Publications by authors named "Tarsicio Uribe-Leitz"

46 Publications

The impact of delayed management of fall-related hip fracture management on health outcomes for African American older adults.

J Trauma Acute Care Surg 2021 Jun;90(6):942-950

From the Center for Surgery and Public Health, Department of Surgery (M.P.J., C.S., M.K.D., M.C.-A., T.U.-L., Z.C.), Brigham and Women's Hospital; Department of Orthopaedic Surgery (M.H.), Massachusetts General Hospital; Department of Orthopedics Surgery (A.v.K.), Brigham and Women's Hospital; and Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery (M.C.-A., Z.C., A.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Black hip fracture patients experience worse health outcomes than otherwise similar White patients, but causes of these disparities are not known. We sought to determine if delays in hip fracture surgery and/or hospital structures contribute to racial disparities in hip fracture outcomes.

Methods: Using 2006 to 2016 Trauma Quality Program Public Use Files, we identified hip fracture patients with primary mechanisms of fall from standing and determined surgical treatment category (no surgery, surgery within 24 hours after arrival, surgery 24-48 hours after arrival, surgery more than 48 hours after arrival) as well as hospital structure characteristics (trauma center designation, teaching status, profit status, bed size). We used generalized structural equation models to conduct path analyses and determine if hip fracture treatment and hospital characteristics mediated the relationship between race (non-Hispanic Black/non-Hispanic White) and outcomes (complications, length of stay, disposition).

Results: Non-Hispanic Black patients were more likely than non-Hispanic White patients to receive treatment at an academic medical center (49.1% vs. 28.0%), at a hospital with >600 inpatient beds (39.5% vs. 25.3%), and at a level I or II trauma center (86.8% vs. 77.7%); were more likely to go without hip fracture repair surgery (22.8% vs. 21.4%); and were more likely to have delayed surgery >48 hours after hospital arrival (15.5% vs. 10.6%). Path analysis suggests hip fracture treatment group and hospital characteristics mediate the relationship with complications, length of stay, and disposition.

Conclusion: Non-Hispanic Black patients with fall-related hip fracture are more likely to experience delays in care, complications, and longer inpatient stays. Hospital characteristics contribute to increased risk of complications and longer length of stay, both as independent determinants of outcomes and as determinants of delays in hip fracture surgery.

Level Of Evidence: Prognostic and epidemiologic, level III.
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http://dx.doi.org/10.1097/TA.0000000000003149DOI Listing
June 2021

Differences in outcomes after emergency general surgery between Hispanic subgroups in the New Jersey State Inpatient Database (2009-2014): The Hispanic population is not monolithic.

Am J Surg 2021 Apr 2. Epub 2021 Apr 2.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Our aim was to examine differences in clinical outcomes between Hispanic subgroups who underwent emergency general surgery (EGS).

Methods: Retrospective cohort study of the HCUP State Inpatient Database from New Jersey (2009-2014), including Hispanic and non-Hispanic White (NHW) adult patients who underwent EGS. Multivariable analyses were performed on outcomes including 7-day readmission and length of stay (LOS).

Results: 125,874 patients underwent EGS operations. 22,971 were Hispanic (15,488 with subgroup defined: 7,331 - Central/South American; 4,254 - Puerto Rican; 3,170 - Mexican; 733 - Cuban). On multivariable analysis, patients in the Central/South American subgroup were more likely to be readmitted compared to the Mexican subgroup (OR 2.02; p < 0.001, respectively). Puerto Rican and Central/South American subgroups had significantly shorter LOS than Mexican patients (Puerto Rico -0.58 days; p < 0.001; Central/South American -0.30 days; p = 0.016).

Conclusions: There are significant differences in EGS outcomes between Hispanic subgroups. These differences could be missed when data are aggregated at Hispanic ethnicity.
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http://dx.doi.org/10.1016/j.amjsurg.2021.03.057DOI Listing
April 2021

Disparities in the Geographic Distribution of Neurosurgeons in the United States: A Geospatial Analysis.

World Neurosurg 2021 Apr 5. Epub 2021 Apr 5.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA; Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: Large disparities in access to neurosurgical care are known, but there are limited data on whether geographic distribution of the neurosurgery workforce potentially plays a role in these disparities. The goal of this study was to identify the geographic distribution of neurosurgeons in the United States and to study the association of the per capita workforce distribution with socioeconomic characteristics of the population.

Methods: The number of practicing neurosurgeons in the United States in 2016 was obtained from the 2017-2018 American Medical Association Masterfile contained within the Area Health Resource File. The association of the number of neurosurgeons per 100,000 population with socioeconomic characteristics was assessed through linear regression analysis at Hospital Referral Region (HRR) level.

Results: The median number of neurosurgeons per capita across all HRRs was 1.47 neurosurgeons per 100,000 population (interquartile range, 1.02-2.27). Bivariable analysis showed that greater supply of neurosurgeons was positively associated with regional levels of college education, median income, and median age. The number of neurosurgeons per capita at the HRR level was negatively associated with unemployment, poverty, and percent uninsured.

Conclusions: Regions characterized by low socioeconomic status have fewer neurosurgeons per capita in the United States. Low income, low number of college graduates, and high unemployment rate are associated with fewer numbers of neurosurgeons per capita. Further research is needed to determine if these geographic workforce disparities contribute to poor access to quality neurosurgical care.
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http://dx.doi.org/10.1016/j.wneu.2021.03.152DOI Listing
April 2021

Access to Essential Surgical Care in Chiapas, Mexico: A System-Wide Geospatial Analysis.

World J Surg 2021 Jun 22;45(6):1663-1671. Epub 2021 Feb 22.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.

Background: Long travel times to reach essential surgical care in Chiapas, Mexico's poorest state, can delay lifesaving procedures and contribute to adverse outcomes. Geographical access to surgical facilities is 1 of the 6 indicators of the Lancet Commission on Global Surgery and has been measured extensively worldwide. Our objective is to determine the population with 2-h geographical access to facilities capable of performing the Bellwether procedures (laparotomy, cesarean delivery, and open fracture repair). This is the first study in Mexico to assess access to surgical facilities, including both the fragmented public sector and the private sector.

Methods: In this cross-sectional study, conducted from June 2019 to January 2020, Bellwether capable surgical facilities from all health systems in Chiapas were geocoded and assessed through on-site data collection, Ministry of Health databases, and verified via telephone. Geospatial analyses were performed on Redivis.

Results: We identified 59 Bellwether capable hospitals, with 17.5% (n = 954,460) of the state residing more than 2 h from surgical care in public and private health systems. Of those, 22 facilities had confirmed 24/7 Bellwether capability, and 23% (n = 1,178,383) of the affiliated population resided more than 2 h from these hospitals.

Conclusions: Our study shows that the Ministry of Health and employment-based health coverage could provide timely access to essential surgical care for the majority of the population. However, the fragmentation of the healthcare system leaves a gap that contributes to delays in care and unmet emergency surgical needs.
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http://dx.doi.org/10.1007/s00268-021-05975-yDOI Listing
June 2021

Assessment of diagnostics capacity in hospitals providing surgical care in two Latin American states.

EClinicalMedicine 2020 Dec 5;29-30:100620. Epub 2020 Nov 5.

Compañeros en Salud, Calle Primera Pte. Sur 25, Centro, 30370, Angel Albino Corzo, Chiapas, Mexico.

Background: Diagnostic services are an essential component of high-quality surgical, anesthesia and obstetric (SAO) care. Efforts to scale up SAO care in Latin America have often overlooked diagnostics capacity. This study aims to analyze the capacity of diagnostic services, including radiology, pathology, and laboratory medicine, in hospitals providing SAO care in the states of Chiapas, Mexico and Amazonas, Brazil.

Methods: A stratified cross-sectional evaluation of diagnostic capacity in hospitals performing surgery in Chiapas and Amazonas was performed using the Surgical Assessment Tool (SAT). National data sources were queried for indicators of diagnostics capacity in terms of workforce, infrastructure and diagnosis utilization. Fisher's exact tests and chi-square tests were used to compare categorical variables between the private and public sector in Chiapas while descriptive statistics are used to compare Amazonas and Chiapas.

Findings: In Chiapas, 53% ( = 17) of public and 34% ( = 20) of private hospitals providing SAO care were assessed. More private hospitals than public hospitals could always provide x-rays (35% vs 23.5%) and ultrasound (85% vs 47.1%). However neither sector could consistently perform basic laboratory testing such as complete blood counts (70.6% public, 65% private). In Amazonas, 30% ( = 18) of rural hospitals were surveyed. Most had functioning x-ray machine (77.8%) and ultrasound (55.6%). The majority of hospitals could provide complete blood count (66.7%) but only one hospital (5.6%) could always perform an infectious panel. Both Chiapas and Amazonas had dramatically fewer diagnostic practitioners per capita in each state compared to the national average capacity.

Interpretation: Facilities providing SAO care in low-resource states in Mexico and Brazil often lack functioning diagnostics services and workforce. Scale-up of diagnostic services is essential to improve SAO care and should occur with emphasis on equitable and adequate resource allocation.
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http://dx.doi.org/10.1016/j.eclinm.2020.100620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788433PMC
December 2020

Projected impact of COVID-19 mitigation strategies on hospital services in the Mexico City Metropolitan Area.

PLoS One 2020 9;15(11):e0241954. Epub 2020 Nov 9.

Anahuac Institute of Public Health, Faculty of Health Sciences, Anahuac University Mexico, Huixquilucan, State of Mexico, Mexico.

Evidence-based models may assist Mexican government officials and health authorities in determining the safest plans to respond to the coronavirus disease 2019 (COVID-19) pandemic in the most-affected region of the country, the Mexico City Metropolitan Area. This study aims to present the potential impacts of COVID-19 in this region and to model possible benefits of mitigation efforts. The COVID-19 Hospital Impact Model for Epidemics was used to estimate the probable evolution of COVID-19 in three scenarios: (i) no social distancing, (ii) social distancing in place at 50% effectiveness, and (iii) social distancing in place at 60% effectiveness. Projections of the number of inpatient hospitalizations, intensive care unit admissions, and patients requiring ventilators were made for each scenario. Using the model described, it was predicted that peak case volume at 0% mitigation was to occur on April 30, 2020 at 11,553,566 infected individuals. Peak case volume at 50% mitigation was predicted to occur on June 1, 2020 with 5,970,093 infected individuals and on June 21, 2020 for 60% mitigation with 4,128,574 infected individuals. Occupancy rates in hospitals during peak periods at 0%, 50%, and 60% mitigation would be 875.9%, 322.8%, and 203.5%, respectively, when all inpatient beds are included. Under these scenarios, peak daily hospital admissions would be 40,438, 13,820, and 8,650. Additionally, 60% mitigation would result in a decrease in peak intensive care beds from 94,706 to 23,116 beds and a decrease in peak ventilator need from 67,889 to 17,087 units. Mitigating the spread of COVID-19 through social distancing could have a dramatic impact on reducing the number of infected people and minimize hospital overcrowding. These evidence-based models may enable careful resource utilization and encourage targeted public health responses.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241954PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652345PMC
November 2020

A National Assessment of Trauma Systems Using the American College of Surgeons NBATS Tool: Geographic Distribution of Trauma Center Need.

Ann Surg 2020 Oct 15. Epub 2020 Oct 15.

Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Objective: To compare the Needs Based Assessment of Trauma Systems (NBATS) tool estimates of trauma center need to the existing trauma infrastructure using observed national trauma volume.

Summary Background Data: Robust trauma systems have improved outcomes for severely injured patients. The NBATS tool was created by the American College of Surgeons (ACS) to align trauma resource allocation with regional needs.

Methods: Data from the Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases, the Trauma Information Exchange Program, and US Census was used to calculate an NBATS score for each trauma service area (TSA) as defined by the Pittsburgh Atlas. This score was used to estimate the number of trauma centers allocated to each TSA and compared to the number of existing trauma centers.

Results: NBATS predicts the need for 117 additional trauma centers across the United States in order to provide adequate access to trauma care nationwide. At least one additional trauma center is needed in 49% of trauma service areas.

Conclusions: Application of the NBATS tool nationally shows the need for additional trauma infrastructure across a large segment of the United States. We identified some limitations of the NBATS tool, including preferential weighting based on current infrastructure. The NBATS tool provides a good framework to begin the national discussion around investing in the expansion of trauma systems nationally, however in many instances lacks the granularity to drive change at the local level.
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http://dx.doi.org/10.1097/SLA.0000000000004555DOI Listing
October 2020

A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care.

J Surg Res 2021 01 8;257:486-492. Epub 2020 Sep 8.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts. Electronic address:

Background: There are well-documented disparities in outcomes for injured Black and Hispanic patients in the United States. However, patient level characteristics cannot fully explain the differences in outcomes and system-level factors, including the trauma center designation of the hospital to which a patient presents, may contribute to their worse outcomes. We aim to determine if Black and Hispanic patients are more likely to be undertriaged, compared with white patients.

Methods: This is a retrospective, cross-sectional, population-based study that uses data from the 2014 Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases. We included data from all states with available State Inpatient Databases data that included both race and hospital characteristics needed for analysis (n = 18). Logistic regression was used to identify predictors of severely injured (Injury Severity Score ≥16) patients being brought to a trauma center.

Results: We identified 70,970 severely injured trauma patients with complete data. Non-Hispanic White represented 74.1% of the study population, 9.8% were non-Hispanic Black, and 9.7% were Hispanic. After adjustment for other demographic and injury characteristics, Non-Hispanic Black and Hispanic patients were more likely to be undertriaged, compared with white patients (odds ratio, 1.20; 95% confidence interval, 1.12-1.29 and odds ratio, 1.39; 95% confidence interval, 1.29-1.48, respectively). Male sex and older age were associated with higher odds of undertriage, whereas urban residence, high injury severity, and penetrating injury were associated with lower odds of undertriage.

Conclusions: Severely injured Black and Hispanic trauma patients are more likely to be undertriaged than otherwise similar white patients. The factors that contribute to racial and ethnic disparities in receiving trauma center care need to be identified and addressed to provide equitable trauma care.
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http://dx.doi.org/10.1016/j.jss.2020.08.031DOI Listing
January 2021

Travel Time to Access Obstetric and Neonatal Care in the United States.

Obstet Gynecol 2020 09;136(3):610-612

Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; the Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada; the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; the Department of Epidemiology, Technical University Munich, Munich, Germany; and the Departments of Obstetrics and Gynecology, Brigham and Women's Hospital, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1097/AOG.0000000000004053DOI Listing
September 2020

Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement.

JAMA Netw Open 2020 07 1;3(7):e209393. Epub 2020 Jul 1.

Forum on Medical and Public Health Preparedness for Catastrophic Events, National Academies of Science, Washington, DC.

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector.

Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons.

Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda.

Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy.

Conclusions And Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.9393DOI Listing
July 2020

Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement.

JAMA Netw Open 2020 07 1;3(7):e209393. Epub 2020 Jul 1.

Forum on Medical and Public Health Preparedness for Catastrophic Events, National Academies of Science, Washington, DC.

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector.

Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons.

Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda.

Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy.

Conclusions And Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.9393DOI Listing
July 2020

Traumatic rib fractures: a marker of severe injury. A nationwide study using the National Trauma Data Bank.

Trauma Surg Acute Care Open 2020 10;5(1):e000441. Epub 2020 Jun 10.

Department of Orthopaedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: In recent years, there has been increasing interest in the treatment of patients with rib fractures. However, the current literature on the epidemiology and outcomes of rib fractures is outdated and inconsistent. Furthermore, although it has been suggested that there is a large heterogeneity among patients with traumatic rib fractures, there is insufficient literature reporting on the outcomes of different subgroups.

Methods: A retrospective cohort study using the National Trauma Data Bank was performed. All adult patients with one or more traumatic rib fractures or flail chest who were admitted to a hospital between January 2010 and December 2016 were identified by the International Classification of Diseases Ninth Revision diagnostic codes.

Results: Of the 564 798 included patients with one or more rib fractures, 44.9% (n=2 53 564) were patients with polytrauma. Two per cent had open rib fractures (n=11 433, 2.0%) and flail chest was found in 4% (n=23 388, 4.1%) of all cases. Motor vehicle accidents (n=237 995, 51.6%) were the most common cause of rib fractures in patients with polytrauma and flail chest. Blunt chest injury accounted for 95.5% (n=5 39 422) of rib fractures. Rib fractures in elderly patients were predominantly caused by high and low energy falls (n=67 675, 51.9%). Ultimately, 49.5% (n=2 79 615) of all patients were admitted to an intensive care unit, of whom a quarter (n=146 191, 25.9%) required invasive mechanical ventilatory support. The overall mortality rate was 5.6% (n=31 524).

Discussion: Traumatic rib fractures are a marker of severe injury as approximately half of patients were patients with polytrauma. Furthermore, patients with rib fractures are a very heterogeneous group with a considerable difference in epidemiology, injury characteristics and in-hospital outcomes. Worse outcomes were predominantly observed among patients with polytrauma and flail chest. Future studies should recognize these differences and treatment should be evaluated accordingly.

Level Of Evidence: II/III.
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http://dx.doi.org/10.1136/tsaco-2020-000441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292040PMC
June 2020

Risk Prediction Accuracy Differs for Transferred and Nontransferred Emergency General Surgery Cases in the ACS-NSQIP.

J Surg Res 2020 03 22;247:364-371. Epub 2019 Nov 22.

Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

Background: Risk prediction accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator has been shown to differ between emergency and elective surgery. Benchmarking methods of clinical performance require accurate risk estimation, and current methods rarely account for admission source; therefore, our goal was to assess whether the ACS-NSQIP predicts mortality comparably between transferred and nontransferred emergency general surgery (EGS) cases.

Materials And Methods: This is a retrospective study using the ACS-NSQIP database from 2005 to 2014including all inpatients who underwent one of seven previously described EGS procedures. The admission source was classified as directly admitted versus transferred from an outside emergency room or an acute care facility. We compared the accuracy of ACS-NSQIP-predicted mortality probabilities using the observed-to-expected (O:E) ratio and Brier score. A subgroup analysis was performed to compare accuracy of high-risk and low-risk procedures.

Results: A total of 206,103 EGS admissions were identified, of which 6.97% were transfers. Overall mortality was 3.26% for the entire cohort and 10.24% within the transfer group. The O:E ratios generated by ACS-NSQIP models differed between transferred patients (O:E = 1.0, 95% confidence interval = 0.97-1.02) and nontransferred patients (O:E = 1.12, 95% confidence interval = 1.09-1.14). The Brier score for transferred patients was greater than that for nontransferred patients (0.063 versus 0.018, respectively) showing higher accuracy for nontransferred patients.

Conclusions: The ACS-NSQIP risk estimates used for benchmarking differ between transferred and nontransferred EGS cases. Analyses of the Brier score by the ACS-NSQIP risk calculator demonstrated inferior prediction for transferred patients. This increased burden on accepting institutions will have an impact on quality metrics and should be considered for benchmarking of clinical performance.
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http://dx.doi.org/10.1016/j.jss.2019.10.007DOI Listing
March 2020

National Study of Triage and Access to Trauma Centers for Older Adults.

Ann Emerg Med 2020 02 13;75(2):125-135. Epub 2019 Nov 13.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.

Study Objective: To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level.

Methods: Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation.

Results: Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles.

Conclusion: Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed.
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http://dx.doi.org/10.1016/j.annemergmed.2019.06.018DOI Listing
February 2020

The Impact of Income on Emergency General Surgery Outcomes in Urban and Rural Areas.

J Surg Res 2020 01 12;245:629-635. Epub 2019 Sep 12.

Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients.

Materials And Methods: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]).

Results: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52).

Conclusions: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.
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http://dx.doi.org/10.1016/j.jss.2019.08.010DOI Listing
January 2020

Trends of caesarean delivery from 2008 to 2017, Mexico.

Bull World Health Organ 2019 Jul 30;97(7):502-512. Epub 2019 Apr 30.

Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA.

Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, we analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. We obtained birth-certificate data from the Mexican General Directorate for Health Information and grouped the total number of vaginal and caesarean deliveries into five categories of facility: health-ministry hospitals; private hospitals; government employment-based insurance hospitals; military hospitals; and other facilities. Delivery rates were calculated for each category nationally and for each state. On average, 2 114 630 (95% confidence interval, CI: 2 061 487-2 167 773) live births occurred nationally each year between 2008 and 2017. Of these births, 53.5% (1 130 570; 95% CI: 1 108 068-1 153 072) were vaginal deliveries, and 45.3% (957 105; 95% CI: 922 936-991 274) were caesarean deliveries, with little variation over time. During the study period, the number of live births increased by 4.4% (from 1 978 380 to 2 064 507). The vaginal delivery rate decreased from 54.8% (1 083 331/1 978 380) to 52.9% (1 091 958/2 064 507), giving a relative percentage decrease in the rate of 3.5%. The caesarean delivery rate increased from 43.9% (869 018/1 978 380) to 45.5% (940 206/2 064 507), giving a relative percentage increase in the rate of 3.7%. The biggest change in delivery rates was in private-sector hospitals. Since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.
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http://dx.doi.org/10.2471/BLT.18.224303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593338PMC
July 2019

Emergency general surgery procedures in hematopoietic stem cell transplant recipients.

Am J Surg 2019 11 28;218(5):972-977. Epub 2019 Feb 28.

Brigham and Women's Hospital, Division of Trauma, Burn, and Surgical Critical Care, Boston, MA, USA.

Background: Outcomes of emergency general surgery (EGS) procedures on hematopoietic stem cell transplant (HST) recipients have not been defined in a large, national database. Whether EGS during HST engraftment admission, or in HST patients with graft versus host disease (GVHD) results in worse outcomes is unknown.

Methods: The National Inpatient Sample (NIS) was examined for patients with a history of BMT between 2001 and 2014.

Results: There were 520,000 HST admissions meeting inclusion criteria, of which, 14,143 (2.7%) required EGS. Of those requiring EGS, 378 (2.7%) were during engraftment admission and 13,765 (97.3%) on subsequent admission. For those requiring EGS during subsequent admission, 9,920 (72.1%) had a history of GVHD and 3,845 (27.9%) did not. On multivariate analysis, requirement of EGS was associated with mortality (OR: 1.71, 95%CI: 1.47-1.99, p < 0.001). For patients requiring EGS, engraftment admission or GVHD was not associated with mortality.

Conclusions: While EGS results in worse survival for the HST population, patients in their engraftment admission do not appear to be at increased mortality risk. In addition, GVHD does not worsen survival.
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http://dx.doi.org/10.1016/j.amjsurg.2019.02.030DOI Listing
November 2019

Transferred Emergency General Surgery Patients Are at Increased Risk of Death: A NSQIP Propensity Score Matched Analysis.

J Am Coll Surg 2019 06 31;228(6):871-877. Epub 2019 Jan 31.

Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Background: Emergency general surgery (EGS) encompasses high-risk patients undergoing high-risk procedures. Admission source, particularly interhospital transfer, is rarely accounted for in clinical performance benchmarking. Our goal was to assess the impact of transfer status on outcomes after EGS.

Study Design: This was a retrospective analysis of the American College of Surgeons NSQIP database (2005 to 2014). All inpatients that underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally were included. Admission source was classified as directly admitted vs transferred from an outside emergency department or an acute care facility. The primary outcomes were overall mortality, overall morbidity, and major morbidity. A 3:1 propensity score matched analysis was used to determine the association of admission source with outcomes. Subgroup analysis was performed for high- and low-risk EGS procedures.

Results: A total of 222,519 EGS admissions were identified, of which 15,232 (6.8%) were transfers. Mean age was 46 years and 51.4% were female. Overall mortality was 3.1% for the entire cohort and 10.8% within the transfer group. After propensity score matched analysis for 33 clinical and demographic variables, transferred patients had higher rates of overall mortality (odds ratio 1.01; 95% CI 1.01 to 1.02), higher overall morbidity (odds ratio 1.07; 95% CI 1.05 to 1.09), and major morbidity (odds ratio 1.06; 95% CI 1.04 to 1.08) compared with directly admitted patients.

Conclusions: After rigorous risk adjustment, interhospital transfer status has a small effect on mortality and morbidity in the EGS population. This could suggest that it is reasonable to transfer patients and that regionalization of care should be encouraged.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.01.014DOI Listing
June 2019

Association of Medicaid Expansion Policy with Outcomes in Homeless Patients Requiring Emergency General Surgery.

World J Surg 2019 06;43(6):1483-1489

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Background: Medicaid expansion has reduced obstacles faced in receiving care. Emergency general surgery (EGS) is a clinical event where delays in appropriate care impact outcomes. Therefore, we assessed the association between non-Medicaid expansion policy and multiple outcomes in homeless patients requiring EGS.

Methods: We used 2014 State Inpatient Database to identify homeless individuals admitted with a primary EGS diagnosis who underwent an EGS procedure. States were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression was used to examine associations between non-Medicaid expansion states and (1) length of stay and (2) total index hospital charges within the homeless population. Multivariable logistic regression was used to assess the associations between non-Medicaid expansion and (1) mortality, (2) surgical complications, (3) discharge against medical advice, and (4) home healthcare.

Results: A total of 6930 homeless patients were identified. Of these, 435 (6.2%) were in non-expansion states. Non-Medicaid expansion was associated with higher charges (coef: $46,264, 95% CI 40,388-52,139). There were non-significant differences in mortality (OR 1.4, 95% CI 0.79-2.62; p = 0.2) or surgical complications (OR 1.16, 95% CI 0.7-1.8; p = 0.4). However, homeless individuals living in non-expansion states did have higher odds of being discharged against medical advice (OR 2.1, 95% CI 1.08-4.05; p = 0.02), and lower odds of receiving home healthcare (OR 0.6, 95% CI 0.4-0.8; p = 0.01).

Conclusion: Homeless patients living in Medicaid expansion states had lower odds of being discharged against medical advice, higher likelihood of receiving home healthcare and overall lower total index hospital charges.
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http://dx.doi.org/10.1007/s00268-019-04932-0DOI Listing
June 2019

Impact of Affordable Care Act-related insurance expansion policies on mortality and access to post-discharge care for trauma patients: an analysis of the National Trauma Data Bank.

J Trauma Acute Care Surg 2019 02;86(2):196-205

From the Department of Surgery (J.W.S.), Harborview Medical Center, University of Washington, Seattle, WA; Department of Surgery (P.U.N., A.S., A.H.H), Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery (T.U.-L., A.S., A.H.H.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (K.W.S.), Boston, MA; Yale School of Medicine (C.K.Z.), New Haven, CT; and Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery (A.S., A.H.H.), Brigham and Women's Hospital, Boston, MA.

Background: Uninsured trauma patients have worse outcomes and worse access to post-discharge care that is critically important for recovery after injury. Little is known regarding the impact of the insurance coverage expansion policies of the Affordable Care Act (ACA), most notably state-level Medicaid expansion, on trauma patients. In this study, we examine the national impact of these policies on payer mix, inpatient mortality, and access to post-acute care for trauma patients.

Methods: We used the 2011-2016 National Trauma Data Bank to evaluate for changes in insurance coverage among trauma patients 18-64 years old. Our pre-/post-expansion models defined 2011-2013 as the pre-policy period, 2015-2016 as the post-policy period, and 2014 as a washout year. To evaluate for policy-associated changes in inpatient mortality and discharge disposition among the policy-eligible sample, we leveraged multivariable linear regression techniques to adjust for year-to-year variation in patient demographics, injury characteristics, and facility traits. We then examined the relationship between the magnitude of facility-level reductions in uninsured patients and access to post-acute care after policy implementation.

Results: We identified 1,656,469 patients meeting inclusion criteria between 2011 and 2016. The pre-policy uninsured rate of 23.4% fell by 5.9 percentage-points after coverage expansion (p < 0.001), with a corresponding 7.5 percentage-point increase in Medicaid coverage (p < 0.001). After policy implementation, there were no significant changes in inpatient mortality. However, there was a >30% relative increase in discharge to a post-acute care facility and a similar increase in discharge with home health services (p < 0.001 for both). The greatest gains in access to post-acute services were seen among facilities with the greatest reductions in their uninsured rate (p = 0.003).

Conclusion: ACA-related coverage expansion policies, most notably Medicaid expansion, were associated with a >25% reduction in the uninsured rate among non-elderly adult trauma patients. Although no immediate impact on inpatient mortality was seen, insurance coverage expansion was associated with a higher proportion of patients receiving critically important post-discharge care.

Level Of Evidence: Epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002117DOI Listing
February 2019

Assessment of Patient-Centered Approaches to Collect Sexual Orientation and Gender Identity Information in the Emergency Department: The EQUALITY Study.

JAMA Netw Open 2018 12 7;1(8):e186506. Epub 2018 Dec 7.

Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Health care and government organizations call for routine collection of sexual orientation and gender identity (SOGI) information in the clinical setting, yet patient preferences for collection methods remain unknown.

Objective: To assess of the optimal patient-centered approach for SOGI collection in the emergency department (ED) setting.

Design, Setting, And Participants: This matched cohort study (Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity [EQUALITY] Study) of 4 EDs on the east coast of the United States sequentially tested 2 different SOGI collection approaches between February 2016 and March 2017. Multivariable ordered logistic regression was used to assess whether either SOGI collection method was associated with higher patient satisfaction with their ED experience. Eligible adults older than 18 years who identified as a sexual or gender minority (SGM) were enrolled and then matched 1 to 1 by age (aged ≥5 years) and illness severity (Emergency Severity Index score ±1) to patients who identified as heterosexual and cisgender (non-SGM), and to patients whose SOGI information was missing (blank field). Patients who identified as SGM, non-SGM, or had a blank field were invited to complete surveys about their ED visit. Data analysis was conducted from April 2017 to November 2017.

Interventions: Two SOGI collection approaches were tested: nurse verbal collection during the clinical encounter vs nonverbal collection during patient registration. The ED physicians, physician assistants, nurses, and registrars received education and training on sexual or gender minority health disparities and terminology prior to and throughout the intervention period.

Main Outcomes And Measures: A detailed survey, developed with input of a stakeholder advisory board, which included a modified Communication Climate Assessment Toolkit score and additional patient satisfaction measures.

Results: A total of 540 enrolled patients were analyzed; the mean age was 36.4 years and 66.5% of those who identified their gender were female. Sexual or gender minority patients had significantly better Communication Climate Assessment Toolkit scores with nonverbal registrar form collection compared with nurse verbal collection (mean [SD], 95.6 [11.9] vs 89.5 [20.5]; P = .03). No significant differences between the 2 approaches were found among non-SGM patients (mean [SD], 91.8 [18.9] vs 93.2 [13.6]; P = .59) or those with a blank field (92.7 [15.9] vs 93.6 [14.7]; P = .70). After adjusting for age, race, illness severity, and site, SGM patients had 2.57 (95% CI, 1.13-5.82) increased odds of a better Communication Climate Assessment Toolkit score category during form collection compared with verbal collection.

Conclusions And Relevance: Sexual or gender minority patients reported greater comfort and improved communication when SOGI was collected via nonverbal self-report. Registrar form collection was the optimal patient-centered method for collecting SOGI information in the ED.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.6506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324335PMC
December 2018

Opioid Prescription Patterns for Children Following Laparoscopic Appendectomy.

Ann Surg 2020 12;272(6):1149-1157

Department of Surgery, Boston Children's Hospital, Boston, MA.

Objective: To describe variability in and consequences of opioid prescriptions following pediatric laparoscopic appendectomy.

Summary Background Data: Postoperative opioid prescribing patterns may contribute to persistent opioid use in both adults and children.

Methods: We included children <18 years enrolled as dependents in the Military Health System Data Repository who underwent uncomplicated laparoscopic appendectomy (2006-2014). For the primary outcome of days of opioids prescribed, we evaluated associations with discharging service, standardized to the distribution of baseline covariates. Secondary outcomes included refill, Emergency Department (ED) visit for constipation, and ED visit for pain.

Results: Among 6732 children, 68% were prescribed opioids (range = 1-65 d, median = 4 d, IQR = 3-5 d). Patients discharged by general surgery services were prescribed 1.23 (95% CI = 1.06-1.42) excess days of opioids, compared with those discharged by pediatric surgery services. Risk of ED visit for constipation (n = 61, 1%) was increased with opioid prescription [1-3 d, risk ratio (RR) = 2.46, 95% CI = 1.31-5.78; 4-6 d, RR = 1.89, 95% CI = 0.83-4.67; 7-14 d, RR = 3.75, 95% CI = 1.38-9.44; >14 d, RR = 6.27, 95% CI = 1.23-19.68], compared with no opioid prescription. There was similar or increased risk of ED visit for pain (n = 319, 5%) with opioid prescription [1-3 d, RR = 1.00, 95% confidence interval (CI) = 0.74-1.32; 4-6 d, RR = 1.31, 95% CI = 0.99-1.73; 7-14 d, RR = 1.52, 95% CI = 1.00-2.18], compared with no opioid prescription. Likewise, need for refill (n = 157, 3%) was not associated with initial days of opioid prescribed (reference 1-3 d; 4-6 d, RR = 0.96, 95% CI = 0.68-1.35; 7-14 d, RR = 0.91, 95% CI = 0.49-1.46; and >14 d, RR = 1.22, 95% CI = 0.59-2.07).

Conclusions: There was substantial variation in opioid prescribing patterns. Opioid prescription duration increased risk of ED visits for constipation, but not for pain or refill.
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http://dx.doi.org/10.1097/SLA.0000000000003171DOI Listing
December 2020

Access Delayed Is Access Denied: Relationship Between Access to Trauma Center Care and Pre-Hospital Death.

J Am Coll Surg 2019 01 22;228(1):9-20. Epub 2018 Oct 22.

Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, the Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Background: Timely access to trauma center (TC) care is critical to achieve "Zero Preventable Deaths after Injury." However, the impact of timely access to TC care on pre-hospital deaths in each US state remains unknown. We sought to determine the state-level relationship between the proportion of pre-hospital deaths, age-adjusted mortality, and timely access to trauma center care.

Study Design: We analyzed state-level analysis of adult trauma deaths reported to the CDC Wide-ranging Online Data for Epidemiological Research (WONDER) (1999 to 2016). Correlation between the state-level pre-hospital:in-hospital death ratio (PH:IH), the proportion of population with access to Level-I/II TC, and the age-adjusted mortality rate (AAMR) was determined. Population proportion with timely access to TC care was compared between states with a high pre-hospital death burden vs all other states. National estimates of potentially preventable pre-hospital deaths were calculated.

Results: There were 1,949,375 trauma deaths analyzed. Overall, 1.19 times more deaths occurred pre-hospital (49%, n = 960,554) than in-hospital (42%, n = 810,387). States with better TC access had a lower AAMR (r = -0.71, p < 0.05) and relatively fewer pre-hospital deaths (r = -0.64, p < 0.05); states with higher AAMR had relatively more pre-hospital deaths (r = 0.70, p < 0.05). States with a high pre-hospital death burden had a lower proportion of population with access to Level-I/II TC within 1 hour vs all other states (63.2% vs 90.2%, p < 0.001). If all states had the same PH:IH death ratio as those among the best quartile for access, 129,213 pre-hospital deaths may potentially have been averted.

Conclusions: States with poor TC access have more pre-hospital deaths, which contribute to higher overall injury mortality. This suggests that in these states, improving TC access will be critical to achieve "Zero Preventable Deaths after Injury."
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.09.015DOI Listing
January 2019

Surgeon-driven variability in emergency general surgery outcomes: Does it matter who is on call?

Surgery 2018 Nov 31;164(5):1109-1116. Epub 2018 Aug 31.

Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA; Department of Surgery, Brigham & Women's Hospital, Boston, MA.

Background: Hospital-level variation has been found to influence outcomes in emergency general surgery. However, whether the individual surgeon plays a role in this variation is unknown.

Methods: We performed an analysis of the Florida State Inpatient Database (2010-2014), which is linked to the American Hospital Association's Annual Survey Database, including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multilevel random effects modeling to quantify the amount of variation in mortality, complications, and 30-day readmissions attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a forward stepwise fashion, and the percent of the variation attributable to surgeons was derived.

Results: Our study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality, explaining 32.77% of the overall variability in mortality risk compared with 0.08% and 2.28% for complications and readmissions, respectively. Peptic ulcer disease operations were most susceptible to surgeon-level variation in mortality and readmissions, whereas appendectomies and cholecystectomies were least susceptible to surgeon-level variation for all outcomes.

Conclusions: Surgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in emergency general surgery should address reducing variability in practice with attention to high-risk, low-frequency procedures.
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http://dx.doi.org/10.1016/j.surg.2018.07.008DOI Listing
November 2018

Parents' Knowledge and Education of Retinopathy of Prematurity in Four California Neonatal Intensive Care Units.

Am J Ophthalmol 2018 07 3;191:7-13. Epub 2018 Apr 3.

Division of General Pediatrics, Stanford University School of Medicine, Stanford, California, USA; Center for Policy, Outcomes, and Prevention, Stanford University School of Medicine, Stanford, California, USA.

Purpose: Retinopathy of prematurity (ROP) may cause visual impairment in infants with very low birth weight. Lack of parent knowledge may contribute to gaps in screening and treatment. We studied parents' knowledge and education of ROP.

Design: Cross-sectional study.

Methods: Setting: Four high-acuity neonatal intensive care units in California (40-84 beds).

Participants: Total of 194 English- and Spanish-speaking parents of very low birth weight (<1500 grams) infants recruited from September 2013 to April 2015.

Main Outcome Measures: We asked parents what they knew about ROP, how they were educated about ROP, and their experiences obtaining outpatient eye care. We used multivariate analysis to assess whether parent knowledge was associated with level of English proficiency and literacy, education modality (verbal, written, online, video), and hospital transfer status.

Results: Of the 194 participants, 131 (68%) completed surveys: 18% had both limited English proficiency and low literacy while overall 26% had limited English proficiency and 37% had low literacy; 17% did not know that ROP is an eye disease, and 38% did not know that very low birth weight and prematurity are both risk factors for ROP. Parents reported receiving verbal (62%) or written (56%) information; few used online resources (12%) or videos (3%). Half reported receiving information about infants' retinopathy status at discharge. No education modality was associated with higher knowledge. Limited English proficiency and low literacy were associated with lower knowledge (vs English-proficient, literate).

Conclusions: Parents of infants with very low birth weight, particularly those with limited English proficiency and low health literacy, lack knowledge about ROP.
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http://dx.doi.org/10.1016/j.ajo.2018.03.039DOI Listing
July 2018

Surgical deserts in California: an analysis of access to surgical care.

J Surg Res 2018 03 15;223:102-108. Epub 2017 Nov 15.

Department of Surgery, Stanford University, Section of Trauma & Critical Care, Stanford, California.

Background: Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties.

Methods: We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis.

Results: There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty.

Conclusions: Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.
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http://dx.doi.org/10.1016/j.jss.2017.10.014DOI Listing
March 2018

Undertriage Remains a Vexing Problem for Even the Most Highly Developed Trauma Systems: The Need for Innovations in Field Triage.

JAMA Surg 2018 04;153(4):328

Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2017.4499DOI Listing
April 2018

Why do patients receive care from a short-term medical mission? Survey study from rural Guatemala.

J Surg Res 2017 07 6;215:160-166. Epub 2017 Apr 6.

Department of Surgery, Stanford University, Stanford, California; Palo Alto VA Health Care System, Palo Alto, California. Electronic address:

Background: Hospital de la Familia was established to serve the indigent population in the western highlands of Guatemala and has a full-time staff of Guatemalan primary care providers supplemented by short-term missions of surgical specialists. The reasons for patients seeking surgical care in this setting, as opposed to more consistent care from local institutions, are unclear. We sought to better understand motivations of patients seeking mission-based surgical care.

Methods: Patients presenting to the obstetric and gynecologic, plastic, ophthalmologic, general, and pediatric surgical clinics at the Hospital de la Familia from July 27 to August 6, 2015 were surveyed. The surveys assessed patient demographics, surgical diagnosis, location of home, mode of travel, and reasons for seeking care at this facility.

Results: Of 252 patients surveyed, 144 (59.3%) were female. Most patients reported no other medical condition (67.9%, n = 169) and no consistent income (83.9%, n = 209). Almost half (44.9%, n = 109) traveled >50 km to receive care. The most common reasons for choosing care at this facility were reputation of high quality (51.8%, n = 130) and affordability (42.6%, n = 102); the least common reason was a lack of other options (6.4%, n = 16).

Conclusions: Despite long travel distances and the availability of other options, reputation and affordability were primarily cited as the most common reasons for choosing to receive care at this short-term surgical mission site. Our results highlight that although other surgical options may be closer and more readily available, reputation and cost play a large role in choice of patients seeking care.
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http://dx.doi.org/10.1016/j.jss.2017.03.056DOI Listing
July 2017

A geospatial evaluation of timely access to surgical care in seven countries.

Bull World Health Organ 2017 Jun 16;95(6):437-444. Epub 2017 Mar 16.

Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305, United States of America (USA).

Objective: To assess the consistent availability of basic surgical resources at selected facilities in seven countries.

Methods: In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh ( = 14), the Plurinational State of Bolivia ( = 18), Ethiopia ( = 19), Guatemala ( = 20), the Lao People's Democratic Republic ( = 12), Liberia ( = 12) and Rwanda ( = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available.

Findings: Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh.

Conclusion: Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.
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http://dx.doi.org/10.2471/BLT.16.175885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5463808PMC
June 2017