Publications by authors named "Aaron Spaulding"

104 Publications

Treatment Contraindications Based on Comorbidity Status in Patients With Melanoma in the United States.

Anticancer Res 2021 Apr;41(4):2067-2070

Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, U.S.A.;

Background/aim: Melanoma incidence has increased in the United States over the past few decades, and disparities in patient treatment have been described. Although most patients with melanoma are good candidates for curative treatment, some are considered poor candidates for treatment because of comorbid conditions. We examined whether patient demographics influence treatment contraindication in melanoma.

Patients And Methods: The National Cancer Database (NCDB) was used to identify patients with melanoma from 2004 through 2015. Multivariate logistic regression was used to determine independent associations, adjusted for confounders. We excluded patients who did not receive treatment for reasons and patients with unknown treatment status.

Results: A total of 499,092 patients met the inclusion criteria. Of these, 525 (0.1%) had Treatment contraindicated because of comorbid conditions (TCBC) and 498,567 (99.9%) received treatment. Multivariate logistic regression showed higher odds of TCBC in patients with government insurance (OR=1.34, 95%CI=03-1.73; p=0.03) and patients without insurance (OR=2.75, 95%CI=1.76-4.29; p<0.001) than patients with private insurance.

Conclusion: Demographic disparities affects treatment decision in oncological patients. Our study demonstrated a significantly higher likelihood of "nontreatment because of comorbid conditions" among melanoma patients with government insurance or without insurance. Greater efforts are needed to address inequalities in melanoma treatment in the United States.
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http://dx.doi.org/10.21873/anticanres.14976DOI Listing
April 2021

Permanent stoma: a quality outcome in treatment of rectal cancer and its impact on length of stay.

BMC Surg 2021 Mar 25;21(1):163. Epub 2021 Mar 25.

Division of Colon and Rectal Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.

Background: This study aimed to identify socioeconomic predictors of permanent stoma in rectal cancer treatment and examine its association with length of stay at the treatment facility.

Methods: Rectal cancer patients who underwent elective surgery between January 2015 and December 2018 were identified from the Agency for Health Care Administration Florida Hospital Inpatient Discharge Dataset. Multivariate regression models were utilized to identify demographic and socioeconomic factors associated with receiving a permanent stoma as well as the associated length of stay of these patients.

Results: Of 2630 rectal cancer patients who underwent surgery for rectal cancer, 21% had a permanent stoma. The odds of receiving permanent stoma increased with higher Elixhauser score, metastatic disease, advanced age, having open surgery, residence in Southwest Florida, and having Medicaid insurance or no insurance/self-payers (p < 0.05). Patients with a permanent stoma had a significantly extended stay after surgery (p < 0.001).

Conclusions: Patients with a permanent stoma following cancer resection were more likely to have open surgery, had more comorbidities, and had a longer length of stay. Having permanent stoma was higher in patients living in South West Florida, patients with Medicaid insurance, and in the uninsured. Additionally, the payer type significantly affected the length of stay.
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http://dx.doi.org/10.1186/s12893-021-01166-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993534PMC
March 2021

Reducing Blood Loss by Changing to Small Volume Tubes for Laboratory Testing.

Mayo Clin Proc Innov Qual Outcomes 2021 Feb 19;5(1):72-83. Epub 2020 Nov 19.

Department of Transplant, Mayo Clinic, Jacksonville, FL.

Objective: To reduce diagnostic blood loss by using small volume tubes for routine laboratory testing throughout the hospital, as blood loss from laboratory testing can be substantial for patients and may lead to hospital-acquired anemia.

Patients And Methods: Diagnostic blood loss was evaluated in hospitalized patients between April 1, 2017, and June 1, 2018. The preintervention, during intervention, and postintervention mean diagnostic blood loss per hospitalized patient was compared across the floors and for each type of tube for hematology, basic metabolic panel, and coagulation tests. Mean hemoglobin levels, blood transfusions per hospitalized patient, and percent redraws were also compared.

Results: The total volume of blood drawn for all the 3 tests decreased across each implementation phase; however, only patients admitted to the transplant and critical care (T/CC) units had increased hemoglobin levels. In addition, there was a significant reduction in transfusions across implementation phases. The incidence risk ratio for transfusion reduced even more in patients admitted to the T/CC units. Finally, there was no significant difference in the overall percent redraws across all the units.

Conclusion: The use of small volume tubes in exchange for standard sized tubes markedly decreased diagnostic blood loss by 25.7% in all the units and 22.9% in the T/CC units. Also, the number of transfusions decreased across units, with the greatest decrease in the T/CC units. An increase in mean hemoglobin levels was observed specifically in patients admitted to the T/CC units, with no corresponding change in percent redraws across all the units.
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http://dx.doi.org/10.1016/j.mayocpiqo.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930757PMC
February 2021

Choosing and Using Patient-Reported Outcome Measures in Clinical Practice.

Arch Phys Med Rehabil 2021 Mar 10. Epub 2021 Mar 10.

Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.

The increasing use of patient-reported outcome (PRO) measures is forcing clinicians and health care systems to decide which to select and how to incorporate them into their records and clinical workflows. This overview addresses three topics related to these concerns. First, a literature review summarizes key psychometric and practical factors (such as reliability, responsiveness, computer adaptive testing, and interpretability) in choosing PROs for clinical practice. Second, three clinical decision support (CDS) issues are highlighted: gathering PROs, electronic health record impact on providers, and incorporating PROs into CDS design and implementation. Lastly, the salience of cross-cutting domains as well as nine key pragmatic decisions are reviewed. Cross-cutting domains are those that are relevant across most medical and mental health conditions, such as the SPADE symptom pentad (sleep problems, pain, anxiety, depression, and low energy/fatigue) and physical functioning. The nine pragmatic decisions include: 1) generic vs. disease-specific scales; 2) single- vs. multi-domain scales; 3) universal scales vs. user-choice selection; 4) number of domains to measure; 5) prioritization of domains when multiple domains are assessed; 6) action thresholds; 7) clinical purpose (screening vs. monitoring); as well as the 8) frequency and 9) logistical aspects of PRO administration.
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http://dx.doi.org/10.1016/j.apmr.2020.12.033DOI Listing
March 2021

Race to the Top of the Hospital Value-Based Purchasing Program.

J Healthc Manag 2021 Mar-Apr 01;66(2):95-108

Department of Health Management and Informatics, University of Central Florida, Orlando.

Executive Summary: Medicare's Hospital Valued-Based Purchasing (HVBP) program measures hospitals' total performance score (TPS); its measurement strategies have changed regularly since its rollout in 2013. Because the program influences care delivery, it is important to examine how the policy has changed hospitals' behavior and how it may inform future policies. The purpose of this study was to assess the relationship between hospitals' performance on TPS annually from 2013 to 2018 and organizational characteristics. Using the HVBP TPS from 2013 to 2018 and associated hospital characteristics-hospital size, teaching hospital status, system membership, ownership type, urban/rural location, average percentages of patients from Medicare and Medicaid, operating margins, percentages of inpatient revenue as a proportion of total revenue, and case mix index-we conducted a retrospective cohort study of all U.S. hospitals participating in the HVBP program. Regression and panel analyses found that organizations that were expected to have robust and rigid resources were unable to score in the superior category consistently. In addition, organizations were unable to consistently perform positively over time because of changes in the HVBP program measurement and the required organizational responses. Policymakers should consider the ability of organizations to respond to changes to the HVBP program. Likewise, healthcare managers, particularly those in larger organizations, should seek to remove bureaucracy or allow for greater resource slack to meet these changes.
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http://dx.doi.org/10.1097/JHM-D-20-00087DOI Listing
March 2021

Mental Health and Chemical Dependency Services at US Cancer Centers.

J Natl Compr Canc Netw 2021 Mar 4:1-10. Epub 2021 Mar 4.

1Department of Psychiatry & Psychology.

Background: It is standard of care and an accreditation requirement to screen for and address distress and psychosocial needs in patients with cancer. This study assessed the availability of mental health (MH) and chemical dependency (CD) services at US cancer centers.

Methods: The 2017-2018 American Hospital Association (AHA) survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases were used to assess availability of services and associations with hospital-level and health services area (HSA)-level characteristics.

Results: Of 1,144 cancer centers surveyed, 85.4% offered MH services and 45.5% offered CD services; only 44.1% provided both. Factors associated with increased adjusted odds of offering MH services were teaching status (odds ratio [OR], 1.76; 95% CI, 1.18-2.62), being a member of a hospital system (OR, 2.00; 95% CI, 1.31-3.07), and having more beds (OR, 1.04 per 10-bed increase; 95% CI, 1.02-1.05). Higher population estimate (OR, 0.98; 95% CI, 0.97-0.99), higher percentage uninsured (OR, 0.90; 95% CI, 0.86-0.95), and higher Mental Health Professional Shortage Area level in the HSA (OR, 0.99; 95% CI, 0.98-1.00) were associated with decreased odds of offering MH services. Government-run (OR, 2.85; 95% CI, 1.30-6.22) and nonprofit centers (OR, 3.48; 95% CI, 1.78-6.79) showed increased odds of offering CD services compared with for-profit centers. Those that were members of hospital systems (OR, 1.61; 95% CI, 1.14-2.29) and had more beds (OR, 1.02; 95% CI, 1.01-1.03) also showed increased odds of offering these services. A higher percentage of uninsured patients in the HSA (OR, 0.92; 95% CI, 0.88-0.97) was associated with decreased odds of offering CD services.

Conclusions: Patients' ability to pay, membership in a hospital system, and organization size may be drivers of decisions to co-locate services within cancer centers. Larger organizations may be better able to financially support offering these services despite poor reimbursement rates. Innovations in specialty payment models highlight opportunities to drive transformation in delivering MH and CD services for high-need patients with cancer.
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http://dx.doi.org/10.6004/jnccn.2020.7657DOI Listing
March 2021

A Panel Evaluation of the Changes in the General Public's Social-Media-Following of United States' Public Health Departments during COVID-19 Pandemic.

J Prim Care Community Health 2021 Jan-Dec;12:2150132721995450

Mayo Clinic, Jacksonville, FL, USA.

Importance: Social media is widely used by various segments of society. Its role as a tool of communication by the Public Health Departments in the U.S. remains unknown.

Objective: To determine the impact of the COVID-19 pandemic on social media following of the Public Health Departments of the 50 States of the U.S.

Design, Setting, And Participants: Data were collected by visiting the Public Health Department web page for each social media platform. State-level demographics were collected from the U.S. Census Bureau. The Center for Disease Control and Prevention was utilized to collect information regarding the Governance of each State's Public Health Department. Health rankings were collected from "America's Health Rankings" 2019 Annual report from the United Health Foundation. The U.S. News and World Report Education Rankings were utilized to provide information regarding the public education of each State.

Exposure: Data were pulled on 3 separate dates: first on March 5th (baseline and pre-national emergency declaration (NED) for COVID-19), March 18th (week following NED), and March 25th (2 weeks after NED). In addition, a variable identifying the total change across platforms was also created. All data were collected at the State level.

Main Outcome: Overall, the social media following of the state Public Health Departments was very low. There was a significant increase in the public interest in following the Public Health Departments during the early phase of the COVID-19 pandemic.

Results: With the declaration of National Emergency, there was a 150% increase in overall public following of the State Public Health Departments in the U.S. The increase was most noted in the Midwest and South regions of the U.S. The overall following in the pandemic "hotspots," such as New York, California, and Florida, was significantly lower. Interesting correlations were noted between various demographic variables, health, and education ranking of the States and the social media following of their Health Departments.

Conclusion And Relevance: Social media following of Public Health Departments across all States of the U.S. was very low. Though, the social media following significantly increased during the early course of the COVID-19 pandemic, but it still remains low. Significant opportunity exists for Public Health Departments to improve social media use to engage the public better.
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http://dx.doi.org/10.1177/2150132721995450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930647PMC
March 2021

Use of Cannabis for Self-Management of Chronic Pelvic Pain.

J Womens Health (Larchmt) 2020 Nov 16. Epub 2020 Nov 16.

Department of Gynecologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system is a potential pharmacological target for pelvic pain as cannabinoid receptors are highly expressed in the uterus and other nonreproductive tissues. We hypothesize that cannabis use is common for self-management of CPP, and our primary objective was to determine the prevalence of cannabis use in this population. A cross-sectional survey of women with pelvic and perineal pain, dyspareunia, or endometriosis was performed between March and August 2019. Subjects were recruited in an outpatient gynecology office. An anonymous, confidential, electronic survey was performed using a tablet. Statistical analysis was performed using JMP (SAS, Cary, NC). A total of 240 patients were approached, with 113 responses (47.1% response rate). There were 26 patients who used cannabis (23%). The majority used at least once per week ( = 18, 72%). Most users ( = 24, 96%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. Over one-third (35%) stated that cannabis use decreased the number of phone calls or messages sent to their provider, and 39% reported decreased number of clinical visits. Side effects, including dry mouth, sleepiness, and feeling "high," were reported by 84% ( = 21). Almost one-quarter of patients with CPP report regular use of cannabis as an adjunct to their prescribed therapy. Although side effects are common, most users report improvement in symptoms. Our study highlights the potential of cannabis as a therapeutic option for patients with CPP.
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http://dx.doi.org/10.1089/jwh.2020.8737DOI Listing
November 2020

Impact of County Health Rankings on Nationwide Liver Transplant Outcomes.

Transplantation 2020 Nov 24. Epub 2020 Nov 24.

Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida Department of Transplantation, Mayo Clinic, Jacksonville, Florida Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota.

Background: There is limited information concerning whether social determinants of health affect postliver transplant (LT) outcomes. This study aims to understand to what extent the health of LT recipients' counties of residence influence long-term LT outcomes.

Methods: We used the United Network for Organ Sharing data to identify adult LT recipients transplanted between January 2010 and June 2018. Patient-level data were matched to county-level County Health Ranking data using transplant recipient zip code, and nationwide County Health Rankings were created. Mixed-effects Cox proportional hazards models were used to examine associations between County Health Rankings and graft and patient survival post-LT.

Results: Health Outcomes rank was significantly associated with posttransplant graft and patient survival, with worst tertile counties showing a 13% increased hazard of both graft failure and patient mortality compared to best tertile counties.

Conclusions: Although county health is associated with LT outcomes, it also appears that LT recipient selection is effective at mitigating major disparities based on county of residence and helps yield equitable outcomes in this respect.
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http://dx.doi.org/10.1097/TP.0000000000003557DOI Listing
November 2020

Impact of travel distance on quality outcomes in colorectal cancer.

Am J Manag Care 2020 11 1;26(11):e347-e354. Epub 2020 Nov 1.

Department of Health Sciences Research, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224. Email:

Objectives: This study sought to examine the impact of distance traveled from place of residence to surgical facility for elective colorectal surgery on surgical outcomes, length of stay, and complication rate.

Study Design: Retrospective study.

Methods: Patients with colorectal cancer were identified from the Florida Inpatient Discharge Database. Distance traveled from primary residence to surgical facility was estimated using zip code. After adjusting for patient and hospital characteristics, multivariate regression models compared bypassed hospitals, the length of stay, and complication rates for patients traveling different distances to receive care.

Results: Patients residing in rural areas and in South (odds ratio [OR], 2.37; 95% CI, 1.55-3.63) and Central Florida (OR, 5.86; 95% CI, 3.86-8.89) were more likely to travel more than 50 miles for treatment. Teaching status of the hospital (OR, 9.99; 95% CI, 6.98-14.31), a hospital's availability of a colorectal surgeon (OR, 1.83; 95% CI, 1.45-2.31), and metastasized cancer (OR, 1.43; 95% CI, 1.17-1.82) influenced the patient's decision to travel farther for treatment. Length of stay was significantly higher for patients traveling farther (P < .0343). However, there was no significant difference in the rate of complications among the groups (those traveling 25-50 miles vs < 25 miles [P = .5766] and those traveling > 50 miles vs < 25 miles [P = .4516]).

Conclusions: A greater number of patients travel more than 50 miles to the surgical facility at a later stage of disease. These patients do not significantly differ from those traveling less than 50 miles in their rates of complications; however, they stay longer at the surgical facility.
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http://dx.doi.org/10.37765/ajmc.2020.88529DOI Listing
November 2020

A cross-sectional study of trauma certification and hospital referral region diversity: A system theory approach.

Injury 2021 Mar 28;52(3):460-466. Epub 2020 Oct 28.

Department of Health Sciences Research, Division of Health Care Policy and Research, College of Medicine, Mayo Clinic Robert D. and Patricia E. Kern, Center for the Science of Health Care Delivery, 4500 San Pablo Road, Jacksonville, FL 32224, United States. Electronic address:

Background: There are clear racial/ethnic disparities in the trauma care service delivery. However, no study has examined the relationships between structural determinants of trauma care designations (L-I through L-IV) or verification and social factors of the surrounding health region in the U.S.

Objective: This study examined the relationship between U.S. community segregation in a hospital referral region (HRR) and hospitals' attainment of trauma certification and trauma designation L-I/II.

Methods: Two-year retrospective analysis of 2,348 acute hospitals that participated in the Hospital Value-Based Purchasing (HVBP) Program. Multivariate Poisson and 1:2 matching ratio using Propensity Score Matching regressions were used. Our primary variables were composite segregation scores for each county-aggregated to the HRR level (n=303)-and hospital performance on the HVBP Program.

Results: Segregated HRRs are 69% and 40% less likely to have an increase in the number of hospitals with trauma care designations L-I/II and trauma certification, respectively. Our matching ratio showed that hospitals with trauma certification or hospitals with trauma care designations L-I/II were more likely to be within HRRs with lower community diversity.

Conclusion: Our findings highlight that system disparities exist in trauma care. Research is needed to determine if other factors, such as resource allocation and reimbursement distribution, impact the availability of trauma facilities.
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http://dx.doi.org/10.1016/j.injury.2020.10.101DOI Listing
March 2021

Amelanotic melanoma of the head and neck: analysis of tumor characteristics from the National Cancer Database.

Int J Dermatol 2021 Mar 11;60(3):347-351. Epub 2020 Oct 11.

Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA.

Background: Amelanotic melanoma is an extremely rare subtype of cutaneous melanoma. The tumor characteristics are still not well understood, especially for those located in the head and neck.

Methods: Tumor characteristics of patients diagnosed with amelanotic melanoma of the head and neck (AMHN) from January 1, 2004, to December 31, 2015, were analyzed by querying the National Cancer Database. Characteristics of AMHN were subsequently compared with common malignant melanoma of the head and neck (CMMHN).

Results: Three hundred and sixty-eight patients were diagnosed with AMHN, and 69,267 were diagnosed with CMMHN. Of those with AMHN, 128 (34.8%) had melanoma located on the scalp and neck, and 172 (46.7%) were diagnosed with an early disease stage (i.e., 0, I, or II). When compared with CMMHN, patients with AMHN were more likely to be diagnosed after 80 years of age (25.3% vs. 18.2%; odds ratio [OR], 3.28; 95% CI, 1.09-9.84; P = 0.03), when Breslow depth was between 2.01 and 4.00 mm (28.5% vs. 6.5%; OR, 1.92; 95% CI, 1.15-3.19; P = 0.01), when ulceration was present (36.7% vs. 9.0%; OR, 1.99; 95% CI, 1.34-2.97; P = 0.001), and when mitotic count was 1 or more/mm (40.5% vs. 12.8%; OR; 2.53; 95% CI, 1.09-5.89; P = 0.03). No statistical difference was found for sex, specific location, stage, or lymph node involvement.

Conclusion: Our study determined that AMHN is associated with older age, increased Breslow depth, presence of ulceration, and greater mitotic count when compared with CMMHN.
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http://dx.doi.org/10.1111/ijd.15243DOI Listing
March 2021

Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review.

Surg Endosc 2020 Sep 28. Epub 2020 Sep 28.

Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.

Background: Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes.

Methods: Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics.

Results: There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (β = - 0.16, p < 0.001) and for each specialty (GS: β = - 0.18, p < 0.001; CRS β = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.
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http://dx.doi.org/10.1007/s00464-020-08039-9DOI Listing
September 2020

Intraoperative Indocyanine Green Fluorescence Angiography Is Sensitive for Predicting Postoperative Wound Complications in Soft-Tissue Sarcoma Surgery.

J Am Acad Orthop Surg 2020 Sep 17. Epub 2020 Sep 17.

From the Department of Orthopedic Surgery (Wilke, Schultz, Sherman, Murray, Forte), the Division of Plastic Surgery (Huayllani, Boczar, Forte), and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL (Huayllani, Boczar, Spaulding, Forte).

Introduction: Indocyanine green (ICG) angiography is a novel technology that has been predictive of postoperative wound complications. It is unknown whether this technology can successfully predict complications after sarcoma resection. In this study, we aimed to evaluate the sensitivity and specificity of ICG angiography in predicting postoperative wound complications after soft-tissue sarcoma resection.

Methods: A prospective cohort study of 23 patients was performed beginning October 2017 at our institution. Patients who underwent soft-tissue sarcoma resection were included. After tumor resection and wound closure, evaluation of tissue perfusion in skin edges was performed with ICG angiography. Wound complications were recorded in the postoperative follow-up.

Results: Eight patients developed postoperative wound complications. Six patients were predicted to have wound complications on the final ICG scans. The accuracy of ICG angiography was dependent on the anatomic location, with improved accuracy in the lower extremity. ICG angiography had a sensitivity of 50%, a specificity and a positive predictive value of 100%, and a negative predictive value of 70% for wound complications after soft-tissue sarcoma resections located in the lower extremity.

Conclusion: ICG angiography has a high predictive value in the lower extremity for postoperative wound complications.

Level Of Evidence: Level III, Diagnostic.
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http://dx.doi.org/10.5435/JAAOS-D-20-00355DOI Listing
September 2020

Magnet Hospitals and 30-Day Readmission and Mortality Rates for Medicare Beneficiaries.

Med Care 2021 01;59(1):6-12

Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic Robert D. and Patricia E. Kern, Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL.

Background: US hospitals are penalized for excess 30-day readmissions and mortality for select conditions. Under the Centers for Medicare and Medicaid Services policy, readmission prevention is incentivized to a greater extent than mortality reduction. A strategy to potentially improve hospital performance on either measure is by improving nursing care, as nurses provide the largest amount of direct patient care. However, little is known as to whether achieving nursing excellence, such as Magnet status, is associated with improved hospital performance on readmissions and mortality.

Objective: The purpose of this study was to examine the relationship between hospitals' Magnet status and performance on readmission and mortality rates for Medicare beneficiaries.

Research Design: This is a cross-sectional analysis of Medicare readmissions and mortality reduction programs from 2013 to 2016. A propensity score-matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals.

Subjects: The sample was comprised of 3877 hospitals.

Measures: The outcome measures were 30-day risk-standardized readmission and mortality rates.

Results: Following propensity score matching on hospital characteristics, we found that Magnet hospitals outperformed non-Magnet hospitals in reducing mortality; however, Magnet hospitals performed worse in reducing readmissions for acute myocardial infarction, coronary artery bypass grafting, and stroke.

Conclusions: Magnet hospitals performed better on the Hospital Value-Based Purchasing Mortality Program than the Hospital Readmissions Reduction Program. The results of this study suggest the need for The Magnet Recognition Program to examine the role of nurses in postdischarge activities as a component of its evaluation criteria.
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http://dx.doi.org/10.1097/MLR.0000000000001427DOI Listing
January 2021

Hospital robotic use for colorectal cancer care.

J Robot Surg 2020 Sep 2. Epub 2020 Sep 2.

Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.

The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.
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http://dx.doi.org/10.1007/s11701-020-01142-yDOI Listing
September 2020

Do Magnet®-Designated Hospitals Perform Better on Medicare's Value-Based Purchasing Program?

J Nurs Adm 2020 Jul/Aug;50(7-8):395-401

Author Affiliations: Associate Professor (Dr Spaulding), Health Services Research, Mayo Clinic; Associate Professor (Dr Hamadi), Health Administration, University of North Florida; Instructor (Dr Moody), Health Administration, University of North Florida; and Instructor (Ms Lentz), Clinical Document Integrity, Mayo Clinic, Jacksonville; Associate Professor (Dr Liu), Health Management and Informatics, University of Central Florida, Orlando; and Advanced Registered Nurse Practitioner (Dr Wu), Mechanical Circulatory Support (MCS) Team, Heart/Lung Transplant Department, University of California San Francisco.

Objective: The aim of this study was to explore the relationship between a hospital's Magnet recognition status, tenure, and its performance in the Hospital Value-Based Purchasing (HVBP) program.

Background: Previous studies have sought to determine associations between quality of care provided in inpatient setting and the Magnet Recognition Program; however, no study has done so using the most recent (FY2017) iteration of the HVBP program, nor determined the influence a hospital's Magnet designation tenure has on HVBP scores.

Method: This study used a cross-sectional study design of 2686 hospitals using propensity score matching to reduce bias and improve comparability.

Results: Magnet-designated hospitals were associated with higher total performance, process of care and patient experience of care scores, and lower efficiency score. No association was identified between the length of time hospitals have been Magnet designated.

Conclusion: Findings suggest non-Magnet status hospitals need to consider implementing the principles of Magnet into their culture or participation in the Magnet Recognition Program to provide higher quality of care.
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http://dx.doi.org/10.1097/NNA.0000000000000906DOI Listing
August 2020

Barriers to accepting mental health care in cancer patients with depression.

Soc Work Health Care 2020 07 14;59(6):351-364. Epub 2020 Jun 14.

Department of Psychiatry & Psychology, Mayo Clinic , Jacksonville, FL, USA.

This study aimed to determine barriers to accepting mental health care among depressed cancer patients. Cancer patients who screened positive for depression were referred for mental health treatment and sent a validated questionnaire designed to assess barriers to receiving mental health care. Responses were compared between patients who accepted their referral and those who did not. Among 75 patients who agreed to participate, 51 (68%) completed the questionnaire. Reported barriers to accessing mental healthcare were not significantly different between the two groups but patients residing within 50 miles of the clinic had increased odds of attending their appointment.
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http://dx.doi.org/10.1080/00981389.2020.1769248DOI Listing
July 2020

Disparities in Access to Autologous Breast Reconstruction.

Medicina (Kaunas) 2020 Jun 8;56(6). Epub 2020 Jun 8.

Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA.

This study aimed to determine if age, race, region, insurance, and comorbidities affect the type of breast reconstruction that patients receive. This analysis used the Florida Inpatient Discharge Dataset from 1 January 2013 to 30 September 2017, which contains deidentified patient-level administrative data from all acute care hospitals in the state of Florida. We included female patients, diagnosed with breast cancer, who underwent mastectomy and a subsequent breast reconstruction. We performed an χ test and logistic regression in this analysis. On the multivariable analysis, we found that age, race, patient region, insurance payer, and Elixhauser score were all variables that significantly affected the type of reconstruction that patients received. Our results show that African American (odds ratio (OR): 0.68, 95%CI: 0.58-0.78, < 0.001) and Hispanic or Latino (OR: 0.82, 95%CI: 0.72-0.93, = 0.003) patients have significantly lower odds of receiving implant reconstruction when compared to white patients. Patients with Medicare (OR: 1.57, 95%CI: 1.33-1.86, < 0.001) had significantly higher odds and patients with Medicaid (OR: 0.61, 95%CI: 0.51-0.74, < 0.001) had significantly lower odds of getting autologous reconstruction when compared to patients with commercial insurance. Our study demonstrated that, in the state of Florida over the past years, variables, such as race, region, insurance, and comorbidities, play an important role in choosing the reconstruction modality. More efforts are needed to eradicate disparities and give all patients, despite their race, insurance payer, or region, equal access to health care.
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http://dx.doi.org/10.3390/medicina56060281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7353892PMC
June 2020

National Comprehensive Analysis of Characteristics of Acral Lentiginous Melanoma.

Anticancer Res 2020 Jun;40(6):3411-3415

Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, U.S.A.

Background/aim: Acral lentiginous melanoma (ALM) is the least common subtype of cutaneous melanoma and typically occurs on the palms, soles, and nails. Tumor characteristics and disease severity in the US population are not well understood. Our aim was to analyze the characteristics of ALM of the extremities.

Patients And Methods: We queried the National Cancer Database to identify patients with the diagnosis of ALM and common malignant melanoma located in the extremities (CMME). We compared demographic, tumor, and treatment characteristics between patients with ALM and those with CMME. Statistical analysis was performed with chi-squared test and multivariate logistic regression models.

Results: We identified 5,203 patients with ALM and 118,485 with CMME. When compared with patients with CMME, those with ALM were more likely to be older than 80. years at diagnosis [odds ratio (OR)=2.85, 95% confidence intervaI (CI)=2.12-3.82; p<0.001], have stage III disease (OR=4.22, 95% CI=1.47-12.16; p=0.01), and have ulceration (OR=1.52, 95% CI=1.33-1.74; p<0.001). Moreover, patients with ALM were less likely to have a mitotic count of 1/mm or greater (OR=0.57, 95% CI=0.48-0.67; p<0.001). No statistical difference was found for sex, lymph node involvement, regression, and use of surgery, radiotherapy, and immunotherapy between groups.

Conclusion: Age, disease stage, ulceration, and mitotic count are independent factors associated with ALM. Knowledge of the disease characteristics may allow for better diagnosis and understanding of disease pathophysiology.
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http://dx.doi.org/10.21873/anticanres.14325DOI Listing
June 2020

Breast cancer in women: a descriptive analysis of the national cancer database.

Acta Biomed 2020 May 11;91(2):332-341. Epub 2020 May 11.

Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida.

Background And Aim Of The Work: Breast cancer is the most common cancer in women in the United States. National Cancer Database (NCDB) is one of the largest tumor databases of the United States. This study aimed to evaluate the features of breast cancer in women from a large updated database.

Methods: We describe and analyze the frequencies and percentages of the clinical and pathological features of women diagnosed with breast cancer registered in NCDB, in a period from 2004 to 2015.

Results: A total of 2,423,875 women were diagnosed with breast cancer between 2004 and 2015. The nationally representative analysis demonstrated that the incidence of breast cancer among women increased over the years. Upper-outer quadrant was the most frequent primary tumor site, and the intraductal carcinoma was the most frequent histology. The prevalence of breast cancer increased with age. The most frequent grade at diagnosis was grade II. Broadly, invasive characteristics were noted more frequently in younger patients. Left and right breast were affected with almost the same frequency, with a slight predominance of the left breast. The most frequent surgical treatment was a partial mastectomy. Reconstruction with implant was the most frequent choice. Post-mastectomy radiation therapy was administered in the majority of patients.

Conclusions: To the authors' knowledge, the current study is the largest descriptive analysis to date on the clinical and pathological features of breast cancer in a population-based database. The increase in incidence over the years indicates an important need for etiologic research and innovative approaches to improve breast cancer prevention.
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http://dx.doi.org/10.23750/abm.v91i2.8399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569667PMC
May 2020

Paget disease of the breast: A national retrospective analysis of the US population.

Breast Dis 2020 ;39(3-4):119-126

Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA.

Background: Paget's disease of the breast is rare. The National Cancer Database (NCDB) is one of the largest tumor databases in the United States.

Methods: We queried the NCDB to identify male and female patients with Paget's disease of the breast who were treated from January 1, 2004, through December 31, 2015. No age limitations were applied. Descriptive statistical analysis and survival analysis were performed.

Results: We analyzed the demographic, disease, and treatment characteristics of 7,191 patients with Paget's disease of the breast. The median (range) age was 64 (20-90) years. Only 2.1% of patients were men, and 85.4% were white. The most common treatment was complete mastectomy (65.3%), followed by partial mastectomy (30.3%). Tumor destruction was performed in 0.1% of patients, and 4.3% of patients did not undergo any surgery. We examined survival in the subset of 6,864 patients who were treated surgically with complete mastectomy or partial mastectomy. The 5-year survival rate after surgery was 82.5% (95% CI, 81.1%-83.9%). Factors associated with shorter survival were older age, black race/ethnicity, higher tumor grade, regional lymph node metastasis, higher cancer stage, metastatic cancer, and larger tumor size.

Conclusions: Paget's disease of the breast usually affects patients older than 60 years, and the most common treatment is complete mastectomy. The 5-year overall survival rate of patients with Paget's disease of the breast is greater than 80% but is lower among older and black people.
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http://dx.doi.org/10.3233/BD-200439DOI Listing
January 2020

Impact of Depression and Anxiety on Opioid Use in Hospitalized Hematopoietic Cell Transplantation Recipients.

Psychosomatics 2020 Jul - Aug;61(4):363-370. Epub 2020 Mar 26.

Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL. Electronic address:

Background: Hematopoietic cell recipients are reported to have a high prevalence of depression and anxiety. The impact of depression and anxiety on opioid use has not been well characterized. This is of significance as the opioid epidemic continues, and over 60% of deaths secondary to drug overdose involve the use of opioids.

Objective: In this retrospective, single-center study of 275 patients who underwent hematopoietic cell transplantation (HCT) (allogeneic and autologous) for hematological malignancies, we explore the impact of depression and anxiety on opioid use.

Results: Patients who were both anxious and depressed at admission for HCT had increased odds of receiving an opioid (odds ratio of 4.50 [95% confidence interval: 1.75, 11.56]) compared with patients who were neither depressed nor anxious. However, patients who were either depressed or anxious did not have different odds of receiving an opioid compared with those who were neither depressed nor anxious. Autologous HCT recipients had reduced odds of receiving an opioid (odds ratio of 0.17 [95% confidence interval: 0.08, 0.38]) compared with patients undergoing allogeneic HCT. Patients with lower Karnofsky performance status (<90 on a scale of 1-100) had an increased incidence of receiving a higher Morphine milligram equivalent daily dosage (incidence rate ratio of 2.59 [95% confidence interval: 1.18, 5.67]) when modeled by zero truncated negative binomial regression.

Conclusion: Presence of depression and anxiety impacts opioid use in patients undergoing HCT.
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http://dx.doi.org/10.1016/j.psym.2020.03.003DOI Listing
March 2020

Hospital-Acquired Conditions Reduction Program, Patient Safety, and Magnet Designation in the United States.

J Patient Saf 2020 Mar 25. Epub 2020 Mar 25.

Department of Health Sciences Research, Division of Health Care Policy, and Research, Mayo Clinic Robert D., and Patricia E. Kern, Center for the Science of Health Care Delivery, Mayo Clinic.

Objective: The aim of the study was to investigate the association between hospitals' nursing excellence accreditation and patient safety performance-measured by the Hospital-Acquired Conditions Reduction Program (HACRP).

Methods: We linked data from the American Nursing Credentialing Center Magnet Recognition Program, Centers for Medicare and Medicaid Services HACRP, and the American Hospital Association annual survey from 2014 to 2016. We constrained the analysis to hospitals participating in Centers for Medicare and Medicaid Services' HACRP and deployed propensity score matching models to calculate the coefficients for our HACRP patient safety measures. These measures consisted of (a) patient safety indicator 90, (b) hospital-associated infection measures, and (c) total HAC scores. In addition, we used propensity score matching to assess HACRP scores between hospitals achieving Magnet recognition in the past 2 versus longer and within the past 5 years versus longer.

Results: Our primary findings indicate that Magnet hospitals have an increased likelihood of experiencing lower patient safety indicator 90 scores, higher catheter-associated urinary tract infection and surgical site infection scores, and no different total HAC scores. Finally, when examining the impact of Magnet tenure, our analysis revealed that there were no differences in Magnet tenure.

Conclusions: Results indicate that the processes, procedures, and educational aspects associated with Magnet recognition seem to provide important improvements associated with care that is controlled by nursing practice. However, because these improvements do not differ when comparing total HAC scores nor Magnet hospitals with different tenure, there are likely opportunities for Magnet hospitals to continue process improvements focused on HACRP scores.
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http://dx.doi.org/10.1097/PTS.0000000000000628DOI Listing
March 2020

Artificial Intelligent Virtual Assistant for Plastic Surgery Patient's Frequently Asked Questions: A Pilot Study.

Ann Plast Surg 2020 04;84(4):e16-e21

Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL.

Background: Artificial Intelligent Virtual Assistants (AIVA) is a segment of artificial intelligence that is rapidly developing. However, its utilization to address patients' frequently asked questions remains unexplored.

Methods: We developed an AIVA to answer questions related to 10 frequent topics asked by plastic surgery patients in our institution. Between July 27, 2018, and August 10 of 2018, we recruited subjects with administrative positions at our health care institution to chat with the virtual assistant. They asked, with their own words, 1 question for each topic and filled out a satisfaction questionnaire. Postsurvey analysis of questions and answers allowed assessment of the virtual assistant's accuracy.

Results: Thirty participants completed the survey. The majority was female (70%), and the mean age was 27.76 years (SD, 8.68 [19-51] years). The overall accuracy of the plastic surgery AIVA was 92.3% (277/294 questions), and participants considered the answer correct in 83.3% of the time (250/294 answers). Most of the participants considered the AIVA easy to use, answered adequately, and could be helpful for patients. However, when asked if this technology could replace a human assistant, they stayed neutral.
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http://dx.doi.org/10.1097/SAP.0000000000002252DOI Listing
April 2020

Wide Excisional Surgery in Invasive Melanoma Treatment: Factors Driving Non-compliance With National Guidelines.

Anticancer Res 2020 Feb;40(2):1065-1069

Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, U.S.A.

Background/aim: Margin size during wide excisional surgery for invasive melanoma treatment have been established by national guidelines. This study identified factors associated with wider than recommended excisional margins and its impact on survival.

Patients And Methods: The National Cancer Database was queried to identify patients with primary invasive melanoma. Statistical analysis was performed using univariate and multivariate analysis. Overall survival was compared using Kaplan-Meier method.

Results: A total of 26,440 patients were included in the analysis. Melanomas located on the trunk were more likely to be treated using wider than recommended excisional margins for certain Breslow depth groups (p<0.05), while the opposite was true for those being treated in an academic/research program (p<0.05). The practice of taking wider than recommended margins was not associated with improved survival.

Conclusion: Tumor location and facility type influence non-compliance with the National Comprehensive Cancer Network guidelines. Lack of survival benefit in patients with wider excisional margins seems to support guideline recommendations.
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http://dx.doi.org/10.21873/anticanres.14044DOI Listing
February 2020

Residual Tumor on Wide Excisional Margins After Treatment of Invasive Melanoma.

Anticancer Res 2020 Feb;40(2):1059-1063

Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, U.S.A.

Background/aim: The surgical management of invasive melanoma has been debated for many years and recommended excisional margins have been established. We aimed to describe the factors and survival related to the presence of residual tumor in patients with invasive melanoma lymph nodes negative.

Patients And Methods: We performed a retrospective study by querying the National Cancer Database from 2004 to 2015. Associations were tested using a multivariate analysis. Overall survival was compared using the Kaplan-Meier method.

Results: A total of 26,440 patients met the inclusion criteria. For Breslow depth groups ≤1 mm and >2 mm, older age and location in the head and neck were factors associated to residual tumor in margins (p<0.05), whereas only location in the head and neck was associated to residual tumor for patients with Breslow depth between 1.01-2.00 mm (p<0.05).

Conclusion: Knowledge of the factors associated with the residual tumor will help establish a patient-centered management and decrease the recurrence of disease.
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http://dx.doi.org/10.21873/anticanres.14043DOI Listing
February 2020

National Analysis of Patients With Ulcerated Melanoma in the United States.

Anticancer Res 2020 Feb;40(2):1055-1058

Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, U.S.A.

Background/aim: Ulceration is associated with unfavorable prognosis in patients with melanoma. The present study aimed to analyze the characteristics associated with ulcerated melanoma in the United States. It was hypothesized that patient disparities associated with increased odds of ulceration exist.

Patients And Methods: We searched the National Cancer Database for melanoma patients from 2004 to 2015. Data regarding patient demographics, facility characteristics, and tumor characteristics were analyzed.

Results: There were higher odds of ulceration in non-white patients, 50 years of age or older, and melanoma on the trunk and extremities. Lower odds were found in women, zip codes with higher income and education levels, and Metro or Urban counties.

Conclusion: Age above 49 years, male sex, non-white race, living in rural areas, and living in zip codes with low income and low education were independently associated with ulcerated melanoma.
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http://dx.doi.org/10.21873/anticanres.14042DOI Listing
February 2020

Impact of Patient Stage and Disease Characteristics on the proposed Radiation Oncology Alternative Payment Model (RO-APM).

Int J Radiat Oncol Biol Phys 2020 04 28;106(5):905-911. Epub 2020 Jan 28.

Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland. Electronic address:

Purpose: The proposed Radiation Oncology Alternative Payment Model (RO-APM) released on July 10, 2019, represents a dramatic shift from fee-for-service (FFS) reimbursement in radiation therapy (RT). This study compares historical revenue at Mayo Clinic to the RO-APM and quantifies the effect that disease characteristics may have on reimbursement.

Methods And Materials: FFS Medicare reimbursements were determined for patients undergoing RT at Mayo Clinic from 2015 to 2016. Disease categories and payment episodes were defined as per the RO-APM. Average RT episode reimbursements were reported for each disease site, except for lymphoma and metastases, and stratified by stage and disease subcategory. Comparisons with RO-APM reimbursements were made via descriptive statistics.

Results: A total of 2098 patients were identified, of whom 1866 (89%) were categorized per the RO-APM; 840 (45%) of those were aged >65 years. Breast (33%), head and neck (HN) (14%), and prostate (11%) cancer were most common. RO-APM base rate reimbursements and sensitivity analysis range were lower than historical reimbursement for bladder (-40%), cervical (-34%), lung (-28%), uterine (-26%), colorectal (-24%), upper gastrointestinal (-24%), HN (-23%), pancreatic (-20%), prostate (-16%), central nervous system (-13%), and anal (-10%) and higher for liver (+24%) and breast (+36%). Historical reimbursement varied with stage (stage III vs stage I) for breast (+57%, P < .01), uterine (+53%, P = .01), lung (+50%, P < .01), HN (+24%, P = .01), and prostate (+13%, P = .01). Overall, for patients older than 65 years of age, the RO-APM resulted in a -9% reduction in total RT reimbursement compared with historical FFS (-2%, -15%, and -27% for high, mid, and low adjusted RO-APM rates).

Conclusions: Our findings indicate that the RO-APM will result in significant reductions in reimbursement at our center, particularly for cancers more common in underserved populations. Practices that care for socioeconomically disadvantaged populations may face significant reductions in revenue, which could further reduce access for this vulnerable population.
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http://dx.doi.org/10.1016/j.ijrobp.2019.12.012DOI Listing
April 2020

An Investigation of Healthcare Worker Perception of Their Workplace Safety and Incidence of Injury.

Workplace Health Saf 2020 May 26;68(5):214-225. Epub 2020 Jan 26.

Mayo Clinic.

Managing the safety climate in health care is a promising tool for improving employee and patient safety in the health care work environment. Gaps in the theoretical and conceptual underpinnings of safety climate, as well as the evidence base for its practical application in health care remain. The purpose of this study was to evaluate the number of work injuries occurring in health care work units and associated safety climate beliefs. : A retrospective analysis was conducted utilizing organizational staff survey data collected by a large medical hospital in the Midwest in 2015. Employees ( = 32,327) were invited to identify safety climate perceptions via survey. Injuries, days restricted, and days absent were identified through the Hospital's Occupational Safety and Health Administration (OSHA) log. Zero inflated negative binomial regressions used injuries as dependent variables and safety climate perceptions as independent variables. : In all, 23,599 employees completed the survey (73% response rate) across 1,805 employee work units which were defined as groupings of employees reporting to a single supervisor. We found that there was an association between fewer injuries and health care workers indicating that they share responsibility for compliance with safety rules and procedures (relative risk [RR] = 0.98, 95% confidence interval [CI] = [0.98, 0.99]). : This study supports the use of a safety climate measure to assess working units' perceptions of employee safety. A continued focus on the health and safety of employees who interact directly with patients is warranted, as well as employees who do not provide direct patient care.
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http://dx.doi.org/10.1177/2165079919883293DOI Listing
May 2020