Amber W. Trickey, PhD, MS, CPH, is a health services biostatistician working with the S-SPIRE Center. She supports multidisciplinary teams in research design, implementation, and analysis. Dr. Trickey obtained degrees in epidemiology and biostatistics, and certifications in public health and SAS data analysis. She has evaluated data quality in surgical and trauma care, supported multiple clinical trials, and led data validation studies using the ACS-NSQIP surgical registry and administrative claims. Dr. Trickey has contributed to public and private grants on surgical safety, healthcare quality metrics, simulation-based training, team communication, error disclosure, and emergency services.

Education & Certifications

  • BS, Tulane University, Biomedical Engineering (2003)
  • MS, University of Texas School of Public Health, Epidemiology (2008)
  • PhD, University of Texas School of Public Health, Epidemiology, Biostatistics, Health Services Research (2012)
  • CPH, Certification in Public Health, National Board of Public Health Examiners, Public Health (2008)

Professional Affiliations and Activities

  • Chapter Leader, University of Texas School of Public Health, Institute for Healthcare Improvement Open School (2009 - 2011)
  • Member, Research & Development Committee, American College of Surgeons Accredited Education Institutes (2016 - 2018)
  • Member, AcademyHealth (2017 - Present)

All Publications

  • Growth of Statewide Emergency Medical Services Bypass Policies for Acute Stroke. JAMA health forum Dunkley, R., Omeaku, N., Trickey, A. W., Tandel, M. D., Garcia, A., Govindarajan, P. 2024; 5 (7): e241752

    View details for DOI 10.1001/jamahealthforum.2024.1752

    View details for PubMedID 38967951

  • Disparities in Access, Quality, and Clinical Outcome for Latino Californians with Colon Cancer. Annals of surgery Dawes, A. J., Rajasekar, G., Arnow, K. D., Trickey, A. W., Harris, A. H., Morris, A. M., Wagner, T. H. 2024


    OBJECTIVE: To compare access, quality, and clinical outcomes between Latino and non-Latino White Californians with colon cancer.SUMMARY BACKGROUND DATA: Racial and ethnic disparities in cancer care remain understudied, particularly among patients who identify as Latino. Exploring potential mechanisms, including differential utilization of high-volume hospitals, is an essential first step to designing evidence-based policy solutions.METHODS: We identified all adults diagnosed with colon cancer between January 1, 2010 and December 31, 2020 from a statewide cancer registry linked to hospital administrative records. We compared survival, access (stage at diagnosis, receipt of surgical care, treatment at a high-volume hospital), and quality of care (receipt of adjuvant chemotherapy, adequacy of lymph node resection) between patients who identified as Latino and as non-Latino White.RESULTS: 75,543 patients met inclusion criteria, including 16,071 patients who identified as Latino (21.3%). Latino patients were significantly less likely to undergo definitive surgical resection (marginal difference [MD] -0.72 percentage points, 95% CI -1.19,-0.26), have an operation in a timely fashion (MD -3.24 percentage points, 95% CI -4.16,-2.32), or have an adequate lymphadenectomy (MD -2.85 percentage points, 95% CI -3.59,-2.12) even after adjustment for clinical and sociodemographic factors. Latino patients treated at high-volume hospitals were significantly less likely to die and more likely to meet access and quality metrics.CONCLUSIONS: Latino colon cancer patients experienced delays, segregation, and lower receipt of recommended care. Hospital-level colectomy volume appears to be strongly associated with access, quality, and survival--especially for patients who identify as Latino--suggesting that directing at-risk cancer patients to high-volume hospitals may improve health equity.

    View details for DOI 10.1097/SLA.0000000000006251

    View details for PubMedID 38407273

  • Disparities in access to high-volume parathyroid surgeons in the United States: A call to action. Surgery Wright, K., Squires, S., Cisco, R., Trickey, A., Kebebew, E., Suh, I., Seib, C. D. 2023


    Parathyroidectomy by a high-volume surgeon is associated with a reduced risk of perioperative complications and of failure to cure primary and secondary hyperparathyroidism. There are limited data on disparities in access to high-volume parathyroid surgeons in the United States.We used publicly available 2019 Medicare Provider Utilization and Payment data to identify all surgeons who performed >10 parathyroidectomies for Medicare fee-for-service beneficiaries, anticipating that fee-for-service beneficiaries likely represent only a subset of their high-volume practices. High-volume parathyroid surgeon characteristics and geographic distribution were evaluated. Inequality in the distribution of surgeons was measured by the Gini coefficient. The association between neighborhood disadvantage, based on the Area Deprivation Index, and proximity to high-volume parathyroid surgeons was evaluated using a one-way analysis of variance with Bonferroni-corrected pairwise comparisons. A sensitivity analysis was performed restricting to high-volume parathyroid surgeons within each hospital referral region, evidence-based regional markets for tertiary medical care.We identified 445 high-volume parathyroid surgeons who met inclusion criteria with >10 parathyroidectomies for Medicare fee-for-service beneficiaries. High-volume parathyroid surgeons were 71% male sex, and 59.8% were general surgeons. High-volume parathyroid surgeons were more likely to practice in a Metropolitan Statistical Area with a population >1 million than in less populous metropolitan or rural areas. The number of high-volume parathyroid surgeons per 100,000 fee-for-service Medicare beneficiaries in the 53 most populous Metropolitan Statistical Areas ranged from 0 to 4.94, with the highest density identified in Salt Lake City, Utah. In 2019, 50% of parathyroidectomies performed by high-volume parathyroid surgeons were performed by 20% of surgeons in this group, suggesting unequal distribution of surgical care (Gini coefficient 0.41). Patients in disadvantaged neighborhoods were farther from high-volume parathyroid surgeons than those in advantaged neighborhoods (median distance: disadvantaged 27.8 miles, partially disadvantaged 20.7 miles, partially advantaged 12.1 miles, advantaged 8.4 miles; P < .001). This association was also shown in the analysis of distance to high-volume parathyroid surgeons within the hospital referral region (P < .001).Older adults living in disadvantaged neighborhoods have less access to high-volume parathyroid surgeons, which may adversely affect treatment and outcomes for patients with primary and secondary hyperparathyroidism. This disparity highlights the need for actionable strategies to provide equitable access to care, including improved regionalization of high-volume parathyroid surgeon services and easing travel-related burdens for underserved patients.

    View details for DOI 10.1016/j.surg.2023.03.028

    View details for PubMedID 37940435

  • Usability of ENTRUST as an Assessment Tool for Entrustable Professional Activities (EPAs): A Mixed Methods Analysis. Journal of surgical education Lee, M. C., Melcer, E. F., Merrell, S. B., Wong, L. Y., Shields, S., Eddington, H., Trickey, A. W., Tsai, J., Korndorffer, J. R., Lin, D. T., Liebert, C. A. 2023


    As the American Board of Surgery transitions to a competency-based model of surgical education centered upon entrustable professional activities (EPAs), there is a growing need for objective tools to determine readiness for entrustment. This study evaluates the usability of ENTRUST, an innovative virtual patient simulation platform to assess surgical trainees' decision-making skills in preoperative, intra-operative, and post-operative settings.This is a mixed-methods analysis of the usability of the ENTRUST platform. Quantitative data was collected using the system usability scale (SUS) and Likert responses. Analysis was performed with descriptive statistics, bivariate analysis, and multivariable linear regression. Qualitative analysis of open-ended responses was performed using the Nielsen-Shneiderman Heuristics framework.This study was conducted at an academic institution in a proctored exam setting.The analysis includes n = 47 (PGY 1-5) surgical residents who completed an online usability survey following the ENTRUST Inguinal Hernia EPA Assessment.The ENTRUST platform had a median SUS score of 82.5. On bivariate and multivariate analyses, there were no significant differences between usability based on demographic characteristics (all p > 0.05), and SUS score was independent of ENTRUST performance (r = 0.198, p = 0.18). Most participants agreed that the clinical workup of the patient was engaging (91.5%) and felt realistic (85.1%). The most frequent heuristics represented in the qualitative analysis included feedback, visibility, match, and control. Additional themes of educational value, enjoyment, and ease-of-use highlighted participants' perspectives on the usability of ENTRUST.ENTRUST demonstrates high usability in this population. Usability was independent of ENTRUST score performance and there were no differences in usability identified in this analysis based on demographic subgroups. Qualitative analysis highlighted the acceptability of ENTRUST and will inform ongoing development of the platform. The ENTRUST platform holds potential as a tool for the assessment of EPAs in surgical residency programs.

    View details for DOI 10.1016/j.jsurg.2023.09.001

    View details for PubMedID 37821350

  • Does tranexamic acid increase venous thromboembolism risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers. Injury Knowlton, L. M., Arnow, K., Trickey, A. W., Sauaia, A., Knudson, M. M. 2023: 111008


    IMPORTANCE: The early use of tranexamic acid (TXA) has demonstrated benefit among some trauma patients in hemorrhagic shock. The association between TXA administration and thromboembolic events (including deep vein thrombosis (DVT), pulmonary embolism (PE) and pulmonary thrombosis (PT)) remains unclear. We aimed to characterize the risk of venous thromboembolism (VTE) subtypes among trauma patients receiving TXA and to determine whether TXA is associated with VTE risk and mortality.METHODS: We analyzed a prospective, observational, multicenter cohort data from the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted across 17 US level I trauma centers between January 1, 2018, and December 31,2020. We studied trauma patients ages 18-40 years, admitted for at least 48h with a minimum of 1 VTE risk factor and followed until hospital discharge or 30 days. We compared TXA recipients to non-recipients for VTE and mortality using inverse probability weighted Cox models. The primary outcome was the presence of documented venous thromboembolism (VTE). The secondary outcome was mortality. VTE was defined as DVT, PE, or PT.RESULTS: Among the 7,331 trauma patients analyzed, 466 (6.4%) received TXA. Patients in the TXA group were more severely injured than patients in the non-TXA group (ISS 16+: 69.1%vs. 48.5%, p<0.001) and a higher percentage underwent a major surgical procedure (85.8%vs. 73.6%, p<0.001). Among TXA recipients, 12.5% developed VTE(1.3% PT, 2.4% PE, 8.8% DVT) with 5.6% mortality. In the non-TXA group, 4.6% developed VTE (1.1% PT, 0.5% PE, 3.0% DVT) with 1.7% mortality. In analyses adjusting for patient demographic and clinical characteristics, TXA administration was not significantly associated with VTE (aHR 1.00, 95%CI: 0.69-1.46, p=0.99) but was significantly associated with increased mortality (aHR 2.01, 95%CI: 1.46-2.77, p<0.001).CONCLUSION: TXA was not clearly identified as an independent risk factor for VTE in adjusted analyses, but the risk of VTE among trauma patients receiving TXA remains high (12.5%). This supports the judicious use of TXA in resuscitation, with consideration of early initiation of DVT prophylaxis in this high-risk group.

    View details for DOI 10.1016/j.injury.2023.111008

    View details for PubMedID 37669883

  • Addressing knowledge gaps in Surgical Safety Checklist use: statistical process control analysis of a surgical quality improvement programme in Ethiopia. The British journal of surgery Nofal, M. R., Starr, N., Negussie Mammo, T., Trickey, A. W., Gebeyehu, N., Koritsanszky, L., Alemu, M., Tara, M., Alemu, S. B., Evans, F., Kahsay, S., Weiser, T. G. 2023


    BACKGROUND: The WHO Surgical Safety Checklist reduces morbidity and mortality after surgery, but uptake remains challenging. In particular, low-income countries have been found to have lower rates of checklist use compared with high-income countries. The aim of this study was to determine the impact of educational workshops on Surgical Safety Checklist use implemented as part of a quality improvement initiative in five hospitals in Ethiopia that had variable experience with the Surgical Safety Checklist.METHODS: From April 2019 to September 2020, each hospital implemented a 6-month surgical quality improvement programme, which included a Surgical Safety Checklist workshop. Statistical process control methodology was used to understand the variation in Surgical Safety Checklist compliance before and after workshops and a time-series analysis was performed using population-averaged generalized estimating equation Poisson regression. Checklist compliance was defined as correctly completing a sign in, timeout, and sign out. Incidence rate ratios of correct checklist use pre- and post-intervention were calculated and the change in mean weekly compliance was predicted.RESULTS: Checklist compliance data were obtained from 2767 operations (1940 (70 per cent) pre-intervention and 827 (30 per cent) post-intervention). Mean weekly checklist compliance improved from 27.3 to 41.2 per cent (mean difference 13.9 per cent, P = 0.001; incidence rate ratio 1.51, P = 0.001). Hospitals with higher checklist compliance at baseline had the greatest overall improvements in compliance, more than 50 per cent over pre-intervention, while low-performing hospitals showed no improvement.CONCLUSION: Surgical Safety Checklist workshops improved checklist compliance in hospitals with some experience with its use. Workshops had little effect in hospitals unfamiliar with the Surgical Safety Checklist, emphasizing the importance of multifactorial interventions and culture-change approaches. In receptive facilities, short workshops can accelerate behaviour change.

    View details for DOI 10.1093/bjs/znad234

    View details for PubMedID 37551706

  • High-dimensional profiling of pediatric immune responses to solid organ transplantation. Cell reports. Medicine Rao, M., Amouzgar, M., Harden, J. T., Lapasaran, M. G., Trickey, A., Armstrong, B., Odim, J., Debnam, T., Esquivel, C. O., Bendall, S. C., Martinez, O. M., Krams, S. M. 2023: 101147


    Solid organ transplant remains a life-saving therapy for children with end-stage heart, lung, liver, or kidney disease; however, ∼33% of allograft recipients experience acute rejection within the first year after transplant. Our ability to detect early rejection is hampered by an incomplete understanding of the immune changes associated with allograft health, particularly in the pediatric population. We performed detailed, multilineage, single-cell analysis of the peripheral blood immune composition in pediatric solid organ transplant recipients, with high-dimensional mass cytometry. Supervised and unsupervised analysis methods to study cell-type proportions indicate that the allograft type strongly influences the post-transplant immune profile. Further, when organ-specific differences are considered, graft health is associated with changes in the proportion of distinct T cell subpopulations. Together, these data form the basis for mechanistic studies into the pathobiology of rejection and allow for the development of new immunosuppressive agents with greater specificity.

    View details for DOI 10.1016/j.xcrm.2023.101147

    View details for PubMedID 37552988

  • Correlation of Performance on ENTRUST and Traditional Oral Objective Structured Clinical Examination for High-Stakes Assessment in the College of Surgeons of East, Central, and Southern Africa. Journal of the American College of Surgeons Liebert, C. A., Melcer, E. F., Eddington, H., Trickey, A., Shields, S., Lee, M., Korndorffer, J. R., Bekele, A., Wren, S. M., Lin, D. T. 2023


    To address the global need for accessible evidence-based tools for competency-based education, we developed ENTRUST, an innovative online virtual patient simulation platform to author and securely deploy case scenarios to assess surgical decision-making competence.In partnership with COSECSA, ENTRUST was piloted during the Membership of the College of Surgeons (MCS) 2021 examination. Examinees (n=110) completed the traditional 11-station oral OSCE, followed by three ENTRUST cases, authored to query similar clinical content of three corresponding OSCE cases. ENTRUST scores were analyzed for associations with MCS Exam outcome using independent sample t-tests. Correlation of ENTRUST scores to MCS Exam Percentage and OSCE Station Scores were calculated with Pearson correlations. Bivariate and multivariate analyses were performed to evaluate predictors of performance.ENTRUST performance was significantly higher in examinees who passed the MCS Exam compared to those who failed (p<0.001). ENTRUST score was positively correlated with MCS Exam Percentage (p<0.001) and combined OSCE Station Scores (p<0.001). On multivariate analysis, there was a strong association between MCS Exam Percentage and ENTRUST Grand Total Score (p<0.001), Simulation Total Score (p=0.018), and Question Total Score (p<0.001). Age was a negative predictor for ENTRUST Grand Total and Simulation Total Score, but not for Question Total Score. Sex, native language status, and intended specialty were not associated with performance on ENTRUST.This study demonstrates feasibility and initial validity evidence for the use of ENTRUST in a high-stakes examination context for assessment of surgical decision-making. ENTRUST holds potential as an accessible learning and assessment platform for surgical trainees worldwide.

    View details for DOI 10.1097/XCS.0000000000000740

    View details for PubMedID 37144790

  • Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-level Frailty Burden Rather than Comorbidities. Annals of vascular surgery George, E. L., Rothenberg, K. A., Barreto, N. B., Chen, R., Trickey, A. W., Arya, S. 2023


    Failure to rescue (FtR), or inpatient death following complication, is a publicly reported hospital quality measure. Previous work has demonstrated significant variation in the proportion of frail patients across hospitals. However, frailty is not incorporated into risk-adjustment algorithms for hospital quality comparisons and risk adjustment is made by comorbidity scores. Our aim was to assess the impact of frailty on FtR quality measurement and as a means of risk adjustment.Patients undergoing open or endovascular aneurysm repair or lower extremity bypass in the Vascular Quality Initiative (VQI) at centers performing > 25 vascular procedures annually (2003-2019) were included. Multivariable logistic regression evaluated in-hospital death using scaled hierarchical modeling clustering at the center-level. Center FtR observed/expected (O/E) ratios were compared with expected values adjusted for either standard comorbidity profiles or frailty as measured by the VQI Risk Analysis Index (RAI). Centers were divided into quartiles using VQI-linked American Hospital Association data to describe the hospital characteristics of centers whose ranks changed.A total of 63,143 patients (213 centers) were included; 1,630 patients (2.58%) were classified as FtR. After accounting for center-level variability, frailty was associated with FtR [scaled odds ratio 1.9 (1.8-2.0), p<0.001]. The comorbidity-centric and frailty-based models performed similarly in predicting FtR with C-statistics of 0.85 (0.84-0.86) and 0.82 (0.82-0.84), respectively. Overall changes in ranking based on O/E ratios were not statistically significant (p=0.48). High and low performing centers had similar ranking using comorbidity-centric and frailty-based methods; however, centers in the middle of the performance spectrum saw more variability in ranking alterations. Forty-nine (23%) of hospitals improved their ranking by 5 or more positions when using frailty vs comorbidity risk adjustment. The centers in Quartile 4, those who performed the highest number of vascular procedures annually, experience on average a significant improvement in hospital ranking when frailty was used for risk adjustment, whereas centers performing the fewest number of vascular procedures and the lowest proportion of vascular surgery cases annually (Quartile 1) saw a significant worsening of ranking position (all p < 0.05). However, total number of surgical procedures annually, total hospital beds, for-profit status and teaching hospital status were not significantly associated with changes in rank.A simple frailty-adjusted model has similar predictive abilities as a comorbidity-focused model for predicting a common quality metric that influences reimbursement. In addition to distilling the risk-adjustment algorithm to a few variables, frailty can be assessed preoperatively to develop quality improvement efforts for rescuing frail patients. Centers treating a greater proportion of frail patients and those who perform higher volumes of vascular surgery benefit from a risk adjustment strategy based on frailty.

    View details for DOI 10.1016/j.avsg.2023.04.024

    View details for PubMedID 37121337

  • Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Annals of internal medicine Seib, C. D., Ganesan, C., Furst, A., Pao, A. C., Chertow, G. M., Leppert, J. T., Suh, I., Montez-Rath, M. E., Harris, A. H., Trickey, A. W., Kebebew, E., Tamura, M. K. 2023


    BACKGROUND: Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function.OBJECTIVE: To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management.DESIGN: Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting.SETTING: Veterans Health Administration.PATIENTS: Patients with a new biochemical diagnosis of PHPT in 2000 to 2019.MEASUREMENTS: Sustained decline of at least 50% from pretreatment eGFR.RESULTS: Among 43697 patients with PHPT (mean age, 66.8years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9years. The weighted cumulative incidence of eGFR decline was 5.1% at 5years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60years or older (HR, 1.08 [CI, 0.87 to 1.34]).LIMITATION: Analyses were done in a predominantly male cohort using observational data.CONCLUSION: Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions.PRIMARY FUNDING SOURCE: National Institute on Aging.

    View details for DOI 10.7326/M22-2222

    View details for PubMedID 37037034

  • ENTRUST: A Serious Game-Based Virtual Patient Platform to Assess Entrustable Professional Activities in Graduate Medical Education. Journal of graduate medical education Lin, D. T., Melcer, E. F., Keehl, O., Eddington, H., Trickey, A. W., Tsai, J., Camacho, F., Merrell, S. B., Korndorffer, J., Liebert, C. A. 2023; 15 (2): 228-236


    As entrustable professional activities (EPAs) are implemented in graduate medical education, there is a great need for tools to efficiently and objectively evaluate clinical competence. Readiness for entrustment in surgery requires not only assessment of technical ability, but also the critical skill of clinical decision-making.We report the development of ENTRUST, a serious game-based, virtual patient case creation and simulation platform to assess trainees' decision-making competence. A case scenario and corresponding scoring algorithm for the Inguinal Hernia EPA was iteratively developed and aligned with the description and essential functions outlined by the American Board of Surgery. In this study we report preliminary feasibility data and validity evidence.In January 2021, the case scenario was deployed and piloted on ENTRUST with 19 participants of varying surgical expertise levels to demonstrate proof of concept and initial validity evidence. Total score, preoperative sub-score, and intraoperative sub-score were analyzed by training level and years of medical experience using Spearman rank correlations. Participants completed a Likert scale user acceptance survey (1=strongly agree to 7=strongly disagree).Median total score and intraoperative mode sub-score were higher with each progressive level of training (rho=0.79, P<.001 and rho=0.69, P=.001, respectively). There were significant correlations between performance and years of medical experience for total score (rho=0.82, P<.001) and intraoperative sub-scores (rho=0.70, P<.001). Participants reported high levels of platform engagement (mean 2.06) and ease of use (mean 1.88).Our study demonstrates feasibility and early validity evidence for ENTRUST as an assessment platform for clinical decision-making.

    View details for DOI 10.4300/JGME-D-22-00518.1

    View details for PubMedID 37139206

    View details for PubMedCentralID PMC10150817

  • Evaluating Emergency Medicaid Program Policy Changes During the COVID-19 Pandemic. The Journal of surgical research Handley, T. J., Boncompagni, A. C., Arnow, K., Sasnal, M., Day, H. S., Trickey, A., Morris, A. M., Knowlton, L. M. 2023; 289: 97-105


    Trauma patients are twice as likely to be uninsured as the general population, which can lead to limited access to postinjury resources and higher mortality. The Hospital Presumptive Eligibility (HPE) program offers emergency Medicaid for eligible patients at presentation. The HPE program underwent several changes during the COVID-19 pandemic; we quantify the program's success during this time and seek to understand features associated with HPE approval.A mixed methods study at a Level I trauma center using explanatory sequential design, including: 1) a retrospective cohort analysis (2015-2021) comparing HPE approval before and after COVID-19 policy changes; and 2) semistructured interviews with key stakeholders.589 patients listed as self-pay or Medicaid presented after March 16, 2020, when COVID-19 policies were first implemented. Of these, 409 (69%) patients were already enrolled in Medicaid at hospitalization. Among those uninsured at arrival, 160 (89%) were screened and 98 (61%) were approved for HPE. This marks a significant improvement in the prepandemic HPE approval rate (48%). In adjusted logistic regression analyses, the COVID-19 period was associated with an increased likelihood of HPE approval (versus prepandemic: aOR, 1.64; P = 0.005). Qualitative interviews suggest that mechanisms include state-based expansion in HPE eligibility and improvements in remote approval such as telephone/video conferencing.The HPE program experienced an overall increased approval rate and adapted to policy changes during the pandemic, enabling more patients' access to health insurance. Ensuring that these beneficial changes remain a part of our health policy is an important aspect of improving access to health insurance for our patients.

    View details for DOI 10.1016/j.jss.2023.03.030

    View details for PubMedID 37086602

    View details for PubMedCentralID PMC10043965

  • Fragmentation of Gastroesophageal Junction Cancer Care in California Rejoice Ngongoni, F., Li, A. Y., Timmerhuis, H., Furst, A., Trickey, A., DeLong, J., Dua, M., Visser, B. SPRINGER. 2023: S151
  • High-dimensional profiling of pediatric immune responses to solid organ transplantation Rao, M., Amouzgar, M., Harden, J. T., Lapasaran, M. G., Trickey, A., Armstrong, B., Odim, J., Debnam, T., Esquivel, C. O., Bendall, S. C., Martinez, O. M., Krams, S. M. WILEY. 2023
  • Mutations In Latent Membrane Protein 1 of Epstein-Barr Virus are Associated with Increased Risk for Post-Transplant Lymphoproliferative Disorder in Children. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Martinez, O. M., Krams, S. M., Robien, M. A., Lapasaran, M. G., Arvedson, M. P., Reitsma, A., Balachandran, Y., Harris-Arnold, A., Weinberg, K., Boyd, S. D., Armstrong, B., Trickey, A., Twist, C. J., Gratzinger, D., Tan, B., Brown, M., Chin, C., Desai, D. M., Fishbein, T. M., Mazariegos, G. V., Tekin, A., Venick, R. S., Bernstein, D., Esquivel, C. O. 2023


    Epstein-Barr virus (EBV)+ post-transplant lymphoproliferative disorder (PTLD) results in significant morbidity and mortality in pediatric transplant recipients. Identifying individuals at increased risk of EBV+ PTLD could influence clinical management of immunosuppression and other therapies, improving post-transplant outcomes. A seven-center prospective, observational clinical trial of 872 pediatric transplant recipients evaluated the presence of mutations at position 212 and 366 of EBV latent membrane protein 1 (LMP1) as an indicator of risk for EBV+ PTLD (Clinical Trials: NCT02182986). DNA was isolated from peripheral blood of EBV+ PTLD cases and matched controls (1:2 nested case-control), and the cytoplasmic tail of LMP1 sequenced. Thirty-four participants reached the primary endpoint of biopsy-proven EBV+ PTLD. DNA was sequenced from 32 PTLD cases and 62 matched controls. Both LMP1 mutations were present in 31/32 PTLD cases (96.9%) and in 45/62 matched controls (72.6%) (p=0.005, OR=11.7, 95% CI 1.5, 92.6). The presence of both G212S and S366T carries a nearly 12-fold increased risk for development of EBV+ PTLD. Conversely, transplant recipients without both LMP1 mutations carry a very low risk of PTLD. Analysis of mutations at positions 212 and 366 of LMP1 can be informative in stratifying patients for risk of EBV+ PTLD.

    View details for DOI 10.1016/j.ajt.2023.02.014

    View details for PubMedID 36796762

  • Insurance churn after adult traumatic injury: a national evaluation among a large private insurance database. The journal of trauma and acute care surgery Fu, S. J., Arnow, K., Barreto, N. B., Aouad, M., Trickey, A. W., Spain, D. A., Morris, A., Knowlton, L. 2022


    Traumatic injury leads to significant disability, with injured patients often requiring substantial healthcare resources to return to work and baseline health. Temporary disability or inability to work can result in changes or loss of employer-based private insurance coverage, which may significantly impact healthcare access and outcomes. Among privately insured patients, we hypothesized increased instability in insurance coverage for patients with higher severity of injury.Adults 18 years and older presenting to a hospital with traumatic injury were evaluated for insurance churn using Clinformatics® Data Mart private-payer claims. Insurance churn was defined as cessation of enrollment in the patient's private health insurance plan. Using injury severity score (ISS), we compared insurance churn over the year following injury between patients with mild (ISS <9), moderate (ISS 9-15), severe (ISS 16-24), and very severe (ISS > 24) injuries. Kaplan-Meier analysis was used to compare time to insurance churn by ISS category. Flexible parametric regression was used to estimate hazard ratios for insurance churn.Among 750,862 privately insured patients suffering from a traumatic injury, 50% experienced insurance churn within 1 year after injury. Compared to patients who remained on their insurance plan, patients who experienced insurance churn were younger and more likely male and non-White. The median time to insurance churn was 7.7 months for those with mild traumatic injury, 7.5 months for moderately or severely injured, and 7.1 months for the very severely injured. In multivariable analysis, increasing injury severity was associated with higher rates of insurance churn compared with mild injury, up to 14% increased risk for the very severely injured.Increasing severity of traumatic injury is associated with higher levels of health coverage churn amongst the privately insured. Lack of continuous access to health services may prolong recovery and further aggravate the medical and social impact of significant traumatic injury.Economic/decision study, Level II.

    View details for DOI 10.1097/TA.0000000000003861

    View details for PubMedID 36623273

  • Risk of permanent hypoparathyroidism requiring calcitriol therapy in a population-based cohort of adults older than 65 undergoing total thyroidectomy for Graves' disease. Thyroid : official journal of the American Thyroid Association Seib, C. D., Meng, T., Cisco, R. M., Lin, D. T., McAninch, E. A., Chen, J., Tamura, M. K., Trickey, A. W., Kebebew, E. 2022


    Total thyroidectomy for Graves' disease (GD) is associated with rapid treatment of hyperthyroidism and low recurrence rates. However, it carries the risk of surgical complications including permanent hypoparathyroidism, which contribute to long-term impaired quality of life. The objective of this study was to determine the incidence of permanent hypoparathyroidism requiring calcitriol therapy among a population-based cohort of older adults undergoing total thyroidectomy for GD in the U.S.We performed a population-based cohort study using 100% Medicare claims from beneficiaries older than 65 with GD who underwent total thyroidectomy from 2007 to 2017. We required continuous enrollment in Medicare Parts A, B, and D for 12 months before and after surgery to ensure access to comprehensive claims data. Patients were excluded if they had a preoperative diagnosis of thyroid cancer or were on long-term preoperative calcitriol. Our primary outcome was permanent hypoparathyroidism, which was identified based on persistent use of calcitriol between 6-12 months following thyroidectomy. We used multivariable logistic regression to identify characteristics associated with permanent hypoparathyroidism, including patient age, sex, race/ethnicity, neighborhood disadvantage, Charlson-Deyo Comorbidity Index, urban or rural residence, and frailty.We identified 4,650 patients who underwent total thyroidectomy for GD during the study period and met inclusion criteria (mean age 72.8 years [SD 5.5], 86% female, and 79% white). Among this surgical cohort, 104 (2.2%, 95% CI: 1.8-2.7%) patients developed permanent hypoparathyroidism requiring calcitriol therapy. Patients who developed permanent hypoparathyroidism were on average older (mean age 74.1 vs. 72.8 years) than those who did not develop permanent hypoparathyroidism (p=0.04). On multivariable regression, older age was the only patient characteristic associated with permanent hypoparathyroidism (odds ratio [OR] age ≥ 76 years 1.68 [95% CI 1.13-2.51] compared to age 66-75 years).The risk of permanent hypoparathyroidism requiring calcitriol therapy among this national, U.S. population-based cohort of older adults with GD treated with total thyroidectomy was low, even when considering operations performed by a heterogeneous group of surgeons. These findings suggest the risk of hypoparathyroidism should not be a deterrent to operative management for GD in older adults who are appropriate surgical candidates.

    View details for DOI 10.1089/thy.2022.0140

    View details for PubMedID 36416252

  • Evaluating the Impact of the Covid-19 Pandemic on Emergency Medicaid Programs: Have Insurance Rates Improved among Trauma Patients? Handley, T. J., Boncompagni, A., Arnow, K. D., Sasnal, M., Trickey, A. W., Morris, A. M., Knowlton, L. LIPPINCOTT WILLIAMS & WILKINS. 2022: S88
  • Defining Essential Surgery in the US During the COVID-19 Pandemic Response. JAMA surgery Mattingly, A. S., Eddington, H. S., Rose, L., Morris, A. M., Trickey, A. W., Cullen, M. R., Wren, S. M. 2022


    This cohort study compares the volume of performed surgical procedures classified as essential, urgent, and nonurgent before and after elective surgeries were restricted during the COVID-19 pandemic in the US.

    View details for DOI 10.1001/jamasurg.2022.3944

    View details for PubMedID 36260330

  • A Systematic Review of the Recruitment and Outcome Reporting by Sex and Race/Ethnicity in Stent Device Development Trials for Endovascular Abdominal Aortic Aneurysm Repair. Annals of vascular surgery Patel, J., Pallapothu, S., Langston, A., Trickey, A. W., Burdon, T., Goodney, P., Arya, S. 2022


    OBJECTIVE: Women and racial/ethnic minority groups have been shown to experience poor outcomes after endovascular aortic aneurysm repair (EVAR). One potential reason is the rare inclusion of these populations in initial phases of device development. The objective of this systematic review is to understand enrollment and outcome reporting by Sex and Race/Ethnicity in industry-funded EVAR device development trials.METHODS: MEDLINE, PubMed, and Embase, were searched from inception to January 2022 without language restrictions using the following terminology: "stent", "graft", "endograft", "device", "abdominal aortic aneurysm".CLINICALTRIALS: gov was also searched from inception to January 2022 for "abdominal aortic aneurysm." Two independent reviewers screened and extracted data. All phase I-III and post-market evaluation trials that included patients ≥ 18 years of age, who underwent EVAR were assessed. Participation-to-prevalence ratios (PPR) were calculated to estimate representation of participants by sex and race/ethnicity in trials compared with their share of disease burden.RESULTS: Among the 4,780 retrieved articles, 55 industry-funded trials met inclusion criteria for this review. A total of 51 trials (93%) reported enrolment by sex/gender, and only 7 trials (13%) reported enrolment by race/ethnicity of the participants. A median of 19 (IQR 4.5, 51) women participants were recruited compared to 171 (IQR 57, 311.5) men, and 17 (IQR 7.5, 21.5) racial/minority patients were recruited compared to 241 (IQR 123, 463.5) White participants. Women represent 16.6% of the disease population, and the median PPR is 0.62 (IQR 0.42, 0.88), which has remained constant over time (Figure 1). None of the device trials reported outcomes based on sex/gender or race/ethnicity.CONCLUSIONS: This systematic review to highlights the disparities in recruitment and outcome reporting based on sex and race/ethnicity in EVAR device development trials. While most trials may be underpowered to study these differences, recent registry studies show differential outcomes based on sex and race/ethnicity of vascular patients. Therefore, it is imperative to include and report outcomes in these participants, starting from the initial device development phases to improve generalizability of device-use and understand sources of variation in device performance.

    View details for DOI 10.1016/j.avsg.2022.09.059

    View details for PubMedID 36272665

  • EMERGENCY MEDICAID PROGRAMS MAY BE AN EFFECTIVE MEANS OF PROVIDING SUSTAINED INSURANCE AMONG TRAUMA PATIENTS: A STATEWIDE LONGITUDINAL ANALYSIS. The journal of trauma and acute care surgery Knowlton, L. M., Tran, L. D., Arnow, K., Trickey, A. W., Morris, A. M., Spain, D. A., Wagner, T. H. 2022


    INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to post-discharge resources, and provides patients with a path to sustain coverage through Medicaid. As HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status six months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment.METHODS: Using a customized longitudinal claims dataset for HPE-approved patients from the California Department of Health Care Services (DHCS), we analyzed adults with a primary trauma diagnosis (ICD-10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at six months. Univariate and multivariate analyses were performed.RESULTS: A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at six months. Compared to patients who did not sustain, those who sustained had higher injury severity score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001) and were more likely to be discharged to post-acute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%) and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < =15: aOR 1.51, p = 0.02) and surgery (aOR 1.85, p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR 0.05, p < 0.001) decreased the likelihood of Medicaid sustainment.CONCLUSION: HPE programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to healthcare services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain.LEVEL OF EVIDENCE: Epidemiologic, Level III.

    View details for DOI 10.1097/TA.0000000000003796

    View details for PubMedID 36138539

  • Adverse Cardiovascular Outcomes Among Older Adults with Primary Hyperparathyroidism Treated with Parathyroidectomy vs. non-operative Management. Annals of surgery Seib, C. D., Meng, T., Cisco, R. M., Suh, I., Lin, D. T., Harris, A. H., Trickey, A. W., Tamura, M. K., Kebebew, E. 2022


    We sought to compare the incidence of adverse cardiovascular events in older adults with primary hyperparathyroidism (PHPT) treated with parathyroidectomy versus non-operative management.PHPT is a common endocrine disorder that is associated with increased cardiovascular mortality, but it is not known whether parathyroidectomy reduces the incidence of adverse cardiovascular events.We conducted a population-based, longitudinal cohort study of Medicare beneficiaries diagnosed with PHPT (2006-2017). Multivariable, inverse probability weighted Cox proportional hazards regression was used to determine the associations of parathyroidectomy with major adverse cardiovascular events (MACE), cardiovascular disease-related hospitalization, and cardiovascular hospitalization-associated mortality.We identified 210,206 beneficiaries diagnosed with PHPT from 2006-2017. Among 63,136 (30.0%) treated with parathyroidectomy and 147,070 (70.0%) managed non-operatively within one year of diagnosis, the unadjusted incidence of MACE was 10.0% (mean follow-up 59.1 [SD 35.6] months) and 11.5% (mean follow-up 54.1 [SD 34.0] months), respectively. In multivariable analysis, parathyroidectomy was associated with a lower incidence of MACE (HR 0.92 [95%CI 0.90-0.94]), cardiovascular disease-related hospitalization (HR 0.89 [95%CI 0.87-0.91]), and cardiovascular hospitalization-associated mortality (HR 0.76 [95%CI 0.71-0.81]) compared to non-operative management. At 10 years, parathyroidectomy was associated with adjusted absolute risk reduction for MACE of 1.7% (95%CI 1.3%-2.1%), for cardiovascular disease-related hospitalization of 2.5% (95%CI 2.1%-2.9%), and for cardiovascular hospitalization-associated mortality of 1.4% (95%CI 1.2%-1.6%).In this large, population-based cohort study, parathyroidectomy was associated with a lower long-term incidence of adverse cardiovascular outcomes when compared with non-operative management for older adults with PHPT, which is relevant to surgical decision-making for patients with a long life expectancy.

    View details for DOI 10.1097/SLA.0000000000005691

    View details for PubMedID 36005546

  • Tutorial: implementing and visualizing machine learning (ML) clinical prediction models into web-accessible calculators using Shiny R ANNALS OF TRANSLATIONAL MEDICINE Eddington, H. S., Trickey, A. W., Shah, V., Harris, A. S. 2022
  • Validity Evidence for ENTRUST as an Assessment of Surgical Decision-Making for the Inguinal Hernia Entrustable Professional Activity (EPA). Journal of surgical education Liebert, C. A., Melcer, E. F., Keehl, O., Eddington, H., Trickey, A. W., Lee, M., Tsai, J., Camacho, F., Merrell, S. B., Korndorffer, J. R., Lin, D. T. 2022


    OBJECTIVE: As the American Board of Surgery (ABS) moves toward implementation of Entrustable Professional Activities (EPAs), there is a growing need for objective evaluation of readiness for entrustment of residents. This requires not only assessment of technical skills and knowledge, but also surgical decision-making in preoperative, intraoperative, and postoperative settings. We developed and piloted an Inguinal Hernia EPA Assessment on ENTRUST, a serious game-based online virtual patient simulation platform to assess trainees' decision-making competence.DESIGN: This is a prospective analysis of resident performance on the ENTRUST Inguinal Hernia EPA Assessment using bivariate analyses.SETTING: This study was conducted at an academic institution in a proctored exam setting.PARTICIPANTS: Forty-three surgical residents completed the ENTRUST Inguinal Hernia EPA Assessment.RESULTS: Four case scenarios for the Inguinal Hernia EPA and corresponding scoring algorithms were iteratively developed by expert consensus aligned with ABS EPA descriptions and functions. ENTRUST Inguinal Hernia Grand Total Score was positively correlated with PGY-level (p < 0.0001). Preoperative, Intraoperative, and Postoperative Total Scores were also positively correlated with PGY-level (p = 0.001, p = 0.006, and p = 0.038, respectively). Total Case Scores were positively correlated with PGY-level for cases representing elective unilateral inguinal hernia (p = 0.0004), strangulated inguinal hernia (p < 0.0001), and elective bilateral inguinal hernia (p = 0.0003). Preoperative Sub-Scores were positively correlated with PGY-level for all cases (p < 0.01). Intraoperative Sub-Scores were positively correlated with PGY-level for strangulated inguinal hernia and bilateral inguinal hernia (p = 0.0007 and p = 0.0002, respectively). Grand Total Score and Intraoperative Sub-Score were correlated with prior operative experience (p < 0.0001). Prior video game experience did not correlate with performance on ENTRUST (p = 0.56).CONCLUSIONS: Performance on the ENTRUST Inguinal Hernia EPA Assessment was positively correlated to PGY-level and prior inguinal hernia operative performance, providing initial validity evidence for its use as an objective assessment for surgical decision-making. The ENTRUST platform holds potential as tool for assessment of ABS EPAs in surgical residency programs.

    View details for DOI 10.1016/j.jsurg.2022.07.008

    View details for PubMedID 35909070

  • Assessment of Second Primary Cancer Risk Among Men Receiving Primary Radiotherapy vs Surgery for the Treatment of Prostate Cancer. JAMA network open Bagshaw, H. P., Arnow, K. D., Trickey, A. W., Leppert, J. T., Wren, S. M., Morris, A. M. 2022; 5 (7): e2223025


    Shared decision-making is an important part of the treatment selection process among patients with prostate cancer. Updated information is needed regarding the long-term incidence and risk of second primary cancer after radiotherapy vs nonradiotherapy treatments, which may help to inform discussions of risks and benefits for men diagnosed with prostate cancer.To assess the current incidence and risk of developing a second primary cancer after receipt of radiotherapy vs nonradiotherapy treatments for prostate cancer.This retrospective cohort study used the Veterans Affairs Corporate Data Warehouse to identify 154 514 male veterans 18 years and older who had localized prostate cancer (tumor stages T1-T3) diagnosed between January 1, 2000, and December 31, 2015, and no cancer history. A total of 10 628 patients were excluded because of (1) incomplete treatment information for the year after diagnosis, (2) receipt of both radiotherapy and a surgical procedure in the year after diagnosis, (3) receipt of radiotherapy more than 1 year after diagnosis, (4) occurrence of second primary cancer or death within 1 year or less after diagnosis, (5) prostate-specific antigen value greater than 99 ng/mL within 6 months before diagnosis, or (6) no recorded Veterans Health Administration service after diagnosis. The remaining 143 886 patients included in the study had a median (IQR) follow-up of 9 (6-13) years. Data were analyzed from May 1, 2021, to May 22, 2022.Diagnosis of a second primary cancer more than 1 year after prostate cancer diagnosis.Among 143 886 male veterans (median [IQR] age, 65 [60-71] years) with localized prostate cancer, 750 (0.5%) were American Indian or Alaska Native, 389 (0.3%) were Asian, 37 796 (26.3%) were Black or African American, 933 (0.6%) were Native Hawaiian or other Pacific Islander, 91 091 (63.3%) were White, and 12 927 (9.0%) were of unknown race; 7299 patients (5.1%) were Hispanic or Latino, 128 796 (89.5%) were not Hispanic or Latino, and 7791 (5.4%) were of unknown ethnicity. A total of 52 886 patients (36.8%) received primary radiotherapy, and 91 000 (63.2%) did not. A second primary cancer more than 1 year after prostate cancer diagnosis was present in 4257 patients (3.0%), comprising 1955 patients (3.7%) in the radiotherapy cohort and 2302 patients (2.5%) in the nonradiotherapy cohort. In the multivariable analyses, patients in the radiotherapy cohort had a higher risk of second primary cancer compared with those in the nonradiotherapy cohort at years 1 to 5 after diagnosis (hazard ratio [HR], 1.24; 95% CI, 1.13-1.37; P < .001), with higher adjusted HRs in the subsequent 15 years (years 5-10: 1.50 [95% CI, 1.36-1.65; P < .001]; years 10-15: 1.59 [95% CI, 1.37-1.84; P < .001]; years 15-20: 1.47 [95% CI, 1.08-2.01; P = .02).In this cohort study, patients with prostate cancer who received radiotherapy were more likely to develop a second primary cancer than patients who did not receive radiotherapy, with increased risk over time. Although the incidence and risk of developing a second primary cancer were low, it is important to discuss the risk with patients during shared decision-making about prostate cancer treatment options.

    View details for DOI 10.1001/jamanetworkopen.2022.23025

    View details for PubMedID 35900763

  • A Tool to Estimate Risk of 30-day Mortality and Complications After Hip Fracture Surgery: Accurate Enough for Some but Not All Purposes? A Study From the ACS-NSQIP Database. Clinical orthopaedics and related research Harris, A. H., Trickey, A. W., Eddington, H. S., Seib, C. D., Kamal, R. N., Kuo, A. C., Ding, Q., Giori, N. J. 2022


    Surgical repair of hip fracture carries substantial short-term risks of mortality and complications. The risk-reward calculus for most patients with hip fractures favors surgical repair. However, some patients have low prefracture functioning, frailty, and/or very high risk of postoperative mortality, making the choice between surgical and nonsurgical management more difficult. The importance of high-quality informed consent and shared decision-making for frail patients with hip fracture has recently been demonstrated. A tool to accurately estimate patient-specific risks of surgery could improve these processes.With this study, we sought (1) to develop, validate, and estimate the overall accuracy (C-index) of risk prediction models for 30-day mortality and complications after hip fracture surgery; (2) to evaluate the accuracy (sensitivity, specificity, and false discovery rates) of risk prediction thresholds for identifying very high-risk patients; and (3) to implement the models in an accessible web calculator.In this comparative study, preoperative demographics, comorbidities, and preoperatively known operative variables were extracted for all 82,168 patients aged 18 years and older undergoing surgery for hip fracture in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2011 and 2017. Eighty-two percent (66,994 of 82,168) of patients were at least 70 years old, 21% (17,007 of 82,168) were at least 90 years old, 70% (57,260 of 82,168) were female, and 79% (65,301 of 82,168) were White. A total of 5% (4260 of 82,168) of patients died within 30 days of surgery, and 8% (6786 of 82,168) experienced a major complication. The ACS-NSQIP database was chosen for its clinically abstracted and reliable data from more than 600 hospitals on important surgical outcomes, as well as rich characterization of preoperative demographic and clinical predictors for demographically diverse patients. Using all the preoperative variables in the ACS-NSQIP dataset, least absolute shrinkage and selection operator (LASSO) logistic regression, a type of machine learning that selects variables to optimize accuracy and parsimony, was used to develop and validate models to predict two primary outcomes: 30-day postoperative mortality and any 30-day major complications. Major complications were defined by the occurrence of ACS-NSQIP complications including: on a ventilator longer than 48 hours, intraoperative or postoperative unplanned intubation, septic shock, deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, sepsis, intraoperative or postoperative myocardial infarction, intraoperative or postoperative cardiac arrest requiring cardiopulmonary resuscitation, acute renal failure needing dialysis, pulmonary embolism, stroke/cerebral vascular accident, and return to the operating room. Secondary outcomes were six clusters of complications recently developed and increasingly used for the development of surgical risk models, namely: (1) pulmonary complications, (2) infectious complications, (3) cardiac events, (4) renal complications, (5) venous thromboembolic events, and (6) neurological events. Tenfold cross-validation was used to assess overall model accuracy with C-indexes, a measure of how well models discriminate patients who experience an outcome from those who do not. Using the models, the predicted risk of outcomes for each patient were used to estimate the accuracy (sensitivity, specificity, and false discovery rates) of a wide range of predicted risk thresholds. We then implemented the prediction models into a web-accessible risk calculator.The 30-day mortality and major complication models had good to fair discrimination (C-indexes of 0.76 and 0.64, respectively) and good calibration throughout the range of predicted risk. Thresholds of predicted risk to identify patients at very high risk of 30-day mortality had high specificity but also high false discovery rates. For example, a 30-day mortality predicted risk threshold of 15% resulted in 97% specificity, meaning 97% of patients who lived longer than 30 days were below that risk threshold. However, this threshold had a false discovery rate of 78%, meaning 78% of patients above that threshold survived longer than 30 days and might have benefitted from surgery. The tool is available here: models of mortality and complications we developed may be accurate enough for some uses, especially personalizing informed consent and shared decision-making with patient-specific risk estimates. However, the high false discovery rate suggests the models should not be used to restrict access to surgery for high-risk patients. Deciding which measures of accuracy to prioritize and what is "accurate enough" depends on the clinical question and use of the predictions. Discrimination and calibration are commonly used measures of overall model accuracy but may be poorly suited to certain clinical questions and applications. Clinically, overall accuracy may not be as important as knowing how accurate and useful specific values of predicted risk are for specific purposes.Level of Evidence Level III, therapeutic study.

    View details for DOI 10.1097/CORR.0000000000002294

    View details for PubMedID 35901441

  • Mutations in latent membrane protein 1 of Epstein Barr virus are associated with increased risk of post-transplant lymphoproliferative disorder Martinez, O. M., Krams, S. M., Robien, M., Lapasaran, M. M., Arvedson, M., Reitsma, A., Weinberg, K., Boyd, S., Armstrong, B., Twist, C., Gratzinger, D., Tan, B., Trickey, A., Sever, M., Brown, M., Bernstein, D., Esquivel, C., CTOC 06 Investigators WILEY. 2022
  • Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable? Clinical orthopaedics and related research Harris, A. H., Ding, Q., Trickey, A. W., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Yoshida, R., Lashgari, D., Nuckols, T. K., Kamal, R. N. 2022


    BACKGROUND: The American Academy of Orthopaedic Surgeons recently proposed quality measures for the initial surgical treatment of carpal tunnel syndrome (CTS). One measure addressed avoidance of adjunctive surgical procedures during carpal tunnel release; and a second measure addressed avoidance of routine use of clinic-based occupational and/or physical therapy (OT/PT) after carpal tunnel release. However, for quality measures to serve their intended purposes, they must be tested in real-world data to establish that gaps in quality exist and that the measures yield reliable performance information.QUESTIONS/PURPOSES: (1) Is there an important quality gap in clinical practice for avoidance of adjunctive surgical procedures during carpal tunnel release? (2) Is there an important quality gap in avoiding routine use of clinic-based occupational and/or physical therapy after carpal tunnel release? (3) Do these two quality measures have adequate beta-binomial signal-to-noise ratio (SNR) and split-sample reliability (SSR)?METHODS: This retrospective comparative study used a large national private insurance claims database, the 2018 Optum Clinformatics Data Mart. Ideally, healthcare quality measures are tested within data reflective of the providers and payors to which the measures will be applied. We previously tested these measures in a large public healthcare system and a single academic medical center. In this study, we sought to test the measures in the broader context of patients and providers using private insurance. For both measures, we included the first carpal tunnel release from 28,083 patients performed by one of 7236 surgeons, irrespective of surgical specialty (including, orthopaedic, plastic, neuro-, and general surgery). To calculate surgeon-level descriptive and reliability statistics, analyses were focused on the 66% (18,622 of 28,083) of patients who received their procedure from one of the 24% (1740 of 7236) of surgeons with at least five carpal tunnel releases in the database. No other inclusion/exclusion criteria were applied.To determine whether the measures reveal important gaps in treatment quality (avoidance of adjunctive procedures and routine therapy), we calculated descriptive statistics (median and interquartile range) of the performance distribution stratified by surgeon-level annual volume of carpal tunnel releases in the database (5+, 10+, 15+, 20+, 25+, and 30+). Like the Centers for Medicare & Medicaid Services (CMS), we considered a measure "topped out" if median performance was greater than 95%, meaning the opportunity for further quality improvement is low. We calculated the surgeon-level beta-binomial SNR and SSR for each measure, each stratified by the number of carpal tunnel releases performed by each surgeon in the database. These are standard measures of reliability in health care quality measurement science. The SNR quantifies the proportion of variance that is between rather than within surgeons, and the SSR is the correlation of performance scores when each surgeons' patients are split into two random samples and then corrected for sample size.RESULTS: We found that 2% (308 of 18,622) of carpal tunnel releases involved an adjunctive procedure. The results showed that avoidance of adjunctive surgical procedures during carpal tunnel release had a median (IQR) performance of 100% (100% to 100%) at all case volumes. Only 8% (144 of 1740) of surgeons with at least five cases in the database had less than 100% performance, and only 5% (84 of 1740) had less than 90% performance. This means adjunctive procedures were rarely performed and an important quality gap does not exist based on the CMS criterion. Regarding the avoidance of routine therapy, there was a larger quality gap: For surgeons with at least five cases in the database, median performance was 89% (75% to 100%), and 25% (435 of 1740) of these surgeons had less than 75% performance. This signifies that the measure is not topped out and may reveal an important quality gap. Most patients receiving clinic-based OT/PT had only one visit in the 6 weeks after surgery. Median (IQR) SNRs of the first measure, which addressed avoidance of adjunctive surgical procedures, and the second measure, which addresses avoidance of routine use clinic-based OT/PT, were 1.00 (1.00 to 1.00) and 0.86 (0.67 to 1.00), respectively. The SSR for these measures were 0.87 (95% CI 0.85 to 0.88) and 0.75 (95% CI 0.73 to 0.77), respectively. All of these reliability statistics exceed National Quality Forum's emerging minimum standard of 0.60.CONCLUSION: The first measure, the avoidance of adjunctive surgical procedures during carpal tunnel release, lacked an important quality gap suggesting it is unlikely to be useful in driving improvements. The second measure, avoidance of routine use of clinic-based OT/PT, revealed a larger quality gap and had very good reliability, suggesting it may be useful for quality monitoring and improvement purposes.CLINICAL RELEVANCE: As healthcare systems and payors use the second measure, avoidance of routine use of clinic-based OT/PT, to encourage adherence to clinical practice guidelines (such as provider profiling, public reporting, and payment policies), it will be critically important to consider what proportion of patients receiving OT/PT should be considered routine practice and therefore inconsistent with guidelines. The value or potential harm of this measure depends on this judgement.

    View details for DOI 10.1097/CORR.0000000000002175

    View details for PubMedID 35274625

  • Prehospital Bypass Policies Increase The Proportion Of Stroke Patients Transported To Primary Stroke Centers - A Quasi-experimental Study In A National Sample Of Medicare Beneficiaries Govindarajan, P., Meng, T., Trickey, A., Matheson, L., Gilchrist, S., Rosenthal, S., Sox-Harris, A., Wagner, T. LIPPINCOTT WILLIAMS & WILKINS. 2022
  • Perspectives on Home Time and Its Association With Quality of Life After Inpatient Surgery Among US Veterans. JAMA network open Arya, S., Langston, A. H., Chen, R., Sasnal, M., George, E. L., Kashikar, A., Barreto, N. B., Trickey, A. W., Morris, A. M. 1800; 5 (1): e2140196


    Importance: Home time, defined as time spent at home after hospital discharge, is emerging as a novel, patient-oriented outcome in stroke recovery and end-of-life care. Longer home time is associated with lower mortality and higher patient satisfaction. However, a knowledge gap exists in the measurement and understanding of home time in the population undergoing surgery.Objectives: To examine the association between postoperative home time and quality of life (QoL), functional status, and decisional regret and to identify themes regarding the meaning of time spent at home after surgery.Design, Setting, and Participants: This mixed-methods study including a survey and qualitative interviews used an explanatory sequential design involving 152 quantitative surveys followed by in-depth interviews with 12 participants from February 26, 2020, to December 17, 2020. US veterans older than 65 years who underwent inpatient surgery at a single-center veterans hospital within the prior 6 to 12 months were studied.Exposures: Quality of life, measured by the Veterans RAND 12-item Health Survey and 19-item Control, Autonomy, Self-realization, and Pleasure scale; functional status, measured by activities of daily living (ADL) and instrumental ADL scales; and regret, measured by the Decision Regret Scale.Main Outcomes and Measures: Home time, standardized as percentage of total time spent at home from the time of surgery to the time of survey administration. Associations between home time and QoL, function, and decisional regret in the survey data were analyzed using Spearman correlation in the overall cohort and in operative stress score subcohorts (1-2 [low] vs 3-5 [high]) in a stratified analysis. The 12 semistructured interviews were analyzed to elicit patients' perspectives on home time in postoperative recovery. Qualitative data were coded and analyzed using content and thematic analysis and integrated with quantitative data in joint displays.Results: A total of 152 patients (mean [SD] age, 72.3 [4.4] years; 146 [96.0%] male) were surveyed, and 12 patients (mean [SD] age, 72.3 [4.8] years; 11 [91.7%] male) were interviewed. The median time to survey completion was 307 days (IQR, 265-344 days). The median home time was 97.8% (IQR, 94.6%-98.6%; range, 22.2%-99.5%). Increased home time was associated with better physical health-related QoL in the Veterans RAND 12-item Health Survey (r=0.33; 95% CI, 0.18-0.47; P<.001) and higher ADL scores (r=0.21; 95% CI, 0.06-0.36; P=.008) and instrumental ADL functional scores (r=0.21; 95% CI, 0.04-0.37; P=.009). Decisional regret was inversely associated with home time in only the high operative stress score subcohort (r=-0.22; 95% CI, -0.47 to -0.04; P=.047). Home was perceived as a safe and familiar environment that accelerated recovery through nurturing support of loved ones.Conclusions and Relevance: In this mixed-methods study including a survey and qualitative interviews, increased home time in the first year after major surgery was associated with improved daily function and physical QoL among US veterans. Interviewees considered the transition to home to be an indicator of recovery, suggesting that home time may be a promising, patient-oriented quality outcome measure for surgical recovery that warrants further study.

    View details for DOI 10.1001/jamanetworkopen.2021.40196

    View details for PubMedID 35015066

  • Host microRNAs are decreased in pediatric solid-organ transplant recipients during EBV+ Post-transplant Lymphoproliferative Disorder. Frontiers in immunology Sen, A., Enriquez, J., Rao, M., Glass, M., Balachandran, Y., Syed, S., Twist, C. J., Weinberg, K., Boyd, S. D., Bernstein, D., Trickey, A. W., Gratzinger, D., Tan, B., Lapasaran, M. G., Robien, M. A., Brown, M., Armstrong, B., Desai, D., Mazariegos, G., Chin, C., Fishbein, T. M., Venick, R. S., Tekin, A., Zimmermann, H., Trappe, R. U., Anagnostopoulos, I., Esquivel, C. O., Martinez, O. M., Krams, S. M. 2022; 13: 994552


    Post-transplant lymphoproliferative disorder (PTLD) is a serious complication of solid organ transplantation. Predisposing factors include primary Epstein-Barr virus (EBV) infection, reactivation of EBV in recipient B cells, and decreased T cell immunity due to immunosuppression. In our previous studies EBV infection was demonstrated to markedly alter the expression of host B cell microRNA (miR). Specifically, miR-194 expression was uniquely suppressed in EBV+ B cell lines from PTLD patients and the 3'untranslated region of IL-10 was determined to be targeted by miR-194. Although EBV has been shown to regulate host miR expression in B cell lymphoma cell lines, the expression of miRs in the circulation of patients with EBV-associated PTLD has not been studied. The objective of this study was to determine if changes in miR expression are associated with EBV+ PTLD. In this study, we have shown that miR-194 is significantly decreased in EBV+PTLD tumors and that additional miRs, including miRs-17, 19 and 106a are also reduced in EBV+PTLD as compared to EBV-PTLD. We quantitated the levels of miRs-17, 19, 106a, 155, and 194 in the plasma and extracellular vesicles (EV; 50-70 nm as determined by nanoparticle tracking analysis) from pediatric recipients of solid organ transplants with EBV+ PTLD+ that were matched 1:2 with EBV+ PTLD- pediatric transplant recipients as part of the NIH-sponsored Clinical Trials in Organ Transplantation in Children, (CTOTC-06) study. Levels of miRs-17, 19, 106a, and 194 were reduced in the plasma and extracellular vesicles (EV) of EBV+ PTLD+ group compared to matched controls, with miRs-17 (p = 0.034; plasma), miRs-19 (p = 0.029; EV) and miR-106a (p = 0.007; plasma and EV) being significantly reduced. Similar levels of miR-155 were detected in the plasma and EV of all pediatric SOT recipients. Importantly, ~90% of the cell-free miR were contained within the EV supporting that EBV+ PTLD tumor miR are detected in the circulation and suggesting that EVs, containing miRs, may have the potential to target and regulate cells of the immune system. Further development of diagnostic, mechanistic and potential therapeutic uses of the miRs in PTLD is warranted.

    View details for DOI 10.3389/fimmu.2022.994552

    View details for PubMedID 36304469

  • Individual and Institutional Factors Associated with PGY5 General Surgery Resident Self-Efficacy: A National Survey. Journal of the American College of Surgeons Kearse, L. E., Schmiederer, I. S., Dent, D. L., Anderson, T. N., Payne, D. H., Jensen, R., Trickey, A. W., Ding, Q., Korndorffer, J. R. 2022; 234 (4): 514-520


    Variability in post-graduate year 5 (PGY5) residents' operative self-efficacy exists; yet the causes of variability have not been explored. Our study aims to determine resident-related and program-dependent factors associated with residents' perceptions of self-efficacy.Following the 2020 American Board of Surgery In-Training Examination, a national survey of self-efficacy in 10 of the most commonly performed Accreditation Council for Graduate Medical Education case-log procedures was completed.A total of 1,145 PGY5 residents completed the survey (response rate 83.8%), representing 296 surgical residency programs. Female sex (odds ratio [OR] 0.46 to 0.67; 95% CI 0.30 to 0.95; p < 0.05) was associated with decreased self-efficacy for 6 procedures. Residents from institutions with emphasis on autonomy were more likely to report higher self-efficacy for 8 of 10 procedures (OR 1.39 to 3.03; 95% CI 1.03 to 4.51; p < 0.05). In addition, increased socialization among residents and faculty also correlated with increased self-efficacy in 3 of 10 procedures (OR 1.41 to 2.37; 95% CI 1.03 to 4.69; p < 0.05). Procedures performed with higher levels of resident responsibility, based on Graduated Levels of Resident Responsibility (GLRR) and Teaching Assistant (TA) scores, were correlated with higher self-efficacy (p < 0.001).Ensuring that residents receive ample opportunities for GLRR and TA experiences, while implementing programmatic support for resident-dependent factors, may be crucial for building self-efficacy in PGY5 residents. Institutional support of resident "autonomy" and increasing methods of socialization may provide a means of building trust and improving perceptions of self-efficacy. In addition, reevaluating institutional policies that limit opportunities for graduated levels of responsibility, while maintaining patient safety, may lead to increased self-efficacy.

    View details for DOI 10.1097/XCS.0000000000000090

    View details for PubMedID 35290270

  • Lessons Learned From the Historical Trends on Thrombolysis Use for Acute Ischemic Stroke Among Medicare Beneficiaries in the United States. Frontiers in neurology Meng, T., Trickey, A. W., Harris, A. H., Matheson, L., Rosenthal, S., Traboulsi, A. A., Saver, J. L., Wagner, T., Govindarajan, P. 2022; 13: 827965


    Background: The most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization.Methods: We built a comprehensive national stroke registry by combining patient-level, stroke center status, and geographical characteristics, using multiple data sources. Using multiple national administrative databases from 2007 to 2014, we generated a mixed-effect logistic regression model to characterize the independent associations of patient, hospital, and geographical characteristics with IVT in 2014.Results: Use of IVT increased consistently from 2.8% in 2007 to 7.7% in 2014, P < 0.001. Between group differences persisted, with lower odds of use in patients who were ≥86 years (aOR 0.74, 95% CI 0.65-0.83), Black (aOR 0.73, 95% CI 0.61-0.87), or treated at a rural hospital (aOR 0.88, 95% CI 0.77-1.00). Higher odds of use were observed in patients who arrived by ambulance (aOR 2.67, 95% CI 2.38-3.00), were treated at a hospital certified as a stroke center (aOR 1.96, 95% CI 1.68-2.29), or were treated at hospitals located in the most socioeconomically advantaged areas (aOR 1.27, 95% CI 1.05-1.54).Conclusions: Between 2007 and 2014, the frequency of IVT for patients with acute ischemic stroke increased substantially, though differences persisted in the form of less frequent treatment associated with certain characteristics. These findings can inform ongoing efforts to optimize the delivery of IVT to all AIS patients nationwide.

    View details for DOI 10.3389/fneur.2022.827965

    View details for PubMedID 35309566

  • Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery. JAMA surgery George, E. L., Massarweh, N. N., Youk, A., Reitz, K. M., Shinall, M. C., Chen, R., Trickey, A. W., Varley, P. R., Johanning, J., Shireman, P. K., Arya, S., Hall, D. E. 1800


    Importance: Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking.Objective: To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals.Design, Setting, and Participants: This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included.Exposures: Surgical care in either a VA or private sector setting.Main Outcomes and Measures: Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication.Results: Of 3 910 752 operations (3 174 274 from VASQIP and 736 477 from NSQIP), 1 498 984 (92.1%) participants in VASQIP were male vs 678 382 (47.2%) in NSQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P<.001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P<.001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n=3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P<.001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P<.001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding.Conclusions and Relevance: VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.

    View details for DOI 10.1001/jamasurg.2021.6488

    View details for PubMedID 34964818

  • Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic. JAMA network open Mattingly, A. S., Rose, L., Eddington, H. S., Trickey, A. W., Cullen, M. R., Morris, A. M., Wren, S. M. 2021; 4 (12): e2138038


    Importance: The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States.Objective: To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19.Design, Setting, and Participants: This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021.Exposures: 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19.Main Outcomes and Measures: Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications.Results: A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures among patients aged ≥65 years [30.2%]). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P<.001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P<.001) and cataract procedures (IRR, 0.11; 95% CI, -0.11 to 0.32; P=.03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P=.10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P<.001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r=-0.00025; 95% CI, -0.0042 to -0.0009; P=.003), but there was no correlation during the COVID-19 surge (r=-0.00034; 95% CI, -0.0075 to 0.00007; P=.11).Conclusions and Relevance: This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.

    View details for DOI 10.1001/jamanetworkopen.2021.38038

    View details for PubMedID 34878546

  • Risk of Fracture Among Older Adults With Primary Hyperparathyroidism Receiving Parathyroidectomy vs Nonoperative Management. JAMA internal medicine Seib, C. D., Meng, T., Suh, I., Harris, A. H., Covinsky, K. E., Shoback, D. M., Trickey, A. W., Kebebew, E., Tamura, M. K. 2021


    Importance: Primary hyperparathyroidism (PHPT) contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing fracture risk in older adults is unknown.Objective: To compare the incidence of clinical fracture among older adults with PHPT treated with parathyroidectomy vs nonoperative management.Design, Setting, and Participants: This was a population-based, longitudinal cohort study of all Medicare beneficiaries with PHPT from 2006 to 2017. Multivariable, inverse probability weighted Cox proportional hazards and Fine-Gray competing risk regression models were constructed to determine the association of parathyroidectomy vs nonoperative management with incident fracture. Data analysis was conducted from February 17, 2021, to September 14, 2021.Main Outcomes and Measures: The primary outcome was clinical fracture at any anatomic site not associated with major trauma during the follow-up period.Results: Among the 210 206 Medicare beneficiaries with PHPT (mean [SD] age, 75 [6.8] years; 165 637 [78.8%] women; 183 433 [87.3%] White individuals), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis, and 147 070 (70.0%) were managed nonoperatively. During a mean (SD) follow-up period of 58.5 (35.5) months, the unadjusted incidence of fracture was 10.2% in patients treated with parathyroidectomy. During a mean (SD) follow-up of 52.5 (33.8) months, the unadjusted incidence of fracture was 13.7% in patients observed nonoperatively. On multivariable analysis, parathyroidectomy was associated with lower adjusted rates of any fracture (hazard ratio [HR], 0.78; 95% CI, 0.76-0.80]) and hip fracture (HR, 0.76; 95% CI, 0.72-0.79). At 2, 5, and 10 years, parathyroidectomy was associated with adjusted absolute fracture risk reduction of 1.2% (95% CI, 1.0-1.4), 2.8% (95% CI, 2.5-3.1), and 5.1% (95% CI, 4.6-5.5), respectively, compared with nonoperative management. On subgroup analysis, there were no significant differences in the association of parathyroidectomy with fracture risk by age group, sex, frailty, history of osteoporosis, or meeting operative guidelines. Fine-Gray competing risk regression confirmed parathyroidectomy was associated with a lower probability of any fracture and hip fracture when accounting for the competing risk of death (HR, 0.84; 95% CI, 0.82-0.85; and HR, 0.83; 95% CI, 0.80-0.85, respectively).Conclusions and Relevance: This longitudinal cohort study found that parathyroidectomy was associated with a lower risk of any fracture and hip fracture among older adults with PHPT, suggesting a clinically meaningful benefit of operative management in this population.

    View details for DOI 10.1001/jamainternmed.2021.6437

    View details for PubMedID 34842909

  • ENTRUST: A Serious Game-Based Virtual Patient Platform to Assess Entrustable Professional Activities in Surgical Education Liebert, C. A., Lin, D. T., Melcer, E. F., Keehl, O. G., Trickey, A., Eddington, H., Merrell, S., Korndorffer, J. R. ELSEVIER SCIENCE INC. 2021: S224
  • Engagement and Adherence with a Web-Based Prehabilitation Program for Patients Awaiting Abdominal Colorectal Surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Shelton, E., Barreto, N. B., Bidwell, S., Folk-Tolbert, M., Shelton, A., Trickey, A. W., Kin, C. J. 2021


    BACKGROUND: Understanding the drivers of patient engagement and adherence is critical to developing and implementing preoperative optimization programs. The aim of this project is to determine whether existing health beliefs are associated with engagement and adherence in a home-based online prehabilitation program.METHODS: Patients undergoing abdominal colorectal operations were enrolled in an online nutrition and exercise program. We collected baseline health beliefs and mindsets, daily exercises, and weekly diet recalls. Multivariable binary logistic regression predicted engagement, multivariable ordinary least squares regression predicted diet adherence, and generalized linear models with a binomial distribution predicted engagement and exercise adherence.RESULTS: Of the 227 patients who agreed to participate, 75% activated their accounts; of those, 75% used the program. Engagement with the program was unrelated to health beliefs or mindsets. Positive diet-related health beliefs and a growth mindset were associated with positive diet behaviors and inversely associated with negative diet behaviors. Exercise-related health beliefs and mindsets were not associated with exercise adherence. Patients enrolled within 4weeks of surgery used the program more than those enrolled more than 4weeks from surgery.CONCLUSIONS: This app-based prehabilitation program demonstrated moderate acceptability, engagement, and adherence. Addressing health beliefs and mindsets may be an effective way of increasing adherence to diet recommendations. To increase adherence to exercise recommendations, further assessment of potential barriers is critical. While an online platform is a highly promising scalable strategy, more customization and user engagement are necessary to make it an effective way of delivering a preoperative health behavior change intervention.

    View details for DOI 10.1007/s11605-021-05171-2

    View details for PubMedID 34668165

  • Financial Burden of Traumatic Injury Amongst the Privately Insured. Annals of surgery Fu, S. J., Arnow, K., Trickey, A., Spain, D. A., Morris, A., Knowlton, L. 2021


    OBJECTIVE: We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs.SUMMARY BACKGROUND DATA: Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown.METHODS: We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A two-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month out-of-pocket costs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure after injury.RESULTS: Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1,703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to HDHP enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12-month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however high-deductible health plan enrollees faced a 13% chance of CHE.CONCLUSIONS: Privately insured trauma patients face substantial out-of-pocket costs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.

    View details for DOI 10.1097/SLA.0000000000005225

    View details for PubMedID 34596072

  • Revascularization for Intermittent Claudication Significantly Increases the 5-year Risk of Major Amputation in the Veterans Health Administration George, E. L., Chen, R., Barreto, N., Langston, A. H., Trickey, A., Arya, S. MOSBY-ELSEVIER. 2021: E309
  • Recruitment and Outcome Reporting for Women and Minorities in Stent Device Development Trials for Endovascular Abdominal Aortic Aneurysm Repair Patel, J., Pallapothu, S., Trickey, A., Langston, A., Goodney, P., Arya, S. MOSBY-ELSEVIER. 2021: E54
  • Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims. Surgery Alobuia, W. M., Meng, T., Cisco, R. M., Lin, D. T., Suh, I., Tamura, M. K., Trickey, A. W., Kebebew, E., Seib, C. D. 2021


    BACKGROUND: Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored.METHODS: Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models.RESULTS: Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primaryhyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanicpatients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidenceinterval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95%confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy.CONCLUSION: Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.

    View details for DOI 10.1016/j.surg.2021.05.037

    View details for PubMedID 34229901

  • Association of parathyroidectomy with 5-year clinically significant kidney stone events in patients with primary hyperparathyroidism. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists Seib, C. D., Ganesan, C., Arnow, K. D., Suh, I., Pao, A. C., Leppert, J. T., Tamura, M. K., Trickey, A. W., Kebebew, E. 2021


    OBJECTIVE: Patients with primary hyperparathyroidism (PHPT) are at increased risk of kidney stones. Guidelines recommend parathyroidectomy in PHPT patients with a history of stone disease. This study aimed to compare the 5-year incidence of clinically significant kidney stone events in patients with PHPT treated with parathyroidectomy vs. non-operative management.METHODS: We performed a longitudinal cohort study of patients with PHPT in a national commercial insurance claims database (2006-2019). Propensity score inverse probability weighting-adjusted multivariable regression models were calculated.RESULTS: We identified 7,623 patients ≥35 years-old with continuous enrollment >1 year before and >5 years after PHPT diagnosis. 2,933 patients (38.5%) were treated with parathyroidectomy. The cohort had a mean age of 66.5 years, 78.1% were female, 72.4% were White. Over 5 years, the unadjusted incidence of ≥1 kidney stone event was higher in patients managed with parathyroidectomy compared to those managed non-operatively overall (5.4% vs. 4.1%) and among those with a history of kidney stones at PHPT diagnosis (17.9% vs. 16.4%). On multivariable analysis, parathyroidectomy was associated with no statistically significant difference in the odds of 5-year kidney stone event among patients with a history of kidney stones (OR 1.03, 95%CI 0.71-1.50) or those without history of kidney stones (OR 1.16, 95%CI 0.84-1.60).CONCLUSION: Based on this claims analysis, there was no difference in the odds of 5-year kidney stone events in PHPT patients treated with parathyroidectomy vs. non-operative management. Time-horizon for benefit should be considered when making treatment decisions for PHPT based on risk of kidney stone events.

    View details for DOI 10.1016/j.eprac.2021.06.004

    View details for PubMedID 34126246

  • Association of Cumulative Social Risk and Social Support With Receipt of Chemotherapy Among Patients With Advanced Colorectal Cancer. JAMA network open Davis, R. E., Trickey, A. W., Abrahamse, P., Kato, I., Ward, K., Morris, A. M. 2021; 4 (6): e2113533


    Importance: Approximately 38% of patients with advanced colorectal cancer do not receive chemotherapy.Objective: To determine whether cumulative social risk (ie, multiple co-occurring sociodemographic risk factors) is associated with lower receipt of chemotherapy among patients with advanced colorectal cancer and whether social support would moderate this association.Design, Setting, and Participants: This cross-sectional, population-based, mailed survey study was conducted from 2012 to 2014. Participants were recruited between 2011 and 2014 from all adults within 1 year after diagnosis of stage III colorectal cancer in the Detroit, Michigan, and State of Georgia Surveillance, Epidemiology, End-Results cancer registries. Patients were eligible if they were aged 18 years or older, had undergone surgery 4 or more months ago, did not have stage IV cancer, and resided in the registry catchment areas. Data analyses were conducted from March 2017 to April 2021.Main Outcomes and Measures: The primary outcome was receipt of chemotherapy. Cumulative social risk represented a sum of 8 risk factors with the potential to drain resources from participants' cancer treatment (marital status, employment, annual income, health insurance, comorbidities, health literacy, adult caregiving, and perceived discrimination). Social support was operationalized as emotional support related to colorectal cancer diagnosis.Results: Surveys were mailed to 1909 eligible patients; 1301 completed the survey (response rate, 68%). A total of 1087 participants with complete data for key variables were included in the sample (503 women [46%]; mean [SD] age, 64 [13] years). Participants with 3 or more risk factors were less likely to receive chemotherapy than participants with 0 risk factors (3 factors, odds ratio [OR], 0.48 [95% CI, 0.26-0.87]; 4 factors, OR, 0.41 [95% CI, 0.21-0.78]; 5 factors, OR, 0.42 [95% CI, 0.20-0.87]; ≥6 factors, OR, 0.22 [95% CI, 0.09-0.55]). Participants with 2 or more support sources had higher odds of undergoing chemotherapy than those without social support (2 sources, OR, 3.05 [95% CI, 1.36-6.85]; 3 sources, OR, 3.24 [95% CI, 1.48-7.08]; 4 sources, OR, 3.69 [95% CI, 1.71-7.97]; 5 sources, OR, 4.40 [95% CI, 1.98-9.75]; ≥6 sources, OR 5.95 [95% CI, 2.58-13.74]). Within each social support level, participants were less likely to receive chemotherapy as cumulative social risk increased.Conclusions and Relevance: Cumulative social risk was associated with reduced receipt of chemotherapy. These associations were mitigated by social support. Assessing cumulative social risk may identify patients with colorectal cancer who are at higher risk for omitting chemotherapy who can be targeted for support programs to address social disadvantage and increase social support.

    View details for DOI 10.1001/jamanetworkopen.2021.13533

    View details for PubMedID 34106262

  • Gender Disparity in Surgical Society Leadership and Annual Meeting Programs. The Journal of surgical research Tirumalai, A. A., George, E. L., Kashikar, A., Langston, A. H., Rothenberg, K. A., Barreto, N. B., Trickey, A. W., Arya, S. 2021; 266: 69-76


    INTRODUCTION: Prior work suggests women surgical role models attract more female medical students into surgical training. We investigate recent trends of women in surgical society leadership and national conference moderator and plenary speaker roles.METHODS: Gender distribution was surveyed at 15 major surgical societies and 14 conferences from 2014 to 2018 using publicly reported data. Roles were categorized as leadership (executive council), moderator, or plenary speaker. Data were cross-checked from online profiles and by contacting societies. Logistic regression with Huber-White clustering by society was utilized to evaluate proportions of women in each role over time and determine associations between the proportion of women in executive leadership, and scientific session moderators and plenary speakers.RESULTS: The proportion of leadership positions held by women increased slightly from 2014 to 2018 (20.6%-26.6%, P = 0.23), as did the proportion of moderators (26.2%-30.6%, P = 0.027) and plenary speakers (26.2%-30.9%, P = 0.058). The proportion of women in each role varied significantly across societies (all P < 0.001): leaders (range 0.0%-52.0%), moderators (12.5%-58.8%), and plenary speakers (11.3%-60.0%). Three patterns of change were observed: eight societies (53.3%) demonstrated increases in representation of women over time, four societies (26.6%) showed stable moderate-to-good gender balance, and three societies (20.0%) had consistent underrepresentation of women.CONCLUSION: There is significant variability in the representation of women at the leadership level of national surgical societies and participating at national surgical conferences as moderators and plenary speakers. Over the past 5 years some societies have achieved advances in gender equity, but many societies still have substantial room for improvement.

    View details for DOI 10.1016/j.jss.2021.02.023

    View details for PubMedID 33984733

  • Patient-reported distress and age-related stress biomarkers among colorectal cancer patients. Cancer medicine Eddington, H. S., McLeod, M., Trickey, A. W., Barreto, N., Maturen, K., Morris, A. M. 2021


    OBJECTIVE: Distress among cancer patients has been broadly accepted as an important indicator of well-being but has not been well studied. We investigated patient characteristics associated with high distress levels as well as correlations among measures of patient-reported distress and "objective" stress-related biomarkers among colorectal cancer patients.METHODS: In total, 238 patients with colon or rectal cancer completed surveys including the Distress Thermometer, Problem List, and the Hospital Anxiety and Depression Scale. We abstracted demographic and clinical information from patient charts and determined salivary cortisol level and imaging-based sarcopenia. We evaluated associations between patient characteristics (demographics, clinical factors, and psychosocial and physical measures) and three outcomes (patient-reported distress, cortisol, and sarcopenia) with Spearman's rank correlations and multivariable linear regression. The potential moderating effect of age was separately investigated by including an interaction term in the regression models.RESULTS: Patient-reported distress was associated with gender (median: women 5.0, men 3.0, p<0.001), partnered status (single 5.0, partnered 4.0, p=0.018), and cancer type (rectal 5.0, colon 4.0, p=0.026); these effects varied with patient age. Cortisol level was associated with "emotional problems" (rho=0.34, p=0.030), anxiety (rho=0.046, p=0.006), and depression (rho=0.54, p=0.001) among younger patients. We found no significant associations between patient-reported distress, salivary cortisol, and sarcopenia.CONCLUSIONS: We found that young, single patients reported high levels of distress compared to other patient groups. Salivary cortisol may have limited value as a cancer-related stress biomarker among younger patients, based on association with some psychosocial measures. Stress biomarkers may not be more clinically useful than patient-reported measures in assessing distress among colorectal cancer patients.

    View details for DOI 10.1002/cam4.3914

    View details for PubMedID 33932256

  • ACQUISITION OF MEDICAID AT THE TIME OF INJURY: AN OPPORTUNITY FOR SUSTAINABLE INSURANCE COVERAGE. The journal of trauma and acute care surgery Jaramillo, J. D., Arnow, K., Trickey, A. W., Dickerson, K., Wagner, T. H., Harris, A. H., Tran, L. D., Bereknyei, S., Morris, A. M., Spain, D. A., Knowlton, L. M. 2021


    INTRODUCTION: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher injury severity (ISS>15) would be more likely to be approved for HPE.METHODS: We identified Medicaid and uninsured patients aged 18-64 years old with a primary trauma diagnosis (ICD-10) in a large level I trauma center between 2015-2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed.RESULTS: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. HPE patients had higher injury severity score (ISS > 15: 14.8% vs. 5.7%, p < .001), longer median length of stay (LOS) (2 [IQR: 0,5] vs. 0 [0,1] days, p < .001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < .001) and discharged to post-acute services (11.9% vs. 0.9%, p < .001). Patient, hospital and policy factors contributed to HPE non-approval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic whites: aOR 1.58, p = .02) and increasing ISS (p ≤ .001) were associated with increased likelihood of HPE approval.CONCLUSION: The time of hospitalization due to injury is an underutilized opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention.LEVEL OF EVIDENCE: Epidemiologic, level III.

    View details for DOI 10.1097/TA.0000000000003195

    View details for PubMedID 33783416

  • Publisher Correction to: The gender gap and healthcare: associations between gender roles and factors affecting healthcare access in Central Malawi, June-August 2017. Archives of public health = Archives belges de sante publique Azad, A. D., Charles, A. G., Ding, Q., Trickey, A. W., Wren, S. M. 2021; 79 (1): 19

    View details for DOI 10.1186/s13690-021-00538-y

    View details for PubMedID 33579368

  • Rectal Prolapse: Age-Related Differences in Clinical Presentation and What Bothers Women Most. Diseases of the colon and rectum Neshatian, L., Lee, A., Trickey, A., Arnow, K., Gurland, B. 2021


    BACKGROUND: Rectal prolapse has a diverse symptom profile that affects patients of all ages.OBJECTIVE: We sought to identify bothersome symptoms and clinical presentation that motivated rectal prolapse patients to seek care, characterize differences in symptom severity with age, and determine factors associated with bothersome symptoms.DESIGN: Retrospective analysis of a prospectively maintained registry.SETTINGS: Tertiary referral academic center.PATIENTS: 129 consecutive women with full thickness rectal prolapse.MAIN OUTCOME MEASURES: Primary bothersome symptoms, 5-item Cleveland Clinic/Wexner Fecal Incontinence questionnaire, 5-item Obstructed Defecation Syndrome questionnaire. Patients were categorized by age<65 vs. age≥65 years.RESULTS: Cleveland Clinic/Wexner Fecal Incontinence score>9 was more common in older patients (87% vs 60%, p=.002). Obstructed Defecation Syndrome score>8 was more common in younger patients (57% vs 28%, p<.001). Older patients were more likely than younger patients to report bothersome symptoms of pain (38% vs 19%, p=.021) and bleeding (12% vs 2%, p=.046). Mucus discharge was reported by most patients (older, 72% vs younger, 66%, p=.54) but was bothersome for only 18%, regardless of age. Older patients had more severe prolapse expression than younger patients (at rest, 33% vs 11%; during activity, 26% vs 19%; only with defecation, 40% vs 64%, p=.006). Older patients were more likely to seek care within 6 months of prolapse onset (29% vs 11%, p=.056). Upon multivariable regression, increasing age, narcotic use and non-protracting prolapse at rest were associated with reporting pain as a primary complaint.LIMITATIONS: Single center; small sample size.CONCLUSIONS: Rectal prolapse-related bothersome symptoms and healthcare utilization differ by age. Although rectal pain is often not commonly associated with prolapse, it bothers many women and motivates older women to undergo evaluation. Patient-reported functional questionnaires may not reflect patients' primary concerns regarding specific symptoms and could benefit from supplementation with questionnaires to elicit individualized symptom priorities. See Video Abstract at .

    View details for DOI 10.1097/DCR.0000000000001843

    View details for PubMedID 33496475

  • Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism. JAMA surgery Seib, C. D., Suh, I., Meng, T., Trickey, A., Smith, A. K., Finlayson, E., Covinsky, K. E., Kurella Tamura, M., Kebebew, E. 2021


    Importance: Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown.Objective: To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults.Design, Setting, and Participants: This population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020.Main Outcomes and Measures: The primary outcome was parathyroidectomy within 1 year of diagnosis.Results: Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n=131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P<.001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]).Conclusions and Relevance: In this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions. Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.

    View details for DOI 10.1001/jamasurg.2020.6175

    View details for PubMedID 33404646

  • Opioid use among patients with pain syndromes commonly seeking surgical consultation: A retrospective cohort. Annals of medicine and surgery (2012) Kin, C., Chou, L., Safer, D. L., Morris, A., Ding, Q., Trickey, A., Girod, S. 2021; 69: 102704


    Surgeons often see patients with pain to exclude organic pathology and consider surgical treatment. We examined factors associated with long-term opioid therapy among patients with foot/ankle, anorectal, and temporomandibular joint pain to aid clinical decision making.Using the IBM MarketScan® Research Database, we conducted a retrospective cohort analysis of patients aged 18-64 with a clinical encounter for foot/ankle, anorectal, or temporomandibular joint pain (January 2007-September 2015). Multivariable logistic regression was used to estimate adjusted odds ratios for factors associated with long-term opioid therapy, including age, sex, geographic region, pain condition, psychiatric diagnoses, and surgical procedures in the previous year.The majority of the cohort of 1,500,392 patients were women (61%). Within the year prior to the first clinical encounter for a pain diagnosis, 14% had an encounter for a psychiatric diagnosis, and 11% had undergone a surgical procedure. Long-term opioid therapy was received by 2.7%. After multivariable adjustment, older age (age 50-64 vs. 18-29: aOR 4.47, 95% CI 4.24-4.72, p < 0.001), region (South vs. Northeast, aOR 1.76, 95% CI 1.70-1.81, p < 0.001), recent surgical procedure (aOR 1.83, 95% CI 1.78-1.87, p < 0.001), male sex (aOR 1.14, 95% CI 1.12-1.16, p < 0.001) and recent psychiatric diagnosis (aOR 2.49, 95% CI 2.43-2.54, p < 0.001) were independently associated with long-term opioid therapy.Among patients with foot/ankle, anorectal, or temporomandibular joint pain, the risk of long-term opioid therapy significantly increased with older age, recent psychiatric diagnoses and surgical history. Surgeons should be aware of these risk factors in order to make high quality clinical decisions in consultations with these patients.

    View details for DOI 10.1016/j.amsu.2021.102704

    View details for PubMedID 34466218

    View details for PubMedCentralID PMC8384768

  • Artificial intelligence for prediction of donor liver allograft steatosis and early post-transplantation graft failure. HPB : the official journal of the International Hepato Pancreato Biliary Association Narayan, R. R., Abadilla, N., Yang, L., Chen, S. B., Klinkachorn, M., Eddington, H. S., Trickey, A. W., Higgins, J. P., Melcher, M. L. 2021


    Donor livers undergo subjective pathologist review of steatosis before transplantation to mitigate the risk for early allograft dysfunction (EAD). We developed an objective, computer vision artificial intelligence (CVAI) platform to score donor liver steatosis and compared its capability for predicting EAD against pathologist steatosis scores.Two pathologists scored digitized donor liver biopsy slides from 2014 to 2019. We trained four CVAI platforms with 1:99 training:prediction split. Mean intersection-over-union (IU) characterized CVAI model accuracy. We defined EAD using liver function tests within 1 week of transplantation. We calculated separate EAD logistic regression models with CVAI and pathologist steatosis and compared the models' discrimination and internal calibration.From 90 liver biopsies, 25,494 images trained CVAI models yielding peak mean IU = 0.80. CVAI steatosis scores were lower than pathologist scores (median 3% vs 20%, P < 0.001). Among 41 transplanted grafts, 46% developed EAD. The median CVAI steatosis score was higher for those with EAD (2.9% vs 1.9%, P = 0.02). CVAI steatosis was independently associated with EAD after adjusting for donor age, donor diabetes, and MELD score (aOR = 1.34, 95%CI = 1.03-1.75, P = 0.03).The CVAI steatosis EAD model demonstrated slightly better calibration than pathologist steatosis, meriting further investigation into which modality most accurately and reliably predicts post-transplantation outcomes.

    View details for DOI 10.1016/j.hpb.2021.10.004

    View details for PubMedID 34815187

  • Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties. JAMA surgery George, E. L., Hall, D. E., Youk, A., Chen, R., Kashikar, A., Trickey, A. W., Varley, P. R., Shireman, P. K., Shinall, M. C., Massarweh, N. N., Johanning, J., Arya, S. 2020: e205152


    Importance: Frailty is an important risk factor for postoperative mortality. Whether the association between frailty and mortality is consistent across all surgical specialties, especially those predominantly performing lower stress procedures, remains unknown.Objective: To examine the association between frailty and postoperative mortality across surgical specialties.Design, Setting, and Participants: A cohort study was conducted across 9 noncardiac specialties in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) from January 1, 2010, through December 31, 2014, using multivariable logistic regression to evaluate the association between frailty and postoperative mortality. Data analysis was conducted from September 15, 2019, to April 30, 2020. Patients 18 years or older undergoing noncardiac procedures were included.Exposures: Risk Analysis Index measuring preoperative frailty categorized patients as robust (Risk Analysis Index ≤20), normal (21-29), frail (30-39), or very frail (≥40). Operative Stress Score (OSS) categorized procedures as low (1-2), moderate (3), and high (4-5) stress. Specialties were categorized by case-mix as predominantly low intensity (>75% OSS 1-2), moderate intensity (50%-75%), or high intensity (<50%).Main Outcomes and Measures: Thirty-day (both measures) and 180-day (VASQIP only) postoperative mortality.Results: Of the patients evaluated in NSQIP (n=2 339 031), 1 309 795 were women (56.0%) and mean (SD) age was 56.49 (16.4) years. Of the patients evaluated in VASQIP (n=426 578), 395 761 (92.78%) were men and mean (SD) age was 61.1 (12.9) years. Overall, 30-day mortality was 1.2% in NSQIP and 1.0% in VASQIP, and 180-day mortality in VASQIP was 3.4%. Frailty and OSS distributions differed substantially across the 9 specialties. Patterns of 30-day mortality for frail and very frail patients were similar in NSQIP and VASQIP for low-, moderate-, and high-intensity specialties. Frailty was a consistent, independent risk factor for 30- and 180-day mortality across all specialties. For example, in NSQIP, for plastic surgery, a low-intensity specialty, the odds of 30-day mortality in very frail (adjusted odds ratio [aOR], 27.99; 95% CI, 14.67-53.39) and frail (aOR, 5.1; 95% CI, 3.03-8.58) patients were statistically significantly higher than for normal patients. This was also true in neurosurgery, a moderate-intensity specialty, for very frail (aOR, 9.8; 95% CI, 7.68-12.50) and frail (aOR, 4.18; 95% CI, 3.58-4.89) patients and in vascular surgery, a high-intensity specialty, for very frail (aOR, 10.85; 95% CI, 9.83-11.96) and frail (aOR, 3.42; 95% CI, 3.19-3.67) patients.Conclusions and Relevance: In this study, frailty was associated with postoperative mortality across all noncardiac surgical specialties regardless of case-mix. Preoperative frailty assessment could be implemented across all specialties to facilitate risk stratification and shared decision-making.

    View details for DOI 10.1001/jamasurg.2020.5152

    View details for PubMedID 33206156

  • Multidisciplinary Preoperative Management of Clinically Complex Patients Results in Delay to Bariatric Surgery Bandle, J., Trickey, A., Chen, R., Eisenberg, D. ELSEVIER SCIENCE INC. 2020: E2–E3
  • Clean Cut (adaptive, multimodal surgical infection prevention programme) for low-resource settings: a prospective quality improvement study BRITISH JOURNAL OF SURGERY Forrester, J. A., Starr, N., Negussie, T., Schaps, D., Adem, M., Alemu, S., Amenu, D., Gebeyehu, N., Habteyohannes, T., Jiru, F., Tesfaye, A., Wayessa, E., Chen, R., Trickey, A., Bitew, S., Bekele, A., Weiser, T. G. 2020: 727-734


    Clean Cut is an adaptive, multimodal programme to identify improvement opportunities and safety changes in surgery by enhancing outcomes surveillance, closing gaps in surgical infection prevention standards, and strengthening underlying processes of care. Surgical-site infections (SSIs) are common in low-income countries, so this study assessed a simple intervention to improve perioperative infection prevention practices in one.Clean Cut was implemented in five hospitals in Ethiopia from August 2016 to October 2018. Compliance data were collected from the operating room focused on six key perioperative infection prevention standards. Process-mapping exercises were employed to understand barriers to compliance and identify locally driven improvement opportunities. Thirty-day outcomes were recorded on patients for whom intraoperative compliance information had been collected.Compliance data were collected from 2213 operations (374 at baseline and 1839 following process improvements) in 2202 patients. Follow-up was completed in 2159 patients (98·0 per cent). At baseline, perioperative teams complied with a mean of only 2·9 of the six critical perioperative infection prevention standards; following process improvement changes, compliance rose to a mean of 4·5 (P < 0·001). The relative risk of surgical infections after Clean Cut implementation was 0·65 (95 per cent c.i. 0·43 to 0·99; P = 0·043). Improved compliance with standards reduced the risk of postoperative infection by 46 per cent (relative risk 0·54, 95 per cent c.i. 0·30 to 0·97, for adherence score 3-6 versus 0-2; P = 0·038).The Clean Cut programme improved infection prevention standards to reduce SSI without infrastructure expenses or resource investments.

    View details for DOI 10.1002/bjs.11997

    View details for Web of Science ID 000571340200001

    View details for PubMedID 34157086

  • Situating Artificial Intelligence in Surgery A Focus on Disease Severity ANNALS OF SURGERY Korndorffer, J. R., Hawn, M. T., Spain, D. A., Knowlton, L. M., Azagury, D. E., Nassar, A. K., Lau, J. N., Arnow, K. D., Trickey, A. W., Pugh, C. M. 2020; 272 (3): 523–28
  • Situating Artificial Intelligence in Surgery: A Focus on Disease Severity. Annals of surgery Korndorffer, J. R., Hawn, M. T., Spain, D. A., Knowlton, L. M., Azagury, D. E., Nassar, A. K., Lau, J. N., Arnow, K. D., Trickey, A. W., Pugh, C. M. 2020; 272 (3): 523-528


    Artificial intelligence (AI) has numerous applications in surgical quality assurance. We assessed AI accuracy in evaluating the critical view of safety (CVS) and intraoperative events during laparoscopic cholecystectomy. We hypothesized that AI accuracy and intraoperative events are associated with disease severity.One thousand fifty-one laparoscopic cholecystectomy videos were annotated by AI for disease severity (Parkland Scale), CVS achievement (Strasberg Criteria), and intraoperative events. Surgeons performed focused video review on procedures with ≥1 intraoperative events (n = 335). AI versus surgeon annotation of CVS components and intraoperative events were compared. For all cases (n = 1051), intraoperative-event association with CVS achievement and severity was examined using ordinal logistic regression.Using AI annotation, surgeons reviewed 50 videos/hr. CVS was achieved in ≤10% of cases. Hepatocystic triangle and cystic plate visualization was achieved more often in low-severity cases (P < 0.03). AI-surgeon agreement for all CVS components exceeded 75%, with higher agreement in high-severity cases (P < 0.03). Surgeons agreed with 99% of AI-annotated intraoperative events. AI-annotated intraoperative events were associated with both disease severity and number of CVS components not achieved. Intraoperative events occurred more frequently in high-severity versus low-severity cases (0.98 vs 0.40 events/case, P < 0.001).AI annotation allows for efficient video review and is a promising quality assurance tool. Disease severity may limit its use and surgeon oversight is still required, especially in complex cases. Continued refinement may improve AI applicability and allow for automated assessment.

    View details for DOI 10.1097/SLA.0000000000004207

    View details for PubMedID 33759839

  • Reply to the Letter to the Editor: How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty? Clinical orthopaedics and related research Trickey, A. W., Harris, A. H. 2020; 478 (8): 1948-1949

    View details for DOI 10.1097/CORR.0000000000001372

    View details for PubMedID 32732582

  • Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines. Surgery Seib, C. D., Meng, T., Suh, I., Cisco, R. M., Lin, D. T., Morris, A. M., Trickey, A. W., Kebebew, E. 2020


    BACKGROUND: Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings.METHODS: We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy.RESULTS: Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]).CONCLUSION: The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.

    View details for DOI 10.1016/j.surg.2020.04.066

    View details for PubMedID 32654861

  • Frailty Increases Reinterventions for Surgical Site Infections After Infrainguinal Bypass Procedures Kashikar, A., Barreto, N. B., George, E. L., Chen, R., Trickey, A. W., Arya, S. MOSBY-ELSEVIER. 2020: E152
  • The Affordable Care Act Is Associated With Increased Coverage and Decreased Charges, but Limited Improvement in Access to Vascular Surgery for Medicaid Patients George, E. L., Kashikar, A., Barreto, N. B., Chen, R., Trickey, A. W., Arya, S. MOSBY-ELSEVIER. 2020: E247–E248
  • Reply to the Letter to the Editor: How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty? Clinical orthopaedics and related research Trickey, A. W., Harris, A. H. 2020

    View details for DOI 10.1097/CORR.0000000000001372

    View details for PubMedID 32568891

  • Compounding Benefits of Sentinel Lymph Node Biopsy for Perineal Melanoma: A Population-Based Retrospective Cohort Analysis. Annals of plastic surgery Patel, R. A., Patel, P. D., Ashack, K., Borrelli, M. R., Trickey, A., Wan, D. C. 2020; 84 (5S Suppl 4): S257–S263


    INTRODUCTION: Sentinel lymph node biopsy (SLNB) in the treatment of melanoma is known to provide valuable prognostic information. However, there is no literature describing an overall or disease-specific survival (DDS) benefit of SLNB. In the perineum, melanoma is often more advanced at presentation with current treatment guidelines translated from nonanatomic specific melanoma. As a result, there is little understanding surrounding the role of SLNB in melanoma of the perineum. Our objective is to better understand the therapeutic benefits of SLNB in perineal melanoma.METHODS: The Surveillance, Epidemiology, and End Results program is a large population-based cancer registry including survival data from millions of patients in the United States. The registry was used to generate patient data for analysis from 2004 to 2016. Inclusion criteria included melanoma of the perineum; Breslow depth of 0.80 mm or greater and less than 0.80 mm with ulceration; SLNB or no intervention; clinically negative nodal disease; and available overall survival data.RESULTS: For 879 patients from 2004 to 2016 with perineal melanoma, significant predictors of reduced survival include older than 75 years, Clark level IV-V, Breslow depth of greater than 4.00 mm, positive ulceration status, regional and distant nodal micrometastases, and clinically positive nodes on presentation. Aggregates for overall survival (OS) and disease-specific survival (DSS) were improved with implementation of SLNB. The 5-year survival rates with SLNB versus no SLNB were 54.0% and 43.0% for OS (P = 0.001) and 57.8% and 53.1% for DSS (P = 0.044). Stratification by Breslow depth yielded significant OS and DSS advantage for greater than 1.00 to 2.00 mm (21.3% benefit, P =0.021, and 16.8% benefit, P = 0.044) and greater than 4.00 mm (30.3% benefit, P = 0.005, and 21.0% benefit, P = 0.007) Breslow depths.CONCLUSIONS AND RELEVANCE: Sentinel lymph node biopsy may provide therapeutic benefits in addition to prognostic information for melanoma of the perineum through an increase in 5-year OS.

    View details for DOI 10.1097/SAP.0000000000002388

    View details for PubMedID 32282396

  • Frailty as measured by the Risk Analysis Index is associated with long-term death after carotid endarterectomy. Journal of vascular surgery Rothenberg, K. A., George, E. L., Barreto, N., Chen, R., Samson, K., Johanning, J. M., Trickey, A. W., Arya, S. 2020


    OBJECTIVE: The role of carotid endarterectomy (CEA) continues to be debated in the age of optimal medical therapy, particularly for patients with limited life expectancy. The Risk Analysis Index (RAI) measures frailty, a syndrome of decreased physiologic reserve, which increases vulnerability to adverse outcomes. The RAI better predicts surgical complications, nonhome discharge, and death than age or comorbidities alone. We sought to measure the association of frailty, as measured by the RAI, with postoperative in-hospital stroke, long-term stroke, and long-term survival after CEA. We also sought to determine how postoperative stroke interacts with frailty to alter survival trajectory after CEA.METHODS: We queried the Vascular Quality Initiative CEA procedure and long-term data sets (2003-2017) for elective CEAs with complete RAI case information. For all analyses, the cohort was divided into asymptomatic and symptomatic carotid stenosis. Scoring was defined as not frail (RAI<30), frail (RAI 30-34), and very frail (RAI ≥35). Mortality information through December 2017 was obtained from the Social Security Death Index. Multivariable models (logistic and Cox proportional hazards regressions) were used to study the association of frail and very frail patients with the outcomes of interest. In a post hoc analysis, we created Kaplan-Meier curves to analyze patient mortality after CEA as well as after postoperative stroke.RESULTS: Of the 42,869 included patients, 17,092 (39.9%) were female, and 38,395 (89.6%) were white. There were 25,673 (59.9%) patients assigned to the asymptomatic stenosis group and 17,196 (40.1%) patients in the symptomatic stenosis group. Frailty was not associated with perioperative or long-term postoperative stroke. The risk of long-term mortality was significantly higher for frail (hazard ratio, 1.9 [1.7-2.3]) and very frail (hazard ratio, 3.1 [2.6-3.7]) asymptomatic patients; symptomatic frail and very frail patients also had a two to three times increased risk of long-term mortality. Frail and very frail patients had two to three times the risk for long-term mortality compared with patients who were not frail. Postoperative stroke negatively affected the mortality trajectory for all patients in the cohort, regardless of frailty status.CONCLUSIONS: RAI score is not associated with postoperative stroke; however, frail and very frail status is associated with decreased long-term survival in an incremental fashion based on increasing RAI. RAI assessment should be considered in the preoperative decision-making for patients undergoing CEA to ensure long-term survival and optimal surgical outcomes vs medical management.

    View details for DOI 10.1016/j.jvs.2020.01.043

    View details for PubMedID 32169359

  • Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center. Hand (New York, N.Y.) Ding, Q., Trickey, A. W., Mudumbai, S., Kamal, R. N., Sears, E. D., Harris, A. H. 2020: 1558944720906498


    Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.

    View details for DOI 10.1177/1558944720906498

    View details for PubMedID 32100568

  • Pancreatic grade 3 neuroendocrine tumors behave similarly to neuroendocrine carcinomas following resection: a multi-center, international appraisal of the WHO 2010 and WHO 2017 staging schema for pancreatic neuroendocrine lesions. HPB : the official journal of the International Hepato Pancreato Biliary Association Worth, P. J., Leal, J., Ding, Q., Trickey, A., Dua, M. M., Chatzizacharias, N., Soonawalla, Z., Athanasopoulos, P., Toumpanakis, C., Hansen, P., Parks, R. W., Connor, S., Parker, K., Koea, J., Srinavasa, S., Ielpo, B., Vicente Lopez, E., Lawrence, B., Visser, B. C., International Pancreatic Neuroendocrine Tumor Study Group 2020


    BACKGROUND: In 2017, the WHO updated their 2010 classification of pancreatic neuroendocrine tumors, introducing a well-differentiated, highly proliferative grade 3 tumor, distinct from neuroendocrine carcinomas. The aim of this study was to investigate the clinical significance of this update in a large cohort of resected tumors.METHODS: Using a multicenter, international dataset of patients with pancreatic neuroendocrine lesions, patients were classified both according to the WHO 2010 and 2017 schema. Multivariable survival analyses were performed, and the models were evaluated for discrimination ability and goodness of fit.RESULTS: Excluding patients with a known germline MEN1 mutation and incomplete data, 544 patients were analyzed. The performance of the WHO 2010 and 2017 models was similar, however surgically resected grade 3 tumors behaved very similarly to neuroendocrine carcinomas.CONCLUSION: The addition of a grade 3 NET classification may be of limited utility in surgically resected patients, as these lesions have similar postoperative survival compared to carcinomas. While the addition may allow for a more granular evaluation of novel treatment strategies, surgical intervention for high grade tumors should be considered judiciously.

    View details for DOI 10.1016/j.hpb.2019.12.014

    View details for PubMedID 32081540

  • Positive and Negative Independent Predictive Factors of Weight Loss After Bariatric Surgery in a Veteran Population. Obesity surgery Kitamura, R., Chen, R., Trickey, A., Eisenberg, D. 2020


    INTRODUCTION: Factors predicting outcomes after bariatric surgery are yet to be elucidated. We aim to characterize patient-level factors that predict midterm weight loss.METHODS: A database of bariatric surgery at a Veterans Affairs (VA) hospital was retrospectively reviewed. Patient characteristics including age, race, sex, median zip code household income, and distance to the VA bariatric center were analyzed for relationships with percent excess body mass index loss (%EBMIL). Univariate and multivariate analyses were conducted to identify factors independently associated with weight loss after accounting for follow-up time, using stepwise variable selection. A multivariable mixed effects linear regression model was constructed with random intercepts for repeated measures by veteran and fixed effects for time, patient, and procedural characteristics, including comorbidities.RESULTS: A total of 1124 observations were analyzed for 340 bariatric patients. Most were male (77%), white (73%); mean age was 53.2years and mean preoperative BMI was 43.9kg/m2. Follow-up ranged from 99% at 1year, 54% at 5years, and 24% at 10years, with a mean of 6.9years for Roux-en-Y gastric bypass (RYGB) and 3.5years for laparoscopic sleeve gastrectomy (LSG). RYGB (p<0.001) and female (p=0.016) predicted greater %EBMIL up to 10years after surgery. African American race and higher comorbidity burden predicted poorer %EBMIL (p=0.008, p=0.012, respectively). Analysis of individual comorbidities demonstrated that type 2 diabetes was most strongly associated with poorer %EBMIL (p=0.048).CONCLUSION: RYGB and female sex are independent predictors of greater midterm weight loss after bariatric surgery. African American race and a high burden of comorbidity are predictive of poorer weight loss. Neither zip code median income nor distance from bariatric center was associated with weight loss.

    View details for DOI 10.1007/s11695-020-04428-0

    View details for PubMedID 32009214

  • Trends in Intravenous Alteplase Use and Mortality Among Medicare Beneficiaries With Acute Stroke: A Eight-Year Retrospective Analysis Meng, T., Trickey, A., Govindarajan, P. LIPPINCOTT WILLIAMS & WILKINS. 2020
  • Eight-year Trends in Ambulance Use in a National Sample of Medicare Beneficiaries With Stroke Meng, T., Trickey, A. W., Govindarajan, P. LIPPINCOTT WILLIAMS & WILKINS. 2020
  • Assessment of Risk Analysis Index for Prediction of Mortality, Major Complications and Length of Stay in Vascular Surgery Patients. Annals of vascular surgery Rothenberg, K. A., George, E. L., Trickey, A. W., Barreto, N. B., Johnson, T. M., Hall, D. E., Johanning, J. M., Arya, S. 2020


    INTRODUCTION: Frailty is a risk factor for adverse postoperative outcomes. We aimed to test the performance of a prospectively-validated frailty measure, the Risk Analysis Index (RAI) in vascular surgery patients and delineate the additive impact of procedure complexity on surgical outcomes.METHODS: We queried the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify six major elective vascular procedure categories (carotid revascularization, abdominal aortic aneurysm [AAA] repair, suprainguinal revascularization, infrainguinal revascularization, thoracic aortic aneurysm [TAA] repair, and thoracoabdominal aortic aneurysm [TAAA] repair). We trained and tested logistic regression models for 30-day mortality, major complications and prolonged length of stay (LOS). The first model, "RAI", used the RAI alone; "RAI-Procedure (RAI-P)" included procedure category (e.g., AAA repair) and procedure approach (e.g., endovascular); "RAI-Procedure Complexity (RAI-PC)" added outpatient versus inpatient surgery, general anesthesia use, work relative value units (RVUs), and operative time.RESULTS: The RAI model was a good predictor of mortality for vascular procedures overall (C-statistic 0.72). The C-statistic increased with the RAI-P (0.78), which further improved minimally, with the RAI-PC (0.79). When stratified by procedure category, the RAI predicted mortality well for infrainguinal (0.79) and suprainguinal (0.74) procedures, moderately well for AAA repairs (0.69) and carotid revascularizations (0.70), and poorly for TAAs (0.62) and TAAAs (0.54). For carotid, infrainguinal, and suprainguinal procedures, procedure complexity (RAI-PC) had little impact on model discrimination for mortality, did improve discrimination for AAAs (0.84), TAAs (0.73), and TAAAs (0.80). While the RAI model was not a good predictor for major complications or LOS, discrimination improved for both with the RAI-PC model.CONCLUSIONS: Frailty as measured by the RAI was a good predictor of mortality overall after vascular surgery procedures. While the RAI was not a strong predictor of major complications or prolonged LOS, the models improved with the addition of procedure characteristics like procedure category and approach.

    View details for DOI 10.1016/j.avsg.2020.01.015

    View details for PubMedID 31935435

  • How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty? Clinical orthopaedics and related research Trickey, A. W., Ding, Q., Harris, A. H. 2020


    BACKGROUND: Surgical outcome prediction models are useful for many purposes, including informed consent, shared decision making, preoperative mitigation of modifiable risk, and risk-adjusted quality measures. The recently reported Surgical Risk Preoperative Assessment System (SURPAS) universal risk calculators were developed using 2005-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), and they demonstrated excellent overall and specialty-specific performance. However, surgeons must assess whether universal calculators are accurate for the small subset of procedures they perform. To our knowledge, SURPAS has not been tested in a subset of patients undergoing lower-extremity total joint arthroplasty (TJA).QUESTIONS/PURPOSES: How accurate are SURPAS models' predictions for patients undergoing TJA?METHODS: We identified an internal subset of patients undergoing non-emergency THA or TKA from the 2012 ACS-NSQIP, the most recent year of the SURPAS development dataset. To assess the accuracy of SURPAS prediction models, 30-day postoperative outcomes were defined as in the original SURPAS study: mortality, overall morbidity, and six complication clusters-pulmonary, infectious, cardiac or transfusion, renal, venous thromboembolic, and neurologic. We calculated predicted outcome probabilities by applying coefficients from the published SURPAS logistic regression models to the TJA cohort. Discrimination was assessed with C-indexes, and calibration was assessed with Hosmer-Lemeshow 10-group chi-square tests and decile plots.RESULTS: The 30-day postoperative mortality rate for TJA was 0.1%, substantially lower than the 1% mortality rate in the SURPAS development dataset. The most common postoperative complications for TJA were intraoperative or postoperative transfusion (16%), urinary tract infection (5%), and vein thrombosis (3%). The C-indexes for joint arthroplasty ranged from 0.56 for venous thromboembolism (95% CI 0.53 to 0.59 versus SURPAS C-index 0.78) to 0.82 for mortality (95% CI 0.76 to 0.88 versus SURPAS C-index 0.94). All joint arthroplasty C-index estimates, including CIs, were lower than those reported in the original SURPAS development study. Decile plots and Hosmer-Lemeshow tests indicated poor calibration. Observed mortality rates were lower than expected for patients in all risk deciles (lowest decile: no observed deaths, 0.0% versus expected 0.1%; highest decile: observed mortality 0.7% versus expected 2%; p < 0.001). Conversely, observed morbidity rates were higher than expected across all risk deciles (lowest decile: observed 12% versus expected 8%; highest decile: observed morbidity 32% versus expected 25%; p < 0.001) CONCLUSIONS: The universal SURPAS risk models have lower accuracy for TJA procedures than they do for the wider range of procedures in which the SURPAS models were originally developed.CLINICAL RELEVANCE: These results suggest that SURPAS model estimates must be evaluated for individual surgical procedures or within restricted groups of related procedures such as joint arthroplasty. Given substantial variation in patient populations and outcomes across numerous surgical procedures, universal perioperative risk calculators may not produce accurate and reliable results for specific procedures. Surgeons and healthcare administrators should use risk calculators developed and validated for specific procedures most relevant to each decision. Continued work is needed to assess the accuracy of universal risk calculators in more narrow procedural categories based on similarity of outcome event rates and prevalence of predictive variables across procedures.

    View details for DOI 10.1097/CORR.0000000000001078

    View details for PubMedID 31904684

  • Body Image Disturbance and Obsessive-Compulsive Disorder Symptoms Improve After Orthognathic Surgery. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons Häberle, A. n., Alkofahi, H. n., Qiao, J. n., Safer, D. n., Mittermiller, P. n., Menorca, R. n., Trickey, A. W., Girod, S. n. 2020


    Although body image disturbance (BID), anxiety, depression, and obsessive-compulsive disorder (OCD) are the most common comorbid psychological conditions among patients presenting for orthognathic surgery (OS), little is known about whether psychological symptoms relate to facial deformity or how symptoms change after OS. To fill these knowledge gaps, this study investigated preoperative and postoperative psychological symptoms and preoperative baseline facial deformity in patients who underwent OS.This study included 49 patients who underwent OS by a single surgeon between 2011 and 2018. The patients completed validated psychological tests to assess symptoms of anxiety (Beck Anxiety Inventory), depression (Patient Health Questionnaire-9), BID (BID Questionnaire, BIDQ), and OCD (Florida Obsessive-Compulsive Inventory). In addition, we measured severity of preoperative facial deformity with the Facial Aesthetic Index (FAI). We compared preoperative and postoperative symptoms using univariate nonparametric Wilcoxon signed rank tests. We tested associations between the 4 types of preoperative psychological symptoms and baseline Facial Aesthetic Index category using Spearman's rank correlations.Postoperatively, both BIDQ scores (median 2 to 1.2, P < .001) and Florida Obsessive-Compulsive Inventory scores (median number of OCD symptoms 1 to 0, P < .001) decreased, whereas anxiety and depression symptoms showed no change (P > .45). Preoperative BIDQ was significantly associated with the severity of the facial deformity (ρ = 0.32, P = .025; median BIDQ: mild FAI = 1.0, severe FAI = 2.1).Our results show that patients with more severe facial deformity have a higher BID preoperatively and that both BID and OCD improve after OS. Interestingly, anxiety and depression symptoms did not change after OS.

    View details for DOI 10.1016/j.joms.2020.07.021

    View details for PubMedID 32810443

  • Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability. BMC health services research Harris, A. H., Meerwijk, E. L., Ding, Q. n., Trickey, A. W., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Nuckols, T. K., Kamal, R. N. 2020; 20 (1): 861


    The American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand recently proposed three quality measures for carpal tunnel syndrome (CTS): Measure 1 - Discouraging routine use of Magnetic resonance imaging (MRI) for diagnosis of CTS; Measure 2 - Discouraging the use of adjunctive surgical procedures during carpal tunnel release (CTR); and Measure 3 - Discouraging the routine use of occupational and/or physical therapy after CTR. The goal of this study were to 1) Assess the feasibility of using the specifications to calculate the measures in real-world healthcare data and identify aspects of the specifications that might be clarified or improved; 2) Determine if the measures identify important variation in treatment quality that justifies expending resources for their further development and implementation; 3) Assess the facility- and surgeon-level reliability of measures.The measures were calculated using national data from the Veterans Health Administration (VA) Corporate Data Warehouse for three fiscal years (FY; 2016-18). Facility- and surgeon-level performance and reliability were examined. To expand the testing context, the measures were also tested using data from an academic medical center.The denominator of Measure 1 was 132,049 VA patients newly diagnosed with CTS. The denominators of Measures 2 and 3 were 20,813 CTRs received by VA patients. The median facility-level performances on the three measures were 96.5, 100, and 94.7%, respectively. Of 130 VA facilities, none had < 90% performance on Measure 1. Among 111 facilities that performed CTRs, only 1 facility had < 90% performance on Measure 2. In contrast, 21 facilities (18.9%) and 333 surgeons (17.8%) had lower than 90% performance on Measure 3 (Median facility- and surgeon-level reliability for Measure 3 were very high (0.95 and 0.96 respectively).Measure 3 displayed adequate facility- and surgeon-level variability and reliability to justify its use for quality monitoring and improvement purposes. Measures 1 and 2 lacked quality gaps, suggesting they should not be implemented in VA and need to be tested in other healthcare settings. Opportunities exist to refine the specifications of Measure 3 to ensure that different organizations calculate the measure in the same way.

    View details for DOI 10.1186/s12913-020-05704-6

    View details for PubMedID 32917188

  • Use of Biological Medications Does Not Increase Postoperative Complications Among Patients With Ulcerative Colitis Undergoing Colectomy: A Retrospective Cohort Analysis of Privately Insured Patients. Diseases of the colon and rectum Rumer, K. K., Dehghan, M. S., Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C. n. 2020; 63 (11): 1524–33


    Existing studies on the effects of biological medications on surgical complications among patients with ulcerative colitis have mixed results. Because biologicals may hinder response to infections and wound healing, preoperative exposure may increase postoperative complications.The purpose of this study was to evaluate associations between biological exposure within 6 months preceding colectomy or proctocolectomy and postoperative complications among patients with ulcerative colitis.This was a retrospective cohort study with multivariate regression analysis after coarsened exact matching.A large commercial insurance claims database (2003-2016) was used.A total of 1794 patients with ulcerative colitis underwent total abdominal colectomy with end ileostomy, total proctocolectomy with end ileostomy, or total proctocolectomy with IPAA. Twenty-two percent were exposed to biologicals in the 6 months preceding surgery.Healthcare use (length of stay, unplanned reoperation/procedure, emergency department visit, or readmission) and complications (infectious, hernia or wound disruption, thromboembolic, or cardiopulmonary) within 30 postoperative days were measured.Exposure to biological medications was associated with shorter surgical hospitalization (7 vs 8 d; p <0.001) but otherwise was not associated with differences in healthcare use or postoperative complications.who underwent total proctocolectomy with IPAA had higher odds of infectious complications compared with those who underwent total abdominal colectomy with end ileostomy (adjusted OR = 2.2 (95% CI, 1.5-3.0); p < 0.001) but had lower odds of cardiopulmonary complications (adjusted OR = 0.4 (95% CI, 0.3-0.6); p < 0.001).Analysis of private insurance database claims data may not represent uninsured or government-insured patients and may be limited by coding accuracy. Matched cohorts differed in age and Charlson Comorbidity Index, which could be influential even after multivariate adjustments.Biological exposure among patients with ulcerative colitis is not associated with higher odds of postoperative complications or healthcare resource use. These data, in combination with clinical judgment and patient preferences, may aid in complex decision-making regarding operative timing, operation type, and perioperative medication management. See Video Abstract at EL USO DE MEDICAMENTOS BIOLÓGICOS NO AUMENTA LAS COMPLICACIONES POSTOPERATORIAS ENTRE PACIENTES CON COLITIS ULCERATIVA SOMETIDOS A UNA COLECTOMÍA: UN ANÁLISIS DE COHORTE RETROSPECTIVO DE PACIENTES CON SEGURO PRIVADO: Estudios existentes sobre los efectos de medicamentos biológicos, en complicaciones quirúrgicas, en pacientes con colitis ulcerativa, presentan resultados mixtos. Debido a que los productos biológicos pueden retrasar la respuesta a las infecciones y curación de heridas, su exposición preoperatoria pueden aumentar las complicaciones postoperatorias.Evaluar las asociaciones entre la exposición biológica dentro de los seis meses anteriores a la colectomía o proctocolectomía y las complicaciones postoperatorias entre los pacientes con colitis ulcerativa.Estudio de cohorte retrospectivo con análisis de regresión multivariante después de una coincidencia exacta aproximada.Una gran base de datos de reclamaciones de seguros comerciales (2003-2016).Un total de 1.794 pacientes con colitis ulcerativa, se sometieron a colectomía abdominal total con ileostomía terminal, proctocolectomía total con ileostomía terminal o proctocolectomía total con anastomosis anal y bolsa ileal. 22% estuvieron expuestos a productos biológicos, seis meses antes de la cirugía.Utilización de la atención médica (duración de la estadía, reoperación o procedimiento no planificado, visita al servicio de urgencias o reingreso) y complicaciones (infecciosas, hernias o dehiscencias de heridas, tromboembólicas o cardiopulmonares) dentro de los 30 días postoperatorios.La exposición a medicamentos biológicos se asoció con una hospitalización quirúrgica más corta (7 frente a 8 días, p <0,001), pero por lo demás, no se asoció con diferencias en la utilización de la atención médica o complicaciones postoperatorias. Los pacientes que se sometieron a proctocolectomía total con anastomosis anal y bolsa ileal, tuvieron mayores probabilidades de complicaciones infecciosas, en comparación con aquellos que se sometieron a colectomía abdominal total con ileostomía final (aOR 2.2, IC 95% [1.5-3.0], p <0.001) pero tuvieron menores probabilidades de complicaciones cardiopulmonares (aOR 0.4, IC 95% [0.3-0.6], p <0.001).El análisis de los datos de reclamaciones, de la base de datos de los seguros privados, puede no representar a pacientes no asegurados o asegurados por el gobierno, y puede estar limitado por la precisión de la codificación. Las cohortes emparejadas diferían en la edad y el índice de comorbilidad de Charlson, lo que podría influir incluso después de ajustes multivariados.La exposición biológica entre los pacientes con colitis ulcerativa, no se asocia con mayores probabilidades de complicaciones postoperatorias, o a la utilización de recursos sanitarios. Estos datos, en combinación con el juicio clínico y las preferencias del paciente, pueden ayudar en la toma de decisiones complejas con respecto al momento quirúrgico, el tipo de operación y el manejo de la medicación perioperatoria. Consulte Video Resumen en (Traducción-Dr Fidel Ruiz Healy).

    View details for DOI 10.1097/DCR.0000000000001684

    View details for PubMedID 33044293

  • Surgical Procedures in Veterans Affairs Hospitals During the COVID-19 Pandemic. Annals of surgery Rose, L. n., Mattingly, A. S., Morris, A. M., Trickey, A. W., Ding, Q. n., Wren, S. M. 2020; Publish Ahead of Print

    View details for DOI 10.1097/SLA.0000000000004692

    View details for PubMedID 33351471

  • Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke? Implementation science communications Harris, A. H., Barreto, N. B., Trickey, A. W., Bereknyei, S. n., Meng, T. n., Wagner, T. H., Govindarajan, P. n. 2020; 1: 50


    Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design.We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects.Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.

    View details for DOI 10.1186/s43058-020-00041-5

    View details for PubMedID 32885206

    View details for PubMedCentralID PMC7427915

  • The gender gap and healthcare: associations between gender roles and factors affecting healthcare access in Central Malawi, June-August 2017. Archives of public health = Archives belges de sante publique Azad, A. D., Charles, A. G., Ding, Q. n., Trickey, A. W., Wren, S. M. 2020; 78 (1): 119


    Women in low and middle-income countries (LMICs) do not have equal access to resources, such as education, employment, or healthcare compared to men. We sought to explore health disparities and associations between gender prioritization, sociocultural factors, and household decision-making in Central Malawi.From June-August 2017, a cross-sectional study with 200 participants was conducted in Central Malawi. We evaluated respondents' access to care, prioritization within households, decision-making power, and gender equity which was measured using the Gender-Equitable Men (GEM) scale. Relationships between these outcomes and sociodemographic factors were analyzed using multivariable mixed-effect logistic regression.We found that women were less likely than men to secure community-sourced healthcare financial aid (68.6% vs. 88.8%, p < 0.001) and more likely to underutilize necessary healthcare (37.2% vs. 22.4%, p = 0.02). Both men and women revealed low GEM scores, indicating adherence to traditional gender norms, though women were significantly less equitable (W:16.77 vs. M:17.65, p = 0.03). Being a woman (Odds Ratio (OR) 0.41, 95% confidence interval (CI) 0.21-0.78) and prioritizing a woman as a decision-maker for large purchases (OR 0.38, CI 0.15-0.93) were independently associated with a lower likelihood of prioritizing women for medical treatment and being a member of the Chewa tribal group (OR 3.87, CI 1.83-8.18) and prioritizing women for education (OR 4.13, CI 2.13-8.01) was associated with a higher odds.Women report greater barriers to healthcare and adhere to more traditional gender roles than men in this Central Malawian population. Women contribute to their own gender's barriers to care and economic empowerment alone is not enough to correct for these socially constructed roles. We found that education and matriarchal societies may protect against gender disparities. Overall, internal and external gender discrimination contribute to a woman's disproportionate lack of access to care.

    View details for DOI 10.1186/s13690-020-00497-w

    View details for PubMedID 33292511

  • Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures. PloS one Choi, J. n., Zamary, K. n., Barreto, N. B., Tennakoon, L. n., Davis, K. M., Trickey, A. W., Spain, D. A. 2020; 15 (9): e0239896


    Pain management is the pillar of caring for patients with traumatic rib fractures. Intravenous lidocaine (IVL) is a well-established non-opioid analgesic for post-operative pain, yet its efficacy has yet to be investigated in trauma patients. We hypothesized that IVL is associated with decreased inpatient opioid requirements among patients with rib fractures.We retrospectively evaluated adult patients presenting to our Level 1 trauma center with isolated chest wall injuries. After 1:1 propensity score matching patients who received vs did not receive IVL, we compared the two groups' average daily opioid use, opioid use in the last 24 hours of admission, and pain scores during admissions hours 24-48. We performed multivariable linear regression for these outcomes (with sensitivity analysis for the opioid use outcomes), adjusting for age as a moderating factor and controlling for hospital length of stay and injury severity.We identified 534 patients, among whom 226 received IVL. Those who received IVL were older and had more serious injury. Compared to propensity-score matched patients who did not receive IVL, patients who received IVL had similar average daily opioid use and pain scores, but 40% lower opioid use during the last 24 hours of admission (p = 0.002). Multivariable regression-with and without sensitivity analysis-did not show an effect of IVL on any outcomes.IVL was crudely associated with decreased opioid requirements in the last 24 hours of admission, the time period associated with opioid use at 90 days post-discharge. However, we did not observe beneficial effects of IVL on multivariable adjusted analyses; we are conducting a randomized control trial to further evaluate IVL's opioid-sparing effects for patients with rib fractures.

    View details for DOI 10.1371/journal.pone.0239896

    View details for PubMedID 32986770

  • The Comprehensive AO CMF Classification System for Mandibular Fractures: A Multicenter Validation Study. Craniomaxillofacial trauma & reconstruction Mittermiller, P. A., Bidwell, S. S., Thieringer, F. M., Cornelius, C., Trickey, A. W., Kontio, R., Girod, S., and the AO Trauma Classification Study Group, Dana, J., Florian, P., Jia, Q., Johanna, S., Karri, M., Moritz, B., Philipp, G., Stacey, M., Tommy, W., Wenko, S. 2019; 12 (4): 254–65


    The AO CMF has recently launched the first comprehensive classification system for craniomaxillofacial (CMF) fractures. The AO CMF classification system uses a hierarchical framework with three levels of growing complexity (levels 1, 2, and 3). Level 1 of the system identifies the presence of fractures in four anatomic areas (mandible, midface, skull base, and cranial vault). Level 2 variables describe the location of the fractures within those defined areas. Level 3 variables describe details of fracture morphology such as fragmentation, displacement, and dislocation. This multiplanar radiographic image-based AO CMF trauma classification system is constantly evolving and beginning to enter worldwide application. A validation of the system is mandatory prior to a reliable communication and data processing in clinical and research environments. This interobserver reliability and accuracy study is aiming to validate the three current modules of the AO CMF classification system for mandible trauma in adults. To assess the performance of the system at the different precision levels, it focuses on the fracture location within the mandibular regions and condylar process subregions as core components giving only secondary attention to morphologic variables. A total of 15 subjects individually assigned the location and features of mandibular fractures in 200 CT scans using the AO CMF classification system. The results of these ratings were then statistically evaluated for interobserver reliability by Fleiss' kappa and accuracy by percentage agreement with an experienced reference assessor. The scores were used to determine if the variables of levels 2 and 3 were appropriate tools for valid classification. Interobserver reliability and accuracy were compared by hierarchy of variables (level 2 vs. level 3), by anatomical region and subregion, and by assessor experience level using Kruskal-Wallis and Wilcoxon's rank-sum tests. The AO CMF classification system was determined to be reliable and accurate for classifying mandibular fractures for most levels 2 and 3 variables. Level 2 variables had significantly higher interobserver reliability than level 3 variables (median kappa: 0.69 vs. 0.59, p <0.001) as well as higher accuracy (median agreement: 94 vs. 91%, p <0.001). Accuracy was adequate for most variables, but lower reliability was observed for condylar head fractures, fragmentation of condylar neck fractures, displacement types and direction of the condylar process overall, as well as the condylar neck and base fractures. Assessors with more clinical experience demonstrated higher reliability (median kappa high experience 0.66 vs. medium 0.59 vs. low 0.48, p <0.001). Assessors with experience using the classification software also had higher reliability than their less experienced counterparts (median kappa: 0.76 vs. 0.57, p <0.001). At present, the AO CMF classification system for mandibular fractures is suited for both clinical and research settings for level 2 variables. Accuracy and reliability decrease for level 3 variables specifically concerning fractures and displacement of condylar process fractures. This will require further investigation into why these fractures were characterized unreliably, which would guide modifications of the system and future instructions for its usage.

    View details for DOI 10.1055/s-0038-1677459

    View details for PubMedID 31719949

  • Surgery, Stomas, and Anxiety and Depression in Inflammatory Bowel Disease: A Retrospective Cohort Analysis of Privately Insured Patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Sceats, L. A., Dehghan, M. S., Rumer, K. K., Trickey, A., Morris, A. M., Kin, C. 2019


    AIM: Inflammatory bowel disease (IBD) patients are diagnosed with anxiety/depression at higher rates than the general population. We aimed to determine the frequency of anxiety/depression among IBD patients and temporal association with abdominal surgery and stoma formation.METHODS: We conducted a retrospective cohort study in adult IBD patients using difference-in-differences methodology using a large commercial claims database (2003-2016). Outcomes were anxiety/depression diagnoses before and after major abdominal surgery or stoma formation.RESULTS: We identified 10,481 IBD patients who underwent major abdominal surgery, 18.8% of whom underwent stoma formation, and 41,924 nonsurgical age- and sex-matched IBD controls who were assigned random index dates. Rates of anxiety and depression increased among all cohorts (p<0.001). Surgical patients had higher odds of anxiety (one surgery: adjusted odds ratio 6.90, 95% confidence interval [6.11-7.79], p<0.001; 2+ surgeries: 7.53 [5.99-9.46], p<0.001) and depression (one surgery: 6.15, [5.57-6.80], p<0.001; 2+ surgeries: 6.88 [5.66-8.36], p<0.001) than nonsurgical controls. Undergoing multiple surgeries was associated with a significant increase in depression from pre- to post-time periods (1.43, [1.18-1.73, p<0.001). Amongst surgical patients, stoma formation was independently associated with anxiety (1.40, [1.17-1.68], p<0.001) and depression (1.23, [1.05-1.45], p=0.01). New ostomates experienced a greater increase in postoperative anxiety (1.24, [1.05-1.47], p=0.01) and depression (1.19, [1.03-1.45], p=0.01) than other surgical patients.CONCLUSIONS: IBD patients who undergo surgery have higher rates of anxiety and depression than nonsurgical patients. Rates of anxiety and depression increase following surgery. Stoma formation represents an additional risk factor. These findings suggest the need for perioperative psychosocial support services.

    View details for DOI 10.1111/codi.14905

    View details for PubMedID 31713994

  • Effect of Acute Stroke Care Regionalization on Intravenous Alteplase Use in Two Urban Counties. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Govindarajan, P., Shiboski, S., Grimes, B., Cook, L., Ghilarducci, D., Meng, T., Trickey, A. W. 2019: 1–14


    Importance: Intravenous alteplase is an effective treatment for acute ischemic stroke and is significantly underutilized. It is known that stroke centers with accreditation provide higher intravenous alteplase treatment, and therefore, policies that increase the number of certified stroke centers and the number of acute ischemic stroke patients routed to these centers may be beneficial. Objective: To determine whether increasing access to primary stroke centers (regionalization) led to an increase in intravenous alteplase use in acute ischemic stroke patients. Design: An observational, longitudinal study to examine treatment trends with log-link binomial regression modeling to compare pre-post policy implementation changes in the proportions of patients treated with intravenous alteplase in two counties. Setting: Two urban counties, Santa Clara and San Mateo, in the western region of US that regionalized acute stroke care between 2005 and 2010. Participants: Patients with primary or secondary diagnosis of stroke were identified from the statewide patient discharge database by International Classification of Diseases (ICD-9) codes. We linked ambulance and hospital data to create complete patient care records. Main outcomes and measures: Stroke treatment, defined as a documented primary procedure code for intravenous alteplase administration (ICD-9: 99.10). Results: In Santa Clara County, intravenous alteplase was administered to 35 patients (1.7%) in the pre-regionalization period and 240 patients (2.1%) in the post-regionalization period. In San Mateo County, intravenous alteplase was administered to 29 patients (1.3%) in the pre-policy period and 135 patients (3.2%) in the post-policy period. After regionalization of stroke care, intravenous alteplase increased two-fold in San Mateo County [adjusted RR 2.20, p = 0.003, 95% CI (1.31, 3.69)] but did not show any statistically significant change in Santa Clara County [adjusted RR 1.10, p = 0.55, 95% CI (0.80, 1.51)]. In the post-regionalization phase, when compared with Santa Clara County, we found that San Mateo County had greater change in paramedic stroke detection, higher number of transports to primary stroke centers and more frequent use of intravenous alteplase at stroke centers. Conclusions: Our findings suggest that greater post-regionalization improvements in San Mateo County contributed to significantly better county-level thrombolysis use than Santa Clara County.

    View details for DOI 10.1080/10903127.2019.1679303

    View details for PubMedID 31599705

  • Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather than Comorbidities George, E. L., Rothenberg, K., Barreto, N. L., Chen, R., Trickey, A. W., Arya, S. ELSEVIER SCIENCE INC. 2019: S163–S164
  • Delayed Fasciotomy Is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia ANNALS OF VASCULAR SURGERY Rothenberg, K. A., George, E. L., Trickey, A. W., Chandra, V., Stern, J. R. 2019; 59: 195–201
  • Something for everyone: the benefits of longitudinal mentorship with the application of the acquisition of data for outcomes and procedure transfer (ADOPT) program to a SAGES hands-on colectomy course. Surgical endoscopy Dort, J., Trickey, A., Schwarz, E., Paige, J. 2019


    Continued professional development of surgeons remains a challenging and unstandardized enterprise. The Continuing Education Committee of SAGES created the Acquisition of Data for Outcomes and Procedure Adoption (ADOPT) program, incorporating a standardized training approach into hands-on courses with a year-long longitudinal mentorship experience. To evaluate the program's transferability to other procedures following its successful application to a SAGES hernia course, the ADOPT method was applied to the SAGES 2017 laparoscopic colectomy course. Participant data included demographics, training and experience, as well as pre-and post-course self-reported colectomy case volumes and procedure confidence. Confidence levels were for techniques taught in the course using a 5-point scale: 1=not confident at all to 5=completely confident. Participants reported confidence in the following skills for laparoscopic right and left colectomy: (1) formulating an operative plan, (2) identifying proper anatomical planes and isolating anatomic structures, and (3) competently conducting the technical steps of the procedure. A total of 18 surgeons enrolled in the SAGES 2017 Colon Program, 10 of whom completed the 6-month post-course questionnaire (56%). Participants reported significantly higher confidence in all skills at 6months compared to pre-course (p≤0.015). Most participants (60%) reported an increase in the number of procedures performed. The lowest pre-course case volume group (≤5 annual cases, n=5 6-month survey responders) demonstrated a trend for increased procedure volume post-course (5.6 vs. 2, p=0.057). The overwhelming majority of survey respondents (90%) felt either "confident" or "extremely confident" performing the procedures learned (range 80-100% across tasks). Participants found the program to be an advantageous method of becoming competent and confident in performing these procedures. The application of the ADOPT program to the laparoscopic colectomy course was successful in increasing surgeon confidence and demonstrated a trend in improving surgeon procedure counts in the novice participant group.

    View details for DOI 10.1007/s00464-019-06900-0

    View details for PubMedID 31218420

  • Frailty as Measured by the Risk Analysis Index Predicts Long-Term Death After Carotid Endarterectomy Rothenberg, K. A., George, E., Barreto, N., Chen, R., Samson, K. K., Johanning, J. M., Trickey, A., Arya, S. MOSBY-ELSEVIER. 2019: E62
  • The Impact of Frailty on Failure to Rescue Following Elective Abdominal Aortic Aneurysm Repair George, E. L., Rothenberg, K. A., Barreto, N., Chen, R., Trickey, A., Johanning, J., Hockenberry, J., Arya, S. MOSBY-ELSEVIER. 2019: E124–E125
  • Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA network open Rothenberg, K. A., Stern, J. R., George, E. L., Trickey, A. W., Morris, A. M., Hall, D. E., Johanning, J. M., Hawn, M. T., Arya, S. 2019; 2 (5): e194330


    Importance: Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.Objective: To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.Design, Setting, and Participants: In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS=0) and those with a LOS of 1 or more days (LOS≥1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.Exposure: Frailty, as measured by the Risk Analysis Index.Main Outcomes and Measures: The main outcome was 30-day unplanned readmission.Results: Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS=0, 2.0%; LOS≥1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS=0, 8.3% vs 1.9%; LOS≥1, 8.5% vs 3.2%; P<.001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS=0, 6.9% vs 2.5%; LOS≥1, 9.8% vs 4.6%; P<.001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS=0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS≥1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS=0, 22.8%; LOS≥1, 29.3%).Conclusions and Relevance: These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.

    View details for DOI 10.1001/jamanetworkopen.2019.4330

    View details for PubMedID 31125103

  • Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2019: 798-+
  • Can Machine Learning Methods Produce Accurate and Easy-to-use Prediction Models of 30-day Complications and Mortality After Knee or Hip Arthroplasty? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Harris, A. S., Kuo, A. C., Weng, Y., Trickey, A. W., Bowe, T., Giori, N. J. 2019; 477 (2): 452–60
  • The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample BURNS Sheckter, C. C., Li, A., Pridgen, B., Trickey, A. W., Karanas, Y., Curtin, C. 2019; 45 (1): 146–56
  • Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients JAMA SURGERY Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C., Staudenmayer, K. L. 2019; 154 (2): 141–49
  • Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing. Journal of the American College of Surgeons Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A., Hawn, M. 2019


    INTRODUCTION: Healthcare value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.METHODS: Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014-2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared to median utilization, accounting for case, patient, and attending-level variables.RESULTS: 111,055 laboratory and 7,360 imaging orders were linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% confidence intervals >1, p<0.05). Compared to the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% confidence interval >1, p<0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.CONCLUSIONS: Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared to imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high utilizers and could be used to educate residents on their ordering patterns.

    View details for PubMedID 30660819

  • Can Machine Learning Methods Produce Accurate and Easy-to-use Prediction Models of 30-day Complications and Mortality After Knee or Hip Arthroplasty? Clinical orthopaedics and related research Harris, A. H., Kuo, A. C., Weng, Y., Trickey, A. W., Bowe, T., Giori, N. J. 2019


    BACKGROUND: Existing universal and procedure-specific surgical risk prediction models of death and major complications after elective total joint arthroplasty (TJA) have limitations including poor transparency, poor to modest accuracy, and insufficient validation to establish performance across diverse settings. Thus, the need remains for accurate and validated prediction models for use in preoperative management, informed consent, shared decision-making, and risk adjustment for reimbursement.QUESTIONS/PURPOSES: The purpose of this study was to use machine learning methods and large national databases to develop and validate (both internally and externally) parsimonious risk-prediction models for mortality and complications after TJA.METHODS: Preoperative demographic and clinical variables from all 107,792 nonemergent primary THAs and TKAs in the 2013 to 2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) were evaluated as predictors of 30-day death and major complications. The NSQIP database was chosen for its high-quality data on important outcomes and rich characterization of preoperative demographic and clinical predictors for demographically and geographically diverse patients. Least absolute shrinkage and selection operator (LASSO) regression, a type of machine learning that optimizes accuracy and parsimony, was used for model development. Tenfold validation was used to produce C-statistics, a measure of how well models discriminate patients who experience an outcome from those who do not. External validation, which evaluates the generalizability of the models to new data sources and patient groups, was accomplished using data from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Models previously developed from VASQIP data were also externally validated using NSQIP data to examine the generalizability of their performance with a different group of patients outside the VASQIP context.RESULTS: The models, developed using LASSO regression with diverse clinical (for example, American Society of Anesthesiologists classification, comorbidities) and demographic (for example, age, gender) inputs, had good accuracy in terms of discriminating the likelihood a patient would experience, within 30 days of arthroplasty, a renal complication (C-statistic, 0.78; 95% confidence interval [CI], 0.76-0.80), death (0.73; 95% CI, 0.70-0.76), or a cardiac complication (0.73; 95% CI, 0.71-0.75) from one who would not. By contrast, the models demonstrated poor accuracy for venous thromboembolism (C-statistic, 0.61; 95% CI, 0.60-0.62) and any complication (C-statistic, 0.64; 95% CI, 0.63-0.65). External validation of the NSQIP- derived models using VASQIP data found them to be robust in terms of predictions about mortality and cardiac complications, but not for predicting renal complications. Models previously developed with VASQIP data had poor accuracy when externally validated with NSQIP data, suggesting they should not be used outside the context of the Veterans Health Administration.CONCLUSIONS: Moderately accurate predictive models of 30-day mortality and cardiac complications after elective primary TJA were developed as well as internally and externally validated. To our knowledge, these are the most accurate and rigorously validated TJA-specific prediction models currently available ( Methods to improve these models, including the addition of nonstandard inputs such as natural language processing of preoperative clinical progress notes or radiographs, should be pursued as should the development and validation of models to predict longer term improvements in pain and function.LEVEL OF EVIDENCE: Level III, diagnostic study.

    View details for PubMedID 30624314

  • Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research Mudumbai, S. C., Pershing, S. n., Bowe, T. n., Kamal, R. N., Sears, E. D., Finlay, A. K., Eisenberg, D. n., Hawn, M. T., Weng, Y. n., Trickey, A. W., Mariano, E. R., Harris, A. H. 2019; 19 (1): 859


    The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

    View details for DOI 10.1186/s12913-019-4640-x

    View details for PubMedID 31752856

  • THE IMPACT OF MEDICAID EXPANSION ON TRAUMA-RELATED EMERGENCY DEPARTMENT UTILIZATION: A NATIONAL EVALUATION OF POLICY IMPLICATIONS. The journal of trauma and acute care surgery Knowlton, L. M., Dehghan, M. S., Arnow, K. n., Trickey, A. W., Tennakoon, L. n., Morris, A. M., Spain, D. A. 2019


    The impact of the 2014 Affordable Care Act (ACA) upon national trauma-related emergency department (ED) utilization is unknown. We assessed ACA-related changes in ED use and payer mix, hypothesizing that post-ACA ED visits would decline and Medicaid coverage would increase disproportionately in regions of widespread policy adoption.We queried the National Emergency Department Sample (NEDS) for those with a primary trauma diagnosis, aged 18 to 64. Comparing pre-ACA (2012) to post-ACA (10/2014 to 09/2015), primary outcomes were change in ED visits and payer status; secondary outcomes were change in costs, discharge disposition and inpatient length of stay. Univariate and multivariate analyses were performed, including difference-in-differences analyses. We compared changes in ED trauma visits by payer in the West (91% in a Medicaid expansion state) versus the South (12%).Among 21.2 million trauma-related ED visits, there was a 13.3% decrease post-ACA. Overall, there was a 7.2% decrease in uninsured ED visits (25.5% vs. 18.3%, p<0.001) and a 6.6% increase in Medicaid coverage (17.6% vs. 24.2%, p<0.001). Trauma patients had 40% increased odds of having Medicaid post-ACA (vs. pre-ACA: aOR 1.40, p<0.001). Patients in the West had 31% greater odds of having Medicaid (vs. South: aOR 1.31, p<0.001). The post-ACA increase in Medicaid was greater in the West (vs. South: aOR 1.60, p<0.001). Post-ACA, inpatients were more likely to have Medicaid (vs. ED discharge: aOR 1.20, p<0.001) and there was a 25% increase in inpatient discharge to rehabilitation (aOR 1.24, p<0.001).Post-ACA, there was a significant increase in insured trauma patients and a decrease in injury-related ED visits, possibly resulting from access to other outpatient services. Ensuring sustainability of expanded coverage will benefit injured patients and trauma systems.Epidemiologic, level III.

    View details for DOI 10.1097/TA.0000000000002504

    View details for PubMedID 31524835

  • Comparison of Surgeon Assessment to Frailty Measurement in Abdominal Aortic Aneurysm Repair. The Journal of surgical research George, E. L., Kashikar, A. n., Rothenberg, K. A., Barreto, N. L., Chen, R. n., Trickey, A. W., Arya, S. n. 2019; 248: 38–44


    Endovascular abdominal aortic aneurysm repair (EVAR) allows us to intervene on patients otherwise considered poor candidates for open repair. Despite its importance in determining operative approach, no comparison has been made between the subjective "eyeball test" and an objective measurement of preoperative frailty for EVAR patients.Patients undergoing elective EVAR were identified in the Vascular Quality Initiative (VQI) database (2003-2017). Patients were classified "unfit" based on a surgeon-reported variable. Frailty was defined using the VQI-derived Risk Analysis Index, which includes sex, age, BMI, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. The association between fitness and/or frailty and adverse outcomes was determined by logistic regression.A total of 11,694 patients undergoing elective EVAR were included of which only 18.1% were "unfit," whereas 34.6% were "frail" and overall 43.6% "unfit or frail." Patients deemed "unfit" or "frail" had significantly increased odds of mortality, complications, and nonhome discharge (P < 0.001), and both frailty and unfitness generated negative predictive values for these outcomes greater than 93%. In adjusted logistic regression, the addition of objective frailty significantly improved model performance in predicting nonhome discharge (C-statistic 0.65 versus 0.71, P < 0.001) and complications (0.59 versus 0.61, P = 0.01), but similarly predicted mortality (0.74 versus 0.73, P = 0.99).Preoperative frailty assessment provides a useful objective measure of risk stratification as an adjunct to a physician's clinical intuition. The addition of frailty expands the pool of high-risk patients who are more likely to experience adverse postoperative events after elective EVAR and may benefit from uniquely tailored perioperative interventions.

    View details for DOI 10.1016/j.jss.2019.11.005

    View details for PubMedID 31841735

  • Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms. Journal of vascular surgery George, E. L., Chen, R. n., Trickey, A. W., Brooke, B. S., Kraiss, L. n., Mell, M. W., Goodney, P. P., Johanning, J. n., Hockenberry, J. n., Arya, S. n. 2019


    Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database.Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year.A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001).There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.

    View details for DOI 10.1016/j.jvs.2019.01.074

    View details for PubMedID 31147116

  • Delayed Fasciotomy is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia. Annals of vascular surgery Rothenberg, K. A., George, E. L., Trickey, A. W., Chandra, V. n., Stern, J. R. 2019


    Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes.Patients who underwent lower extremity revascularization for ALI from 2005-2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations between patient characteristics, comorbidities, fasciotomy timing and patient outcomes were evaluated.A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford acute limb ischemia classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, p<0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, p=0.003). Ischemia time > 6 hours was noted in 66.7% of patients, though this was not significantly associated with fasciotomy occurrence (≤6 hours 21.7% fasciotomy vs. >6 hours 34.8% fasciotomy, p=0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, p=0.002).The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.

    View details for PubMedID 31034949

  • The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Li, A., Pridgen, B., Trickey, A. W., Karanas, Y., Curtin, C. 2018


    BACKGROUND: Human cadaveric skin (allograft) is used in treating major burns both as temporizing wound coverage and a means of testing wound bed viability following burn excision. There is limited information on outcomes, and clinicians disagree on indications for application in intermediate-sized burns. This study aims to improve understanding of allograft use in 20-50% total body surface burns by assessing current utilization and evaluating inpatient outcomes.METHODS: Discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality assessed 3557 major burn patients (>second degree depth and 20-50% TBSA) undergoing operative treatment. Outcomes were evaluated with propensity score matching. The primary outcome was mortality with secondary outcomes including complications, length of stay, total burn operations, and charges.RESULTS: After matching, 771 allografted patients were paired with 1774 controls. Covariate mean standard differences were all <11% after matching. The average treatment effect (ATE) of allograft on inpatient mortality was an increase of 2.8% (95% CI 0.2-5.3%, p=0.041). Allograft ATEs were all significantly higher for secondary outcomes: composite complication index increased 0.13 (95% CI 0.07-0.20, p<0.001), length of stay 8.4days (95% CI 6.1-1.9 days, p<0.001), total burn operations 1.6 (95% CI 1.4-1.9, p<0.001), and total charges $139,476 [$100,716-178,236, p<0.001).CONCLUSIONS: Allograft use in major burns 20-50% TBSA was associated with a significant increase in inpatient mortality. There was a notable correlation with increased inpatient complications, longer length of stay, more burn operations, and greater total charges. Better studies are needed to justify the use of this costly and limited resource in the intermediate sized major burn population.

    View details for PubMedID 30527451

  • Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA surgery Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C., Staudenmayer, K. L. 2018


    Importance: Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.Objective: To compare the outcomes of nonoperatively managed appendicitis against appendectomy.Design, Setting, and Participants: This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.Exposures: Appendectomy (control arm) or nonoperative management (treatment arm).Main Outcomes and Measures: Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.Results: Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P<.001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P=.02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P<.001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P<.001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P=.003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.Conclusions and Relevance: According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.

    View details for PubMedID 30427983

  • Nonoperative Management of Appendicitis in Privately Insured Patients Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C. J., Staudenmayer, K. D. ELSEVIER SCIENCE INC. 2018: S156–S157
  • Interaction of Frailty and Postoperative Complications on Unplanned Readmission after Elective Outpatient Surgery Stern, J. R., Blum, K., Trickey, A. W., Hall, D. E., Johanning, J. M., Morris, A. M., Hawn, M. T., Arya, S. ELSEVIER SCIENCE INC. 2018: E25
  • Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2018: S228–S229
  • Coordination of Care in Colorectal Cancer Patients: A Population-Based Study Miller, M. O., Trickey, A. W., Kin, C. J., Hawley, S. T., Abrahamse, P., Morris, A. M. ELSEVIER SCIENCE INC. 2018: S141–S142
  • Evaluating Surgical Residents' Patient-Centered Communication Skills: Practical Alternatives to the "Apprenticeship Model" JOURNAL OF SURGICAL EDUCATION Newcomb, A., Trickey, A. W., Lita, E., Dort, J. 2018; 75 (3): 613–21


    The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to assess communication skills and provide feedback to residents. We aimed to develop a feasible data collection process that generates objective clinical performance information to guide training activities, inform ACGME milestone evaluations, and validate assessment instruments.Residents care for patients in the surgical clinic and in the hospital, and participate in a communication curriculum providing practice with standardized patients (SPs). We measured perception of resident communication using the 14-item Communication Assessment Tool (CAT), collecting data from patients at the surgery clinic and surgical wards in the hospital, and from SP encounters during simulated training scenarios. We developed a handout of CAT example behaviors to guide patients completing the communication assessment.Independent academic medical center.General surgery residents.The primary outcome is the percentage of total items patients rated "excellent;" we collected data on 24 of 25 residents. Outpatient evaluations resulted in significantly higher scores (mean 84.5% vs. 68.6%, p < 0.001), and female patients provided nearly statistically significantly higher ratings (mean 85.2% vs. 76.7%, p = 0.084). In multivariate analysis, after controlling for patient gender, visit reason, and race, (1) residents' CAT scores from SPs in simulation were independently associated with communication assessments in their concurrent patient population (p = 0.017), and (2) receiving CAT example instructions was associated with a lower percentage of excellent ratings by 9.3% (p = 0.047).Our data collection process provides a model for obtaining meaningful information about resident communication proficiency. CAT evaluations of surgical residents by the inpatient population had not previously been described in the literature; our results provide important insight into relationships between the evaluations provided by inpatients, clinic patients, and SPs in simulation. Our example behaviors guide shows promise for addressing a common concern, minimizing ceiling effects when measuring physician-patient communication.

    View details for PubMedID 28993121

  • Survivability of Existing Peripheral Intravenous Access Following Blood Sampling in a Pediatric Population. Journal of pediatric nursing O'Neil, S. W., Friesen, M. A., Stanger, D., Trickey, A. W. 2018


    Although pediatric patients report venipuncture as their most feared experience during hospitalization, blood sampling from peripheral intravenous accesses (PIVs) is not standard of care. Blood sampling from PIVs has long been considered by healthcare personnel to harm the access. In an effort to minimize painful procedures, pediatric nursing staff conducted a prospective, observational study to determine if blood sampling using existing PIVs resulted in the loss of the access. The ability to obtain the sample from the PIV was measured along with patient and PIV characteristics.Specimen collection using 100 existing PIVs was attempted on pediatric inpatients. Each PIV was observed for functionality, infiltration, occlusion, and dislodgement following collection and again in 4h. Frequencies of PIV loss and successful blood sampling were calculated. Patient age, PIV gauge, access site, and PIV age were evaluated for associations with successful sampling using chi-square tests, Fisher's exact tests, and logistic regression.PIV survivability was reported at 99%. The ability to obtain a complete specimen was reported at 76% and found to be significantly related to PIV age and site. Size of PIV and patient's age were not significantly related to successful sampling.Encouraging rates of PIV survivability and collectability suggest blood sampling from PIVs to be a valuable technique to minimize painful and distressful procedures.Nursing practice was changed in this pediatric department. Patients and families are saved the pain and distress of venipuncture. Nurses reported saving time and personal distress by avoiding the venipuncture procedure.

    View details for DOI 10.1016/j.pedn.2018.02.009

    View details for PubMedID 29525119

  • Clinical Predictors of Positive Postoperative Blood Cultures ANNALS OF SURGERY Copeland-Halperin, L. R., Stodghill, J., Emery, E., Trickey, A. W., Dort, J. 2018; 267 (2): 297–302


    To define clinical features of surgical patients in whom postoperative blood cultures are likely to identify pathogens.Bacteremia is a worrisome postoperative complication and blood cultures (BCx) are routinely used for evaluation of postoperative bacteremia, but are costly and not always diagnostic. Better methods are needed to select patients in whom BCx identify pathogens.We reviewed records of patients ≥18 years old with BCx drawn ≤10 days after surgery in 2013 seeking independent predictors of positive cultures by simple and multiple logistic regression models with statistical significance at α = 0.05.Of 1804 BCx, excluding contaminants yielded 1780 cultures among 746 patients for analysis. The yield was low, with only 4% identifying potential pathogens. Positive BCx were most common after cardiac, ear/nose/throat, obstetric, and urologic procedures [odds ratio (OR) =10.3, P < 0.001 vs low-yield procedures: eg, gynecologic, neurosurgical, plastic surgical, podiatric, transplant]. Cultures more often grew pathogens when drawn in association with higher peak temperature (Tmax, P = 0.001) and longer interval from procedure to Tmax (P = 0.001). Antibiotic therapy at time of culture reduced yield (2.9% with vs 5.5% without antibiotics, P = 0.007). Multivariable logistic regression analysis found antibiotics at culture, procedure specialty, Tmax, and postoperative timing of Tmax were associated with blood culture results.Ordering blood cultures based on fever or another single predictor inconsistently identifies pathogens. Our dataset, the largest available, identify clinical predictors in the first 10 postoperative days to guide identification of patients with bacteremia.

    View details for DOI 10.1097/SLA.0000000000002077

    View details for Web of Science ID 000424031700042

    View details for PubMedID 27893534

  • All in: expansion of the acquisition of data for outcomes and procedure transfer (ADOPT) program to an entire SAGES annual meeting hands-on hernia course. Surgical endoscopy Dort, J. n., Trickey, A. n., Paige, J. n., Schwarz, E. n., Cecil, T. n., Coleman, M. n., Dunkin, B. n. 2018


    Continuing professional development (CPD) for the surgeon has been challenging because of a lack of standardized approaches of hands-on courses, resulting in poor post-course outcomes. To remedy this situation, SAGES has introduced the ADOPT program, implementing a standardized, long-term mentoring program as part of its hernia hands-on course. Previous work evaluating the pilot program showed increased adoption of learned procedures as well as increased confidence of the mentored surgeons. This manuscript describes the impact of such a program when it is instituted across an entire hands-on course.Following collection of pre-course benchmark data, all participants in the 2016 SAGES hands-on hernia course underwent structured, learner-focused instruction during the cadaveric lab. All faculty had completed a standardized teaching course in the Lapco TT format. Subsequently, course participants were enrolled in a year-long program involving longitudinal mentorship, webinars, conference calls, and coaching. Information about participant demographics, training, experience, self-reported case volumes, and confidence levels related to procedures were collected via survey 3 months prior to 9 months after the course.Twenty surgeons participated in the SAGES ADOPT 2016 hands-on hernia program. Of these, seventeen completed pre-course questionnaires (85%), ten completed the 3-month questionnaire (50%), and four completed the 9-month questionnaire (20%). Nine of ten respondents of the 3-month survey (90%) reported changes in their practice. In the 9-month survey, significant increases in the annualized procedural volumes were reported for open primary ventral hernia repair, open components separation, and mesh insertion for ventral hernia repair (p < 0.001).The expansion of the ADOPT program to an entire hands-on hernia course is both feasible and beneficial, with evidence of Kirkpatrick Levels 1-4a training effectiveness. This expanded success suggests that it is a useful blueprint for the CPD of surgeons wishing to learn new techniques and procedures for their patients.

    View details for PubMedID 29717374

  • Patient Perspectives of Surgical Residents' Communication: Do Skills Improve Over Time With a Communication Curriculum? Journal of surgical education Newcomb, A. B., Liu, C. n., Trickey, A. W., Lita, E. n., Dort, J. n. 2018; 75 (6): e142–e149


    We aimed to assess surgical residents' communication confidence and skills, analyze resident feedback on our ongoing communication curriculum, and report feedback-driven updates.Surgical residents care for patients in the clinic and hospital and participate in a communication curriculum. We measure patient perception of resident communication using the Communication Assessment Tool (CAT). We assess resident skills confidence and collect curriculum feedback after each quarterly session.900-bed tertiary care hospital with surgical residency program and simulation center.General surgery residents (PGY 1-5).We collected 353 CAT forms from patients in the clinic and hospital on 27 residents. Overall percent "excellent" scores (primary outcome) was 84%. In multivariate analysis we found a statistically significant increase in individuals' CAT scores over time at a rate of 1% improvement per month (p = 0.02). We observed significant improvement of skill confidence in 9 out of 10 training modules. Resident perception of the curriculum has improved over time with 90% of learners rating the course "A" or "A+" across all years. We updated the curriculum to be more learner-centered by: 1) providing differential scenarios for learner level; 2) engaging chief residents as co-faculty; 3) using both professional and volunteer (former patient) actors as SPs; and 4) refining the flow and timing of module practice.We assessed and analyzed surgical residents' communication skills and confidence over 17 months; both showed significant increase over the course of the communication curriculum. We adapted our curriculum using resident feedback and engagement. Our results suggest that communication training can be an effective tool to improve non-technical skills.

    View details for PubMedID 30093327

  • Tell Me Straight: Teaching Residents to Disclose Adverse Events in Surgery. Journal of surgical education Newcomb, A. B., Liu, C. n., Trickey, A. W., Dort, J. n. 2018; 75 (6): e178–e191


    The purpose of this effort was to create an educational experience that provided learners a realistic disclosure experience and improved resident confidence discussing an adverse outcome with a patient and family.Residents practiced disclosing a surgical complication to a patient/family with simulated patients (SPs). We paired professional SPs with former patient SPs to present a realistic case. Junior residents were given extra training time before their disclosure of a laparoscopic cholecystectomy conversion to an open procedure; senior residents disclosed a bile duct injury. Residents rated pre and post-module confidence levels, and skills performance using the Disclosure of a Complication Checklist.900-bed tertiary care hospital with surgical residency program and simulation center.General surgery residents (PGY 1-5).Eighteen residents participated in the disclosure module. Analysis of the medians and interquartile ranges of pre and post-module confidence scores showed significant improvement for each individual item and mean score of learners. Residents assessed their completion rates of individual Checklist tasks positively. For example, 94% self-endorsed completion of "explanation of facts," 89% self-endorsed "took responsibility," and 78% self-endorsed "apologized sincerely." Self-rated competence scores from the Checklist were low: 7% indicated they would be "extremely comfortable" entrusting their loved one's care to themselves, 11% rated their ability to explain the facts as "outstanding," and 12% felt they were "outstanding" in their "ability to disclose a complication in a professional manner."Residents received important skills practice in our disclosure training; disclosure confidence increased after participation. Residents scored high on completion of disclosure tasks and low on comfort and proficiency of those tasks. The Checklist provided a useful set of tasks to review and complete in the exercise. Separating residents by PGY level enabled senior residents to experience a more complex scenario and junior residents extra time to practice.

    View details for PubMedID 30249514

  • Exploration of Portal Activation by Patients in a Healthcare System CIN-COMPUTERS INFORMATICS NURSING Mook, P. J., Trickey, A. W., Krakowski, K., Majors, S., Theiss, M., Fant, C., Friesen, M. 2018; 36 (1): 18–26


    A study of patient portal utilization was conducted at a not-for-profit healthcare system in Northern Virginia. The healthcare system serves more than 2 million people each year. The encounters with the portal included 461 700 different patients occurring between July 2014 and June 2015. Univariate analysis and multivariable logistic regression indicated associations between patient portal activation and predictive factors. Multiple findings emerged: patient portal activation was greater for English-speaking patients; differences in portal activation were observed by patient age; and patients who had an identified primary care provider were more likely to use the portal. The implications were that patients who have limited English skills and have economic challenges may be less engaged. This review demonstrates the importance of understanding the population using a patient portal and provides insight for future development on how to engage patients to interact with their providers through the portals.

    View details for DOI 10.1097/CIN.0000000000000392

    View details for Web of Science ID 000419841900004

    View details for PubMedID 29049084

  • Low socioeconomic status is associated with lower weight-loss outcomes 10-years after Roux-en-Y gastric bypass. Surgical endoscopy Carden, A. n., Blum, K. n., Arbaugh, C. J., Trickey, A. n., Eisenberg, D. n. 2018


    Roux-en-Y gastric bypass (RYGB) is the criterion standard operation for weight loss. Low socioeconomic status (SES) is common in the Veteran population undergoing bariatric surgery, but the impact of SES on long-term weight-loss outcomes is not known. We hypothesize that low socioeconomic status is associated with less weight loss after gastric bypass in long-term follow-up.We performed a retrospective review of patients undergoing RYGB at a single Veterans Affairs (VA) hospital. Patients with at least 10 years of follow-up data in the electronic health record were included in the analysis. Weight loss was measured as percent excess body mass index loss (%EBMIL). The primary predictor variable, median household income, was determined using zip codes of patient residences matched to publicly available 2010 U.S. census data. Univariate relationships between income, weight loss, and other patient characteristics were evaluated. We calculated a multivariate generalized linear model of %EBMIL to estimate independent relationships with median household income quartile while controlling for patients' age, race, sex, and VA distance.Complete 10-year follow-up data were available for 83 of 92 patients (90.2%) who underwent RYGB between 2001 and 2007 and survived at least 10 years. The majority of patients were male (79.5%) and white (73.5%). The mean 10-year %EBMIL was 57.8% (SD: 29.5%, range - 36.0% - 132.8%). In univariate analysis, income was significantly associated with race (p < 0.001) and median distance to the VA bariatric center (p = 0.034), but income did not differ by gender (p = 0.73) or age (p = 0.45). Multivariate analysis revealed significantly lower 10-year %EBMIL for patients with the lowest income compared to patients with low-mid income (p = 0.03) and mid-high income (p = 0.01), after controlling for gender, race, age, and VA distance.Low socioeconomic status is associated with lower weight-loss outcomes, 10 years after RYGB. Durable weight loss is observed in all income groups.

    View details for PubMedID 29987570

  • Morbidity and mortality conference is not sufficient for surgical quality control: Processes and outcomes of a successful attending Physician Peer Review committee AMERICAN JOURNAL OF SURGERY Reines, H., Trickey, A. W., Donovan, J. 2017; 214 (5): 780–85


    Physician Peer Review (PPR) is required by The Joint Commission to assure examination of individual and group outcomes. Although surgeons may utilize Morbidity and Mortality (M&M) conference, applying these data to determine Focused Professional Practice Evaluations involves outcomes review. A PPR Committee of senior surgeons was created. This report describes one institution's surgical PPR process and results.A two-year (2014-2015) retrospective review of significant non-trauma complications and unanticipated deaths evaluated by PPR was performed. A faculty questionnaire evaluated perceptions of quality outcomes reporting.Of 395 reviewed cases, almost half (48.9%) demonstrated no care improvement opportunities, 48.6% revealed possible improvements, 2% were deviations from standard of care, and 0.5% represented unacceptable care. Although most surgeons (94%) wanted to know their complication rates, only 41% reported maintaining an outcomes database.As a complement to M&M, PPR is a valuable tool in the evaluation of individual surgical quality and can be the basis for further quality improvement opportunities. This process has been largely successful; only a small number of significant concerns were discovered.

    View details for DOI 10.1016/j.amjsurg.2017.04.008

    View details for Web of Science ID 000415221700002

    View details for PubMedID 28502556

  • Hands-on 2.0: improving transfer of training via the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Dort, J., Trickey, A., Paige, J., Schwarz, E., Dunkin, B. 2017; 31 (8): 3326–32


    Practicing surgeons commonly learn new procedures and techniques by attending a "hands-on" course, though trainings are often ineffective at promoting subsequent procedure adoption in practice. We describe implementation of a new program with the SAGES All Things Hernia Hands-On Course, Acquisition of Data for Outcomes and Procedure Transfer (ADOPT), which employs standardized, proven teaching techniques, and 1-year mentorship. Attendee confidence and procedure adoption are compared between standard and ADOPT programs.For the pilot ADOPT course implementation, a hands-on course focusing on abdominal wall hernia repair was chosen. ADOPT participants were recruited among enrollees for the standard Hands-On Hernia Course. Enrollment in ADOPT was capped at 10 participants and limited to a 2:1 student-to-faculty ratio, compared to the standard course 22 participants with a 4:1 student-to-faculty ratio. ADOPT mentors interacted with participants through webinars, phone conferences, and continuous email availability throughout the year. All participants were asked to provide pre- and post-course surveys inquiring about the number of targeted hernia procedures performed and related confidence level.Four of 10 ADOPT participants (40%) and six of 22 standard training participants (27%) returned questionnaires. Over the 3 months following the course, ADOPT participants performed more ventral hernia mesh insertion procedures than standard training participants (median 13 vs. 0.5, p = 0.010) and considerably more total combined procedures (median 26 vs. 7, p = 0.054). Compared to standard training, learners who participated in ADOPT reported greater confidence improvements in employing a components separation via an open approach (p = 0.051), and performing an open transversus abdominis release, though the difference did not achieve statistical significance (p = 0.14).These results suggest that the ADOPT program, with standardized and structured teaching, telementoring, and a longitudinal educational approach, is effective and leads to better transfer of learned skills and procedures to clinical practice.

    View details for DOI 10.1007/s00464-016-5366-z

    View details for Web of Science ID 000409037100032

    View details for PubMedID 28039640

  • Two-Year Experience Implementing a Curriculum to Improve Residents' Patient-Centered Communication Skills. Journal of surgical education Trickey, A. W., Newcomb, A. B., Porrey, M., Piscitani, F., Wright, J., Graling, P., Dort, J. 2017


    OBJECTIVES: Surgery milestones from The Accreditation Council for Graduate Medical Education have encouraged a focus on training and assessment of residents' nontechnical skills, including communication. We describe our 2-year experience implementing a simulation-based curriculum, results of annual communication performance assessments, and resident evaluations.DESIGN: Eight quarterly modules were conducted on various communication topics. Former patient volunteers served as simulation participants (SP) who completed annual assessments using the Communication Assessment Tool (CAT). During these 2 modules, communication skills were assessed in the following standardized scenarios: (1) delivering bad news to a caregiver of a patient with postoperative intracerebral hemorrhage and (2) primary care gallstone referral with contraindications for cholecystectomy. SP-CAT ratings were evaluated for correlations by individual and associations with trainee and SP characteristics. Surgical patient experience surveys are evaluated during the curriculum.SETTING: Independent academic medical center surgical simulation center.PARTICIPANTS: Twenty-five surgery residents per year in 2015 to 2017.RESULTS: Residents have practiced skills in a variety of scenarios including bad news delivery, medical error disclosure, empathic communication, and end-of-life conversations. Residents report positive learning experiences from the curriculum (90% graded all modules A/A+). Confidence ratings rose following each module (p < 0.001) and in the second year (p < 0.001). Annual assessments yielded insights into skills level, and relationships to resident confidence levels and traits. Communication scores were not associated with resident gender or postgraduate year. Over the course of the curriculum implementation, surgical patients have reported that doctors provided explanations with improved clarity (p = 0.042).CONCLUSIONS: The simulation-based SP-CAT has shown initial evidence of usability, content validity, relationships to observed communication behaviors and residents' skills confidence. Evaluations of different scenarios may not be correlated for individuals over time. The communication curriculum paralleled improvements in patient experience concerning surgeons' clear explanations. An ongoing surgery resident communication curriculum has numerous educational, assessment, and institutional benefits.

    View details for PubMedID 28756146

  • EVIDENCE-BASED PRACTICE: VIDEO-DISCHARGE INSTRUCTIONS IN THE PEDIATRIC EMERGENCY DEPARTMENT JOURNAL OF EMERGENCY NURSING Wood, E. B., Harrison, G., Trickey, A., Friesen, M., Stinson, S., Rovelli, E., McReynolds, S., Presgrave, K. 2017; 43 (4): 316–21


    While a high quality discharge from a Pediatric Emergency Department helps caregivers feel informed and prepared to care for their sick child at home, poor adherence to discharge instructions leads to unnecessary return visits, negative health outcomes, and decreased patient satisfaction. Nurses at the Inova Loudoun Pediatric ED utilized the Johns Hopkins Model of Evidence Based Practice to answer the following question: Among caregivers who have children discharged from the ED, does the addition of video discharge instructions (VDI) to standard written/verbal discharge instructions (SDI) result in improved knowledge about the child's diagnosis, treatment, illness duration, and when to seek further medical care?A multidisciplinary team reviewed available evidence and created VDI for three common pediatric diagnoses: gastroenteritis, bronchiolitis, and fever. Knowledge assessments were collected before and after delivery of discharge instructions to caregivers for both the SDI and VDI groups.Analysis found that the VDI group achieved significantly higher scores on the post test survey (P < .001) than the SDI group, particularly regarding treatment and when to seek further medical care. After integrating the best evidence with clinical expertise and an effective VDI intervention, the team incorporated VDI into the discharge process.VDI offer nurses an efficient, standardized method of providing enhanced discharge instructions in the ED. Future projects will examine whether VDI are effective for additional diagnoses and among caregivers for whom English is not the primary language.

    View details for DOI 10.1016/j.jen.2016.11.003

    View details for Web of Science ID 000407303200008

    View details for PubMedID 28359707

  • Resident Operative Experience at Independent Academic Medical Centers-A Comparison to the National Cohort. Journal of surgical education Joshi, A. R., Trickey, A. W., Jarman, B. T., Kallies, K. J., Josloff, R., Dort, J. M., Kothuru, R. 2017; 74 (6): e88-e94


    Independent Academic Medical Centers (IAMCs) comprise one-third of U.S. general surgery training programs. It is unclear whether IAMCs offer qualitatively or quantitatively different operative experiences than the national cohort. We analyzed a large representative sample of IAMCs to compare operative volume and variety, with a focus on low-volume procedures.Accreditation Council for Graduate Medical Education Program Case Reports from 27 IAMCs were collected and analyzed for 3 academic years (2012-2015). IAMCs were compared to the national cohort for specific defined category volumes and selected low-volume cases. One-sample two-way t-tests were calculated comparing IAMC totals to national program averages.IAMCs had a median of 3 chief residents per year (range: 1-6). IAMCs reported significantly more "total major" procedures in 2013-2014 (p = 0.046). Other case totals were statistically similar between IAMCs and the national cohort for "total major", "surgeon chief", "surgeon junior", and "teaching assistant" cases. In 2013-2014, IAMCs reported more laparoscopic complex (138.3 vs. 110.6, p = 0.010) and alimentary tract cases (276.5 vs. 253.5, p = 0.019). IAMC esophagogastroduodenoscopy case totals were higher in 2013-2014 (55.9 vs. 41, p = 0.038) and 2014-2015 (47.8 vs. 41, p = 0.047). IAMCs had fewer pancreas cases than the national cohort in all three years by about three cases per resident (p ≤ 0.026). In 2012-2013 IAMCs reported fewer (by about one) esophagectomy, gastrectomy, and abdominal perineal resections. No differences were observed in the following selected procedures: open common bile duct exploration, inguinal hernia, laparoscopic appendectomy, laparoscopic cholecystectomy, and colonoscopy.The IAMCs studied appear to provide equivalent exposure to specific subcategories mandated by the Accreditation Council for Graduate Medical Education and American Board of Surgery. Graduates of IAMCs gain similar operative experience in low-volume, defined categories when compared to the national cohort. Certain specific cases subject to regionalization pressure are less well represented among IAMCs. This has important implications for medical students applying to surgery residency.

    View details for DOI 10.1016/j.jsurg.2017.05.020

    View details for PubMedID 28602526

  • Interrater Reliability of Hospital Readmission Evaluations for Surgical Patients AMERICAN JOURNAL OF MEDICAL QUALITY Trickey, A. W., Wright, J. M., Donovan, J., Reines, H., Dort, J. M., Prentice, H. A., Graling, P. R., Moynihan, J. J. 2017; 32 (2): 201–7


    Value-based purchasing initiatives have helped shift attention to the accuracy of hospital readmission information at the most clinically detailed level. The purpose of this study was to determine the interrater reliability (IRR) of surgical experts in assessing surgical inpatient readmissions for categorical causes, relation to index procedure, and potential preventability. Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program local database. Of 1840 cases, 156 patients (8.5%) were readmitted within 30 days of the procedure. Surgical site infection was the most common readmission cause (32%), followed by obstruction or ileus (17%). IRR was moderate for readmission cause (60% agreement, κ = 0.51), substantial for readmission in relation to surgical procedure (92%, κ = 0.70), and lowest for potential preventability of readmissions (57%, κ = 0.18). Results suggest that readmission cause and relation to surgical procedure can be determined with moderate to high degree of IRR, while preventability of readmissions may require stricter definitions to improve IRR.

    View details for DOI 10.1177/1062860615623854

    View details for Web of Science ID 000396202100013

    View details for PubMedID 26911664

  • Talk the Talk: Implementing Commasnication Curriculum for Surgical Residents JOURNAL OF SURGICAL EDUCATION Newcomb, A. B., Trickey, A. W., Porrey, M., Wright, J., Piscitani, F., Graling, P., Dort, J. 2017; 74 (2): 319–28


    The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program.The curriculum is presented in quarterly modules over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios.Surgical simulation center in a 900-bed tertiary care hospital.Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios.We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum.Our approach using Trauma Survivors Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance patient care for institutions providing such education as well as for institutions where residents continue on in fellowships or begin their surgical practice.

    View details for DOI 10.1016/j.jsurg.2016.09.009

    View details for Web of Science ID 000397836000019

    View details for PubMedID 27825662

  • Assessment of Surgery Residents' Interpersonal Communication Skills: Validation Evidence for the Communication Assessment Tool in a Simulation Environment. Journal of surgical education Trickey, A. W., Newcomb, A. B., Porrey, M., Wright, J., Bayless, J., Piscitani, F., Graling, P., Dort, J. 2016; 73 (6): e19-e27


    Although development of trainees' competency in interpersonal communication is essential to high-quality patient-centered surgical care, nontechnical skills present assessment challenges for residency program directors. The Communication Assessment Tool (CAT) demonstrated internal reliability and content validity for general surgery residents, though the tool has not yet been applied in simulation. The study provides validation evidence for using the CAT to assess surgical residents' interpersonal communication skills in simulation scenarios.Simulations of delivering bad news were completed by 21 general surgery residents during a mandatory communication curriculum. Upon completion of the 10-minute scenario, standardized participants (SPs) assessed performance using the 14-item CAT rating scale and individually provided feedback to residents. Discrete communication behaviors were recorded on video review by a trained blinded observer. The traits emotional intelligence questionnaire short form (TEIQue-SF) was completed by the residents 6 months later. SP-CAT ratings are evaluated with respect to learner characteristics, observed behaviors, and TEIQue results.Surgical simulation center in a 900-bed tertiary care hospital.General surgery residents were targeted learners. Trauma survivors network volunteers served as SPs, acting as a family member of a patient who developed an intracerebral hemorrhage following a small bowel procedure.Discrete communication behaviors were reliably assessed by the observer (interrater reliability with trainer: 89% agreement, κ = 0.77). SP-CAT ratings ranged from 34 to 61. Higher SP-CAT ratings were correlated with positive communication behaviors (Spearman ρ = 0.42, p = 0.056). Total TEIQue was positively related to SP-CAT ratings (ρ = 0.42, p = 0.061). The TEIQue emotionality factor was strongly correlated with SP-CAT ratings (ρ = 0.52, p = 0.016).The CAT demonstrates content validity in a simulation environment with former patients acting as SPs. This study provides validation evidence relating the SP-CAT to discrete observations of communication behaviors by a trained, reliable observer as well as residents' self-reported emotional intelligence traits.

    View details for DOI 10.1016/j.jsurg.2016.04.016

    View details for PubMedID 27216300

  • Characteristics of Independent Academic Medical Center Faculty. Journal of surgical education Joshi, A. R., Trickey, A. W., Kallies, K., Jarman, B., Dort, J., Sidwell, R. 2016; 73 (6): e48-e53


    Little is known about the characteristics of teaching faculty in US surgical residencies based at Independent Academic Medical Centers (IAMCs). The purpose of this study was to survey teaching faculty at IAMCs to better define their common characteristics.An online, anonymous survey was distributed through program officials at 96 IAMCs to their faculty and graduates. Respondents were asked about their demographic information, training history, board certification, clinical practice, and exposure to medical students. Student t-tests and chi-square tests were calculated to evaluate associations between faculty characteristics.Independent Academic Medical Center general surgery training programs PARTICIPANTS: A total of 128 faculty at 14 IAMCs participated in the study.In total, 128 faculty from 14 programs responded to the survey. The mean age of faculty respondents was 52 years and 81% were men. 58% were employed by a nonuniversity hospital, and 28% by a multispecialty practice. 79% of respondents were core faculty. The mean length of time since graduation from surgery residency was 19 years. 86% were currently board certified. 55% of those who were currently board certified had an additional certification. 45% had trained in an IAMC, 50% in an university program, and 5% in a military program. 73% were actively practicing general surgeons, with the majority (70%) performing between 101 and 400 cases annually. The vast majority of faculty (90%) performed <200 endoscopies annually, with 44% performing none. 84% and 35% provided ER and trauma coverage, respectively. 81% listed mentorship as their primary motivation for teaching residents. 23% received a stipend for this teaching. 95% were involved in medical student teaching. Faculty who completed training at university programs had more additional certifications compared with those with IAMC training (67% vs. 43%, p = 0.007). Certification differences by program type were consistent across age and time since residency completion. Age was not associated with residency program type (p = 0.87) nor additional certifications (p = 0.97).IAMC faculty and graduates are overwhelmingly involved in general surgery, and most faculty have additional certifications. 90% of faculty have clinical exposure to medical students. Faculty at IAMCs were as likely to have been trained at an university program as an IAMC. In a time of increasing surgeon subspecialization and anxiety about the ability of 5-year training programs to train well-rounded surgeons, IAMCs appear to be a repository of consistent general surgical training.

    View details for DOI 10.1016/j.jsurg.2016.05.006

    View details for PubMedID 27321985

  • Deep vein thrombosis screening and risk factors in a high-risk trauma population JOURNAL OF SURGICAL RESEARCH Michetti, C. P., Franco, E., Coleman, J., Bradford, A., Trickey, A. W. 2015; 199 (2): 545–51


    Trauma patients requiring acute inpatient rehabilitation are significantly injured, with increased risk for deep vein thrombosis (DVT). We evaluated routine screening for occult DVT in such patients, and analyzed DVT risk factors.Data from level I trauma center patients discharged to a single acute rehabilitation center (ARC) from 2007-2011 were retrospectively reviewed. Routine lower extremity duplex was performed on ARC admission. Follow-up data were collected for patients with occult DVT (ARC DVT). DVT predictors were evaluated using logistic regression.Of 622 patients, 534 (86%) had screening duplex; 26 (4.8%) had an ARC DVT. A majority of 442 patients (71%) received enoxaparin prophylaxis in hospital, for a median 64% of hospital days. Of ARC DVT patients, 17 received full anticoagulation and 16 received vena cava filters. Thirty-seven patients had DVT diagnosed in the hospital (hospital DVT) before discharge to ARC. Hospital DVT and ARC DVT groups were comparable except shorter median hospital length of stay and lower head abbreviated injury scale in ARC DVT patients. On multivariate analysis, increased intensive care unit length of stay, age >65 y, a lower percentage of hospital days receiving chemoprophylaxis, and delayed initiation of chemoprophylaxis were significantly predictive of DVT after adjustment for sex, mechanism, injury severity score, and admission systolic blood pressure. Presence of pelvic fractures and ages 50-65 y also posed an increased risk.The incidence of occult DVT on ARC admission is low in trauma patients. Several risk factors for DVT in the trauma ARC population were identified. Nonselective screening of all trauma patients on admission to ARC is not supported by this analysis.

    View details for DOI 10.1016/j.jss.2015.04.069

    View details for Web of Science ID 000364433600037

    View details for PubMedID 25998183

  • Applicant Characteristics Associated With Selection for Ranking at Independent Surgery Residency Programs. Journal of surgical education Dort, J. M., Trickey, A. W., Kallies, K. J., Joshi, A. R., Sidwell, R. A., Jarman, B. T. 2015; 72 (6): e123-9


    This study evaluated characteristics of applicants selected for interview and ranked by independent general surgery residency programs and assessed independent program application volumes, interview selection, rank list formation, and match success.Demographic and academic information was analyzed for 2014-2015 applicants. Applicant characteristics were compared by ranking status using univariate and multivariable statistical techniques. Characteristics independently associated with whether or not an applicant was ranked were identified using multivariable logistic regression modeling with backward stepwise variable selection and cluster-correlated robust variance estimates to account for correlations among individuals who applied to multiple programs.The Electronic Residency Application Service was used to obtain applicant data and program match outcomes at 33 independent surgery programs.All applicants selected to interview at 33 participating independent general surgery residency programs were included in the study.Applicants were 60% male with median age of 26 years. Birthplace was well distributed. Most applicants (73%) had ≥1 academic publication. Median United States Medical Licensing Exams (USMLE) Step 1 score was 228 (interquartile range: 218-240), and median USMLE Step 2 clinical knowledge score was 241 (interquartile range: 231-250). Residency programs in some regions more often ranked applicants who attended medical school within the same region. On multivariable analysis, significant predictors of ranking by an independent residency program were: USMLE scores, medical school region, and birth region. Independent programs received an average of 764 applications (range: 307-1704). On average, 12% interviews, and 81% of interviewed applicants were ranked. Most programs (84%) matched at least 1 applicant ranked in their top 10.Participating independent programs attract a large volume of applicants and have high standards in the selection process. This information can be used by surgery residency applicants to gauge their candidacy at independent programs. Independent programs offer a select number of interviews, rank most applicants that they interview, and successfully match competitive applicants.

    View details for DOI 10.1016/j.jsurg.2015.04.021

    View details for PubMedID 26073713

  • Factors and Influences That Determine the Choices of Surgery Residency Applicants. Journal of surgical education Jarman, B. T., Joshi, A. R., Trickey, A. W., Dort, J. M., Kallies, K. J., Sidwell, R. A. 2015; 72 (6): e163-71


    We sought to evaluate characteristics of residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer.An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference.Independent general surgery residency programs.A total, of 1220 applicants were selected to interview at one of 33 independent programs.In total, 670 surveys were completed (55% response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs.Applicants selected to interview at independent programs are competitive for general surgery training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleviate bias against their programs.

    View details for DOI 10.1016/j.jsurg.2015.05.017

    View details for PubMedID 26143518

  • Laparoscopic Cholecystectomy Performed by Acute Care Surgeons and General Surgeons AMERICAN SURGEON Michetti, C. P., Griffen, M., Tran, H., Crosby, M. E., Trickey, A. W. 2015; 81 (5): E220–E221

    View details for Web of Science ID 000354895700013

    View details for PubMedID 25975316

  • Description of the Moderate Brain Injured Patient and Predictors of Discharge to Rehabilitation ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Rogers, S., Richards, K. C., Davidson, M., Weinstein, A. A., Trickey, A. W. 2015; 96 (2): 276–82


    To describe patients with moderate traumatic brain injury (TBI) treated and discharged at levels I and II trauma centers in the United States; and to describe the predictors of discharge to rehabilitation after acute care.Retrospective, cross-sectional, descriptive study.Trauma centers.Patients with moderate TBI (N=2087; age range, 18-64 y) as reported in the 2010 National Sample Project.None.Discharge destination (rehabilitation vs home with no services).Multivariate logistic regression models revealed that demographic, clinical, and financial characteristics influenced the likelihood of being discharged to rehabilitation. Increased age, increased severity, Medicare use, longer length of stay, and trauma center locations in the Midwest and Northeast all increased the likelihood of discharge to rehabilitation.The decision to discharge a person with moderate TBI from acute care to rehabilitation appears to be based on factors other than just clinical need. These findings should be considered in creating more equitable access to postacute rehabilitation services for patients with moderate TBI because they risk long-term physical and cognitive problems and have the potential for productive lives with treatment.

    View details for DOI 10.1016/j.apmr.2014.09.018

    View details for Web of Science ID 000348751800014

    View details for PubMedID 25305630

  • An Evidence-Based Medicine Curriculum Improves General Surgery Residents' Standardized Test Scores in Research and Statistics. Journal of graduate medical education Trickey, A. W., Crosby, M. E., Singh, M., Dort, J. M. 2014; 6 (4): 664-668


    The application of evidence-based medicine to patient care requires unique skills of the physician. Advancing residents' abilities to accurately evaluate the quality of evidence is built on understanding of fundamental research concepts. The American Board of Surgery In-Training Examination (ABSITE) provides a relevant measure of surgical residents' knowledge of research design and statistics.We implemented a research education curriculum in an independent academic medical center general residency program, and assessed the effect on ABSITE scores.The curriculum consisted of five 1-hour monthly research and statistics lectures. The lectures were presented before the 2012 and 2013 examinations. Forty residents completing ABSITE examinations from 2007 to 2013 were included in the study. Two investigators independently identified research-related item topics from examination summary reports. Correct and incorrect responses were compared precurriculum and postcurriculum. Regression models were calculated to estimate improvement in postcurriculum scores, adjusted for individuals' scores over time and postgraduate year level.Residents demonstrated significant improvement in postcurriculum examination scores for research and statistics items. Correct responses increased 27% (P < .001). Residents were 5 times more likely to achieve a perfect score on research and statistics items postcurriculum (P < .001).Residents at all levels demonstrated improved research and statistics scores after receiving the curriculum. Because the ABSITE includes a wide spectrum of research topics, sustained improvements suggest a genuine level of understanding that will promote lifelong evaluation and clinical application of the surgical literature.

    View details for DOI 10.4300/JGME-D-14-00117

    View details for PubMedID 26140115

    View details for PubMedCentralID PMC4477558

  • Using NSQIP to Investigate SCIP Deficiencies in Surgical Patients With a High Risk of Developing Hospital-Associated Urinary Tract Infections AMERICAN JOURNAL OF MEDICAL QUALITY Trickey, A. W., Crosby, M. E., Vasaly, F., Donovan, J., Moynihan, J., Reines, H. 2014; 29 (5): 381–87


    The study objectives were to identify risk factors for surgical patients who develop postoperative urinary tract infections (UTIs) and to characterize urethral catheter practices at the study hospital. Patients from the 2006-2010 institutional National Surgical Quality Improvement Program database were evaluated. Patients with UTIs within 30 postoperative days (n = 116) were compared to patients without UTIs (n = 8685) using multivariable logistic regression. A nested case-control study evaluated the effects of catheter practices on postoperative UTI using conditional logistic regression. Independent predictors of UTI were sex, age, inpatient stay, functional status, renal failure, preoperative transfusion, and preoperative hospital stay. Compared with controls, patients with UTI more often maintained catheters for >2 postoperative days (66% vs 43%, P < .001) and had longer mean catheter duration (11.6 vs 5.1 days, P < .001). Study findings led to institutional recommendations to reduce catheter-associated UTIs. Quality improvement initiatives can increase awareness of performance enhancement opportunities and encourage collaborative, interdisciplinary improvement through shared objectives.

    View details for DOI 10.1177/1062860613503363

    View details for Web of Science ID 000341284000002

    View details for PubMedID 24045369

  • Are pediatric concussion patients compliant with discharge instructions? JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Hwang, V., Trickey, A. W., Lormel, C., Bradford, A. N., Griffen, M. M., Lawrence, C. P., Sturek, C., Stacey, E., Howell, J. M. 2014; 77 (1): 117–22


    Concussions are commonly diagnosed in pediatric patients presenting to the emergency department (ED). The primary objective of this study was to evaluate compliance with ED discharge instructions for concussion management.A prospective cohort study was conducted from November 2011 to November 2012 in a pediatric ED at a regional Level 1 trauma center, serving 35,000 pediatric patients per year. Subjects were aged 8 years to 17 years and were discharged from the ED with a diagnosis of concussion. Exclusion criteria included recent (past 3 months) diagnosis of head injury, hospital admission, intracranial injury, skull fracture, suspected nonaccidental trauma, or preexisting neurologic condition. Subjects were administered a baseline survey in the ED and were given standardized discharge instructions for concussion by the treating physician. Telephone follow-up surveys were conducted at 2 weeks and 4 weeks after ED visit.A total of 150 patients were enrolled. The majority (67%) of concussions were sports related. Among sports-related concussions, soccer (30%), football (11%), lacrosse (8%), and basketball (8%) injuries were most common. More than one third (39%) reported return to play (RTP) on the day of the injury. Physician follow-up was equivalent for sport and nonsport concussions (2 weeks, 58%; 4 weeks, 64%). Sports-related concussion patients were more likely to follow up with a trainer (2 weeks, 25% vs. 10%, p = 0.06; 4 weeks, 29% vs. 8%, p < 0.01). Of the patients who did RTP or normal activities at 2 weeks (44%), more than one third (35%) were symptomatic, and most (58%) did not receive medical clearance. Of the patients who had returned to activities at 4 weeks (64%), less than one quarter (23%) were symptomatic, and most (54%) received medical clearance.Pediatric patients discharged from the ED are mostly compliant with concussion instructions. However, a significant number of patients RTP on the day of injury, while experiencing symptoms or without medical clearance.Care management, level IV. Epidemiologic study, level III.

    View details for DOI 10.1097/TA.0000000000000275

    View details for Web of Science ID 000338389600031

    View details for PubMedID 24977765

  • Colectomy without mechanical bowel preparation in the private practice setting TECHNIQUES IN COLOPROCTOLOGY Otchy, D. P., Crosby, M. E., Trickey, A. W. 2014; 18 (1): 45–51


    Despite randomized trials and meta-analyses demonstrating the safety of omitting mechanical bowel preparation (MBP) before colorectal surgery, private practice surgeons may hesitate to eliminate MBP for fear of being outside community standards. This study evaluated the safety of eliminating MBP before colectomy in a private practice setting.This prospective observational study included elective abdominal colorectal operations from one surgeon's practice from October 2008 to June 2011. MBP was not routinely utilized after November 2009. Postoperative 30-day complication rates and length of hospital stay were compared in patients with and without MBP. Multivariable regression models were developed to compare outcomes among study groups, adjusting for demographics, diagnoses, procedures, and year.A total of 165 patients were analyzed. Demographics were similar between groups. Laparoscopic procedures were more common in patients without MBP due to increased laparoscopy over time (43 vs. 61 %, p = 0.03). As regards complications, infection rates were similar between groups (MBP 10.5 % vs. no MBP(NMBP) 11.4 %, adj p = 0.57). Patients without MBP had a shorter length of hospital stay (median: 6 vs. 5 days, p = 0.01), but those differences were not statistically significant after adjustment (p = 0.14).Private practice surgeons should embrace evidence-based practice changes and make efforts to quantitatively evaluate the safety of those changes. Omission of MBP for most elective colectomy procedures appears to be safe with no significant increase in complications or length of hospital stay. Because MBP has substantial drawbacks, there is little justification for its routine use in the majority of elective abdominal colorectal procedures.

    View details for DOI 10.1007/s10151-013-0990-2

    View details for Web of Science ID 000329710100008

    View details for PubMedID 23467770

  • Transcranial Doppler Investigation of Hemodynamic Alterations Associated With Blunt Cervical Vascular Injuries in Trauma Patients JOURNAL OF ULTRASOUND IN MEDICINE Purvis, D. L., Crutchfield, K., Trickey, A. W., Aldaghlas, T., Rizzo, A., Sikdar, S. 2013; 32 (10): 1759-1768


    Blunt cervical vascular injuries, often missed with current screening methods, have substantial morbidity and mortality, and there is a need for improved screening. Elucidation of cerebral hemodynamic alterations may facilitate serial bedside monitoring and improved management. Thus, the objective of this study was to define cerebral flow alterations associated with single blunt cervical vascular injuries using transcranial Doppler sonography and subsequent Doppler waveform analyses in a trauma population.In this prospective pilot study, patients with suspected blunt cervical vascular injuries had diagnoses by computed tomographic angiography and were examined using transcranial Doppler sonography to define cerebral hemodynamics. Multiple vessel injuries were excluded for this analysis, as the focus was to identify hemodynamic alterations from isolated injuries. The inverse damping factor characterized altered extracranial flow patterns; middle cerebral artery flow velocities, the pulsatility index, and their asymmetries characterized altered intracranial flow patterns.Twenty-three trauma patients were evaluated: 4 with single internal carotid artery injuries, 5 with single vertebral artery injuries, and 14 without blunt cervical vascular injuries. All internal carotid artery injuries showed a reduced inverse damping factor in the internal carotid artery and dampened ipsilateral mean flow and peak systolic velocities in the middle cerebral artery. Vertebral artery injuries produced asymmetry of a similar magnitude in the middle cerebral artery mean flow velocity with end-diastolic velocity alterations.These data indicate that extracranial and intracranial hemodynamic alterations occur with internal carotid artery and vertebral artery blunt cervical vascular injuries and can be quantified in the acute injury phase by transcranial Doppler indices. Further study is required to elucidate cerebral flow changes resulting from a single blunt cervical vascular injury, which may guide future management to preserve cerebral perfusion after trauma.

    View details for DOI 10.7863/ultra.32.10.1759

    View details for Web of Science ID 000326357000010

    View details for PubMedID 24065257

  • The impact of missing trauma data on predicting massive transfusion Trickey, A. W., Fox, E. E., del Junco, D. J., Ning, J., Holcomb, J. B., Brasel, K. J., Cohen, M. J., Schreiber, M. A., Bulger, E. M., Phelan, H. A., Alarcon, L. H., Myers, J. G., Muskat, P., Cotton, B. A., Wade, C. E., Rahbar, M. H., PROMMTT Study Grp LIPPINCOTT WILLIAMS & WILKINS. 2013: S68–S74


    Missing data are inherent in clinical research and may be especially problematic for trauma studies. This study describes a sensitivity analysis to evaluate the impact of missing data on clinical risk prediction algorithms. Three blood transfusion prediction models were evaluated using an observational trauma data set with valid missing data.The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study included patients requiring one or more unit of red blood cells at 10 participating US Level I trauma centers from July 2009 to October 2010. Physiologic, laboratory, and treatment data were collected prospectively up to 24 hours after hospital admission. Subjects who received 10 or more units of red blood cells within 24 hours of admission were classified as massive transfusion (MT) patients. Correct classification percentages for three MT prediction models were evaluated using complete case analysis and multiple imputation. A sensitivity analysis for missing data was conducted to determine the upper and lower bounds for correct classification percentages.PROMMTT study enrolled 1,245 subjects. MT was received by 297 patients (24%). Missing percentage ranged from 2.2% (heart rate) to 45% (respiratory rate). Proportions of complete cases used in the MT prediction models ranged from 41% to 88%. All models demonstrated similar correct classification percentages using complete case analysis and multiple imputation. In the sensitivity analysis, correct classification upper-lower bound ranges per model were 4%, 10%, and 12%. Predictive accuracy for all models using PROMMTT data was lower than reported in the original data sets.Evaluating the accuracy clinical prediction models with missing data can be misleading, especially with many predictor variables and moderate levels of missingness per variable. The proposed sensitivity analysis describes the influence of missing data on risk prediction algorithms. Reporting upper-lower bounds for percent correct classification may be more informative than multiple imputation, which provided similar results to complete case analysis in this study.

    View details for DOI 10.1097/TA.0b013e3182914530

    View details for Web of Science ID 000330458600011

    View details for PubMedID 23778514

    View details for PubMedCentralID PMC3736742

  • Implications of Medicare procedure volumes on resident education AMERICAN JOURNAL OF SURGERY Broughan, T. A., Crosby, M. E., Trickey, A. W., Ma, A., Bratzler, D. W. 2013; 205 (6): 737–44


    Preparation of future general surgeons requires the ongoing assessment of projected case experience.Surgical procedures (2005-2008) were abstracted from the Centers for Medicare and Medicaid Services inpatient National Claims History Part A 100% Nearline File for all general surgeons. The most frequent Medicare surgical procedures and physician caseloads were compared by practice population.Over 5 million procedures were evaluated, with procedures decreasing over time in urban and large rural areas. A total of 15 procedures comprised the top 10 for all population/year categories. The most frequent surgical procedures were similar in rural and urban areas. Rural surgeons' caseloads consisted of a higher proportion of endoscopic procedures.The most common Medicare general surgery procedures are similar across population areas and are required experience for residents. Separate surgical educational programs for urban and rural general surgeons may not be necessary to provide adequate care to rural patients.

    View details for DOI 10.1016/j.amjsurg.2012.11.006

    View details for Web of Science ID 000319802500018

    View details for PubMedID 23540717

  • A Novel Decision Tree Approach Based on Transcranial Doppler Sonography to Screen for Blunt Cervical Vascular Injuries JOURNAL OF ULTRASOUND IN MEDICINE Purvis, D., Aldaghlas, T., Trickey, A. W., Rizzo, A., Sikdar, S. 2013; 32 (6): 1023-1031


    Early detection and treatment of blunt cervical vascular injuries prevent adverse neurologic sequelae. Current screening criteria can miss up to 22% of these injuries. The study objective was to investigate bedside transcranial Doppler sonography for detecting blunt cervical vascular injuries in trauma patients using a novel decision tree approach.This prospective pilot study was conducted at a level I trauma center. Patients undergoing computed tomographic angiography for suspected blunt cervical vascular injuries were studied with transcranial Doppler sonography. Extracranial and intracranial vasculatures were examined with a portable power M-mode transcranial Doppler unit. The middle cerebral artery mean flow velocity, pulsatility index, and their asymmetries were used to quantify flow patterns and develop an injury decision tree screening protocol. Student t tests validated associations between injuries and transcranial Doppler predictive measures.We evaluated 27 trauma patients with 13 injuries. Single vertebral artery injuries were most common (38.5%), followed by single internal carotid artery injuries (30%). Compared to patients without injuries, mean flow velocity asymmetry was higher for single internal carotid artery (P = .003) and single vertebral artery (P = .004) injuries. Similarly, pulsatility index asymmetry was higher in single internal carotid artery (P = .015) and single vertebral artery (P = .042) injuries, whereas the lowest pulsatility index was elevated for bilateral vertebral artery injuries (P = .006). The decision tree yielded 92% specificity, 93% sensitivity, and 93% correct classifications.In this pilot feasibility study, transcranial Doppler measures were significantly associated with the blunt cervical vascular injury status, suggesting that transcranial Doppler sonography might be a viable bedside screening tool for trauma. Patient-specific hemodynamic information from transcranial Doppler assessment has the potential to alter patient care pathways to improve outcomes.

    View details for DOI 10.7863/ultra.32.6.1023

    View details for Web of Science ID 000319895500016

    View details for PubMedID 23716524

  • Website Usage and Weight Loss in a Free Commercial Online Weight Loss Program: Retrospective Cohort Study JOURNAL OF MEDICAL INTERNET RESEARCH Hwang, K. O., Ning, J., Trickey, A. W., Sciamanna, C. N. 2013; 15 (1): e11


    Online weight loss programs are increasingly popular. However, little is known about outcomes and associations with website usage among members of free online weight loss programs.This retrospective cohort study examined the association between website usage and weight loss among members of a free commercial online weight loss program (SparkPeople).We conducted a retrospective analysis of a systematic random sample of members who joined the program during February 1 to April 30, 2008, and included follow-up data through May 10, 2010. The main outcome was net weight change based on self-reported weight. Measures of website usage included log-ins, self-monitoring entries (weight, food, exercise), and use of social support tools (discussion forums, friendships).The main sample included 1258 members with at least 2 weight entries. They were 90.7% female, with mean (SD) age 33.6 (11.0) and mean (SD) BMI 31.6 (7.7). Members with at least one forum post lost an additional 1.55 kg (95% CI 0.55 kg to 2.55 kg) relative to those with no forum posts. Having at least 4 log-in days, weight entry days, or food entry days per 30 days was significantly associated with weight loss. In the multiple regression analysis, members with at least 4 weight entry days per 30 days reported 5.09 kg (95% CI 3.29 kg to 6.88 kg) more weight loss per 30 days than those with fewer weight entry days. After controlling for weight entry days, the other website usage variables were not associated with weight change.Weekly or more frequent self-monitoring of weight is associated with greater weight loss among members of this free online weight loss program.

    View details for DOI 10.2196/jmir.2195

    View details for Web of Science ID 000315113200018

    View details for PubMedID 23322819

    View details for PubMedCentralID PMC3636231

  • Speaking Up and Sharing Information Improves Trainee Neonatal Resuscitations JOURNAL OF PATIENT SAFETY Katakam, L. I., Trickey, A. W., Thomas, E. J. 2012; 8 (4): 202–9


    To identify teamwork behaviors associated with improving efficiency and quality of simulated resuscitation training.Secondary analysis of a randomized controlled trial of trainees undergoing neonatal resuscitation training was performed. Trainees at a large academic center (n = 100) were randomized to receive standard curriculum (n = 36) versus supplemental team training curriculum (n = 62). A 2-hour team training session focused on communication skills, and team behaviors served as the intervention. Outcomes of interest included resuscitation duration, time required to complete a simulated newborn resuscitation, and performance score, determined by evaluation of each of the team's steps during simulated resuscitation scenarios.The teamwork behaviors assertion and sharing information were associated with shorter resuscitation duration and higher performance scores. Each additional use of assertion (per minute) was associated with a duration reduction of 41 s (95% confidence interval [CI], -71.5 to -10.2) and an increase in performance score of 1.6% (95% CI, 0.4-2.7). Each additional use of sharing information (per minute) was associated with a 14-second reduction in duration (95% CI, -30.4 to 2.9) and a 0.8% increase in performance score (95% CI, 0.05-1.5).Teamwork behaviors of assertion and sharing information are 2 important mediators of efficiency and quality of resuscitations.

    View details for DOI 10.1097/PTS.0b013e3182699b4f

    View details for Web of Science ID 000313586500009

    View details for PubMedID 23007245

    View details for PubMedCentralID PMC3504644

  • General Surgery vs Fellowship: The Role of the Independent Academic Medical Center JOURNAL OF SURGICAL EDUCATION Adra, S. W., Trickey, A. W., Crosby, M. E., Kurtzman, S. H., Friedell, M. L., Reines, H. D. 2012; 69 (6): 740-745


    To compare career choices of residency graduates from Independent Academic Medical Center (IAMC) and University Academic Medical Center (UAMC) programs and evaluate program directors' perceptions of residents' motivations for pursuing general surgery or fellowships.From May to August 2011, an electronic survey collected information on program characteristics, graduates' career pursuits, and career motivations. Fisher's exact tests were calculated to compare responses by program type. Multivariate logistic regression was used to identify independent program characteristics associated with graduates pursuing general surgery.Data were collected on graduates over 3 years (2009-2011).Surgery residency program directors.Seventy-four program directors completed the survey; 42% represented IAMCs. IAMCs reported more graduates choosing general surgery. Over one-quarter of graduates pursued general surgery from 52% of IAMC vs 37% of UAMC programs (p = 0.243). Career choices varied significantly by region: over one-quarter of graduates pursue general surgery from 78% of Western, 60% of Midwestern, 40% of Southern, and 24% of Northeastern programs (p = 0.018). On multivariate analysis, IAMC programs were independently associated with more graduates choosing general surgery (p = 0.017), after adjustment for other program characteristics. Seventy-five percent of UAMC programs reported over three-fourths of graduates receive first choice fellowship, compared with only 52% of IAMC programs (p = 0.067). Fellowships were comparable among IAMC and UAMC programs, most commonly MIS/Bariatric (16%), Critical Care/Trauma (16%), and Vascular (14%). IAMC and UAMC program directors cite similar reasons for graduate career choices.Most general surgery residents undergo fellowship training. Graduates from IAMC and UAMC programs pursue similar specialties, but UAMC programs report more first choice acceptance. IAMC programs may graduate proportionately more general surgeons. Further studies directly evaluating surgical residents' career choices are warranted to understand the influence of independent and university programs in shaping these choices and to develop strategies for reducing the general surgeon shortage.

    View details for DOI 10.1016/j.jsurg.2012.05.006

    View details for Web of Science ID 000311024100012

    View details for PubMedID 23111040

  • Sound Levels, Staff Perceptions, and Patient Outcomes During Renovation Near the Neonatal Intensive Care Unit HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL Trickey, A. W., Arnold, C. C., Parmar, A., Lasky, R. E. 2012; 5 (4): 76–87


    Sound levels, staff perceptions, and patient outcomes were evaluated during a year-long hospital renovation project on the floor above a neonatal intensive care unit (NICU).Construction noise may be detrimental to NICU patients and healthcare professionals. There are no comprehensive studies evaluating the impact of hospital construction on sound levels, staff, and patients.Prospective observational study comparing sound measures and patient outcomes before, during, and after construction. Staff were surveyed about the construction noise, and hospital employee satisfaction scores are reported.Equivalent sound levels were not significantly higher during construction. Most staff members (89%) perceived the renovation period as louder, and 83% reported interruptions of their work. Patient outcomes were the same or more positive during construction. Very low birth weight (VLBW) infants were less likely to require 24+ hours' mechanical ventilation during construction: 54% vs. 59% before (OR = 1.6, p = 0.018) and 62% after (OR = 1.48, p = 0.065); and they required a shorter total period of mechanical ventilation: 3.6 days vs. 8.0 before (p = 0.011) and 9.5 after (p = 0.001). VLBW newborns' differences in ventilation days were mostly in the upper extremes; medians were similar in all periods: 0.6 days vs. 1 day preconstruction and 2 days postconstruction.Construction above the NICU did not cause substantially louder sound levels, but staff perceived important changes in noise and work routines. No evidence suggested that patients were negatively affected by the renovation period. Meticulous construction planning remains necessary to avoid interference with patient care and caregiver work environments.

    View details for DOI 10.1177/193758671200500407

    View details for Web of Science ID 000309436900007

    View details for PubMedID 23224808

  • Acceptability of narratives to promote colorectal cancer screening in an online community PREVENTIVE MEDICINE Hwang, K. O., Trickey, A. W., Graham, A. L., Thomas, E. J., Street, R. L., Kraschnewski, J. L., Vernon, S. W. 2012; 54 (6): 405–7


    To assess the acceptability of narratives to promote colorectal cancer (CRC) screening among members of an online weight loss community.Members of online weight loss community completed an Internet survey in 2010. Multiple logistic regression models examined demographic and attitudinal correlates of interest in sharing and receiving CRC screening narratives.Participants (n=2386) were 92% female with mean (SD) age 58 (6) years; 68% were up-to-date with CRC screening. Among those who were up-to-date, 39% were interested in sharing their narratives with other members. African-Americans were more likely than other racial groups to be interested in sharing narratives (adjusted OR 2.02, 95% CI 1.14-3.57). Older, married members and those with greater CRC screening worries were less likely to be interested in sharing narratives. Among those not up-to-date, 63% were interested in receiving narratives from online community members, and those with higher perceived salience of CRC screening were more likely to be interested in receiving narratives (adjusted OR 1.86, 95% CI 1.31-2.65).Members of this online weight loss community expressed interest in sharing and receiving narratives for CRC screening promotion. Attitudes and demographic characteristics may predict successful recruitment of those who would share and receive narratives.

    View details for DOI 10.1016/j.ypmed.2012.03.018

    View details for Web of Science ID 000305378900007

    View details for PubMedID 22498021

    View details for PubMedCentralID PMC4154343

  • Team Training in the Neonatal Resuscitation Program for Interns: Teamwork and Quality of Resuscitations PEDIATRICS Thomas, E. J., Williams, A. L., Reichman, E. F., Lasky, R. E., Crandell, S., Taggart, W. R. 2010; 125 (3): 539–46


    Poor communication and teamwork may contribute to errors during neonatal resuscitation. Our objective was to evaluate whether interns who received a 2-hour teamwork training intervention with the Neonatal Resuscitation Program (NRP) demonstrated more teamwork and higher quality resuscitations than control subjects.Participants were noncertified 2007 and 2008 incoming interns for pediatrics, combined pediatrics and internal medicine, family medicine, emergency medicine, and obstetrics and gynecology (n = 98). Pediatrics and combined pediatrics/internal medicine interns were eligible for 6-month follow-up (n = 34). A randomized trial was conducted in which half of the participants in the team training arm practiced NRP skills by using high-fidelity simulators; the remaining practiced with low-fidelity simulators, as did control subjects. Blinded, trained observers viewed video recordings of high-fidelity-simulated resuscitations for teamwork and resuscitation quality.High-fidelity training (HFT) group had higher teamwork frequency than did control subjects (12.8 vs 9.0 behaviors per minute; P < .001). Intervention groups maintained more workload management (control subjects: 89.3%; low-fidelity training [LFT] group: 98.0% [P < .001]; HFT group: 98.8%; HFT group versus control subjects [P < .001]) and completed resuscitations faster (control subjects: 10.6 minutes; LFT group: 8.6 minutes [P = .040]; HFT group: 7.4 minutes; HFT group versus control subjects [P < .001]). Overall, intervention teams completed the resuscitation an average of 2.6 minutes faster than did control subjects, a time reduction of 24% (95% confidence interval: 12%-37%). Intervention groups demonstrated more frequent teamwork during 6-month follow-up resuscitations (11.8 vs 10.0 behaviors per minute; P = .030).Trained participants exhibited more frequent teamwork behaviors (especially the HFT group) and better workload management and completed the resuscitation more quickly than did control subjects. The impact on team behaviors persisted for at least 6 months. Incorporating team training into the NRP curriculum is a feasible and effective way to teach interns teamwork skills. It also improves simulated resuscitation quality by shortening the duration.

    View details for DOI 10.1542/peds.2009-1635

    View details for Web of Science ID 000275945700018

    View details for PubMedID 20156896

  • Teamwork behaviours and errors during neonatal resuscitation QUALITY & SAFETY IN HEALTH CARE Williams, A. L., Lasky, R. E., Dannemiller, J. L., Andrei, A. M., Thomas, E. J. 2010; 19 (1): 60-64


    To describe relationships between teamwork behaviours and errors during neonatal resuscitation.Trained observers viewed video recordings of neonatal resuscitations (n = 12) for the occurrence of teamwork behaviours and errors. Teamwork state behaviours (such as vigilance and workload management, which extend for some duration) were assessed as the percentage of each resuscitation that the behaviour was observed and correlated with the percentage of observed errors. Teamwork event behaviours (such as information sharing, inquiry and assertion, which occur at specific times) were counted in 20-s intervals before and after resuscitation steps, and a generalised linear mixed model was calculated to evaluate relationships between these behaviours and errors.Resuscitation teams who were more vigilant committed fewer errors (Spearman's rho for vigilance and errors = -0.62, 95% CI -0.07 to -0.87, p = 0.031). Assertions were more likely to occur before errors than correct steps (OR = 1.44, 95% CI 1.10 to 1.89, p = 0.008) and teaching/advising occurred less frequently after errors (OR = 0.59, 95% CI 0.37 to 0.94, p = 0.028). Though not statistically significant, there was less information sharing before errors (OR = 0.90, 95% CI 0.77 to 1.05, p = 0.172).Vigilance is an important behaviour for error management. Assertion may have caused errors, or perhaps was an indicator for some other factor that caused errors. Teams may have preferred to resolve errors directly, rather than using errors as opportunities to teach their teammates. These observations raise important questions about the appropriate use of some teamwork behaviours and how to include them in team training programmes.

    View details for DOI 10.1136/qshc.2007.025320

    View details for Web of Science ID 000274641500012

    View details for PubMedID 20172885

  • Heart Rate Variability in Response to Pain Stimulus in VLBW Infants Followed Longitudinally During NICU Stay DEVELOPMENTAL PSYCHOBIOLOGY Padhye, N. S., Williams, A. L., Khattak, A. Z., Lasky, R. E. 2009; 51 (8): 638–49


    The objective of this longitudinal study, conducted in a neonatal intensive care unit, was to characterize the response to pain of high-risk very low birth weight infants (<1,500 g) from 23 to 38 weeks post-menstrual age (PMA) by measuring heart rate variability (HRV). Heart period data were recorded before, during, and after a heel lanced or wrist venipunctured blood draw for routine clinical evaluation. Pain response to the blood draw procedure and age-related changes of HRV in low-frequency and high-frequency bands were modeled with linear mixed-effects models. HRV in both bands decreased during pain, followed by a recovery to near-baseline levels. Venipuncture and mechanical ventilation were factors that attenuated the HRV response to pain. HRV at the baseline increased with post-menstrual age but the growth rate of high-frequency power was reduced in mechanically ventilated infants. There was some evidence that low-frequency HRV response to pain improved with advancing PMA.

    View details for DOI 10.1002/dev.20399

    View details for Web of Science ID 000272671000004

    View details for PubMedID 19739134

    View details for PubMedCentralID PMC2936240

  • The behavioral pain response to heelstick in preterm neonates studied longitudinally: Description, development, determinants, and components EARLY HUMAN DEVELOPMENT Williams, A. L., Khattak, A. Z., Garza, C. N., Lasky, R. E. 2009; 85 (6): 369–74


    Preterm infants often experience multiple painful procedures during their stay in neonatal intensive care units (NICUs). The objectives of this study were to evaluate behavioral responses to heelstick in preterm newborns, characterize developmental changes and the effects of other demographic and clinical variables on the pain response, and estimate the contributions of individual Neonatal Infant Pain Scale (NIPS) behaviors to the summary pain score.A longitudinal study was conducted to evaluate the behavioral responses of 35 preterm newborns to multiple heelstick procedures during their stay in the NICU. Sixty-one video recordings of blood collection by heel lance were evaluated for behavioral pain response using the NIPS. Generalized linear mixed models were calculated to address the study objectives.The increases in NIPS scores from the baseline to the blood draw were highly significant (mean baseline score=3.34, mean blood draw score=5.45, p<0.001). The newborns' pain responses increased an average of 0.23 points on the NIPS scale each week (p=0.002). Lower NIPS scores during the heelstick procedure were associated with four clinical variables: younger post-menstrual age at birth, lower birthweight, mechanical ventilation, and longer length of stay in the NICU. Crying, arousal state, and facial grimace contributed more than 85% of the increase in NIPS scores during the heelstick procedure.While behavioral responses to pain are attenuated in young, severely ill preterm newborns, they can be reliably detected. The most robust pain behaviors are crying, changes in arousal state, and facial grimacing.

    View details for DOI 10.1016/j.earlhumdev.2009.01.001

    View details for Web of Science ID 000266851700005

    View details for PubMedID 19167172

  • Intensive Care Noise and Mean Arterial Blood Pressure in Extremely Low-Birth-Weight Neonates AMERICAN JOURNAL OF PERINATOLOGY Williams, A. L., Sanderson, M., Lai, D., Selwyn, B. J., Lasky, R. E. 2009; 26 (5): 323-329


    Noise in neonatal intensive care units (NICUs) may impede growth and development for extremely low-birth-weight (ELBW, < 1000 g) newborns. We calculated correlations between NICU sound levels and ELBW neonates' heart rate and arterial blood pressure to evaluate whether this population experiences noise-induced stress. Sound levels inside the incubator, heart rate (HR), and arterial blood pressure recordings were simultaneously collected for eight ELBW neonates for 15 minutes during the first week of life. Cross-correlation functions were calculated for NICU noise, HR, and mean arterial blood pressure (MABP) recordings for each subject. ELBW neonates' HR and MABP were significantly correlated ( R = 0.16 at 2-second lag time), with stronger correlation apparent for higher-birth-weight ELBW newborns (0.22 versus 0.10). Lower-birth-weight newborns responded to increased noise with HR acceleration from 45 to 130 seconds after noise events, and higher-birth-weight infants initially responded with an HR deceleration at 25 to 60 seconds, then HR acceleration ~175 seconds after noise increased. MABP was not as strongly correlated with NICU sound levels, although some correlation coefficients were slightly outside the 95% confidence interval. Higher-birth-weight newborns' more mature neurological systems may be responsible for stronger correlations between HR and MABP. NICU noise influenced newborns' HR, indicating that these infants hear and respond to NICU sounds. ELBW newborns in the first week of life seem to maintain a relatively stable blood pressure in response to moderate NICU sound levels (50 to 60 dBA).

    View details for DOI 10.1055/s-0028-1104741

    View details for Web of Science ID 000265577700001

    View details for PubMedID 19085678

  • A randomized clinical trial evaluating silicone earplugs for very low birth weight newborns in intensive care JOURNAL OF PERINATOLOGY Abou Turk, C., Williams, A. L., Lasky, R. E. 2009; 29 (5): 358–63


    To determine whether very low birth weight (VLBW) newborns (<1500 g) wearing silicone earplugs grow larger and perform better on developmental exams than controls.VLBW newborns (n=34) were randomized to wearing earplugs or not. Hospital outcomes were abstracted from medical charts by research staff masked to intervention status. Fourteen extremely low birth weight (ELBW) newborns (<1000 g) were also evaluated at 18 to 22 months.After adjusting for birth weight, 11 surviving newborns in the earplug group were 225 g (95% CI: 45, 405) heavier at 34 weeks post menstrual age than the 13 controls. Six ELBW earplug infants scored 15.53 points (95% CI: 3.03, 28.02) higher than six controls on the Bayley Mental Development Index. Their head circumferences were 2.59 cm (95% CI: 0.97, 4.21) larger.Earplugs may facilitate weight gain in VLBW newborns. Better outcomes may persist at 18 to 22 months at least in ELBW infants.

    View details for DOI 10.1038/jp.2008.236

    View details for Web of Science ID 000265853300005

    View details for PubMedID 19194455

    View details for PubMedCentralID PMC2674530

  • Noise and Light Exposures for Extremely Low Birth Weight Newborns During Their Stay in the Neonatal Intensive Care Unit PEDIATRICS Lasky, R. E., Williams, A. L. 2009; 123 (2): 540-546


    The objectives of this study were to characterize noise and light levels for extremely low birth weight newborns throughout their stay in the NICU, evaluate factors influencing noise and light levels, and determine whether exposures meet recommendations from the American Academy of Pediatrics.Sound and light were measured inside the beds of extremely low birth weight newborns (n = 22) from birth to discharge. Measurements were recorded for 20 consecutive hours weekly from birth until 36 weeks' postmenstrual age, biweekly until 40 weeks, and every 4 weeks thereafter. Clinical variables including bed type and method of respiratory support were recorded at each session.Age-related changes in respiratory support and bed type explained the weekly increase of 0.22 dB in sound level and 3.67 lux in light level. Old incubators were the noisiest bed types, and new incubators were the quietest. Light levels were significantly higher in open beds than in incubators. The variations in noise and light levels over time were greatest for open beds. Noise and light levels were much less affected by respiratory support in incubators compared with open beds. A typical extremely low birth weight neonate was exposed to noise levels averaging 56.44 dB(A) and light levels averaging 70.56 lux during their stay from 26 to 42 weeks' postmenstrual age in the NICU. Noise levels were rarely within American Academy of Pediatrics recommendations (5.51% of the time), whereas light levels almost always met recommendations (99.37% of the time).Bed type and respiratory support explained differences in noise and light levels that extremely low birth weight newborns experience during their hospital stay. Noise levels exceeded recommendations, although evidence supporting those recommendations is lacking. Well-designed intervention studies are needed to determine the effects of noise reduction on the development of extremely low birth weight newborns.

    View details for DOI 10.1542/peds.2007-3418

    View details for Web of Science ID 000262678700017

    View details for PubMedID 19171620

  • Changes in the PQRST Intervals and Heart Rate Variability Associated with Rewarming in Two Newborns Undergoing Hypothermia Therapy NEONATOLOGY Lasky, R. E., Parikh, N. A., Williams, A. L., Padhye, N. S., Shankaran, S. 2009; 96 (2): 93-95


    Little is known about the effects of hypothermia therapy and subsequent rewarming on the PQRST intervals and heart rate variability (HRV) in term newborns with hypoxic-ischemic encephalopathy (HIE).This study describes the changes in the PQRST intervals and HRV during rewarming to normal core body temperature of 2 newborns with HIE after hypothermia therapy.Within 6 h after birth, 2 newborns with HIE were cooled to a core body temperature of 33.5 degrees C for 72 h using a cooling blanket, followed by gradual rewarming (0.5 degrees C per hour) until the body temperature reached 36.5 degrees C. Custom instrumentation recorded the electrocardiogram from the leads used for clinical monitoring of vital signs. Generalized linear mixed models were calculated to estimate temperature-related changes in PQRST intervals and HRV.For every 1 degrees C increase in body temperature, the heart rate increased by 9.2 bpm (95% CI 6.8-11.6), the QTc interval decreased by 21.6 ms (95% CI 17.3-25.9), and low and high frequency HRV decreased by 0.480 dB (95% CI 0.052-0.907) and 0.938 dB (95% CI 0.460-1.416), respectively.Hypothermia-induced changes in the electrocardiogram should be monitored carefully in future studies.

    View details for DOI 10.1159/000205385

    View details for Web of Science ID 000266881900004

    View details for PubMedID 19252411

    View details for PubMedCentralID PMC2957844

  • Spectral analysis of time series of events: effect of respiration on heart rate in neonates PHYSIOLOGICAL MEASUREMENT van Drongelen, W., Williams, A. L., Lasky, R. E. 2009; 30 (1): 43–61


    Certain types of biomedical processes such as the heart rate generator can be considered as signals that are sampled by the occurring events, i.e. QRS complexes. This sampling property generates problems for the evaluation of spectral parameters of such signals. First, the irregular occurrence of heart beats creates an unevenly sampled data set which must either be pre-processed (e.g. by using trace binning or interpolation) prior to spectral analysis, or analyzed with specialized methods (e.g. Lomb's algorithm). Second, the average occurrence of events determines the Nyquist limit for the sampled time series. Here we evaluate different types of spectral analysis of recordings of neonatal heart rate. Coupling between respiration and heart rate and the detection of heart rate itself are emphasized. We examine both standard and data adaptive frequency bands of heart rate signals generated by models of coupled oscillators and recorded data sets from neonates. We find that an important spectral artifact occurs due to a mirror effect around the Nyquist limit of half the average heart rate. Further we conclude that the presence of respiratory coupling can only be detected under low noise conditions and if a data-adaptive respiratory band is used.

    View details for DOI 10.1088/0967-3334/30/1/004

    View details for Web of Science ID 000263031300004

    View details for PubMedID 19075368

  • Effects of hypoxic-ischemic encephalopathy and whole-body hypothermia on neonatal auditory function: A pilot study AMERICAN JOURNAL OF PERINATOLOGY Mietzsch, U., Parikh, N. A., Williams, A. L., Shankaran, S., Lasky, R. E. 2008; 25 (7): 435–41


    We assessed the effects of hypoxic-ischemic encephalopathy (HIE) and whole-body hypothermia therapy on auditory brain stem evoked responses (ABRs) and distortion product otoacoustic emissions (DPOAEs). We performed serial assessments of ABRs and DPOAEs in newborns with moderate or severe HIE, randomized to hypothermia ( N = 4) or usual care ( N = 5). Participants were five boys and four girls with mean gestational age (standard deviation) of 38.9 (1.8) weeks. During the first week of life, peripheral auditory function, as measured by the DPOAEs, was disrupted in all nine subjects. ABRs were delayed but central transmission was intact, suggesting a peripheral rather than a central neural insult. By 3 weeks of age, peripheral auditory function normalized. Hypothermia temporarily prolonged the ABR, more so for waves generated higher in the brain stem but the effects reversed quickly on rewarming. Neonatal audiometric testing is feasible, noninvasive, and capable of enhancing our understanding of the effects of HIE and hypothermia on auditory function.

    View details for DOI 10.1055/s-0028-1083842

    View details for Web of Science ID 000259542200008

    View details for PubMedID 18720323

    View details for PubMedCentralID PMC2586420

  • Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial JOURNAL OF PERINATOLOGY Thomas, E. J., Taggart, B., Crandell, S., Lasky, R. E., Williams, A. L., Love, L. J., Sexton, J. B., Tyson, J. E., Helmreich, R. L. 2007; 27 (7): 409–14


    To add a team training and human error curriculum to the Neonatal Resuscitation Program (NRP) and measure its effect on teamwork. We hypothesized that teams that received the new course would exhibit more teamwork behaviors than those in the standard NRP course.Interns were randomized to receive NRP with team training or standard NRP, then video recorded when they performed simulated resuscitations at the end of the day-long course. Outcomes were assessed by observers blinded to study arm allocation and included the frequency or duration of six team behaviors: inquiry, information sharing, assertion, evaluation of plans, workload management and vigilance.The interns in the NRP with team training group exhibited more frequent team behaviors (number of episodes per minute (95% CI)) than interns in the control group: information sharing 1.06 (0.24, 1.17) vs 0.13 (0.00, 0.43); inquiry 0.35 (0.11, 0.42) vs 0.09 (0.00, 0.10); assertion 1.80 (1.21, 2.25) vs 0.64 (0.26, 0.91); and any team behavior 3.34 (2.26, 4.11) vs 1.03 (0.48, 1.30) (P-values <0.008 for all comparisons). Vigilance and workload management were practiced throughout the entire simulated code by nearly all the teams in the NRP with team training group (100% for vigilance and 88% for workload management) vs only 53 and 20% of the teams in the standard NRP. No difference was detected in the frequency of evaluation of plans.Compared with the standard NRP, NRP with a teamwork and human error curriculum led interns to exhibit more team behaviors during simulated resuscitations.

    View details for DOI 10.1038/

    View details for Web of Science ID 000247533200003

    View details for PubMedID 17538634

  • Longitudinal assessment of heart rate variability in very low birth weight infants during their NICU stay EARLY HUMAN DEVELOPMENT Khattak, A. Z., Padhye, N. S., Williams, A. L., Lasky, R. E., Moya, F. R., Verklan, M. 2007; 83 (6): 361–66


    Maturation of the autonomic nervous system has not been studied in high-risk very low birth weight (VLBW) infants in the first few weeks of life.To characterize developmental changes in autonomic nervous system activity of high-risk VLBW infants from 23 to 38 weeks post-menstrual age by measuring heart rate variability (HRV).In this prospective cohort study 38 infants admitted to Children's Memorial Hermann Hospital NICU were longitudinally followed weekly or biweekly. Heart period data were recorded while infants were resting in active sleep.Growth of spectral power of HRV in low-frequency (0.05-0.25 Hz) and high-frequency (0.25-1.00 Hz) bands was modeled with linear mixed-effects models. The high-frequency power provides a measure of respiratory sinus arrhythmia (RSA).Low-frequency power increases with post-menstrual age, and intubated infants have lower HRV. The increase in low-frequency power is faster (0.50+/-0.12 dB/week) than the increase in RSA (0.17+/-0.09 dB/week).This longitudinal data exhibits developmental maturation of the RSA and of the low-frequency power of HRV in high-risk VLBW infants.

    View details for DOI 10.1016/j.earlhumdev.2006.07.007

    View details for Web of Science ID 000246654700003

    View details for PubMedID 16978804

  • Noise in contemporary neonatal intensive care Williams, A. L., van Drongelen, W., Lasky, R. E. ACOUSTICAL SOC AMER AMER INST PHYSICS. 2007: 2681–90


    Weekly sound surveys (n = 63) were collected, using 5 s sampling intervals, for two modern neonatal intensive care units (NICUs). Median weekly equivalent sound pressure levels (LEQ) for NICU A ranged from 61 to 63 dB (A weighted), depending on the level of care. NICU B L(EQ) measurements ranged from 55 to 60 dB (A weighted). NICU B was recently built with a focus on sound abatement, explaining much of the difference between the two NICUs. Sound levels exceeded 45 dB (A weighted), recommended by the American Academy of Pediatrics, more than 70% of the time for all levels of care. Hourly L(EQ)s below 50 dB (A weighted) and hourly L10s below 55 dB (A weighted), recommended by the Sound Study Group (SSG) of the National Resource Center, were also exceeded in more than 70% of recorded samples. A third SSG recommendation, that the 1 s L(MAX), should not exceed 70 dB (A weighted), was exceeded relatively infrequently (< 11% of the time). Peak impulse measurements exceeded 90 dB for 6.3% of 5 s samples recorded from NICU A and 2.8% of NICU B samples. Twenty-four h periodicities in sound levels as a function of regular staff activities were apparent, but short-term variability was considerable.

    View details for DOI 10.1121/1.27175001

    View details for Web of Science ID 000246378200022

    View details for PubMedID 17550168