Publications by authors named "Sara Fernandes-Taylor"

45 Publications

How Do Academic Otolaryngologists Decide to Implement New Procedures Into Practice?

Otolaryngol Head Neck Surg 2021 Sep 21:1945998211047434. Epub 2021 Sep 21.

Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA.

Objective: To identify barriers and facilitators to adoption of a new surgical procedure via an implementation science framework to characterize associated socioemotional, clinical, and decision-making processes.

Study Design: Qualitative study with a semistructured interview approach.

Setting: Large tertiary care referral center.

Methods: Academic otolaryngologists with at least 2 years of practice were identified and interviewed. Transcripts were thematically coded and separated into steps in the clinical pathway. Synthesis of major themes characterized facilitators and barriers to uptake of a new surgical technique.

Results: Of 22 otolaryngologists, 19 were interviewed (85% male). They had a median 18 years of practice (interquartile range, 7.8-26.3), and 65% were subspecialty trained. In the decision to implement a new procedure, improving patient outcomes and addressing unmet clinical needs facilitated adoption, whereas costs and adopting profit-driven technologies without improved outcomes were barriers. In patient consults, establishing trust facilitated implementation of new techniques; barriers included participants' hesitation to communicate about the unknowns of a new procedure. Intraoperatively, little change to existing workflow or improved efficiency facilitated adoption, while a substantial learning curve for the new procedure was a barrier. Achieving favorable outcomes and patient satisfaction sustained implementation of new procedures. Too few referrals or indications for the new procedure hindered implementation.

Conclusion: Our study demonstrates that innovation in otolaryngology is often an individual iterative process that providers pursue to improve patients' outcomes. Although models for the oversight of surgical innovation emphasize the need for evidence, obtaining sufficient numbers of providers and patients to generate evidence remains a challenge in specialty surgical practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/01945998211047434DOI Listing
September 2021

General surgeon involvement in the care of patients designated with an American Association for the Surgery of Trauma-endorsed ICD-10-CM emergency general surgery diagnosis code in Wisconsin.

J Trauma Acute Care Surg 2021 Aug 25. Epub 2021 Aug 25.

University of Wisconsin-Madison; Madison, WI University of California-San Diego; San Diego, CA Legacy Health; Portland, OR University of Colorado Health; Loveland, CO Brigham and Women's Hospital; Boston, MA University of Colorado Health; Colorado Springs, CO Stanford University; Palo Alto, CA University of Florida; Jacksonville, FL University of California-Davis; Sacramento, CA.

Background: The current national burden of emergency general surgery (EGS) illnesses and the extent of surgeon involvement in the care of these patients remain largely unknown. To inform needs assessments, research, and education, we sought to: (1) translate previously developed International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes representing EGS conditions to ICD-10-CM codes and (2) determine the national burden of and assess surgeon involvement across EGS conditions.

Methods: We converted ICD-9-CM codes to candidate ICD-10-CM codes using General Equivalence Mappings then iteratively refined the code list. We used National Inpatient Sample 2016-2017 data to develop a national estimate of the burden of EGS disease. To evaluate surgeon involvement, using Wisconsin Hospital Association (WHA) discharge data (1/1/16-6/30/18), we selected adult urgent/emergent encounters with an EGS condition as the principal diagnosis. Surgeon involvement was defined as a surgeon being either the attending provider or procedural physician.

Results: 485 ICD-9-CM codes mapped to 1,696 ICD-10-CM codes. The final list contained 985 ICD-10-CM codes. Nationally, there were 2,977,843 adult patient encounters with an ICD-10-CM EGS diagnosis. Of 94,903 EGS patients in the WHA dataset, most encounters were inpatient as compared to observation (75,878 [80.0%] vs 19,025 [20.0%]). 57,780 patients (60.9%) underwent any procedure. Among all Wisconsin EGS patients, most had no surgeon involvement (64.9% [n = 61,616]). Of the seven most common EGS diagnoses, surgeon involvement was highest for appendicitis (96.0%) and biliary tract disease (77.1%). For the other five most common conditions (skin/soft tissue infections, gastrointestinal hemorrhage, intestinal obstruction/ileus, pancreatitis, diverticular disease), surgeons were involved in roughly 20% of patient care episodes.

Conclusion: Surgeon involvement for EGS conditions ranges from highly likely (appendicitis) to relatively unlikely (skin/soft tissue infections). The wide range in surgeon involvement underscores the importance of multidisciplinary collaboration in the care of EGS patients.

Level Of Evidence: Prognostic/epidemiological, Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000003387DOI Listing
August 2021

Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments.

Am J Emerg Med 2021 02 13;40:83-88. Epub 2020 Dec 13.

Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.

Background: Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States.

Method: We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital.

Results: Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals.

Conclusion: Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2020.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074541PMC
February 2021

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice.

Ann Surg 2021 03;273(3):474-482

Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin.

Objective: The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

Background: In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

Methods: A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

Results: Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

Conclusions: Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004355DOI Listing
March 2021

Age-Dependent Costs and Complications in Pediatric Umbilical Hernia Repair.

J Pediatr 2020 Jul 3. Epub 2020 Jul 3.

Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI.

Objectives: To characterize regional variation in the age of patients undergoing umbilical hernia repair to determine costs and subsequent care.

Study Design: We performed a cross-sectional descriptive study using a large convenience sample of US employer-based insurance claims from July 2012 to December 2015. We identified children younger than 18 years of age undergoing uncomplicated (not strangulated, incarcerated, or gangrenous) umbilical hernia repair as an isolated procedure (International Classification of Diseases, Ninth Revision procedure codes 53.41, 53.42, 53.43, or 53.49, International Classification of Diseases, Tenth Revision procedure code 0WQF0ZZ, or Current Procedural Terminology procedure codes 49580 or 49585).

Results: In all, 5212 children met criteria for inclusion. Children younger than age 2 years accounted for 9.7% of repairs, with significant variation by census region (6% to 14%, P < .001). Total payments for surgery varied by age; children younger than 2 years averaged $8219 and payments for older children were $6137. Postoperative admissions occurred at a rate of 73.1 per 1000 for children younger than age 2 years and 7.43 for older children; emergency department visits were 41.5 per 1000 for children younger than age 2 years vs 15.9 for older children (P < .001).

Conclusions: Umbilical hernias continue to be repaired at early ages with large regional variation. Umbilical hernia repair younger than age 2 years is associated with greater costs and greater frequency of postoperative hospitalization and emergency department visits.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpeds.2020.07.008DOI Listing
July 2020

Effect of Transfer Status on Outcomes of Emergency General Surgery Patients.

Surgery 2020 08 23;168(2):280-286. Epub 2020 May 23.

Department of Surgery, University of Wisconsin, Madison, WI. Electronic address:

Introduction: Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database.

Methods: We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design.

Results: We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay.

Conclusions: EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2020.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390656PMC
August 2020

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

JAMA Otolaryngol Head Neck Surg 2020 01;146(1):20-29

Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research.

Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease.

Design, Setting, And Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook.

Main Outcomes And Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications.

Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk.

Conclusions And Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaoto.2019.3022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824232PMC
January 2020

Study protocol to develop a patient-reported outcome measuring disability associated with unilateral vocal fold paralysis: a mixed-methods approach with the CoPE collaborative.

BMJ Open 2019 10 30;9(10):e030151. Epub 2019 Oct 30.

Division of Otolaryngology, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA.

Introduction: Patient-reported outcome (PRO) measures are increasingly developed with multisite, representative patient populations so that they can serve as a primary endpoint in clinical trials and longitudinal studies. Creating multisite infrastructure during PRO measure development can facilitate future comparative effectiveness trials. We describe our protocol to simultaneously develop a PRO measure and create a collaborative of tertiary care centres to address the needs of patients with unilateral vocal fold paralysis (UVFP). We describe the stakeholder engagement, information technology and regulatory foundations for PRO measure development and how the process enables plans for multisite trials comparing treatments for this largely iatrogenic condition.

Methods And Analysis: The study has three phases: systematic review, measure development and measure validation. Systematic reviews and qualitative interviews (n=75) will inform the development of a conceptual framework. Qualitative interviews with patients with UVFP will characterise the lived experience of the condition. Candidate PRO measure items will be derived from patient interviews and refined using cognitive interviews and expert input. The PRO measure will be administered to a large, multisite cohort of adult patients with UVFP via the CoPE (vocal rd aralysis xperience) Collaborative. We will establish CoPE to facilitate measure development and to create preliminary infrastructure for future trials, including online data capture, stakeholder engagement, and the identification of barriers and facilitators to participation. Classical test theory psychometrics and grounded theory characterise our approach, and validation includes assessment of latent structure, reliability and validity.

Ethics And Dissemination: Our study is approved by the University of Wisconsin Health Sciences Institutional Review Board. Findings from this project will be published in open-access journals and presented at international conferences. Subsequent use of the PRO measure will include comparative effectiveness trials of treatments for UVFP at CoPE Collaborative sites.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2019-030151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830693PMC
October 2019

Breast Cancer Found Incidentally After Reduction Mammaplasty in Young Insured Women.

Ann Surg Oncol 2019 Dec 19;26(13):4310-4316. Epub 2019 Sep 19.

Department of Surgery, Clinical Science Center, University of Wisconsin-Madison, Madison, WI, USA.

Background: Reduction mammaplasty is a common operation performed for healthy women. The estimated incidence of breast cancer diagnosed at the time of reduction mammaplasty varies from 0.06 to 4.5%, and information on the care of these patients is limited. This study aimed to determine the incidence of breast cancer identified incidentally during reduction mammaplasty and to characterize preoperative imaging.

Methods: Women 18 years of age or older who underwent reduction mammaplasty from 2013 to 2015 were identified from the Truven Health MarketScan Research Databases. Patients with prior breast cancer were excluded. Descriptive statistics were calculated for patient characteristics, incidental breast cancer, preoperative breast imaging, and postoperative treatment.

Results: Reduction mammaplasty was performed for 18,969 women with a mean age of 42.5 years. Of these patients, 186 (0.98%) were incidentally found to have breast cancer, with 134 (0.71%) having invasive breast cancer and 52 (0.27%) having carcinoma in situ. The patients with incidentally found cancer were older than the patients without cancer (50.8 vs. 42.5 years; p < 0.001). Overall, 58.2% of the patients had undergone mammography before reduction mammoplasty. The rates were higher (> 80%) for the patients older than 40 years. Preoperative mammography was performed for 76.3% of those with a diagnosis of breast cancer at time of reduction mammoplasty.

Conclusions: Breast cancer diagnosed incidentally at the time of reduction mammaplasty is uncommon and often radiographically occult. The majority of women older than 50 years appropriately received preoperative mammography. These data can be used to manage patient expectations about the potential for the incidental diagnosis of breast cancer at reduction mammaplasty, even with a negative preoperative mammography.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07726-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486797PMC
December 2019

Natural history and cost analysis of surgical bypass versus endoscopic stenting for the palliative management of malignant gastric outlet obstruction.

HPB (Oxford) 2020 04 10;22(4):529-536. Epub 2019 Sep 10.

University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States. Electronic address:

Background: Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes.

Methods: Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured.

Results: A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028).

Conclusion: In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hpb.2019.08.009DOI Listing
April 2020

Factors Associated With the Interhospital Transfer of Emergency General Surgery Patients.

J Surg Res 2019 08 9;240:191-200. Epub 2019 Apr 9.

Department of Surgery, University of Wisconsin, Madison, Wisconsin.

Background: Transferred emergency general surgery (EGS) patients constitute a highly vulnerable, acutely ill population. Guidelines to facilitate timely, appropriate EGS transfers are lacking. We determined patient- and hospital-level factors associated with interhospital EGS transfers, a critical first step to identifying which patients may require transfer.

Methods: Adult EGS patients (defined by American Association for the Surgery of Trauma International Classification of Diseases, Ninth Revision diagnosis codes) were identified within the 2008-2013 Nationwide Inpatient Sample (n = 17,175,450). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multivariate proportional cause-specific hazards model with a competing risk analysis to assess the effect of risk factors for transfer.

Results: 1.8% of encounters resulted in a transfer (n = 318,286). Transferred patients were on average 62 y old and most commonly had Medicare (52.9% [n = 168,363]), private (26.7% [n = 84,991]), or Medicaid insurance (10.8% [n = 34,279]). 67.7% were white. The most common EGS diagnoses among transferred patients were related to hepatic-pancreatic-biliary (n = 90,989 [28.6%]) and upper gastrointestinal tract (n = 60,088 [18.9%]) conditions. Most transferred patients (n = 269,976 [84.8%]) did not have a procedure before transfer. Transfer was more likely if patients were in small (hazard ratio 2.52, 95% confidence interval 2.28-2.79) or medium (1.32, 1.21-1.44) versus large facilities, government (1.19, 1.11-1.28) versus private facilities, and rural (4.58, 3.98-5.27) or urban nonteaching (1.89, 1.70-2.10) versus urban teaching facilities. Patient-level factors were not strong predictors of transfer.

Conclusions: We identified that hospital-level characteristics more strongly predicted the need for transfer than patient-related factors. Consideration of these factors by providers as care is delivered in the context of the resources and capabilities of local institutions may facilitate transfer decision-making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.11.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7053531PMC
August 2019

Reply to: Confounding factors on the analysis of opioid prescription after pediatric umbilical hernia repair.

Surgery 2019 08 5;166(2):232-233. Epub 2019 Apr 5.

Department of Surgery, University of Wisconsin-Madison, WI.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2019.02.019DOI Listing
August 2019

Characteristics and Timing of Interhospital Transfers of Emergency General Surgery Patients.

J Surg Res 2019 01 26;233:8-19. Epub 2018 Jul 26.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background: Transferred emergency general surgery (EGS) patients have increased morbidity, mortality, and costs, yet little is known about the characteristics of such transfers. Increasing specialization and a decreasing general surgery workforce have led to concerns about access to care, which may lead to increased transfers. We sought to evaluate the reasons for and timing of transfers for EGS diagnoses.

Methods: We performed a retrospective medical record review of patients transferred to a tertiary academic medical center between January 4, 2014 and March 31, 2016 who had an EGS diagnosis (bowel obstruction, appendicitis, cholecystitis/cholangitis/choledocholithiasis, diverticulitis, mesenteric ischemia, perforated viscus, or postoperative surgical complication).

Results: Three hundred thirty-four patients were transferred from 70 hospitals. Transfer reasons varied with the majority due to the need for specialized services (44.3%) or a surgeon (26.6%). Imaging was performed in 95.8% and 35.3% had surgeon contact before transfer. The percentage of patients who underwent procedures at referring facilities was 7.5% (n = 25), while 60.6% (n = 83) underwent procedures following transfer. Mean time between transfer request and arrival at the accepting hospital was lower for patients who subsequently underwent a procedure at the accepting hospital compared to those who did not for patients originating in emergency departments (2.6 versus 3.4 h, P < 0.05) and inpatient units (6.9 versus 14.3 h, P < 0.05).

Conclusions: Interhospital transfers for EGS conditions are frequently motivated by a need for a higher level of care or specialized services as well as a need for a general surgeon. Understanding reasons for transfers can inform decisions regarding the allocation and provision of care for this vulnerable population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.06.017DOI Listing
January 2019

National variation in opioid prescribing after pediatric umbilical hernia repair.

Surgery 2019 04 1;165(4):838-842. Epub 2018 Dec 1.

Department of Surgery, University of Wisconsin-Madison, WI.

Background: Pediatric umbilical hernia repair is a common procedure that requires minimal tissue disruption. We examined variation in opioid prescription fills after repair of uncomplicated umbilical hernias to characterize the types and doses of medication used and persistent postsurgical use.

Methods: Using the Truven Health Analytics MarketScan© Research Database for June 2012-September 2015, we identified pediatric patients undergoing umbilical hernia repair. We excluded patients with obstruction, gangrene, an earlier repair or a concurrent surgical procedure, and those without available pharmacy claim data. Analyses describe filled outpatient prescriptions by age, geographic region, drug type, quantity, and second prescriptions/refills.

Results: Of 4,407 procedures performed, 2,292 patients (52%) filled a prescription for postoperative opioids (age 0-1 years: 21.6%, age 2-3 years: 51.5%, age 4-5 years: 54.3%, 6 years or older: 57.9% [P < .0001]). In the northeast United States, 42% of patients filled narcotic prescriptions, compared with 59% of patients in the south (P < .0001). Hydrocodone/acetaminophen was most commonly prescribed (51%), followed by codeine/acetaminophen (30%). Durations were ≤3 days (50%), 4-10 days (46%), and >10 days (4%). A total of 6% of patients filled a second opioid prescription within 30 days.

Conclusion: Although many patients do not require opioids for umbilical hernia repair, most pediatric patients fill opioid prescriptions, including for prolonged courses and refills. Guidelines for appropriate prescribing of opioids after common, simple procedures, such as umbilical hernia repair, could improve the quality of care for children and impact the US epidemic of opioid abuse.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2018.10.029DOI Listing
April 2019

Practice Variation in Umbilical Hernia Repair Demonstrates a Need for Best Practice Guidelines.

J Pediatr 2019 03 15;206:172-177. Epub 2018 Nov 15.

Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Objective: To evaluate and better understand variations in practice patterns, we analyzed ambulatory surgery claims data from 3 demographically diverse states to assess the relationship between age at umbilical hernia repair and patient, hospital, and geographic characteristics.

Study Design: We performed a cross-sectional descriptive study of uncomplicated hernia repairs performed as a single procedure in 2012-2014, using the State Ambulatory Surgery and Services Database for Wisconsin, New York, and Florida. Age and demographic characteristics of umbilical hernia repair patients are described.

Results: The State Ambulatory Surgery and Services Database analysis included 6551 patients. Across 3 states, 8.2% of hernia repairs were performed in children <2 years, 18.7% in children age 2-3 years, and 73.0% in children age ≥4 years, but there was significant variability (P < .001) in practice patterns by state. In regression analysis, race, Medicaid insurance and rural residence were predictive of early repair, with African American patients less likely to have a repair before age 2 (OR 0.62, P = .046) and rural children (OR 1.53, P = .009) and Medicaid patients (OR 2.01, P < .001) more likely to do so. State of residence predicted early repair even when holding these variables constant.

Conclusions: The age of pediatric umbilical hernia repair varies widely. As hernias may resolve over time and can be safely monitored with watchful waiting, formal guidelines are needed to support delayed repair and prevent unnecessary operations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpeds.2018.10.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6389373PMC
March 2019

Cohort Study of Overutilization of Preventive Screening for Patients With Pancreatic Cancer.

Pancreas 2018 10;47(9):e65-e67

Department of Surgery and Wisconsin Institute for Surgical Outcomes Research, University of Wisconsin, School of Medicine and Public Health, Madison, WI Wisconsin Institute for Surgical Outcomes Research, University of Wisconsin, School of Medicine and Public Health, Madison, WI Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI Department of Surgery and Wisconsin Institute for Surgical Outcomes Research, University of Wisconsin, School of Medicine and Public Health, Madison, WI Wisconsin Institute for Surgical Outcomes Research, University of Wisconsin, School of Medicine and Public Health, Madison, WI

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPA.0000000000001131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457241PMC
October 2018

Adaptation and Implementation of a Transitional Care Protocol for Patients Undergoing Complex Abdominal Surgery.

Jt Comm J Qual Patient Saf 2018 12 8;44(12):741-750. Epub 2018 Aug 8.

Background: Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery.

Approach: The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC). Adaptation was accomplished using a modification of the Replicating Effective Programs (REP) model, which has four phases: (1) preconditions, (2) preimplementation, (3) implementation, and (4) maintenance and evolution. A random sample of five patients each month was selected to complete a phone survey regarding patient satisfaction. Preimplementation planning allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. The adapted protocol specifically addressed surgical issues such as nutrition, fever, ostomy output, dehydration, drain character/output, and wound appearance. After protocol launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions.

Outcomes: Survey responders reported 100% overall satisfaction with the transitional care program.

Key Insights: The adaptable nature of sC-TraC may allow for low-resource hospitals, such as rural or inner-city medical centers, to use the methodology provided in this study for implementation of local phone-based transitional care protocols. In addition, as the C-TraC program has begun to disseminate nationally across US Department of Veterans Affairs (VA) hospitals and rural health settings, sC-TraC may be implemented using the existing transitional care infrastructure in place at these hospitals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcjq.2018.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474978PMC
December 2018

Analysis of 90-day cost for open versus minimally invasive distal pancreatectomy.

HPB (Oxford) 2019 01 31;21(1):60-66. Epub 2018 Jul 31.

University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States. Electronic address:

Background: Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear.

Methods: Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments.

Results: 693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p<0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p<0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p<0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000.

Conclusion: MIDP is associated with >$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hpb.2018.07.003DOI Listing
January 2019

A scoping review of patient-sharing network studies using administrative data.

Transl Behav Med 2018 07;8(4):598-625

Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

There is a robust literature examining social networks and health, which draws on the network traditions in sociology and statistics. However, the application of social network approaches to understand the organization of health care is less well understood. The objective of this work was to examine approaches to conceptualizing, measuring, and analyzing provider patient-sharing networks. These networks are constructed using administrative data in which pairs of physicians are considered connected if they both deliver care to the same patient. A scoping review of English language peer-reviewed articles in PubMed and Embase was conducted from inception to June 2017. Two reviewers evaluated article eligibility based upon inclusion criteria and abstracted relevant data into a database. The literature search identified 10,855 titles, of which 63 full-text articles were examined. Nine additional papers identified by reviewing article references and authors were examined. Of the 49 papers that met criteria for study inclusion, 39 used a cross-sectional study design, 6 used a cohort design, and 4 were longitudinal. We found that studies most commonly theorized that networks reflected aspects of collaboration or coordination. Less commonly, studies drew on the strength of weak ties or diffusion of innovation frameworks. A total of 180 social network measures were used to describe the networks of individual providers, provider pairs and triads, the network as a whole, and patients. The literature on patient-sharing relationships between providers is marked by a diversity of measures and approaches. We highlight key considerations in network identification including the definition of network ties, setting geographic boundaries, and identifying clusters of providers, and discuss gaps for future study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/tbm/ibx015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6086089PMC
July 2018

Feasibility of an Image-Based Mobile Health Protocol for Postoperative Wound Monitoring.

J Am Coll Surg 2018 03 19;226(3):277-286. Epub 2018 Jan 19.

Wisconsin Institute of Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, WI.

Background: Surgical site infection (SSI) is the most common nosocomial infection and the leading cause of readmission among surgical patients. Many SSIs develop in the postdischarge period and are inadequately recognized by patients. To address this, we developed a mobile health protocol of remote wound monitoring using smartphone technology. The current study aims to establish its feasibility among patients and providers.

Study Design: We enrolled vascular surgery patients during their inpatient stay. They were trained to use our mobile health application, which allowed them to transmit digital images of their surgical wound and answer a survey about their recovery. After hospital discharge, participants completed the application daily for 2 weeks. Providers on the inpatient team reviewed submissions daily and contacted patients for concerning findings.

Results: Forty participants were enrolled. Forty-five percent of participants submitted data every day for 2 weeks, with an overall submission rate of 90.2%. Submissions were reviewed within an average of 9.7 hours of submission, with 91.9% of submissions reviewed within 24 hours. We detected 7 wound complications with 1 false negative. Participant and provider satisfaction was universally high.

Conclusions: Patients and their caregivers are willing to participate in a mobile health program aimed at remote monitoring of postoperative recovery, and they are able to complete it with a high level of fidelity and satisfaction. Preliminary results indicate the ability to detect and intervene on wound complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamcollsurg.2017.12.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919967PMC
March 2018

Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery.

J Surg Res 2018 01 26;221:196-203. Epub 2017 Sep 26.

The Ohio State University College of Medicine, Columbus, Ohio.

Background: Readmission within 30 d of an acute hospital stay is frequent, costly, and increasingly subject to penalties. Early readmission is most common after vascular surgery; these patients are often discharged to skilled nursing facilities (SNFs), making postacute care an essential partner in reducing readmissions. We characterize 30-day readmissions among vascular surgery patients discharged to SNF to provide evidence for this understudied segment of readmission after specialty surgery.

Methods: We utilize the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries to study 30-day readmission or death after discharge to SNF following abdominal aortic aneurysm repair or lower extremity revascularization from 2005-2009. Descriptive statistics and logistic regression with Least Adaptive Shrinkage and Selection Operator were used for analysis.

Results: Two thousand one hundred ninety-seven patients underwent an abdominal aortic aneurysm procedure or lower extremity revascularization at 686 hospitals and discharged to 1714 SNFs. Eight hundred (36%) were readmitted or had died at 30 d. In adjusted analysis, predictors of readmission or death at 30 d included SNF for-profit status (OR [odds ratio] = 1.2; P = 0.032), number of hospitalizations in the previous year (OR = 1.06; P = 0.011), number of comorbidities (OR = 1.06; P = 0.004), emergent procedure (OR = 1.69; P < 0.001), renal complication (OR = 1.38; P = 0.003), respiratory complication (OR = 1.45; P < 0.001), thromboembolic complication (OR = 1.57; P = 0.019), and wound complication (OR = 0.70; P = 0.017).

Conclusions: Patients discharged to SNF following vascular surgery have exceptionally high rates of readmission or death at 30 d. Many factors predicting readmission or death potentially modify decision-making around discharge, making early detection, discharge planning, and matching patient needs to SNF capabilities essential to improving outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2017.08.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6091856PMC
January 2018

Improving Patient-Centered Transitional Care after Complex Abdominal Surgery.

J Am Coll Surg 2017 Aug 23;225(2):259-265. Epub 2017 May 23.

Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S Middleton Memorial Veterans Hospital, Shorewood Hills, WI. Electronic address:

Background: Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol.

Study Design: The intervention includes in-person enrollment of patients. Follow-up protocolized phone calls by specially trained surgical C-TraC nurses addressed medication management, clinic appointments, operation-specific concerns, and identification of red-flag symptoms. Enrollment criteria included pancreatectomy, gastrectomy, operative small bowel obstruction or perforation, ostomy, discharge with a drain, in-hospital complication, and clinician discretion. Engaged patients participated in the first phone call, which was within 48 to 72 hours of discharge and continued every 3 to 4 days. Patients completed the program once they and surgical C-TraC nurse agreed that no additional follow-up was needed or the patient was readmitted.

Results: Two hundred and twelve patients were enrolled, October 2015 through April 2016, with a mean age of 56 years (range 19 to 89 years); 33% of patients were 65 years or older. Surgery sites included colon (46%), small bowel (16%), pancreas (12%), multivisceral (9%), liver (4.5%), retroperitoneum/soft tissue (4.5%), gastric (4%), biliary (2%), and appendix (1.5%). Refusal rate was 1% and engagement was 95%. At initial call, 47% of patients had at least 1 medication discrepancy (range 0 to 6). Mean number of calls from provider to patient was 3.2 (range 0 to 20, median 3).

Conclusions: A phone-based transitional care protocol for surgical patients is feasible, with <1% refusals and 95% engagement. Medication management is a prominent issue. Future studies are needed to assess the impact of surgical C-TraC on post-discharge healthcare use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamcollsurg.2017.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606230PMC
August 2017

30-day Readmission After Pancreatic Resection: A Systematic Review of the Literature and Meta-analysis.

Ann Surg 2017 08;266(2):242-250

*University of Wisconsin, Department of Surgery, Division of Surgical Oncology, Madison, WI †University of Wisconsin, Department of Surgery, Wisconsin Institute for Surgical Outcomes Research, Madison, WI.

Objective: The aim of this study was to identify and compare common reasons and risk factors for 30-day readmission after pancreatic resection.

Background: Hospital readmission after pancreatic resection is common and costly. Many studies have evaluated this problem and numerous discrepancies exist regarding the primary reasons and risk factors for readmission.

Methods: Multiple electronic databases were searched from 2002 to 2016, and 15 relevant articles identified. Overall readmission rate was calculated from individual study estimates using a random-effects model. Study data were combined and overall estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor. Multivariable data were qualitatively synthesized.

Results: The overall 30-day readmission rate was 19.1% (95% CI 17.4-20.7) across all studies. Infectious complications and gastrointestinal disorders, such as failure to thrive and delayed gastric emptying, together accounted for 58.9% of all readmissions. Demographic factors did not predict readmission. Heart disease (OR 1.37, 95% CI 1.12-1.67), hypertension (OR 1.44, 95% CI 1.09-1.91), and intraoperative blood transfusion (OR 1.45, 95% CI 1.15-1.83) were weak predictors of readmission, while any postoperative complications (OR 2.22, 95% CI 1.55-3.18) or severe complications (OR 2.84, 95% CI 1.65-4.89) were stronger predictors.

Conclusions: Readmission after pancreatic resection is common and can largely be attributed to infectious complications and inability to maintain adequate hydration and nutrition. Focus on outpatient resources and follow-up to address these issues will prove valuable in reducing readmissions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000002230DOI Listing
August 2017

Feasibility of Implementing a Patient-Centered Postoperative Wound Monitoring Program Using Smartphone Images: A Pilot Protocol.

JMIR Res Protoc 2017 Feb 22;6(2):e26. Epub 2017 Feb 22.

Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI, United States.

Background: Surgical site infections (SSI) represent a significant public health problem as the most common nosocomial infection and a leading cause of unplanned hospital readmissions among surgical patients. Many develop following hospital discharge and often go unrecognized by patients. Telemedicine offers the opportunity to leverage the mobile technology to remotely monitor wound recovery in the transitional period between hospital discharge and routine clinic follow-up. However, many existing telemedicine platforms are episodic, replacing routine follow-up, rather than equipped for continued monitoring; they include only low-risk patient populations and those who already have access to and comfort with the necessary technology; and transmit no visual information.

Objective: Drawing upon the Coleman model for care transitions and the Proctor model for implementation, we propose a protocol of postoperative wound monitoring using smartphone digital images. In this study, we will establish the feasibility of such a program, both for patients and for the clinical care team.

Methods: We will recruit 40 patients or patient/caregiver pairs from our inpatient vascular surgery service. Eligible patients will be English-speaking, 18 years of age or older, and have an incision at least 3 cm in length. Participants will receive a training session, during which they will learn to use the device and the wound monitoring smartphone app. Following hospital discharge, they will submit digital images of their wound and responses to a survey about their recovery for 14 days. Experienced health care providers on the vascular surgery inpatient service will review transmitted data daily and contact patients for any concerning findings.

Results: Primary outcomes will include participant adherence to the protocol, time required for providers to review submissions, time from submission to provider review, and participant satisfaction. Secondary outcomes will include SSI detection and hospital readmission.

Conclusions: Health systems are increasingly dedicating efforts to transitional care improvement programs. This feasibility trial will confirm whether patients and their caregivers can learn to use a postdischarge wound monitoring smartphone app and will assess patient and provider satisfaction. This protocol will provide preliminary evidence for a shift in the delivery of postdischarge care in a patient-centered and cost-effective manner.

Trial Registration: Clinicaltrials.gov NCT02735525; https://clinicaltrials.gov/ct2/show/NCT02735525 (Archived by WebCite at http://www.webcitation.org/6oIvN4Mab).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/resprot.6819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5343214PMC
February 2017

Endovascular Versus Open Revascularization for Peripheral Arterial Disease.

Ann Surg 2017 02;265(2):424-430

*Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine & Public Health, Madison, WI †Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine & Public Health, Madison, WI ‡Departments of Population Health Sciences and Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Objective: The aim of this study was to determine whether endovascular or open revascularization provides an advantageous approach to symptomatic peripheral arterial disease (PAD) over the longer term.

Summary Of Background Data: The optimal revascularization strategy for symptomatic lower extremity PAD is not established.

Methods: We evaluated amputation-free survival, overall survival, and relative rate of subsequent vascular intervention after endovascular or open lower extremity revascularization for propensity-score matched cohorts of Medicare beneficiaries with PAD from 2006 through 2009.

Results: Among 14,685 eligible patients, 5928 endovascular and 5928 open revascularization patients were included in matched analysis. Patients undergoing endovascular repair had improved amputation-free survival compared with open repair at 30 days (7.4 vs 8.9%, P = 0.002). This benefit persisted over the long term: At 4 years, 49% of endovascular patients had died or received major amputation compared with 54% of open patients (P < 0.001). An endovascular procedure was associated with a risk-adjusted 16% decreased risk of amputation or death compared with open over the study period (hazard ratio: 0.84; 95% confidence interval, 0.79-0.89; P < 0.001). The amputation-free survival benefit associated with an endovascular revascularization was more pronounced in patients with congestive heart failure or ischemic heart disease than in those without (P = 0.021 for interaction term). The rate of subsequent intervention at 30 days was 7.4% greater for the endovascular vs the open revascularization cohort. At 4 years, this difference remained stable at 8.6%.

Conclusions: Using population-based data, we demonstrate that an endovascular approach is associated with improved amputation-free survival over the long term with only a modest relative increased risk of subsequent intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000001676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174695PMC
February 2017

Evaluating Patient Usability of an Image-Based Mobile Health Platform for Postoperative Wound Monitoring.

JMIR Mhealth Uhealth 2016 Sep 28;4(3):e113. Epub 2016 Sep 28.

Wisconsin Institute of Surgical Outcomes Research, University of Wisconsin, Madison, WI, United States.

Background: Surgical patients are increasingly using mobile health (mHealth) platforms to monitor recovery and communicate with their providers in the postdischarge period. Despite widespread enthusiasm for mHealth, few studies evaluate the usability or user experience of these platforms.

Objective: Our objectives were to (1) develop a novel image-based smartphone app for postdischarge surgical wound monitoring, and (2) rigorously user test it with a representative population of vascular and general surgery patients.

Methods: A total of 9 vascular and general surgery inpatients undertook usability testing of an internally developed smartphone app that allows patients to take digital images of their wound and answer a survey about their recovery. We followed the International Organization for Standardization (ISO) 9241-11 guidelines, focusing on effectiveness, efficiency, and user satisfaction. An accompanying training module was developed by applying tenets of adult learning. Sessions were audio-recorded, and the smartphone screen was mirrored onto a study computer. Digital image quality was evaluated by a physician panel to determine usefulness for clinical decision making.

Results: The mean length of time spent was 4.7 (2.1-12.8) minutes on the training session and 5.0 (1.4-16.6) minutes on app completion. 55.5% (5/9) of patients were able to complete the app independently with the most difficulty experienced in taking digital images of surgical wounds. Novice patients who were older, obese, or had groin wounds had the most difficulty. 81.8% of images were sufficient for diagnostic purposes. User satisfaction was high, with an average usability score of 83.3 out of 100.

Conclusion: Surgical patients can learn to use a smartphone app for postoperative wound monitoring with high user satisfaction. We identified design features and training approaches that can facilitate ease of use. This protocol illustrates an important, often overlooked, aspect of mHealth development to improve surgical care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/mhealth.6023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5062001PMC
September 2016

Inter-rater agreement and checklist validation for postoperative wound assessment using smartphone images in vascular surgery.

J Vasc Surg Venous Lymphat Disord 2016 07 26;4(3):320-328.e2. Epub 2016 Mar 26.

Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc. Electronic address:

Objective: Surgical site infection (SSI) is the most common nosocomial infection, in vascular surgery patients, who experience a high rate of readmission. Facilitating transition from hospital to outpatient care with digital image-based wound monitoring has the potential to detect and to enable treatment of SSI at an early stage. In this study, we evaluated whether smartphone digital images can supplant in-person evaluation of postoperative vascular surgery wounds.

Methods: We developed a wound assessment checklist using previously validated criteria. We recruited adults who underwent a vascular surgical procedure between 2014 and 2015, involving an incision of at least 3 cm, from a high-volume academic vascular surgery service. Vascular surgery care providers evaluated wounds in person using the assessment checklist; a different group of providers evaluated wounds by a smartphone digital image. Inter-rater agreement coefficients for wound characteristics and treatment plan were calculated within and between the in-person group and the digital image group; the sensitivity and specificity of digital images relative to in-person evaluation were determined.

Results: We assessed a total of 80 wounds. Regardless of modality, inter-rater agreement was poor when wounds were evaluated for the presence of ecchymosis and redness; moderate for cellulitis; and high for the presence of a drain, necrosis, or dehiscence. As expected, the presence of drainage was more readily observed in person. Inter-rater agreement was high for both in-person and image-based assessment with respect to course of treatment, with near-perfect agreement for treatments ranging from antibiotics to surgical débridement to hospital readmission. No difference in agreement emerged when raters evaluated poor-quality compared with high-quality images. For most parameters, specificity was higher than sensitivity for image-based compared with "gold standard" in-person assessment.

Conclusions: Using smartphone digital images is a valid method for evaluating postoperative vascular surgery wounds and is comparable to in-person evaluation with regard to most wound characteristics. The inter-rater reliability for determining treatment recommendations was universally high. Remote wound monitoring and assessment may play an integral role in future transitional care models to decrease readmission for SSI in vascular or other surgical patients. These findings will inform smartphone implementation in the clinical care setting as wound images transition from informal clinical communication to becoming part of the care standard.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jvsv.2016.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913032PMC
July 2016

Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review.

J Am Coll Surg 2016 05 13;222(5):915-27. Epub 2016 Feb 13.

Department of Surgery, University of Wisconsin School of Medicine & Public Health, Madison, WI. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamcollsurg.2016.01.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5660861PMC
May 2016

Managing psychosocial issues faced by young women with breast cancer at the time of diagnosis and during active treatment.

Curr Opin Support Palliat Care 2015 Sep;9(3):279-84

aWisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin bSchool of Public Health, University of California at Berkeley, Berkeley, California, USA.

Purpose Of Review: This review examines recent literature on the psychosocial needs of and interventions for young women. We focus on the active treatment period given the toxicity of treatment, the incidence of anxiety, and depressive symptoms in these women during treatment. This review summarizes research relevant to addressing their social and emotional concerns.

Recent Findings: Young women undergoing treatment for breast cancer remain understudied despite unique needs. Psychoeducational interventions help to relieve symptoms and emotional distress during treatment, but effects do not appear to persist over the longer term. In the clinical context, the performance of prognostic-risk prediction models in this population is poor. Surgical decision-making is often driven by fear of recurrence and body image rather than prognosis, and decision aids may help young women to synthesize information to preserve their role in the treatment process.

Summary: First, shared decision-making, second, balancing body image, fear of recurrence, and recommended treatment, and third, palliative care for metastasis are essential research priorities for the clinical setting. In the larger social context, unique family/partner dynamics as well as financial and insurance concerns warrant particular attention in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SPC.0000000000000161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787858PMC
September 2015
-->