- Musunga Mulenga
- Department of Surgery, Wright State University, Dayton, Ohio
| | | | - Sherry M Wren
- Department of Surgery, Stanford University, Stanford, California
| | - Priti P Parikh
- Department of Surgery, Wright State University, Dayton, Ohio
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Wild H, Stewart BT, LeBoa C, Stave CD, Wren SM. Pediatric casualties in contemporary armed conflict: A systematic review to inform standardized reporting. Injury 2021; 52:1748-1756. [PMID: 34006405 DOI: 10.1016/j.injury.2021.04.055] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Children represent a significant percentage of casualties in modern conflict. Yet, the epidemiology of conflict-related injury among children is poorly understood. A comprehensive analysis of injuries sustained by children in 21st-century armed conflict is necessary to inform planning of local, military, and humanitarian health responses. METHODS We conducted a systematic search of databases including PubMed, Embase, Web of Science, World Health Organization Catalog, and Google Scholar to identify records that described conflict-related injuries sustained by children since 2001. RESULTS The search returned 5,264 records. 9 eligible reports without potentially duplicative data were included in analysis, representing 5,100 pediatric patients injured in 5 conflicts. Blast injury was the most frequent mechanism (57%), compared to 24.8% in adults. Mortality was only slightly higher among children (11.0% compared to 9.8% among adults; p <0.05). Non-uniform reporting prevented pooled analysis and limited the conclusions that could be drawn. CONCLUSIONS Children sustain a higher proportion of blast injury than adults in conflict. Existing data do support the conclusion that child casualties have higher mortality than adults overall; however, this difference is slighter than has been previously reported. Specific subpopulations of children appear to have worse outcomes. Overall, non-uniform reporting renders currently available data insufficient to understand the needs of children injured in modern conflict.
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Affiliation(s)
- Hannah Wild
- Department of Surgery, University of Washington, Seattle, WA USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA USA; Global Injury Control Section, Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | | | - Christopher D Stave
- Lane Medical Library, Stanford University School of Medicine, Stanford, CA, USA
| | - Sherry M Wren
- Stanford University School of Medicine, Stanford, CA, USA
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Perera ND, Turner BE, Shen JZ, Wong BO, Litt HK, Stavins MA, Bellomo TR, Saleki M, Bell A, Ionescu R, Shyu M, Wang MM, Tao J, Sarsour N, O'Keefe RM, Takasugi JM, Steinberg JR, King R, Mahipal A, Wren SM. The surgical oncology clinical trial landscape: A cross-sectional analysis of ClinicalTrials.gov from 2008-2020. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.1561] [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: 11/20/2022] Open
Abstract
1561 Background: Surgical interventions are studied less often than medical or radiation interventions in oncology clinical trials. We characterized surgical oncology trials registered on ClinicalTrials.gov, analyzed funding sources and identified features associated with early discontinuation and results reporting. Methods: We employed a cross-sectional study design with descriptive, logistic regression, cox regression, time series and survival analyses. We downloaded all 270,172 studies registered on the Aggregate Analysis of the ClinicalTrials.gov database from October 1, 2008 to March 9, 2020. After excluding non-interventional trials, applying cancer/oncology specific Medical Subject Heading terms to the remaining trials and excluding phase 1 trials, 27,915 trials were identified for manual review. Primary exposure variables were trial focus: neoplasia site and treatment modality (surgical interventions included investigations of outcomes from surgical resection or intra-operative/peri-operative changes), and funding: industry, U.S. government, academic. Results: 26,815 trials were found to have true oncology content; 1,661 (6.2%) involved surgical oncology, representing 311,789 patients. Funding sources were: 82.7% by academic institutions, 10.9% by industry, and 6.2% by U.S. government. The most studied neoplasia sites were colorectal (17.4% of trials), breast (10.7%), gastric (10.5%), hepatic (8.6%), lung (7.5%), brain/CNS (6.7%) and cervical (6.6%). U.S. government funded surgical oncology trials had the lowest risk of early discontinuation (adjusted HR 0.50, 95% CI: 0.26-0.99, p<0.047) and the highest odds of results reporting (adjusted OR 1.08, 95% CI: 0.55-2.11, p=0.83) (Table 1). Conclusions: There is a paucity of surgical oncology clinical trials compared to other treatment modalities, especially in context of surgery’s role in overall cancer care. From 2008-2020 only 6.2% of trials focused on surgical oncology, and U.S. government funded trials displayed the lowest hazard of early discontinuation and highest odds of results reporting. Stakeholders should look to government funded trials as models of improvement, but must increase representation and results dissemination of surgical oncology trials to guide treatment recommendations. Surgical oncology trial features and associated early discontinuation/results reporting. [Table: see text]
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Affiliation(s)
- Nirosha D. Perera
- School of Medicine, Stanford University, Stanford, CA, and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Brandon E. Turner
- Department of Radiation Oncology, Harvard Medical School, Boston, MA
| | - Jolie Z. Shen
- University of Washington School of Medicine, Seattle, WA
| | | | - Henry K. Litt
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | | | | | - Massoud Saleki
- School of Medicine, University of Washington, Seattle, WA
| | - Alexander Bell
- School of Medicine, University of California San Francisco, San Francisco, CA
| | | | - Margaret Shyu
- Department of Medicine, Mount Sinai Hospital, New York, NY
| | - Max M. Wang
- Medical Scientist Training Program, Northwestern University, Chicago, IL
| | - Jacqueline Tao
- School of Medicine, Stanford University, Stanford, CA, and Department of Medicine, New York-Presbyterian Weill Cornell, New York, NY
| | - Nadeen Sarsour
- School of Medicine, University of Michigan, Ann Arbor, MI
| | - Ryan M O'Keefe
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Jecca R. Steinberg
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Roderick King
- School of Medicine, Stanford University, Stanford, CA, and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Sherry M. Wren
- Department of General Surgery, Stanford University and Palo Alto Veterans Affairs Health Care System, Stanford, CA
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Affiliation(s)
- Liam Rose
- Health Economics Resource Center, Department of Veterans Affairs, Palo Alto, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California
| | | | - Arden M Morris
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California
- Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California
| | - Qian Ding
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California
| | - Sherry M Wren
- Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Liou DZ, Patel DC, Bhandari P, Wren SM, Marshall NJ, Harris AH, Shrager JB, Berry MF, Lui NS, Backhus LM. Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population. World J Surg 2021; 45:1706-1714. [PMID: 33598723 DOI: 10.1007/s00268-021-05979-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population. METHODS The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared. RESULTS A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c > 7, and 4.4% had serum albumin < 3. In the S4S2 group, 87.8% were smokers, 84.8% had HbA1c > 7, and 27.4% had albumin < 3. Major complications, reoperations, length of stay, and 30-day mortality increased progressively from S4S0 to S4S3 groups. S4S3 had the greatest adjusted mortality risk (adjusted odds radio [AOR] 2.56, p = 0.04) followed by S4S2 (AOR 1.58, p = 0.02) and S4S1 (AOR 1.34, p = 0.02). CONCLUSION In the VA population, patients who had all three S4S risk factors, namely active smoking, suboptimal nutritional status, and poor glycemic control, had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors.
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Affiliation(s)
- Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Deven C Patel
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Prasha Bhandari
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Sherry M Wren
- Department of Surgery, Stanford University, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | | | - Alex Hs Harris
- Department of Surgery, Stanford University, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Mark F Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Natalie S Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Leah M Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, USA.
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Azad AD, Charles AG, Ding Q, Trickey AW, Wren SM. Publisher Correction to: The gender gap and healthcare: associations between gender roles and factors affecting healthcare access in Central Malawi, June-August 2017. ACTA ACUST UNITED AC 2021; 79:19. [PMID: 33579368 PMCID: PMC7881664 DOI: 10.1186/s13690-021-00538-y] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Amee D Azad
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.
| | - Anthony G Charles
- University of North Carolina Department of Surgery, Chapel Hill, NC, USA
| | - Qian Ding
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, CA, USA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, CA, USA
| | - Sherry M Wren
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.,Palo Alto Veterans Healthcare System, Palo Alto, CA, USA
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Azad AD, Charles AG, Ding Q, Trickey AW, Wren SM. The gender gap and healthcare: associations between gender roles and factors affecting healthcare access in Central Malawi, June-August 2017. ACTA ACUST UNITED AC 2020; 78:119. [PMID: 33292511 PMCID: PMC7672876 DOI: 10.1186/s13690-020-00497-w] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 10/30/2020] [Indexed: 11/21/2022]
Abstract
Background Women in low and middle-income countries (LMICs) do not have equal access to resources, such as education, employment, or healthcare compared to men. We sought to explore health disparities and associations between gender prioritization, sociocultural factors, and household decision-making in Central Malawi. Methods From June–August 2017, a cross-sectional study with 200 participants was conducted in Central Malawi. We evaluated respondents’ access to care, prioritization within households, decision-making power, and gender equity which was measured using the Gender-Equitable Men (GEM) scale. Relationships between these outcomes and sociodemographic factors were analyzed using multivariable mixed-effect logistic regression. Results We found that women were less likely than men to secure community-sourced healthcare financial aid (68.6% vs. 88.8%, p < 0.001) and more likely to underutilize necessary healthcare (37.2% vs. 22.4%, p = 0.02). Both men and women revealed low GEM scores, indicating adherence to traditional gender norms, though women were significantly less equitable (W:16.77 vs. M:17.65, p = 0.03). Being a woman (Odds Ratio (OR) 0.41, 95% confidence interval (CI) 0.21–0.78) and prioritizing a woman as a decision-maker for large purchases (OR 0.38, CI 0.15–0.93) were independently associated with a lower likelihood of prioritizing women for medical treatment and being a member of the Chewa tribal group (OR 3.87, CI 1.83–8.18) and prioritizing women for education (OR 4.13, CI 2.13–8.01) was associated with a higher odds. Conclusion Women report greater barriers to healthcare and adhere to more traditional gender roles than men in this Central Malawian population. Women contribute to their own gender’s barriers to care and economic empowerment alone is not enough to correct for these socially constructed roles. We found that education and matriarchal societies may protect against gender disparities. Overall, internal and external gender discrimination contribute to a woman’s disproportionate lack of access to care. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-020-00497-w.
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Affiliation(s)
- Amee D Azad
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.
| | - Anthony G Charles
- University of North Carolina Department of Surgery, Chapel Hill, NC, USA
| | - Qian Ding
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, CA, USA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford, CA, USA
| | - Sherry M Wren
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.,Palo Alto Veterans Healthcare System, Palo Alto, CA, USA
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Rajasingh CM, Wren SM. Translating Outcomes Data Into Improved Shared Decision-Making in Patients With Left Ventricular Assist Devices. JAMA Netw Open 2020; 3:e2025673. [PMID: 33180126 DOI: 10.1001/jamanetworkopen.2020.25673] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, California
- Surgical Service, Palo Alto Veterans Health Care System, Palo Alto, California
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Wren SM, Wild HB, Gurney J, Amirtharajah M, Brown ZW, Bulger EM, Burkle FM, Elster EA, Forrester JD, Garber K, Gosselin RA, Groen RS, Hsin G, Joshipura M, Kushner AL, Norton I, Osmers I, Pagano H, Razek T, Sáenz-Terrazas JM, Schussler L, Stewart BT, Traboulsi AAR, Trelles M, Troke J, VanFosson CA, Wise PH. A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare. JAMA Surg 2020; 155:114-121. [PMID: 31722004 PMCID: PMC6865259 DOI: 10.1001/jamasurg.2019.4547] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Question What are consensus components of a framework for humanitarian surgical response in modern conflict zones? Findings This survey study using responses from 35 participants in the Stanford Humanitarian Surgical Response in Conflict Working Group suggests that humanitarian responses include both care of traumatic injury and emergency surgical needs of the population. Lessons from civilian and military trauma systems as well as humanitarian settings were translated into a tiered continuum of response from patient presentation through rehabilitation. Meaning Evidence suggests that modern trauma systems save lives but providing this standard of care in insecure conflict settings places new burdens on humanitarian systems; the framework presented herein integrates advances in surgical care to these environments. Importance Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures The working group’s method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.
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Affiliation(s)
- Sherry M Wren
- Stanford University School of Medicine, Stanford, California
| | - Hannah B Wild
- Stanford University School of Medicine, Stanford, California
| | - Jennifer Gurney
- US Army Institute of Surgical Research/Joint Trauma System, San Antonio, Texas
| | | | - Zachary W Brown
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle.,Committee on Trauma, American College of Surgeons, Chicago, Illinois
| | - Frederick M Burkle
- Harvard T. H. Chan School of Public Health, Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts
| | - Eric A Elster
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | | | - Kent Garber
- Department of Surgery, University of California, Los Angeles
| | | | - Reinou S Groen
- Department of Obstetrics and Gynecology, Alaska Native Medical Center, Anchorage
| | - Gary Hsin
- Stanford University School of Medicine, Stanford, California
| | | | - Adam L Kushner
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public health, Baltimore, Maryland
| | - Ian Norton
- Emergency Operations and Partnerships, Emergency Operations, World Health Organization, Geneva, Switzerland
| | - Inga Osmers
- Médecins Sans Frontières, Amsterdam, the Netherlands
| | | | - Tarek Razek
- Centre for Global Surgery, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | | - John Troke
- Samaritan's Purse, Boone, North Carolina
| | | | - Paul H Wise
- Stanford University School of Medicine, Stanford, California
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Lerman BJ, Popat RA, Assimes TL, Heidenreich PA, Wren SM. Association Between Heart Failure and Postoperative Mortality Among Patients Undergoing Ambulatory Noncardiac Surgery. JAMA Surg 2020; 154:907-914. [PMID: 31290953 DOI: 10.1001/jamasurg.2019.2110] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Heart failure is an established risk factor for postoperative mortality, but how heart failure is associated with operative outcomes specifically in the ambulatory surgical setting is not well characterized. Objective To assess the risk of postoperative mortality and complications in patients with vs without heart failure at various levels of echocardiographic (left ventricular systolic dysfunction) and clinical (symptoms) severity who were undergoing ambulatory surgery. Design, Setting, and Participants In this US multisite retrospective cohort study of all adult patients undergoing ambulatory, elective, noncardiac surgery in the Veterans Affairs Surgical Quality Improvement Project database during fiscal years 2009 to 2016, a total of 355 121 patient records were identified and analyzed with 1 year of follow-up after surgery (final date of follow-up September 1, 2017). Exposures Heart failure, left ventricular ejection fraction, and presence of signs or symptoms of heart failure within 30 days of surgery. Main Outcomes and Measures The primary outcomes were postoperative mortality at 90 days and any postoperative complication at 30 days. Results Among 355 121 total patients, outcome data from 19 353 patients with heart failure (5.5%; mean [SD] age, 67.9 [10.1] years; 18 841 [96.9%] male) and 334 768 patients without heart failure (94.5%; mean [SD] age, 57.2 [14.0] years; 301 198 [90.0%] male) were analyzed. Compared with patients without heart failure, patients with heart failure had a higher risk of 90-day postoperative mortality (crude mortality risk, 2.00% vs 0.39%; adjusted odds ratio [aOR], 1.95; 95% CI, 1.69-2.44), and risk of mortality progressively increased with decreasing systolic function. Compared with patients without heart failure, symptomatic patients with heart failure had a greater risk of mortality (crude mortality risk, 3.57%; aOR, 2.76; 95% CI, 2.07-3.70), as did asymptomatic patients with heart failure (crude mortality risk, 1.85%; aOR, 1.85; 95% CI, 1.60-2.15). Patients with heart failure had a higher risk of experiencing a 30-day postoperative complication than did patients without heart failure (crude risk, 5.65% vs 2.65%; aOR, 1.10; 95% CI, 1.02-1.19). Conclusions and Relevance In this study, among patients undergoing elective, ambulatory surgery, heart failure with or without symptoms was significantly associated with 90-day mortality and 30-day postoperative complications. These data may be helpful in preoperative discussions with patients with heart failure undergoing ambulatory surgery.
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Affiliation(s)
- Benjamin J Lerman
- Division of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Rita A Popat
- Division of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Themistocles L Assimes
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Section of Cardiology, Medical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Section of Cardiology, Medical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Sherry M Wren
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California
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Schussler L, Burkle FM, Wren SM. Protecting Surgeons and Patients During Wars and Armed Conflicts: Importance of Predeployment Training on the Geneva Conventions and International Humanitarian Law. JAMA Surg 2020; 154:683-684. [PMID: 31141147 DOI: 10.1001/jamasurg.2019.0041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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)
- Lilli Schussler
- Medical student, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Frederick M Burkle
- Harvard Humanitarian Initiative, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts.,Woodrow Wilson International Center for Scholars, Washington, DC
| | - Sherry M Wren
- Department of Surgery, Stanford University, Palo Alto, California
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Affiliation(s)
- Elizabeth L George
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Lerman BJ, Livingston EH, Wren SM. Optimizable Risk Factors Contributing to Mortality in Patients With Heart Failure Undergoing Noncardiac Surgery. JAMA Surg 2020; 155:530-531. [PMID: 32267503 DOI: 10.1001/jamasurg.2020.0257] [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)
- Benjamin J Lerman
- Department of Health Research and Policy (Division of Epidemiology), Stanford University School of Medicine, Stanford, California
| | | | - Sherry M Wren
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California
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Garber K, Kushner AL, Wren SM, Wise PH, Spiegel PB. Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway. Confl Health 2020; 14:5. [PMID: 32042308 PMCID: PMC7001520 DOI: 10.1186/s13031-019-0249-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016-July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts. METHODOLOGY A qualitative study design was used to examine the Mosul civilian trauma response. From August-December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified. RESULTS The Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system. CONCLUSIONS The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.
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Affiliation(s)
- Kent Garber
- 0000 0000 9632 6718grid.19006.3eDepartment of Surgery, University of California, Los Angeles, CA USA ,0000 0001 2171 9311grid.21107.35Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Adam L. Kushner
- 0000 0001 2171 9311grid.21107.35Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA ,Surgeons OverSeas, New York, NY USA
| | - Sherry M. Wren
- 0000000419368956grid.168010.eDepartment of Surgery, Stanford University, Palo Alto, CA USA
| | - Paul H. Wise
- 0000000419368956grid.168010.eDepartment of Pediatrics, School of Medicine, Stanford University, Stanford, CA USA
| | - Paul B. Spiegel
- 0000 0001 2171 9311grid.21107.35Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Wren SM, Kushner AL. The Realities of External Validity in Global Surgery Research-Reply. JAMA Surg 2020; 155:172-173. [PMID: 31642875 DOI: 10.1001/jamasurg.2019.4090] [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)
- Sherry M Wren
- Center for Global Health and Innovation, Stanford University School of Medicine, Palo Alto, California.,Clinical Surgery, Palo Alto Veterans Hospital, Palo Alto, California
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Wren SM, Schussler L, Burkle FM. Global Action Needed to Protect Humanitarian Surgeons and Patients During Wars and Armed Conflicts-Reply. JAMA Surg 2020; 155:90-91. [PMID: 31532473 DOI: 10.1001/jamasurg.2019.3501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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)
- Sherry M Wren
- Department of Surgery and Center for Global Health and Innovation, Stanford University, Stanford, California.,Palo Alto Veterans Hospital, Palo Alto, California
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Conway AA, Gerry JM, Sacco F, Wren SM. High Prevalence of Adenomatous Polyps in Alaska Native People Aged 40-49 years. J Surg Res 2019; 243:524-530. [PMID: 31377493 DOI: 10.1016/j.jss.2019.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 03/05/2019] [Revised: 06/02/2019] [Accepted: 07/03/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although colorectal cancer occurs earlier in life and at twice the frequency in Alaska Native (AN) people compared with the general population, the colorectal polyp burden in this group has not been quantified. In addition, an appropriate age for initial screening in ANs has not been defined. MATERIALS AND METHODS A retrospective chart review of 766 AN people who had screening colonoscopy from 2015 to 2016 was performed. The polyp burden in patients aged 40-49 y was compared with that in those aged 50-59 y in both the AN and the general US populations. RESULTS In total, 345 adenomas were removed: 121 (35%) from 40- to 49-year-olds and 224 (65%) from 50- to 59-year-olds. Twenty-six percent of AN people aged 40 y to 49 y and 40% of AN people aged 50 to 59 y had at least one adenoma. Low- and high-risk adenomas were significantly less frequent in the younger group (22% versus 29%, P = 0.048; 9.2% versus 15%, P = 0.035; respectively). Advanced adenomas were also less frequent in the younger group, although not statistically significant. Polyp histology, size, location, and morphology did not differ significantly between groups. CONCLUSIONS The adenoma and advanced adenoma prevalence in 40- to 49-year-old AN people is high, suggesting colorectal cancer screening should begin at age 40 y in ANs.
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Affiliation(s)
- Alison A Conway
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jon M Gerry
- Department of Surgery, Alaska Native Medical Center, Anchorage, Alaska
| | - Frank Sacco
- Department of Surgery, Alaska Native Medical Center, Anchorage, Alaska
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, California; Department of Surgery, Palo Alto Veterans Health Care System, Palo Alto, California.
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Mattingly AS, Lerman BJ, Popat R, Wren SM. Association of Sex With Postoperative Mortality Among Patients With Heart Failure Who Underwent Elective Noncardiac Operations. JAMA Netw Open 2019; 2:e1914420. [PMID: 31675085 PMCID: PMC6826642 DOI: 10.1001/jamanetworkopen.2019.14420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Sex differences in postoperative outcomes in patients with heart failure (HF) have not been well characterized. Women generally experience a lower postoperative mortality risk after noncardiac operations. It is unclear if this pattern holds among patients with HF. OBJECTIVES To determine if the risk of postoperative mortality is associated with sex among patients with HF who underwent noncardiac operations and to determine if sex is associated with the relationship between HF and postoperative mortality. DESIGN, SETTING, AND PARTICIPANTS This multisite cohort study used data from the US Department of Veterans Affairs Surgical Quality Improvement Project database for all patients who underwent elective noncardiac operations from October 1, 2009, to September 30, 2016, with a minimum of 1 year follow-up. The data analysis was conducted from May 1, 2018, to August 31, 2018. EXPOSURES Heart failure, left ventricular ejection fraction, and sex. MAIN OUTCOMES AND MEASURES Postoperative mortality at 90 days. RESULTS Among 609 735 patients who underwent elective noncardiac operations from 2009 to 2016, 47 997 patients had HF (7.9%; mean [SD] age, 68.6 [10.1] years; 1391 [2.9%] women) and 561 738 patients did not have HF (92.1%; mean [SD] age, 59.4 [13.4] years; 50 862 [9.1%] women). Among patients with HF, female sex was not independently associated with 90-day postoperative mortality (adjusted odds ratio [aOR], 0.97; 95% CI, 0.71-1.32). Although HF was associated with increased odds of postoperative mortality in both sexes compared with their peers without HF, the odds of postoperative mortality were higher among women with HF (aOR, 2.44; 95% CI, 1.73-3.45) than men with HF (aOR, 1.64; 95% CI, 1.54-1.74), suggesting that HF may negate the general protective association of female sex with postoperative mortality (P for interaction of HF × sex = .03). This pattern was consistent across all levels of left ventricular ejection fraction. CONCLUSIONS AND RELEVANCE Although HF was associated with increased odds of postoperative mortality in both sexes compared with their peers without HF, the odds of postoperative mortality were higher among women with HF than men with HF, suggesting that HF may negate the general protective association of female sex with postoperative mortality risk in noncardiac operations.
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Affiliation(s)
| | - Benjamin J. Lerman
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Rita Popat
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Sherry M. Wren
- Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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LeBrun DG, Del Rosario J, Kelly JD, Wren SM, Spiegel DA, Mkandawire N, Gosselin RA, Kushner AL. An Estimation of the Burden of Sports Injuries among African Adolescents. J Epidemiol Glob Health 2019; 8:171-175. [PMID: 30864759 PMCID: PMC7377560 DOI: 10.2991/j.jegh.2017.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/25/2017] [Indexed: 11/06/2022] Open
Abstract
The extent to which sports injuries contribute to the burden of injury among adolescents in low- and middle-income countries (LMICs) is unknown. The goal of this study was to estimate the incidence of sports injuries among adolescents in Africa. Data from the World Health Organization Global School-Based Student Health surveys were used to estimate the annual number of African adolescents sustaining sports injuries. Gender-stratified injury rates were calculated and applied to every African country’s adolescent population to estimate country-specific and continent-wide injury totals. A total of 21,858 males and 24,691 females from 14 countries were included in the analysis. Country-specific annual sports injury rates ranged from 13.5% to 38.1% in males and 5.2% to 20.2% in females. Weighted average sports injury rates for males and females were 23.7% (95% CI 23.1%–24.2%) and 12.5% (95% CI 12.1%–12.9%), respectively. When these rates were extrapolated to the adolescent populations of the African continent, an estimated 15,477,798 (95% CI 15,085,955–15,804,333) males and 7,943,625 (95% CI 7,689,429–8,197,821) females sustained sports injuries. Our findings suggest that over 23 million African adolescents sustained sports injuries annually. Further work will help to more precisely define the burden of sports injuries in LMICs and the role that surgery can play in mitigating this burden.
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Affiliation(s)
- Drake G LeBrun
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.,Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Jordan Medical Education Center, Philadelphia, PA 19104, USA
| | - Julius Del Rosario
- School of Engineering and Applied Science, University of Pennsylvania, 220 South 33rd Street, 107 Towne Building, Philadelphia, PA 19104, USA
| | - John D Kelly
- Division of Sports Medicine, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 235 S 33rd St, Philadelphia, PA 19104, USA
| | - Sherry M Wren
- Department of Surgery, Stanford University, School of Medicine, 300 Pasteur Dr, Stanford, CA 94305, USA
| | - David A Spiegel
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Nyengo Mkandawire
- Department of Orthopaedic Surgery, University of Malawi, College of Medicine, P/B 360, Chichiri, Blantyre 3, Malawi.,Flinders University School of Medicine, Sturt Rd, Bedford Park, South Australia 5042, Australia
| | - Richard A Gosselin
- Institute of Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Adam L Kushner
- Department of Surgery, Columbia University College of Physicians and Surgeons, 177 Fort Washington Ave., New York, NY 10032, USA.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA.,Surgeons OverSeas, 99 Avenue B, Suite 5E, New York, NY 10009, USA
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Affiliation(s)
- John T Leppert
- Department of Urology, Stanford University School of Medicine, CA; Veterans Affairs Palo Alto Health Care System, CA.
| | - Sherry M Wren
- Veterans Affairs Palo Alto Health Care System, CA; Department of Surgery, Stanford University School of Medicine, CA
| | - Jonathan Bergman
- David Geffen School of Medicine and Olive View-UCLA Medical Center, Sylmar, CA; Veterans Administration Greater Los Angeles Healthcare System, CA
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