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Gattozzi DA, Erginoglu U, Khanna O, Hosokawa PW, Martinez-Perez R, Baskaya MK, Youssef AS. Novel classification of foramen magnum meningiomas predicted by topographic position relative to neurovascular bundle. Acta Neurochir (Wien) 2024; 166:199. [PMID: 38687348 DOI: 10.1007/s00701-024-06091-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/13/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Proximity to critical neurovascular structures can create significant obstacles during surgical resection of foramen magnum meningiomas (FMMs) to the detriment of treatment outcomes. We propose a new classification that defines the tumor's relationship to neurovascular structures and assess correlation with postoperative outcomes. METHODS In this retrospective review, 41 consecutive patients underwent primary resection of FMMs through a far lateral approach. Groups defined based on tumor-neurovascular bundle configuration included Type 1, bundle ventral to tumor; Type 2a-c, bundle superior, inferior, or splayed, respectively; Type 3, bundle dorsal; and Type 4, nerves and/or vertebral artery encased by tumor. RESULTS The 41 patients (range 29-81 years old) had maximal tumor diameter averaging 30.1 mm (range 12.7-56 mm). Preoperatively, 17 (41%) patients had cranial nerve (CN) dysfunction, 12 (29%) had motor weakness and/or myelopathy, and 9 (22%) had sensory deficits. Tumor type was relevant to surgical outcomes: specifically, Type 4 demonstrated lower rates of gross total resection (65%) and worse immediate postoperative CN outcomes. Long-term findings showed Types 2, 3, and 4 demonstrated higher rates of permanent cranial neuropathy. Although patients with Type 4 tumors had overall higher ICU and hospital length of stay, there was no difference in tumor configuration and rates of postoperative complications or 30-day readmission. CONCLUSION The four main types of FMMs in this proposed classification reflected a gradual increase in surgical difficulty and worse outcomes. Further studies are warranted in larger cohorts to confirm its reliability in predicting postoperative outcomes and possibly directing management decisions.
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Affiliation(s)
- Domenico A Gattozzi
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
| | - Ufuk Erginoglu
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Omaditya Khanna
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
| | - Patrick W Hosokawa
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Mustafa K Baskaya
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - A Samy Youssef
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA.
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2
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Gergen AK, Hosokawa PW, Idrovo JP. Early Initiation of Parenteral Nutrition in Elderly Emergency General Surgery Patients. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.122] [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: 10/20/2022]
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3
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Hansen CK, Hosokawa PW, Mcintyre RC, McStay C, Ginde AA. A National Study of Emergency Thoracotomy for Trauma. J Emerg Trauma Shock 2021; 14:14-17. [PMID: 33911430 PMCID: PMC8054813 DOI: 10.4103/jets.jets_93_20] [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: 06/08/2020] [Revised: 09/17/2020] [Accepted: 11/24/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction: The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT). Methods: The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets. Results: The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215. Conclusion: Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers.
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Affiliation(s)
- Christopher K Hansen
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patrick W Hosokawa
- Adult and Child Center for Outcomes Research and Dissemination Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert C Mcintyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher McStay
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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4
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Zerd F, Moore BE, Malango AE, Hosokawa PW, Lillehei KO, Mchome LL, Ormond DR. Photomicrograph-Based Neuropathology Consultation in Tanzania. Am J Clin Pathol 2020; 154:656-670. [PMID: 32715312 DOI: 10.1093/ajcp/aqaa084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/12/2022] Open
Abstract
OBJECTIVES Since neuropathologic diagnosis in the developing world is hampered by limitations in technical infrastructure, trained laboratory personnel, and subspecialty-trained pathologists, the use of telepathology for diagnostic support, second-opinion consultations, and ongoing training holds promise as a means of addressing these challenges. This study aims to assess the utility of static teleneuropathology in improving neuropathologic diagnoses in low- and middle-income countries. METHODS Consecutive neurosurgical biopsy and resection specimens obtained at Muhimbili National Hospital in Tanzania between July 1, 2018, and June 30, 2019, were selected for retrospective, blinded static-image neuropathologic review followed by on-site review by an expert neuropathologist. RESULTS A total of 75 neuropathologic cases were reviewed. The agreement of static images and on-site glass diagnosis was 71% with strict criteria and 88% with less stringent criteria. This represents an overall improvement in diagnostic accuracy from 36% by general pathologists to 71% by a neuropathologist using static telepathology (or from 76% to 88% with less stringent criteria). CONCLUSIONS Telepathology offers a promising means of providing diagnostic support, second-opinion consultations, and ongoing training to pathologists practicing in resource-limited countries. Moreover, static digital teleneuropathology is an uncomplicated, cost-effective, and reliable way to achieve these goals.
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Affiliation(s)
- Francis Zerd
- Department of Pathology, Muhimbili National Hospital, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Brian E Moore
- Division of Neuropathology, Department of Pathology, Aurora
| | - Atuganile E Malango
- Department of Pathology, Muhimbili National Hospital, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Patrick W Hosokawa
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora
| | - Kevin O Lillehei
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora
| | | | - D Ryan Ormond
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora
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5
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Domen CH, Greher MR, Hosokawa PW, Barnes SL, Hoyt BD, Wodushek TR. Are Established Embedded Performance Validity Test Cut-Offs Generalizable to Patients With Multiple Sclerosis? Arch Clin Neuropsychol 2020; 35:511-516. [DOI: 10.1093/arclin/acaa016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 02/20/2019] [Accepted: 02/27/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
Data for the use of embedded performance validity tests (ePVTs) with multiple sclerosis (MS) patients are limited. The purpose of the current study was to determine whether ePVTs previously validated in other neurological samples perform similarly in an MS sample.
Methods
In this retrospective study, the prevalence of below-criterion responding at different cut-off scores was calculated for each ePVT of interest among patients with MS who passed a stand-alone PVT.
Results
Previously established PVT cut-offs generally demonstrated acceptable specificity when applied to our sample. However, the overall cognitive burden of the sample was limited relative to that observed in prior large-scale MS studies.
Conclusion
The current study provides initial data regarding the performance of select ePVTs among an MS sample. Results indicate most previously validated cut-offs avoid excessive false positive errors in a predominantly relapsing remitting MS sample. Further validation among MS patients with more advanced disease is warranted.
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Affiliation(s)
- Christopher H Domen
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael R Greher
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Sierra L Barnes
- Neurosciences, University of Colorado Health, Aurora, CO, USA
| | - Brian D Hoyt
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Thomas R Wodushek
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
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Harland TA, Wang M, Gunaydin D, Fringuello A, Freeman J, Hosokawa PW, Ormond DR. Frailty as a Predictor of Neurosurgical Outcomes in Brain Tumor Patients. World Neurosurg 2020; 133:e813-e818. [DOI: 10.1016/j.wneu.2019.10.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/02/2019] [Indexed: 01/27/2023]
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7
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Karsy M, Azab MA, Harper J, Abou-Al-Shaar H, Guan J, Eli I, Brock AA, Ormond RD, Hosokawa PW, Gouripeddi R, Butcher R, Cole CD, Menacho ST, Couldwell WT. Evaluation of a D-Dimer Protocol for Detection of Venous Thromboembolism. World Neurosurg 2019; 133:e774-e783. [PMID: 31605841 DOI: 10.1016/j.wneu.2019.09.160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/27/2019] [Accepted: 09/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of venous duplex ultrasonography (VDU) for confirmation of deep venous thrombosis in neurosurgical patients is costly and requires experienced personnel. We evaluated a protocol using D-dimer levels to screen for venous thromboembolism (VTE), defined as deep venous thrombosis and asymptomatic pulmonary embolism. METHODS We used a retrospective bioinformatics analysis to identify neurosurgical inpatients who had undergone a protocol assessing the serum D-dimer levels and had undergone a VDU study to evaluate for the presence of VTE from March 2008 through July 2017. The clinical risk factors and D-dimer levels were evaluated for the prediction of VTE. RESULTS In the 1918 patient encounters identified, the overall VTE detection rate was 28.7%. Using a receiver operating characteristic curve, an area under the curve of 0.58 was identified for all D-dimer values (P = 0.0001). A D-dimer level of ≥2.5 μg/mL on admission conferred a 30% greater relative risk of VTE (sensitivity, 0.43; specificity, 0.67; positive predictive value, 0.27; negative predictive value, 0.8). A D-dimer value of ≥3.5 μg/mL during hospitalization yielded a 28% greater relative risk of VTE (sensitivity, 0.73; specificity, 0.32; positive predictive value, 0.24; negative predictive value, 0.81). Multivariable logistic regression showed that age, male sex, length of stay, tumor or other neurological disease diagnosis, and D-dimer level ≥3.5 μg/mL during hospitalization were independent predictors of VTE. CONCLUSIONS The D-dimer protocol was beneficial in identifying VTE in a heterogeneous group of neurosurgical patients by prompting VDU evaluation for patients with a D-dimer values of ≥3.5 μg/mL during hospitalization. Refinement of this screening model is necessary to improve the identification of VTE in a practical and cost-effective manner.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Mohammed A Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan Harper
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA; Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Ilyas Eli
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrea A Brock
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Ryan D Ormond
- Department of Neurosurgery, University of Colorado, Aurora, Colorado, USA
| | - Patrick W Hosokawa
- Department of Neurosurgery, University of Colorado, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | | | - Ryan Butcher
- Department of Bioinformatics, University of Utah, Salt Lake City, Utah, USA
| | - Chad D Cole
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA
| | - Sarah T Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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8
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Chapman BC, Weyant M, Hilton S, Hosokawa PW, McCarter MD, Gleisner A, Nader ND, Gajdos C. Analysis of the National Cancer Database Esophageal Squamous Cell Carcinoma in the United States. Ann Thorac Surg 2019; 108:1535-1542. [PMID: 31302081 DOI: 10.1016/j.athoracsur.2019.05.053] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Esophageal squamous cell carcinoma (ESCC) has been poorly studied, approached with therapeutic nihilism, and likely undertreated. We studied the impact of clinical and patient factors on the survival of ESCC in the United States. METHODS We selected patients with stage I to III ESCC from 2004 to 2013, using the National Cancer Database. Patients were categorized into the following treatment modalities: (1) definitive chemoradiation therapy (CR), (2) neoadjuvant therapy followed by esophageal resection (ER), (3) ER alone, and (4) ER followed by adjuvant therapy. Our main outcome measure was overall survival. RESULTS We identified 11,229 patients with ESCC undergoing definitive CR (78.6%); neoadjuvant therapy followed by ER (8.5%), ER alone (10.1%), and ER followed by adjuvant therapy (2.6%). Compared with neoadjuvant therapy, both ER alone and definitive CR were associated with substantially increased mortality. Patients treated at high-volume centers (>20), regardless of whether they underwent ER, had improved survival compared with facilities that performed 10 to 19, 5 to 9, and less than 5 ERs per year. CONCLUSIONS Patients treated at high-volume facilities were more likely to receive neoadjuvant therapy, and there was a marked inverse relationship between annual surgical volume and long-term survival for both surgically and non-surgically treated patients with stage I to III ESCC.
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Affiliation(s)
- Brandon C Chapman
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Michael Weyant
- Department of Cardiothoracic Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Sarah Hilton
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Patrick W Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, Colorado
| | - Martin D McCarter
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Ana Gleisner
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Nader D Nader
- Department of Anesthesiology, University of New York at Buffalo, Buffalo, New York; Department of Surgery, University of New York at Buffalo, Buffalo, New York
| | - Csaba Gajdos
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado.
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9
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Thomas JF, Novins DK, Hosokawa PW, Olson CA, Hunter D, Brent AS, Frunzi G, Libby AM. The Use of Telepsychiatry to Provide Cost-Efficient Care During Pediatric Mental Health Emergencies. Psychiatr Serv 2018; 69:161-168. [PMID: 29032703 DOI: 10.1176/appi.ps.201700140] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [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] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study evaluated a videoconference-based psychiatric emergency consultation program (telepsychiatry) at geographically dispersed emergency department (ED) sites that are part of the network of care of an academic children's hospital system. The study compared program outcomes with those of usual care involving ambulance transport to the hospital for in-person psychiatric emergency consultation prior to disposition to inpatient care or discharge home. METHODS This study compared process outcomes in a cross-sectional, pre-post design at five network-of-care sites before and after systemwide implementation of telepsychiatry consultation in 2015. Clinical records on 494 pediatric psychiatric emergencies included ED length of stay, disposition/discharge, and hospital system charges. Satisfaction surveys regarding telepsychiatry consultations were completed by providers and parents or guardians. RESULTS Compared with children who received usual care, children who received telepsychiatry consultations had significantly shorter median ED lengths of stay (5.5 hours and 8.3 hours, respectively, p<.001) and lower total patient charges ($3,493 and $8,611, p<.001). Providers and patient caregivers reported high satisfaction with overall acceptability, effectiveness, and efficiency of telepsychiatry. No safety concerns were indicated based on readmissions within 72 hours in either treatment condition. CONCLUSIONS Measured by charges and time, telepsychiatry consultations for pediatric psychiatric emergencies were cost-efficient from a hospital system perspective compared with usual care consisting of ambulance transport for in-person consultation at a children's hospital main campus. Telepsychiatry also improved clinical and operational efficiency and patient and family experience, and it showed promise for increasing access to other specialized health care needs.
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Affiliation(s)
- John F Thomas
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
| | - Douglas K Novins
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
| | - Patrick W Hosokawa
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
| | - Christina A Olson
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
| | - Dru Hunter
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
| | - Alison S Brent
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
| | - Gerard Frunzi
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
| | - Anne M Libby
- Except for Ms. Hunter and Mr. Frunzi, the authors are with the University of Colorado School of Medicine, Aurora. Dr. Thomas and Dr. Novins are with the Department of Psychiatry, Mr. Hosokawa is with the Adult and Child Consortium for Outcomes Research and Dissemination Science, Dr. Olson and Dr. Brent are with the Department of Pediatrics, and Dr. Libby is with the Department of Emergency Medicine. Dr. Thomas and Dr. Olson are also with the Department of Telemedicine, where Ms. Hunter and Mr. Frunzi are affiliated, and Dr. Novins is also with the Pediatric Mental Health Institute, all at Children's Hospital Colorado, Aurora
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10
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Overbey DM, Glebova NO, Chapman BC, Hosokawa PW, Eun JC, Nehler MR. Morbidity of endovascular abdominal aortic aneurysm repair is directly related to diameter. J Vasc Surg 2017; 66:1037-1047.e7. [DOI: 10.1016/j.jvs.2017.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 01/31/2017] [Indexed: 02/05/2023]
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11
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Chapman BC, Weyant MJ, Hosokawa PW, Overbey DM, Hilton S, McCarter M, Gleisner A, Edil BH, Gajdos C. Current trends and survival in patients with esophageal squamous cell carcinoma: An analysis of the National Cancer Database from 2007 to 2013. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.4032] [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
4032 Background: Although surgical resection is the treatment of choice for patients with esophageal squamous cell carcinoma (ESCC), some evidence suggests that definitive chemoradiation (CR) may have equivalent survival compared to surgery alone. The objective of this study was to evaluate current trends in the treatment of ESCC and its impact on overall survival (OS). Methods: Using the NCDB (2004-2013), patients with non-metastatic/loco-regional ESCC were categorized into definitive CR, neoadjuvant CR/surgery, surgery alone, and surgery/adjuvant therapy. Multivariate Cox proportional hazard models by stepwise selection were applied to estimate hazard ratios (HR) of predictors of OS. Results: We identified 11,229 patients with ESCC undergoing definitive CR (n = 8855, 78.9%), neoadjuvant therapy/surgery (n = 953, 8.5%), surgery alone (n = 1130, 10.1%), and surgery/adjuvant therapy (n = 291, 2.6%). The distance of primary tumor from incisors was comparable for all four groups. On multivariable analysis, treatment modality had the largest impact on OS followed by AJCC stage, age and annual surgical volume. Compared to neoadjuvant therapy/surgery, both surgery only (HR 1.17, 95% CI 1.04-1.32) and definitive CR (HR 1.51, 95% CI 1.37-1.66) were associated with increased long-term mortality. However, there was no difference in mortality in the surgery/adjuvant therapy group (HR 1.10, 95% CI 0.94-1.30) compared to the neoadjuvant therapy/surgery group. Patients treated at facilities performing more than 20 esophagectomies per year, regardless of whether they underwent surgical resection, had improved OS compared to facilities performing 10-19 per year (HR 1.47, 95% CI 1.29-1.68), 5-9 per year (HR 1.44, 95% CI 1.29-1.62), and < 5 per year (HR 1.53, 95% CI 1.38-1.70). Conclusions: Patients receiving either neoadjuvant therapy or adjuvant therapy and esophagectomy for ESCC have improved OS compared to patients undergoing esophagectomy alone and definitive CR. These findings suggest that patients with ESCC should be considered for multimodality treatment at high-volume centers and surgery should be included in the treatment plan whenever possible.
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Affiliation(s)
| | | | - Patrick W Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, CO
| | | | - Sarah Hilton
- University of Colorado School of Medicine, Aurora, CO
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12
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Overbey DM, Cowan ML, Hosokawa PW, Chapman BC, Vogel JD. Laparoscopic colectomy in obese patients: a comparison of laparoscopic and hand-assisted laparoscopic techniques. Surg Endosc 2017; 31:3912-3921. [PMID: 28281115 DOI: 10.1007/s00464-017-5422-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 01/20/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP)-based evidence indicates that laparoscopic (LAP) colectomy results in improved outcomes compared to hand-assisted laparoscopic (HAL) colectomy in the general population. Previous comparative studies demonstrated that the HAL technique offers distinct advantages for obese patients. The aim of this study was to perform comparative analyses of HAL and LAP colectomy and low anterior resection (LAR) in obese patients. METHODS The ACS-NSQIP public use file and targeted colectomy dataset, 2012-2014, were utilized for patients undergoing colectomy and LAR. Only obese patients (BMI > 30) and laparoscopic or hand-assisted operations were included. Patient, operation, and outcome variables were compared in two separate cohorts: colectomy and LAR. Bivariate analysis compared the approaches, followed by multivariable regression. RESULTS Of 9610 obese patients included, HAL and LAP colectomy were performed in 3126 and 3793 patients and LAR in 1431 and 1260 patients, respectively. In comparison to LAP colectomy, HAL colectomy patients had increased comorbidities including class 2 and 3 obesity. HAL colectomy was associated with higher overall morbidity (20 vs. 16%, p < 0.001), infectious complications (10.2 vs. 7.7%, p < 0.001), anastomotic leaks (3.0 vs. 2.2%, p = 0.03), and ileus (11 vs. 8%, p < 0.001). Multivariate analysis indicated that overall morbidity (OR 1.27, 95% CI 1.11-1.44), infectious complications (OR 1.35, 95% CI 1.14-1.59), and ileus (OR 1.33, 95% CI 1.12-1.57) were each increased in the HAL colectomy cohort but not different for HAL and LAP LAR. CONCLUSIONS In comparison to LAP colectomy, the HAL technique is used more often in obese patients with an increased operative risk profile. While inherent bias and unmeasured variables limit the analysis, the available data indicate that the HAL technique is associated with increased perioperative morbidity. Alternatively, HAL and LAP LAR are performed in obese patients with a similar risk profile and result in similar postoperative outcomes.
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Affiliation(s)
- Douglas M Overbey
- Department of Surgery, University of Colorado, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA.,Department of Surgery, VA Eastern Colorado HealthCare System, Denver, CO, USA
| | - Michelle L Cowan
- Department of Surgery, University of Colorado, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA.,Department of Surgery, VA Eastern Colorado HealthCare System, Denver, CO, USA
| | - Patrick W Hosokawa
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO, USA
| | - Brandon C Chapman
- Department of Surgery, University of Colorado, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Jon D Vogel
- Department of Surgery, University of Colorado, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA.
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Lin Y, Meguid RA, Hosokawa PW, Henderson WG, Hammermeister KE, Schulick RD, Shelstad RC, Wild TT, McIntyre RC. An institutional analysis of unplanned return to the operating room to identify areas for quality improvement. Am J Surg 2016; 214:1-6. [PMID: 28057294 DOI: 10.1016/j.amjsurg.2016.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 07/30/2016] [Revised: 10/22/2016] [Accepted: 10/27/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Unplanned return to the operating room (uROR) has been suggested as a hospital quality indicator. The purpose of this study was to determine reasons for uROR to identify opportunities for patient care improvement. METHODS uROR reported by our institution's American College of Surgeons National Surgical Quality Improvement Program underwent secondary review. RESULTS The uROR rate reported by clinical reviewers was 4.3%. Secondary review re-categorized 64.7% as "true uROR" with the most common reasons for uROR being infection (30.9%) and bleeding (23.6%). Remaining cases were categorized as "false uROR" with the most common reasons being inadequate documentation (60.0%) and not directly related to index procedure (16.7%). CONCLUSIONS Strict adherence to NSQIP definitions results in misidentification of true uROR. This raises concerns for using NSQIP-identified uROR as a hospital quality metric. Improved processes of care to prevent infection and hemorrhage at our institution could reduce the rate of true uROR.
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Affiliation(s)
- Yihan Lin
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patrick W Hosokawa
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Karl E Hammermeister
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan C Shelstad
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Trevor T Wild
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert C McIntyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Chapman BC, Paniccia A, Hosokawa PW, Henderson WG, Overbey DM, Messersmith W, McCarter MD, Gleisner A, Edil BH, Schulick RD, Gajdos C. Impact of Facility Type and Surgical Volume on 10-Year Survival in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma. J Am Coll Surg 2016; 224:362-372. [PMID: 27923615 DOI: 10.1016/j.jamcollsurg.2016.11.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/18/2016] [Accepted: 11/22/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Previous studies have demonstrated improved in-hospital mortality after hepatic resection for hepatocellular carcinoma (HCC) at teaching hospitals. The objective of this study was to evaluate if resection of HCC at academic cancer programs (ACP) is associated with improved 10-year survival. STUDY DESIGN Using the National Cancer Data Base (NCDB) (1998 to 2011), we evaluated patients undergoing hepatic resection for HCC at ACPs, comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). High volume cancer programs (HVCPs) were defined as performing 10 or more hepatectomies per year. Multivariate Cox proportional hazard models by stepwise selection were applied to estimate hazard ratios (HR) of predictors of survival. The Kaplan-Meier method was used to generate survival curves at each facility type, and survival rates were compared using the log-rank test. RESULTS We identified 12,757 patients undergoing hepatic resection for HCC at ACPs (n = 8,404), CCPs (n = 483), and CCCPs (n = 3,870). Sixty-two percent (n = 5,191) of patients treated at ACPs were at high volume institutions compared with 11.6% (n = 446) and 0% of CCCPs and CCPs, respectively (p < 0.0001). On multivariable analysis, patients undergoing hepatic resection at transplant centers (p < 0.0001) and HVCPs had significantly improved survival (p < 0.0001). Adjusted 10-year survival rates were 28.7% at high volume ACPs, 28.2% at high volume CCCPs, 24.9% at low volume CCCPs, 25.1% at low volume ACPs, and 21.3% at CCPs (p ≤ 0.0001). CONCLUSIONS Patients undergoing hepatic resection for HCC at HVCPs had a significantly improved 10-year survival. Regionalization of HCC treatment to HVCPs may improve long-term survival.
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Affiliation(s)
- Brandon C Chapman
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Alessandro Paniccia
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Patrick W Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO
| | - William G Henderson
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO
| | - Douglas M Overbey
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Wells Messersmith
- Department of Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Barish H Edil
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Csaba Gajdos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO.
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Libby AM, Hosokawa PW, Fairclough DL, Prochazka AV, Jones PJ, Ginde AA. Grant Success for Early-Career Faculty in Patient-Oriented Research: Difference-in-Differences Evaluation of an Interdisciplinary Mentored Research Training Program. Acad Med 2016; 91:1666-1675. [PMID: 27332867 PMCID: PMC5177544 DOI: 10.1097/acm.0000000000001263] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
PURPOSE Since 2004, the Clinical Faculty Scholars Program (CFSP) at the University of Colorado Anschutz Medical Campus has provided intensive interdisciplinary mentoring and structured training for early-career clinical faculty from multiple disciplines conducting patient-oriented clinical and outcomes research. This study evaluated the two-year program's effects by comparing grant outcomes for CFSP participants and a matched comparison cohort of other junior faculty. METHOD Using 2000-2011 institutional grant and employment data, a cohort of 25 scholars was matched to a cohort of 125 comparison faculty (using time in rank and pre-period grant dollars awarded). A quasi-experimental difference-in-differences design was used to identify the CFSP effect on grant outcomes. Grant outcomes were measured by counts and dollars of grant proposals and awards as principal investigator. Outcomes were compared within cohorts over time (pre- vs. post-period) and across cohorts. RESULTS From pre- to post-period, mean annual counts and dollars of grant awards increased significantly for both cohorts, but mean annual dollars increased significantly more for the CFSP than for the comparison cohort (delta $83,427 vs. $27,343, P < .01). Mean annual counts of grant proposals also increased significantly more for the CFSP than for the comparison cohort: 0.42 to 2.34 (delta 1.91) versus 0.77 to 1.07 (delta 0.30), P < .01. CONCLUSIONS Institutional investment in mentored research training for junior faculty provided significant grant award gains that began after one year of CFSP participation and persisted over time. The CFSP is a financially sustainable program with effects that are predictable, significant, and enduring.
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Affiliation(s)
- Anne M Libby
- A.M. Libby is professor and vice chair for academic affairs, Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado. P.W. Hosokawa is senior professional research associate, Adult and Child Consortium for Outcomes Research and Dissemination Sciences (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado. D.L. Fairclough is professor, Department of Biostatistics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado. A.V. Prochazka is professor, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, and assistant chief, Research, Ambulatory Care, Denver Veterans Affairs, Denver, Colorado. P.J. Jones is clinical instructor, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. A.A. Ginde is associate professor, Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
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Overbey DM, Chapman BC, Hosokawa PW, Eun JC, Nehler MR. Morbidity of Endovascular Abdominal Aortic Aneurysm Repair Is Directly Influenced by Size but Remains Less Than in Open Repair. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.05.021] [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: 10/21/2022]
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Paniccia A, Hosokawa PW, Schulick RD, Henderson W, Kaplan J, Gajdos C. A matched-cohort analysis of 192 pancreatic anaplastic carcinomas and 960 pancreatic adenocarcinomas: A 13-year North American experience using the National Cancer Data Base (NCDB). Surgery 2016; 160:281-92. [PMID: 27085687 DOI: 10.1016/j.surg.2016.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 09/25/2015] [Revised: 01/15/2016] [Accepted: 02/03/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anaplastic pancreatic carcinoma (APC) is a rare and poorly characterized disease. We sought to compare the clinical characteristics and outcomes of APC to pancreatic adenocarcinoma (PDAC). METHODS The American National Cancer Data Base was queried for patients with resected APC and PDAC using histologic and operative codes. APC cases were matched 1:5 with PDACs based on age, sex, pathologic tumor stage, operative margin status, lymph node positivity ratio, and use of adjuvant chemotherapy. RESULTS After 1:5 matching, 192 APCs and 960 PDACs were analyzed. When comparing APC vs PDAC the median tumor size was 45 mm (interquartile range, 33-60) vs 30 mm (interquartile range, 23-40; P < .001), and metastatic nodal disease was present in 40.6% and 38.0% of the cases (P = .25), respectively. APC cases were distributed equally between the head and the body/tail region of the pancreas (50%), while PDAC cases were located mainly in the head of the pancreas (75%; P < .001). Although the resected APC group had a lesser survival during the first year after the diagnosis (51% vs 69%; P = .029), the overall survival was similar in the 2 groups, with 21.6% vs 17.4% alive at 5 years, respectively for APC and PDAC (P = .32). Subgroup analysis of patients with APC with (n = 18) versus those without (n = 80) osteoclastlike giant cells showed a greater 5-year survival (50% versus 15%, P < .001). CONCLUSION Patients with resected APC tend to present with large tumors equally distributed between the head and body/tail of the pancreas. While APC is thought to have a more aggressive biology, our matched analysis showed similar overall survival compared with PDAC. The presence of osteoclastlike giant cells portends a significantly better prognosis compared with other histologic features of APCs.
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Affiliation(s)
- Alessandro Paniccia
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Richard D Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Jeffrey Kaplan
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Csaba Gajdos
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO.
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Tsai AG, Felton S, Wadden TA, Hosokawa PW, Hill JO. A randomized clinical trial of a weight loss maintenance intervention in a primary care population. Obesity (Silver Spring) 2015; 23:2015-21. [PMID: 26334108 DOI: 10.1002/oby.21224] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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] [Received: 03/02/2015] [Revised: 06/16/2015] [Accepted: 06/19/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In-person weight loss maintenance visits have been shown to reduce weight regain after initial weight loss. This study examined, in a primary care population, whether in-person visits plus portion-controlled meals were more effective in reducing 12-month weight regain than mailed materials plus portion controlled meals. METHODS Study participants (n = 106) received 6 months of intensive behavioral treatment. Participants who completed this phase (n = 84) were then randomized to continue monthly in-person visits for weight loss maintenance as well as telephone calls between visits ("intensified maintenance") or to receive materials by mail ("standard maintenance"). All participants had access to subsidized portion-controlled foods during the 6-month run-in and the 12 months of maintenance. The primary outcome was weight change during the 12 months after randomization. RESULTS During months 0-12 after randomization, individuals assigned to standard maintenance regained 5.3% ± 0.8% of body weight, while those assigned to intensified maintenance regained 1.6% ± 1.2% of body weight. The difference between groups (3.7% ± 1.4%) was statistically significant (P = 0.01). CONCLUSIONS In a primary care population, continued in-person visits during the weight loss maintenance phase led to greater weight loss than contact by mail.
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Affiliation(s)
- Adam G Tsai
- Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
- Anschutz Health and Wellness Center, University of Colorado, Aurora, Colorado, USA
| | - Sue Felton
- Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
- Anschutz Health and Wellness Center, University of Colorado, Aurora, Colorado, USA
| | - Thomas A Wadden
- Center for Weight and Eating Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick W Hosokawa
- Colorado Health Outcomes Program, University of Colorado, Aurora, Colorado, USA
| | - James O Hill
- Anschutz Health and Wellness Center, University of Colorado, Aurora, Colorado, USA
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Norton WE, Hosokawa PW, Henderson WG, Volckmann ET, Pell J, Tomeh MG, Glasgow RE, Min SJ, Neumayer LA, Hawn MT. Acceptability of the decision support for safer surgery tool. Am J Surg 2014; 209:977-84. [PMID: 25457241 DOI: 10.1016/j.amjsurg.2014.06.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/04/2014] [Accepted: 06/09/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events. METHODS The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests. RESULTS During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably. CONCLUSION The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.
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Affiliation(s)
- Wynne E Norton
- Department of Health Behavior, University of Alabama at Birmingham School of Public Health, 1665 University Boulevard, Birmingham, AL 35294, USA.
| | - Patrick W Hosokawa
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Health Outcomes Program, University of Colorado Denver, Denver, CO, USA
| | - William G Henderson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Health Outcomes Program, University of Colorado Denver, Denver, CO, USA
| | - Eric T Volckmann
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Joyce Pell
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Robert E Glasgow
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Sung-Joon Min
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Health Outcomes Program, University of Colorado Denver, Denver, CO, USA
| | - Leigh A Neumayer
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Mary T Hawn
- Department of Surgery, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294, USA
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Linnebur SA, Vande Griend JP, Metz KR, Hosokawa PW, Hirsch JD, Libby AM. Patient-level medication regimen complexity in older adults with depression. Clin Ther 2014; 36:1538-1546.e1. [PMID: 25456562 DOI: 10.1016/j.clinthera.2014.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [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: 07/29/2014] [Revised: 10/06/2014] [Accepted: 10/06/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE Polypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity. METHODS A sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained. FINDINGS The cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7-8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing. IMPLICATIONS As expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient's entire regimen for opportunities to reduce complexity and improve ease of self-care.
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Affiliation(s)
- Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado.
| | - Joseph P Vande Griend
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Kelli R Metz
- Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Patrick W Hosokawa
- Colorado Health Outcomes Program, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jan D Hirsch
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California; Veterans Affairs of San Diego Healthcare System, San Diego, California
| | - Anne M Libby
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado; Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
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Hirsch JD, Metz KR, Hosokawa PW, Libby AM. Validation of a patient-level medication regimen complexity index as a possible tool to identify patients for medication therapy management intervention. Pharmacotherapy 2014; 34:826-35. [PMID: 24947636 PMCID: PMC4260116 DOI: 10.1002/phar.1452] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [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] [Indexed: 11/13/2022]
Abstract
Background The Medication Regimen Complexity Index (MRCI) is a 65-item instrument that can be used to quantify medication regimen complexity at the patient level, capturing all prescribed and over-the-counter medications. Although the MRCI has been used in several studies, the narrow scope of the initial validation limits application at a population or clinical practice level. Purpose To conduct a MRCI validation pertinent to the desired clinical use to identify patients for medication therapy management interventions. Methods An expert panel of clinical pharmacists ranked medication regimen complexity for two samples of cases: a single-disease cohort (diabetes mellitus) and a multiple-disease cohort (diabetes mellitus, hypertension, human immunodeficiency virus infection, geriatric depression). Cases for expert panel review were selected from 400 ambulatory clinic patients, and each case description included data that were available via claims or electronic medical records (EMRs). Construct validity was assessed using patient-level MRCI scores, medication count, and additional patient data. Concordance was evaluated using weighted κ agreement statistic, and correlations were determined using Spearman rank-order correlation coefficient (ρ) or Kendall τ. Results Moderate to good concordance between patient-level MRCI scores and expert medication regimen complexity ranking was observed (claims data, consensus ranking: single-disease cohort 0.55, multiple disease cohort 0.63). In contrast, only fair to moderate concordance was observed for medication count (single-disease cohort 0.33, multiple-disease cohort 0.48). Adding more-detailed administration directions from EMR data did not improve concordance. MRCI convergent validity was supported by strong correlations with medication count (all cohorts 0.90) and moderate correlations with morbidity measures (e.g., all cohorts; number of comorbidities 0.46, Chronic Disease Score 0.46). Nonsignificant correlation of MRCI scores with age and gender (all cohorts 0.08 and 0.06, respectively) supported MRCI divergent validity. Limitations This study used cross-sectional, retrospective patient data for a small number of patients and clinical pharmacists from only two universities; therefore, results may have limited generalizability. Conclusions The patient-level MRCI is a valid tool for assessing medication regimen complexity that can be applied by using data commonly found in claims and EMR databases and could be useful to identify patients who may benefit from medication therapy management.
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Affiliation(s)
- Jan D Hirsch
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California; Veterans Affairs of San Diego Healthcare System, San Diego, California
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Abstract
BACKGROUND Patients with HIV often have multiple medications besides antiretrovirals (ARV). Medication regimen complexity-formulations, dosing frequencies, and additional directions-expands pill burden by considering self-care demands. Studies show an inverse association between ARV adherence and medication complexity for ARVs only. Patient-level medication regimen complexity beyond ARV complexity is unknown. OBJECTIVE To measure and characterize Patient-level Medication Regimen Complexity Index (pMRCI) and Antiretroviral Medication Regimen Complexity Index (ARCI) for patients in 2 HIV clinics. We hypothesized that an all-medication complexity metric will exceed disease-state-defined complexity metrics; for ARVs only, the pMRCI score will be smaller than the ARCI score by capturing fewer features of regimens. Associations between complexity and adherence were not assessed. METHOD Electronic records supplied a retrospective, random sample of adult patients with HIV; medication lists were used to code the pMRCI (n=200). A random subsample (n=66) was coded using ARCI for ARV regimens only. RESULT Medication counts ranged from 1 to 27; pMRCI scores ranged from 2 to 67.5. ARVs contributed roughly 25% to the pMRCI; other prescriptions contributed about 66%. Dosing frequency made the largest contribution of all components (62%) to the pMRCI. For ARVs, pMRCI and ARCI scores did not differ statistically. CONCLUSION Unique dosing frequencies raised complexity and may provide opportunities for intervention. Other prescriptions drove pMRCI scores, suggesting that HIV management programs should review all medications. A patient-level approach added value to understanding the role of medications in patient complexity; future work can assess association of pMRCI with adherence and patient outcomes.
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Affiliation(s)
- Kelli R Metz
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Douglas N Fish
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | | | - Jan D Hirsch
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, CA, USA
| | - Anne M Libby
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Glasgow RE, Hawn MT, Hosokawa PW, Henderson WG, Min SJ, Richman JS, Tomeh MG, Campbell D, Neumayer LA. Comparison of prospective risk estimates for postoperative complications: human vs computer model. J Am Coll Surg 2013; 218:237-45.e1-4. [PMID: 24440066 DOI: 10.1016/j.jamcollsurg.2013.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [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: 08/01/2013] [Revised: 10/23/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk. STUDY DESIGN This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes. RESULTS The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity. CONCLUSIONS Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications.
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Affiliation(s)
| | - Mary T Hawn
- Department of Surgery, University of Alabama, Birmingham, AL
| | | | | | - Sung-Joon Min
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Majed G Tomeh
- University of Colorado Health Outcomes Program, Aurora, CO
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Schilling LM, Kwan BM, Drolshagen CT, Hosokawa PW, Brandt E, Pace WD, Uhrich C, Kamerick M, Bunting A, Payne PRO, Stephens WE, George JM, Vance M, Giacomini K, Braddy J, Green MK, Kahn MG. Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) Technology Infrastructure for a Distributed Data Network. EGEMS (Wash DC) 2013; 1:1027. [PMID: 25848567 PMCID: PMC4371513 DOI: 10.13063/2327-9214.1027] [Citation(s) in RCA: 22] [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] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction: Distributed Data Networks (DDNs) offer infrastructure solutions for sharing electronic health data from across disparate data sources to support comparative effectiveness research. Data sharing mechanisms must address technical and governance concerns stemming from network security and data disclosure laws and best practices, such as HIPAA. Methods: The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) deploys TRIAD grid technology, a common data model, detailed technical documentation, and custom software for data harmonization to facilitate data sharing in collaboration with stakeholders in the care of safety net populations. Data sharing partners host TRIAD grid nodes containing harmonized clinical data within their internal or hosted network environments. Authorized users can use a central web-based query system to request analytic data sets. Discussion: SAFTINet DDN infrastructure achieved a number of data sharing objectives, including scalable and sustainable systems for ensuring harmonized data structures and terminologies and secure distributed queries. Initial implementation challenges were resolved through iterative discussions, development and implementation of technical documentation, governance, and technology solutions.
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Libby AM, Fish DN, Hosokawa PW, Linnebur SA, Metz KR, Nair KV, Saseen JJ, Vande Griend JP, Vu SP, Hirsch JD. Patient-Level Medication Regimen Complexity Across Populations With Chronic Disease. Clin Ther 2013; 35:385-398.e1. [PMID: 23541707 DOI: 10.1016/j.clinthera.2013.02.019] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/19/2013] [Accepted: 02/21/2013] [Indexed: 01/01/2023]
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Richman JS, Hosokawa PW, Min SJ, Tomeh MG, Neumayer L, Campbell DA, Henderson WG, Hawn MT. Toward prospective identification of high-risk surgical patients. Am Surg 2012; 78:755-760. [PMID: 22748533] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: "low" risk corresponding to the bottom quartile, "average" to the middle two quartiles, and "high" to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of "high-risk" patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.
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Affiliation(s)
- Joshua S Richman
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama 35222, USA.
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Richman JS, Hosokawa PW, Min SJ, Tomeh MG, Neumayer L, Campbell DA, Henderson WG, Hawn MT. Toward Prospective Identification of High-Risk Surgical Patients. Am Surg 2012. [DOI: 10.1177/000313481207800713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: “low” risk corresponding to the bottom quartile, “average” to the middle two quartiles, and “high” to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of “high-risk” patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.
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Affiliation(s)
- Joshua S. Richman
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
- Division of General Surgery, Gastrointestinal Section, University of Alabama School of Medicine, Birmingham, Alabama
| | - Patrick W. Hosokawa
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
| | - Sung-Joon Min
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
| | | | | | | | - William G. Henderson
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
- Department of Biostatistics & Informatics, School of Public Health, University of Colorado Denver, Denver, Colorado
| | - Mary T. Hawn
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
- Division of General Surgery, Gastrointestinal Section, University of Alabama School of Medicine, Birmingham, Alabama
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Mullen JT, Davenport DL, Hutter MM, Hosokawa PW, Henderson WG, Khuri SF, Moorman DW. Impact of body mass index on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. Ann Surg Oncol 2008; 15:2164-72. [PMID: 18548313 DOI: 10.1245/s10434-008-9990-2] [Citation(s) in RCA: 256] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 05/05/2008] [Accepted: 05/06/2008] [Indexed: 01/27/2023]
Abstract
BACKGROUND Obesity is an increasingly common serious chronic health condition. We sought to determine the impact of body mass index (BMI) on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. METHODS A prospective, multi-institutional, risk-adjusted cohort study of patients undergoing major intra-abdominal cancer surgery was performed from the 14 university hospitals participating in the Patient Safety in Surgery Study of the National Surgical Quality Improvement Program (NSQIP). Demographic, clinical, and intraoperative variables and 30-day morbidity and mortality were prospectively collected in standardized fashion. Analysis of variance, Bonferroni multiple comparisons of means tests, and multivariable logistic regression analysis were performed. RESULTS We identified 2258 patients who underwent esophagectomy (n = 29), gastrectomy (n = 223), hepatectomy (n = 554), pancreatectomy (n = 699), or low anterior resection/proctectomy (n = 753). Patients were stratified by National Institutes of Health (NIH)-defined BMI obesity class, with 573 (25.4%) patients classified as obese (BMI > 30 kg/m(2)). There were no differences in mean work relative value units, total time of operation, or length of stay amongst the BMI classes. After adjusting for other risk factors, obesity was not a risk factor for death or major complications but was a risk factor for wound complications. The risk of postoperative death was greatest in underweight patients (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.7-16.2). CONCLUSION In patients undergoing major intra-abdominal cancer surgery, obesity is not a risk factor for postoperative mortality or major complications. Importantly, underweight patients have a fivefold increased risk of postoperative mortality, perhaps a consequence of their underlying nutritional status.
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Affiliation(s)
- John T Mullen
- Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Stoneman 912, Boston, MA 02215, USA.
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Kelz RR, Freeman KM, Hosokawa PW, Asch DA, Spitz FR, Moskowitz M, Henderson WG, Mitchell ME, Itani KMF. Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Ann Surg 2008; 247:544-52. [PMID: 18376202 DOI: 10.1097/sla.0b013e31815d7434] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To examine the association between surgical start time and morbidity and mortality for nonemergent procedures. SUMMARY BACKGROUND DATA Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined. METHODS We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000-2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity. RESULTS Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P < or = 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P < or = 0.005). CONCLUSIONS When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine "business" hours within the VA System may face an elevated risk of complications that warrants further evaluation.
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Affiliation(s)
- Rachel R Kelz
- Department of Surgery, Philadelphia VA Medical Center, Philadelphia, PA, USA.
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